Recovering from shoulder surgery

[Bond007]

On November 13, 2003 I had surgery on my left to correct SIS (Shoulder Impingement Syndrome....yet another acronym) caused by a hooked acromion. My doc just recently released me from physical therapy and advised to stat rebuilding strength in the shoulder. My concern lies in the fact that my body tends to heal rather quickly and I produce an overabundance of scar tissue. I found all this out when I had my right shoulder fixed (due to the same reason) 2.5 years ago and had to have it operated on a second time to remove excessive scar tissue.

I want to avoid building up too much scar tissue AND a possible second surgery. My orthepedist is highly aware of my tendancy and really worked hard to keep me held back during the last 8 weeks. I'm wondering if any you are aware of a supplement I could take that would help to inhibit the scar tissue growth.

I start lifting again last night, and I used extremely light weights. The shoulder is tender this morning, but not painful as it would be from the SIS.

If the scar tissue build-up is inevitable, Im interested in learning about non-surgical options for breaking it up.

Thanks!

[Bond007]

Uh, the word "shoulder" should have been in that first sentence....And, sorry for all the damn typos! Too many interruptions whilst typing.

[Bill Hartman]

First unless bryanc has something up his sleeve, you'll not find anything worth your while to prevent the formation of new tissue. Nor would you want to really.

The tissue should remodel based on the stresses that you apply to the shoulder. Try to come back too fast, and you'll probably experience your "too much scar tissue" problem from causing repeated trauma to the shoulder.

I think it's an interesting surgical perspective when they tell you that the cause of your shoulder impingement is the shape of your acromion. Unless you have some sort of bony change due to some form of stress applied the acromion, your shoulder has pretty much been that way since you reached adult skeletal structure. Why would a "hooked" acromion be a problem now? Perhaps is more related to your stabilization strategy? Isolated weakness in the scapular stabilizers? Poor training protocols? A flexibility issue?

That means there's got to be a mechanical/coordination issue that precludes the impingement.

My experience in the clinic is that the surgeons like to do what they do (cut on people) in their attempt to fix things. Well you can certainly cut things that seem to be the issue, but the coordination of muscles/movements and strength-related issue that may actually be the cause are not addressed.

Anyway, not much you can do about that after the fact and don't be concerned about that now. I'm sure you'll be fine. Just keep it in mind for future reference.

For now, follow the "Statute of Fitness Limitations" (see the post of the same name). If I were you, I would try to avoid as much soreness as possible during, after, and next day. You may still have THE mechanical problem that promoted the impingement in the first place. The no pain, no gain thing does not apply here. Don't try to work through the soreness.

Did they D/C you from therapy with any functional progression to return to training (are they even aware that that was your intention?)?

What exercises did you do in your first training session?

Do you have full pain-free range of motion in all planes (can you reach behind your back comfortably)?

Where was the soreness?

Bill

[Bond007]

In all the years that I've been training, I've always experienced a "popping" in both my shoulders. And, I always ignored it. Sometimes, that "popping" would hurt, other times it was just plain annoying. I also did not know much about proper training techniques until VERY recently and my training did change. It was explained to me that this might be coming about now due to overuse (I love to work shoulders and have pushed it VERY hard and I love to swim and play tennis) coupled with free-floating and torn cartilage, also dramatic gains in strength and size while simultaneously decreasing flexibility. It all made sense when my docs suggested it. Perhaps, I was led down the garden path, but that's all water under the bridge.

I do know NOT to work through this kind of pain. So, I'm not pushing it. I lift what I can comfortably and no more. I understand that I'll get my strength and size back and that patience must win out.

I was D/C from therapy with instructions from my doc to continue with my stretching exercises and also to begin SLOWLY rebuilding strength. He wants me to still take it easy for the next 6 weeks. He does know that I'm dedicated to my workouts and he wants me to get back into them; however, I was given no specific progression.

For my first training session, I started Ian King and Lou Schuler's Book Of Muscle. My exercises were thus:

AB Circuit:
Thin tummy
Curl up, Cheat up + Slow lower
Russian Twist
Pushup hold

Calf Triset:
Standing single leg calf raise
Calf raise on leg press, single leg
Seated calf raise, single leg

Superset 1:
DB wrist curl
DB wrist extension

Superset 2:
DB lying pullover
DB seated lat raise

Superset 3:
DB seated shoulder press, palms in
Lat pull down behind neck

Superset 4:
BB seated shoulder press
Lat pull down

Everything, except the ab work, had a warm-up set followed by just one set of exercises with slightly increased reps. The only exercise above that caused any slight discomfort in my shoulder was the DB Lat Raise. But, I adjusted my form slightly and I had no more pain.

