8-year update

This is the first time I revisited the blog in years. I'm glad it's still being read. I would recommend anybody in a recovery situation to read about the experiences of others in the comments section, since they give perspectives different than my own. I was very lucky to having completely recovered.

It has been another great year, although I have stopped running due to knee issues. I still can't complete more than six pull ups in a row. But that's good enough for me.

I hardly think about the accident and I've been back ice rink several times without fear. But I've met even more colleagues and friends of friends who also broke their humerus. Often, it turns out, by slipping on a wet floor or falling in the stairs at home. It's dangerous outside, but perhaps more dangerous at home… Several of them, if not most, have not recovered completely. Some have difficulties sleeping, while others never regained full range of motion. Sorry, I don't mean to discouraging, rather there's something to be learned. I think my PT did the right thing: he had a mean streak, but by emphasizing the importance of, and forced me to working the ROM early on and not worry so much about muscle mass, I recovered. I really wanted to use heavier weights early on, but his arguments were quite compelling and I trusted him. In hindsight, the PT was a much more important person than the orthopedic surgeon.

Eight years ago to the day and six days after the accident, the brace was not on, I was still taking Percocet and not knowing what was going to happen, how hard the recovery would be and how much PT that would be necessary. In the end, the accident made me a stronger person. Most of all it taught me that life could change really quickly, and that good health should not be taken for granted.

Humerus Day

Half jokingly we call December 22 Humerus Day. It's a day to remember the accident and be grateful for the successful recovery, and a day to appreciate our health.

I have since the accident three years ago encountered friends and friends of friends who also fractured their bones, and in a few cases even their humerus. Sometimes the break was far from as severe as mine, but the recovery took more time nevertheless. It seems to be almost impossible to predict how the healing will go based on the initial x-ray. Nerves can get damaged and so can tendons and the blood circulation.

I have no recurring nightmares about falling, but last summer I fell during running at deep decline and rolled around on the asphalt a couple of turns. The pain was quite severe and my first thought was to check the mobility of my arms. The injuries were mere scratches and healed in a couple of weeks. But the incident reminded me again how quickly things can change.

Two-year update 2

I just read some comments to my Two-year update post. Philip asked how I could be happy not having a straight bone. That's a good question, so I'll respond:

I am happy because I'm not aware of any angle. The last x-ray was taken long time ago, and before the bone had healed. Also, my doctor use to say that the x-ray image was lagging a few weeks behind what was happening inside. It was then strong enough for daily life (perhaps not push-ups). The angle at the last x-ray at week 18 was not that bad, a few degrees, perhaps, but it didn't look completely aligned – that's true.

What then happens in the healing process was that the bone solidifies and the body moves bone material from one side to the other, so that the angle more or less disappears. This is called Remodeling and doesn't only occur after a fracture, but throughout life. It also adapts to stress: a right handed tennis player will have higher bone mass in the right arm.

How much "straightening out" that has occurred in my case is impossible to say without another x-ray, but why take another image (and be exposed to more radiation) when things are going fine? Apparently, the remodeling after a fracture could take up to five years, so things are still happening in there. But today I performed 20 dips on gymnastic rings, not too shabby for a middle-aged former couch potato, who couldn't perform even one only three years ago.

When I feel the humerus bone, it's impossible to tell that it was ever broken and no misconfiguration is visible from any angle. So to my knowledge, it is perfect.

Thanks for the question Philip!

Two-year update

I didn't think I would write more, but since this blog is still read, I'll give a brief update.

Two years ago, I just started the cable column workouts (with no weights). Being in the gym triggered an interest in strength training and CrossFit, something I've never been into before. I don't exercise too much in the gym now, one–two sessions a week in addition to running and biking, but I can now do fairly advanced body-weight exercises such as pull-ups and dips something that helps running form. I'm significantly stronger than before the accident, and I have no restriction in my range of motion or any kind of pain. In a strange way, the accident changed my life in a positive direction.

I just discovered a fantastic blog for stretching that would have come handy two years ago: Mobility WOD. WOD is CrossFit jargon for Workout of the Day. The blogger, Kelly Starrett, who posts one exercise a day for one full year is a PT and CrossFitter and is convinced that stretching is absolutely necessary, not only for athletes. Many of the exercises are intended for the lower body, but search the archives for "shoulder", and quite a few videos pop up, many of which use a rubber band, such as this one.

One year

It has been one year to the day. This will be my last posting. Thanks to all of you who have contributed with comments and sharing your experiences.

