Brandon Cohen DC, CSCS
A bit of an update here.
She has been a thorn in my side. She was not convinced of the diagnosis at the ROF. I reviewed the dx during the first tx visit explaining that she has some adhesion, but the majority of her pain is from the joint and the likely tear. I mentioned if treatment doesn’t progress the way we both want it to, we will need to get an MRI. She looked away and we moved into treatment. We did treatment and had a reasonable change in the range and symptoms. I told her to ice if it was sore, and to avoid any activities that would aggravate pain to include pressing and pulling.
The second visit she told me that her symptoms were better until the day of the next visit. What did she do over the weekend? Rock Climbing gym. I worked really hard to make the connection of rock climbing = too much load = pain in the shoulder. She said it didn’t hurt until the next day. I said, “Right, that’s what happens.” She didn’t really believe me. At this point, I am more convinced that she thinks her problem is not that big of a deal, and that it should be fixed without much effort. I left her with the same instructions as before, but was more specific. No pushing and pulling, or anything that uses the shoulder until we get this under control.
The third visit she had relief from pain until about an hour before her visit. It was sore because she just came from the gym. This is the first I’m learning of the details of her work out, but its a HIIT program with a personal trainer consisting of varied movement including, rowing, burpees, pull-ups, and shoulder presses. I explained that this is the reason her shoulder continues to be painful, and that we discussed the last time that she knows what activities aggravate the shoulder ( pressing and pulling) and that we cannot make progress if she continues these activities. She looked away and then told me she didn’t know if those were exercises were aggravating things, because its only sore after she does the workout. (You all can see this is the same conversation we had the prior visit) I emphasized my previous point to which she said, “Well, I don’t know if I can because my trainer plans the workouts in advance, so she would have to change the plan for the day.” I explained that all good trainers want you to be healthy so you can continue to make progress, and its hard to get in better shape if you are hurting. She agreed to modify her workouts and not do things that irritated it. Each visit we make the range a couple of degrees better, and adhesion in the subscap is more and more reduced. Treatment is working.
Sidebar. This is the point where I should have drawn the line in the sand. I gave her too many chances, and she proved she was incapable of making good decisions. #1 The ROF she demonstrated a lack of understanding of the severity of her problem. #2 the first follow up visit there were non-verbal cues that she did not believe the story I was telling her. #3 after the first visit she did not follow my advice and went rock climbing (I gave her a pass on this one because she’s not that sharp, and I actually believe she didn’t think it would hurt the shoulder). #4 the 3rd visit where she needed to be hit over the head with a cast iron skillet to understand what was irritating and aggravating the shoulder.
Now, should have I ordered the imaging sooner? In hindsight, I should have because it would have confirmed/refuted my dx of labral tear. It would have strengthened my communication with her. My thought process was to see what kind of progress we could make and order it after 4-5 visits if needed. However, at the end of that third visit, I should have had the “Come to Jesus” talk about not being able to continue with treatment if she continued to do things that were not in her best interest. I thought about it, but thought that it was me just being too emotionally charged from the interaction for that day as she eventually agreed to my terms of modifying workouts.
She called the next day and canceled all her remaining appointments.
Lessons:
1. Have the “Come to Jesus Talk”
2. Maintain case control by keeping patients accountable for their part.
3. Get the damn imgaging if it will help your patient make good decisions about their future.
4. Don’t let your impression of what the patient is feeling/thinking interfere with your clinical decisions.
5. Always apply the basics.
6. Don’t get in your own way.
7. Be totally zen.