scar tissue | digitalflood.com

Run far and don't look back. -- Snapshots by Jasonlove.com

Last time around in my previous post I caught up a bit later than our normal weekly updates on my recovery from Open Bankart Shoulder Surgery on my right arm. I did that to show you the large amount of pivotal progress that is made in week five compared to previous weeks.

The latter part of week five into week six has been much the same. During my last PT session (12/2) my therapist began a more aggressive massage methodology on my scar tissue and shoulder blade. She advised me that what she was doing was flattening out and extending the scar tissue. This allows the scar tissue to become more flexible like normal muscle tissue, but still provide enough stabilization in the shoulder as to hold my bones in place. Only when really pressed on does the surgery scar even exhibit any noticeable pain. My humerus head is still sore, but not as bad as in the past. There is also still soreness around the shoulder blade and back muscles related to both non-usage, as well as, the strain being put on the muscles by my continued attempts to adjust my posture. My therapist stated left untouched the scar tissue would build into a large mounded mass and become too hard limiting range of motion. Worse yet it would also stick to the other muscles and soft tissue limiting their movement as well. All in all, the importance of continued massaging of the surgery scar by a PT is important at this point as internally there is still late stage healing going on.

We then did some light stretching and shoulder blade rotations. Then came the grueling part. We began slowly with the therapist and an assistant’s help moving my arm upward above my head (as if I was reaching upward except I was really laying flat on my back). The first time we measured 142 degrees, which is two degrees up from last session earlier this week (see previous entry link above). Again, to recap, 180 degrees is the maximum measurement for an upward reach and my ultimate goal. 142 degrees came with minor discomfort and is my “pain limit”. The next two upward reaches went beyond my pain limit. First to 145 (where intense pain set in) and then beyond to what was my true flexibility reach (where muscles in my arm tightened rigid with no more ability to stretch from shoulder to wrist– it sounds as horrible as it really is but is actually less pain than the intense pain threshold where the shoulder joint has to slide into one another at the collar bone and humerus). My final reach at true flexible limits of motion was 150 degrees. This is ahead of schedule and a good sign. My goal is over the next session to reach that 150 deg. limit without the intense pain point occurring and to continue to limber up the collar bone to humerus joint that is limiting my existing reach with pain.

This is what I saw in the ER basically... yeah. Posterior Shoulder Dislocation - Courtsey of http://lifeinthefastlane.com

To do that, my therapist and I discussed adding another exercise for at home PT– a wall climb. The wall climb is done in the shower after heating the arm with warm water (to encourage flexibility and blood flow). You stand facing a flat wall. Reach out with your arm extended to touch the wall with your finger tips “spider” style on the wall. You then walk the “spider” up the wall at the same time you slowly move towards the wall itself. The result is your hand slowly climbs the wall and is supported by it. Once at the apex of the wall you hold it for fifteen seconds. Then walk back down while stepping away from the wall. This is done three times and should encourage the motion limit to lift over the coming weeks.

Other than that we then did ice and electric stimulation to ease both swelling and pain from the session.

Six weeks marks the end of high risk of dislocation and infection. There are still minor risks of both over the last six weeks, but you can finally go into public without a sling. You still need the sling when you sleep though. Six weeks marks the point where some normality returns to your life and you can look back to see the large amount of progress made over the course of the prior weeks. It did feel like an incredibly long time, but now at least there is the encouragement of knowing something is really happening and you really are starting to feel better.

The biggest thing is now that you start feeling better to not get lazy. You need to still get PT, still do your at home exercises, and still need to keep in mind your arm is not 100% (realistically it’s about 50% at this point or a bit lower). This insures you continue to heal and make progress.

Next week I return to work and I’ll be switching to document how that interacts with PT and exercises. I had to get a note from my orthopedic surgeon during my five week post-op visit saying I could come back. I then handed that back into HR and they’ll file the closing of my disability claim with NYS when I return on 12/7/09. I already discussed with my direct supervisor and my HR manager my “special needs” such as PT sessions and a 20 minute “exercise break”. I’m swapping out lunch and a fifteenth minute break then making up whatever time I go over on by staying longer. This was all approved without issue (your employer will just be glad to have you back). I do have a 10 lb. lifting limit on my work, but other than that because most of my work is clerical and managerial in nature I can do my normal workload.

If you do physical labor you may not be able to return to work at this point, but that is between you and your surgeon to determine. After 12 weeks most people can return to most jobs, but again– cases vary and you need to consult your medical professional about that, as well as, work out arrangements with your employer (including FMLA and disability where needed).

