Friday, November 21, 2014

"be vigilant in rehab" : Ream and run - patient observations at four years after the procedure for the bad arthritic triad

Report received this week from a man who had a ream run four years ago for a particularly severely arthritic glenoid with biconcavity, retroversion and posterior humeral subluxation (Walch B2+!). Here's a video of his function at two years after surgery.

Preop films

Post op flims at 3 months

Four Year Anniversary
Hello !
I am writing to you again, on this my four year anniversary from “ream and run” surgery on my left shoulder.  I will not go into the detail that I have done before regarding what I can now do with my shoulder that I could not for some 10-15 years prior to the surgery but I will say that I just finished 4 games of full court basketball.  My left shoulder feels great and after all that basketball, I just wish the rest of my body was holding up as well as my shoulder.
Even though I was feeling stronger every year after surgery, I did have the nagging thought in the back of my mind about the possibility of arthritis returning to the glenoid joint after it had been reamed.  However, I do not ever feel stiffness in my left shoulder.  When I wake up in the morning, it feels great even after nights I somehow end up on my left side during sleep.
If I could give any of your perspective patients any advice as they ponder having this surgery, I would tell them that they must be vigilant in rehab.  Be persistent but also patient in working through those first 3 months after surgery when it feels like your shoulder is just not getting much better.  During the first 3 months, every time you begin your exercises it feels like you did not do them 2-3 hours before.  Such stiffness, but it gets better.  I would tell them months 3-6 are when they will start to see great improvement but they must stick to the program and although it’s difficult, do not do too much (although doing not enough is also not acceptable).  Exercising in the pool is the way to go!  I would also tell them to keep working even beyond 1 year as they will still see improvement.  But the best news I can tell them is that after 4 years, they can expect to feel great. 
Thank you again!  Any happy anniversary!

Three Year Anniversary.
Even though you advised me that my shoulder would never be completely the way it was when I was younger, I really think it’s about 90 or 95% there.  I just wish the rest of my body was doing that well!  LOL
My shoulder has continued to improve over the last year and for the most part, I have completely forgotten that it was once my “bad” shoulder.  For those of you with injuries, you will know what I mean in that even when an injury has healed, you “favor” that injured limb or joint for a long time to come.  For 15 years, I favored my left shoulder and had to do it more and more every year as the deterioration increased.  Being left-handed only made living with my arthritic shoulder worse.
Now three years after the surgery, I have no limitations and only my cool looking scar reminds me that I once could not use my left arm for much of anything.  My wife and I just returned from a vacation in Costa Rica where we rappelled, went zip-lining, white water rafting and also kayaked, played volleyball and tennis, hit the gym and swam.  I could have done none of that in 2010 before the surgery with the exception of tennis (but at that time I had learned to play right handed) and really limited gym work-outs.
Not much to add (see year one and two comments below) other than to say thank you Dr. Matsen and staff!  You have truly improved the quality of my life several fold and please let me know if I can ever talk to any of your prospective or current patients about the recovery they will face after surgery and the results I have enjoyed!