When I look back, the day of the accident and the following week was the worst time: the pain, the uncertainties, the helplessness, and the lack of sleep. The feeling of having the broken arm just hanging in a sling was just an appalling feeling. (Since my accident two colleagues broke their collar bone and ankle, respectively; they were back to work within a week. A humerus fracture is really something else.) But from then on, things improved, slowly, not always daily but on a relatively straight path.

Today, though, I'm in better shape than before the accident. I'm stronger, I swim better, I run faster (at least the 5k distance) than eight years ago. I have no tendonitis any longer, and the range of motion is the same in the left and right arm. I know that I'm able to overcome severe difficulties. I've also met people at the hospital and rehab who are far worse off than me.

I also experienced American health care at its best. My doctor was wonderful. He never tried to over-treat me to make a few extra bucks. He never tried to hide anything from me, may it be the level of pain of recovery time, and all his predictions turned out to be correct.

The flip side is the knowledge that I'm not immortal. I can feel it slippery winter days and I may be a bit overly cautious sometimes.

In hindsight, I there were good things about the accident. But I hope it will never happen again. And, I have not returned to the ice arena. I probably won't unless my kids want to go.

Week 34

August 22. It's been a while since my last post. The reason was simple not much has happened until the last couple of weeks when my tendonitis disappeared. I consider myself completely recovered, the only difference from before the accident is that I can't reach between my shoulder blades with my left arm, but it's getting there. I haven't been back to the ice arena (although summer skating is really nice when it's hot outside). The psychological block is not the main issue, rather that I don't feel the need for that kind of exercise since the rest of my training is going so well.

Strength-wise, I'm exercising my right arm as well to keep the balance, and I've never been a better swimmer than now (thanks to great colleague who's also a swimming coach; I was at quite a low level even before the accident). The combination of breast stroke and crawl is quite beneficial.

The intense cross training has one incredible benefit of which I knew before, but never experiences since I did mostly jogging and biking: It's possible to exercise every day,weight exercises at home along with swimming 2-3 times a week, jogging 2 times a week, and some biking. I have no knee problems whatsoever from running, something I used to have.

Week 24

June 10. I completed the Duathlon (running-biking-running again) without any complications except for leg and knee soreness the following day. The time wasn't that great, but I'm happy I was able to finish. The arm didn't cause any problems, not even after 50 minutes on the bike.

After a couple of weeks with only limited weight training, the tendons have been pain free, and there was no clicking when raising the arm. But I have to improve the strength. It seems that the problems are aggravated by heavy weights, so I'll go back to my 8 pounders and elementary exercises such as simply raising the straight arm in different angles and low impact cable column exercises. I have also discovered the pec fly/rear delt machine at the gym. It gives a wonderful stretch in the pec fly position.

Week 21: what I would have done differently

May 20. For a week or so, I have lived in a world every-other-day pain. I go to the gym and use the cable column, the elliptical machine, and swim. The following day, I'm sore in both arms. The tendons are clicking, sometimes even more in the right shoulder. But the day of training I have virtually no pain at all. I still perform stretching exercises every day, and I'm using the Wii Fit quite a bit, especially the yoga and strenght exercise programs.

I'm now pondering whether or not to register for my first duathlon (=triathlon minus swimming; I'm still far too slow and weak for half a mile in a crowded cold lake, but I'm not a much worse swimmer than before the accident). I'm concerned about injuries, especially knee injuries while running (2 miles and 5 miles within 14 miles of biking in between).

In hindsight, there're a few things I would have done differently, had I known the healing process:

I would have kept exercising my hand grip more, which was very weak when I started PT. The motion would have increased the blood flow and possibly stimulated bone growth. Hadn't it been really cold and snowy, I would have tried to outside earlier on.

I would also have exercised my right arm, both before and during PT. When I used the cable column for rows today, my left arm was now stronger (some 50 pounds with much more to go).

But except for that, things went quite well. I meticulously followed the instructions from doc and PT. I watched my food intake, and I'm now back up to where I was before,  about 180 pounds.

May 23. All the $ numbers are in now. I had to pay more for PT than I thought, some $600 out of pocket. The entire bill charged by the PT clinic was in the $3,500 range, about $100 per visit.

So altogether I paid less than $1,000 of pocket and the total cost billed to the insurance company was less than $8,000. Quite a lot, but significantly less than having surgery.

