Friday, April 20, 2012

Shoulders and fly fishing anglers

Practicing shoulder surgery in the Pacific Northwest, we get the chance to meet a wonderful variety of outdoors people who become limited in their ability to enjoy climbing, skiing, kayaking, diving, windsurfing, sailing and, of course, fly fishing. 

On the drive over to the Yakima for a wonderful day of dry fly fishing, I had the chance to reflect on some recent encounters with avid devotees of this remarkable activity. Before I tell you their stories, there are some common features to be recognized:
(1) These individuals are steadfastly dedicated to fly fishing, and would rather stand in a river waiving a rod than eat
(2) These individuals are in the prime of life (i.e. they are all 60 and over) 
(3) They came into the office because their shoulders limited their ability to cast and/or land fish.

The important fact is that the shoulders of folks in this age group are at risk for shoulder stiffness, weakness, pain and loss of function from two principal causes: osteoarthritis and rotator cuff wear. Fortunately, limitations from these conditions can often be reduced by gentle range of motion exercises. Just as the use of barbless hooks and avoiding handling of the fish can prevent attrition of trout and steelhead in our rivers, gently stretching the shoulder before and during a day of fly casting is a great way to keep the joint limber and comfortable and to prevent shoulder problems.

Meet Angler A,  70 year old adventure guide for fishing and diving around the world. The problem here was mild arthritis and stiffness. The symptoms greatly improved with a minor smoothing procedure and lots of mobilization exercises.

While folks under the age of 60 may tear their cuff tendons with a fall, those of us more senior than that can wear, thin or tear the rotator cuff tendons with lifting an anchor over the side of the boat or in getting the canoe off the car top carrier. Keeping the shoulder flexible, being thoughtful about lifting, and getting help with heavy things can be useful preventative strategies. 

When the rotator cuff tendon is acutely torn from a sudden injury, surgical repair is a strong consideration. However, when the cuff fails progressively over time without a definite injury, stretching exercises may help resolve the symptoms. If the shoulder remains painful, a 'smooth and move' procedure often makes the shoulder more comfortable and functional without the long rehabilitation from a rotator cuff repair. Not infrequently we meet anglers over the age of 60 who have had a surgical attempt at rotator cuff repair, only to learn that the rotator cuff tendon tissue was not good enough for a solid repair and to fail to improve after surgery. Perhaps surprisingly, a smooth and move procedure can often restore substantial comfort and function, even though the integrity of the rotator cuff is not restored.

Meet Angler B, a 69 year old avid spring creek fly fisher and author from Montana having had two previous attempts at rotator cuff repair with a painful clicking and weak shoulder. The MRI (shown below) shows lack of tendon healing. If the shoulder does not improve with range of motion exercises, a smooth and move procedure will help get the shoulder ready for the planned angling trip to South America.

Individuals over 60 not uncommonly have lost some of the cartilage that normally provides a smooth bearing surface for the shoulder joint. This 'wear and tear' arthritis can cause stiffness, pain and loss of function. Once again, gentle home exercises can often temper the symptoms and prevent progression of the condition.

If symptoms become severely limiting of the quality of living, surgical reconstruction in the form of a ream and run or a total shoulder can be considered.

Meet Angler C, a 68 year old steelhead guide, who lives on the bank of one of Oregon's most famous rivers. Arthritis of the shoulder took the enjoyment out of spey casting (see the loss of joint space in the joint on the x-rays below. Alongside the shoulder is a pacemaker, keeping his ticker ticking).

Exercises improved his condition, but not enough, so he proceeded with a ream and run procedure (shown below) which has him back on the river.

Let us end with a perspective provided by Robert Fulghum in It Was on Fire When I Lay Down on It

"The River-Runner's Maxim, taught to me when I was learning white-water canoeing from friend Baz, a maximum pro: "Sitting still is essential to the journey." When heading off downriver, pull over to the bank from time to time and sit quietly and look at the river and think about where you've been and where you're going and why and how. "

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