another visit to the doctor

I visited the doctor on Tuesday; she had wanted to see how things were going after I'd been doing physical therapy for a while.

I explained that I'd initially had quite a lot of pain with the PT, but that the condition seemed to be slowly improving now. She repeated all the stuff she had told me earlier - it can take two years, etc. But she also said that she didn't think I needed any more physical therapy sessions per se, and that doing the exercises at home should be enough to help. She said that since I'm an active person, she expects that I will challenge the shoulder enough with my usual activities, which will help to reduce the stiffness.

She didn't seem thrilled that the physical therapist had been causing so much pain. She said the condition is associated with inflammation, and forcing the shoulder into painful positions is likely to produce more inflammation. However, she admitted that there's so little known about the condition that you can't really make any absolute statements.

Well, I think I pretty much agree with her. I can't actually tell whether the PT is helping, hurting, or indifferent at this point. I don't know what state I'd be in now without the PT. I'm inclined to think it helped me over the worst of the problem, but it's so hard to tell. But at this point, I have a feeling I'm just as well off doing exercises at home.

I had my 12th PT session on Monday, the day before visiting the doctor. I'd decided to cut back to once a week on the sessions, to see if things continue to improve without so many visits. PT consumes such large chunks of time, and seems to make things so much worse for a couple of days. I want to see what happens if I continue on my own. The visit to the doctor influenced me though, so that I now think I'll stop PT and see how things go. If the improvement slows, I can always go back for more sessions, so far as I know.

In fact there's a perverse incentive for me to continue PT even though it's not clear to me that I need it. There's only a $10 co-pay. I might think "let me just keep going to as many sessions as I can get insurance to pay for. Why not? It's not that expensive and I get more treatment!" The insurance company should give me a reward for saving them money, no? Well, no, I guess that would be asking too much from an insurance company.

zinc

Early on, I asked both my doctor and my physical therapist if there was anything I could do nutritionally to improve my condition. It's unfortunate, but still very typical, that medical professionals appear to know next to nothing about nutrition. In any case, nobody had a suggestion.

I went snooping around the internet to see if I could find anything. Nutritional supplements are one of those things that snake oil salesmen like to latch onto, and searching the internet turns up a ton of dubious claims.

As for the science, you can find suggestive, but not definitive, research that zinc is important to production of collagen. In rats, anyway.

A few years ago, I kept tabs on my diet. At the time, I appeared to be deficient in zinc. However, I hadn't noticed any issues caused by it, and I've always been reluctant to take supplements without reason, so I didn't do anything to correct the situation.

Is it possible that my zinc deficiency led to frozen shoulder? I suppose so, although I guess there's no way to know for sure. In any case, I decided to start taking a zinc supplement soon after I started physical therapy.

I'm taking chelated zinc (50 mg of zinc amino acid chelate, 333% of the RDA) since it's supposed to be one of the more bioavailable forms of zinc. In addition, since zinc interferes with copper absorption, I'm taking a copper supplement (2 mg of copper gluconate, 100% of the RDA). I take the zinc mid-morning on an empty stomach, since that's supposed to be better for absorption. That typically gives it a couple of hours to float around without a lot of competition. I take the copper later in the day, but not on an empty stomach, since I haven't read anything that indicates that would be useful.

Recall that I had noticed an article about shoulder pain in Nigerians at PubMed. When I first thought about zinc being a possible factor in frozen shoulder, I immediately wondered whether the Nigerian diet might be deficient in zinc, leading to more cases of frozen shoulder in that area of the world. However, it doesn't appear to be the case. Some research by Onianwa, et al, says that "the estimated weighted average dietary intakes for the entire adult population [of Nigeria] were calculated to be 2.64 mg Cu/day and 15.8 mg Zn/day" which is quite near the US RDA for those minerals. So, there are no helpful clues from that research.

mri results

left shoulder coronal view

left shoulder sagittal view

left shoulder axial view

The next week, while I was cooling my heels in the doctor's office, I took a look at the MRI report which was open on a computer screen in the exam room. Here's what it said:

Examination: MRI study of the left shoulder

History: Left shoulder weakness and stiffness with history of earlier injury

Technique: Axial coronal and sagittal T1 and T2-weighted images of the left shoulder are reviewed.

