Understanding Frozen Shoulder With Dr. Claudia Ginsberg
Today's blog is based on a conversation that Dr.Natty had on the Myokinetix podcast with Dr. Claudia Ginsburg of Tri-County Orthopedics. Dr. Ginsberg is an expert in the non-operative treatment of musculoskeletal injuries. She received her undergraduate degree from Dartmouth College and attended medical school at Cornell University. Currently, she's a team physician for a couple of high schools and was also a former medical consultant for the New York Jets. In this article, we have information on what it means to be a non-operative orthopedic specialist, as well as the process for treating patients with frozen shoulder.
How did Dr.Ginsburg get where she is?
After medical school, she went into general internal medicine but it wasn't the right fit for her. She came across the field of non-operative sports medicine, a branch of internal medicine and family practice, and that fit better with the kind of patient that she really thought she could help most. She completed a fellowship in sports medicine at the University of Pittsburgh, where she took care of sports teams and learned from surgeons and non-surgeons about how to best treat all kinds of musculoskeletal injuries and problems. After that, she joined a big orthopedic group (Tri-County Orthopedics), to continue her learning, and it's where she's been for the last 17 years!
Who does Dr.Ginsburg treat?
Dr.Ginsburg sees patients in the office every day for a variety of musculoskeletal issues of patients of all ages, from 11-12 years old to her oldest patients at over 100.
What does Dr.Ginsburg do to assess a patient?
The key is really in the history - How did the injury happen? When did it start? What kind of things aggravates it or improves the situation? What has the patient tried before? What's their goal and what are they looking to get back to? Understanding what the problem is and how it's interfering with this person's lifestyle is the first step.
After that, a patient needs a thorough physical exam to figure out exactly what the issue is with the joint, and if any other joints might be involved. Then most patients will need an X-ray because people have often been having pain for a while, so you want to make sure to rule out calcium deposits, bone spurs, arthritis, alignment, or any other issues. Sometimes further imaging is required and people might need an MRI or a CT scan, and then sometimes they don't.
From there, they will be a discussion on what is thought to be the problem, and what the initial plan of care would be, and what the long-term plan should be. Then the next step is to decide if there's a particular physical therapist, they should see, or if there's a particular medicine they should try? Are there different shoes that would be more appropriate to help the issue? Would injections help? Everything else is thought of before considering the surgical option.
Two problems can be treated very differently in different people, depending on how it affects their lifestyle and what kind of physical activities they participate in. There's no cookie-cutter approach if you are really going to try to individualize or tailor the care to what's right for that person.
It's Important That the Patient Feels You Understand Them
If a patient feels that you, as their doctor, haven't listened to them, or you haven't examined them, or you don't understand what it is that they're trying to achieve, you've lost the patient's buy-in. If you suggest an injection or medication or physical therapy, or a certain exercise, the patient will wonder why they would put their energy or their time or their money towards something that they don't really believe is necessarily the right fit for them. We all want to really believe in whatever we're doing.
Discussing Frozen Shoulder
For frozen shoulder, you absolutely need buy-in from the patient, because they might have all kinds of ideas about what this might be before they've gotten it officially checked out. If a doctor finally can explain it to them, and they understand what is really going on and what it is, they trust you that what you suggest is the right thing.
Frozen shoulder, officially called adhesive capsulitis, is a very painful condition of the shoulder, where patients lose range of motion in their arm. It happens more commonly in women versus men, typically ages 40 to 60, but can be seen in patients younger or older than this average. Sometimes patients come in having had pain at least six to eight weeks, and sometimes they come in with a year of pain.
Frozen shoulder is never something that happens in just a couple of days. Frozen shoulder builds up over a number of weeks or months, with the patient feeling increasing pain and having a decreasing range of motion in their shoulder slowly.
Patients will often come in and they say things like "I can't reach up overhead to put away a plate", "I can't reach behind my back to unhook my bra", "I can't reach into my back pocket to get out my wallet", or "It's so painful reaching over in bed to turn off the alarm clock". It may have started out as tendinitis, but over time, the soft tissues around the shoulder have just started to tighten up and become scarred down in such a way that the patient is pulling on very tight, inflamed tissue when they try to rotate their arm into various positions. This is miserable and is a very, very painful condition.