Week 20

Two weeks without any PT or doc visits. My range of motion is fine, except for the behind the back "police move." I don't suffer from any severe pain, even when lifting my arm straight up with an eight-pound weight. I do, however, still feel the tendonitis, but that is nothing the prevents me from anything important in my daily life. One of my PT's last statements was, "increased range of motion will lead to increased strength." He was right, ROM and strength feed off each other. I haven't done much weight lifting the last weeks, but when I do, it's much easier than before. 

Week 18

April 28. Last Wednesday my PT discharged me. Had my insurance covered more visits than 30, I could probably have stayed a few more weeks, but the main hurdle had been cleared. I can lift my arm straight up, although with some muscle pain. I got some new stretching exercises to extend my range of motion, some of which I done by myself before: leaning on a wall with a raised arm as high as possible, and standing in a corner flexing the shoulders. He warned for tearing off my tendon by lifting the arm. After that session I had some tendon clicking noises after I lowered the arm from high elevation. Not only was it unpleasant to listen to, it also hurt a bit after a few times. Today though, my doc calmed me (as so many times before) and said that it would be unlikely that I would tear a tendon, it was just the biceps tendon slipping out and in of the grove of the humerus there was probably a hint of tendonitis as well, but nothing to worry about; just take ibuprofen. He thought my range of motion was quite good. The x-rays showed an increased level of bone mass along with a remodeling to make it straighter.

So he too discharged me. I felt a hint of sentimentality. I met interesting people at the hospital and learned about other priorities in life than work. 

Week 17

April 20. I just rediscovered these drawings by Leonardo, made some 500 years ago. They make sense now in explaining the vast number of exercises necessary for recovery.

My achilles heal, low to high diagonal exercise, is still impossible to perform on a cable column, but it's ok, but hard, with a four-pound weight. Strange.

But I tried to swim today, and it went quite well for some-50 meters. A few underutilized muscles had to work and there was a nice stretch. The hot tub afterwards was sensational.

Week 16

April 13. Time flies. Just when I thought I had muscle recovery under control, my PT introduced the Cable Column and one exercise in particular that was incredibly difficult: lifting the arm from down right diagonally up to the left. I simply couldn't do it even with only one pound resistence. So I'm back to the rubber bands at home as this exercises doesn't really need gym equipment, only diagonal resistance.

Except for that exercise, it was an easy day at the PT's. A pleasant surprise was performing the rows on the machine. It's easier to stand, rather than lying on my belly so the rows are much more effective.

As of last doc visit, the clinic has started to charge only what the insurance company is willing to pay, $35, instead if $65. That's very nice of them. Although I'm an easy patient--each visit takes less than five minutes with the doctor--that digital x-ray machine looks awfully expensive...

April 16. Today I went to the (real) gym for the first time since the accident. I certainly could have done it months ago, but now my home equipment started to show the limitations: a few weights, the rubber band, and a stationary bike. The Cable Column is simply a great tool, although i still couldn't perform the low right to high left exercise even without weight, but 40 pounds of rows was no problem (although I don't know if the actual weight is 40 pounds considering the leverage achieved by the pulleys). Another great machine was the elliptical trainer. The combined arm motion with the high heart rate made wonders.

April 17. It was a good and productive day at the PT's. I still couldn't do the diagonal low to high exercise, but everything else went and after "stretching" (it's rather bending) I was able to raise my arm to what felt like 180 degrees.

The weather was wonderful and I took a 30-minute bike ride, the forward leaning position of which felt like a nice stretch. My speed and cadence were similar to before the accident. But I don't I'll race soon, I'm too scared of falling.

There's one good thing coming out if this. I'm going to take more care of my upper-body strength.

Week 15

April 8. My PT increases the weights quite significantly (15 pounds in one-arm rows and eight pounds curls, for example), but I still can't lift my arm over my head. It's getting slightly annoying.

Last night I woke up sitting and having arm pain. I had a nightmare and got up using both arms. I'm glad this didn't happen two months ago.

April 10. It was supposed to be one of my regular measuring sessions with the gentle PT. He too knew some some torturous tricks: when stretching he didn't give in for my agony, but kept going. He increased my passive range from 130 degrees to 150 in five minutes, and laughed when I replied 9 to the question: "what was the pain like, 1-10"?). 10 was the day of the accident.

Then he increased the rows weight to 20 pounds, so in a week I went from 8 to 20. This had no direct impact on my range of motion standing up, which is still the achilles heal. But now I can easily reach above 110 degrees with straight arm standing and above 90 degrees with two pounds. The one pound weight is not in use any more, and the two-pound one, only while standing up. The rest is 4 pound minimum. Lying down on the side lifting the arm 90 degrees with the 4-pound weight is still very hard, but it's getting easier.

