The Clinical Coach: Post-surgical Shoulder Rehab

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This is one of my first post-surgical rehab cases that dealt with shoulder rehabilitation weeks after their surgery.

I won’t bore you with too much of the past details. For ease of communication I will give my patient a fictitious name, a ±3 age gap, and a small window into who she was at the time this happened.

Sue was a 44 year old real estate manager who’d been coming to my office for general neck, shoulder and back pain. Most of her pain would be exacerbated secondary to her diagnosis of psoriatic arthritis. This was being managed by her rheumatologist, therefore our care was more in line with improving her overall health.

Over the year we’d been working together, she’d cleaned up her diet, starting lifting weights, built muscle and dropped about 30 lbs simply by following my recommendations.

One day, I got a text message.

“I need to cancel my appointments. I got in a motorcycle wreck and I need surgery.”

My heart sank. If you haven’t experienced something like this with a patient, you have not truly connected with your patients.

Instead of responding via text message, I waited a few minutes and gave her a call.

She picked up, we chatted for the next 15 minutes.

Here’s the summary:

She was on her motorcycle taking a turn when the back wheel slipped and her motorcycle took a fall. As she landed, she fell on her left shoulder. The impact shattered her scapula, broke her humerus in three different places (almost shattering the head of the humerus) and now three days later needed reconstructive surgery.

Yep. You read that right.

Three days later. It gets better.

The surgery was a total success! Her scapula was fixed with a plate and three different screws. Her humerus was fixated with a few screws and a plate (which later would come out), and her capsule was cleaned up and the muscles were reattached.

A week later she called to come into the office to get some care in her low back. After the fall, surgery and being limited for the last week, she knew she needed to get moving.

I took the opportunity to assess her shoulder (as best as we could) it was still in a sling.

When I asked her about her physical therapy recommendations. She told me her doctor had not sent her to PT yet. He wanted her to be on the sling for at least 6 weeks before she started any movement.

He didn’t want her shoulder out of the sling other than when she showered.

I voiced my concerns. Muscle atrophies quite quickly when immobilized, which could lead to sarcopenia. Once this happens, any chance of rehabilitation would be much more limited and difficult. We also know that bones tend to heal “faster”

I am not one to be negative when it comes to rehab. Myself and others have proven doctors wrong when it came to not returning to play, or never being able to do X exercise successfully.

However, the shoulder is one of the most off-loaded structures in the body. The only load that it carries is that of the weight of the arm. When not loaded adequately, shoulder atrophy, deconditioning and injury is more likely to occur.

Not to mention all the other regions that are in close proximity. Chest, mid-back and neck.

She agreed that she would like to start some type of therapy early, but she didn’t want to make her surgeon mad. (Why is this even a thing?)

I told her to talk to him, and voice these concerns with him. Hopefully he’d agree and would at least get her scheduled with a PT sooner than later.

A week later (after her revision) she called. “The doctor said that’s not going to happen. The shoulders is going to be fine, and he much rather have the sutures fully healed before I go see a PT.”

I’m not a surgeon… but if there’s one thing that I understand is tissue healing, growth and conditioning.

I voiced my recommendations, but I was not going to be too pushy. After all I had only been in practice for 3 years, and I didn’t want a malpractice case against me that early in my career.

She kept in touch throughout the next few weeks. Ten weeks later (after her surgery) she came into the office for some low back care again. She wasn’t wearing a sling, but was wearing a compression brace on her shoulder. She had to take it off in order to lay down.

I noticed that she was still not moving her left arm. So I began asking questions.

She had at least started PT. She had been going to PT twice a week for the last three weeks.

When I asked her what they had her do, she listed the following:

• Passive ROM controlled by the PT

• E-stim

• Red light therapy

That was her PT… for the last three weeks.

When I asked what she was doing at home, she said she’d been told to do pendulum swings a few times a day, but to keep her brace on as much as possible. With the brace on her shoulder was severely limited.

She asked for my opinion. I said I’d have to think about the next steps, but we could assess it in the office.

So we did just that.

Her range of motion assessment:

• 0 degrees of active abduction (without trunk lean)

• 0 degrees of active extension

• 0 degrees of ExRot

• 90 degrees of InRot

• 20 degrees of active flexion

• 10 degrees of passive abduction before “tightness”

• 20 degrees of passive extension before “tightness”

• 60 degrees of passive flexion before “tightness”

• 10 degrees of ExRot before “tightness”

• 90 degrees of InRot no discomfort

Her muscle tone on the L arm in comparison to her R side:

• deltoid atrophy

• subscap atrophy

• infraspinatus atrophy

• bicep atrophy

• tricep atrophy

Muscle strength on the L arm in comparison the the R side.