Some Risk Factors for Developing Frozen Shoulder
People with certain conditions are more likely to develop a frozen shoulder. People with diabetes are at an increased risk for frozen shoulder, as well as if you've had a stroke in the past, if you've had a seizure disorder, or if you have fibroid problems or other endocrine conditions. It can even be affected by you having had a fracture in your arm or your humerus and then you didn't move your arm for a while, or if you were restricted from using your arm because you had a mastectomy on that side. Basically for any reason that you have pain and inflammation, and then didn't really use the arm in all the different ways that one would normally use it. Someone who has been self-restricting their motion a little bit is the perfect setup for someone who might get a frozen shoulder.
It usually starts as tendinitis or inflammation, or even just from something as simple as walking the dog. If a dog is a real puller for example and yanked on the leash many times, then over time the shoulder can get inflamed and irritated. It doesn't have to be a big injury, but sometimes it is.
It's Important to Keep Moving to Prevent Frozen Shoulder
Joints need to be moved because that's how you get blood flow circulating to get the inflammation out when it kind of pools and sits in one spot. Anyone who has shoulder pain, or has been diagnosed with tendinitis, needs to make sure that every day they raise their arm up fully overhead, even if it's a little uncomfortable. You can't leave the arm plastered to your side, which becomes an issue if someone has a fracture. Some light range of motion exercises, just to keep moving, even a little bit, can help so you don't develop the tightening that can happen after a period of immobilization.
Typical Treatment for Frozen Shoulder
On average, most people are stretching on their own, with a physical therapist helping them to further mobilize their joints. Many people need something for pain control. Whether it's Tylenol, Advil, Aleve, or a cortisone injection, which allows people to avoid the oral medications and just deliver the medicine right into the joint.
There are no two people that respond in the same way, as people come in with different stages of frozen shoulder. Some people really only have pain when they really force the arm behind their back or fully up overhead. Through an exam, you can tell the characteristics of how the shoulder has lost its normal dynamic of motion. Then there are some people that come in, and they can almost not move their arm more than 30 degrees in front of them or to the side.
These patients are in a lot of pain, sometimes having been to multiple doctors. They're not always sure that you as the doctor know what you're talking about, cause they don't understand how this amount of pain is caused by just their shoulder tightening up. Sometimes they've already been to physical therapy and say that it didn't help them. Once a doctor is confident in the patient's diagnosis, then they can explain it to a skeptical patient. If the patient understands and then buys into it as well, then they need to start doing their necessary exercises for frozen shoulder.
Usually, in the office, doctors show how there are a few things that patients should start doing right away to try to start to better their range of motion. Patients usually receive a prescription for physical therapy. Although during the pandemic, Dr.Ginsburg experienced many people who didn't want to go to PT. So she would go over a lot of exercises and then bring them back every couple of weeks to check where they were improving and what ranges of motion were still really restricted and what else that they could be doing. Patients just have to recognize that they're gonna have pain when doing these exercises. Many people have been told their whole life that, if it hurts, don't do that. Frozen shoulder is just not one of those times, as you have to know that you're not going to hurt yourself further, as long as you are being gentle and gradual. Just bring yourself into that zone of discomfort, but not so much that you torture yourself.
Stages of Frozen Shoulder
For the patient, stages 1 & 2 are basically pain, and then stage three, where patients are getting a little better in pain. Stage four is where patients can move their arm and the pain is gone. Some specific names will refer to the middle portion of the process as the freezing phase, thawing phase, etc.
As far as the patient is concerned, if they try to start moving the shoulder and can't, then it's up to the doctors to try to figure if the patient needs something more. Do they need a different oral anti-inflammatory? Do you need a cortisone injection to a different part? Sometimes patients need to take pain medication before they do their exercises at night. Sometimes they need to go to physical therapy more frequently, and sometimes they need to switch to a different physical therapist because it's just not working right, or it's not a good match for them.
For everyone, these timelines of stages can be very different. If a patient waits a really long time before coming in to start treatment, that's gonna put them at a disadvantage for sure. On average, without surgery, it's about three months in physical therapy. A lot of insurances don't cover it for that long though, so sometimes patients will start with PT, and then they finish up by doing a lot of it on their own. With the combination of some medication, anti-inflammatories, or an injection with home exercises, and formal physical therapy, that is the most common recipe. Typically about three months, but certainly some patients get rid of it more quickly. Then definitely there are other patients who are at six months or nine months. During the pandemic with people hesitant to come to a physical therapy facility, the timeline could be pushed back.
