On this episode of the #AskMikeReinold show we talk about why people may have a shoulder shrug sign after surgery, and what to do about it in physical therapy. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 194: Correcting the Shrug Sign After Shoulder Surgery
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Execution Plans from my Inner Circle:
- How to Assess Overhead Shoulder Mobility
- Assessing the Shoulder Shrug Sign
- How to Assess Shoulder Capsular Mobility
Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about should or shouldn’t we worry about shoulder shrug signs after shoulder surgery.
Andrew King: So we have a Theo from Pittsburgh: “When dealing with a post op shoulder patient, how do you correct increased shoulder shrug when they began active flexion or abduction.”
Dave Tilley: You put on Thriller and you teach them.
Mike Reinold: I know what our thumbnail is going to be.
Mike Reinold: All right, so for a post op patient? Post-op shoulder, how do we… Was it avoid, or how do we treat?
Andrew King: How do we correct?
Mike Reinold: How do we correct a shoulder shrug sign post op patient. So pretty common, right to have a shoulder shrug sign shou… [Crosstalk 00:01:41]
Mike Reinold: The shoulder shrug sign, that was still hard. That happens a lot post op, right? Any type of injury tends to cause some sort of pain, inflammation and anything that may happen from an injury post op type thing, it tends to shut down the cuff.
Mike Reinold: Lots of potential things that we can have here to have a shoulder shrug sign that happens post op. So before we talk about how do we fix it, I think the number one thing we should talk about is what are the potential reasons why they may have that right? Cause there’s a handful and I know we’ve talked about this in past episodes, but I think at this point we’ve talked about everything, but I like how you said specifically post op. So anyone want to jump in and say what are some of the causes of shoulder shrug sign?
Dan Pope: All right, so I think the main reason why people get a shoulder shrug sign is because they’re compensating through the shoulder blade, right? So if you have some sort of pain, weakness, or stiffness in the shoulder, which you’re going to have after a shoulder surgery then you’re going to compensate through the shoulder blade to make up for the issue at the shoulder joint itself.
Mike Reinold: Okay and sometimes this is the path of least resistance. You’re afraid or it’s painful to move the limb so it’s easier to just try to do that right?
Mike Reinold: So I think there is number one right there and let’s call that a neuromuscular patterning issue that the person has meaning they can do it, they just aren’t doing it, right?
Mike Reinold: So maybe some education on how to help them do that so usually that’s a progression of passive, active assisted and then active range of motion type things. But I think it’s more about showing them that A) they can do it and then maybe facilitating them to do it either by using some of your hands, doing some active assisted type things but I think, that’s a good one.
Mike Reinold: Nice. One. What’s next? Who wants to jump in with number two?
Lenny Macrina: Soft tissue, either muscle or capsule is going to probably guess if, usually if it’s a cuff repair. It’s shoulder right?
Lenny Macrina: For cuff repair, then they’re probably 40 plus. So they have a tendency to just get capsular stiffness more so and probably some tightness in their muscles around the joint so you got to be able to address that through a range of motion and maybe some mobz, soft tissue work to soften all the muscles around the area try to loosen it up.
Lenny Macrina: Cause if it’s the capsule’s not moving well, the Humeral head is going to get stuck and what’s going to happen is, you’re going to try to fight through that sticking and just try to raise it up any way you can and you’re not getting normal arthrokinematics in the joints. The Humeral head can’t roll, glide and slide where it needs to cause it’s physically limited. So you got to work on that as well.
Mike Reinold: All right, so I like it.
Mike Reinold: So mobility restriction, so you just had surgery, either you were immobilized by the physician, like you’re in a sling or an abduction pillow or whatever it may be. Maybe you self immobilized because it didn’t feel very well, right? So you mobilize for a little bit and then you had some adaptations to the rotator cuff… The muscles I should say or the capsular tissue that started to get a little tight. Good one, nice.
Mike Reinold: So what would we do for treatment for that one? Well, easy, soft tissue, joint mobility type things. Trying to get them to actually increase their mobility through some of our manual therapy. And probably again the exercises we give them, so good. And I think these all play together, that’s a good one, good.
Mike Reinold: What else? Who wants to jump in? Little more, little more, yeah there we go, right.
Dave Tilley: I’d say, weakness is probably one, a little bit farther down the road that maybe you’re doing exercise, like you’re trying a standing full can variation or even when with weight but that itself is a long lever arm so it’s too much on the cuff to maybe do comfortably or do with the proper mechanics.
Dave Tilley: And so maybe laying someone on their side and starting with a bent elbow on their side eliminates gravity and then progressing them to a straight arm and then putting some dumbbells in their hands on their side. That will help the smoother transition to get strong over a couple of weeks.
Mike Reinold: Perfect. So weakness, specifically in the rotator cuff, so it’s probably not stabilized in the Humeral head so you’re getting superior migration when you’re shrugging right?
Mike Reinold: So I like that, so gravity assisted or eliminated position, very helpful, right? I think that’s a good one.
