Monday, January 21, 2013

Building and Rebuilding Nolan Berry: Part Two

I was encouraged to learn that Nolan was put in splints and not casts.  Immobilization of any joint makes rehab more challenging. But immobilization of the elbow ups the ante. It is a complex joint with many connections, articular surfaces and degrees of freedom. It connects the shoulder and the wrist and allows the basketball player to handle and shoot the ball with grace and unlimited variety.

Failure to do the rehab well from the beginning might compromise Nolan’s ability to shoot and play in the future, not just keep him from playing this season. I had to make sure he understood this from day one, regardless of how painful, boring or monotonous the work was.

It is interesting to note that immediately after the fall on November 19, Nolan's wrists hurt the most and were the focus of initial evaluation.  He could move his elbows fine.  It was only after sitting with ice on his wrists for several minutes that the injury to the elbows became apparent. After icing his wrists, he discovered he could not bend or straighten his elbows.

The splints were removed November 26, exactly one week after the injury.  Nolan was given instructions to “let pain be your guide” and to move the arms as much as possible doing simple tasks of daily living--wash hair, put on socks, use laptop, button shirts, open doors, etc. The one limitation was to not lift anything of significance--someone even had to carry his school backpack. He started physical therapy at Pro Rehab on Tuesday November 27th and was supposed to see me on Wed the 28th, but got the flu and missed all of his sessions at Pro Rehab that week.  I knew it was imperative to get him moving; he was able to start with me on Friday November 30th.

Again, Nolan's work at Pro Rehab focused specifically on the hand, wrist and elbow. His work with me would focus on integrating the arms into common gross motor/sport movements and with the shoulder and scapula.

Here are some highlights of Nolan's progression and our work during the first two weeks . Keep in mind, about the only thing he could do with his arms on Nov 30 was feed himself with his R hand.

Nov 30:  Entered w/R hand holding L in protective manner. No arm swing.  Mom had to untie/tie shoes and help change clothes.  Lacked about 40 deg extension in L and 30 in R.  Less than 50% of flexion. No pronation or supination R/L .Reviewed home exercise program (HEP) from Pro Rehab therapist with mom and Nolan.  Discussed need to incorporate and set goals with  activities of daily living (ADLs). Began shoulder ROM exercises in supine/standing.  L hand particularly “dead” and inhibited by pain. Wax on-wax off with wash cloth, fold towels.

Dec  1:  Today able to walk with both arms at side;  R shoulder abduction full, L shoulder abduction with stick assist, but not independent secondary to “heavy sensation and pain.”  Put basketball in hands, wax on wax off, fold towels—folding VERY challenging for L arm/wrist.

Dec  5:  Walks holding 2 lb power balls and Indian clubs to distract elbow and maintain full extension. Light leg work, shoulder movements in all planes.  Now able to abduct L arm/shoulder without pain, full range of motion. 

Dec 6: Diagonals 1 and 2, light tubing shrugs (scapular emphasis, elbows straight), step ups with weighted vest, incline DB press (no dumbbells), tubing rows (no tubing), foam tennis ball wall touches, review 4-way jumping jack arms (in standing; too painful to jump).

Dec 7: Light jogging, squats, lunges, squat jumps on side of court during practice. Nolan begins to join team at practice even though he cannot participate in contact. First running and reconditioning begins.

Dec 8: First day being able to put on and tie basketball shoes, put on sweatshirt independently. Full shoulder abduction and flexion with L arm.  L hand and fingers moving normally again.  Shadow throwing motion with R arm (football, foam ball)—can throw and catch foam tennis ball against wall with R.  Able to incline press with stick without pain. Attempted jump rope arm motion: only able to get jumprope around/over head 1/4 of time; able to use R UE and L for single rope turning.

Dec 9:  Light running in practice; jumped up and touched rim with both R and L (gingerly) hands; dribbled with R arm and shot a few layups with R (no pain reported to coach).

December 11:  First day of driving while supervised. Begins ball handling/shooting work in earnest to work on pronation/supination. Farmer’s walks and Hexlite bar deadlifts for full elbow extension; no pain. Still painful, especially in L wrist with pronation/supination. Unable to bear anything but very light pressure on either arm. Unable to put full back-spin and follow-through with R (shooting) hand due to lack of full supination combined with elbow flexion. See some of the things we did in the video below.

Dec 12-14:  Able to drive independently now, but still very painful in L wrist after two full weeks of therapy and work. Nolan seems to have lost some enthusiasm and focus—mom, coach and I notice change in demeanor.  Progress since Tuesday of this week has been limited by L wrist pain.

So here we were, it was December 14--less than 4 weeks after the accident--and we had made very, very good progress, but it seemed like it had stalled. Nolan seemed a bit distant. He was not happy sitting on the bench in street clothes.  His goal of playing in the Meramec Tournament was slipping away.  And the continued pain in his L wrist and forearm was disconcerting. Were there injuries lower in the arm that the xrays hadn’t shown?

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