Basic Shoulder Therapy Excercises

Three weeks removed from my shoulder surgery, not much has changed since my last post. It’s typical during recovery from Open Bankart surgery to plateau. In other words, there are points where you seemingly do not progress and in some instances take a few steps back. This is due to the way your body naturally recovers. Left unattended there are major side effects to shoulder surgery such as muscle atrophy, which is a weakening of the muscles due to lack of use. There is also a danger of tightening of ligaments and tendons leading to paralysis of the shoulder and arm. The root culprit of this is two fold.

First, scar tissue (while stabilizing the overall structure of the wound) creates a hardened almost callas like formation within the arm preventing normal range of motion. The second, is because your arm stays in a protected position (usually close to your body and slightly bent with the shoulder propped forward) similar to when it was in the sling. Because of that positioning the arm muscles literally begins to form and stabilize in that unnatural position. This places a tremendous burden on your neck and back, as well as, leading to a limited range of motion in the shoulder itself. It also causes the now shortened ligament to begin tensing up and shortening themselves. The result is the tendons and ligaments become so tensile it becomes hard to fully open and extend your arm. This effect is particularly noticeable during the morning when you first take your arm out of the sling and alleviates over the first few hours (especially after I do my morning exercise regimen) with normal use. Left unattended for weeks though the ligaments would become near impossible to move and tighten to a dangerous level of shortening.

The scar tissue is good though. My orthopedist actually purposely created scar tissue during surgery because during the course of letting my shoulder deterioate in the years prior to surgery I actually destroyed the scar tissue that was trying to form in my shoulder. As stated earlier, the scar tissue is necessary to help stabilize/support the joint, which prevents tearing and provides a tough layer of tissue to protect the joint, but this tissue must be strategically broken apart so it does have flexilbity enough to allow normal range of motion.

We’ll get into how they address all these under use dangers later in the post when I discuss PT (physical therapy).

The exact opposite can be said about over use. Over using or extending the joint beyond the shoulder line (such as washing your hair or reaching upward) or applying weight over 5 lbs. during lifting of objects comes with the risk of tearing the scar tissue at the incision point, as well as, causing a shoulder dislocation risk that would effectively undo your surgery. This risk is particularly high during the first six weeks after surgery. Common sense and caution must be used. If something causes pain verses normal discomfort you need to stop doing whatever you’re doing immediately. If that painful feeling does not subside within a few minutes you need to call your doctor ASAP.

The final big risk is infection and normal daily showering will prevent this along with being sure to change your shirt each day. I know this sounds like common sense, but you must keep yourself clean hygiene wise to avoid infection. I also like during the last part of my shower to turn the shower head on massage and kick up the heat on the water a bit. I run my arm, back, and opposite arm under the warm jet stream slowly for a total of about 10 minutes. This warms and soothes all the muscles helping to expedite healing. After three weeks, according to my PT, you can begin moving away from ice and towards heat. Ice is for post PT work out, but heat is for sitting around the house and relieving normal aches/pains that may arise. Purchasing a heating pad is thus a great idea.

This brings up the balance that at three weeks you must walk. You should use your arm where ever possible, but you should also not over use the arm. I’ve limited my arm usage to typing, limited body washing in the shower on the torso and abdomen, occasional eating, and light sweeping. These short, brief, and non-intensive tasks test the shoulder without tasking. You should not do any motion that requires upward or outward extension such as reaching above your head. You should around the house when awake not wear the sling at this point. Keep your arm free and let it rest on a pillow verses be in the sling.

As mentioned above, ice is important as well during the first three weeks. You should ice your shoulder with an ice pack for at least 20 minutes three times a day during the third week. As noted before, you’ll then switch to a combo of ice after exercising and heat to relieve aches/pains after three weeks for five minutes after the work out. This keeps swelling down and helps relieve the soreness associated with the in home or at PT therapy regimen. Speaking of the regimen, it is important you do your daily prescribed exercises. These motions have helped soften the plateaus and long term I notice improvement to the overall range of motion in the shoulder by religiously doing them each day.

When not in use I try to prop my shoulder up. The key is to get the shoulder not to slump forward. Putting a pillow under my arm while sitting watching TV helps make this happen (as noted above).

Wrecking Ball Style Shoulder Excercise

The most important thing is to not let soreness slow you down to a halt. Yes, you can rest your arm and ice your arm. You should take your pain meds as prescribed. By all means though, unless told otherwise by your medical professionals, do not stop using your arm completely. It is important to work through discomfort and to keep going despite it. There is a noticeable difference between discomfort and pain though. My movements may come with soreness or discomfort, but anything over a three on the pain meter should be noted to your medical professional ASAP. I make sure to tell my PT and orthopedist during my visits any pain no matter minor regardless though as point of habit. It’s better to be told that’s okay then to ignore something that turns out to be important.