I don't yet have pain-free movement through all my normal range of motion. The only pain I still have is when I'm trying reach across my torso with my left hand and lay my palm on my right shoulder. I can reach behind my back comfortably, but I can't get my left hand up between my shoulder blades without pain like I used to. Also, raising my left hand straight up in the air and flexing is uncomfortable, but I had no pain doing shoulder presses.

As for the soreness, it was my entire shoulder. Now, my right shoulder was also sore, but not nearly to the level or extent of my left. I will say, though, that I did not have any shooting pain going down my biceps and into my elbow like I'd had prior to surgery.

[russ]

I think it's an interesting surgical perspective when they tell you that the cause of your shoulder impingement is the shape of your acromion. Unless you have some sort of bony change due to some form of stress applied the acromion, your shoulder has pretty much been that way since you reached adult skeletal structure. Why would a "hooked" acromion be a problem now? Perhaps is more related to your stabilization strategy? Isolated weakness in the scapular stabilizers? Poor training protocols? A flexibility issue?

While there seems to be some controversy in the ortho world regarding the importance of the shape of the acromion, my impression is that it's reasonably well established that a hooked acromion can facilitate supraspinatus impingement during shoulder abduction. Couldn't the fact that 'it's a problem now' be the result of longstanding repetitive microtrauma? That is, the impingement has been going on for a long time, but the symptoms began only recently.

[Bill Hartman]

Bond,

With your history, the pulldown behing the neck is a no-no. Pullovers are probably a question mark as well due to the tendency to promote impingement.

I would also stay away from barbell anything. Use DB's to promote increased stabilization and lower prime mover forces. Also doing a DB press followed with BB press is rather redundant...thinking overuse here. You'll also run into problems due to the fact that ROM is not painfree. If you self-limit ROM, your flexibility will be compromised.

Be enthusiastic and cautious (I'm sure you will be) and good luck.

Bill

[Bond007]

Bill, I can see part of your point about the 2 shoulder press exercises promoting overuse, but the redundancy is irrelevent due to the form that is employed. The DB press is done with palms in and thus forcing your elbows to come in front of your body -- this is actually an exercise that my therapist had me doing. The BB press is done with palms facing forward and a slightly wider than shoulder-width grip, thus forcing the elbows out to the sides of your torso and maintaining the same distance width of your grip throughout the entire motion.

I was unsure about the behind the neck lat pulldown because I do know that it can cause problems. Why did I do it, then? Mostly because there was no pain involved throughout the ROM. It's highly possible that my thinking is still a little out of whack. To be honest, I haven't done this particular exercise in years since I did discover that it could lead to shoulder problems, but I was also thinking that if there was no pain, then it wouldn't hurt. That's probably where I've taken a left turn.

If you self-limit ROM, your flexibility will be compromised.

Can you please elaborate on this statement? I don't think that I'm limiting my ROM in any way. I'm still stretching the shoulder twice daily and if I can't do an exercise without "impingement-type" pain, then I don't do that exercise. Otherwise, if I can do it, I take the exercise to it's full ROM as described in my book.

Thanks for all the helpful comments thus far. I appreciate the input. I want this recovery to go smoother than the first one.

[Bill Hartman]

Russ,

There's no doubt that long standing microtrauma is an issue AND that the hooked acromion can be a contributor. My point is that there's other stuff to go with it (the hooked acromion) that often is not addressed that may very well be "the cause".

For instance, you do the acromioplasty but never effectively address issues of shoulder girdle posture, effective stabilization strategies, program design, exercise technique, "muscle balance", fatigue patterns, dynamic instabilities, etc. What frequently happens if the patient goes back to prior activities without adequate instruction, re-education, restoration of ROM, movement patterns, and strength? More shoulder pain/impingement. Well, then was it the hooked acromion or something else?

Granted, therapy is supposed to address this but restrictions on frequency/duration and a blatant lack of knowledge on the part of PT's regarding the above issues (all therapy is not created equal) lends itself to more problems. There's also the patient's responsibility to follow-thru which is a huge part of successful rehab.

Not trying to blame anyone per se, just offering a perspective based on treating my share of patients "destined" for surgery who ended up not needing it, and those who have had the surgery and ended up back in therapy later on. There are certainly times for everything.

