Tuesday, March 3, 2015

How do revised shoulders that are culture positive for Propionibacterium differ from those that are not?

This article presents the investigation of 132 shoulders undergoing surgical revision of a prior shoulder arthroplasty, comparing the 66 that were culture positive for Propionibacterium to the 66 that did not culture out this organism.

The authors' goal was to identify preoperative and intraoperative characteristics that may alert surgeons to an increased likelihood of positive cultures. This is important because while many shoulder arthroplasties revised for pain, stiffness, or component loosening are culture positive for Propionibacterium, the results of these cultures remain unknown until days or weeks after surgery - too late to inform intraoperative surgical decisions and immediate postsurgical antibiotic treatment. 

The authors found that Propionibacterium-positive and Propionibacterium negative shoulders were similar with respect to many characteristics; however, Propionibacterium negative shoulders were revised sooner after the index procedure and were significantly more likely to be female, to have sustained a fall, to have instability, and to have rotator cuff deficiency. Propionibacterium-positive shoulders demonstrated more glenoid erosions, glenoid osteolysis, glenoid loosening, and a higher incidence of a soft tissue membrane between the humeral component and humeral endosteum. Shoulders culture positive for Propionibacterium were more likely to be culture positive for another bacteria, such as coagulase negative Staphylococcus.

A characteristic picture of Propionibacterium  infection is the onset of stiffness, pain, loosening and / or osteolysis after a 'honeymoon' of good function following a shoulder arthroplasty, especially in a male patient. Such shoulders may merit multiple deep cultures at the time of revision surgery and consideration of aggressive surgical and medical treatment.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Monday, March 2, 2015

Ream and run: rehabilitation tips from the super stars #18, #19 and #20

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips. There are many many more, but we'll conclude for now with these three. We hope these descriptions are helpful in conveying on one had the dedication involved in the recovery from the ream and run and on the other hand the great results that this dedication can produce.

Here's #18

Thank you for the Ream & Run procedure. I'm doing everything I want to and most importantly, doing the activities pain free. Although I'm 71 , I'm extremely active - road biking, handball, backpacking, swimming and still functioning as a pediatric dentist . The three words that best describe why I'm where I'm are patience, discipline and dedication. The healing process is long and you need to be patient and not become discouraged during the recovery. It requires lots of discipline to perform all the exercises when you sometimes don't think you're improving whatsoever. There are numerous plateaus in the total recovery process. Finally, you have to be dedicated and commit to a lifetime of exercises to maintain strength and range of motion to insure continual health of the shoulder. I know looking back it was worth it. I'm living life on my terms at least in regards to my shoulder.

JS
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Here's #19

Upon returning home from UW we followed the Physical Therapist instructions. My  raised my arm to 180 degrees at least twice daily. After a month or two I was able to do it by myself. Every morning after breakfast I would lay on my back & raise my arm to 180 degrees. As I gained strength I added weight. I kept this up for 2 years & now am able to do anything especially golf & work with no pain even to this day. My advice to anyone considering this surgery is to do the therapy religiously for best results.

RB

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Here's #20

First and most importantly was the incredible skill and surgical experience that ha been brought to the mechanics of the operation. Without that, whatever I did would have had a lesser outcome or no significant improvement of my greatly deteriorated shoulder. The skill of the repair was tantamount to the success because it created the platform for what I could do to build on that perfect foundation and rehab the shoulder.

Pain management was also a crucial component. Aggressive management of the initial trauma enabled me to meet the immediate movement protocols. I was not prepared to begin rehab within an hour from being moved out of recovery, but pain management gave me the confidence to embrace what was requested and stay with that protocol throughout my stay at the hospital. Same for my recovery and rebuild at home- not pain free, but manageable so I could engage all the exercises- initially using the cable raise, then self-assisted movement to about 150+ degrees overhead. By the way, that was a move that had caused partial dislocation prior to surgery and a position that required no small of measure of mental "bracing" to engage in.

The single element that allowed me to succeed in this replacement is simply this: I believed I had the best surgical team available; I followed every direction and completed all rehab instructions and religiously logged completion of every exercise and the time of exercise provided by the world-class physical therapy team at the medical center. Believe, Trust and Do. When it hurts- push through. It was amazing to me, that the initial prescription for oxycodone appeared to me running out before my followup exam, so I called for a refill, which arrived in the mail (paper Rx) just three days before my return to the office. I still had a couple doses left, so I filled that Rx on my visit. Because the recovery had caught up with the pain threshold, I no longer needed the oxy and could manage on the Tylenol alone. That prescription remained sealed with the red tape until I flushed it a couple of months later. The rehab protocol had taken me from surgical recovery to pain free, not even tylenol needed, by mid-November (merely 60 days). From my perspective, that's nothing less than amazing and it has changed my life. I am most thankful and appreciate everything you and your team have done to give me a pain-free life back.

