More shoulder stuff

Thanksgiving day surfing...

My shoulder continues to feel great... There are still a few spots at the outside range of movement where I can still feel twinges.. But I suspect that may be due to lack of strength. It is certainly much easier to do most of the physio shoulder exercises now. Including actually being able to do some that I simply couldn't before

So the question now, is this a temporary relief, or can I hope for long term benefits.

From the reading below, it appears that the role of the cortisone is NOT for pain relief directly, but is for it's anti-inflamatory effects. The cortisone plus the dilation and rupturing of the capsule is to get the inflammation of that area to be reduced. Frozen shoulder can be thought of as a type of positive feedback loop, the more inflamed the area gets, the worse it gets and the more inflamed it gets... etc. This procedure hopes to break the feedback loop.

The studies seem to show that there is lasting effect as compared to other treatments and placebo, with few people requiring a second treatment and very very few people needing more than two treatments.

From Corticosteroid Injections : My favourite injections:

No 3: Shoulder hydrodilatation

As a clinical entity, frozen shoulder (adhesive capsulitis) is relatively easy to diagnose, although treatment of this condition can be frustrating. But subtle forms of capsular restriction can either mimic or enhance other causes of shoulder pain, such as a subacromial impingement. If a patient with shoulder pain presents with nocturnal pain (in the absence of a rotator cuff tear), and their range of motion is subtly restricted in end abduction, internal rotation and horizontal flexion, and their anterior-posterior glide is diminished, then a component of capsular restriction should be considered. In cases of subacromial impingement in which this capsular restriction is present, it is very difficult to treat the impingement successfully without dealing with the capsular restriction.

Capsular restriction does not usually respond favourably to manual therapy.Often attempts to mobilise the shoulder result in a flare-up of the patient’s pain. One efficient way to treat these patients is with a hydrodilatation procedure. This is performed by a radiologist under X-ray control. A needle is inserted into the offending glenohumeral joint, and a mixture of corticosteroid, local anaesthetic and saline is injected. A large volume is required, and in ideal circumstances capsular rupture is achieved. When this happens, the communication between the shoulder joint and the subscapularis bursa is seen to open up. If this treatment is successful, it is very rewarding and satisfying for practitioner and patient alike. It also allows for expedient rehabilitation of the coexisting condition.

The above matches my current experience. Very little progress with exercises and other physiotherapies. Just changing areas where the pain was. But (almost) immediate relief after treatment, and with subsequent ability to do a much wider range of exercises... My Simple Shoulder Test (see below) score went from about 8-9 out of 12 to about 2-3.

Note 1 - Frozen Shoulder is same as Adhesive Capsulitis

Note 2 - Hyrdodialation, or Distension Arthography is a technique using cortisone and saline solution to treat a Frozen shoulder.

Some interesting URL's.

• Adhesive Capsulitis (or Frozen Shoulder)
  
• Frozen Shoulder 1
• Frozen Shoulder 2
• Corticosteroid Injections : My favourite injections
  
• Hydrodilatation (distension arthrography): a long-term clinical outcome series
  
• Treatment of Frozen Shoulder Using Distension Arthrography
• The Simple Shoulder Test

Frozen Shoulder - Cortisone injection

In China they make you pay for the bullet.... in BC if you need a Cortisone injection you have to buy the Cortinsone yourself :-)

After the MRI (the radiologist suggested an impingement and possibly a laberal tear) my GP got me referred to a an ortho-surg via the cast clinic at the local hospital (it is reasonably easy to get in appointments for these, but you get about 2-3 minutes of his time typically.) 

He looked at the MRI, said it was inconclusive at best... that he didn't do "elective shoulder surgery" and said he would refer me to another ortho-surg who specializes in shoulders. That took almost a month... (the GP said it could have taken HIM almost a year to get me in to this guy..)

That new ortho-surg's (who is highly recommended by my wife the physio and her physio friends and my GP) first diagnosis was a possible frozen shoulder. (I think this link is good overview.) His first suggestion was that we try a cortisone injection.

I had that done yesterday. A fairly complicated procedure done by a radiologist. They light freeze the skin over the shoulder (lydicaine I think she said). Then using the X-ray machine they place a needle into the general area of the joint capsule. Next they inject a dye that allows them to see the capsule better and replace the needle to get it into the capsule.

Next they shoot in saline solution to distend the joint. Then the cortisone. Two vials of 40mg. Along with a bunch of saline solution. The instructions from the ortho-surg where to "rupture" the capsule. Presumbaly so that the cortisone would get into a wider area. The effect felt much like a small balloon in there.. unconfortable but not painful (like eating too much turkey dinner at Thanksgiving.)

All in all, took longer than I thought it would, about 30-35 minutes. And not was painful or traumatic as you might think. Fun if you like watching the TV monitor of the X-ray to see what is happening. Kind of like an episode of House (but without blood squirting all over the place, although at one point there was a nice spray of saline..)

The effect overall seems fairly effective 24 hours in. The shoulder is still very weak in the areas where the impingement was. But certainly at this point a lot less pain. Only time will tell if this is just a temporary or permanent change. 

The plan is to continue the shoulder and physio exercises. Which with less pain may get me into better condition. Which may keep the situation under control. They will repeat once if the situation warrants. 

Longer term if a second injection doesn't do the trick either then he (ortho-surg) will look at surgery. The problem being his waiting list is about two years... But at least at this point I'm (hopefully) on the list.

Anyway I'm back to the orth-surg in January time frame. Which gives me three months to see what this does for us.

The good news all along is that for the most part this has not impacted training. I only have problems on the bike if I go out for longer than 3-4 hours.  

What has been a problem is sleeping. The shoulder pain tends to be noticable and recurrent mostly at night (when in-active). And typically will wake me up in the middle of the night. So I end up taking ibuprofen about 2-3 nights a week to get back to sleep.

[Soapbox mode on]

I still have no explanation from anyone why you have to buy and bring your own Cortisone. Not particularily expensive at $26Cdn... Given what the procedure cost overall (a half hour plus of X-Ray room in Vancouvers 2nd or 3rd largest hospital, radioligist and assistant, x-ray dye, saline, disposable needles and syringes etc) I can't believe that $26 (or probably half that if the hospital was paying for it wholesale) would be more than a few percent of the total. Go figure.

Exercising those sore shoulders

Terry Ritter was kind enough to make some suggestions for shoulder exercises and therapy using the following product.

Here's the product that I was talking about and the company that I just bought my latest edition from:

http://www.betterfitnessproducts.com/sportcord.html

I used the green cords before, and ordered the blue and black this time. It might have been better, if you were just doing shoulders, to go with the green and blue.

Hope this helps.

--
Terry T. Ritter
USA Cycling Coach
Full Potential Training Services
Reach Your FULL POTENTIAL
www.fpts.biz