My Journey Back

On January 28, 2016 I underwent extensive Rotator Cuff Surgery on my right arm. This series of posts will focus on my experience through the recovery from this procedure with emphasis on the effects on my ability to regain the dexterity necessary to practice dentistry.

It is my routine to do an extensive Google search on any topic that captures my interest. Needless to say that a diagnosis of a totally torn and retracted rotator cuff in your dominant arm tends to get ones attention. My first research project involved the nuts and bolts of the procedure. I found extensive posts, blogs, videos, etc. on all subjects regarding the current techniques of minimally invasive shoulder restoration. My second focus was on the immediate care and feeding of the arm after the procedure. Again there were scores of hits on my Google and youtube searches. I found the same thing as I looked into  the Physical Therapy phases inherent in the recovery and restoration of function. This process took me through the first month following surgery with out a hitch. At about the 5th week post op, I was allowed to begin to move my hand enough that I felt that I could use my right hand to sign some sort of a seemingly important document. Up till this time if a signature was required then what passes for a left handed autograph had to suffice. But, darn it I was gonna start the path back to normal today! I picked up a pen in my left hand and passed it to my right, closed my thumb and fingers in the normal way. A pain shot from my thumb that was far more intense than anything that I had endured in my recovery too that point. I dropped the pen and grabbed my hand to massage it as one does when it hurts. My fingers closed on the muscle at the base of the thumb and discovered that there was only about half the thickness that there used to be. I was devastated. My supposed 4 month convalescence followed by a return to my dental carrier of 40 years immediately morphed into “Oh Lord, will I ever be able to fully use this hand again?” Once I regained my composure I began the process that had served me well up to this point. Now I am a bull dog when it comes to finding what I need on Google. I will read through as many as 10 or 20 pages of returns because I have learned that what ever order the algorithm picks what I want is often way down at the bottom of the pack…. if its there at all. So I asked the Oracle of 2016, “How does a Dentist recover his dexterity after his hand is damaged?” in about a hundred different ways and all I got was crickets. I won’t go into all the ways that I tried to find out anything about this topic, but all of the results were the same. Nearly nothing, some anecdotal tales of “yes, I had it” tales, but no substantive information on how to work through the restoration of the high function that my profession requires.

Initially through what I hope will be a series of posts I intend to relate what I have learned and experienced through the months since the fateful day when I could not even hold a pen to my return to fixing teeth. Hopefully, when the next doc is going through something similar and Googles “What the heck do I do now?” they will find a bit more information than I did.

 

 

 

Another Post Out Of Order

I want to post a current update on my progress. Earlier this week I had my 4 month followup with DR K. While he was pleased overall, he said I really needed to work on my External Rotation (ER). In everyday speak ER is the motion made with the elbow bent at 90 degrees and rotating away from the body. He said that any and all motions above my shoulder would be hindered until this was freed. He gave me the green light to up my stretches to accomplish this task.

Now let me explain what happens when we raise our arm above the shoulder and why ER is  important. The scapula or shoulder blade must rotate to allow the upper arm to reach its full height. It seems self evident, but it was not obvious to me until I have experienced the effect of a shoulder joint too stiff to allow it to happen. In a normal joint, the upper arm can raise approximately 120 degrees , and the rotation of the scapula adds another 60 degrees of potential motion. If the attachment of the two is so tight that the shoulder blade rotation cannot occur then arm raised in any plane are limited to more or less  shoulder level.

External Rotation has been my nemesis over the time since I was let loose from my sling. I had really been at a plateau with my progress, and all the stretches and PT manipulations were giving small if any gains. Einstein has been credited with this quote “The definition of insanity is doing the same thing again and expecting a different result.” While others might disagree, I do not consider my self more than standard everyday crazy. So I started one of my Google studies to find some different modalities to try. From my efforts I found three ideas to try and see if they would do what needed to be done.

1. Heated Weighted Passive Stretch: 2 to 3 pounds weight 20-30 minutes time. Great to do while watching TV. Follow with 10 minutes of ice cool down
2. Advanced ER stretch with PVC aid custom made by yours truly and dubbed the ERmanizer. This can be used in many planes and is much more effective then the straight pole that I had been using past about 90 degrees. 
3. Finally strap assisted door jam Er stretch. A web belt is used to draw the arm toward the jam to rotate the shoulder externally. 

I have used these three modalities to achieve more increase in range of motion in a couple of days than I had achieved in two weeks of the former protocol.