RO

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Again, this is a small sample of the rehabilitation tips we have received from the many superstars. Hopefully these experiences expressed in the words of the patients is informative.


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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Sunday, March 1, 2015

Ream and run: rehabilitation tips from the super stars #16 and 17

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #16:

The success for me in being able to use my shoulders without restrictions is due to many factors. The following are my opinions on what makes for success:

-The surgeon in charge of the procedure
-The team (dedicated and motivated to make the surgery successful)
-Beginning physical therapy while coming out of anesthesia
-The motivation and determination of the patient
-The team's analysis of the situation before the event to determine if the patient is up to the challenge to do what it takes to make the procedure successful
- For me, I had to endure discomfort and to know that was part of the process; -My belief in what I needed to do and my desire to make that happen was a motivating factor to keep going -- I knew there would be a silver lining.
- Consistency and repetition. Every day keep the body parts going and religiously go through the therapy and exercises and never stop.
-I feel when you take this surgery on, fitness, movement and the motivation to use your shoulders without pain means to do what it takes to keep that going for as long as you live. This is not a short time commitment. In order to make that happen, I was more than willing to practice my shoulder therapy exercises every day - which I continue to do and believe is what has helped make this successful.
- To this day, I keep pushing the envelope because I feel stronger and my shoulders are handling the load. I always ask on my return visits if I'm doing too much and how far can I go.
- I do practice some levels of scrutiny regarding how much weight I am lifting.
- I just keep doing the fundamental therapy every day, and stay active working out. My saying "monotonous repetition of fundamental skills makes champions of us all."
- I am constantly thankful for the life this procedure has given back to me.
- Bottom line is the incredible team inspiring confidence in the patient, believing in the surgeon, and having a strong desire to make it work.

BH

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and #17

I didn't know if you or any fellow ream and runners might find helpful a few personal rehabilitation observations.

ICE...To reduce inflammation and discomfort, I kept 4-5 small reusable ice packs (5/9in) in the freezer, at all times.
For the first three months they were used for pain, after stretching, and when going to bed. After that, they were used after strengthening routines as well as after visiting the physical therapist.

ROPES VS FLOOR FOR STRETCHING....Initially, I found it very beneficial to do both. After I had pretty decent range of motion, with the ropes I found it difficult to improve without creating a pulling motion. At this point, I switched entirely to the floor. After floor stretching, my shoulder was less sore and recovered quicker.

ROTATOR CUFF PRECAUTIONS.....What I've learned about rotator cuff muscles has come at the expense of an injury during rehabilitation. Before surgery, I had routinely done bar dips in the weight room. At 15 months, my shoulder was doing great and it felt pretty much 'bullet proof'......or so I thought. Unfortunately, all it took was one simple bar dip to change things. Although not a complete tear, it was a major setback. If one looks at the recovery time chart (http://shoulderarthritis.blogspot.com/2011/03/sst-in-tracking-recovery-after-shoulder.html), it is very understandable why -  from disuse and surgery -  the cuff muscles are the last muscles to become strong again. Maximum recovery is not reached until the 30th month or 2 1/2 years. I didn't believe it then, but I do now. Be aware of exercises prone to cause rotator cuff injury: 
   1. With cuff muscles, it is also important for many months not to make any quick movements. The affected arm is weak and it is easy to drop something, accidentally. Don't instinctively reach to catch anything or you'll know it in a hurry.
2. Be careful too, getting in and out of cars. Wearing the sling is a good idea for the first 6 weeks.
3. FALLS...Be careful walking, jogging, going out after dark, climbing stairs, etc. At 4 months, I was looking for a workout and was slowly running stairs for exercise. I slipped and automatically started to catch myself on the steps. For a brief moment my shoulder lit up like 4th of July. End of workout. I dodged a bullet...just barely.

All of us feel a great debt of gratitude for this procedure. The surgery has helped us regain our active and pain free lifestyles. We all know the importance of daily stretching and maintenance. With all the time and effort that we have invested, it is our responsibility to keep our shoulders healthy. With this in mind, and with a good physical therapist, it is imperative to develop a personal maintenance program that one can stick with for the rest of our lives and most importantly, injury free. It's a small price to pay. During rehabilitation it's often hard to be patient, but now I've learned that it's not a race, either.

