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Old 02-04-2013, 10:05 AM   #1
Michael Marziotto
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Preparing for Shoulder Surgery- ->

I am prompted to write after listening to the Fitness Pain Free Podcast Episode 18: All About Shoulder Surgery. Thank you to both Dan Pope and Dr. Sean Rockett for a great episode!

I am a 50 year old male, Crossfit for about a year. Prior to 2012, I had long period of inactivity. A desk jockey by day, so my body had about ten years of poor posture and low mobility, plus a good deal of excess weight. Crossfit is responsible for a level of fitness today, that I NEVER had.. Down 40lbs from March 2012, strong and lean.

However, around April of last year I severely aggravated a shoulder injury from about twenty years ago. I didn't know then, what I know now and almost two decades ago I probably tore something in my right shoulder. The inactivity allowed the injury to lay dormant for years and a kipping pull-up with an unconditioned body blew the right shoulder out. Still not knowing the extent of the damage, I continued at CF and trained for, and completed the Super Spartan last year and am registered for two Spartan event this year. But it took a cortisone shot in the right side to get through the event.. something I very much regret doing (the shot, not the Super Spartan).

My recent MRI reads like a war-zone:
- Moderate tendinosis of the supraspinatus tendon. High-grade partial insertion tear of the anterior tendinous component, 1 cm in AP dimension and fraying of the articular aspect of the tendon. The anterior leading edge of the tendon is fully detached and approximately 0.4 cm retracted from the tuberosity.
- Detachment of the adjacent coracohumeral ligament from the anterior margin of the greater tuberosity (axial series 6, images 16 and 17).
- Mild tendinosis of the subscapularis tendon, associated with 1.2 cm calcification adjacent to the tuberosity attachment of the tendon.
- degenerative cystic changes of the greater tuberosity.
- partial tear involving the superior subscapularis tendon from the lesser tuberosity without retraction.
- mild tenosynovitis of the long head of the biceps tendon.
- the glenohumeral joint articular surfaces are intact.
- degenerative change and fraying of the superior glenoid labrum.
- anterior capsulolabral complex and posterior labrum appear intact.
- subacromial/subdeltoid bursitis.

Impression:
Small insertion tear of anterior bundle of the supraspinatus tendon which is full thickness at the anterior margin along with detachment of the humeral aspect of the coracohumeral ligament. Fraying at the articular aspect is evident. Calcific tendinitis of the infraspinatus tendon. Tendinopathy and partial tear of superior subscapularis tendon with tendon delamination. Tenosynovitis of the long head of the biceps tendon. Acromial hypertrophic change. Subacromial/subdeltoid bursitis.

Much of this is normal wear and tear, expected to be found, to some degree, on a 50 yr old type A athlete. I would believe that in the absence of the detachments I could get along okay scaling at CF and rehab with focused protocol.

The Ortho led off the review of the MRI with "you'll never do what you want to do if you don't have surgery to fix it... but, prove me wrong if you like. That said, don't rush into this..what you have is a Quality of Life issue, not quantity of life..take your time figuring it out".

I've put the 2013 Spartan events on hold (June & Sept) because the mental toll was killing me.. one less thing to contend with I suppose.

I'm planning to do the surgery in October 2013, assuming something doesn't change one way or the other, and it's my intent to take the coming months to get as strong as possible. Either I will feel well enough to NOT do the surgery or I'll reduce post-op rehab as much as I can. We'll see.

I've completed 5 weeks of physical therapy with myofascial release treatments, and had great results, but we've plateaued. Simultaneously, I continued CF albeit with ZERO shoulder movements. The combination of the two have resulted in some great gains, a huge relief in pain level and mobility (though sound sleep still eludes me). This is the model I would like to continue over the coming months in tandem with continuing to trail run.

My PT thought I am looking at 8-10 weeks of post-op rehab based on how he saw me respond to the last 5 weeks of therapy, but the Ortho said 6 months..so either the Ortho doesn't know how fast I can recover or he's doing a lot more work than the therapist expected.

I've looked (casually) at alternatives.. Regenexx Stem Cells Injection; Hyaluronan Injection; continued PT; HGH. No idea if any of this is worth a look. My head is still spinning.

