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Therapy after Open Distal Clavicular Resection

 
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Therapy after Open Distal Clavicular Resection - February 24, 2007 7:27:00 PM   
cutterpose

 

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Hello,

I tried posting this rather long question in the Ortho section of the forum, but haven't gotten any replies yet. I thought perhaps this might be a more appropriate venue and hope someone can give me some insight on how long it can take, and how best to facilitate healing of the deltoid after an open distal clavicular resection. This is the situation:

I am looking for info regarding the optimal post-surgical PT following a distal clavicular resection that was performed open, rather than arthroscopically. My situation is complicated in that I am wheelchair-bound due to a spinal cord injury that occured years ago. The lesion was incomplete, and I've been able to stand and walk with a walker quite easily. Prior to the clavicular resection, I was able to live independently, work as a researcher, and maintain an at-home PT regimen as well as aquatherapy at least once a week.

Due to an auto accident several years ago, I suffered a type 1 shoulder separation that was excruciatingly painful and refractory to 8 months of conservative therapy. The orthopedic surgeon with whom I consulted said she was confident that surgery would restore my shoulder to 99% of it's capacity. Obviously, because I use a wheelchair, I must use both arms a great deal. In planning for the surgery and recovery, I made certain to emphasize and demonstrate to both the surgeon and her PA how much and in what ways I used my arms for transfers, standing, pushing the chair, etc.

The clavicular resection was performed and revealed an unstable distal clavicle and very small rotator cuff tear. No labral tears or any other problems were found. The surgeon had intended to perform the procedure arthroscopically, but had to do it via the deltoid because, she said, I'm a petite female and she simply didn't have enough room in the joint to work arthroscopically. After the surgery, she warned me to be very careful of straining the shoulder for 2 weeks, to prevent damage to the raphe. I used a transfer board for any necessary transfers (bathroom) and remained homebound. At two weeks she said I was healing nicely, and an occupational therapist started me on resistive exercises. I asked the surgeon several times what activities I should avoid, and her response was to use the shoulder as much as possible until it became too painful. I followed the PT regimen assidously, and was told I'd done a great job rehabbing the shoulder. It's mobility and strength were quite good; although the pain was still intolerable and I was put on a pain control regimen. About threee months after surgery the surgeon gave me the OK to resume driving and ADL's, and said we were done. I attempted to do so, only to find that the shoulder was still excruciatingly painful, and that this pain was hugely exacerbated by transferring,and ADL's such as trying to grocery shop, and return to work. About 6 months after the surgery, the pain was still intolerable, I was generally housebound, and profoundly depressed. I returned to the ortho group and explained the problems to the PA, who said that I must avoid any weight-bearing for another 6 months on the shoulder or it would not heal. His attitude was less than compassionate; he made a comment to the effect that 'well, you'll eventually develop a RCT on the right shoulder, so?"

I would add here that I adhered strictly to all the PT protocols I was instructed to do, and although I used the shoulder as advised I never tried anything ridiculous like lifting heavy objects, etc. And as regards pain, I've been told I have a high threshold. I think this is credible; prior to surgery we tried a few injections of steroids into the AC joint. I'm told this is regarded as a very painful injection. To me it was nothing, especially in comparison to the pain of the AC joint sprain.

I eventually contacted the PT who had rehabbed me through the SCI. His advice was to rest the shoulder as completely as possible for several months, as he felt that the deltoid had never had a chance to heal properly and that with every painful strain on the shoulder I was simply reinjuring the deltoid. It is almost 2 years since the surgery, I'm homebound, the PT regimen that helped keep me healthy and active despite the SCI is not doable, and I'm being very careful not to strain the shoulder, which seems to help because finally it's less painful.

I would greatly appreciate any insight from those familiar with rehabbing shoulders post open acromioplasty. Were resistive exercises started too early?

In other posts on this board I have seen discussions regarding the quality of care received by athletes compared to the average patient. I have received the impression from some of my caregivers that because I have a pre-existing severe disability, being more disabled is not a particular concern. This situation has prevented me from resuming ADL's and getting back to work in my chosen profession of cancer immunology research. It took a great deal of hard work and determination on my part to earn my degrees, despite my SCI. I am totally perplexed why a relatively common surgery that I've read generally yields good to excellent results has so far basically ruined my life.