Remember: I had specific instruction from my surgeon to increase my efforts in stretching my external rotation. I did not push past the point of mild discomfort in my stretches and quit when fatigued.

I hope that this helps anyone who gets to the point where the SOP plateau is reached.

Think about how you were taught to write the first time

This post is a bit out of order in the saga of my recovery, but I feel that today’s subject is important and its on my mind. Also, the discussion of the damage to my hand is proving to require much thought and research to succinctly communicate my thoughts accurately. Today I am going to  fast forward to my first appointment with Courtney Garbade CHT (Certified Hand Therapist).

Details will come later, but by 5 1/2 weeks after surgery my hand skills had deteriorated to the point that I could barely hold a pen and sign my name. My coordination was pitiful. The large muscle at the base of my thumb was atrophied to 50% of the size of the left hand. One of the exercises that had come to mind was to screw nuts on and off of bolts. At this stage that was barely possible and I would have to rest my hand after just a few moments. I was referred/recomended by my Physical Therapist to a specialized Occupational Therapist, Courtney. My first appointment with her was March 7, 2016. A full discussion of this appointment will come later, today I want to mention a work book that she prescribed as part of my therapy. “Handwriting for Heroes Learn to write with your non-dominant hand” is a book developed by three dedicated therapists who were working with injured soldiers at Walter Reed Army Medical Center and else where. This book is the culmination of their work to restore the dignity and independence that being able to write for someone who has lost the use of or had their dominant hand amputated. When Courtney showed me the hand written letter from a soldier that had the ability to write restored to him, I’ll admit the tears freely flowed from my eyes. I am so very grateful that God allowed these fine therapists to be the avenue of His Grace.

While my condition did not fall into that category, I was in a similar kind of need to restore my hand to function again. Handwriting For Heroes presents a 6 week long series of work book pages similar to the ways we were taught in elementary school, but written and designed for adults. Through the lessons of loops and swirls, coloring and copying; the authors provide you with exercises that strengthen both the fine motor muscles as well as the hand eye coordination needed to write. Just like the McGuffey Readers of the old days the repetition is not idle, most of the sentences that you copy offer encouraging words to brighten your day and strengthen your resolve.

I faithfully went through the book from cover to cover, and I can say that the improvement in my hand skills was dramatic. I still write like a doctor, but less so than before my surgery.

I give the book my highest recommendation. It should be on the list of must haves for anyone going though something similar to my experience.

 

To Numb or not to Numb, that is the Question

Up to this point, other than the introductory post, I have been discussing the nuts and bolts of the series of events that led to needing extensive reconstruction of my shoulder. Today I am going to begin to explore the real reason for this series of articles. As a dentist, I need to function at the highest level of manual dexterity. the University of Indiana has a web page devoted to explaining the manual dexterity requirements for dentists. hpplc.indiana.edu/ohp/d-md.shtml

“Manual Dexterity

A dentist must have superior manual dexterity skills. Stop and consider for a moment the size of the average person’s mouth. In order to perform dental procedures, a dentist must be able to work with precision on an extremely small scale. A dentist must be able to exercise very fine motor control and possess excellent hand-eye coordination. If you aspire to a career as a dentist you should engage in deliberate activities through which you can develop manual dexterity skills that are transferable to the practice of dentistry.

Dental school admissions committees expect that applicants have worked to develop these skills prior to admission. When you apply to dental school, you must be able to do more than say, “I’m good with my hands.” You must be able to demonstrate to an admissions committee that you have systematically engaged in activities through which you have developed the necessary manual dexterity skills.

There is another good reason to participate in these activities prior to applying to dental school. If you find that you do not enjoy working with your hands or that you are lacking in manual dexterity skills, it may be an indication that you could find dental school a frustrating experience. Participating in activities to develop your manual dexterity skills will allow you to test out your abilities and determine if you derive satisfaction from the kinds of activities that will consume a large portion of your time as a practicing dentist. Making this determination before you begin dental school (and you are paying dental school tuition) is a smart idea.

Activities that are particularly helpful in building these abilities include playing a musical instrument (piano, guitar, flute), producing three-dimensional artwork (jewelry-making, ceramics, sculpture), or hobbies such as making miniature models. Lab work that requires a steady hand and good hand-eye coordination can also be an excellent way to develop manual dexterity skills.

