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A Shoulder Subluxation or Dislocation   (2009)

 


Bill carried my 'therapy' ball for months.

Introduction

In April of 2009 just after turning 58 I partially, or perhaps fully, dislocated my left shoulder. We were in a small Montenegrin town (a coastal part of the former Yugoslavia) traveling by bicycles.

My husband and I diagnosed and treated the injury on our own while continuing to travel overseas for the next 8 months. I did not seek a professional diagnosis or evaluation because we thought that the injury was of limited scope and that the language and culture differences might conspire to make it a useless exercise.  

I share with you what I learned and experienced in hopes it will serve you in recovering from a similar injury, though I trust you'll enjoy more professional support in your journey.

 

I. Responding To The Pain

Making the Diagnosis/The First Hour

Excruciating pain is one of the hallmarks of shoulder dislocations, which is why intentionally causing dislocations has long been used as a form of torture. I had studied a bit about dislocations as a yoga teacher more than 10 years ago and as soon as I banged my shoulder to the wet pavement "I've dislocated my shoulder" was blaring in my brain. I was stunned at that instantaneous pronouncement, but it seemed to have been accurate. What we didn't know, and still don't know, is if I fully or partially  dislocated it. (A partial dislocation is a 'subluxation.')

Full dislocations fall into 2 basic categories: those that self-correct and those that don't. Sometimes the dislocated arm bone "pops" back in to the joint socket on its own; other times the bone must be professionally repositioned with the patient under anesthesia because of the pain involved. Mine may have been a full dislocation that self-seated as I had 2 intense waves of back-to-back pain. For simplicity in reading, I'll refer to my injury as a dislocation.

My first pain wave occurred when I slipped on a very steep road and landed backwards on the shoulder. The second bout of pain hit when I drew my arm down from its forced overhead position, which is when the arm bone might have popped back into the shoulder joint.

With partial dislocations or subluxations, the head of the humerus, the upper arm bone, only partially slips out of the shoulder joint and immediately reseats itself. The process of the bone partially sliding out and back into the joint socket still does a lot of damage along the way, so the distinction between a full and partial dislocation may have little impact on the treatment or healing course.

The pain was so intense with both bouts that I almost passed out when I tried to stand. After what seemed like too long, I was able to roll out of the street into a driveway and then sit up. I had to keep my head below my knees for several minutes to remain conscious. After perhaps 10 minutes I was able to walk the short distance 'home' to our hillside Montenegrin tourist apartment and solicit my husband's help.

Once indoors, I immediately laid down and applied the bags of frozen dinner vegetables that we had in our tiny freezer to the painful area and popped an ibuprofen. My husband got online and began reading about dislocations. While I iced and the flood of stress hormones slowly cleared from my head, he read about associated injuries, like a broken collarbone, so as to make a decision about the scope of my injuries and if I'd need outside help.

Within a half hour of being back in our room, less than an hour of the injury, I was feeling much better. The pain was only off-the-charts in the initial minutes and it gradually diminished to a dull ache after that. By the end of the first hour I was up and walking around and ready to eat, rather than wear, my delayed dinner. 

 

Inflammation & Pain Control with Medications

Controlling inflammation is an important strategy in dealing with any injury to the body. Inflammation is one of the body's necessary healing responses but it's a response that causes damage if left unchecked. Inflammation is what causes the redness, the swelling, and sometimes the warm-to-the-touch quality on the skin. Inflammation itself can cause pain because of the excessive swelling it generates.

Taking a pill is an appealing remedy to body problems and anti-inflammatories are there to do the job. I took an anti-inflammatory, ibuprofen, right away but I decided to use it sparingly. I used it 3 times a day the first 5 days after my injury, then stopped. When the pain level spiked at about 5 weeks, I used ibuprofen at night as needed so I could sleep.  During my worst spells, I took the anti-inflammatory at bedtime and had a second tablet ready to go when the pain woke me up 4 hours later.

Years ago when I was dealing with chronic knee problems the conventional wisdom was to control swelling by using anti-inflammatories around the clock. These are the NSAIDs or 'non-steroidal anti-inflammatory drugs' like aspirin and ibuprofen. But a few years ago I read that the continuous stream of NSAIDs was now 'out' and that the drugs were thought to be more effective when minimally used--that they have more punch as an infrequent treatment. So, that's what I did with this shoulder injury: I hit it hard with the NSAIDs the first few days to control the pain and inflammation and then stopped their use until I had another pressing interval of pain over a month later.

 

Inflammation & Pain Control with Ice

    Applying ice packs to injured tissue is another approach to controlling inflammation. Icing has the advantages over NSAIDs of not triggering any harmful side effects and not losing its effectiveness over time. It is of course tremendously less convenient than taking a pill and unappealing to do in the middle of the night if the pain kicks up. Icing usually means sitting still for 20 minutes and managing the potential mess of the melting ice. It also wildly unappealing to apply ice to your skin and leave it there. And in Europe one can rarely buy ice and travelers almost never have access to a freezer, so bags of frozen vegetables have to be sought on a daily basis and used promptly in order to ice an injury.  

Despite all of the difficulties involved in icing, prior chronic knee conditions had made me a believer in the potency of the anti-inflammatory effect and I began icing my shoulder within about 20 minutes of injuring it. Luckily, I'd bought frozen vegetables for our dinner that night so ice was on hand. I used 1 kg or 2 lb bags of frozen vegetables to ice the front of the shoulder joint, the top of the shoulder, and all around my upper arm. I'd put the veggies in extra plastic bags and either prop myself so there was some pressure on the ice cold bags or tie them in place with clothing or an exercise band.


