How to Shorten Your Shoulder Scope Recovery Time!

Shoulder - AC sprain 281Today is a true day of “role reversal” for me.  Instead of being the physical therapist, I’ll be the patient rolling into the operating room for surgery to fix a chronic shoulder injury by Jacksonville Jaguars Head Team Physician Dr Kevin Kaplan at Jacksonville Orthopaedic Institute.

I have to admit, consulting others about a shoulder scope is much more fun than being the one starving yourself after midnight and wearing the paper-thin johnnie!  I’ve had my share of surgeries.  I find them all to be great opportunities for me to learn better ways to help athletes recover quicker when they have to “go under the knife”.

The AC Joint Injury

I’ve had a chronic grade 3 acromioclavicular (AC) joint sprain for many years that needs to be fixed.  How did I get it?  Here comes the entertaining part of the blog post.  I crashed hard on my mountain bike doing a downhill slalom race at Mt Snow in Vermont……in March….in blizzard conditions!  No, it truly wasn’t my smartest day, but it sure was a fun event until I slammed on the ice with my shoulder.  As a fan of extreme sports I might not be any smarter today than I was back then but I’ve learned how to crash more gracefully.

Here’s my game plan for a successful shoulder surgery:

Loosen Up the Good Stuff

I started doing extra shoulder, upper back, neck, rotator cuff and chest stretching during the past week.  Those ligaments, joints, muscles, fascia and tendons are the very things that will dictate my shoulder function after the surgery.  Therefore, I want those structures to be limber, strong and relaxed going into the operation.

Get Rid of the Bad Stuff

Inflammation and edema are bad so my shoulder filed a Restraining Order against them just last week.  Meanwhile, I’ve focussed on icing, controlled exercises and massage as key steps to start the recovery process from my  surgery before I even get to the hospital.

Hydrate the Right Way

Healing tissue needs to be happy tissue.  Approximately 60% of the human body is water.  Staying well hydrated starting three days before the surgery will make the doctor’s job easier and my recovery faster.  I take my hydration serious in any type of weather so when it comes to recovering from surgery, water is my best friend.

Tune Up My Rotator Cuff

Resisted rotator cuff exercises such as external rotation, forward flexion and side raises will continue to be done 3 times per day right up to 2 hours before the surgery.  I want “my cuff” to be as active and as strong as possible before Dr Kevin Kaplan sticks that scalpel into my arm.

Listen to Your Commanders

The surgeon and his staff are your commanding officers so listen to them closely.  They know best so read their memos and listen to their tips.  They will ultimately play a huge role in your outcome so be a great patient before, during and after your surgery.  Post-surgery rehabilitation is priceless.

Plan the Recovery

I have my ice, bottled water, pillows, books and, most importantly, my beautiful wife ready before I leave the house today.  Limping in the door with my arm in a sling is not the time to be setting up my recovery zone.

Think & Be Positive

Healing and recovery starts between the ears.  Positive thoughts and self-talk about my shoulder is dominating my mind today and will continue for the next four weeks.  Those healthy images involve much more than just my body and mind.  They include a strong sense of gratitude for Dr. Kaplan and his highly skilled staff involved with my care.

In Closing……

I view my involvement with today’s surgery as an active process, not a passive event left to the skills of others.  I’ve prepared my body, mind and home to both maximize the benefits of the surgery and accelerating my body’s recovery from the trauma of the operation.

I have way too many exciting things I want to do this off-season with this better-than-new shoulder and just laying around isn’t one of them!


Impingement Syndrome of the Shoulder: Tennis Shoulder

Impingement Syndrome of the Shoulder: Tennis Shoulder

Years back, a friend of a former colleague came to see me with left shoulder pain. I had helped him resolve prior issues in this other shoulder, so I took it as a compliment that he came back to see me when a new problem arose on the opposite side.

Given that his case was fairly typical, I think it provides a helpful example of how to quickly and properly manage acute “tennis shoulder.”

