A young athlete presented with the following history. "I am 31 years old. I’ve been having shoulder problems since I was around 16 years old. I had torn my posterior labrum pitching in baseball. At that time I was advised that surgery was not necessary since shoulder was not hurting. Over the next 10 years I did more strenuous shoulder activities: weight lifting, golfing, football, etc.
In 2015, I was already having a severe difficulty raising my arm, I got into a motorcycle accident which made things even worse. After the accident, I was advised to have arthroscopic posterior labrum slap tear surgery. Now in 2020, I have increased pain/pressure in my shoulder."
At presentation, he had a painful stiff right dominant shoulder and these radiographs showing advanced glenohumeral arthritis. The axillary "truth" view shows posterior decentering of the humeral head on a B2 glenoid with posterior bone loss.
Because of his young age and desire to return to sports, he elected the ream and run procedure. The procedure was performed under general anesthesia. On the first post operative day he had full assisted flexion and was taking only Tylenol for comfort.
He vigorously pursued the rehabilitation program (see this link). He sent frequent videos of his progression. Here are a few still shots of his function at six months after surgery.
1) First and foremost sticking religiously to your stretching regimen since the first day of surgery was essential. Without that the recovery would have been extremely difficult. I think that because I was so amazed I could stretch again, I didn't see the stretches as a difficult/arduous task, but rather it was fun to push my shoulder through the stretches. I was looking forward to some stretches especially the pulley workouts - each stretch I did I tried to get to full extension or 180-degrees. I am actually still doing that now whenever I casually stretch (not with the pulleys – just natural arm raises and reaches).I don’t quite get to 180, but I am still trying!
2) Swimming - I wish I had done this more because it would have been the single best rehabilitation exercise. The times that I did swim - my shoulder was really able to stretch and function nicely. At first, breaststroke and crawl/freestyle were painful and impossible - I could not swim. When that happened I went to the hot tub and performed breaststroke until it mildly hurt. I particularly like hot tubs and how my muscles feel there so it made perfect sense to take the swimming strokes to the hot tub. On top of that I didn’t feel like I had to stay there for an hour so it became 10-15 minutes of focused swimming stroke training in hot water. Perfect for me – comfortable and short work out. In the hot tub my intent was just to have my shoulder do the swimming motions and pull enough water to activate the stiffness/tenderness in my shoulder. If I swam and then did this daily, my recovery would have been much faster - Unfortunately I just don’t like to swim – but I do like to bike.
3) What I believe helped me most was cycling. I cycle 7 miles a day commuting to work (round trip). On the surface, cycling as supposed to kill two birds with one stone - I was able to get blood flow through the joint by riding quickly, and I was able to train my shoulder stability by adjusting the pressure I put on the handlebars. Additionally, the ride was not too long nor stressful so it was just the right amount of time my shoulder needed under pressure. I constantly rode feeling out places where my shoulder was unstable/mildly hurting and made it a point to focus on those areas while I cycled. This was something I did in all modes of the rehab. When I stretched, reached for cups, or the remote, I would feel out the stiffness and take a few minutes to work it out and push through it gently. I became very familiar with my stiff points until they became unstiff. What I didn't realize about cycling was that I would be building shoulder strength when I was off the bicycle by simply walking the bike at my side. At first my shoulder was completely incapable of performing this task – if it leaned into me at any angle the bike would fall to my hip (painless for my hip, but painful for my shoulder) - my shoulder failed to support it. I then had to lean into the bike to raise it upright or use my other hand to assist it upright. This immediately became another short term goal of mine - supporting the bicycle as I walk it at my side with limited pain from my shoulder. Mentally, I couldn't be the weak link that couldn't support his own bicycle so this naturally was a short term goal. Another part of my work commute includes catching the train with my bicycle - so I again get to train my shoulder walking the bicycle at my side. Also, to access the train I have to take stairs/escalators. It would be easier to sit the bike on the escalator or elevator, stand and ride the machine up - but that takes too long and I like to be on the go and I am not patient enough to stand in one place when I could be moving. So I was forced mentally to train my shoulder in hoisting my bicycle on my right shoulder. (I could not use my left shoulder because the center gear would have made my clothes black with gear lubricant before arriving to work). I carried my bicycle up on my shoulder up the stairs - Twice Daily - 5 days a week. At first this too was impossible, I couldn't lift the bicycle so I had to use my left arm to assist in hoisting the bicycle on my right shoulder. The practice of then removing the bike from my shoulder was painful/sore as well, however it was key to slowly building the muscle/resistance needed to perform the task of eventually raising the bicycle to my shoulder. I could not be the weak link who couldn't lift his bike to his shoulder so this became another goal of mine. Cycling was not only good for bloodflow/stability training, but it forced my shoulder muscles to undertake tasks similar to what you had outlined in your program - it just was a bit more fun and challenging to do with the bicycle. I can compare the act of supporting of the bike at my side to the act of pushing out against the wall at my side - very similar exercises, except holding the bike at your side also trains your muscles to perform precise movements rather than just strength building.