Nightly icing with 2 lbs of Brussels sprouts.

I had iced my knees for years and always favored the upper limit of 20 minutes in the recommended therapeutic interval of 10-20 minutes. Generally icing longer than 20 minutes is counterproductive because the cold then stimulates more inflammation in the area. On days when I felt the need to ice even more spots on my shoulder and upper arm, I would ice for 40 minutes, moving the veggie bags around to a new position every 10 minutes. (We believe I also tore parts of my biceps muscle as that muscle required considerable attention for months after my injury.)

I iced my shoulder and arm twice a day most days for about the first 10 days. After that we cautiously resumed our bike travels and I continued with the almost daily icing for nearly 3 months, though usually only once a day. At the 3 month point in my recovery, it happened to become difficult to get frozen veggies and it was feeling less urgent to ice, so I let the routine go.
    Were I at home with this injury I would have rushed to buy one of those expensive gel-filled packs with straps specifically designed for icing shoulders. I would love to have been able to simultaneously ice my shoulder blade area, the traps at the top of the shoulder, the front of the shoulder joint and the biceps and triceps of the upper arm as they all hurt at different times. I'm sure I could have purchased one of these aids in Europe but we rarely had a frig at night and a freezer compartment was even less likely so it would have been next to useless.

Actively using a muscle after icing is usually a really bad idea but I found it an extremely helpful practice in some stages of my healing. At about 5 to 6 weeks I began having significant pain from muscle spasms and icing would interrupt the spasms. I also had found that some essential range of motion (ROM) work was too painful to do before icing but was quite accessible after icing, presumably because the icing decreased the muscle spasms. So give yourself the option of icing before doing your rehab exercises, but be sure to move freshly iced muscles with caution to prevent new injuries if you do so.

 

Immobilization or Not

Icing and anti-inflammatory drugs were good first-responses to my shoulder dislocation. Next, we needed to decide if I likely had other injuries, like broken bones. As we talked and Bill ever so carefully moved my arm into a number of different positions, we were fairly certain that the serious damage was limited to my shoulder joint.

Proceeding on the assumption that my injuries were limited to the soft tissues and didn't involve any bones, the next decision was whether to immobilize the joint or not.  Bill read online for guidance and there were clearly 2 camps: one was not to immobilize, the other was to immobilize for 2-3 weeks. With a shoulder dislocation, immobilization usually means supporting the arm in a sling.

One reference said that immobilization could be invaluable in some particular instances but that those instances were few and far between. Immobilizing is the conservative and traditional way to treat the injury, but it isn't without its own risks. A very real hazard of immobilizing is creating a "frozen shoulder" which in itself is a serious condition. I desperately wanted to avoid that painful and difficult to treat condition as I'd known people who had suffered from it.

Independent of what Bill was reading, we also knew that a very general rule is that inactivity slows healing. Generally, healing is hastened by activity if for no other reason than the increased circulation keeps the good and bad chemicals moving through the tissues more quickly.

 Given that we thought my injury was likely an uncomplicated situation because my pain was so isolated and since my bias is always towards moving rather than not moving to solve just about any problem, it was easy to commit to the 'no immobilization' approach. Bill also later confessed that he knew that immobilization was a complete mismatch with my personality and it would go better for all of us if I was mobile during the initial recovery period.

Our decision not to immobilize my shoulder joint was strongly endorsed a few days later by my sports massage therapist back home whom I had emailed for advice, which was reassuring. He went even farther, which was strongly advising to avoid the "broken wing" position altogether and keep moving my arm around.

Six weeks after my injury Bill read a recommendation for 'relative immobilization' for about the first 3 days, which is what I happened to have done. I tried to limit the "broken wing" position that my LMT (licensed massage therapist) advised against and yet found it deeply compelling at times and occasionally surrendered to it.

When out for my 2-hour daily walks, which I resumed the day following my injury, I instinctively held my injured arm to my chest for the first several days as a relative immobilization position. I would either hold it there on its own or support it with my healthy arm. I would also let it rest in this relative immobilization position for an hour or 2 at a time while indoors those first days by holding it close to my chest. I listened carefully to the feedback from my body and it seemed to be a good guide as to when the shoulder needed a prolonged rest.

On Day 3 or 4 I walked with my hand in my pocket part of the time as an intermediate position--it wasn't as secure as being held to my chest but it wasn't subjected to the normal swings of walking either. This was a 'barely immobilized' transition position. A day or 2 of 'hand in the pocket' immobilization was enough and then I was able to let my arm swing gently on subsequent walks.

Our 2009 travel journal entry: "#2 Marking Time:  Healing a Shoulder in Ulcinj, Montenegro"  has a detailed description of my first 10 days of healing if you want to know more. This journal entry describes my healing process and parallels it with the seasonal changes occurring in my R&R town in coastal Montenegro.

 

II. Surviving

An Unwelcome Guest: Pain for a New Reason

The first month or so of my shoulder injury recovery went quite well. We were both satisfied that my "self-directed care program" was successful and on track and I continued to see daily improvements. I was still a long way from having normal strength and mobility, but the steady gains pointed to a complete 'fix' being down the road. But at about Week 5 my pain level shot up without provocation.

Bill was concerned that we'd missed an underlying, additional injury. He again raised the issue of returning home to seek professional care--something I was in no hurry to do. It was only May and the best months of our 2009 touring season were ahead of us. If we went home now we'd miss the good cycling weather and the highpoints of our itinerary.