• deltoid - unable to abduct 2.5lbs on the L, 10lb on the R

• ex rot - unable to complete

• bicep - curl 5 lbs on the L 15lbs on the R

• tricep - tricep ext. 7.5lbs on the L 20lbs on the R

Needless to say, there was a lot to work on.

I am not going to say this was an AMAZING transformation in as little as XX days.

We began working together the following week two days a week in person and gentle active exercises at home.

The first six weeks were tough. Not only physically, but mentally for her.

Working with sets of 3-5 reps with 5-8lbs was just defeating her both physically and mentally.

There were a lot of sessions that ended up in frustration and tears.

But progress crept up. Slowly.

Three months into working together, she decided to stop going to her PT as she didn’t think it was working. We were doing more during our session than she was doing at her PT.

Six months later.

Her range of motion assessment:

• 32 degrees of active abduction (without trunk lean)

• 12 degrees of active extension

• 20 degrees of ExRot

• 90 degrees of InRot

• 110 degrees of active flexion

Her muscle tone on the L arm in comparison to her R side:

• deltoid atrophy

• subscap improved

• infraspinatus improved

• bicep improved

• tricep improved

Muscle strength on the L arm in comparison the the R side.

• deltoid - able to abduct 5lbs on the L to 45 degrees, 10lb on the R

• ex rot - able to complete unassisted

• bicep - curl 15lbs bilaterally

• tricep - tricep ext 20lbs bilaterally

We sat down to chat and update her expectations.

It was obvious she had made tremendous improvements on paper.

Unfortunately, she didn’t see it like that. Her voice was shaky, strained and there was a sense of gloom when she started talking.

Six months into her rehab and she felt she was just catching up to who she was before her accident.

I wanted to be silent for a second and let her think about what she had just said. But it wasn’t a second later, that I said “but you are not that person anymore.”

I caught myself before saying anything else. I wasn’t sure how she’d respond to that statement even tho I’d known her now for almost two years.

“You are right, I am not the same person anymore,” she said. “The old me would’ve given up after the fall. I wouldn’t have pushed myself in my rehab. I wouldn’t be getting back on the motorcycle.”

I was relieved! She saw exactly what I was seeing in her. A stronger, confident and capable woman.

At 44 years old very few people take on new challenges to challenge themselves. Most live a quite life and stay in their lane. If injury happens, most backtrack on their progress. Let things go and decide it wasn’t for them.

Her disposition changed. Her voice brightened. Her smile came out to play!

From here on our conversation shifted to her future expectations and continued rehab.

I laid out my expectations, small and limited progress. I wasn’t sure how much more shoulder range of motion she was going to regain.

But she wasn’t worried about that! She trusted me that I was going to continuously push the envelope and make sure she continued to make progress one way or another.

Over the next couple of months, we kept working together. At this point, I hadn’t quite stepped into the hybrid practice that I now have. We kept working twice a week at the office. During these days we played with new ranges, loaded them, and backed off when we needed to. We needled various times throughout her care, and we adjusted when needed.

After working together for 13 months post accident.

This was her update:

Her range of motion assessment:

• 60 degrees of active abduction (without trunk lean)

• 17 degrees of active extension

• 30 degrees of ExRot

• 90 degrees of InRot

• 115 degrees of active flexion

Her muscle tone on the L arm in comparison to her R side:

• deltoid improved

• subscap improved

• infraspinatus improved

• bicep resolved

• tricep resolved

Muscle strength:

• deltoid - able to abduct 15lbs to 50 degreees bilaterally

• ex rot - added 10lb band resistance

• bicep - curl 25lbs bilaterally

• tricep - tricep extension 55lbs bilaterally

• Bench Press - from zero to 115lbs

• Safety Squat - 195lbs

• Deadlift - 205lbs.

She even started running on her own, and completed a few 5K races.

By now it’s October 2023. I am now closing the office in St. Charles, and making the transition to Nixa.

On her last visit we decided it would be more beneficial for her to continue seeing someone in person, rather than transitioning into the online approach. Her personality just needs it.

It had been almost a year since I last saw her.

During one of my trips to STL to teach a CDNP course, I ran into her.

She’d lost over 50lbs I hardly recognized her.

She thanked me for never giving up on her and for setting her up with her new trainer. While her shoulder hasn’t improved much since I left, she has completed more 5K and 10K races in the last year than in the last 10 years. Continues to lift 3 times a week, and her and her husband are riding motorcycles with confidence all across Missouri and Illinois.

It may not happen every day. It may not happen often.

But, our work has the power to change lives.

In health and strength,