My doc has been right in everything he predicted several weeks in advance: the day of removing the sling, the removal of the brace, and the week when I would be able to lift my arm higher. 

Week 14

March 30. Another day at the PT factory. I found out that I only have three more weeks of PT, since my insurance won't cover more. Luckily, today the work went better. I have only pain in the deltoids when raising my arm straight standing up, or from horizontal to vertical while laying on my side. All the other exercises are just stretching or regular muscle fatigue. It's simply amazing how fast some muscles have recovered, and how slow others have been. In fact, some exercises that I do in parallel motion with left and right arm are tougher for the right arm. Today the arm bike was easier. I kept an average of 90 rpms for six minutes, and I could have continued; the blood flow felt great. 

Today was the first time I tried my bike outside. It was pretty demanding on both arms since I have a road bike with a forward-leaning set up of the handlebar and saddle. But it felt good and gave life a bit excitement. 

March 31. Three months check-up with the doc. He was very pleased. I just want to see me one more time, and he said that I would see progress in PT fairly soon. I asked him what I've been thinking about for quite a while: "What about steroids?" The answer was no, the side effects are to risky. Natural healing is the best. I agree in principle, but why are there steroids if they never can be used? I didn't ask him that.

I'm now allowed to do anything except for contact sports, or ice skating... He believed that much would happen in terms muscle strength and range of motion during the next couple of weeks.

The mid x-ray above illustrates what he said during last visit: The body compensates the angle and adds more bone to the concave side and removes it from the convex (it's the osteoclast – osteoblast thing). In a year, there will be no angle, just perhaps a small bend. The bone during remodeling is recycled and I don't have to worry about calcium deficiency. I peeked in his notes from last time, and they were as positive as his words directly to me. I wouldn't have liked being lied to. 

April 1. Today I remembered to take an Ibuprofen before PT. That helped a lot, because it was a tough day. My PT added an extra pound to a few arm lifting exercises that were heavy enough with two pounds, and with the leverage of the long arm with the extra weight, the power increases significantly on the deltoid. 

He also wanted to perform simple straight-arm-raising exercises with no weights while standing, but make it static., holding the arm up for as long as possible. That's hard on my good arm too, especially after two minutes.

April 4. The straight-arm lifts while standing have worked wonders, although they're quite painful. I can go above 90 degrees. Although I'm beyond 135 degrees while lying down, the muscle strength is not sufficient to actively lift the arm that high. But it's getting better.

It struck me that the benefit of having a non-physical job that allowed me to work from home the first four weeks with no monetary loss, is now a problem. All kinds of physical activity feels good now: running, biking, garden work, but most of my time I have to spend in front of the computer and that stiffens the muscles.

Week 13

March 23. Another assessment day at the PT's. My passive abduction lying down was 133 degrees, but I certainly can't lift my arm that high standing up.

I don't get a sense of immense progress. It still hurts lifting the arm high--I can hardly lift it beyond 90 degrees while standing--but I can do 8 pounds with biceps curls. I can actually feel that there is a muscle now, and triceps has been noticeable for quite a while.  The annoying this is that I can live without biceps strength right now, but not raising my arm above my head.

March 26. Today my PT reiterated the statement that he could probably bring my arm straight 180 without destroying and muscles or tendons, but that I would probably pass out. For a second I was tempted: a couple of days of severe pain for a gigantic gain of extension. But I passed. And it wasn't really an offer.

He also thought that I had the muscle strength to lift the arm all the way up, but that the joints and competing muscles are preventing this motion. It's very annoying. But the rubber band work at home really helps. The red colored one feels too easy already.

Week 12

March 16. My regular PT was back. He must have read the notes from last week since he offered me a large number of new exercises with or without weights. The best ones were the "bungy chords," different colored rubber chords anchored to the wall to be pulled in different ways. The resistance felt nice on the yellow, the lightest one. Then I worked on stationary bike for the arm: a crankshaft in chest level with settings just like a bike. That stimulated my speed and blood circulation (and I burned 15 calories).

Hardest is raising the straight arm to 90 degrees forward and sideways. It's still almost unbearable, even with just the 1-pound rod. That's the most central exercise now, it in two directions each standing, laying on my side, and laying on my back, thus working different muscle groups against gravity. 

March 18. This was the toughest day in the PT gym thus far. Every exercise had weights now. The snow angel exercise, for example, that I really struggled with only a week ago felt much better even with a one-pound weight. He even let me do some bicepts life with 5-pound bars. That's very easy, and irrelevant at this point. But I'm certainly sore. 