Bill responded to his concern for my shoulder by spending an afternoon with his nose to the laptop screen doing additional online searches. Nothing he read supported his concern about there being more extensive damage in my shoulder.  What he did find however was startling, which was that there are 2 aspects to healing from a dislocation. The first aspect was the one we knew of, the aspect we'd been tending to, which was supporting the healing of the tissues. The second aspect was totally unknown to us: the need to retrain, to reprogram the brain.

 

Retraining the Brain

As we suspected, the torn and damaged tissues were likely mostly healed at this 5-6 week point after my injury. What we hadn't understood at all was that the source of my discomfort had probably seamlessly shifted from the tissue injury to instead being caused by miscuing--miscuing because the necessary reprogramming in my brain had lagged behind the changes in the tissues.

Even when 100% healed, my internal shoulder topography would have changed forever because of the injury. It would never be exactly as it was before I fell and Bill had understood that--all along he had been referring to it as my "new shoulder."

Akin to GPS, the brain has a precise map of the highly mobile shoulder joint and it has strict criteria as to which positions are safe and unsafe for the shoulder. Unfortunately, my brain had lagged behind and its map was still of my "old shoulder."

Sometimes when my new shoulder was in a safe and desirable location my brain registered the positioning information from the shoulder nerves as being potentially injurious. The brain's response to the joint being at risk was to signal the surrounding muscles to contract to stabilize and protect the joint from injury. Since there was a mismatch between what the brain sensed at the joint and what was actually happening, the protective muscle contractions would continue out of control, hence the muscle spasms. My brain was stuck on protecting that which no longer existed--the old shoulder. 

So as the tissue healing waned, reprogramming my body's "proprioception," or spatial awareness and responses of my shoulder to that awareness, became the main challenge. This new information about the need to update my shoulder's proprioception was very comforting as it, and not an undiagnosed injury, was likely the source of my pain.

This was the good news:  we now understood the issues around this phase of healing and we could further refine our treatment plan to support this additional process. The bad news was that this phase was likely to be a very slow process. Based on prior studies I knew that neuro-muscular programming can take about 6 months, which could represent a lot of pain in  my future. Moreover, protracted pain was one of themes in the online testimonials from shoulder dislocation patients, all of whom were receiving professional treatment.

From what Bill read, there wasn't much more to do for my proprioception updating than I was already doing. In hindsight, it seemed that the hours of bike riding that I was engaged in almost every day was probably well targeted to my brain's needs as for hours every day it was hearing the message "Yes, this is what we do." Cycling unwaveringly delivered that message despite my brain's protests, despite its old map information that said somebody was going to get hurt. It seemed that it was going to be a war of 'data points' and cycling was relentlessly streaming new data points to my brain. The droning message delivered by cycling combined with my ongoing efforts to challenge my shoulder each day seemed to be all that there was to do--and to wait.

 

Sleeping

The spike in pain at 5 to 6 weeks was what prompted Bill to learn about the proprioception retraining that my brain was struggling to complete. The increased pain during the day time was annoying and distracting, but it was the pain at night when I tried to sleep that created the crisis.

Month #2 of my recovery was defined by the nightmare of trying to sleep; Month #2 is when it really became clear that my healing journey was a "family project". Lying down seemed to be sufficient to trigger my shoulder muscles to go into spasm. It seemed too that the stillness, the lack of constantly changing positions that usually occurred during the daytime, also resulted in spasms at night.

An hour or 2 after falling asleep I would awaken with biting pain in my arm. I'd jump out of bed and pace around trying to remedy the distress. Sometimes Bill would awaken and massage the muscles for the second time that night. Other times I would try self-massage, stretching, repeatedly contracting and releasing the muscles, shaking, and anything else I could think of to quiet the noise in my shoulder and arm.

Bill read online that sleeping is a common problem at this stage in the healing process and some dislocation patients do their best to sleep sitting up. I knew from past experience that that isn't very easy, but I certainly would have given it a try if I'd had the pillows and bolsters to support me. Given that we were traveling during my entire recovery, propping myself up that much wasn't an option.

Finding a "position of comfort" when sleeping was hard but I would always hope to find 2 tolerable positions to make it through each night. I experimented with a different strategy every night for months hoping to find what I needed on a given night to get enough rest.

I propped my arm as best I could when I slept. Most nights I had little more to work with than my small traveling wardrobe. There were however 2 propping positions I used a lot. One was to fold my compact, crop-top T shirt and place in inside my armpit. I believe that this opened the injured shoulder joint a bit thought I'm clueless as to why it added to my comfort. The padding wasn't very thick and sometimes it felt best rammed high into the armpit and other times it provided more relief when it wasn't so high.


Pillow-props ready for side-lying on either side.

The second prized propping position was using my thin fleece shirt or my skort, either of which I folded and placed under my injured shoulder when I was on my back. This propping conferred more relief when it wasn't near the top of the shoulder but down a few inches. This support seemed to relieve the tension in the muscles by rolling the shoulder in (internal rotation). It was comforting to both have the shoulder held in place a bit and to have the gentle rotation. Again, this propping position didn't rely so much on a lot of bulk but instead on strategic positioning.  

Providing a high support, as with a pillow, for my arm when side-lying on the uninjured shoulder was less successful. It always seemed like a good idea, but it was hard to get it right. When our room for the night had an extra pillow or blanket I would often fold it so as to form a long tube on which to rest my arm. Occasionally I'd get more sleep using such a support but I often created some very stiff neck muscles by morning. If I'd been at home I'd probably invested in a body-pillow to see if that would have provided the relief I needed.

When I was able to tolerate a bit of side-lying on my injured shoulder, I would bend my elbow and rest the hand of my injured side on top of my pillow in front of my face. Putting a small folded garment or towel under my shoulder seemed to make this position more comfortable.