TF

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'




Saturday, February 28, 2015

Ream and run: rehabilitation tips from the super stars #15

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #15:

For months 0-3, I did the exercises you gave me religiously. I would do the shoulder stretch using a table and then the rope and pulley stretches 6 times a day. Sleeping was a little rough but not bad. There were times where I would wake up with pain and just go do my stretches. Please warn future patients that each time you do your stretches it feels like you have never done them before. It can seem like your shoulder will never get better and that the painful stretches you just went through 2-3 hours earlier had no benefit. But day by day, things slowly get better. One thing that really helped me was doing exercises in the pool. The water gives you both support and resistance. I was able to do things in the pool with my shoulder that I could not do outside the pool. It served both to steadily strengthen my shoulder in many different planes of movement and to provide encouragement in knowing that one day I would have the same functionality outside the pool. At one month, I was finally seeing significant improvement. On the exact 3 month anniversary of my shoulder surgery, I was able to lift my arm completely vertical over my head for the first time.


Months 3-6 were also pretty difficult but I think I was pushing too hard. My goal was to be back to 90% by 6 months but since my range of motion had been so limited for so long, I think I should have been more patient. As a result, I had a couple of set-backs with rotator cuff muscle strains but the joint has never had an issue. At that point I had a couple of appointments with different physical therapist down here in So CA. I learned from both of them to be more patient with my progress. The soft tissue in my shoulder had atrophied significantly over the past 15 years and even though some of the stronger muscles of the shoulder were ready to go, I really had to focus on doing the rotator cuff muscles exercises (doing the colored rubber band stuff) and rotator cuff stretches.


I also would like you to re-enforce to prospective patients that they have to commit 100% to rehab. You actually have to like it and must be persistent! Interesting that many of your survey questions ask about depression since I can see going through rehab does have its ups and down, but if you keep a long term focus, the progress you make can definitely put a bounce in your step. Rehab can actually give one a purpose and a break from life’s sometime same old routine. I think it is helpful to set goals (3 month, 6 month, 12 month goals) and have a final picture in your mind of how you want things to be. Also, try to measure your progress through a journal or even a video journal.

The key is to be both patient and persistent! And “YES” it was well worth it for me. One of the best decisions in my life.

SS
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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Friday, February 27, 2015

Ream and run: rehabilitation tips from the super stars #13 and 14

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

Here's #13

In terms of various shoulder replacement choices, like automobiles... I tend to think of Ream and Run as the premium, heavy-duty, long lasting, high performance model. As I look back now, coming for Ream and Run was one of the best decisions I've ever made. After initial surgery the outcome is very much dependent upon the patient. Any potential candidate must have the proper mindset ahead of time. You really have to 'earn' a successful result. An excellent recovery is not a given, nor is it fast and easy. For anyone considering Ream and Run, rehabilitation takes a stern commitment, dogged perseverance, and enormous patience. Stretch, stretch, and stretch some more. Latch on to a really good physical therapist. Strengthen gradually but prudently and then stay on a conscientious maintenance program. Fortunately, these days whether playing handball, body surfing, doing push-ups, or starting to do pull-ups again....it's all been well worth it.

TF
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and #14

Happy to send along a few thoughts on outcome of my shoulder(ream and run) surgery. Throughout the process I was struck with the notion that I was being cared for by a team of providers that worked closely with each other and communicated frequently about my surgery and recovery. I was diligent about the physical therapy and was impressed with the two therapist that I meet with twice weekly. What helped me through the process(aside from being a bit compulsive) was the post op physical therapy routine. One can't imagine how difficult it is to hold a position for a three minute stretch for 3 to 6 reps only to find out that you have more than one stretch to do at each session(recommended three times daily). What finally really worked for me was to take the pain meds 30 minutes before each stretching session. While the sessions were still painful( and I think I have a fairly high pain tolerance) the meds allowed me to push myself farther than I would have without the pain medication. This and the discovery that my new phone had a timer i could set and watch as the seconds slowly approached the 3 minute mark.

I with be forever thankful for the improvement in my quality of sleep and enjoyment of physical activities.

GE

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Thursday, February 26, 2015

Should I have a ream and run or a total shoulder?

Should I have a ream and run or a total shoulder?

This is a question that confronts many patients with shoulder arthritis. In both procedures the arthritic ball (humeral head) is replaced with a smooth metal ball (humeral head) attached to a stem that is fitted down the inside of the arm bone (shown below).




