What brings you to see me?
One of the first things I ask a current or potential patient is “what brings you to see me?”. People often say what they think I want to hear (pain, stiffness, etc), but the question is aimed at teasing out a much broader answer. What are their goals? How is life is being affected? What do they want to achieve? More than feelings of pain, or stiffness, these are often what our patients really care about, but how often are they given the opportunity to express themselves? Taking time to understand the patient’s true goals ensures that we don’t get to the end of the plan of care with me thinking I am great because they have no pain, while the patient is frustrated because they can still not pick up their grandson, play ball, or whatever the case may be. Asking this question gives us the opportunity for true success! Sometimes the goals of my patients are ambitious and may take significant time to achieve. But, as long as they are realistic, we will discuss how long they might take to achieve and what interim goals we can set to gauge progress. Today’s blog is an example of how understanding my client’s true goals made all the difference in his treatment and outcome.
When Pearson came to see me he was 23, had a small lawncare company, and looked like a fit, well-built, and healthy guy. However, he actually was very frustrated because of a long history of shoulder problems that were stopping him from confidently working out his upper body and pursuing his passion of boxing and MMA. Six years ago, he suffered a dislocation of his shoulder. Although the joint spontaneously relocated, he had ongoing pain and feelings of instability. Three years went by, and he went to an orthopedic surgeon – MRI showed a labral tear and a Hills Sach lesion (a small divot in the cartilage on the humeral head). He underwent a surgical repair, followed up with physical therapy, but he continued to have the same problems. I first saw him over a year following the surgery and he was still struggling with the same symptoms. He had returned to the surgeon, but he found visits were relatively short, without any real answer, until they eventually said he had probably torn something else or damaged the initial repair. They wanted to get another MRI and expected him to need another surgery. Given his experience thus far, Pearson was understandably reluctant to go for another surgery. He decided to try something different and reached out to me.
One of the first things that was very evident was that he desperately wanted to get back to MMA/Boxing and was not so concerned with a little pain. However, he was also concerned about causing additional damage to his shoulder and the potential long-term consequences for his future health. This was a perfect segway to discussing his beliefs about pain, how he could monitor pain, and what the potential was for further injury and success.
Pearsons Shoulder Problem
Moving into his examination, I found he had full shoulder and elbow range of motion. With him laying on the table, I took hold of his arm and passively moved his shoulder joint and found that he had a lot of mobility into external rotation When I did this, there was a look of apprehension on his face. We call this an “apprehension test”, and it suggests some instability of the shoulder. The test is a slow and careful motion, giving a sensation of instability, but in real life, a quick and forceful movement in that direction at the very least might be painful and concerning, but could also cause subluxation or dislocation. The test has an additional portion where I put my hand on the front of the joint and gently push down, providing a relocating force. The relocation portion of the test removed the pain. I then tested shoulder strength and found he was significantly weak in flexion and external rotation of the shoulder. This is quite a helpful finding as we now know that two of the rotator cuff muscles, the supraspinatus, and infraspinatus, should be very active in these two movements. Weakness in these two muscles could explain some if not all of the instability, as the major job of the rotator cuff is to provide stability to the shoulder joint. So I was able to explain that it is entirely possible that the instability he had been experiencing was more likely due to weakness in the rotator cuff than a new or old labrum tear that needs more surgery. I learned that Pearson did not feel his rehab had gone well prior to or subsequent to surgery, partly due to his attitude at that time, and also due to his experience of in-network physical therapy. As I asked questions about his rehab, it was very apparent that it had never stressed him to the level that he needed to return to boxing and meet his goals.
Given all of this information, I was able to formulate a hypothesis of why Pearson had continued to struggle with shoulder problems – he had weakness in his rotator cuff muscles. I also knew there was a possibility that he could have a labrum or rotator cuff tear, but even if he had a scan showing a tear, research shows that surgery is not necessarily required. I discussed all of this with him and explained that we needed to load the shoulder to strengthen the rotator cuff and build load tolerance to the activities he wanted to do. I instructed him in a simple set of strengthening exercises, provided him with electronic instructions at the PhysioWorks portal, and booked him a follow-up three weeks later. If you have done PT before you may be used to 2-3 x a week, but in my opinion, this is typically not needed. In Pearson’s case, he had been struggling with this injury for several years, and he needed time to reverse the muscle loss. I made sure he had all the tools and information he needed to make progress during those three weeks and kept in touch via phone and text in-between appointments.
Pearsons Shoulder Success!
After the evaluation, Pearson came for a total of four follow-ups over a five month period. At each visit, we reassessed and progressed the loading exercises. We saw progress at each appointment, and after the second follow-up, we started to add exercises that mimicked boxing and MMA motions (e.g. grappling). The feeling of instability went away, and he was able to get back into training at the boxing gym. Progress wasn’t always a linear progression with each day being a little better – there were some very good days, average days and even some days where it felt like things backslid. However, the overall trend was progression month on month. At the beginning of the year Pearson was in the process of moving out of state, so we held off on any visits and he would contact me when back in town for a period. At the beginning of June, I got a call asking if I would be able to meet him in the boxing gym. One of the great flexibilities my practice brings is the ability to go outside of the clinic and see athletes or workers in their environment, so I was happy to go! I went to Rocket City Rocks Boxing Gym and had the opportunity to review his shoulder and then watch him workout and then spar. His shoulder felt solid and above all, he was able to hit hard. A year before he came to me with a shoulder that felt fragile, and now he had confidence. There were still a couple of areas that felt weak, and we discussed that he just needed to continue to build strength and build load tolerance in those positions. I was great to see Pearson enjoying the sport he is so passionate about! His dream is to take it to a higher level, even to go pro, and his coaches say he has a shot at it! I will be cheering for him all the way!
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