Any insight and or advice would be greatly appreciated. It's been my experience that a good physical therapist and a motivated patient can achieve things that the MD's view as almost impossible. Thanks!
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Re: Therapy after Open Distal Clavicular Resection - February 24, 2007 7:38:00 PM   
SJBird55

 

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cutterpose, frankly, it has been 2 years since your surgical procedure... you are reporting on your memory, unless you have specific notes sitting right there in front of you. There is no way that I'd choose to stick my neck out and comment if someone did something right or wrong in your case.

I will comment on the research that you read - I am very, very sure that the excellent results were for people who did not have a SCI. You repetitively use your upper extremities in a different manner and with more of a weightbearing component than those without a SCI.

(in reply to cutterpose)
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Re: Therapy after Open Distal Clavicular Resection - February 25, 2007 12:36:00 PM   
cutterpose

 

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Dear SJBird,
Thank you for your comments. As a matter of fact, I did and do keep a brief daily log of activities, exercises performed, pain levels, therapist's instructions, etc. so I am reporting from documentation rather than reporting 'on' my memory.
And I am sorry that you interpreted my queries as a request for someone to 'stick their neck out'and attempt to make a judgement as to whether someone did something right or wrong. Obviously, nobody in this venue of communication would be in a position to have enough medical information to render any such opinion. I would simply like to know if and what is the generally accepted time frame for the institution of resistive exercises following an open procedure that involves resecting the deltoid, and was hoping for any opinion regarding deltoid healing.

As per your comment on the literature, yes, this is so. I could find no study in which the test group was comprised of individuals with SCI that compared surgical outcomes against a control group without SCI. However,I'm uncertain what information you were attempting to convey regarding the existing studies. Are you implying that your opinion is that an excellent surgical outcome would be unlikely for an individual with SCI?
And here is a very interesting question--if one hypothesizes that a less than optimal surgical outcome is to be expected in individuals that repetitively use their upper extremities in a different manner and with more of a weightbearing component than those without a SCI, how does this affect the treatment and/or expected outcome of athletes such as baseball players, swimmers, weightlifters whom also must rigorously exert their arm and shoulder muscles?

Thank you very much for your input; it has provided me with a much better perspective on how my situation might be regarded by persons in your area of expertise.

(in reply to cutterpose)
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Re: Therapy after Open Distal Clavicular Resection - February 25, 2007 4:32:00 PM   
SJBird55

 

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What does "resistive exercises" mean to you? What were the "resistive exercises?" Being vague and ambiguous in your communication won't assist in the manner of an open discussion either.

Clavicular resections are generally performed secondary to AC pain because of arthritis/degenerative changes or with rotator cuff repairs to decompress the region.

Stability of the AC joint is provided by the acromioclavicular capsular-ligamentous complex and the coracoclavicular ligaments. You mention that you had AC instability... to my knowledge a clavicular resection doesn't provide any stability - how much was resected?

Often times with AC separations, life is easy and conservative treatment is successful. A grade I AC separation (that you initially stated you had) does not fall into a category for surgical intervention. Grade III AC separations have the potential for surgical interventions. So, of course, just knowing that grade I AC separations are generally not treated via a surgical intervention, my first question to you would be how that decision was made? Grade I AC separations are not unstable.

I'm not comparing you to athletes. I made a very simple statement that the way you use your shoulder because you have a SCI is very different than those of us who do not have a SCI. I did not state either way the likelihood of excellent results for someone in your individual situation. There isn't any specific data out there to say one way or another.

Seeing that it has been 2 years... I would honestly doubt that your complaints of pain are secondary to the deltoid. That muscle is probably healed just fine. You haven't stated anything about the amount of motion in your shoulder though, so I'm just speaking from my gut.

When athletes come in with AC separation, my biggest advice is to eliminate any weightbearing activity through that joint so that the ligaments can scar down and heal. Generally for them, push ups is the big thing they need to stop doing. I also recommend that they back off on the resistance during bench and military press. Now, if I think of you and your ADL... can you realistically eliminate any weightbearing through that joint? You also never mentioned your weight, so I have no clue how much force is going through the shoulder.

I'm not sure what not "straining the shoulder" means to you. I would tend to believe less weightbearing through the joint would be the ticket to reducing symptoms because I would bet you that you still have an ongoing sprain in that AC joint. I've never heard of a resection resolving AC sprains.

(in reply to cutterpose)
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Re: Therapy after Open Distal Clavicular Resection - February 25, 2007 8:00:00 PM   
Dr.Wagner


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Is there a lawsuit pending? Are there damages being sought? Have you gotten a second opinion?