As the weeks progressed, I also tried dangling my arm off the side of the bed when resting on my belly, sometimes putting a pillow or folded blanket on the floor to support my hand. I couldn't sleep like this long, but some nights it was the second sleeping position I so desperately needed.

I also found I slept better if I introduced a new exercise into my rehab routine in the morning rather than later in the day. An hour or so after getting up and doing my regular exercises was a good time for something new as my shoulder had recovered from its overnight crankiness. By challenging it in the morning with a novel movement that was likely to irritate it, I had the entire day's activities to coax it out of reactive spasm, which increased my odds of sleeping that night.

Had I access to either acupuncture or muscle relaxants when the pain escalated at the difficult 5 week point I would have pursued them both for pain control in hopes of more restful sleep.

 

Massage

I couldn't have coped with the pain from the muscle spasms that flared up at about the 5-6 week point after my injury without Bill massaging the muscles to release the spasms--sometimes several times a day. At bedtime he would massage around the shoulder blade along the edge closest to my spine. Then I would roll myself up into a ball over a bed pillow so as to draw my shoulder blade away from my spine. This bowed position exposed some nasty knots in my Teres muscles, which he was able to release. Some days my traps along the top of the shoulder would ache and become hard from muscle spasms. I also had a lot of discomfort in my biceps, triceps, and deltoids of the upper arm. And of course, if you have enough pain anywhere, the neck muscles get into the act. For me, it is the deeply buried Scalenes that caused the most discomfort.

Fortunately years ago I had taken several anatomy and massage classes at a local massage school and Bill and I were both regular consumers of massage for years before we started traveling. Self-massage and exchanged massage are a routine part of our injury prevention and care so Bill had confidence in his massage skills before my shoulder dislocation occurred.

Knowing the names of the muscles and where they attach is far less important than having the courage to massage whatever hurts. If you are dealing with a shoulder dislocation, I strongly urge you to recruit a partner--live-in or otherwise--to learn enough massage to help you. Few of my spasms occurred where I could reach them in a compelling way--most required another person to address them. Find a sports massage therapist to support you through your healing process and negotiate to have part of your treatment time be spent in giving instruction to your helper.

Well into my 4th month of healing, Bill was giving me daily massages at bedtime so we both could sleep. On my worst nights, starting at about week 6, he was even  giving me a quick tune-up in the middle of the night when the spasms would keep me awake. After my 4 month anniversary, the pain from the spasms was down enough that we began weaning my shoulder off of its daily massages.

Ice and ibuprofen were the key treatments for the initial phase of my recovery; massage was the essential treatment for the intermediate to late healing phases.

 

III. Thriving

Healing Stages

Bill's online searches revealed an excellent website that described healing from dislocations as occurring in 3 stages, with the first stage being the first days when you begin moving the arm with assistance from the other arm through the 3rd stage, which is the long, slow final healing. It was also this same website that educated us about the proprioception issues in healing a shoulder: Oxford Radcliffe Hospitals, NHS Trust Physiotherapy Department "Rehabilitation After Shoulder Dislocation," http://www.oxfordradcliffe.nhs.uk/forpatients/patientinfoleaflets_updatedOct07/shoulder_dislocation.pdf

From a rehabilitation exercise standpoint, the 3 stages have crisp boundaries, though the boundaries for the shoulder healing itself were less distinct to me. My 3 healing phases had blurry lines though I think I was entering the 3rd stage when the pain level  rose again into the second month. We have come to understand that it was the phase where I was dealing with re-educating my brain more than working with the injured tissues.

 

"Fear-Biting"

"Fear-biting" was a concept to which we were introduced 25 years ago as we studied canine behavior in anticipation of becoming dog owners for the first time. There is a brief window in a puppy's development when it is important to expose it to the full range of people and moving objects that it will encounter later in life. Tall people, people with limps, people in wheelchairs, children on bicycles, adults on roller blades--all of these different shapes and sizes of people out in the world need to be a part of a puppy's experience so that it won't be afraid of them. Anything that the dog encounters later in life that is too unfamiliar puts the dog at risk of biting the unknown form out of fear.

This concept of "fear biting" popped into my mind as I approached the end of my second month of living with my injured shoulder. I felt like I needed to expose my 'new shoulder' to the full range of motions that it would experience in the coming years so that they would all be accepted as normal. I could imagine that like a puppy that had missed exposure to particular types of people (like those on roller-skis with poles in the case of our dog) that my shoulder might 'bite' me with pain when it later encountered a rare activity.

At 9 weeks into my recovery, we spent the night in a tiny Italian mountain village with a single hotel and quite unexpectedly, that hotel had a small swimming pool. There were all sorts of reasons to not take a dip: my swim suit was at the bottom of my pannier; the next 2 days would be very hard riding days and I shouldn't risk irritating my shoulder; getting ready for the swim and showering off afterwards would take more time than I'd spend in the pool; and on and on. But as travelers we seem to have about 1 swimming opportunity a year fall in our laps like this one and 9 weeks into my recovery seemed like the perfect time to expose my shoulder to the array of unusual forces involved in swimming.

"Fear biting" was on my mind and possibility waiting 3 or 4 more months for another chance at a swim seemed too late. I had read nothing about this concept in relation to healing a shoulder and yet my own body wisdom was telling me to accept the model. My gut-reaction was that I had until about the 3 month point to expose my shoulder to a host of activities before I risked an overactive response akin to fear-biting. And even if the concept was irrelevant, rehabilitating my shoulder with a wide range of activities was relevant so I let the fear-biting model further spur my rehab.

