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Dr. Pat Consults: When to Call In a Physiatrist

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I like to work as a collaborative physician. My patients, I believe, will be my best partners in providing diagnostic information -- as long as they are asked the right questions. I also believe in consulting with the best medical minds on issues that require specialization or unique clinical experience. To help one answer some important questions about shoulder pain, I have enlisted the expertise of Dr. James F. Wyss, a physiatrist at New York City's Hospital for Special Surgery.

Dear Dr. Pat:

I am an Executive Assistant to the head of a big nonprofit. I work long hours and carry papers and a laptop back and forth to work. I take a bus and often have to stand with this heavy carryall on my shoulder. This summer I took some yoga classes for the first time, and after three classes I found that I had right-shoulder pain when I moved my arm in certain directions. I have changed to a backpack to reduce the pain from carrying my heavy workbag, and of course I've stopped the yoga, but the pain never got better. In fact, I developed something that I learned was "almost a frozen shoulder."

My boss sent me to an orthopedic surgeon, who ordered X-rays of my shoulder and found that I had a slight tear in one of the muscles that support the shoulder. He recommended that I see a physiatrist and begin a course of physical therapy. While I am glad that the orthopedist didn't suggest surgery right away, what is a physiatrist, and how can physical therapy help this painful problem? When will I know that the physical therapy isn't working?

Samantha


Dear Samantha:

Your question is such a universal one for the modern packhorses that many of us have become. The shoulder joint is held in place with several muscles, ligaments, and tendons, and both overuse and acute injury can cause a seriously painful condition that often limits many daily activities. We need to think before we carry too much, and should consider changing from a shoulder bag to a rolling bag when possible. I have asked Dr. James F. Wyss, who is an assistant attending physiatrist at the Hospital for Special Surgery -- and a new member of our Medical Advisory Board -- to discuss your question in detail.

Thanks for sending in your question about this all-too-common problem.

Dr. Pat

Dealing with Musculoskeletal Pain

By James F. Wyss, MD, PT

Dear Samantha:

A physiatrist is a physician who specializes in the practice of physical medicine and rehabilitation. These physicians are trained to diagnose and treat musculoskeletal and/or neurological conditions, although some physiatrists specialize in the rehabilitation of cardiovascular or pulmonary conditions.

Physiatrists practice in various settings, such as acute care hospitals, rehabilitation hospitals, or outpatient clinics. In my opinion, the key difference between physiatrists and other medical specialties is the emphasis on evaluation and treatment of the whole person to improve his or her function and quality of life. In my practice, I diagnose and treat orthopedic problems, such as your shoulder condition. I utilize lifestyle changes, activity modifications, rehabilitation services (like physical or occupational therapy), medications, and injections to decrease pain but -- more important -- to restore function.

Physical therapy is one, if not the most important, of the rehabilitation services available for the treatment of a painful shoulder condition. A physical therapist, especially one who specializes in sports and orthopedic therapy, can evaluate the way you move your shoulder and determine if there are any problems with muscle flexibility, strength, or joint mobility. Exercise, manual therapy, and modalities (e.g. heat or ice) can then be used correct these problems.

When your shoulder functions better, then stress on the source of the pain may be alleviated and your body will have a better chance to heal. For example, in your case you reported using a heavy shoulder bag and the onset of pain after the yoga classes. The shoulder bag may have led to muscular tightness and abnormal movements of the shoulder blade, or scapula. Then, attempting to participate in yoga with a shoulder that wasn't functioning properly may have led to the injury. A physician or physical therapist can pick up on these abnormal movements of the shoulder blade, which is also known as scapular dyskinesia, and the proper exercises can correct this problem

As a physiatrist, I have noticed that if function improves with therapy, then pain generally recedes. Unfortunately not every patient responds favorably to physical therapy, and not every shoulder condition is amenable to physical therapy. Patients commonly return to my office after one to two months of physical therapy. If the patient reports progress and the shoulder examination demonstrates improvements, then continued use of therapy or a home exercise program is appropriate. If the condition has failed to improve with the appropriate physical therapy, then additional diagnostic tests and treatment options would be considered.

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