Ream and run - a great demonstration of rehabilitation exercises

A man in his early 50s presented with a very stiff and painful left shoulder and these x-rays.

 He elected a ream and run procedure at which time we performed extensive soft tissue releases and used a thin humeral head component to optimize his flexibility.

At two weeks after surgery he sent a series of videos, which provide a 'text book' on post ream and run rehab. He generously offered to let us reproduce them here.

The supine stretch

The forward lean

The pulley in flexion

The pulley in abduction

External rotation to zero degrees

The sleeper stretch

External rotation isometrics

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

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

How you can support progress in shoulder surgery

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

Simple shoulder exercises = the road to recovery

Many shoulder problems will respond to a gentle, safe and slowly progressive exercise program that starts with a focus on range of motion and then progressively adds strengthening as comfort allows. Our rehabilitation program is intentionally quite simple and uses minimal equipment. This avoids confusion and enables our patients to perform them just about anywhere. We often use these exercises for the non-operative management of various shoulder conditions as well as in preparation for surgery and in different stages of post-surgical rehabilitation.

The exercises are shown here for illustrative purposes only. Be sure to consult your treating physician to see what exercises may be appropriate for your shoulder.

For stretching exercises, be sure to hold the stretch for a full two minutes.

*Exercises to help gain passive elevation of the arm.

    A. Forward Elevation: Supine

    B. Forward Elevation: Over Door Pulley
    C. Forward Elevation: Forward Lean

*Exercises to stretch the posterior shoulder

    D. Cross Body Adduction

    E. Internal Rotation Up Back 
    F. Internal Rotation Lying On Your Side 

*Exercise to stretch the shoulder out to the side

    G. Abduction stretching - the sideways lean

*Exercise to build strength of the shoulder

    H. Supine Press with Progressive Incline 
    I.  Activating deltoid by controlled descent with pulley

*Traction exercises

   J. Rowing Machine Exercise
   K. Pull Down Bar Exercise 
   L. Weighted Arm Swing

* Cautions about exercises after joint replacement

    M. Exercises to avoid are shown here.

    N.  Rehabilitation after shoulder arthroplasty - protect the subscapularis!

University of Washington Shoulder Rehabilitation Videos.

Click here for a quick summary of the material above

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

Supporting progress in shoulder surgery

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'

Ream and run for a decentered arthritic shoulder - progress report at one month

A month ago we had the opportunity to see an active man from Hawaii with shoulder pain and stiffness and these x-rays.

 Note the posterior decentering of his humeral head on the axillary 'truth' view.

He elected a ream and run procedure. His post operative x-rays are shown here.

Note the centering of his humeral head on the conservatively reamed glenoid.

Yesterday he emailed this progress report that contains some helpful observations.

"Hi

Things are going well at 4 weeks and one day.

A couple of days ago I noticed that my stretching sessions were much easier if they were done closer together. Yesterday, I started doing them essentially once per hour during my waking hours and, in general my shoulder is much looser all the time. I spoke to Sarah about this today.

I’ve got four stretches I’ve been instructed to do (see this link): 

1) The guided overhead reach while laying flat

2) Over door pulley

3) Tabletop Drop down slide

4) Assisted External Rotation to neutral

#1 I do most often since it is the most difficult/painful and I therefore presume I’m getting the most from it.

#2 I sometimes alternate with #1

#3 I do when I’m out and about somewhere and it is inconvenient to lie down someplace

#4 isn’t a stretch since I can get there without feeling anything so I really don’t bother with this one.

When I started stretching hourly (vs 5 sets per day), I don’t have to psych myself up to do #1 since it hardly hurts to do at all.

I’m using Ice and 800mg doses of Ibuprofen to manage inflammation and aching." 

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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

Information about shoulder exercises can be found at this link.

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'See from which cities our patients come.

Be careful of the rotator cuff after shoulder arthroplasty

One our concerns is that patients may stress their rotator cuff after shoulder arthroplasty. It is important to keep in mind that in the arthritic shoulder, the rotator cuff is disused. After shoulder arthroplasty, the joint is freed up and mobile, but the cuff is not ready for heavy use and is at risk for failure as observed here.

The web is wonderful, but it may tempt folks to exercises that are not ideal for their shoulder situation. The following exercises sent to me by one of our patients are NOT recommended after shoulder arthroplasty.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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

Information about shoulder exercises can be found at this link.

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'See from which cities our patients come.

The table slide - the key to gaining motion after the ream and run

Our favorite shoulder therapist says, 'motion is lotion'. Some of our joint replacement surgeries require lots of lotion. 