I did go swimming and was pleasantly surprised that only the back crawl stroke made me wince. The tiny pool helped me moderate my effort as it was only long enough for about 10 strokes--5 with each arm leading. I cautiously did a half-dozen different strokes down and back, stopping at each end of the pool to assess my shoulder's response. It went well enough that I decided to repeat all of the strokes again for a second set, then called it 'good'. I knew that I was always at risk of over-doing so doing less rather than more was the discipline I needed to rally with my injured shoulder.

Later that night I decided that the swimming had been especially helpful for my cranky neck muscles. I guessed that the 3 different strokes performed on my back were what had helped my neck. Swimming on one's back requires strongly tucking and holding the chin towards the chest and I am suspicious that working in such a way knocked my neck muscles out of their orbit of cranky contraction. In addition to the benefits to the shoulder, I highly recommend adding swimming to your rehab routine to keep your neck muscles calm.

 

Rehab Exercises       

The shoulder joint is complex so as to be highly mobile and you don't want to lose any of its mobility as a result of an injury. As a consequence, there are well-established routines for rehab'ing a shoulder injury. Online searches and sites like You-Tube will deliver an endless supply of exercises to supplement those offered by your physical therapist. The afore mentioned website of the Oxford Radcliffe Hospitals has a nicely illustrated, easy to follow program that I periodically referred to during my recovery.


Exercising with latex bands rebuilds shoulder strength.

But like most everyone, I quickly found the clear cut, methodical list of physical therapy exercises just too tedious, just too boring. And having to take my turn in the evening to use our laptop to review them created yet another obstacle to my compliance. So, even though I was committed to having a highly effective  rehab process, I chose to rely on my own customized exercise program instead of following a professionally designed format for the bulk of my rehab.

I knew that like with our brains, most of us don't use all of the capacities of our shoulder and there is a risk during one's recovery that one won't notice some of the mobility losses until much later. One may rehab thoroughly for one's current activities and then take up a new sport or activity year's later and bump into restrictions. The other problem is that after about 6 months of recovery, the scar tissue that forms as a part of the healing process locks-in your options so regaining mobility after that point will likely require professional help, a concerted rehabilitation effort on your part, and some new pain.

Having taught yoga left me with a bigger bag of tricks for exploring on my shoulder mobility than the average person and I tried hard to recall all of the odd shoulder maneuvers I'd ever learned, especially the non-mainstream wiggles, twists, and weight-bearing positions. I tried those moves as early in my recovery as I dared and if some were too painful, I retried them every few weeks until each became accessible. I relied on these yoga skills to discover my mobility challenges and to conquer them.

I injured my left shoulder, my non-dominant side, and one of my rehab strategies was to use the injured arm like it was my dominant side. I tried to use the left arm for more than its share of lifting, reaching, and twisting. I  opened jars with the injured arm in both the high and low position; when we had a high closet that required using a special stick to reach the hangers, I used my injured side; and my left arm was called upon to operate roller devices like on some European window coverings and the cover for the hotel's little swimming pool.


Bill bought a ball to help with my shoulder rehab.

Keys, levers, door knobs, and handles all became physical therapy objects for my injured side. When doing the daily marketing, I'd always carry as heavy an item as I could tolerate in my left hand as I shopped. This habit also helped me bulk-up the left arm and shoulder which we hoped would protect me from a second dislocation to my now-vulnerable shoulder.

Bill read online that bouncing a ball was a good action for rehab and he promptly bought me an inexpensive, small beach ball. Indeed, that action of resisting and repelling the force through the ball was a bit annoying to my shoulder. Any action like that of the ball that was unusual and different was worth repeating so that my shoulder would reorganize with these stresses and demands eventually registering as normal.

We carry a pair of mini-ping pong paddles and balls with us on our bikes and every few weeks we'd spot a table and stop, if only for a few minutes. It was definitely rehab and not a game as we both did our best to make contact with the ball using our non-dominate hands with the miniature paddles. But even a few minutes of lame ping pong was enough to annoy my shoulder, which meant it was right-on as a rehab activity. In some ways it was a similar action to bouncing a ball but being in a different plane made all the difference.

Bill had also read online that balance activities were good for restoring normal functioning in an injured shoulder. Headstand and a 1-legged kicking activity from Qi-gong were a part of my daily routine before the injury and I resumed doing those in modified forms immediately after hurting my shoulder. Only weeks later did I understand that they were excellent for my rehab because of the balancing challenges. And of course the cycling we were doing almost every day after my initial recovery added to the balance training.


No point keeping score: left-handed ping-pong with mini-paddles.

Wobbling is a variant of balancing that is also desirable in retraining an injured shoulder. Almost all of my wobbling rehab came from spending part of every riding day with only my injured arm on the handlebars. And even though I can hold a headstand for 10 minutes, there is a constant bit of continuous readjusting in the upper back and arm muscles in that position that also gave my new shoulder wobble training.

Several times we'd briefly considered returning home from our overseas bike travel to have professional guidance in rehab'ing my shoulder but it quickly became clear that our traveling lifestyle put more demands on my shoulder than a physical therapist ever would. Almost every day I was riding a bike loaded with luggage that weighed over 100 lbs for several hours and muscling it around on sidewalks and over curbs. I was lifting my 20-30 lbs panniers off and on the bike and forcing my left arm to do its share (as it could) in carrying them in and out of hotels.


Rock climbing made rehab more fun.

Between healing months 3 and 4 we were hiking in the Alps, some of which involved hours of rock climbing.  