The Athlete:

  • Approximately 38 years old
  • Active military, excellent health, top-notch strength and conditioning
  • Right-hand dominant (with a history of impingement syndrome in the right shoulder), but favors his left arm when playing tennis

The Symptoms:

  • Significant sharp shoulder pain in the left AC joint
  • Approximately 50% strength loss in functional activities such as turning the steering wheel in car or holding something away from the body
  • Shoulder pain while lifting the arm
  • Inability to sleep on the left shoulder due to pain

The History:

  • No falls, accidents or episodes that would lead to shoulder symptoms
  • Competitive tennis player in his youth; recent tennis activity with his daughter on a frequent basis
  • Over the last two weeks, an increase in localized shoulder pain while lifting his arm, along with more intense point tenderness on the AC joint (tip of the shoulder)

The Examination:

  • Point tenderness, approximately the size of a dime, was easily located at the end of the left collarbone on the front of the AC joint.
  • Intense pain occurred with active motion when attempting to reach across the body with the left hand to touch the back of the right shoulder.
  • Passive extension of the shoulder, with the elbow extended and wrist pronated, maximized the stretch on the longhead of the biceps brachii muscle.
  • Manual muscle tests used to assess shoulder strength with motions including external rotation, flexion, abduction, supraspinatus elevation and extension demonstrated approximately 70% less strength than observed in the right shoulder.
  • Other tests performed to rule out issues such as shoulder joint instability, AC joint separation, nerve pathologies and an SC joint sprain were normal and symptom-free.

The Diagnosis:

Acute Impingement Syndrome of Shoulder, aka Tennis Shoulder

The Plan:

  • Discontinue tennis and all other activities that lead to shoulder symptoms for two weeks.
  • Perform consistent pendulum swings with a light weight.
  • Implement an aggressive one-week strengthening routine for external rotation (ER).
  • If strength in ER returns to approximately 90% in one week, resume pain-free weight training while continuing to avoid all overhead lifting and exercises involving the left arm crossing the midline of the body.
  • Improve posture with pain-free chest and anterior shoulders stretches.
  • Consistently massage chest muscles immediately before exercising the upper-mid back with shoulder blade retraction or “pulling together” exercises.
  • Ice the shoulder three to five times per day.
  • Consume over-the-counter anti-inflammatory medicine for a short period of time, only as needed for pain.
  • Avoid sleeping on left shoulder for two weeks.
  • Nail down a successful pre-tennis routine that will:

> Warm up the shoulder joint, AC joint and surrounding musculature

> Allow for normal mechanics and patterns for movement

> “Fire up” the shoulder’s external rotators to help decelerate the arm during the follow-through phase of the tennis swing

It was a pleasure working with this gentleman, who understood he may need to permanently limit his overhead lifting and consistently focus on the strength of his external rotators bilaterally based on his history. More imminently, I expected him to be able to return to his normal activities as an active military specialist and tennis vet within three weeks following his exam. Game, set, match!

AC Joint Separation Management

AC Joint Separation Management

Acromioclavicular (AC) joints are easily injured and susceptible to secondary issues such as arthritis, laxity, and shoulder pain.  Often referred to as a “separated shoulder,” an AC separation occurs when the ligaments that stabilize the collar bone (clavicle) and the shoulder blade (scapula) are damaged.

The acromioclavicular joint connects the lateral end of the clavicle (collar bone) and the lateral end of the scapula (shoulder blade).  This bony section of the scapula is referred to as the acromion. The AC joint creates a stabilizing union between the front and back of the shoulder girdle.  It’s important to note that when healthy, this joint has ample mobility that allows for significant motion of the shoulder.  The AC joint forms an important archway that protects the rotator cuff and shoulder joint below.

Stabilized by a joint capsule, the acromioclavicular joint encompasses the ends of the clavicle and acromion along with several ligaments. Because ligaments attach bones to bones, when the AC joint ligaments (located under the clavicle) are damaged due to a separated shoulder, there is a downward pull to the clavicle and AC joint.

What Causes a Sprained AC Joint?

Falls are a main cause of separated shoulder injuries.  The AC joint is not overly stable, and its location makes it quite vulnerable to injury.

The two most common injury mechanisms are:

  • Landing on the lateral part of the shoulder, forcing the shoulder downward
  • Landing on an outstretched arm or elbow, forcing the shoulder joint upward into the undersurface of the acromioclavicular joint

Either of these situations noted above will disrupt the AC joint capsule and compromise the stabilizing ligaments.  The grade, or degree, of separation depends on the level of damage to both the ligaments and capsule.