Two Year Anniversary.
If I was happy with my shoulder at one year after surgery, I am ecstatic after two years.  While I was able to have nearly fully range of motion at one year, over the last year I have added strength and with it more speed and quickness in my shoulder versus a year ago.  I could really see this in hitting a baseball or softball.  Improved bat speed in the summer of 2012 versus the summer of 2011 led to a great increase in power.  In basketball, I can now easily shoot from outside the three point line and in flag football, I can extend my left arm without thinking about it first, something I really couldn’t get myself to do naturally after one year.
The good news for prospective patients is that you can expect continued improvement after 1 year if you keep working on it.
In my one year summary (listed below), I did point out that my goal was to play volleyball which I have recently been able to do.  As timing would have it, I strained my Achilles tendon and it really plagued me all summer so I did not have a chance to force my son to enter a volleyball tournament with me.  However, in the Fall I have been able to play volleyball and can hit hard overhead serves and spike left-handed.  Rick, the good news here is that since I can’t jump well anymore, I do not spike very often so will unlikely stress my shoulder too much. 
Due to my sore Achilles, I worked on my throwing strength this summer.  That has come around pretty slowly.   Throwing a baseball or softball still does not cause any shoulder joint pain, but there is discomfort but mainly in the soft tissues of the shoulder (muscle atrophy).  This summer I decided to work on throwing a football instead since it felt a little better on my shoulder.  I have now got to the point where I can throw an NFL football 30 yards.  I think a year ago I could maybe throw it 15-20 yards at most.  To give you some perspective on this, I could throw a football 55 yards when I was in my twenties but was probably down to 25 yards by the time I was 35 and had to start throwing right handed by the age of 38.  It’s been a very long time since I could throw at all so at age 52, it is very exciting to me to see where I am today.  Can I get to 40 yards by my third anniversary?
Currently I try to get into the gym around 3-4 times a week and work out no more than about 45 minutes per workout, so I am really not spending a great deal of time on this but it is the consistency that I think is so important.  I also typically stretch a couple times a day as it has become a habit.  I do not do the lever/pulley stretch or the table stretch anymore but I will do the three basic rotator cuff stretching exercises especially before, during and after hitting the gym or playing a sport.  Also I regularly stretch my shoulder against a wall.
Again, I would greatly encourage your patients to get into the water.  Working on your range of motion and strength in the pool really helps bring about improvement.
Please call me if you have any questions and thank you again for making me left-handed again!

One Year Anniversary
One year ago, November 16, 2010, I had surgery on my shoulder and today my shoulder is doing great.  At 1 year, I am playing basketball, flag football, tennis, swimming, going to the gym, golfing, ping-pong and just about anything I want to do.  Some of that may not sound like much but please recall my left shoulder (and I am left handed) had very limited range of motion for around 10 to 15 years with the last couple of years being so bad I could not even play darts left handed.  I could not comb my hair left handed without support from my right hand.  I could not raise my hand more than 1 foot above my head.  Needless to say, I could not do any of the sports lift above.  I even found I could no longer bowl left-handed and golf had become too painful to play toward the last could of years. 
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.  On the exact 3 month anniversary of my shoulder, 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.  The concern I have about PT is that sometimes they want you to just keep coming back to them.  I made it clear to them that I was no stranger to the gym and was just looking for guidance.  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.

Even after month 6, I have continued to see improvement up through today.  At 6 months I was not quite at 60 feet for throwing the software.  I really wanted to be there for my 6 month survey but today I can throw over 90 feet.   My arm still feels pretty weak in terms of soft tissue when I throw (but there is no joint pain) so I am taking it very easy.   Eventually I want to play in a softball league but I want to be able to throw hard without issue before that happens.  At 6 months I was still playing tennis right handed but by month 10 I could tennis left handed including serving left-handed.  My most visible improvement is in basketball.  I gave that up 14 years ago because I could no longer shot left handed or rebound with two hands.  Today, I am playing without pain and can extend my left arm without pain or resistance.  Please note that my skill level is pretty bad but I can no longer blame it on my shoulder.

The interesting thing is that some of the planes of motion are completely better while others have come around much more slowly.  For instance I can do 12 pull-ups easily and am back to full strength for many exercises in the gym (curls, rows, tricep extensions, etc…) but I am still pretty weak when benching or doing flies (while lying on my back).  Don’t worry; I am not doing any military press or any exercises involving lifting weights repetitiously over-head.  One motion that I have not improved in is raising my left hand behind my back.  It just does not go but I have not really worked on that motion too much.

In closing I just wanted to thank you and your team again for giving me back my shoulder and increasing the quality of my life.  It has really allowed me to get back into many things that I had long ago given up.  I just can’t thank you enough and please let me know if you ever need me as a reference patient or if there is any way I can ever assist you.
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.  Interesting that many of your survey questions touch on 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 for the ordinary.  I think you need to set goals (3 month, 6 month, 12 month goals) and have a final picture of how you want things to be.  For me, my goal is to still be able to play in 2 man volleyball tournaments with my son.  I still cannot swing hard left-handed to hit a volleyball and that may not be a motion that would be recommended but I want to be able to do that.

I will keep you posted as to when that finally takes place.  The other difficult part of that equation is getting my 19 year old son to agree to do it.


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