PNF

Today was my 7th physical therapy session for a total of 3 weeks. It was more of the usual: start by applying moist heat to the shoulder for about 10 minutes, then do some exercises, and finally the massage and mobilization techniques applied by the physical therapist himself.

Almost every time I go, they throw something new into the mix, though. This time, the physical therapist asked an assistant to work with me on some PNF. I was intrigued, because I had just seen this acronym in an article last night but hadn't had time to look into it.

In this particular case, it was a rather lame exercise. I lay down on my back, and moved my arm straight up in an arc as far past 90 degrees as possible (which is not much), with my thumb pointing in the direction of travel. Then I rotated my hand so the thumb was pointing towards my feet and moved my arm back down to my side. While doing this, the assistant applied a very small resistive force against the motion of my arm. This really felt completely useless, but in any case didn't go on for long.

It's a mixed bag in the area of pain. With so little sleep yesterday, I fell asleep pretty easily. I still woke up a couple of times with pain in the middle of the night, but fell back to sleep without much trouble.

When I awoke this morning, the pain was pretty bad, and I kept debating whether I should go to physical therapy, scheduled for midday. I went anyway. The mobilization techniques were still agonizing, but it was more bearable, similar to what was done last time. The therapist has been easing up a little, and I think that is helping.

Since I did 1.5 hours of physical therapy today, I opted to do my weight-lifting workout tonight. For any exercises involving my left shoulder, I use very light weights and try to stay away from anything that causes the least bit of pain... I feel pretty good right now, no pain at all. This disease is strange, the way you can be in fierce pain in the morning and then feel normal just hours later.

I still don't have any ibuprofen so I wonder how I'll sleep tonight.

articles

I had asked my physical therapist for resources or articles to gain more insight into my condition. Yesterday, he gave me a couple of sites where I could look into frozen shoulder further. He pointed me to the article on adhesive capsulitis at the Professional Baseball Athletic Trainers Society. The article is okay, but it's mostly a rehash of the same information that I've found elsewhere online. There's quite a lot of discussion about surgical treatments, if you're into that kind of thing. The illustrations for the site are the best thing about it, although you wonder how correct they are. My preference is usually to go to wiki for general information like this.

In addition, he had told me to search PubMed for the terms "shoulder adhesive capsulitis". I'd actually already tried PubMed, but the first result I got was about shoulder pain in Nigerians, which didn't sound very relevant, and I had quickly decided to look elsewhere.

In fact, PubMed seems to be a good resource after all. Since he suggested I try it, I returned and immediately struck gold. I found a single case report¹ and a more extensive study².

I'm still in the process of reading the articles, and I'll write about them more if I find anything notable.

1 Positional Stretching of the Coracohumeral Ligament on a Patient with Adhesive Capsulitis: A Case Report, by Jose Orlando Ruiz
2 Comparison of High-Grade and Low-Grade Mobilization Techniques in the Management of Adhesive Capsulitis of the Shoulder: Randomized Controlled Trial, by Henricus M Vermeulen et al.

more problems sleeping

I had a physical therapy session yesterday evening at 6. It lasted just a little over an hour. It was still plenty painful, but less so than usual. The physical therapist told me that he's trying to be more gentle, so as to avoid aggravating the tendinitis.

I woke up at 2:30 this morning, and felt too awake to get back to sleep. After lying in bed for an hour, I finally got up.

There was some pain in my shoulder that was bothering me, but I had pain in my forearm - extreme soreness - which was worse. This is new. I think it's due to the physical therapy. My elbow has been giving me trouble too.

I've been sleeping worse since I started PT. Previously, I might wake up at 5, but I'd be able to get back to sleep. Now I'm waking up at all hours between midnight and 7. Tonight I'm going to try some ibuprofen. The only thing I've tried so far is naproxen sodium, and that doesn't seem to help much.

Maybe I should avoid doing PT in the evening; that might help with the sleep.

insurance snafu

My second physical therapy session was similar to the first. Prior to working on me, they had me warm up and do a few exercises. Then the physical therapist repeated his massage followed by the painful pulling and twisting manipulations. Then they showed me a couple more exercises.