The difference in the two procedures is the way in which the glenoid socket side of the joint is managed.

In a total shoulder, the surface of the glenoid bone is covered with a plastic implant that fits the metal humeral head component and that is fixed to the bone beneath it by fluted pegs and a small amount of bone cement. This immediately gives the humeral head a smooth surface to move on – no healing of the surface is required. While range of motion exercises are necessary to achieve and maintain the shoulder’s range of motion, these exercises are not needed to shape the socket. After this procedure it is recommended that the patient avoid impact loading (e.g. chopping wood) and weight workouts (e.g. bench press) to minimize the risk of wear and loosening of the plastic glenoid component.





In the ream and run, the bone of the glenoid socket is reamed to a concavity that fits the metal humeral head component.


Persistent five times daily stretching exercises are necessary to stimulate the reamed surface (below left) to heal over with a layer of fibrocartilage (below right).


At the time of surgery, we assure that the shoulder is stable and capable of an excellent range of motion. However, each person’s healing response is different - some shoulders want to tighten up due to their body's vigorous healing response. As a result the amount of time required for healing varies, but seems to be largely dependent on the daily dedication of the patient to the simple, but critical exercise program. The most successful patients keep a calendar and check off each of their five daily exercise sessions – bringing the calendar to the office for their follow-up visit.




In many cases this healing process is well under way by 6 months after surgery, but in some cases it can take a year or longer. For some individuals these exercises seem easy, while others find them uncomfortable and at times frustrating. The key is to achieve over 150 degrees of elevation of the arm by 6 weeks after surgery and to maintain it. If this goal is not achieved by six weeks, we recommend an outpatient manipulation of the shoulder under anesthesia and muscle relaxation. When rehabilitation is complete, the patient can progressively return to use of the arm as the comfort of the shoulder allows. In this procedure there is not a need for limiting activity to minimize the risk of failure of a plastic implant. In some instances the pain relief with the ream and run is not as complete as with a total shoulder, however in many cases the pain relief is excellent.

Both the total shoulder and the ream and run procedures carry a small, but definite risk of infection from the bacteria that grow on the patient's skin. This risk is higher in male patients and in those shoulders having had prior surgical procedures.

The average patient with shoulder arthritis prefers a total shoulder because for most individuals it gives the best and most rapid relief of pain without a very demanding rehabilitation program. Individuals having this procedure can often return to swimming and golf.  The ream and run is attractive to those individuals who want to return to high levels of activity involving impact and major loads without having to be concerned about wear or loosening of the plastic glenoid socket. While it is a real joy to see patients achieve high levels of function after the ream and run, it is saddening to see some patients struggling with their exercise program. Thus, if the patient is unsure about their ability to stay motivated and dedicated to the rehabilitation program, we counsel the patient to have a total shoulder. The question comes down to how much the patient is willing to dedicate to a possibly difficult, five times daily rehabilitation exercises in exchange for avoiding the potential limitations in activity needed to protect the plastic socket. Often we get a question like "I desire to restore a more normal movement of my shoulder, reduce or eliminate pain and be able to keep riding my off-road motorcycles through the many trails in the Southeast US.   Could the R&R procedure accomplish these goals for me?" The answer is, "no' the ream and run cannot accomplish these goals by itself, but a solid rehabilitation effort after a ream and run procedure can often lead to great shoulder function and improved comfort. In considering this procedure, be sure to read the posts entitled "ream and run: rehabilitation tips from the superstars" to get an idea of the level of commitment.





Ream and run: rehabilitation tips from the super stars #10, 11 and 12

We've invited some of the folks who have done a great job of their rehabilitation after a ream and run to share their tips.

#10

I think the most important part of my recovery has been my frame of mind. I thought very hard about getting this surgery, and I knew one thing was for sure. The recovery is going to take me 2 years. The first thing you said to me after surgery was “I am sorry.” You explained that my shoulder was in such a deteriorated state that you had to make the “joint” extremely tight. That told me that I could expect possibly a longer recovery than many of the patients I have read about.

Ok---so, that’s it----I have 24 to 26 months of recovery time. I keep that in my head at all times. It’s important to understand where you are and where you are going. If I were to lie to myself, and expect a full recovery in 1 year or 16 months I would be setting myself up for disappointment. Knowing my timeframe has allowed me to be at peace with the negative effects of that---I will lose a lot of weight, I will lose muscle mass, my cardio will suffer, etc. But, all of that will come back, focus on why we are here---focus on getting the shoulder better. That has been my psyche.

