It's Always Fun...

...when you can shock your doctor. I went to see Dr. Hershon for my 4th post-op visit on Tuesday (POD 69) and he was amazed by my progress.

He asked me to take off my shirt and move my arm and I mimicked his motion. Then he asked me to lift my arms straight up in front of me to observe my front flexion and when I threw both my hands up in the air, his eyes bugged out of his head!!! Then he tested me further and asked me to put my left hand behind my back to test my internal rotation. Again, he was shocked that I was able to almost get my thumb up to my scapula.  "That's the one most people have trouble with." he said. He told me he was very pleased and that he was not so happy with my progress the last time I was there. I told him that the external rotation was the thing that still needed the most work and he assured me it would get there. He also told me that high end athletes (obviously, not me) have a really hard time with this injury because it takes a long time to get back to full function and most of them are unwilling or unable to wait.

He gave me another prescription to extend my PT, shook my hand, told me to keep up the good work and go back to see him in 6-8 weeks.

PT Update 1

It's been a while since I've written. There are a bunch of reasons/excuses. I came down with a cold shortly after my last post and did not feel like doing anything but eating and sleeping for about a week. There was also the fact that there was not much to say until last Wednesday and I was not going to write for the sake of writing. Then my PT schedule changed, the sessions became longer and it was just wiping me out. But now I'm buckling down again to do some writing.

So my PT routine had remained what I described in my last post until last Wednesday, which also happened to be the 2 month anniversary of my surgery. Last week David, my therapist, added 4 exercises to my routine. David added the hand bike, scapular retraction, shrugs, and front raises to my exercises.

The Hand bike is just what it sounds like. It is a stationary bike but, instead of using your feet to turn the mechanism, you use your hands. The bike was set for 6 minutes on level two and I was told to do three minutes going forward and three minutes back. It felt okay going forward but after about a minute of going back the shoulder started protesting. So I finished tha last 2 minutes forward and moved on. It wasn't terrible, it just didn't feel right.

Scapular retraction is probably the most mysterious sounding thing in the list of new exercises.OOOOOOOOHHHHHHHHH!! Well let me end the wonder. It is similar to a rowing type exercise. While in a standing position I hold a Thera-band in my hands, while my elbows are at 90 degrees and pull back so that I feel the squeeze between my shoulder blades. It is supposed to assist with strengthening the rhomboids and aid good posture. It felt good. I quickly moved up two levels of resistance so that I'm using the green bands for that exercise now.

The dumbbell shrugs are a pretty basic weight lifting exercise. I just stand with 2lb. dumbbells in my hands and I raise my shoulders up as high as I can and repeat for 3 sets of ten. This helps to build the trapezius muscles.

The final exercise was the front raise. Standing with a 1 lb. dumbbell in my left hand and 2 lb in my right I lifted the weights straight out in front of me and kept my elbow straight. Once I reached the 90 degree mark I lowered them and repeated for 3 sets of 10. It wasn't much but it's the most exercise I'd gotten in a quite a while so it wore me out.

In addition to the exercise it is just the time I'm putting in. The addition of these exercises to the routine I was already doing pushed the time I was spending at the PT clinic to 1 1/2 hours. After a full day of work and doing PT exercises and stretches through the day and then putting that kind of time in after work was taking it out of me. On the up side, I've been sleeping really well.

People keep asking if I'm in pain or if the PT hurts. Maybe I have a high tolerance for pain but it has not really been bothering me all that much. Yes, I'm sore and yes, I've winced while Dave is digging his thumbs into my trap but there hasn't been any overwhelming, incapacitating pain during PT. The worse thing is on the days I don't go that I'm really dreading doing the last set of external rotation exercises because I'm just so sore. Overall, I feel better when I leave the clinic and I've noticed a marked improvement in my range of motion and my ability to do every day tasks.

The greatest testament to what I've accomplished so far is the things I do with realizing them. I was driving around over the weekend and I propped my elbow up on the door without realizing I had even done it. This was my normal driving pose before the surgery and I just went back to it without any pain. I was shocked because as little as two weeks ago I could not do it.

The other thing was that I tucked in my pants in the back with my left arm. It's the kind of motion you make every day and don't think twice about. I've been thinking about it a lot lately since every time I went to do it my shoulder let me know it was a bad idea. Then one day last week I just got dressed and didn't even realize I had done it until I had gotten half way to work.

The bottom line is this: I'm putting the time in and I'm seeing results and I'm excited.

PT Update 2 coming soon.

