The biggest complication after shoulder stabilization surgery is a loss of motion.
Think about it, the person had instability or too much mobility in general. The surgery is designed to reduce this instability.
So it’s no wonder that sometimes people get tight. Most of the time, this is OK, but sometimes you need to push.
Here’s how we deal with that in our patients.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 288: Working with Tight Shoulders After Surgery
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Show Notes
Transcript
Student:
Okay. Hannah from Michigan wants to know, “How do you deal with shoulder tightness that develops post shoulder surgery? It seems to be a big complication when young hypermobile people have a labral repair and have to follow a very restricted protocol and heal quickly, making them very tight.”
Mike Reinold:
All right. Great question, Hannah, and really similar to what we talked about a few weeks ago with Jason, about the knee flexion. I didn’t realize how similar those questions were, but in retrospect they’re quite similar, but thank you.
Mike Reinold:
I think this one’s a little bit more specific though, and this might have been what we were thinking here. So what Hannah is saying here is, “How do you deal with shoulder tightness post shoulder surgery?” And I think the difference was, if you flash back a few episodes, if you haven’t yet, go back, listen to a few episodes. But we asked… We answered a question about… Somebody was immobilized a little bit too long probably, after knee surgery, and they got tight from that.
Mike Reinold:
I think this one’s a little different, because what we’re doing here is we had a procedure that intentionally tightened the person up. And I think that was where I think this question’s a little different with Hannah’s. You have somebody, like a hypermobile person with a labral repair, and they get tight because they have a restricted protocol after. What do we do? So I don’t know. Let’s see, Kev, you want to start with this one here? I think there’s some good sound strategy we can give to help with this kind of concept. But Kev, what have you noticed in your experience?
Kevin Coughlin:
Yeah. So I’ll shout out Mike Scaduto to start here.
Mike Reinold:
Wow. Is that, is that a first?
Diwesh Poudyal:
RIP.
Lenny Macrina:
Who? [crosstalk 00:04:05]
Kevin Coughlin:
Shout out to Scaduto.
Lenny Macrina:
Is he on the podcast?
Mike Reinold:
He’s on… He doesn’t listen to the episodes after, so we can speak freely here. [crosstalk 00:04:14] Mike’s on his monthly golf trip right now, so he’s unable to attend. But Kev, what? Sorry.
Kevin Coughlin:
Yeah, no, that’s okay. So, there was someone that I saw one visit that Scaduto’s been seeing who he evaluated, I believe probably a month ago now. This guy’s a pitcher so he’s younger, say early 20s, but he had an anterior-inferior capsular repair and Bankart repair. So kind of similar procedure where the goal is to tighten the capsule. So he came in four months after his surgery. He was doing PT elsewhere, but when he came in, he was super tight, especially in that external rotation at 90-degree position. And I believe he came in somewhere around 100 degrees of external rotation, somewhere around 130 on his left side. He’s right-handed.
Mike Reinold:
Wow.
Kevin Coughlin:
So yeah, definitely. And you know, this guy has aspirations of playing professional baseball. So-
Mike Reinold:
Can it be a big chance to be… Can he be a lefty?
Kevin Coughlin:
Can he be a lefty, yeah. So definitely a big deal. And it’s been really cool to watch the process. I think Mike kind of explained it to me where he’s breaking it up in phases of treatment. So the first four phases, you think four months out, you’re really getting after some strengthening at this point, but he prioritized those first four weeks of therapy to restore range of motion. And the guy would come in for an hour, and it was really an hour of manual therapy. Just really moving his shoulder any way that he could, and that approach has worked. So we kind of start with heating the shoulder. I think that just calms things down. It’s a good way to start before you start your manual therapy. And then he’ll kind of follow that up with a lot of passive range of motion, especially in the restricted position. Because four months out now, we don’t really have any range of motion restriction.
Kevin Coughlin:
So even some strategies like contract-relax, or hold-relax type stuff seems to work for this guy. So it got to the point where at the end of the session, he’d be leaving with about 120, 125 degrees of motion. And then Mike gave him some things to work on at home, so very frequent motion throughout the day. I think it was 10 or 20 reps of external rotation at that 90-degree abduction position, where he could do it on his own with a golf club or stick, and he just did that as frequently as possible.
Kevin Coughlin:
And at first there was a little rough spot where he was coming in back at 110, but now they’ve been working together about a month, and that four week motion phase seems to have really helped. And he’s coming in at 120, 125, and he’s leaving at 130, 135. So they’ve made great progress, and I think the big takeaways are working on the motion a lot in the clinic, and giving them something to work on at home. Because that frequent motion at home is really what’s going to make the difference.