This evening I will be taking my last Vicodin. I’m going to try to go on Ibuprofen alone. The pain meds are there to support your capabilities and again– depending on your pain threshold you may need them longer. I’ve been these past few days extending my med time interval to 8 hours to see how manageable the pain was with just the Ibuprofen. Again, this is part of the dialogue between you and your medical professionals.

I’m able to drive one handed short distances (say less than 5 miles) on one off occasions. I do so with my meds well worn off (do not be medicated and drive– it’s as bad as drinking and driving if not worse), but at this point driving with any regular ability would be impossible. I leave the vast majority of driving to my wife.

I’ve still having some trouble sleeping full nights. I don’t wake up tired, but I find that every six or so hours I wake up for whatever reason. After some laying there I manage to fall back asleep on my own. I think it may be a side effect of the Vicodin and I’ll have to see if I fair better tomorrow without being on the narcotic.

Today’s second PT session was about 30 minutes. My PT (physical therapist) spent mos of the session doing a massage on my arm while I lied flat on my back. We then did some reach forward and reach over body stretches. I then laid on my left side while he massaged my arm and then again we did some reach forward stretches. We then did some resistance work where lying on my left side I pushed back on his hand with the shoulder as he pushed against my shoulder blade. The session was minor in pain and no worse than my daily pain. Particularly sore is the back of my arm and my upper shoulder blade. That again– comes from lack of use of the joint and arm.

Deltoid Muscle Structure

This goes back to where I started. The PT massages do wonders to offset the muscle and tendon breakdown caused by the healing process. I felt at least 50% better after the massage. The PT worked hard to “break apart” the scar tissue and soften the ligaments. My PT explained he would do this again on Friday. He’s also going to consult directly with my orthopedist to develop an individual recovery plan. The light stretching and massaging will slowly over the next few weeks work into actual work outs where I put physical light effort on the shoulder. Again, my PT will coordinate that with my orthopedist to make sure the timing is correct based on the orthopedist’s recovery plan. Even on the day of PT you should do your PT at home sessions. It’s important to stick with it no matter how tired or sore you may be. Again (I must stress this) there is a difference between sore and being in true pain. If you find yourself in real pain you need to call your doctor– even if it’s dismissed better safe than sorry. The PT is a must though. The massages, stretching, and exercising off set any improper healing and keep your body’s recovery on track. Do not skip PT! There is no way I can see any one recovering on their own without it. Having said that, even with insurance it is expensive. I’m looking at about $600 for six weeks of PT in co-pays and I know by no means is that cheap, but it is worth it to heal right.

So in short at weeks three you’ll be:

Able to shower with your left arm and wash your hair. May be able to lightly wash upper body with right arm.
You’ll still have to brush your teeth and use the toilet with your left.
Able to eat briefly with right. Possibly able to cut soft meat or bread with knife. Mostly still eating with left hand.
Able to write for short periods with right hand legibly.
Short trips with an automatic vehicle (must let meds wear off). No regular trips or commuting.
Wash a few dishes.
Light sweeping.
Able to open jars, but be careful of that twisting motion and don’t over do it.
Typing on keyboard. Mouse will be moved by left arm though cause of lateral motions required.
Still sleeping with sling on. Laying flat on back propped up with two pillows.
Still not able to work or sustain long term activity.
Long walks are painful and stress the back because of shoulder “slump”. Sling helps that, but will not totally elevate the effect. Try to keep sustained activity or standing to under an hour.
Must wear sling in crowded places such as mall or supermarket due to risk of bumping into another person causing shoulder dislocation.
Everything else is done with left arm still (brushing teeth, shaving, pouring drinks, opening doors, etc…).

The hardest thing to learn left handed is (I know this gross, but I’m going to say it) wiping your hind side on the toilet. Second hardest is brushing your teeth. Everything else was pretty easy to do and able to be figured out within a few days of getting into the routine of things.

My youngest daughter (who’s two years old and about 25 lbs.) accidentally fell on my shoulder while I was lying on the bed yesterday. It stung a bit, but didn’t dislocate so it’s obviously harder to pull it out than a simple bump; but again– the risk is there so don’t do anything stupid. Stay at home. You’re still a bit crippled– don’t forget that.

I spend 95% of my day in my house lounging around. You still will most likely need to rest most the day, but you can now do so sitting up most of the day in a chair with arms to support your elbows (and ultimately both shoulders) to avoid back pain. You’ll no longer need to nap as much as you did when you were on heavy pain meds during the first two weeks. Getting 8 hours of sleep is essential so get your rest and make sure to eat right. I also have not drank alcohol for about four weeks. You really shouldn’t drink while on your meds. It also could slow down your body’s healing process.

So there is where I’m at with week three in the bag. We’ll see how things go into week four.