I'm pretty spoiled to work with a group of surgeons who'd rather exhaust rehab possibilities rather than do the surgery right away.

Bill

[russ]

There's no doubt that long standing microtrauma is an issue AND that the hooked acromion can be a contributor. My point is that there's other stuff to go with it (the hooked acromion) that often is not addressed that may very well be "the cause".

I agree.

The remainder of your post basically answers what would have been my follow-up questions [img]smile.gif[/img]

My own experience with orthopedic surgeons is that they will recommend extensive rehab prior to recommending surgery. However, I live in a country where OR time is at a premium. Unfortunately, that may affect the surgical decision making process

[Bill Hartman]

Bond,

It's impossible for me to be certain about some things not having done your rehab or watched train. I have to speak from a precautionary perspective.

The barbell press is more stable than the DB's which means that larger "prime movers" produce more force. Being larger they also have greater endurance capacity in addition to your non-surgical side (this time) being stronger and prolonging the set. That means that scapular stabilizers and the rotator cuff may fatique sooner than prime movers, but you'll still be able to perform the movement. If stabilization changes and alters mechanics (allowing the humeral head to translate upward or forward), you can still impinge and not feel it.

If you feel you must do both exercises, use DB's and alter the shoulder position (flexed or abducted). Your earlier description of the "popping" shoulders also makes me wonder if you have some anterior instabilty or there's something going on with your subscapularis.

This can also become a problem if the subscapularis fatigues and can't hold the humeral head in place during overhead movments (it is partially responsible for depressing the humeral head under the acromion), you'll impinge. Again the DB's may protect you from this as your set will end when the affected shoulder fatigues rather than when stronger shoulder can no longer complete the movement.

Bill

P.S. Forgot the ROM thingy...If ROM is limited in any plane because of pain, you may be substituting movement somewhere else to achieve full ROM in other planes (like reaching overhead in a press...you may be hyperextending the lower back to achieve full flexion). Resistance training sends a very strong signal to the CNS as to how far a joint can move. Repeatedly performing limited ROM strength training can then limit active ROM even if you stretch.

It's like cyclists having tight hip flexors because of the repetition and loading in a shortened position or swimmers standing with their shoulders in internal rotation. The muscles "learn" to stay in a shortened position through repetition.

You may just want to have someone observe you while you perform some exercises to make sure you're not substituting to avoid pain or limited ROM.

[Bond007]

Awesome! Gee, you've been more help than both my ortho and my therapist put together!!

I do have one more question, when you have the time. In your first response you mentioned something about a "functional progression to return to training." Since I received only a "vague" direction at best, do you have any suggestions as to what I can do during the next several weeks to rehab this shoulder? Yeah, I've been through this twice before on the right shoulder, but I know now that I didn't rehab it correctly the first time and I'm starting to think that I just got lucky the second time.

Maybe, I just need to go visit my Mom in Carmel, IN for a long weekend and hire you to run me through a few things??

[Bill Hartman]

Your functional progression would be a series of exercises/activities to break you back into your regular daily/exercises activities based on your specific surgical/rehab outcome.

They may have and just not done so formally. It would like when you and do "such and such" then it will be okay to do "this" and so forth. Kind of a progression of milestones to get you back to normal.

Holy crap! Small world...what part of town does your Mom live? Are you from Carmel?

Bill

[Bond007]

That makes sense. I was doing several strengthing exercises in PT with very light DB's that I can continue to do in the gym and perhaps postpone getting any more involved in King's shoulder workouts for the time being.

MamaBond lives about half a block South of 116th and just East of 431 (N. Meridian Street), just off N. College. She's been there for a couple of years now. Prior to that we were living on 75th Street, just West off Dean Road. We moved there in 1987. Prior to that, we lived in South Harbor up in Noblesville. I actually moved there with my mom, step-dad and half-sister when I was 9. I went to Noblesville City Schools and swam competitively while there. My sister actually went to North Central High.

I also have an aunt who lives on Bay Shore Drive in Indy immediately behind N. Keystone Ave.

[Bill Hartman]

I drive by your Mom's place all the time...I wave next time.

Bill

[Bond007]

Now that's a SMALL WORLD!!

btw, you know any single men in their early 50's who are stable, well-established, reasonably good-looking and willing to date a wonderful, beautiful, mature, twice-divorced mother of 2 who's going through the "change"? Yeah, I'm pimping for my ma! I really don't care for the guy she's on-again, off-again kind of dating.