For Friday he warned me, strength is not the issue, range of motion is, especially lifting the arm above 90 degrees, "take some Ibuprophen before you come." Ouch, that's gonna hurt at night.

March 20. He was right, it did hurt. But he liked my joke about the torture chamber of the Spanish Inquisition. I would have confessed everything even with 200mg of Ibuprohen. He extended my range of motion quite a bit, which really evident when I used the pulley to raise my arm. It certainly not going 180 degrees up, but far above 90. This was great torture. The 5-pound bench press also feels good now. So there is hope.

Week 11

March 9. The exercises went much better today. But no time to enjoy any victories, as my PT introduced new ones: laying on my back with my arm straight and parallel to my body I was raising it straight up. That hurts a great deal just below the shoulder joint. Another tough one was "Snow angel," moving the arm parallel to the floor while laying down. I'm also performing the wood rod exercise standing up in three ways now: forward lifting with straight arms holding the rod overhand as well as underhand. Underhand is significantly harder and hurts a lot, but I have done it several times since I came home and it's getting easier. Instead of doing 10 reps of each morning and night, I'm doing 5 every hour, or so. I'm also holding the rod behind my back and stretch back with straight arms. This is very easy, and there's no significant difference between my left and right arm. It's striking how some muscles cambe back to normal fairly, while others are very slow to recover.

I looked through the exercises on my Wii Fit game. Not much to benefit recovery: it was either too hard (as the yoga ones; the tree pose doesn't work if you can't life your arm straight up) or not engaging the arm at all (as skiing), but the jogging game is fine, and so was boxing from Wii Sports.

March 12. I've learned from "doogiedoc's" remarkable recovery that changing PT once in a while could be very beneficial. My regular one was away, so I got a colleague of his. She stated out very soft with a stretching massage that hardly extended my reach--I thought it was going to be a waste of time--but then she introduced a few more exercises and, above all, added weights. It was a whole new world that opened up. I did five pounds bench press, and it wasn't that hard. The weight made it easier to extend the reach over my head (I'm just about at 90 degrees). 

Just a pound's weight made it also easier to stretch the arm forward, when I was laying on my stomach. She ended the session by icing the shoulder. I'm not sure how beneficial that was, but it certainly felt nice.

She also made me aware of my insurance limit: I only have 30 visits, and I've spent 16 already, including occupational therapy. She recommended that cut it down to once or twice a week after my next evaluation on March 23, that way I'll have some extra visits after my March 31 orthopedic visit, if needed (and I have no doubts that it will be needed).

March 13. Another 90-minute session with the alternative PT. She pointed out the obvious: I'm compensating too much, some of which I knew about, after a few lifts I start leaning my body to raise the arm, but others were more subtle. She brought me to the mirror and let me life the 2 pound rod on straight arms forward, and I could see that my left should followed along quite a bit. I had been too focused on the angle, rather than exercising the right muscles. I need strength in my trapezius and rotator cuff. 

Another exercise she introduced, but didn't demand that I do is the "police hold": arm behind the back holding on to a towel and pull it over my right shoulder. This resulted in an intense stretch feeling, although I could only lift it an inch or so. It was very painful.

Today I also brought my violin to show the OT what an intensely complex instrument it is to play. It's completely non-ergonomical to hold and takes lots of different kinds of motions and rotations, particularly of the hand. She was amazed how the shoulder worked (I guess I was compensating a bit to keep the instrument up, but it didn't feel different than before the accident). Indeed, many musicians ought to work with a physical therapist to avoid many problems that occur sometimes early in the career. 

Week 10

March 3. The bone has improved a lot since the last visit. This 45 degree angle corresponds

to this one, only three weeks ago. Some of the difference could probably be attributed to the brace worn in the earlier picture. The doc said that the body compensates for the lack of bone on one side. I don't completely get it, since it is obvious on the x-ray which bone is new and which is old, and I can't see any balancing act going on. But the difference between these two images explains why my doc was not concerned about the non-straight angle. The body takes care of such imperfections, and even if there is an angle, the elbow joint is extremely flexible and can deal with it.

From the front view the new bone is clearly visible. Again, doc pointed out that the x-ray is two weeks behind what's inside.