PT Evaluation and first two visits

Now that I've carried on enough about the nonsense I had to go through to get my physical therapy appointments set up, let me tell you about the appointments themselves.

My first appointment was my evaluation which I went to on a Thursday night, POD 43. I waited a few minutes in the waiting room before I was seen. Once I went in the therapist, James sat me down on an exam table and we had a chat and he evaluated my shoulder. He checked my range of motion and asked exactly what I had done. There was some confusion because it seems that Dr. Hershon wrote that I had a posterior repair on my prescription but, as far as I knew, I had a Bankart Repair which is an anterior repair and I always dislocated anteriorly. James wanted to know for sure because it was going to make a difference as to how much they were going to push my shoulder for certain ranges of motion. To be certain, he asked me to call the doctor's office and get the operative report. The report would tell us exactly what had been done. He told me that if I had had a Bankart Repair we would not push the external rotation beyond 75 or 80 degrees because it puts pressure on the front of the labrum, which is exactly what I had repaired. He wanted to know but it was not going to make a difference for this visit. He also told me that, even though we would not recover the full 90 degrees of external rotation, I would not notice it in day to day life.

After we did the evaluation he told me what we were going to do while I was there and what he wanted me to do for the day and what I would be doing for ,at least, the next two visits. They started me off with about 20 minutes worth of heat , then they had me work on the pulleys for 30 reps, which is similar to the assisted front flexion I'd been doing at home, a set of the pendulum (Codman) exercises and they showed me how to do the wand exercise for external rotation.

They had me lay on a table to do the wand exercise. I laid on my back and put the head of a golf club in my left hand and with my elbow at my side and with my forearm bent at 90 degrees. I then took the grip of the club in my right hand and pushed my left arm toward an externally rotated position until I felt resistance and then held it for 5 seconds. I did the three sets of ten was that I was assigned.

After I finished the exercises, James did an ultrasound treatment which he said would help with internal swelling and stiffness and then he stretched me out. He worked on my flexion and external rotation and generally loosening the arm. When he pushed me to my tolerances there was some discomfort but no pain to speak of. The front flexion felt weird. I'm still very guarded but it didn't hurt. After that they sat me down for ice and electrical stimulation. I've had stim many times before and this was the first time I was able to say that it didn't feel like my shoulder was going to come out of the socket when they turned it up high.

Before I left, James told me I should come in three times a week for now since I needed a lot of work on my external rotation and I would need to spend much of my time working on that one motion. He also told me to do my Codman and the front flexion exercises at home twice a day and the wand exercises 4 times a day, 30 reps each. It was a lot of work to do but it was what was needed.

The day after my evaluation I called Dr. Hershon's office and they faxed me the operative report. In spite of what had been written on the prescription, the report indicated that I had a Bankart repair. I brought it to my next appointment and we decided to go with what was written in the report as gospel. I didn't even know such a document would be available to me. If you're planning on going to PT after a surgery you should definitley ask your doctor for this and bring it with you.

My next two appointments were pretty much the same routine as my evaluation. I started with heat, followed by pulleys, Codman, wand exercises then ultrasound, stretching and massage and finally, ice and stim. During my third appointment I was shown how to do the wand exercise to work on my front flexion but that was the only change. The illustration shows the flexion being done standing but I did mine laying down. I think it helps to have gravity on your side. I also found that using the wand seems to help me get over that guarded feeling much more than just using my right hand. Maybe I can sleep with my hands behind my head again soon!

I worked on doing my exercises at home. 4 times a day was a lot to try to do the wand exercises, especially when I was working. After a few days I managed to borrow a yoga mat and a golf club at work which allowed me to spread the sets out through the day. I do have to say that doing the wand exercise for the external rotation as much as I've been doing it has left me sore in my pectoral muscle and I've also felt it in my latissimus dorsi. I also noticed that my shoulder feels better immediately after the PT sessions. I was able to do things without some of the pain and discomfort I had felt before. Little things like turning the wheel on my car was easier, putting dishes on the drain board and I was almost able to get up to the first fret on my guitar this afternoon. Even though I've only been to PT three times I'm noticing improvements.

Men Plan, God Creates Health Insurance & LAUGHS

Those of you who know me know that events rarely pass without me having something to bitch about. Physical Therapy was, apparently, not going to be an exception. I was not only ready but actually excited about my first PT visit. After weeks of being immobilized and not being able to use my left arm I was eagerly anticipating moving forward and side to side, for that matter. I knew it was going to be a lot of work and possibly a lot of pain but it also meant progress toward my goal.