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Re: Therapy after Open Distal Clavicular Resection - February 25, 2007 8:12:00 PM   
cutterpose

 

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I weigh about 106 lbs.

Although vague, I considered resistive exercises to be any of the many used to increase strength of the shoulder musculature, in contrast to the passive exercises used to maintain ROM.

About 0.9 cm of clavicle was resected. The shoulder ROM was/is excellent. Surgery was offered as an option after 8 months of conservative therapy, i.e. rest, NSAIDS, and then PT to reduce joint impingement. The AC joint was still highly painful and the clavicle was then observably deformed. The dx of grade 1 AC joint separation was made by the standard criteria; Xray, Neer's Test, resolution of pain after AC joint corticosteroid injection, etc.

Below are links I found useful in understanding the injury and the criteria for surgery.

http://www.athleticadvisor.com/Injuries/UE/Shoulder/a_-_c_sprain.htm
When and why is surgery necessary for AC Joint separations?
Usually surgery is reserved for those cases where there is residual pain or unacceptable deformity in the joint after several months of conservative treatment. The pain can occur with direct pressure on the joint, such as with straps from underwear or work clothing. Sometimes there will be catching, clicking, or pain with overhead activities, such as lifting, throwing, or reaching.

http://www.wheelessonline.com/ortho/ac_joint_arthrosis_distal_clavicle_excision
Wheeless Textbook of Orthopedics
- Indications For Excision:
- pts w/ incomplete AC separation (type I & II) who develop degenerative
changes & persistant symptoms may require excision of distal Clavicle;

- Contra-indications:
- it is inappropriate to excise the distal clavicle in chronic type III, IV, V or VI AC separations;
- this may increase the patients symptoms, by converting a displaced long clavicle, into a short displaced clavicle;

- Technique:
- consider excising only 1 cm of the distal clavicle;
- excision of the distal 1.5-2.0 cm of the clavicle ensures that impingement will not occur (excision of this fragment
may cut trapezoid ligament);
- the remaining conoid ligament is sufficient to anchor the distal clavicle to the coracoid process;
- however, as pointed out by Eskola et al 1996, excision of more than 1 cm of the distal clavicle was more often
associated with pain;
- with the excision of only a small segment of the distal clavicle and with the time, the distal clavicle may develop a spur;
- in the report by Scott David Martin et al, the authors evaluated the surgical results in 31 consecutive patients (32 shoulders) with
AC pathology with concomitant subacromial impingement;
- mean age of the patients at the time of surgery was thirty-six years (range, 18 to 67 years).
- 25 patients, including four professional athletes, were actively involved in sports activities;
- mean duration of follow-up was four years and ten months (range, three to eight years).
- of 25 patients who participated in sports, 22 (including the four professional athletes)
returned to their previous level of sports activity;
- 26 patients had no pain, three reported mild pain on strenuous repetitive overhead activity,
two (both weight-lifters) had occasional pain in the AC joint and the lateral aspect
of the shoulder with bench-pressing, and two (both baseball players) had mild pain in the posterior
aspect of the shoulder with throwing;
- all of the patients were satisfied with the results;
- no patient had superior migration of the clavicle;
- amount of distal clavicular resection averaged 9 mm (range, 7 to 15 mm).
- 5 patients had calcification at the anterior deltoid insertion into the acromion that was
asymptomatic, with no impingement on overhead activity and no pain on direct palpation;
- Arthroscopic Resection of the Distal Aspect of the Clavicle with Concomitant Subacromial Decompression
Scott David Martin, MD J Bone Joint Surg [Am] 83-A: 328-35, 2001


http://ajs.sagepub.com/cgi/content/abstract/16/2/97
American Journal of Sports Medicine, Vol 16, Issue 2 97-100, Copyright 1988 by American Orthopaedic Society for Sports Medicine
Mumford procedure in athletes. An objective analysis of function

http://www.emedicine.com/sports/TOPIC3.HTM
Acromioclavicular Joint Injury; eMedicine Specialties > Sports Medicine > Shoulder

http://orthoinfo.org/fact/thr_report.cfm?Thread_ID=181&topcategory=Shoulder

Thanks

(in reply to cutterpose)
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Re: Therapy after Open Distal Clavicular Resection - February 26, 2007 5:34:00 AM   
SJBird55

 

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From: Michigan
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A grade I AC separation is not unstable.