Mike Reinold:
Yeah. I like that. And again, very similar to what we talked about with the knee a few weeks ago here too, is the frequency of what we do is super important. The part of what I like about what you said there, Kevin, here too, is that every patient’s a little different, right? So if you’re just following a protocol, or maybe you’re erring on the side of conservative, for example, I think that approach is appropriate for several types of people. But for this specific person, they have a functional and really a work… need to get back to that end range of motion for them.
Mike Reinold:
So you could argue, what’s our end game with each patient kind of in front of you? And you say, what’s our ultimate goal? What’s our end game with some of these things? For this person is, if they can’t get their external rotation back, they’re going to have a hard time being able to use their shoulder. So the end game of them being tight into external rotation is technically unacceptable to their goal in their functional outcome that they’re looking for. So that’s one thing we have to keep in mind as we kind of bring them through this procedure.
Mike Reinold:
We also have to keep in mind that sometimes people get tight because they’re mobilized, and sometimes they get tight because the surgery over-tightens them a little bit. And that changes things a little bit from that approach too. So, good stuff with this specific person. They may have been a little bit over-tight, they might have went a little bit slow, but for me, I think it’s important as they’re going through this process that we’re checking their range of motion, right? And I’d rather say week four, five, six, seven, eight… Okay, your motion’s there, now let’s back off. Let’s check your motion. Okay, it’s there, now back off. If it’s a touch behind, you’re going to get behind, and you’re going to get more and more behind as it goes on. So it’s kind of a sequence as we go on. But who else wants to add to that? I know Len, you probably dealt with a ton of these surgical things. What are some of your strategies?
Lenny Macrina:
Yeah. I don’t remember. Maybe the students or somebody can refresh my memory. How far out of surgery is this person, do we know? I know it’s a hypermobile person, meaning they have a lot of mobility.
Mike Reinold:
This one wasn’t specific, but-
Lenny Macrina:
I didn’t think so. Okay.
Mike Reinold:
Sounds like Hannah sees this a lot.
Lenny Macrina:
To me, if somebody’s hypermobile, meaning they have a lot of mobility like Scaduto’s patient, who has 130 degrees of external rotation on their non-throwing side, I almost want them to get stiff. And I don’t freak out because over time, even if it’s a prolonged time than what you are comfortable with as a clinician, they loosen up. So I know we always try to hit our milestones of six weeks out of surgery, eight weeks out of surgery, they have full motion.
Lenny Macrina:
But if somebody is hypermobile and they have a surgery to either tighten them, or they just have a general surgery and they are tight and it’s still eight weeks out, I don’t freak out. I’m actually happy, because that means that they are going to maintain that mobility or that stability long term, because that hypermobile person has too much elastin to collagen ratio in their tissue. So if you took sample biopsies of that person’s shoulder, or skin tissue, or tissue in general, they have more elastin to collagen ratio than maybe me, who’s not as hypermobile. And so I think that person is going to easily stretch out.
Lenny Macrina:
There was a study. It was probably 15 to 20 years ago at this point, and I forget the author’s name. It’s a common surgeon who looked at biopsies of tissue in hypermobile patients, and they had a ton more elastin to collagen. And so to me, that tells me that that elastin component is going to allow for the tissue to stretch out. So I want them to kind of get a little stiff, and then I’ll use the principles that Kevin talked about, of multiple bouts of motion a day to begin to assess their mobility and their end-feel.
Lenny Macrina:
If they have a really firm and tight end-feel or spasm end-feel, I got to kind of modify stuff. But if it’s kind of becoming capsular and stretchy, then I know that the tissue’s ready to stretch out and then you can get the motion back. So again, don’t freak out if they’re hypermobile, that’s probably a good thing because again, think of this person a year, two years, three years from now. Are they going to get too stretched out in all that… All the limitations are now gone, and now they’re loose again. We want them to get that stability through, from the surgery and from some scarring too, believe it or not.
Mike Reinold:
Yeah. I can’t tell you how many people I’ve thought were too tight that somehow just magically over… Even a little later too, like that four, five, six month mark after surgery, that motion kind of slowly get back as things settle down and everything. And you’re nervous that whole time, because you don’t want them to be too tight, but you definitely kind of see that over time.
