Coming Back From The Brink
“Torn rotator cuff, surgical repair recommended” are words every wheelchair user dreads. Unfortunately, an active life on wheels can put more demands on the shoulders than they were designed for. Just as time, age and injury can cause ambulatory people to face knee and hip surgery, wheelchair users often end up with shoulder damage that requires surgery.
Fortunately, rotator cuff repair techniques exist and continue to evolve. A surgery developed in 2007 called SCR — superior capsular reconstruction — is able to mend many severe rotator cuff tears that previously would have been considered beyond repair. Before this discovery, severe tears required reverse shoulder replacement. RSR is a complex surgery that generally limits wheelchair users to a power chair, as it is unclear how long the materials used to reconstruct the ball and socket would last under the rigors of pushing a manual chair. Also, a recent study reports higher complication rates from RSR for wheelers than the general public.
As the lifespans of people with spinal cord injury become more comparable with the general public, surgeons are becoming more creative with shoulder restoration. Regardless of the type of repair, recovery is a long and arduous process. It starts with no weight bearing — pushing and transfers — for 10 weeks to six months. Then the real work begins, rebuilding muscles strengthened by years or decades of daily activity that had quickly atrophied during the post-surgery rest period.
Here is a look at shoulder surgery rehab from the experience of four wheelchair users, along with a clinician’s explanation of the process. All four had over 30 years on wheels and diligently maintained their shoulders in hopes of countering the added wear and tear of their active lifestyles, but still found themselves facing surgery. Although three of the surgeries were SCRs and one was a unique “save” where the only viable tendon was the infraspinatus, they all had similar recovery experiences.
“Unfortunately, surgery is the easy part,” says Erica Platil, a physiotherapist, PT assistant, and certified athletic trainer who works in Denver, Colorado, and has over 30 years in the rehab field. “Rotator cuff surgery rehab generally takes about a year for maximum recovery.”
Diagnosis and Surgery
Bill Bowness, 60, in his 42nd year as a T12-L1 para, is currently rehabbing his third rotator cuff repair. His right rotator cuff was done in 2015, and his left in 2017. “My right shoulder started acting up again, especially during transfers and/or lifting my arm up. It got to the point that it hurt so much that it was time to get it fixed,” says Bowness. He went under the knife earlier this year to repair a full-thickness, medium-sized tear of the supraspinatus tendon — the tendon that runs on top of the shoulder and is responsible for lifting the arm. Due to the severity of the tear, Bowness’s surgeon chose to perform SCR, which reinforces the repair with some type of graft. In Bowness’s case, that meant a tendon from a cadaver sutured into anchors drilled into the shoulder bones.
“Over the years, my right shoulder started hurting and aching more and more. It finally got to the point where it was so bad I couldn’t sleep at night, and I couldn’t lift my arm up over my head,” says Doug Garven, 52, in his 30th year as a T6 para. An MRI diagnosed a complete tear and retraction of his supraspinatus. Garven’s surgeon was able to reconstruct it using the SCR technique. “My surgeon said a repair for this type of injury usually takes about 45 minutes, but mine was so bad it took him two hours.”
“My right shoulder had been bothering me for a while,” says Matt Feeney, 56, in his 31st year as a T9 complete para. “One night I went to transfer from my bed to my chair and the shoulder collapsed. I had intense pain on the head of the shoulder and it shot down my arm, and all the strength just went out of it.” He managed to get into his chair and his roommate helped him transfer into his car and get to the emergency room. The ER doc examined him, suggested a workup with an orthopedist and gave him painkillers that enabled him to finagle slow and difficult transfers. “By the next day I was able to transfer but I didn’t have any lateral strength,” he recalls.
Feeney underwent SCR reconstruction surgery to repair a full-thickness retracted tear of the supraspinatus tendon and also a full-thickness tear in his infraspinatus tendon. “My surgeon said I really did a number on my shoulder, and he had to do some extensive work to put it back together.”