I used my trekking pole in my left hand as much as possible for the extra conditioning when on the trails. In getting to hiking venues, we hopped on and off several ski lifts with our back packs and slipped and slid on patches of unexpected snow--all of which moved my shoulder in novel ways.

My challenge was to be as thorough in my rehab as a therapist would be. I trusted that my yoga repertoire would be sufficient to regain my full mobility, but I worried about redeveloping my strength in odd positions. I added in push-ups, a back-bending push-up from yoga, and exercise band work to cover a bigger range of strength work than my daily routines delivered just to be sure.

 

IV. The Long Journey Continued    

The 3 Month Anniversary

I had hoped to have a major break-through in my healing at 3 months, but it didn't quite happen. I'd felt like I was on the verge of a bump-up in comfort and capability in the days approaching the 3 month point, but by the time "the day" arrived, my progress continued to be incremental. Three months was also the point at which I had hoped to being living with my shoulder like it was almost normal.


A 3-month healing anniversary celebration in the Dolomites.

But fortunately I only missed the mark by less than a week. A few days past my 12 week healing point, I suddenly stopped awakening from intense pain several times a night. Over the previous weeks the intractability of the nighttime pain had decreased. It had begun by keeping me up for 20-30 minutes at a time and had ever-so-slowly diminished to the point that I didn't have to get out of bed to release the discomfort when it occurred--rolling over was usually enough. Then, finally, it just stopped abruptly waking me up.

At about the same time--within a day or 2 of the intense nighttime pain events subsiding--I was finally able to sleep on my injured shoulder a bit. Having a reliable second sleeping position was a huge aid in getting more rest. And with these changes, I was on a roll.  I stopped propping my arm when sleeping and could reliably rest on my back or belly for positional relief. It was a a monumental change to go to bed and go to sleep without lining up props and struggling every night to find restful positions for my shoulder. It must have been the same kind of relief new parents feel when Baby finally sleeps through the night.


Yes! Wheel pose was mine again!

There were associated changes after Week 12 that increased the possibilities of my shoulder during the day too. There is a challenging yoga pose nicked name 'wheel' that I had begun carefully working towards retrieving. I wasn't sure I'd ever be able to do it again, but I'd been cautiously trying to keep the door open to it. Coincidentally, it was a week later on my Week 13 anniversary that it finally felt right to try the full pose. I was thrilled that I was able to do it at all and was very pleased that it was accomplished with a reasonable amount of ease.

With the retrieval of my wheel pose and the sudden improvement in my sleep situation a few days prior, I felt catapulted to a new level of my healing journey. There had been no such leaps forward in the prior 13 weeks, only slow, plodding progress. Luckily I never had any setbacks, only steady progress forward.

These improvements emboldened me to push a bit harder on my rehab. I'd somewhat arbitrarily set the 3 month point as the juncture at which I should cease being so cautious and start being more demanding. It had seemed that by 3 months the healing journey should have mostly been completed and that I would more fully be into the "function recovery" phase. I was off by about 1 week, but I felt like my body had dropped the flag on Week 13, that now my new shoulder was committed to being a normal shoulder--in a little while.

In hindsight, my deep longing to once again do wheel pose from my yoga practice was a helpful goal to have as a part of my rehab. I wanted to retrieve my ability to do this particular pose because I had previously discovered that it was my perfect antidote to cycling-related neck pain. But having the wheel pose as a goal also kept broadening my approach to my rehab as the standard physical therapy exercises wouldn't go far enough to achieve this extreme position. Having this more exotic goal kept me innovating, kept me pushing to find intermediate exercises to give me both the strength and flexibility I needed. I had emailed a professional I knew for guidance in how to start down this path and then relied on my own body awareness from there.

I wasn't sure pushing up into wheel was an attainable goal, but I knew achieving any portion of the pose would be better than nothing, so there was no possibility of failure. And when I did succeed at Week 13 of my recovery, it gave me a huge boost in confidence and sense that a full recovery was possible.

 

Weeks 13 to 15

Suddenly Much Better

It was in the Week 13 to 15 interval during the 4th month after my shoulder injury that my mind reorganized around the entire injury. For over 3 months I'd lived as a person in recovery from a bad injury but rather suddenly it gave way to feeling like I was a person who was almost healed from a bad injury.

Now I could feel the burdensome fear and apprehension being shed. I was no longer so anxious about "What if I fall". One day when hiking during this 4th month of recovery I tumbled into a bush and broke the fall with the hand of my injured arm. My brain quickly said "Let go" and I tumbled a little farther onto my rear end to spare the shoulder from the brunt of the impact. Embarrassed to have dumped over on an easy trail I was none the less pleased that my shoulder had survived the jarring fall and also that my subconscious mind was taking over--it rather than my conscious mind was protecting the shoulder now. It felt like the old protective system was back to normal, that I didn't need to be so vigilant.

It was also in this interval that I could be a little more cavalier about doing new movements with my shoulder and not be punished by interrupted sleep that night. Sleep disruption due to pain had been my primary system for deciding how much to push during the day and suddenly sleep disruption was no longer an issue. One day I tried a number of untested moves with my 'new shoulder' on a Par Course fitness path in Italy. Dangling from a bar, doing leg hops over a log while resting on my hands, and a couple of other maneuvers were just fine--they didn't hurt at the time nor did my muscles go into spasm in the middle of the night.

New Tasks

It was also in this Week's 13-15 interval that I shifted my focus. I'd hoped to stop pampering and start pushing my shoulder at Week 12 but when the time arrived, that strategy was clearly premature. A week later, it seemed more appropriate. I gradually started being more demanding. Arm positions that had been painful from the onset of the injury and hadn't improved much needed to be tackled now. The time had come to endure more pain in those few remaining positions in order to regain my full mobility.