Mike Reinold:
Len, when do you… I appreciate what you just said at six weeks, eight weeks… When do you start to worry more? Or when do you start to panic? Is there a specific zone, like a week or something? When do you start actually feeling like, okay, that little snugness that I liked at six to eight weeks is now behind. When does that happen in this type of person?
Lenny Macrina:
Probably I start to think about things around 12 weeks. Normally in a person who has a shoulder surgery, it depends again on their goals and their age and so many different things and what the surgery was. But around eight weeks, I like to see close to full motion, or at least beginning to see the end-feel is good and they’re beginning to stretch out, we’re still making gains in our motion. If it gets to 12, 14, maybe even 16 weeks, if they’re really loosey-goosey, then I’ll begin… But very rarely do I see a truly hypermobile person who is stiff, it’s at 14, 16 weeks, and I’m freaking out. Again, I just don’t see it in my hand, because I think they never really get stiff enough that the motion doesn’t come back, again because of their underlying hypermobility that they have. I’m not seeing it.
Lenny Macrina:
So maybe this person is too early in the timeframe to start thinking about that they’re truly stiff. I kind of think they probably want them to be stiff. I’m imagining the surgeon stiffening them up through a capsular shift or plication or something like that. So I’d probably want to see the op report too, and see what they did exactly in the surgery. Because a lot of times the script says, “status post labral repair” or something like that, or “Bankart repair,” and you don’t really know… oh wait, they did do a plication in there. But it was never put on the script for some reason. So I’d be cautious to, again, maybe stretch them out too quickly. Maybe we want that stability.
Mike Reinold:
Yeah. Communication with the physician, I think, is key with these types of people too. Like you said, you might read the op note and be like, oh, there’s nine anchors. Well yeah, they’re definitely going to be a little stiff there.
Mike Reinold:
I think you’re generally right. I think you’re right. The majority of time is the way you think of it. But we always get that one person stuck in our head. And I think this is what’s happening with Hannah. You get that one person that’s stuck in your head that has that. And we’ve all had the person like, everything looks good. This motion looks good. This motion looks good. And then just something hits a wall and in your head, you’re like, is that the anchor? It’s so specific. One area loss of motion, you’re like, there’s no way that could be potentially loss of motion. So, I think that would be the only thing I would add on to that, to Lenny and everybody’s answer.
Mike Reinold:
I think that was a good overall thought process. If you do have a person where they do seem like they’re loosening up as expected, like Lenny said, and you have that nice snugness in there, I think that’s great. If somebody has just that one little specific area that’s snug, that’s something that you can maybe focus on a little bit, right? Especially as you start getting 12 weeks, 16 weeks… You know at that point, the surgery’s healed. It’s structurally sound and able to be stressed a little bit. You might want to work specifically on that range.
Mike Reinold:
Now, if you feel it’s a surgical restriction, to me, that’s where we’re less aggressive. And again, it goes back to more frequency and just low-load stuff. We have to get that tissue to kind of heal a little bit around that new surgical repair. But I would just say that would be the only thing I would add there, Len. That’s what I think of. And maybe that’s what Hannah’s thinking. But I think you’re right though. I think probably the majority of the time it goes the way Lenny just said, but we get nervous about that one person where it’s like… You almost feel like they’re hanging onto one tight anchor and you have to kind of push a little bit. So keep that in mind too, Hannah. I think that’s a big part of it is, like Lenny said, six weeks, eight weeks, maybe we’re okay with a little snugness as long as you’re seeing progression.
Mike Reinold:
And this is where I want you in your head to kind of calculate. What’s the range of motion, what’s the quantity and the quality? So how much motion do they have? What’s the end-feel? How does it feel in your hands? And as long as that’s slowly progressing week to week, as you’re doing your treatments with that person, I think we’re happy. I think that’s a big part of it that is good for us. If you get one area that seems to be a little stuck, you may have to work on that a little bit. But in general, I think this is going to be one of those things that patience just helps with over time as well. So awesome. So good question, Hannah.
Mike Reinold:
I bet a lot of people deal with that too, especially varied surgeons all over the world. If you work in a clinic where you get a variety of different surgeons that are sending you people, you probably get some people that feel tight, some people that feel loose, and everywhere around that spectrum. So it gets pretty challenging to figure out. Even that’s another variable we haven’t even talked about, is surgical technique. So something to keep in mind here, too. That’s challenging.
Mike Reinold:
So great question, Hannah, we really appreciate it. Please head to Apple podcast, Spotify and subscribe, rate, review this podcast, and we’ll keep pumping them out, and we’ll see you in the next episode. Thank you so much.
