Thursday, February 28, 2019

(Zen and) The Art of Rehabilitating a Shoulder - Part one, stretching

Writing this reminds us a bit of this book, which may be known to some of you more senior readers. In it, the author explores the meaning and concept of "quality" a phenomenon that exists between the subject and the object. You'll have to decide whether you prefer the "classical" or the "romantic" approaches that he describes. Here is our "classical" approach to the rehabilitation of most of our total shoulders, ream and runs, cuff tear arthropathy arthroplasties, and hemiarthroplasties.

This rehab program is based on the tenet that the "patient is the method": the patient is the "subject" and the shoulder is the "object". The success of the program will depend on the patient's dedication to it and on the patient's willingness to experiment a bit with the art to see how many repetitions, how much resistance, and what pace of progression works best.

We will assume that the goal is excellent function and that there are no special considerations based on the findings at surgery or on the specifics of the procedure performed. We do not use this approach for reverse total shoulders and, on occasion, need to modify it for anatomic total shoulders or ream and run procedures. Don't even think about launching on this program after an operation without reviewing it in detail with the surgeon.

 We use several "rules of thumb" for our stretching exercises - best done five times a day and best done with a one minute hold at a point just beyond the comfortable range of motion using the opposite arm for power while the rehabilitating arm is relaxed. The goal is to gain a few degrees each day, starting the evening after surgery.

Stretching in flexion. Here's a goal for six weeks after a usual anatomic shoulder replacement

Check progress by lying on a flat surface and having someone take a photo from the side so that you can measure the angle with a protractor

 or goniometer.

There are three exercises that are useful in getting this range of flexion after a joint replacement (demonstrated by one of our ream and run rock stars).

(1) Pulley (often the easiest)(see this youtube)

(2) Supine stretch (see this youtube)

(3) Forward lean (usually the most effective)(see this youtube)

In most cases it is also important to stretch the posterior capsule.

There are four exercises that are helpful in achieving this goal

(4) Cross body adduction (see this youtube)

(5) Reaching up the back (see this youtube)

(6) Sleeper stretch (see this youtube)

(7) Sideways lean (see this youtube)

We specifically avoid stretching in external rotation for the first 3 months after a shoulder joint replacement for reasons explained in this link. In situation where external rotation is deemed appropriate, it can be performed as shown here

(8) External rotation stretch AVOID For three months after a shoulder arthroplasty!

In our next post, we'll talk some about strengthening.
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

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