Almost a year since Shoulder Labral Repair - Mechanics all wrong.

[welshwizard]

Hi,

This could potentially be a long one, so brace yourselves and wish me luck.

In May '13 I was 70 minutes in to a game of Rugby League, tired, I was hit face on AND from the side which dislocated my left shoulder. On falling to the floor, the impact helped the shoulder back in to position. Unfortunately, my mental toughness meant I had unfinished business and went back on to the field only to suffer the same fate within seconds.

I left it a couple of days before seeking help. I visited A&E who X-rayed my shoulder. This showed nothing, but the discomfort was too much and I found that when my shoulder was elevated in front of me, i.e. putting a pair of socks on, or reaching above for something I would get this painful catching sensation that felt very similar to a subluxation. As a result, I hounded and hounded my GP until he referred me to a pre-orthopedic physio.

They didn't do much in respect to my shoulder, but helped to improve my posture so when I went for a consultation with the orthopedics, they wouldn't turn me away and claim it was due to bad posture. Moving on to this consultation...

They did tests, results, scans (MRI) only for it all to show up with nothing. In their very words they claimed;

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I knew there was something up and asked them for a diagnostic arthoscropy which they agreed to. So in July '14 I underwent surgery and this is what they found;

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Recovery went well and on the 14th of October I was discharged. Upon the discharge, I was told it was very important to continue work on my scapular stabilizer in the posterior kinetic chain. For a couple of weeks I followed this advice, but figured I knew my body better than anyone else and started lifting weights again. It wasn't until around mid September that I started directly training shoulders and before long I was over head pressing dumbbells that I shouldn't have been. Bench pressing was also common in my routine. Basically, I was doing exercises now I know I should never have been doing as this, on top of very minimal physio has created imbalances and underlying issues within my shoulder. My mechanics are all wrong.

Around a month ago I had some cortisone shots for Bursitis which my GP seems to think was a result of the overhead pressing. Since, I have paid to see a private physio and this was their assessment;

Apologies for the late reply. You can inform your GP that following my assessment I feel that you have a shoulder impingement due to muscle imbalance around the shoulder and scapula with weakness of the posterior cuff muscles and tightness of the pectorals and medial rotators of the shoulder. A course of physiotherapy including mobilisations to the shoulder joint with a progressive home exercise program to strengthen the weak muscles and stretch the tight ones should help in resolving your symptoms. This may take 3-4 months with a course of 6-8 treatment sessions.

Now my goal is to get back playing Rugby, albeit not the level I was at- but I need some enjoyment back in my life and I feel my shoulder is stopping me. Unfortunately, as I'm working for a company who are putting me through some NVQ's, I'm earning lemonade wages and I cannot afford to continue seeing my physio, which brings me to this post;

From the physios assessment, to the consultations advice; what can I add in to my current routine at the end of lifting sessions (might I add I have become much cleverer with my training and improvised well) to continue my rehab?

At the minute; I'm not certain the 20-30 minutes I spend each day is benefiting me. I spend some time stretching out the chest and the moving on to what my physio recommended I did in my 1st assessment. I can upload a video of these exercises? I need & MUST sort my mechanics/mobility/posture out and I was really hoping you guys could help me until I can financially justify seeing a physio again.

Here are some photos. I appreciate the lighting is not the best but I hope it gives you a fair idea.

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Thank you so much,
Ashley Owen

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[physiobob]

Hi Ashley, thanks for the detailed history. Seems you had a labral tear. Did they try a repair on it? If so there would have been a fairly specific post op plan so as not to damage the repair. Looking at you there is no need for mass bulking up, but more as you say of a balancing of the shoulder area. I think we best start with what you main problem is as it is a little unclear. Unfortunately once a shoulder had become unstable it it likely to remain somewhat unstable even with a labral repair. There are some should braces that can be used when playing rugby that will limit some arm positions that are more likely to cause subluxation. Right now if you have had the need for a cortisone injection it would follow that less is more in terms of the rehab. Pass on some short terms goals and I'll be happy to pass on some commentary. Might not be until tomorrow though.