It was also the time to survey my activities for all that had been abandoned since my injury and to reclaim them. For the most part they were subtle, easily overlooked movements, like jumping. For several years I've made a point to include jumping in my life. Part of the motivation was that it's good for strengthening the bones but it's also something that people stop doing as they age. In my early 50's I decided to reintroduce jumping into my life as it was one of the movements that I saw kids doing that I was no longer doing. But the jarring from jumping was wildly unwelcome on my injured shoulder and it was one of the lost movements. So, now that I was an "almost healed" person, I again began jumping. I'd jump up to look on a closet shelf and jump down off of a rock on a hiking trail or a low wall around town.

Shaking, wiggling, and twisting had all slipped out of my body's repertoire after my shoulder injury because the infirmed new shoulder didn't like anything unpredictable. But like jumping, there was no longer any reason for those motions to be banded--my new shoulder could take it so it was time to reintroduce those movements so as not to create permanent limitations.

My goal in this interval was to let the guarded quality drop away from my movements and regain a bit of reckless spontaneity. It was time to again move about with less consideration and less calculation; it was time to let the burden of so much caution drop away as it was no longer needed.

As planned before my injury, our activities in July shifted from biking to hiking, which coincided with my 3rd month anniversary.  I had my first fall since the injury and caught myself on my injured arm but with no ill effects. Over the next weeks, I slipped on snow and landed on both hands and we did a half dozen hikes that involved a lot of arm strength with rock climbing. Though it was coincidental, in hindsight I think the timing of switching to hiking was ideal for my shoulder. My shoulder was suddenly expected to behave normally in demanding moves untested since the injury and for the most part it did. (Before when I decided to treat it like it was well, it didn't like it at all.) After this point, when I was fearful about hurting myself, it was all of me, not just my shoulder.

 

4 Month Anniversary

There was no balloon for my 4 month anniversary as there had been at Month #3. My healing process had moved off of the center stage of our daily lives--it was nice for the anniversary to be a non-event. Though the slightest provocation, including during sleep, was still cause for my shoulder to remind me that it was "special," its noise had moved into the background of my life.

At 3 months I counted on one hand the accomplishments that were still missing and at Month 4 it was really only 1 significant position still to be regained. As Month 4 approached, I'd reclaimed my ability to do 10 full push-ups with my former high-standard of 15 looking quite accessible. Reaching across my torso to apply force that had made me wince, as in rubbing sunscreen on my other arm, was quite doable. There was still a little weakness in this position, but forcing the injured arm to do some daily leg massage was a win-win bit of rehab.


Incomplete, but encouraging progress.

It was the movements behind my back that still made me turn green from the flood of unhappy sensations as I nudged the shoulder to let the arm travel where it once went willingly.  This was the final hurdle, the final major capability to reclaim: the ability to clasp my fingers behind my back with my injured arm in the low position and the uninjured arm dropping down over my shoulder. At Month 3 even resting the forearm of of my injured side behind my waist was painful, so the progress had been good even if it was incomplete.

 

5 Month Anniversary

A blow to my confidence marked the day that was exactly 5 months from the date of my shoulder dislocation. We were doing a short Via Ferrata or Klettersteig in Austria that required more muscling than any we'd done before and I discovered the hard way that my new shoulder wasn't up to it. It was only our first Austria climb on the wires but it was enough for Bill to conclude part way through "The Italian's like to dance on their climbs, the Austrian's like to muscle their way through." It may not always be true in Austria, but it sure was at this Lngenfeld course.

My shoulder had been reporting the extra effort from the beginning of the heavy upper body workout on the route and by the time it came to the finale, which was clawing from under a 30 overhang with my pack on my back, I bailed after one failed attempt. I couldn't be sure from the feedback from my shoulder at the moment that a second attempt wouldn't be too much, but I reluctantly decided an overhang a 1000' above a ravine was no place to find out, even if I was wearing a safety harness. I was lucky this time, as there was a way to bail--unlike the usual routes--there was a backdoor, an easier way around the difficult ledge.

The general sense of fatigue and soreness a few hours later told me I'd been wise not to push it any further but nonetheless, it was a sobering experience. The sense of performance failure with my new shoulder jabbed deep into my core; my sense of vulnerability skyrocketed.

I'd been so pleased with my healing course and yet this event made it clear that I still was damaged, that I'd still have to moderate my adventures with my 'disability' in mind. And it wasn't just with new activities that I'd need to be cautious, as this was a variation on a theme I'd done a half dozen times in the last 2 months.

It wasn't the lack of confidence in my skill and my courage that was the source of my limitations, it was confidence in my shoulder's abilities that was holding me back. I was left to wonder if this would restrict me and erode my confidence for months or for years. It left me to wonder what other activities might reveal my deficiencies, though paddling sports quickly came to mind.

Once off the wire, Bill indulged me as I did a protracted debriefing of 'hitting the wall' with my shoulder. At that time, it still wasn't clear whether I'd made the right decision to bail.

The strength required on the overhang was at the limit of my ability before the injury and now with a compromised shoulder, it was even more compelling to increase my upper body strength on both sides. The challenge would be to devise an exercise routine specific for climbing on the underside of overhangs but without the use of specialized equipment so I could do it as we traveled. As we hiked down the exit route from the climb, I began visualizing how I could use things like tables and chairs in our hotel rooms as exercise props for strengthening the specific muscles needed to prevent another crisis in confidence.