I went to PT twice the next week. After my third session, I learned that the insurance company still did not have a referral from my PCP. Since it had been a week since I had asked for the referral, I thought there might be some problem, so I cancelled my next PT session. I called up my PCP and went through their bizarre automated phone service to request a referral again. I had to visit my PCP's office to pick up the MRI CDs, anyway. While I was there, I found that my referral had just come through, so I didn't have to cancel the next session.

I'm glad I have insurance, but I do think it's kind of ridiculous that insurance can be such a hassle. I spent about an hour on the phone trying to get information about the referral and making sure that the PT would be covered. If lots of people are having to do this, it seems to me a great waste of time in aggregate.

Throughout this process I've been annoyed by how few things you can do online. I'd like to be able to make medical appointments and find out about insurance issues online. My referral request would have been much more easily done via a form on the internet.

initial physical therapy session

As soon as I left my orthopedist, I went looking for a physical therapist. The clinic recommended their own physical therapy center, but they were booked solid for a couple of weeks, and there was no way I was waiting. An assistant suggested a place located in a sports club close to work. I called them immediately, and found out that they had an opening for the following day. w00t! I booked it, first verifying that they would accept my insurance.

The physical therapy center was well-versed in the ways of insurance. They told me I'd need an external referral from my PCP in order for insurance to cover my tab. So I rang up my doctor, and had to navigate a bizarre automated phone response system in order to enter my referral request. I never actually spoke to a person, and the message said that there would be no confirmation that the referral was sent. Hm.

The next day, when I went to the center, I asked how much the session would cost if my insurance didn't cover it. The answer was $150 per session. At that rate, I would only attend a few sessions if it were not covered... I would probably be doing all exercises at home at this point, if not for the insurance. As it is, I only have a $10 co-pay.

During the first session, I showed my physical therapist the MRI report, and emphasized the other conditions I had in addition to adhesive capsulitis. He seemed reasonably attentive. He did a few tests of my shoulder (more than the orthopedist had done on my first visit to her). Then he had me lie down on a table and gave my left shoulder a really deep massage. It felt wonderful and didn't hurt at all. That was followed by some very painful manipulations of my arm and shoulder.

Finally, he printed out a sheet with six physical therapy exercises on it, and told me to do them at home each day.

The whole session took about 1 h 20 min. I was surprised that it ran over an hour, but I figured this was because it was the first session. In fact they regularly run over an hour (and sometimes start late). I can't really complain about this, since the physical therapist told me that the more PT I do, the faster I'll regain my range of motion. I'm able to do between 40 and 90 minutes of PT exercises at home, usually. I try to spread them out over the course of the day.

I asked the physical therapist what pro athletes do if they get this condition. Surely they can't afford to be out of action for months at a time? He told me that 1) they take any injection necessary (presumably meaning corticosteroids, which I have no intention using) and 2) they do PT 3-4 hours per day. I'm not confident that the therapist knew for sure of athletes who have adhesive capsulitis; he may have been speaking of pro sports injuries in general. I'd like to read more about how pro athletes deal with this condition.

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.

mri

A week after my visit to the orthopedist, I went in for my scheduled MRI. It was the first time I'd had an MRI. I had read up on them a little, so I would know what to expect. I was a little worried because I'd read that they're very loud, but I hadn't bothered to bring earplugs. Fortunately, they gave me earplugs before going in for the test.

I got a little alarmed when they had me sign some forms saying I wasn't allergic to the contrast dye used for MRIs. Nobody had said anything about injections! In the end, I was not given an injection, whew!

The MRI was pretty loud, but it's intermittent, so it didn't bother me too much. It's a weird experience. I'm not claustrophobic, but I did have the strong urge to sit up a few times, even though I knew I couldn't. The whole thing took about 30 or 40 minutes. By the end, my muscles were getting little spasms from lying still for so long. But the MRI technician said the images were fine.

I was scheduled to see the orthopedist again in another week. I hated having to wait that long for the verdict.