If you go to physical therapy, twice or three times a week, and that's the only place you're doing your exercises to stretch the shoulder, you're not going to make nearly the progress that you would make if you actually do your homework. You actually have to be spending the time every night, in the shower, or every morning, stretching the arm very gently overhead behind your back out to the side, and into a place of discomfort. If a patient is not willing to do that, it's going to take an awfully long, long time.
What Dr.Ginsburg Recommends When Looking for a Physical Therapist
When looking for a physical therapist, you can start by reading all the reviews online, but it's such an individual thing that might not get you the results you want just from doing that. You need someone who's going to listen to you and who's really going to connect with you.
Frozen shoulder requires that you have a PT with some experience on how far you can push a patient with this condition. Someone who's fresh out of school might not have the experience that's needed to really work on and help someone with frozen shoulder, especially if they don't have the confidence about having treated patients before and knowing how the shoulder responds to the stretching. You need a PT who has a hands-on approach, hopefully, who has some experience with frozen shoulder.
Why Dr. Ginsburg is So Passionate About and In-Tune With Frozen Shoulder
As Dr. Ginsburg has had many patients with frozen shoulder come in, she has seen how they are hurting, in tears, often describing how they can't sleep, that they can't get dressed, and how they are really pretty miserable. This is one of the most painful conditions that she treats, but she knows that it can be treated and get so much better. She has seen that if they can just partner with her and be diligent with the exercises, that it can get better.
She's taken patients who have seen other doctors for it, and maybe another doctor had misdiagnosed it or, didn't take it seriously, or a physical therapist who they might have gone to on their own that didn't work out, and they never really had an exact diagnosis. Dr. Ginsburg finds it so rewarding to be able to help someone who needs it so much and just wants to figure out what's wrong. At that point, you can really connect with them and say, "This is what's going on. And this is how we're gonna treat it. And this is exactly your path. This is what you need to do." Knowing that it's such a treatable condition, and patients are so thankful, is what makes it so rewarding.
Dr. Ginsburg often says to people that yes, this is a bad diagnosis just because of how painful it is and for how long a patient's been suffering from it, and the fact that it's going to take a while to get rid of it. However, it is also a good diagnosis because doctors know frozen shoulder when they see it, and since they understand what it is, there's usually a clear path on how to get you better. Once someone is done with it, they'll be done with it. Most people do not get a repeat frozen shoulder on the same side, but they are at increased risk for getting it on the other side. If it happens in the other shoulder though, patients will be smarter, they'll know what it is, and come in right away and not wait for 6 months before coming in next time.
Advice From Dr. Ginsburg For Someone Suffering From Frozen Shoulder Right Now
First, know that this is a very common diagnosis and that you are not alone. Try mentioning it to a neighbor, or a colleague or a friend, or a family member, and you'll likely hear stories of people who have had it or knew someone who did. You'll hear that "so and so had it, they got through it, they just did this, that or the other thing". It's important to know that it's common, it is something that you're going to get through, you have to be committed, and you have to be willing to be religious, with your exercises a little bit at a time. Be optimistic that it's gonna get better, and make a calendar and check the days off when you've done your homework. Make sure that you're being treated by someone who you feel is listening to you, and that goes for both the therapist as well as the physician. Just remember you are not alone!
At Myokinetix - We Take a Similar Approach to Dr.Ginsburg to Assess Patients
At Myokinetix, we like to ask our patients, "what are your goals?" - so that way, we can work together to help you get there. And a big part for us here is we have a huge whiteboard where patients have to write down their goals. We start with what do you need to do, and then we take time during the evaluation to kind of reverse engineer it. We'll start with a short-term goal, then if there is another short-term goal, then once you get through your short-term goals, we set you up for a long-term goal.
Myokinetix's Experience With Frozen Shoulder
At Myokinetix, we've seen frozen shoulder patients firsthand. We've treated countless patients with this condition, and it is painful and challenging for sure.
Often with frozen shoulder, it's the things you take for granted that you can't do anymore, like washing your hair. When you are able to do these things again though, it's a big victory. We always like to tell our patients to celebrate the small wins! It's just a slow process, a slow grind, but just like anything else in life, you're gonna have to push forward.
There's a saying that we say at Myokinetix when someone has frozen shoulder: "If you don't use it, you're gonna lose it".
With frozen shoulder, when we do work with the patients with this diagnosis, all we do is just really encourage them to get through the pain and really communicate with them letting them know that they can do it, that the pain during recovery is part of the healing process. This pain they experience is not something that's going to harm them any further, but it's a necessary part of the rehab to get them to the next level!