You should choose an activity that you will enjoy and participate in it on a consistent basis over an extended period of time, preferably throughout your college years. It is helpful if you can find a way to document the level of skill you have developed for an admissions committee, such as taking courses for college credit, performing in a concert, providing samples of your artwork, or obtaining a letter of recommendation from your teacher in an art or music class, or your supervisor in a lab.” 

I have taken to use the term high functioning hand skill individuals to describe those professions that require a similar in this requirement. It has been a bit of a disappointment to me that my study has not shown that this concept is common in the surgical and rehabilitative professions. There is an obvious intuitive skill level needed by  someone who has to create a precise 3D preparation in a decayed tooth that is measured in millimeters at the back of a small dark hole that moves all without hurting or nicking the tooth next to it. That skill level is higher than someone who does data entry, or paints a wall, or washes dishes. If there is a ranking of professions based on manual dexterity I have not found it. An analogy that might be similar, The physical ability and requirements of a professional athlete are intuitively higher than those of an amateur recreational participant in the same sport.

As we will see in the coming posts, the process of the surgery and recovery greatly deteriorated my level of manual dexterity. I feel that some of this could have been mitigated by both changing protocol and some by bringing a Certified Hand Therapist on to the pre and post surgical team. Exploring this in all its details is my sole purpose in writing this series of posts.

 

If I Could Turn Back Time…

By the time that I reached the point that I sought the help of a surgeon, I was far advanced into the deterioration of my shoulder. I think that in order for you to understand my surgical starting point, I need to explain some physiology of the structures of the human shoulder. I will do my best to stay out of the weeds of Real Doctor Speak, and keep the explanations in plain english.

The way that God made us is truly amazing. There are several anatomical structures that need to be defined at this point in my story in order to keep everyone on the same line of thought. At first glance these definitions may seem simplistic and elementary, but humor me, these definitions are important to keep this tale on track.

• Bones: solid parts of the frame thats give the body its structure. There are three bones that form our shoulder. The upper arm bone called the humerus. The shoulder blade known as the scapula, and the collar bone or clavicle.
• Muscles: only two possible functions 1. pull, tense 2. relax, un-tense (they can not push) there are 4 muscles that attach to the rotator cuff. Their names are not relevant at this point. They job is to do two things. 1. Hold the ball part of the humerus against the socket part of the scapula, 2. help the joint move through most of the motions possible.
• Tendons: strong bands that attach muscles to bones. The rotator cuff is made up of the fused tendons of the 4 shoulder muscles mentioned above.
• Nerves: wires that connect the brain to all the parts. They transit control signals from the brain to the muscles and feed back from the muscles to the brain.

My MRI showed a complete tear of the rotator cuff. What we call the rotator cuff is the broad flat tendon that attaches the muscles of the shoulder blade to the ball at the top of the upper arm bone. Its job is very simple; to transfer the pull from those muscles to the arm bone. Since the other end of this tendon was still attached to the muscles, and all they can do is contract, once the tear was complete the end of the rotator cuff had retracted over the head of the upper arm bone (Humerus). One of the unfortunate results that occur when muscles are released at one end is that they get used to their contracted length and are difficult to re-streach if you need to reattach them. This makes the surgical repair of this rotator cuff more complicated especially when, as in my case, this retraction is long standing. Not only does the surgeon need to stretch the tendon back to position, it needs not to be so tight that it will pull through the stitches that attach the tendon to the bone for the months required for healing.

Another unfortunate result to muscles that are detached or are disconnected from their nerve connection, is that when they are not loaded they loose their fitness, get flabby and even can undergo irreversible conversion to fatty tissue. This had occurred in the three muscles on the back of my shoulder blade two to a moderate level and one severely. While this piece of bad news will effect my eventual recovery, it has no bearing on the surgical repair.

My MRI also showed two other complications that would effect and complicate my surgical repair. My Biceps tendon was also involved. and there were boney projections that had grown into the space where the muscles and tendon move snagging the movement and constricting the functional space within the joint. These damaged structures would need to be felt with in the surgery procedure.

All of these issues put together made the surgical process about as high as it gets on the difficulty scale. It took an arthroscopic Rembrandt to pull it off. I am so thankful that God led me to my surgeon!

In the next post I will discuss an supplemental anesthesia procedure that is currently recommended in this type of procedure and its potential side effects.

 

 

Background Cont.

