Brian Schiff’s Blog

For those following my rehab journey, this entry will recap days 8-14 after surgery. At this point, I had been off pain meds for 4 days. However, I will admit I took one pain pill prior to my first PT session exactly one week out from surgery. For two decades I have listened to patients recount stories of their own or friends who report how painful therapy is after this surgery. Oddly enough, most of my patients over the years said it was not so bad. Perhaps, there is great variability in the intensity of the passive stretching among therapists.

Research Nuggets

The literature offers support and caution for early motion after rotator cuff repair. While ROM is generally better early on with early motion, there is some concern about higher re-tear rates. I am in the camp that gentle early passive range of motion (PROM) is okay given the proper regimen and patient compliance. Early active range of motion (AROM) or too vigorous PROM is likely to be more detrimental to the repair. Ultimately, these decisions are made based on the size of the tear, tear configuration, patient’s health and age, MD preference and whether or not this is a primary or revision repair.

The article abstract below is a great reference for activities and activation of the rotator cuff as measured by surface EMG to provide some insight for patients and clinicians regarding safe movement and exercise in the rehab process:

https://pubmed.ncbi.nlm.nih.gov/28704624/

In addition, here is another article that outlines post-op rehab (you can download the entire article for free)

https://pubmed.ncbi.nlm.nih.gov/29399735/

My First PT Visit

So, I would be lying if I said I was not nervous. I mean I was always the guy stretching the fresh post-op shoulders, and suddenly I am the one laying on the table a week out from surgery about to let someone move my stiff, sore shoulder. Fear of the unknown is probably the worst in that moment. My therapist is a colleague in my own clinic who actually reports to me. No pressure on him, right? LOL

He and I agreed to co-pilot my rehab and map everything out through constant dialogue and feedback. He has done a good job thus far. That first day the shoulder felt like a cement block to me. It seemed like super glue was preventing it from moving much. The focus was on gentle external rotation and flexion range of motion. Both hurt, but the flexion was by far the worst for me.

After doing pendulums and the PROM with him, my routine consisted of:

• Seated passive external rotation using a cane on my own – 2 sets of 15
• Scapular retraction (gentle squeezing of the shoulder blades together) – 2 sets of 15
• Seated table slides with a towel – 2 sets of 15
• Game Ready x 15 minutes with low compression

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Last week I began sharing my story about my left arthroscopic rotator cuff repair. As reminder, I had surgery on May 20. In this post, I will share more about the first week. I get many common questions like: How bad does it hurt? When can you get rid of the sling? How long is the total recovery?

The entire outpatient procedure went well. I barely remember getting an interscalene block (kudos to the anesthesiologist) and the entire operation lasted about 45 minutes. The  oldest feeling is not feeling the left arm and having no control of the arm until the block wears off. The entire arm is essentially paralyzed and numb. Great for pain management to be sure, but not even being able to use the hand is inconvenient for small prehensile tasks.

I was fortunate that I did not have any adverse reaction to the anesthesia itself. I was a bit tired and groggy for the first 4-6 ours after surgery. The biggest adjustment is getting used to the sling and abduction pillow (see below)

Learning how to sit, adjust and take this off/put it on takes some getting used to. However, I quickly learned how valuable and supportive it was once the block wore off. My surgery was at 8:45 AM on a Thursday. The block wore off about 18 hours later at 3 AM. Let’s just say that aha moment was enough to get my attention.

Pain 

I would say pain level was 7/10 for me. The doctor and his staff had advised me to start taking pain pills ahead of the block wearing off and I had initiated that about 8 hours after surgery. I was alternating ibuprofen every 2 hours while taking oxycodone every 4 hours. I can only imagine how much more it would have hurt if I had waited for the block to wear off.

Cryotherapy

The first 3-4 days afterward were the worst in terms of pain. Generally, pain at rest was probably 3-4/10, occasionally spiking to 9/10 if I moved the wrong way. Aside from the meds, I used cryotherapy, specifically a Game Ready, extensively (20 minutes on, 40 minutes off) 8-10 times per day the first week. I cannot say enough about how helpful this is in managing pain and inflammation.

This unit provides cold and compression, however, I would recommend low or no compression initially as your incisions will be tender, especially once the surgical dressing is removed at day 3 post-op. I sat upright in a chair and supported the elbow while using this machine. The hospital or outpatient facility will offer a polar care unit for $250, but I opted for this unit as I have used it for years in the clinic, while hearing countless patients tell me how much better it is. A 3-week rental will cost you $300, but it is well worth it.

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The Backstory

It all began with a burning sensation in my left shoulder in November 2020 with a simple gesture. I did not give it a second thought, as it subsided in a few minutes. However, I soon began to notice more regular pain with certain movements and difficulty sleeping at night. Honestly. I thought it would subside and chalked it up to some mild rotator cuff inflammation. For years, I had avoided overhead lifts and heavy bench press, while restricting range of motion to reduce stress on my shoulders. With that said, this pain led to me further modifying my workouts.

A few weeks later, the nocturnal pain became more intense and prevalent. I knew it was time to formally rehab my shoulder. So, I did what I would advise my patients to do. I embarked on 6 weeks of rotator cuff and scapular strengthening 3x/week, while using laser, ice, and non-steroidal anti-inflammatory meds to resolve the pain. I stuck religiously to this plan from mid December to the end of February. Unfortunately, nothing helped. Sleeping was interrupted consistently, and my function was limited.

As such, I sought the counsel of a trusted surgeon I work closely with. He ordered an MRI, which revealed a 1 cm near full-thickness tear in the supraspinatus tendon, a type II acromion and a big anterolateral bone spur. As you can see from the list below, I have a borderline medium-size tear.

Rotator Cuff Tear Classification:

Small < 1 cm

Medium 1-3 cm

Large 3-5 cm

Massive > 5 cm

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The idea behind this exercise is applying progressive gradients of resistance that encourage the faulty motion (pulling the leg into adduction and internal rotation) to facilitate increased activation of the gluteus medius/minimus and small lateral rotators to create an anti-adduction/internal rotation force by forcing the brain to work against the unwanted motion (better central nervous system activation). Decreasing such moments at the knee will reduce IT Band issues, patellofemoral pain, ACL injury risk and overuse problems often seen in running.

The video below from my online column for PFP magazine demonstrates how to execute this exercise. It is a great corrective and prehab training activity.

At times, athletes I work with have shoulder or low back pain that is related to restrictions in the thoracic spine. Rotational sports rely upon adequate mobility in the thoracic spine to ensure proper force transmission throughout the body’s kinetic chain. This exercise featured in one of my recent PFP online columns is a nice corrective exercise or mobility drill that can be used to optimize t-spine mobility and resolve any asymmetries.

Keep in mind that forcing through pain or stiffness is not advisable. This exercise can be done daily or as part of the warm-up routine.