“My left shoulder had started to ache as years went by,” says Don Lively, 58, in his 38th year as a C7 quad. “One day I was getting out of the pool and something popped. It felt like somebody stabbed me in the shoulder, and the pain radiated down my arm.” Lively couldn’t lift his arm to shoulder height and he had to hold his body at an angle to prevent the shoulder from pushing out of the socket when wheeling up a slope. In 2011, an MRI showed all of his rotator cuff tendons except for his infraspinatus tendon — which attaches the muscle of the shoulder blade to the top of the shoulder — were beyond repair. However, because Lively didn’t have much arthritis, his surgeon felt that even with one fixable tendon, his biological joint would last longer than the only other option, a reverse shoulder replacement. Lively agreed, and his surgeon deftly rebuilt what he could with the infraspinatus.
Perhaps the toughest part of rotator cuff repair is immediately following surgery. For six weeks, your arm must be completely immobilized in a sling with an abduction pillow. At around two weeks, under the careful guidance of a therapist, your arm can be taken out of the sling to hang and do slow circles. Around week three or four, the therapist will carefully guide you through range of motion exercises and slowly build to you performing ROM under your own power. At the six-week mark, the sling can come off and muscle building can gradually start, under guided therapy.
All four people I spoke with said that while using a sling they needed assistance to sit up, dress or change positions. Garven and Bowness had arranged to borrow power chairs and Hoyer lifts, and since their wives are both physical therapists and able to assist them, both were able to go home the same day as their surgery. Lively spent three days in the hospital, a week in a rehab hospital and then returned home. His insurance rented him a Hoyer lift and hospital bed and he was fortunate to have the resources to pay out of pocket for an attendant to come in every morning to help with bathroom duties, showers and getting dressed. “Our house is flat with smooth floors, so I chose to stay in my manual chair and use my good arm to get around,” he says, adding that he used an “alternating wheel push” until he healed. His wife Gail, a C5 incomplete quad, was able to use the Hoyer lift to get him into bed and undressed in the evening.
Feeney’s acute rehab was the toughest. Medicare and Medicaid covered his power chair rental and a stay at a skilled nursing facility. After visiting four SNFs, he found one that looked great and assured him it would secure an air mattress to prevent pressure injury before he arrived. It didn’t.
He was still on heavy pain killers when he arrived at the SNF and was placed on a firm mattress. It took four days before his air mattress arrived. When it did, it was incorrectly assembled, resulting in motor failure that rolled Feeney, in slow motion, onto the floor — on his good shoulder. “After 10 minutes of hitting the call button and yelling, I used my cell phone to call the front desk for help,” he says. The events caused a pressure injury on his tailbone. He called a wound-care rehab and was admitted the next day. “The lesson I learned is to have a friend or family member as a medical advocate, and have them frequently visit, especially if you’re going to be on pain medication,” he says.
For wheelchair users, the big question following rotator cuff surgery is when they can start weight bearing and working on transfers. “This is another gray area and varies from surgeon to surgeon, as well as with each therapist,” says Platil. “Because the healing peaks at around the four-month mark, waiting until then to begin transfers offers the least risk for re-injury, especially if you fall and have to catch yourself with your repaired arm.” Both Feeney and Lively were cleared to use a transfer board and then slowly start working on independent transfers at 10 weeks. Bowness’s surgeon is more conservative and told him “no transfers for four months.”
Garven’s surgeon said “absolutely no pushing your chair and no transfers for six months, and that goes for small tear repairs as well as major ones!” At first, Garven thought that was too long, but it turned out to be great advice. “Within the first week of going back to my manual chair I flipped onto the floor and I had to climb up my shower bench to my chair — exactly what the doctor said not to do. I was terrified I might have re-torn my shoulder. It turned out to be OK, but I’m very glad I waited so long. I can’t imagine if this had happened at the three-month mark.”
“Unfortunately, muscles atrophy fast,” says Platil. “By the time a wheeler’s shoulder repair is cleared for transfers, they have a long, slow, steady road of work to rebuild strength. In general, it takes about a full year to get back to the level of function — pushing and transfers — prior to surgery.” Both Lively and Bowness say the “full-year to gain maximum function” is right on the mark.