I asked him how much it would take to break it again. The answer was "let's not find out." But he told me it would take quite a bit of force. He still thinks I should wear the brace if it's slippery out, but spring is here, so I'll burn my old friend, or perhaps turn it into a piece of art. I've not been wearing the brace while at home for several weeks and not outside for a week. But I'm not sure that the outside is the most dangerous place. There are lots of traps at home: the children's toys and the stairs (I almost fell the other day), not to speak of the shower.

March 5: Encouraged by the good orthopedic news my PT brought the heavy artillery: I can now do two pounds in bench press. Using a bar bell wasn't that hard, worse was doing it only with my left arm holding a one-pound weight. The real weight work will begin when I can raise my arm above 90 degrees. As the doctor said two days earlier, "you and I are not that strongly built," what he meant was: you were weak even before the accident and the recovery would be faster for a body builder. Although, after having just discovered this site, I'm not so sure. Even the bodybuilders seem to come out of a cast or brace with very weak muscle strength and limited joint mobility.

The OT believed my hand and underarm would be fine. I was 4 degrees from stretching it to the same angle as my right arm (175, I think). Active bending of the elbow won't be a problem, she thought, although it's 20 degrees from the right arm's ability right now. I have started to do small easy, but quite effective, tasks: brushing my teeth with my left hand, holding my left hand on the steering wheel in the car, even if I don't have to, holding the phone with my left hand, etc. And best of all, sleep without the brace. I kept using it at night until this week due to fear of night time "events" (not completely unfounded since I've done a few weird things in my sleep).

March 6: another day at the PT gym. The PT thought he saw some biceps growth, but it was just the bone callus. I'm fine with weak biceps and triceps, I rather have more deltoid strength. I'm dying to start swimming again, and if I could stretch out my arm, it would take care of many issues, I think. I'm just waiting for his words: whenever he tells me to exercise my biceps and triceps, I'll go full throttle. I still have my gym membership.

It's not all bad

I've been thinking about this thread for quite a while. My experiences have not been all negative. Not only did I get time to catch up on some reading and movie watching, I could relax a bit and appreciate the small things, and to adjust expectations. My plan for this time of year was to get in great shape and complete my first triathlon. That won't happen, swimming half a mile will be impossible, but life goes on. 

But of course, my relaxation was my wife's extra work. 

The extra sleep I got after the first four weeks sleeping in a chair has been very beneficial in general. Whereas virtually all my friends and colleagues have been sick from viruses, I've made it thus far. I was also able to decline night-time events without any complaints from colleagues. This has been a time to appreciate the important parts of my life: family and health. To focus less on the trivial aspects of work has been mostly positive.

I've met quite interesting people at the hospital, both medical staffers and patients, some of whom in much worse condition than mine. I have connected with colleagues who also broke a bone at some point. It feels like a secret society, like the Free Masons of fractures.

At this point, when there is daily progress, along with spring approaching, I have an incredible sense of optimism.

Financial Implications

Although it's far too early to assess the complete financial impact, I can make a few observations: As of the end of February, I ran up a tab of close to $4,000 from the orthopedic clinic, emergency room, and an x-ray consulting service, most of which was for the day of the accident and the first visit to the clinic. Each follow up is less than $100. The ambulance bill was $350 and I got as much Percocet I ever wanted for $8 (I've been extremely lucky regarding the pain, and haven't touched the stuff for at least four weeks, and used less than half of my 110-pill supply). I have paid some $300 out of pocket, thus far. The rest has been covered by insurance. Each visit to the clinic is relatively simple: Two x-rays and a five-minute examination, not exactly rocket science. $200 is my deductible for physical therapy. I don't know how much they charge yet, but one visit could last one hour those days I have both PT (working on the shoulder) and OT (Occupational Therapist, working on the wrist and elbow), and they're dedicated professionals who take their jobs seriously. 

It's a lot of money in absolute terms, but not that much in the twisted world of American health care. The advantage from a cost perspective seems to be that this is an established kind of injury that follows the rule book: it's not a hard-to-diagnose decease with many different methods of treatments and testings. The recovery is long and hard, but relatively straight forward. It can be measured in the abduction hight and rotation angles, and the increase in exercise weights.

I'm lucky to have a physically light job, and very understanding management, that allowed me to work part time for a couple of weeks without any salary cuts. The financial impact could have been huge otherwise.