To this point, I've had very little trouble with my health insurance company. Actually, I've had no trouble. All throughout my pre-op, the surgery and my post operative visits I've not heard a peep from the insurance company. Everything has been approved and I just flowed through the process, effortlessly. This was about to change.

I wound up choosing a Physical Therapy clinic in my neighborhood in Brooklyn but it was not my first choice. The list my surgeon's office sent me with the recommended PTs was quite long but I soon found out my choices were going to be limited. Although there were a whole slew of places listed in Manhattan, they were several locations for one practice. What that meant to me was that when I called and one location did not accept my insurance it eliminated a whole group from the list. Also there were one or two places that listed my insurance as being accepted but when you called they said they took "out of network benefits." Translation: they don't take the insurance. The list suddenly became very short.

After weeding out the facilities that were of no use to me I settled on a practice. They accepted my insurance and they had locations through out Brooklyn including one in my neighborhood. I called Wednesday and was not able to get an appointment until the following Thursday because I needed an evening appointment. The receptionist took my insurance information and I just knew I had 8 days to wait. I placed a call to my insurance company to inquire about the number of visits I was allowed per year and to ask if there was anything else I needed to know. I was told 60 and all seemed well.

Thursday came and I was excited as I left work. I was highly motivated and ready to get in there and put my time in. As I boarded the bus at 4:20 pm to make my way home, my cell phone rang and I checked it once I sat down. The call was from the receptionist at the Physical Therapy Clinic.

She felt this was the appropriate time to call and let me know that I would need a referral from my Primary Care Physician or they would not be able to see me. When I asked why she was calling me an hour and a half before my appointment to tell me this when she had my insurance information for 8 days she responded "Well, we're very busy here and I just got to call the insurance company." To add insult to injury, I would not be able to be seen for another week unless I was willing to take time off work, which I was trying to avoid and also why I had waited a week for an appointment in the first place. AHHHHHH!!!!!!

I called the insurance company to verify that I needed the referral. Turns out I did but I could also get it from the surgeon. Still pissed, I called the surgeons office and with it being after 4:30 I was greeted by the answering service. No help there. I called my PCP's office. The good news was they were opened until 5:30 that day, the bad news was that I got voicemail. I left a message explaining my plight and continued ranting to anyone who would listen. Erik wound up getting an earful over IM. Thanks, again, for letting me vent.

Luckily I got a call back from my doctor's office. They heard how worked up I was an called the PT office for me and worked it out. They called me back and told me that I had my referral and it had been faxed to the PT office. I would get to keep my appointment.

I was happy but I was still annoyed that I had to deal with all that aggravation to get there. Two things in particular annoyed and continue to annoy me. The first is that I got the call about the referral so late. I know all these offices call the insurance the same day but a call at noon would have easily resolved the issue instead of my scrambling to find an open office at 4:40 PM. Secondly, when I called the insurance company the rep did not mention anything about a referral. I didn't specifically ask if I needed a referral but I did ask if there was anything else I needed to know and was told "No." If either person would have stepped up and put forth a little more effort I would have been saved some grief.

I went for my appointment and all went well with the evaluation.(I will post another, non ranting, entry with details about my evaluation.) As I was leaving I asked to make an appointment for my next visit and I was told that I now had to get authorization! Does the madness ever end? I asked the receptionist how long that would take and she said it could take 48 hours after it was submitted and she would submit it the next day, Friday. I made appointments for the following Tuesday and Thursday and went home, knowing that I was going to aggressively follow up if I wanted to keep my appointments.

Monday morning came and I called the PT office around 10 AM. I was greeted with confusion and asked if I could be called back. "I have charts everywhere and I can't find yours right now." It didn't exactly inspire confidence, yet again. Much to my surprise, I got a call back within the hour only to be told that my request for authorization had not been submitted because she was out sick on Friday and she would submit it now. Things were not looking good for my keeping my appointment.

I followed up by calling my insurance company on Monday afternoon to be sure they had received the request and they had, so that was a step in the right direction. I then called again on Tuesday morning and afternoon to follow up on the authorization. Finally, I got approval on Tuesday afternoon so I would be able to keep my PT appointment. You would think this would end the frustration, but no.

