July 11th, 2012
by James D. Hundley, MD
During my first year of residency, Dr. Charles Neer, a famous shoulder surgeon, was our visiting professor. We learned a lot from Dr. Neer but the idea that stuck with me forever was his simple technique for regaining shoulder range of motion following surgery.
Dr. Frank Wilson, our training chief, was very influential with his description of the shoulder capsule as being analogous to the leaves of an accordion. You had to tease them apart bit by bit. Except in rare cases, he frowned on manipulation under anesthesia.
Keep in mind that this is about regaining functional use of the shoulder in average people after a fracture or other injury and surgery. It is not about regaining strength other than in daily use of the limb and it’s certainly not about the definitive rehabilitation of athletes.
Naturally I must insert a disclaimer: I am not your treating physician. I am simply telling you what has worked for my patients for many years. Your treating physician is the one you should listen to primarily. Consider these ideas as supplementary or complimentary to what you’ve been told.
Here are some ideas to keep in mind:
- Most use of the shoulder is to put the hands in front of the body so if you can reach up in front enough to get to a cabinet above eye level and reach down to your lap, you can do most of what you want to do.
- A simple way to accomplish this is to grasp your palms together and interlock your fingers. Straighten the elbows. Then use the normal arm to lift the hurt one. It works better if you lie supine since once you get to 90 deg. of forward flexion, gravity will assist you rather than fight you.
- Steady, almost constant, gentle stretching is needed, is generally safe, and can be very effective.
- You need to move your shoulder often, not just once a day or so when a therapist is there to help you.
- Manipulation under anesthesia seems fast but carries the risk of muscle and tendon ruptures as well as fracture. Furthermore, after a manipulation there is a tendency to quickly return to the pre-manipulation contractures
- Passive range of motion precedes active range of motion. “Passive range of motion” means that something moves the affected limb other than the muscles of that limb. In these techniques you are using your good arm to move your bad one. “Active range of motion” may be contraindicated following some operations (rotator cuff repair for example) and fractures. Listen to your surgeon about when you can start active motion. Unless you regain passive range of motion, there is no chance of regaining active range of motion.
- Flexion to get the arm overhead also helps with external rotation. Concentrate on flexion and don’t worry much about external rotation. It will follow.
- It absolutely helps to lie supine to use gravity when using the Neer technique. Otherwise, “gravity uses you”.
- If you will prop your arm away from your body (pillows or arm rest or arm over the back of a sofa when sitting, elbow on a table or desk), you can change your starting point from down by the side to a better place. That gives you a head start and helps tease those sticky layers of capsule apart.
- Be innovative. Figure out ways yourself to stretch your arm forward and upward. Reach up to a tree limb, bar, door jamb, whatever it takes, and hold on to it for as long as possible.
- Internal rotation is another matter. You have to make that happen. The best way is to reach the bad arm as far behind your back as you can and grasp the wrist of the bad arm with the hand of your good arm. Initially it will be just pulling to get it behind your body. Ultimately you need to start lifting the hand up the back until you get it as high as the hand of the good one will go.
- Physical Therapists are very important in the rehabilitation process. If you depend on them to do all of the work, however, you are missing many opportunities to help yourself do better. They can treat you once every day or two. You need to be moving your shoulder almost all of the time.
- Finally, here’s something to keep in mind about healing and my concept of “cumulative pain”. The body is a remarkable organism and starts trying to heal things almost the instant it is injured. That includes surgery. Healing starts with bleeding followed by formation of scar tissue and so on. If you wait until the pain of injury/surgery has subsided before you do any serious movement of a joint, I think that there is a 100% chance of it scarring down and never moving well. Early motion is critical. Cumulative Pain: I’ve always told my patients that the pain of regaining motion in injured joints can be equated to the pain of walking barefooted across a bed of hot coals. If you go slowly, I believe that you will hurt longer than if you push through the pain and go faster. Thus, your ultimate pain burden will be less if you move on and get it over with. That’s not to say that you can regain your motion in a day, but you probably do need to regain it in two or three weeks. Once four to six weeks have passed, you have a big mountain to climb.
- You can and need to help yourself regain motion in your shoulder after injury or surgery. Your therapist is important but cannot do it all for you.
- If you are doing your own pulling, you may cause pain but you are unlikely to harm yourself.
- Time is critical. You cannot wait weeks and weeks to regain substantial range of motion.
- Forward flexion is the most important movement. Do this by grasping the hands together and lifting the good arm with the bad. This is easier when lying supine than when vertical.
- Prop your arm away from your body as often, as far, and for as long as you can.
- External rotation tends to improve along with forward flexion, so concentrate on forward flexion.
- Internal rotation needs special attention. Regain that by pulling the wrist of the bad arm behind and then up the back with the good hand.
- Check with your physician/surgeon before doing these exercises and do not begin lifting the bad arm with its own muscles without your surgeon’s approval.
Dr. Hundley is a retired orthopaedic surgeon and is the president of OrthopaedicLIST.com.