Grades of Separation

Shoulder Separation, Grade I

Mild disruption of the AC joint capsule, resulting in minimal joint instability

Shoulder Separation, Grade II

Moderate disruption of both the AC joint capsule and stabilizing ligaments, resulting in moderate AC joint instability.  Partial tears of both the AC joint capsule and stabilizing ligaments are present.  Holding a weighted object with the injured arm at one’s side will present moderate AC joint laxity with visible elevation of the outer clavicle. The amount of elevation with a Grade II AC sprain is typically ½ to 1 inch, when compared bilaterally.

Shoulder Separation, Grade III

Significant disruption of both the AC joint capsule and stabilizing ligaments results in significant AC joint instability.  Complete tears of the AC joint capsule, and possibly complete tears of at least some of the stabilizing ligaments, are present. When the injured arm rests at the side of the body, there is visible laxity of the acromioclavicular joint and visible elevation of the outer clavicle.  When the arm reaches across the body toward the back of the other shoulder, abnormal lateral clavicle elevation increases.

AC Sprains Grade IV to VI are much more severe and based on the hyper-mobility of the acromioclavicular joint.

Signs & Symptoms of an AC Joint Sprain

  • Pain and localized swelling on the top of the shoulder at the acromioclavicular joint
  • Swelling and/or bruising on the top of the shoulder
  • An obvious bony lump on the top of the shoulder, which is the end of the displaced collarbone (the higher the grade of shoulder separation, the larger the elevation of the outer tip of the clavicle)
  • Limited range of motion (ROM) and pain when lifting the arm
  • With Grade II and Grade III AC joint sprains, a “clicking” or shifting felt in the AC joint with shoulder motion
  • Significant AC pain with active motion (personally moving the arm) or passive motion (someone else moving the arm), horizontally across the body toward the back of the other shoulder

Treating a Separated Shoulder

  • Ice the top and front of the shoulder with the elbow flexed to approximately 90 degrees and supported.
  • Use an arm sling if pain or clicking occur when walking.  This helps to support the weight of the arm while also restricting motion.
  • Once a fracture is ruled out, initiate early motion to reduce stiffness and pain.  Avoid horizontal adduction motion (horizontal movement of the arm across the midline of the body) until pain-free motion is achieved.
  • Perform easy pendulum swings to help regain motion of the shoulder.
  • Initiate a shoulder strengthening program early on with a Grade I & II sprain, if tolerable.  Start with rotational motions and progress with overhead lifts, continuing to avoid horizontal adduction as long as possible.

Ask the Right Questions Like a Pro

As always, my goal is to help you get back in the game as quickly as possible while ensuring a safe return.  Ask the following questions—the same ones smart professional athletes with a separated shoulder would ask their sports medicine specialist—so you too can recover quickly and safely:

1. What grade is my shoulder separation?

2. Do you think I can successfully rehab this AC joint sprain and avoid surgery?

3. Are special padding, taping, or sports equipment alterations needed to reduce the chance of reinjuring my acromioclavicular joint?  Which specific lifts, activities, and motions should I avoid to help my AC joint separation heal quickly?

Sports Medicine Tips For an AC Joint Separation

  • No Need for the Knife – AC joint surgeries are not overly common unless instability is severe or complex limitations are present.
  • Sleep Well? – Plan to avoid sleeping on the injured shoulder for a while.  I severely separated my right AC joint in a winter mountain bike race on a ski slalom course (I know, not the smartest thing that I’ve ever done, but it sure was fun…until I crashed!) in Vermont in 1994. I still can’t sleep on that side!
  • Prioritize Posture – Any position, movement or activity that rounds your shoulders will worsen the pain. It’s that simple.
  • Ice, Motion, Ice – Ice it, move it (in pain-free directions) and then ice it again. It’s a simple formula with fast results.
  • Exercise Efficiently – While sitting or standing tall, relax your arms while squeezing your shoulder blades (scapula) together and exhaling hard.  Hold for 2 seconds and repeat 10 times.  Do this drill as much as possible to stretch out your chest muscles, strengthen your shoulder stabilizing muscle and, most importantly, decompress your AC joint.