“At the four- to six-month mark, I usually work with them twice a week and have them do their prescribed PT exercise — 15-30 minutes of rehab exercise — on a daily basis,” says Platil. She adds that wheelchair users in shoulder recovery should do prescribed rehab exercises, but no more and no harder than prescribed. Prescribed harder workouts like handcycle or strength training are limited to three days a week max. “Doing additional workout will not speed things along but is likely to set a person up for re-injury because as a wheelchair user you are always using your arms so there is no time for them to rest, and muscles need to rest to rebuild.”
Bowness feels this may be why his first shoulder repair needed to be re-done in four years. “I probably pushed into transfers and then sports too early, which is likely why I re-tore it a second time,” he says.
“A difficult thing to remember, something which is often very frustrating, is it takes about six weeks to build up muscle, and it isn’t linear — sometimes it builds, or it may plateau for a bit,” explains Platil.
In addition to patience and perseverance, body weight becomes a factor, especially in transfers. It helps if one is able to get their weight down before and while recovering from surgery. Lively kept his weight at a svelte 130 pounds, which probably enabled him to do car transfers a quick four months following his surgery. “And still, I ended up on the doorsill of the car the first time I tried it,” he says. “To this day my left arm is a little weaker, but I do have full range of motion. I can lift my arm over my head, transfer and push my chair, so it is pretty good.”
“By the six-month mark, when I was cleared to go back to my manual chair and work on transfers, my shoulder was really weak,” says Garven. “And using a power chair for six months caused me to gain about 15 pounds.” He was able to do sliding board transfers right away. And now, seven and a half months post-surgery, he is able to do transfers to his car, bed and shower bench with no sliding board. “At this point when I do a transfer, it feels like I weigh 500 pounds.” Garven’s big goal now is to build his strength enough to transfer in and out of his beloved ’74 Porsche Carrera, as well as in and out of his handcycle.
Life Goes On
“This whole process has been an exercise in patience, and I’m finding out I have a lot more patience than I thought. But right now I feel like I’m running out,” says Feeney. At eight months post-surgery, he can do a lot of his own transfers, but still needs a sliding board for some, like chair-to-car. Feeney also laments putting on weight during rehab. “I probably gained 15 pounds — I’m the heaviest I’ve been since I was injured.” He can do a 20-mile handcycle ride, but still needs help getting from his handcycle into his chair. “I’ve come a long way, but it’s frustrating. I feel like I plateaued in the last month. I’ll keep doing what they tell me to do and hope I make a breakthrough in the next few months, but there is a little concern here.”
Bowness found that following all three shoulder surgeries, by the time he was released for transfers his shoulder had atrophied. “I’m 16 weeks post-surgery, and my shoulder is doing fine, but it is super weak,” he says. He is pushing a manual chair but still has to use a sliding board for transfers. On his first two surgeries, his shoulders came back good and strong but not as strong as before the surgery, he reports. “This time I’m going to make sure I’m 100% before decide to get back to sports. I’ve been through this three times, and I’m here to tell you, there is a full life after shoulder surgery.”
The Stages of Healing
Understanding the three post-surgery phases of healing and what is going on in the body during each can be helpful says PT Erica Platil:
• The first three weeks post-surgery are known as the inflammatory phase as inflammatory cells multiply around the surgery site. During this phase, the arm is still in a sling and movement is limited to using a squeeze ball, and some neck and scapula stretches.
• The repair phase, also known as the proliferation phase, starts around week three or four. In this phase healing cells rapidly multiply and start rebuilding around the repaired area. This is also where gentle range of motion is started.
• The third phase, the remodeling phase, starts at around six weeks, around the time the arm is released from the sling, and therapy begins to include more ROM and lifting light weights. In the remodeling phase, scar tissue forms and matures, reaching maximum repair strength at about 12-16 weeks after surgery.
• A Non-Surgical Option For Shoulder Repair, newmobility.com/2015/07/non-surgical-option-for-shoulder-repair
• Shoulder of Fortune: Surviving Shoulder Surgery, newmobility.com/2017/08/shoulder-surgery
• Shouldering the Load, newmobility.com/2005/09/shouldering-the-load
• Total Shoulder Replacement in Wheelchair Users, newmobility.com/2015/09/shoulder-replacement-wheelchair-users