Someone sitting in an office somewhere had decided that I was authorized for 8 sessions during the next 6 weeks and any further visits would require further authorization. This was in spite of the fact that my surgeon had prescribed 2-3 sessions per week for the next six weeks. So if I decided to attend the bare minimum number of sessions they were undercutting my prescription by 4 visits. When I pointed this out I was told that this is just how it is and I have no choice. I expressed my frustration to the customer service rep at the company and explained the frustration I had experienced already with the PT office being on top of following up on this stuff and that I did not have the greatest faith in their diligence to keep up on the paperwork and that this was impacting my recovery. I also pointed out the insanity of having to jump through so many hoops to get a authorization for PT after surgery that they authorized and paid for. The rep, while compassionate, could do nothing.

I now called the PT office to let them know I would be keeping my appointment and about the authorization had received. I was informed that the fax machine was down and, as a result, they had not gotten the authorization. I told her the situation and she said they could get a verbal authorization if they needed to and I asked her to make a note in my chart. I was also told that it would be easier to get authorized for further visits since it was a part of continuing care. I'm not convinced but I guess I don't have much choice. I'm sure there will be another health insurance related rant down the line.

The lesson learned here is to do your homework. Ask questions when it seems there are no questions to ask and when you're given an answer, ask again. In spite of all the doctor's and medical professionals you may be working with, you are the one responsible for getting what you need.

Post Op Visit 3 - POD 34

I went back to see Dr. Hershon yesterday. It was another short visit but I received some good news. After an hour long bus ride from 23rd St. to 60th St. (I hope I feel comfortable to get on the subway soon!) and an hour long wait in the waiting room of the office I finally got in to see him. I was pretty damn beat at that point but happy to finally get my turn.

When I was put in the exam room I took of the immobilizer and my shirt so I would be ready, unlike my last visit. Dr. Hershon came in, asked me how long it had been and asked me to move my arm. First he asked me to move my arm out in front of me. I was able to get it to about 45 degrees thanks to the shoulder flexion I had been doing for the past week and to the little over 90 with his help. When he asked me to move my arm out to the side it was slightly comical. i could not get my arm more than 2 or 3 degrees away from my side. I just looked at him and he said "Let me help you with that." He lifted my arm a little further, to about 30 degrees, and he looked at my shoulder as he did it. My arm would just not move.

After that he said "Okay, let's get you some PT and get this shoulder moving." I was told to wein myself off the immobilizer and start using my arm. He wrote me a script for PT and advised me to keep the immobilizer on in situations where I might have someone unintentionally grab, bump or hug me. We chatted for a minute or two, I asked about the aches I was experiencing and he reassured me it was perfectly normal. Dr. Hershon asked me to come back and see him in a month and left. That was it.

I had become so attached to and dependant on the immobilizers that I was afraid to give it up. I knew my arm would not just start working after surgery and 5 weeks and I was not sure what it was going to feel like. On the other hand, I was really ready to get the hell out of those things so I was willing to give it a try.

Once I got home I, happily hung the immobilizer up and went about doing what I had been doing for the past few weeks at home. It was nice that I was allowed to now use my arm but I quickly found that it was not much use. I could not quite get my hand up to my face to wash it when I got in the shower and I couldn't exactly get my arm all the way extended to turn on the water but at least i was able to try. I still slept with the immobilizer on last night. I'm still worried that I'm going to roll over in the night and wake up in pain.

Being able to take the immobilizer off at work today was very helpful. While I had to walk my hand up to the keys on my keyboard, I was able to type with two hands. I would have to say it increased my productivity, well, two fold. It also made things like going to the bathroom a lot easier. I kept the immobilizer off while I was at my desk and on my floor and I put it on when I went off my floor or went out side and on the commute home. That was more as a visual reminder to others than for me. I was in a little pain by the time I came home but it is not that surprising.

The thing that is most interesting to me is that I did not experience much pain during the initial recovery from the surgery. It would seem that I am entering the period now where pain is going to be an issue. The way I see it, I have a prescription sitting here for 18 torture sessions.

I also got the list of recommended physical therapists from Dr. Hershon's office. I was pretty excited to have the list and get started with PT but I kinda had my bubble burst. I had chosen a place from the list, that a friend from work had been to and was happy with and was very convenient for me to go to from my office. However, when I called them they would not take my insurance and that was the case with most of the places I called. I finally called One on One Physical Therapy in Brooklyn and they took my insurance. The problem is the only appointment I could get for an evaluation that fit my schedule was next Thursday. So I have to spend the next 8 days with a barely useful arm while waiting for my evaluation. I want to get this started so it's frustrating having to wait.

Two bright notes to end this post. 1. I am now officially caught up so now I can start posting in real time. and 2. I'm wrapping up my first two handed post. Woo Hoo!!!