Milestones I have reached during year 1:

1) Ran a 10k 7 months after surgery. That may not sound like much, since that has nothing to do with my shoulder. On the contrary---until months 4-5 I could not jog, I could not go up/down stairs without the pounding hurting my shoulder. I was not able to pump my arm as much as I should, but, I ran the entire race with zero pain.

2) Played tennis 6 months after surgery. I will not say it was all that pretty, but, it was legitimate. I was hitting the ball mostly with a two handed grip, but, often used a single hand grip effectively

3) Played in annual Turkey bowl 9 months after surgery. No doubt the guys took it easy on me! I was very timid when it came to extending my arms straight out to do any kind of blocking, but, I was able to make many catches, with extended arms. Again---not all that pretty, but, since I had to sit out of last year’s game because the pain prior to surgery was too much, I am happy.

4) Push-ups—Ok, these go on the good and bad list. I am able to do 30 push ups-with my knees down. That is on the good list, because as of 3 months ago, I was only able to 3.

5) Just finished round one (5 weeks) of a cardio/plyo program called T25. A lot of jumping, and moving of the arm. It’s not pretty, but, I am able to do the majority of the moves-including some very slow and controlled straight arm burpees .

Things I did not expect:

1) The pain/tightness in my bicep area is sometimes more limiting and painful than the shoulder. That has been much better lately.

2) Pushup’s/ planks---I was not expecting the pain to still be around at year one. There is still a burning sensation while doing these moves, but, that is also improving. Example---I just did a 2.5minute plank followed by 30 pushups. Sitting in the plank did not hurt the shoulder, but, when I release from the position it hurts.

3) Mornings! Ugh---mornings stink for me. I like to exercise in the am, but, right now, the arm is so sore, and fairly useless first thing in the morning. Once I shower and stretch it loosens up

4) Beware the handshake—a powerful handshake could still bring you to your knees

Goals for year 2:

1) Legitimate push ups

2) Legitimate throwing of a ball. I am able to throw now, but, it’s not pretty!

3) Adding in a weight training program

4) Continued ROM improvement

If I can give any advice to prospective patients:

Rehab stinks, both physically, and mentally----be stronger and overcome any negativity---it has no place in this arena

Famous words from the surgeon---“it’s about reps, not weight”. If you can only do 5lbs db presses, stick with that for as long as you need---what are you gaining from struggling with 10lbs? That is what got us in trouble in the first place---we start to overcompensate, form suffers, and for what? You are not gonna get jacked, buy pressing 10lbs anyway----relax, and take your time----you have 2 years!!

Use your arm---do not shy away from doing everyday things with it. I suffered from this for many months. I have found the NYC subway to be a great place to stretch---Getting dressed, brushing hair, teeth, showering, putting things back in refrigerator, etc. I sit on a train for 4 hours a day----and if I do not move the arm during that time it will freeze up----my mantra (ABS----Always Be Stretching)---I do many stretches at work---I have a band attached to my office door and use it throughout the day----Use the arm! That is why we went with Ream and Run and not the replacement….

I am not a success story yet! But, I will be.

AI
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# 11
I believe motivation and an ongoing commitment to physical therapy were key elements to my speedy recovery. As for my motivation: My goal was to return to playing senior softball, within 6 months following my surgery. I accomplished that goal. How? From the day of my surgery to the present time, I do my shoulder exercises every day. One very helpful aspect of my recovery was having someone available, from day one, to help me lift and stretch my arm into the position over my head. In the first several days following surgery, it’s quite difficult to do this stretching on your own, and therefore could be ignored. Because of this help, I was able to increase my range of motion much more quickly. After a couple of weeks, of physical therapy, I learned many more exercises and continue to perform them daily.

Thank you so much for helping me regain my strength and range of motion. My softball buddies thank you too!

BB

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#12
I am so pleased with the procedure words cannot describe. I had asked you and your team to fix my shoulder so that I could return to a somewhat normal life. I have surpassed that by miles. I am totally pain free and have 95% of my flexibility. The 5% being the high middle of my back ( I bought a back scratcher).

The best advice I have for anyone that does the Ream and Run is to treat therapy and exercise like a good paying job. Stay on it relentlessly everyday and collect the rewards. I was told that if it hurts don’t do it. Unlike when I was in high school “no pain no gain” was the mantra. I did my exercises everyday as I was told and I could feel and see the results just as often. I am now playing catch with my son, playing hockey, riding snow mobiles, shoveling snow, raking the leaves and I even split over a cord of wood by hand from trees I cut down in our yard for our fireplace.

LG
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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'