When I realized that my shoulder was in too much trouble to heal itself, I had to decide who to ask for help. I was still in the typical male mindset of “rub some dirt on it.”  I just wanted someone who knew where to put it and what kind of dirt to use. From my work with jaw muscle issues in my dental practice I recognized the pain that I was having as muscular in origin. This pain can be exquisite and refer from the site of the injured part to distant locations in patterns that have been extensively studied. This muscle pathology has many causes. The most common cause, the one that I deal with in my practice, is chronic muscle tension or what we know as “overuse”. The muscle fibers get fatigued from constant contraction and build up chemistry that disrupts their normal function. This leads to breakdown of the normal anatomy and the formation of distinct abnormal structures we call trigger points. It sounds positively medieval, but one of the best ways to treat these trigger points is to physically disrupt them by poking them with a needle. The technique is called dry needling. Most of us are familiar with acupuncture. Dry needling is the process where an acupuncture needle is inserted through the skin and into the trigger point. This process is not anymore than uncomfortable and in my case remarkably effective. I am getting ahead of my story.

I knew a Physical Therapist that had treated my patients with trigger points in their jaw muscles. I consulted Matthew and he agreed to see me for evaluation. His evaluation was a frozen shoulder and that I had trigger points in just about all of the muscles in my shoulder that he thought he could help with dry needling, massage, and an exercise regiment. He would not commit to healing my shoulder, but that he would see what degree of benefit that PT could provide. Over the next month we had, I would guess, 8 sessions of PT and dry needling, and my pain was reduced significantly. My sleeping was back to normal and my outside the office activity was pretty normal as long as I was gentile and careful.

My range of motion, however did not improve and during this time. I had some significant pain and weakness in some of the arm motions that I use in my practice. There was one specific patient that needed some difficult fillings on the lower right molars. There are times in daily practice when it is necessary to use your hands for multiple functions in addition to actually doing the procedure. This was one of those situations where I had to hold cotton rolls in place on both sides of the teeth retracting both the tongue and the cheek to keep the area open and dry. My shoulder was screaming! How I managed to get the job done I will never know. Right then I realized that beyond any doubt I needed to go see a real doc and have a full work-up done. I will not go into details. but after two work-ups, X-rays, MRI, and a steroid injection. I was given my diagnosis … complete a total rotator cuff tear with biceps tendonopathy. I was basically given three choices: Live with it as long as I could; have a reverse total shoulder arthroplasty (thats a Real Doctor name for creating a new joint from titanium parts); or to attempt to reconstruct the shoulder with original factory installed parts. My decision was easy, I had to do something and the thought of using hardware to fix the shoulder if I did not absolutely have to was not attractive so I opted to have reconstructive arthroscopic surgery. This was done on January 28, 2016 on an outpatient basis.

My next post will cover the procedure itself and the initial recovery.

Background

Lets start this tale with the events that led to the need for surgery in the first place. I was born a young lad ….. just kidding. It is true that this bad shoulder starts its deterioration a long way back in time. There was no one time or event that I can identify as a single cause of my issues. As I look back, however, I realize that I was probably in trouble 10 to 15 years ago when I stopped throwing the football with my kids when we were together. My arm would hurt and I had no strength in that weighted overhead motion. But at no time did anything effect my ability to function in my daily life. Another clue to the genesis of rotator cuff tearing was evident about 7 years ago. I was building a cover on a boat house at a lake lot that we owned at that time. After a Saturday of pounding nails and sawing boards, I would ride home with my right arm propped on the back of the seat of my pickup truck. When I got home I would have to lift my right arm off the seat back with my left hand. Again the arm did not hurt or was my daily functioning affected. Using the logic of a typical American male, lifting weights, the heavier the better, solves all joint and muscle problems. Indeed, the shoulder did improve after a while in spite of my ham handed recovery efforts. From that time until last fall I had few issues to come to my attention. Through the summer of 2015 I did have some increase in stiffness and soreness in that shoulder that would lead me to take my other fall back, 800 mg ibuprofen, several times a week. Again, I got by without any real hinderance. That was until I had to paint a shed at our cabin. It was on the first Saturday in September 2015 where the heat and humidity of summer was abated. I spent all day up and down, working over head all day long. Did I quit when my arm got tired. No! Im no pansy! Did I quit when my shoulder cramped and kinda just quit working? No! but I did switch to my left hand to finish. From that time, for the next month or so I was in misery. I could not move my right arm with out pain. I could not hold my arm in any position that I needed for work for any length of time at all. I could not get comfortable enough to sleep for more than a short time. Something was finally wrong enough for me to seek professional help.

In my next post I’ll take the story from this point till my X-rays, MRI.