[QUOTE]clavicular resection was performed and revealed an unstable distal clavicle[/QUOTE]Was it grade I or not grade I?

I'm curious as to your response to Wags too. Why don't you get a second opinion?

The research is nice, but the population is not the group in which you belong. You are not an athlete and you use your upper extremities in a very different way and have frequent weightbearing through your shoulders.

(in reply to cutterpose)
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Re: Therapy after Open Distal Clavicular Resection - February 26, 2007 3:10:00 PM   
Sebastian Asselbergs

 

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I agree with SJ. It is highly improbable that the deltoid is the source of pain - or any soft or hard tissue "damage" for that matter. Any disruption in the tissues have long since healed. And I agree that Grade I is a considered "stable".

Possible neurological (peripheral) dysfunction - i.e. entrapments - can be sources for pain. And central sensitisation can maintain the perception.

Pain is a poor guide for what is really going on in the area, since after 2 years (with pain before surgery too) the whole nervous system HAS to be involved in a major way. Circulation, both in nerves and musculotendinous tissues has been compromised, subtle changes in patterns of stabilisation in the shoulder can play a role, heightened neuromuscular tension can be present, etc etc.

Was resistive exercise started too soon? NO idea. I wasn't there - don't know the reps, the resistance, the sets, the directions, the qualty of your motion, the status of your tissues, .... Impossible to tell.

You need another assessment. Good luck.

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Re: Therapy after Open Distal Clavicular Resection - February 26, 2007 6:54:00 PM   
cutterpose

 

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Gentlemen, thank you all very much for your input. Quite likely a major error on my part was not seeking a second opinion from a different Orthopedic group at the beginning of this mess. I shall do so at the soonest opportunity. I found Mr. Asselbergs' commens re: prolonged pain, neuropathic and circulatory affects to be very enlightening. At this point, I haven't contemplated litiginous action. I just wish the **** thing would quit hurting after any weightbearing activity, like transferring to a car or attempting to stand up, so that I can get on with my life. Luckily, I've been able to modify everything in my home so that when transferring I can gently slide into bed or onto the commode without weightbearing. Again, thank you all for your insight and advice. I'll be sure to let you know what I might find out after another assessment, and how it all goes.

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Re: Therapy after Open Distal Clavicular Resection - February 27, 2007 8:46:00 AM   
Dr.Wagner


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I will give a few final comments...

1. Surgery is surgery, and is NEVER painfree especially on weight bearing areas. Never. Having a resection, to put it simply, sucks. Your clavicle will NEVER be the same, there never should have been that implication or assumption. Especially on the clavicle that is now a primary weight bearing extremity.
I feel pretty bad for you, as your biomechanics are tremendously different than mine, because you use your shoulder girdle in more ways than I do, therefore the demands are much different. Thus, the surgical approach MUST be different, including the assumption of a surgical "cure".

2. You now are in need of a second orthopedic surgical opinion. Unfortunately, you are in a position which is not envious.

_____________________________

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Moderator of Medical Complexity Forum

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Re: Therapy after Open Distal Clavicular Resection - February 27, 2007 4:07:00 PM   
cutterpose

 

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Dear Dr. Wagner,
Thank you for your insight and true concern and empathy.

I know this is rather an unanswerable question, but I'm blowing off a little steam, rather than falling into despair.

Why in the heck then, would this surgeon, after a long conversation after conservative treatment failed, so blithely say she was 'Confident she could get my shoulder back to 99% of it's previous condition"? And at just 2 months post-injury, I went in for a corticosteroid shot and a DIFFERENT surgeon recommended surgery at that time point, didn't even suggest waiting to see how well a conservative approach worked.

At any rate, I've been using an electric wheelchair for some time now and have been treating the arm and shoulder very carefully the past few weeks. This seems to be helping a great deal so far; although I haven't again attempted any weightbearing activities as of yet.

p.s. The term 'unstable distal clavicle' was taken from the surgeon's medical records of the surgery. Ver batim: "the distal clavicle was found to be visually and physically unstable". Quoth the raven, nevermore. Sorry- I'm a bit distraught and use levity as a coping skill.

Anyway, I will certainly get another opinion from an orthopedic surgeon who isn't pals with this group, and let you know how it goes. My deepest appreciation to all of you who've taken the time to offer your insight and expertise in this matter. Thank you all very much.

(in reply to cutterpose)
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