One of our recent patients (a martial artist in his mid fifties) schooled us on the table slide exercise. Here he is demonstrating four weeks after his ream and run.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

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

Information about shoulder exercises can be found at this link.

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'See from which cities our patients come.

Non-operative treatment of shoulder arthritis with posterior decentering (subluxation)

Today this email came in:

"We met several months ago. Dr. X had recently completed a cortisone procedure on my left and arthritic shoulder. As I recall when you analyzed my x-ray you noted that my humerus bone was posterior in the socket and as a consequence mobility was restricted and plenty of crepitus based on the the bone moving in the unintended part of the socket. Irrespective of the type of initial dislocation you explained that the bone is mis-placed and remains there (due If guess to the composite if all existing forced from damaged/weak muscles, tendons, etc). You offered to try to respond by email to follow-up questions that I might have.

I'd like to learn exactly which physical exercises might rebuild or retrain my physiology in such a way that the bone would find a new and better equilibrium in its socket (that enables improved mobility and less bone-on-bone wear that is undoubtedly taking place). I would like your advice or referral of a therapist with solid experience relating to shoulder anatomy and damage. For the most part I've only encountered PTs who described standard exercises that offered negligible value. They had no regard to exact status of my condition and had no ability to develop a treatment trajectory that would be optimal.

I look forward to your thoughts."

Comment: Posterior humeral decentering (subluxation) is a common feature of glenohumeral osteoarthritis

Once the glenoid develops a pathologic posterior concavity, the humeral head tends to fall into it when the arm is elevated to a functional position as shown in the three 'truth views' above. The deeper the posterior concavity, the less likely it is that exercises can help.

For early stages of arthritis, we recommend avoiding pushups, bench presses and other pushing exercises while focusing on external rotator strengthening so that the posterior rotator cuff muscles can help resist the tendency for the shoulder to slide out of the back of the joint. See below

as well as stretching exercises to minimize stiffness (see this link). We do not use steroid or other injections into the shoulder joint.

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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 run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.

See the countries from which our readers come on this post.

How do rotator cuff tears influence shoulder motion?

Scapulohumeral rhythm relative to active range of motion in patients with symptomatic rotator cuff tears

These authors studied 14 patients with rotator cuff tears and 14 healthy individuals with 35 reflective markers on the trunk and upper limb tracked by an optoelectronic system to measure the scapulohumeral rhythm (the ratio of glenohumeral to scapulothoracic motion in arm elevation) while the subjects carried out 5 comfortable scapular plane maximal arm elevations. They found a value of 3.9 for healthy controls.

Patients were separated by maximal arm elevation of 85° (category A) and 40° (category B). 

The mean scapulohumeral rhythm ratio during arm elevation was 2.8 for patients in category A; these patients  had a relatively consistent pattern as shown below with much lower values than controls (that is relatively less glenohumeral movement and relatively more scapulothoracic motion).  

The patients with only 40 degrees of active motion (Group B) had widely varying patterns of motion as shown below

The authors concluded that patients who reached at least 85° compensated for the loss of glenohumeral motion by increased scapulothoracic contribution.  In contrast, patients who had less active range of motion had less contribution from scapulothoracic motion.

Comment: This study demonstrates that some patients with cuff deficiency can compensate by increasing the scapulothoracic contribution to active motion. There were only seven patients in each group and we are not presented with the cuff tear sizes in the two groups.

In our management of individuals with chronic cuff tears we encourage them to try a simple exercise program that encourages use of both the glenohumeral and scapulothoracic musculature (shown below)

It is interesting that some patients sent to us for consideration of reverse total shoulders because of apparent pseudoparalysis are able to regain substantial function with this simple exercise.

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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

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Rehabilitation after shoulder arthroplasty - cautions!

A key to success after shoulder replacement for arthritis is the post operative exercise program. Click on this link: rehabilitation program to see our usual approach, although this may be modified in certain circumstances.

One of the key facts to keep in mind during the first 3 months after shoulder joint replacement is that the subscapularis muscle is cut off the front of the humerus early in the surgical operation to gain access to the joint. In the figure below, the subscapularis has been retracted to the right with two sutures.

Near the end of the case, repair sutures are placed through the bone.

Once the humeral implant is in position, the subcapularis is repaired to the previously placed sutures.

Although this repair is usually strong enough for Phase I of the early motion program, advanced healing of the repair is necessary before the shoulder can be stretched in passive external rotation or strengthened in active internal rotation. For this reason the two sets of exercises shown below are AVOIDED. 