Week 9

February 27. As I keep bombarding my PT with more or less trivial questions, I get some important information. Q: "when can I perform push-ups?" A: laugh, "in three months." In his assessment, the bone is not the issue, since people with a broken leg are encouraged to walk on it after eight weeks. The issue is muscle strength. When I asked him when to begin with weights, I was told that a bigger muscle mass is not important at this point, not until the range has been expanded. Muscles could retract and prevent increased motion. Good to know. When I asked him what would happen if I didn't come for PT, he told me about frozen shoulder. It was simply terrifying to listen to his description, but highly motivational for working hard. I also asked if it is possible at this stage to damage anything by the exercises I'm doing, he said No. The weakness of the muscles would prevent me from overdoing anything, and the bone should be strong enough for carrying out any task that only involves the weight of the arm itself.

So I keep working on the shoulder range in all directions: chicken wing (laying down on the side and lift the elbow, first by resting the hand on the right hand fist, and then without support), external shoulder rotation (I'm not using a weight as in the video, but I turn it much further), wood rod bench press but now with extension of range over my head (not possible in my case yet), laying on my stomach lifting the hand, and then lifting the arm straight holding it parallel to my body. 

Week 8

No more Mr. Nice Guy. The second week of PT began with hard exercise: lifting the arm in different positions. My favorite was the quarter pound bench press--a simple wood rod that felt like lead. I managed ten pathetic reps... I am now working with a sports PT who's used to high effort. He told me a rule of thumb that I'd expected to be true for quite some time now: for each day the arm has been immobilized, it will take three days for the muscles and joints to get back on track again.

He noticed though that my range had extended in only three days. I still can't life the arm up to 90 degrees while standing, which according to aofoundation constitutes a complete healing of the fracture (albeit not a complete recovery), but I'm above 45 degrees now.

I'm also working with an Occupational Therapist on my underarms and hands. It's certainly not as urgent as the shoulder--two-hand typing is no problem, and has never been--but I do want to be able to play violin again.

On 2/21 I went outside without the brace for the first time, against the doctor's order. I just couldn't take it any more. It was slippery and snowing I the thought of falling and breaking the arm again was simply horrifying.

Tips and tricks

For those early weeks when a full shower is impossible: baby wipes can do wonders. My favorite is melon-scented Huggies.

Using regular dental floss is impossible without any aid was impossible, even after two months. Luckily, there are disposable one-hand floss picks, along with other tools.

Weight gain? After weeks of inactivity I was concerned about gaining weight. I didn't, instead I lost a few pounds, some may be due to the loss of some muscle, but the key is healthy eating. I drank quite a bit of kids orange juice with lots of vitamin C, D, and calcium.

Week 7

February 10. The fracture healing has gone very well. The doctor could even feel some hard callus. The took the arm and bent it at the fracture site. It didn't hurt, but it was a bit weird watching it--and it was quite rigid. Next visit will be in three weeks. He believed that that will be the day to remove the brace, which, at this time, only has a protective function, not supporting. In fact, I'm mostly out of brace when at home. If it weren't for the fact that I almost fell once, and got very nervous, I would only wear it at night (you never know what you can do in your sleep).

But now it was time for a referral to Physical Therapy. I got an appointment straight away. The PT was a little concerned, as his copy of the x-ray didn't show that much healing. But we started with the normal exercises I've been doing for some weeks already: leaning forward and make circles with the arm in both directions. He added pendulum exercises, raising the shoulders, and pulling the shoulders backwards. Especially the last two felt good. He also gave me some Play-Dooh-like jelly to squeeze with my hand. Definitely necessary: The power in my right hand was 80 pounds while it was only 40 in the left. 

This will be a major time commitment, as he scheduled me for three appointments a week for six weeks.

Links

There're a number of sites useful for this kind of injury. Personally, I prefer those dealing with real recoveries, rather than descriptions of the physiological process in general. Although there are a few useful general ones: emedicine, the Duke Medical School (filled with detailed medical language and no pictures but x-rays), or the aofoundation. The latter is a Swiss-based organization that pioneered the systematic research on orthopedic surgery. The site is quite elaborate, but very interesting. One can click on the bone of a skeleton, and select type of fracture and treatment. It in the right margin of each topic, there are a number of references to further studies.

These sites are focused almost exclusively on bone healing, but in my opinion, more time consuming and difficult is the muscle recovery.

The first one I read was this one. The injury was quite different from mine (spiral and upper humerus), but the recovery process was quite similar. It did not prepare me for the tedious muscle recovery process.

But this skiing accident provides lots of details for the physical therapy process. The fracture was in four parts and the full recovery was painful. I'm at the point now when I realize that the fracture is not the main problem, regaining motion and strength is. The patient, "doogiedoc," has been a great source of inspiration for me. His determination has been astonishing (like wearing a hat during PT, so that the therapist won't see him cry and then not push him as hard).