Findings: Hypertrophic changes are seen around the acromioclavicular joint with small amount of fluid in the subdeltoid bursa consistent with bursitis and mild changes of tendinitis involving the most anterior portion of the supraspinatus tendon. There is a small partial articular surface tear involving leading edge of the infraspinatus tendon with adjacent synovial cysts seen at the base of the humeral head. The rotator cuff is intact and no abnormalities are seen in the biceps tendon which is located normally in the bicipital groove. Glenoid labrum is preserved. No fractures or bony contusion is seen. No bony destruction is identified. Normal study otherwise.

Conclusion: Mild degenerative changes acromioclavicular joint with subdeltoid bursitis and tendinitis in the supraspinatus region.
2. Partial articular surface tear of the leading edge of the infraspinatus tendon.

The MRI photos mostly looked okay to me, but what did I know? I had looked at some rotator cuff tears online already, and the bad ones had a lot of white areas. Mine only had some small white areas. So that was encouraging. But reading that I had a partial tear was alarming, and I feared the doctor would recommend surgery.

In fact, she did not. She told me that I almost certainly had adhesive capsulitis, and recommended physical therapy. I asked about the partial tear - wasn't that a concern? No, she said, it will eventually heal on its own. She also brushed aside the concerns I raised about the bursitis and tendinitis described in the report, saying that my main problem was adhesive capsulitis, end of story. At some point she also said something like "well you don't have any tendinitis" and I had to correct her, having read the report myself. (As you might imagine, my confidence in the doctor was not swelled by her remark.)

So two months after first seeing a doctor for the problem, I was on my way to PT. A good month of the delay was my own fault, and I wish I had not procrastinated so much.

I was able to obtain a copy of the MRI images free of charge, which was sweet. It's fun to run them as an animation, and I hope to create an animation for a blog post, but for now I've just posted one each from the different views. I wish the doctor had gone through all of the images with me. I'd like to know what parts of the image indicate the partial tear, bursitis and tendinitis.

first visit to the orthopedist

A few days before visiting the orthopedist, I did a little research into the shoulder to get an idea about what to expect. I tried memorizing the parts of the shoulder, learned the mnemonic for the rotator cuff muscles (SITS), and found some informative videos about the shoulder exam. The best were posted by bluetentorthop.

Finally, it was time to see the orthopedist. The doctor performed a very few tests, and declared with certainty that I had frozen shoulder. She prescribed an MRI to see if there was any underlying cause. That was scheduled for the following week.

I was disappointed because I had expected the whole battery of tests that I'd seen in the videos. In fact, she didn't even visually inspect the shoulder, something that was supposed to be part of every good exam, according to the videos I'd seen.

However, I was happy that she hadn't decided instantly that I had a rotator cuff tear, something that I had been a bit worried about. I didn't realize at the time how big a problem frozen shoulder is.

first visit to a doctor

Meantime, on December 16, 2009, I saw my primary care physician (PCP) to ask for a referral to get some physical therapy for the shoulder. At this point, I didn't think it was too serious, but I felt it wasn't going to heal on its own.

Before visiting the doctor, I recall testing my range of motion with the left arm and being a little alarmed at how limited it had become. When I stretched my left arm out up in front of me, I could barely get it past 90 degrees. My right arm could easily go up all the way past my head, a little beyond 180 degrees.

The doctor gave me a quick look. She asked if I was waking up with any pain at night, and I said no (I thought "why on earth would I have pain at night when I'm not doing anything?" - there was some foreshadowing going on there). I was only having mild pain during some activities at that point.

Anyway, the doc decided I had a rotator cuff injury, and told me it would likely give me a lot of pain and would take a long time to heal. "Oh no!" was my reaction.

She referred me to an orthopedist. I figured, OK, the orthopedist will look at me, and refer me to physical therapy. It seemed like a waste of time, but ya gotta jump through the hoops. She also sent me to get x-rays immediately - they came back normal a few days later. (It was nice to confirm that I hadn't broken anything. In fact, if it had been up to me, I wouldn't have taken x-rays, since I was completely sure I hadn't broken anything. But later my orthopedist told me that you may not realize it when you have broken something in this area!)

Before leaving my PCP's office, I went to make an appointment with orthopedist. The computer systems were down! They told me to call for an appointment the next day. But it was just before Christmas, and I was very busy at work, and I was just coming down with a cold, so I procrastinated.

In fact I procrastinated until after my January ski trip. When I got back, the earliest I could see the orthopedist was in the middle of February. Bummer, I wanted to go immediately.