 

6 Months On

My big event as the 6 month anniversary of my shoulder recovery approached was visiting a fitness center in an Austrian mountain village to do a little circuit training on the upper body resistance equipment.  My goal was to flush-out any hidden weakness in my shoulder muscles, to locate some pocket that I had missed. Happily, nothing much came of it. On most machines my 3 sets of 15 reps revealed little side-to-side differences in my shoulders. When I finished, I could tell that some little muscles around my collar bone were a bit jazzed, but nothing major. The workout was a welcome affirmation that my rehab process had likely been thorough enough.

An unexpected benefit from exercising on the weight machines was that something in my upper arm must have gotten "tweaked" in the process. For months there had been an almost pinpoint specific spot in my arm that still caused pain at night. I would awaken several times in the night and notice mild pain in that spot. But after that single workout, that troublesome spot that Bill couldn't dispatch with massage, was history. That small but dramatic shift reinforced the importance of continuing to add new demands into my daily routines to aid my shoulder in having a full recovery.

Other than the evaluation work at the fitness center, during this 6th month I continued working on my general shoulder strength and flexibility in the problematic "cow's head" position behind my back.

 

Where I Am Now at 30 Weeks (November 9, 2009)

A few weeks ago I experienced an abrupt shift, one that came out of nowhere but was nonetheless distinct: on a subtle level it felt like my new shoulder had just fully settled in.  It was a quiet but clear sensation: in a new way my shoulder felt strong, capable, willing, and in harmony with my body.

After reveling in the new sense of ease, I imagined that the proprioception changes that my brain had to make in response to my shoulder injury had just  completed another phase. Years ago I'd learned that neuromuscular programming can take about 6 months, so this seemed plausible. But whatever the cause, it was a delightful and reassuring change as I suddenly felt whole again.

 I am now at the stage where I realize that it will only be in hindsight that I will know that my shoulder has completed its healing journey. Many moments during the day it reminds me that it's had a difficult time, but it is no longer continuous chatter. It no longer makes me fearful of hurting it, it no longer demands special treatment.

I hope that one of these days I'll notice that I haven't been noticing--that I will realize that I missed the moment when it decided to stop being different, that I'll hesitate for a moment and ask myself "Was it the left or right shoulder?"  I know that this final bit of healing may be another 6 to 12 months away but I trust it too will come.

 In the meantime, I will continue to exercise my left shoulder and arm more than the right side to protect it from re-injury as it will always be more vulnerable to dislocation than it was before. The next hurdle will be when I return home to the States in December as at that time I will have my shoulder evaluated by professionals. Then I will get my final grade for our family project, our 'self-directed rehab program.' Then I'll know if I missed anything in my strength or mobility work in rehab'ing my dislocation.

 

Back Home

I was thrilled when my sports massage therapist gave me a "100% recovery" for my range of motion in December, 9 months after the injury. He commented that the current condition of my dislocated shoulder was equal to or better than the level of recovery that most of his clients ever achieved. As we'd hoped, our family project of rehab'ing my shoulder in a non-traditional way was a success.

Not unexpectedly however, he only rated my total healing as about 80% complete. The strength was back, the flexibility was back, but it wasn't fully healed. The persistent though low level of discomfort made that pronouncement no surprise. He took over the recovery process with very deep work, including working on the muscles on the underside of the shoulder blade and between the bones around the top of the shoulder. My shoulders and upper back ached continuously for weeks as the deep work continued. Another massage practitioner I see who now does energetic work found plenty to rearrange also. As expected, I felt like I was in good hands as my healing process continued.  My expectation was that by the end of our 3 month stay that the nagging discomfort in my shoulder would have vanished.

 

One Year Anniversary

At the one year point after dislocating my shoulder I am satisfied with my recovery though am still aware of the injury. It is the dull, vague ache in the deltoid muscle that reminds me of more painful times. I am told that this is referred pain from other muscles that still are not at peace with their new relationships and not an issue in the deltoid itself. The discomfort isn't even a nuisance, just a reminder. It is made worse by doing strength work and the yoga cow's head pose that deeply challenges the range of motion of the joint. In the short term I am sure that it would feel better if I didn't push the strength and flexibility work but I know in the long term that avoidance would be worse.

I am continuing to give my left shoulder a few minutes of extra strength or flexibility work every day or 2 and continue to use my left hand as though it was my dominant hand for some chores. I am still hopeful that someday it will be completely quiet and yet it hardly matters if it never gets any better than it is now.


Two Year Anniversary

I am pleased to say that at the 2 year point that my shoulder injury is essentially a non-issue for me, but I still do know that I injured it. I had hoped to be beyond that point at 2 years. But a couple of weeks after the April anniversary we started doing the P90X Extreme Fitness DVD's and I am optimistic that the diverse exercise routine in their program will catapult me to a new level of healing. Their yoga segment demands long isometric holdings of the arms out parallel to the floor, which makes my left shoulder muscles scream in protest. The muscles have no trouble at all getting into position, they just don't want to work that hard. I grit my teeth and push them a little harder each week and they are improving nicely. The resistance training (weight lifting) is also therapeutic as is their marital arts routine. I don't think I've done any harm by not 'rounding out' my rehab to this point earlier but clearly my shoulder was up to this intricate work long ago. The lingering dull ache noted at the 1 year point finally disappeared about 6 weeks after I started the daily workout series--probably with the support of ongoing massage work. In hindsight, I'd recommend taking an assortment of different kinds of fitness and/or dance classes, perhaps starting at the 6 or 9 month point, depending on your sense of vulnerability to use those reluctant muscles to their fullest.

 

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