EXTERNAL ROTATION STRETCHING  

INTERNAL ROTATION STRENGTHENING

 Our resident Zlomislic (see this link) demonstrated that the tension is not evenly distributed across the repair sutures and that the superior suture takes the preponderance of the load in the activities shown above - activities that put it at risk of pulling through the tendon.

One our concerns is that patients may stress their rotator cuff after shoulder arthroplasty. It is important to keep in mind that in the arthritic shoulder, the rotator cuff is disused. After shoulder arthroplasty, the joint is freed up and mobile, but the cuff is not ready for heavy use and is at risk for failure as observed here.

The web is wonderful, but it may tempt folks to exercises that are not ideal for their shoulder situation. The following exercises sent to me by one of our patients are NOT recommended after shoulder arthroplasty.

The safest exercise program is shown here.

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

Click here to see the new Rotator Cuff Book

Check out the new Shoulder Arthritis Book - 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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Rotator cuff tears - can an exercise program improve the workings of the shoulder?

Effects of exercise therapy for the treatment of symptomatic full-thickness supraspinatus tears on in vivo glenohumeral kinematics.

These authors investigated the effectiveness of a 12 week exercise program in improving kinematics (smaller translations and increased subacromial space) and patient self-assessed comfort and function.

The five subjects (3 women and 2 men; mean age, 60.2 ± 7.6 years) with a symptomatic small, degenerative full-thickness rotator cuff tear isolated to the supraspinatus tendon and a greater percentage of supraspinatus muscle than fat (Goutallier grade 2 or less) . Dynamic stereoradiography system was used to determine the glenohumeral translation during abduction in the coronal plane.

After therapy humeral translation on the glenoid was reduced as shown below for a single patient before therapy (left) and after therapy (right). The contact center is represented by a black circle, and the path followed by the contact center throughout the range of abduction is represented by the white line. 

Clinical parameters were also improved

Comment: This is a small series providing some encouragement for the non-operative management of degenerative rotator cuff tears. When the cuff tear is not acute, it is reasonable to offer the patient a rehabilitation program to see if they are satisfied with the results. 

We have observed that the some of the deltoid and residual cuff muscle weakness observed in patients with chronic cuff tears is due to disuse and is reversible with gentle progressive strengthening. Similarly, the stiffness that can be limiting for individuals with chronic tears can often be lessened by a gentle progressive strengthening program. This study excluded patients with 'severe capsular tightness', yet these may be some of the best candidates for non-operative treatment.

Finally, it is reasonable that a period of 'prehabilitation' before cuff surgery may be helpful in conditioning both the shoulder and the patient.

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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

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'

See from which cities our patients come.

See the countries from which our readers come on this post.

An experienced ream and runner's comments

This man achieved a perfect result on his first ream and run ...

and came in for his second side. He had some advice for future patients on pre-surgical exercises:

Hard to argue with the result:

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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.

See from which cities our patients come.

See the countries from which our readers come on this post.

Careful of the cuff after shoulder arthroplasty!

One our concerns is that patients may stress their rotator cuff after shoulder arthroplasty. It is important to keep in mind that in the arthritic shoulder, the rotator cuff is disused. After shoulder arthroplasty, the joint is freed up and mobile, but the cuff is not ready for heavy use and is at risk for failure as observed here.

The web is wonderful, but it may tempt folks to exercises that are not ideal for their shoulder situation. The following exercises sent to me by one of our patients are NOT recommended after shoulder arthroplasty.

The safest exercise program is shown here.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link.

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

Click here to see the new Rotator Cuff Book

Check out the new Shoulder Arthritis Book - 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'

See from which cities our patients come.

See the countries from which our readers come on this post.

Living well with arthritis

In spite of the many great advances in the medical and surgical management of arthritis, some residual loss of comfort and function may remain. Thus the opportunity is to learn strategies for living well with arthritis.

We have assembled some information that may be useful to patients for managing their arthritis

Lifestyle

  College and arthritis

  Diet

  Family

  Fatigue

  Frequently asked questions about arthritis

  Frequently asked questions about living with arthritis

  Joints

  Laboratory tests

  Pain

  Pregnancy

  Sex

  Stress

  Travel

  Using joints wisely

  Vocational rehabilitation

  Work

Exercises

  Exercise

  Exercise videos

  Water exercises

Medications - the good and the bad
  Arthritis Foundation Drug Guide
  Medications and joint replacement

Unproven remedies

Related conditions
  Back Pain
  Carpal Tunnel Syndrome
  Diabetes
  Fibromyalgia

The Arthritis Foundation
The Arthritis Foundation - Washington/Alaska Chapter

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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.

See from which cities our patients come.

See the countries from which our readers come on this post.