4) Going to the gym every so often was godo but I wouldn't say it was extremely helpful for me early on. In fact I would try to limit the gym until late in the process – it can easily be replaced with swimming/cycling for me. When it comes to my shoulder, my body is a little different than most. The less force I put on my shoulder, the more naturally flexible it becomes. I had learned that from my first surgery, however I thought it would be different with the ream and run. Early on I was very worried about building strength in my shoulder so my goal was to 15-30 reps of using very light weights with the recommended workouts. However, I found that my shoulder became too tired and stiff consistently. So I thought let me just relax it, and stretch plenty more than I lift weights. I began to go to the gym once a week at maximum (I was already working it out cycling and walking my bicycle daily) – My arm began to take on natural movements quickly as a result. When I visited the gym consistently again, those natural movements became difficult so I knew working out fully was not in my body's playbook. That's when I let Physical Therapy sessions handle the strength training aspect of my recovery. The best thing I got from physical therapy was the massaging followed by the stretching they performed on me - and I believe this is what helped me the most with regaining strength. My recommendation for strength training (for my body) is to be very mild with resistance training until you have reached a point where you are extremely comfortable with your flexibility and find a way to have consistent massages and deep stretches. Younger patients will benefit from this most because it is much easier for them to regain strength. My body builds muscle quickly, however the goal early on was mobility. I knew that there was no purpose in having the strength if I didn’t have the flexibility, so my mind was centrally focused on having maximum flexibility first and foremost. The Gym was a distraction to that, but it would be something I needed later on.
5) After Months 12-ish I started back in the gym with a little more consistency – still weak but able to the workouts and not be stiff. I began doing upright rows, curls, lawn mowers, lat pull downs – all with light weight and high reps. When I did certain workouts I noticed my shoulders were uneven and my right shoulder was cheating in the workouts so I made it a point to make the weight light enough so I could do the workouts while keeping my shoulders even throughout the workouts – this meant using extremely light weights because the work out was not about lifting, it was about pushing through the tightness of the shoulder and building out those small muscles that you used during routine motions. I did not want my shoulders to cheat workouts either – I always prefer to do the workout correctly with no weights than incorrectly with weights. Eventually I was able to do these workouts with a little bit of weight and still maintain square shoulders during the workouts – that is where I am now and slowly increasing the weight. I still cannot do a clean pushup, but I can do clean pull ups. I can run without pain in my shoulder and I can cycle without pain in my shoulder. Hoisting my bike on my shoulder is now painless as well. I believe a lot of the success I’ve had with this shoulder is from the mental side of things. I constantly challenged myself to maximize the stretch routines that you had given me, make sure my shoulders were square while resistance training, and work out any points of weakness/struggle when I found them. Additionally, because I had to bike to work I was blessed with an ideal mixture for a successful rehabilitation. I still find tightness/stiffness and I still work them out for a few minutes just to ensure no stone is left unturned.
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Here are some videos that are of shoulder interest