I am hoping to hear from any of you who are of similar age and have had similar injuries. Hoping you can share the steps you took and how your recovery went. If you opted for surgery, what did your rehab look like and how well did you recover? If you opted to NOT do surgery, how have your WoDs and life been impacted...
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Old 02-04-2013, 08:51 PM   #2
Sean Rockett
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Re: Preparing for Shoulder Surgery- ->

Quote:
Originally Posted by Michael Marziotto View Post
I am prompted to write after listening to the Fitness Pain Free Podcast Episode 18: All About Shoulder Surgery. Thank you to both Dan Pope and Dr. Sean Rockett for a great episode!

I am a 50 year old male, Crossfit for about a year. Prior to 2012, I had long period of inactivity. A desk jockey by day, so my body had about ten years of poor posture and low mobility, plus a good deal of excess weight. Crossfit is responsible for a level of fitness today, that I NEVER had.. Down 40lbs from March 2012, strong and lean.

However, around April of last year I severely aggravated a shoulder injury from about twenty years ago. I didn't know then, what I know now and almost two decades ago I probably tore something in my right shoulder. The inactivity allowed the injury to lay dormant for years and a kipping pull-up with an unconditioned body blew the right shoulder out. Still not knowing the extent of the damage, I continued at CF and trained for, and completed the Super Spartan last year and am registered for two Spartan event this year. But it took a cortisone shot in the right side to get through the event.. something I very much regret doing (the shot, not the Super Spartan).

My recent MRI reads like a war-zone:
- Moderate tendinosis of the supraspinatus tendon. High-grade partial insertion tear of the anterior tendinous component, 1 cm in AP dimension and fraying of the articular aspect of the tendon. The anterior leading edge of the tendon is fully detached and approximately 0.4 cm retracted from the tuberosity.
- Detachment of the adjacent coracohumeral ligament from the anterior margin of the greater tuberosity (axial series 6, images 16 and 17).
- Mild tendinosis of the subscapularis tendon, associated with 1.2 cm calcification adjacent to the tuberosity attachment of the tendon.
- degenerative cystic changes of the greater tuberosity.
- partial tear involving the superior subscapularis tendon from the lesser tuberosity without retraction.
- mild tenosynovitis of the long head of the biceps tendon.
- the glenohumeral joint articular surfaces are intact.
- degenerative change and fraying of the superior glenoid labrum.
- anterior capsulolabral complex and posterior labrum appear intact.
- subacromial/subdeltoid bursitis.

Impression:
Small insertion tear of anterior bundle of the supraspinatus tendon which is full thickness at the anterior margin along with detachment of the humeral aspect of the coracohumeral ligament. Fraying at the articular aspect is evident. Calcific tendinitis of the infraspinatus tendon. Tendinopathy and partial tear of superior subscapularis tendon with tendon delamination. Tenosynovitis of the long head of the biceps tendon. Acromial hypertrophic change. Subacromial/subdeltoid bursitis.

Much of this is normal wear and tear, expected to be found, to some degree, on a 50 yr old type A athlete. I would believe that in the absence of the detachments I could get along okay scaling at CF and rehab with focused protocol.

The Ortho led off the review of the MRI with "you'll never do what you want to do if you don't have surgery to fix it... but, prove me wrong if you like. That said, don't rush into this..what you have is a Quality of Life issue, not quantity of life..take your time figuring it out".

I've put the 2013 Spartan events on hold (June & Sept) because the mental toll was killing me.. one less thing to contend with I suppose.

I'm planning to do the surgery in October 2013, assuming something doesn't change one way or the other, and it's my intent to take the coming months to get as strong as possible. Either I will feel well enough to NOT do the surgery or I'll reduce post-op rehab as much as I can. We'll see.

I've completed 5 weeks of physical therapy with myofascial release treatments, and had great results, but we've plateaued. Simultaneously, I continued CF albeit with ZERO shoulder movements. The combination of the two have resulted in some great gains, a huge relief in pain level and mobility (though sound sleep still eludes me). This is the model I would like to continue over the coming months in tandem with continuing to trail run.

My PT thought I am looking at 8-10 weeks of post-op rehab based on how he saw me respond to the last 5 weeks of therapy, but the Ortho said 6 months..so either the Ortho doesn't know how fast I can recover or he's doing a lot more work than the therapist expected.

I've looked (casually) at alternatives.. Regenexx Stem Cells Injection; Hyaluronan Injection; continued PT; HGH. No idea if any of this is worth a look. My head is still spinning.

I am hoping to hear from any of you who are of similar age and have had similar injuries. Hoping you can share the steps you took and how your recovery went. If you opted for surgery, what did your rehab look like and how well did you recover? If you opted to NOT do surgery, how have your WoDs and life been impacted...