Here is another one, which gives a financial perspective. The patient is a business owner, and his accident turned out to be quite taxing for his work.

This link provides a vast amount of accounts, some are quite disturbing, the non-union cases, particular, as when you wait for two months and then realize that surgery will be necessary.  It kept reminding me that this is a serious injury and things can go wrong, but also that I've been lucky thus far.

Here is another one I just discovered from the site discussbodybuilding. It contains a large number of accounts, especially spiral fractures caused by arm wrestling. The great advantage is its large number of x-ray images, and wide range of treatments and PT experiences.

Week 5

January 27 was a big day. I was allowed  to remove the sling and let the arm hang free. This seemed like progress at first, but as so many times previously, it turned out to be two steps forward and one backwards. Shortly after the removal, my hand and underarm started to swell. It seems only natural that the lymph system would have problems given the big callus blocking the return of the liquid. The situation was so bad so I had to call the doctor. He just said it was normal, and not Compartment Syndrome as one friend told me it could be. After three days I found a way to deal with the problem: horizontal position with the hand elevated above the heart.

I was also allowed to remove the brace to take showers and care for the skin. This was a big deal, although the lack of complete showers was never my main concern. The first couple of times in the slippery shower was truly scary.

By now, I was used to the x-ray that showed little progress for the untrained eye, but the soft bone is really apparent. Apparently, the x-ray is two weeks behind what has is happening inside due to its inability to show soft tissue.

During this visit the doctor extended my recovery one week. Originally, he had estimated a recovery period of six weeks, meaning six weeks until the brace could come off. However, the starting day was not the day of the accident, but one week later when the brace came one. And, of course, recovery doesn't end with a healed bone.

During this appointment, doc told my wife the now famous words in our family: "Don't let him baby that arm." 

Week 4

On January 15 I was able to lose the wrist strap and move the underarm up and down. It felt incredibly strange. The muscles were weak, of course, but moving the arm with the knowledge that it was still broken was psychologically hard. But recently, I'd noticed that the ends had started to fuse. It felt as if they were locked together by muscle tension, rather than collagen matrix. 

Week 3

On my second visit, January 8, the brace had shifted a bit, so it had to be reajusted. This was something I was supposed to have done myself. The tightening resulted in an extra set of x-rays, and the the angle changed from 16 to 14 degrees. And for this visit I started to bring the camera to document the process.

It was still not possible to sleep in my bed--I tried to lay down a couple of times, but it was too painful for my arm--and sometimes the bone ends hit each other and created a painless, but very audible click.

Week 2

My first visit to the orthopedist on December 30 went well, but was painful. Just getting in and out of the car was a major undertaking. Driving was of course a non-option. The whole ordeal took quite a toll on my wife and kids.

The x-rays showed the desired result: The ends of the bones were now facing each other, albeit at an angle of some 15 degrees. But it was good enough to put on the brace--the important thing is the that there is some overlap between the two ends--a hard plastic device that would align the bone ends. It was firmly tightened and felt quite comfortable at first. At this time I had cut down on Percocet to perhaps one a day, but the brace changed all that. It is a device that really compresses the arm and the ends could easily cut into the elbow or armpit. I went back to a couple a day, and especially one or two at night time.

The orthopedic surgeon appeared competent. He had worked in the military and once broken his own humerus in a car accident. There was no sugarcoating: "you're going to have a difficult couple of weeks ahead of you." He was right indeed. Although an orthopedic surgeon was adamant to avoid surgery if possible. There are more things that can go wrong, nerve problems and infections, in particular.

Week 1

I left the hospital equipped with a sling that locked the shoulder in a fixed position. It consisted of straps around my chest held up on my shoulder and fastened at two points on the arm. A quite unstable arrangement for the fracture, but the idea is to let gravity do the work to pull down the lower part of the arm. I was absolutely miserable. I couldn't put any clothes on, but had to leave the hospital in the gown with the open back, this in  freezing conditions.

It was absolutely impossible to lay down. I slept sitting in a reclining chair. I also received 30 Percocet pills. I limited my intake to 1 every six hours. With so much free time on my hands I could read up on wide array of topics, some of which were quite frightening: the use of Percocet as a party drug, its addictive properties, and cases where humerus fractures have serious complications. And this in combination with Christmas time made the entire ordeal incredibly depressing. The first days I was only up on my legs for a few hours a day. Although I was exhausted, sleeping was difficult. I typically spent three hours every night in a state of insomnia, watching movies alone.