Putting the Cart Before the Horse: Managing Post-Op Patients

[iwhitney]

As we all know, the management of post-op patients can sometimes be quite difficult and I feel it can be easy to put the blame on ourselves whenever they aren’t achieving milestones in the timeline that we expect. This week, I wanted to reflect on a post-op patient that I have found to be particularly challenging as of late based on the significant regressions he’s incurred. The patient is a 22 y.o. male professional baseball player who is 12 weeks post-op posterior labral repair and glenoid OATS procedure on his R shoulder. He was playing for a farm team in CA when his injury occurred, which brought him back home to get the procedure performed and do his rehab close to home before continuing with his career. No pressure, right?

Overall, the patient is a really nice guy and easy to work with. He’s also undergone Tommy John’s surgery in the past on the same arm, so he understands the importance of a lengthy rehab and being compliant to an HEP, at least I thought. Up until about 2 weeks ago, he was doing quite well and progressing as expected with almost full AROM with minimal pain at end range. A lot of what we were working on included scapular control as he has a tendency to over-activate his upper trap when performing shoulder elevation. 2 weeks ago, he began to experience a significant increase in anterior shoulder pain that was constant and extremely limiting, even radiating down to his elbow at times. When I asked what he thought could’ve caused it, he mentioned performing prone y’s at home when he felt like he noticed a “pop” and subsequent pain. He also states that he will occasionally notice popping while moving into elevation, which worries him that he did something to mess up the procedure.

I was concerned about the increase in his pain, but I didn’t feel worried that he did anything to compromise the integrity of the procedure, just given the amount of time since his surgery and amount of healing that has occurred up until this point. I assessed his joint mobility and PROM, which showed no significant signs of posterior labral compromise, but did show signs of LH biceps tendonitis. Realizing what I thought could’ve been going on, I questioned the patient further about his HEP and regular exercise routine over the past couple weeks. It was pretty obvious that he was progressing a lot of exercises on his own and overdoing it to the point where he was causing inflammation at his biceps tendon. At our last visit, we spent a lot of time on education, pain modulation, and low grade exercise in order to reduce his symptoms.

Reflecting back on this patient encounter, I realize that I could’ve done a much better job at emphasizing to this patient the importance of progressing things slowly and ensuring we perform exercises in the clinic before he decides to try them on his own. I also realize that I just assumed he understood this, based on his background and PMH, having been through a long rehab with Tommy John’s that went well. I’ll be honest in admitting I felt a great deal of guilt after this patient encounter, as I felt responsible for his increase in pain, especially after the patient mentioned he wants to take a break from PT until after his next follow-up with his surgeon. I’ve done a lot of reflection on this and feel like it’s easy for us as caring therapists to put the blame on ourselves when our patients aren’t doing well. However, I think there are so many extraneous variables that can cause a patient to regress and the reality is we aren’t spending every day with them monitoring their activity. Also, it’s a difficult part of our job to scale some patients back, especially when we’re so used to trying to encourage them to do more at home.

I’m confident with the education I’ve provided and the regression in exercises, this patient will get over this speed bump in his rehab process and be well on his way to a good recovery. Following this encounter, I most definitely will be careful about how I approach my education and HEP to ensure that it’s clear from day one what I am asking from patients while they aren’t in PT. That way, the cart isn’t being put in front of the horse and patients aren’t experiencing a setback from overtraining or progressing too quickly on their own.

Has anyone experienced anything similar? What strategies do you use to ensure patients aren’t doing too much, too soon?

[Author]

Posts