Glad you liked the podcast. Our guidelines are pretty simple-full thickness tears do not reattach and should be fixed if you are symptomatic. If you continue with pain, the tear can get bigger. People will sometimes say,"No big deal I'll just get it fixed." The problem with that is you need more anchors to fix it. We know that results are based on the size of the tear, smaller repairs do better than larger repairs. Does that make sense?
As far as duration of PT, usually 10-12 weeks of supervised PT followed by another 3 months of strengthening. Sometimes gymnastic Crossfit maneuvers can take 9 months to get back to same level. Sean
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Old 02-05-2013, 04:24 AM   #3
Gravel Brown
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Re: Preparing for Shoulder Surgery- ->

Surgery is worth it mate. I eventually had an operation on my SLAP tear after months of second guessing myself. The surgery was the best thing I ever did. I'm now 15 months post op and I'm fitter and stronger than ever.

I'm 39 years old so by no means a young pup.

Fix your shoulder to suit your life.... rather than adjust your life to suit your shoulder.
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Old 02-05-2013, 10:11 AM   #4
Michael Marziotto
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Re: Preparing for Shoulder Surgery- ->

Quote:
Originally Posted by Sean Rockett View Post
Glad you liked the podcast. Our guidelines are pretty simple-full thickness tears do not reattach and should be fixed if you are symptomatic. If you continue with pain, the tear can get bigger. People will sometimes say,"No big deal I'll just get it fixed." The problem with that is you need more anchors to fix it. We know that results are based on the size of the tear, smaller repairs do better than larger repairs. Does that make sense?
As far as duration of PT, usually 10-12 weeks of supervised PT followed by another 3 months of strengthening. Sometimes gymnastic Crossfit maneuvers can take 9 months to get back to same level. Sean
Makes perfect sense, thank you. I don't fall into the "No big deal" camp. I am a subscriber to "Do No Harm".

I've already let this go longer than I should have, but fortunately I was careful. I really just lost time.

Your PT time falls right in the middle of what I have found thus far. My biggest hurdle is not being able to drive in the early part of the rehab.. I commute to my office. So you estimate 6 mos to be at or near full recovery, yes?

I listened to the podcast again (also spent some time on your website..thank you) and have a few follow-up questions.

You mention that as we age our tendons become more brittle and dehydrated. Are there any steps we can take to reduce this? Supplements? Dietary?

You did suggest that the PT has more contact with the patient post-op, which makes sense, but on average, how frequently do you meet with a patient post-op to gauge recovery? Do you request follow-up MRI's? If so, how soon and how frequent?

Unrelated.. You mention you made it a one or two year commitment to visit other boxes to see how the trainers operate and how the trainers are being trained. I am curious how other affiliates deal with CF members who want to pay a visit for one or a few sessions.. for instance, if you're traveling.. do affiliates typically make their box available to non-members for some fee?

After pondering overnight, I have come to the decision that I am not waiting until October. Sooner is better. Rehab in the sun trumps the cold winter. Flip flops and tank tops, or no shirt beats boots and a coat.. With focused PT I'll be better by the time I would have just been readying myself for surgery.

Plus the mental turmoil is wrecking me...


Quote:
Originally Posted by Gravel Brown View Post
Surgery is worth it mate. I eventually had an operation on my SLAP tear after months of second guessing myself. The surgery was the best thing I ever did. I'm now 15 months post op and I'm fitter and stronger than ever.

I'm 39 years old so by no means a young pup.
Thanks.. it's not a matter of if, but when.. and it looks like it will be week two of April.

Quote:
Originally Posted by Gravel Brown View Post
Fix your shoulder to suit your life.... rather than adjust your life to suit your shoulder.
Those might be the finest words I have heard in a long time.. I thank you
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Old 02-05-2013, 08:31 PM   #5
Michael Marziotto
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Re: Preparing for Shoulder Surgery- ->

Had a conversation with my PT this evening... He said I should expect to lose 1/4 to a 1/3 of my muscle mass within the first week, post-op.. OMG!
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Old 02-06-2013, 02:54 PM   #6
Daniel Pope
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Re: Preparing for Shoulder Surgery- ->

Thanks for the kind words Michael. Thanks again to Dr. Rockett for his time and expertise. Anyone who wishes to listen to the podcast can find it here:

http://fitnesspainfree.com/?p=3004

Best of luck Michael, I'm curious though. Are you getting exercises to go along with the myofascial release? If you're rotator cuff has so much tendonosis then improving this is going to take some very dedicated exercise. Surgery won't fix your tissue quality and a long term fix will need solid shoulder rehab.