Mike Reinold: And then the other thing is just get super strong down here, right? That’s the no brainer part right there. So those are good ones, right? Cause sometimes you’ll have somebody that doesn’t have any mobility restrictions but they’re still shrugging right?
Or you have somebody that doesn’t have any weakness issues and they’re still shrugging. So those are the two big ones that kind of go into play. One more I’m thinking of, which kind of isn’t much different, but anybody else want to try? I think we nailed the 98% of the time.
Mike Scaduto: Say narrow, like nerve involvement somewhere.
Mike Reinold: That’s a good point, right?
Mike Scaduto: Surgical trauma.
Mike Reinold: You could have some surgical nerve related stuff too, which then would probably feed into Dave’s weakness type thing. But I think the difference with that is, instead of trying to get weight and get stronger, if it’s a neurological, neurogenic weakness type thing, you probably doing more reps and lighter load, right. Kind of get some of that.
Dave Tilley: Stem trigger would also maybe be more appropriate for that.
Mike Reinold: Yeah, neuromuscular stem would be great to get that, I like that.
Mike Reinold: I think the other thing I would add and I think it maybe it just piggybacks on Len, it’s like a subset of what Lenny just said was that maybe you actually had a capsule repair and not only now is your capsule tight, but perhaps your capsule is surgically tightened or over tightened a little bit.
Mike Reinold: So I guess it’s pretty similar that your capsules tight like Lenny said, but it’s not just that you got, you are immobilized and you got stiff. I think it’s sometimes, especially with the capsule repair for Hypermobility or whatever it may be you actually get some surgical tightness.
Mike Reinold: And the reason why I bring that up is I think the treatment’s a little bit different with that, right? Because you have to be careful with what we’re doing if we’re early within those phases. So you do the best you can with your mobility, but you can’t be super aggressive with it because you can’t disrupt the repair. So that’s probably the one time that we’re actually saying, hey pump the brakes a little bit on that.
Mike Reinold: Hopefully as the capsular tissue gets a little bit looser, then over time that shrug will go away. Especially if you are subsequently working on the strength and the stability down below, right?
Lenny Macrina: I will say it’s a good point and I think we take some of that for granted because I’ve had a bunch of people recently, now that I’m in a cash based setting, people find us, especially me, I can speak for me, that I find people are a year or two years plus out of surgery.
Lenny Macrina: They’re still not happy with their outcomes and even though people seem to be functional, there’s a subset of people that the capsule just never gets this mobility back the way it was before the surgery and people struggle.
Lenny Macrina: And especially if they’re going at a high level of something, whether it’s CrossFit or, I have a female right now dancer and she has what everybody would say is full range of motion in her shoulder and the doc was probably happy and her PT was probably happy, but she’s still not satisfied over a year out of surgery because her shoulder just doesn’t feel right. She still gets this little pinch. So I think that something we can’t take for granted is we got to protect the area, but we have to get back that normal capsular mobility the way it was before the surgery.
Lenny Macrina: And how do we know it? People will tell you they feel a pain in the back, they feel a pain in the front, just doesn’t feel right. But this is months down the road so you got to figure out a way to protect the area but still get that mobility back in the glenohumeral joint because it will affect subtle arthrokinematics and the joint that still bothered a good group of people down the road after these types of surgeries and she had a subscap repair and an anterior labor repair, do you know what I mean? So bigger deal, a lot going on, younger person and she still doesn’t feel right. We’ve had to..
Mike Reinold: Open?
Lenny Macrina: No scope.
Mike Reinold: Scope, that’s got to be hard to do.
Lenny Macrina: So a dancer, good tissue quality, very flexible but her capsule is still not the way she wants it and we’ve made some good gains by some of the stuff I’ve done. That’s a different story.
Mike Reinold: Capsules, exactly how the surgeon wanted it though.
Lenny Macrina: Probably, yeah right.
Mike Reinold: Success, they did it right.
Lenny Macrina: She doesn’t feel right.
Mike Reinold: That’s a big part. We used to see this a lot more with open procedures, you had the incision and you had to take down the subscap to get in there. It got pretty tight after those things, whereas we’re seeing it less with scopes. But there is certain physicians that just over-tighten it, they like to make it tight because in their mind they’re trying to weigh the consequences of them having instability again down the road versus not.
Mike Reinold: So sometimes you’re kind of limited with what you can do, but hopefully even if it’s over-tightened surgically, that’ll affect them more at end range, right. Initially over here, but at end range. So meaning we shouldn’t really have a shrug in there so something to keep in mind.
Mike Reinold: So I think we nailed that. I think we covered like a bunch of reasons why you could potentially have that shoulder shrug. Pretty common, but definitely something that you want to try to get rid of right away.
Mike Reinold: So appreciate the question. Head to MikeReinold.com, click on the podcast link and you can fill out the form to ask us more questions and…
Mike Scaduto: See you on the next episode.