[welshwizard]

I'm not sure why I used my full name to finish that opening post, haha. I did have a labral tear and they did repair it. The post op plan was clear, and I followed it to a TEE until they discharged me and I wavered some what by lifting too much too soon. There is no retear, the ultrasound which pinpointed my bursitis showed that. My goal now is to just balance things out again and get my mechanics working correctly.

The main problem is as described from that physio assessment I had, "Shoulder impingement due to muscle imbalance around the shoulder and scapula with weakness of the posterior cuff muscles and tightness of the pectorals and medial rotators of the shoulder." which is causing some pain and discomfort which comes and goes.

As well, when training certain muscle groups- I don't get as much of a "pump" in the left (shoulder in question), or for better terms it doesn't feel like much blood is flowing. It's a very difficult one to explain.

I appreciate the short term goal and am willing to be patient and put Rugby to the back of my mind for now.

[physiobob]

OK, thanks for the additional information. The short of it is that once a shoulder has undergone a dislocation it won't 'feel the pump' in the same way as the non-injured side. The brain with has some apprehension with the movements and it will not allow the muscles to work as fully as they did before until they are dead certain that there is no chance of reinjury. Now that can take years, not months. With potentially more movement available in the joint the balance on the rotator cuff needs to be better than ever and the general necessity is to strengthen the external rotators/ rhomboids, lower fibres of trapezius and lengthen the internal rotating mechanisms, including the PECs (especially minor). Also important will be cervical and thoracic mobilisation as without that things aren't going to stay lengthened.

Importantly on the external rotators it is the eccentric strength i.e. the strength controlling the arm as it returns to neutral from the fully externally rotated position. You need to has a therapist show you the progress of this from an elbow by the side position, eventually with arms out to the side like a laternal bumbell raise position. It is light weight first and then speed progression with control at that same weight before you up the weight, then again speed control with that weight before uping again. I would not suggest cortisone as a useful tool at this stage. It might just hide the symptoms you need to ensure you are not doing any further damage to the area. Mentally take on board this could take 18months to feel more normal and taking a more general body approach to your fitness and core connection e.g via body pump classes or even cross fit with light weight might be a way forward too..

[welshwizard]

I figured there wasn't much more to it than what you explained regarding the blood flow or pump as we gym folk know it so thanks for confirming that.

All in all thank you for your reply. I know it can be quite difficult to consult over the internet when you are not able to do a one on one practical assessment. Moving forward, until I can finance more physio sessions, do you recommend a website that will have videos of exercises I can use following on from your advice and furthermore are there any specific ones you recommend?

As hard as it is to accept, I know it will take longer than just 10 months to be perfect again; but I don't really want to be wasting my time much longer with movements/exercises that are not benefiting me. The 2 exercises my physio asked me to follow are;

1. Tie a resistance band to form as a resistance bringing your arms forward and raise so your fingers are pointing towards the ceiling, applying resistance against the band on the way up and down. Palms facing outwards. Very much like my movement in the pictures 4&5 below.

2. Lie flat on the floor on your side, body straight and perform a static rotator cuff "push out" using a light DB

As explained, I always stretch my PECs, do facepulls using light weight and also do some light dumbbell scapular retraction.

Should I carry on with this until I see her again in a months or so time? Are there any exercises you'd recommend adding or removing from my routine that takes roughly 20 minutes a day 4-5 times a week?

Thank you!

[physiobob]

It's hard to tell you the progression of the exercises without seeing where you are at with them and how the form is with them so it is best to seek advice on that. However you should not be stuck on these same exercises for a month. You should be able to get a progress list to work on over the month as in that time I would expect you to be rather competitent with them and moving on to more whole body exercise. Again I can't impress on you enough the need to work on whole body core exercises and not to focus to much individually on the shoulder except for the eccentric control work through range of should movement. After than more pressup variations, planks, side planks, medicine ball lunges with a twist of the waist etc to get it connected. That's what will end up getting you a better end result and for now you have a 'bursitis' so you won't want to be aggravating that with too much pure shoulder focus.

[welshwizard]

That all makes perfect sense, and reaffirms that I need to carry on seeing my physio.

Thanks for all your help.

[physiobob]

Cheers and let us know how you get on in a few weeks time ;-)

[toddchaney]

I would also recommend you to continue with physical therapy. He will be able to keep a track on your recovery. Have patience..