Good luck, keep us updated,
Dan Pope www.fitnesspainfree.com
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Old 02-07-2013, 03:27 AM   #7
Gravel Brown
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Re: Preparing for Shoulder Surgery- ->

Quote:
Originally Posted by Michael Marziotto View Post
Had a conversation with my PT this evening... He said I should expect to lose 1/4 to a 1/3 of my muscle mass within the first week, post-op.. OMG!
Yep it falls off quick mate. Don't worry though, as soon as you start lifting again it comes back fast, it's almost l like your body remembers what muscle mass it used to have and replaces it fast. I was amazed how quick I regained my lean muscle mass.
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Old 02-07-2013, 06:34 AM   #8
Sean Rockett
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Re: Preparing for Shoulder Surgery- ->

For Michael's post

For the question about tendons becoming less brittle, that is really the fountain of youth. I don't know of any study that suggests we can reverse the process.
For follow up, I see people at 10-14 days post-op, then 6 week intervals. Mri not needed as long as they listen to the protocol and don't hurt themselves post op.
Typically I have seen a drop in fee to visit other boxes.
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Old 02-08-2013, 12:55 AM   #9
Russ Monzon
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Re: Preparing for Shoulder Surgery- ->

hey Michael!

i am typing this post one-handed right now as i am about a week post surgery. my MRI read a lot like yours and the arthroscopic pics were definitely the proof in the pudding. my supraspinatus tendon was torn and separated, my labrum had some fraying but not to the extent of a SLAP tear, and i had some subacromial "spurs". it's all been repaired and cleaned and now it's my job to be patient and heal.

i wanted to have it fixed last year, but the first ortho i saw wanted to do a mumford procedure. i sought out a second opinion and got another MRI (but with contrast) showing a definite tendon rupture..

im glad you are deciding on sooner than later. if you can move it from April to tomorrow - do it. i am 48 and, maybe like you, was tired of being in pain during and post workout and not feeling like i was benefiting from all the hard work we put in at the box. i could barely throw or participate in most sports and carrying my daughter was painful! my GPP seemed like it was at it's lowest.

anyway, the first few days suck, i ain't gonna lie. i was off the pain meds by day 4 and back sleeping in my bed by day 5. still uncomfortable? heck yeah, but probably not much more than the constant night pain pre-surgery.

so far, recovery has been much better than i thought it was gonna be, and besides already losing some hard earned muscle, i don't anticipate it getting any worse.

feel free to PM or post any questions. between Gravel's well-documented experience (thanks brother!), Dan Pope and Sean Rockett's expertise (amazing podcast, btw!) and everyone else here - you're not alone!

Last edited by Russ Monzon : 02-08-2013 at 01:00 AM. Reason: spelling
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Old 02-08-2013, 03:20 PM   #10
Michael Marziotto
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Re: Preparing for Shoulder Surgery- ->

Quote:
Originally Posted by Daniel Pope View Post
Thanks for the kind words Michael. Thanks again to Dr. Rockett for his time and expertise. Anyone who wishes to listen to the podcast can find it here:

http://fitnesspainfree.com/?p=3004

Best of luck Michael, I'm curious though. Are you getting exercises to go along with the myofascial release? If you're rotator cuff has so much tendonosis then improving this is going to take some very dedicated exercise. Surgery won't fix your tissue quality and a long term fix will need solid shoulder rehab.

Good luck, keep us updated,
Dan Pope www.fitnesspainfree.com
Might be the fourth time I have listened to that podcast.. And a bunch of others you've posted as well..

The deep tissue massage is a very small part of the PT sessions. About ten to fifteen minutes post session, followed by ice. The meat of the session has evolved since starting back in early December. From basic stretching early on, to full WoDs now. T-bar, lat pull-downs, neutral bar, preacher curls, military press, some triceps work and now we've added body weight stability moves.

Since I have had the injury, my upper body work at CF has been anemic at best. The bar bell sets out in front of my face and puts my shoulder in bad position. Switching to dumbbell work at PT has resulted in some amazing (pain free) progress and I am able to do things previously impossible. Posture, power, mass, RoM, scapular position and range... All improved measurably.

But those detachments aren't going to reattach themselves no matter how strong the supporting cast gets, so while I had fleeting visions of Pre-hab'ng to the point surgery might not be needed, I don't think that is realistic.
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