Saturday, May 7, 2016

Why Do So Many Physical Therapists Want to Hurt Us?

A recent experience with a frozen shoulder prompted this post. It also also relates very much to my days with knee pain because I noticed a similar dynamic at play.

First: the frozen shoulder is almost unfrozen now. That’s the good news. Frozen shoulder by the way is a term for adhesive capsulitis, a condition where the movement of the shoulder becomes quite restricted and simple tasks – such as threading your belt through loops with an arm behind your back or extending your arm over your head – become difficult or even impossible.

Before I knew it was a frozen shoulder (I thought I had torn my rotator cuff), my doctor advised physical therapy. Okay, that’s fine I thought. I waited however until I got a diagnosis, thinking that it made no sense to begin physical therapy before we even knew the exact problem. After frozen shoulder was diagnosed using an MRI, I made the appointment with the therapist.

His advice: perform stretching and range-of-movement exercises. In a variety of exercises, I was challenged to move my arm to the extreme that I comfortably could, and even try to go a little further. We did some exercises together. He also kneaded the tissue a little, then photocopied a couple of pages of exercises for me to take home.

Okay, I thought. Got a plan. That’s good.

There were about eight different stretches/exercises. I did them each morning. My range of motion began to improve.

But I felt terrible. Immediately after the exercises, I would notice a clicking/snapping of a tendon in my shoulder. This may have been the byproduct of inflammation. At night, I often had trouble sleeping. Once I had to take some Advil to get through the night.

A few days after that I had this realization: this just isn’t working. Sorry, but I’ve seen this same bad movie before, when I had knee pain. Sometimes it takes courage to reject a failed course and rip up what seems like a solid plan and come up with a better way forward.

But if I couldn’t even get a good night’s sleep, I knew I wasn’t getting better.

So I poked around online, looking for exercises for frozen shoulder. I found some illustrated on YouTube that were super easy. Swing your arms, loose and easy, like a pendulum, trying to let gravity do most of the work. Swing them up and down. Swing them back and forth. Swing them in circles.

Okay, I’m going to do that, I figured. It’s motion. Motion is good for joints, I learned from having bad knees. I tried to swing my arms 10 to 15 minutes every morning.

And the frozen shoulder began to get better, over the course of weeks. Now I’m almost over it. Thank goodness.

All it took was easy, gentle motion. Sort of like slow walking, or pool walking, or easy cycling to heal a pair of bad knees.

Maybe you’re thinking: Fine. It worked for you. But this stretching regimen surely makes the most sense for most patients with frozen shoulder.

Maybe not. From a paper, Adhesive Capsulitis: Use the Evidence to Integrate Your Interventions (Phil Page and Andre Labbe):
It has been suggested that “gentle” therapy (painfree pendulum and active exercises) is better than “intensive” therapy (passive stretching and manipulation up to and beyond the pain threshold.
Anyway, this post is getting long. Let's return to the original question: Why do so many physical therapists try to hurt us to make us better, when gentle therapy might produce better results? Here are some quick theories:

* Physical therapists tend to be young, healthy individuals. They know of your condition through what they’ve read in textbooks; they haven’t actually suffered your condition. They are missing an experiential bit of knowledge that may be quite useful.

* Physical therapists tend to be well-schooled in muscle groups, in forces and opposing forces, and various stresses on different parts of the body. They sometimes sound like physics nerds. That may encourage them to focus on stretching/working muscles in a more intense manner than may be warranted.

* Physical therapists tend to be in good shape, not surprisingly. I suspect a lot of them work out. People who work out are familiar with that old saying, “no pain, no gain.” They may carry a bit of that bias into the practice of their profession.

In any event, in this case, I found what was effective turned out to be easy motion. I wouldn’t be surprised if we find that to be a more successful intervention for many joint issues.


  1. Dear Richard ,
    I was diagnosed with Chondromalacia Patella few months ago and inflamed femoral nerve but they didn't notice that , I went to an PT and he said that "Maltracking is the main reason the VMO " and started strengthening the Muscles , after the fifth session I felt that my muscles turned stronger , but the problem was with the inflamed nerve thereupon I stopped going to the PT and sought another Orthopedic doctor and after checking my MRI
    HE SAID : " It's Chondromalacia grade 1 just Glucosamine for 3 months, but the burning and the numbness you are complaining from isn't from your knee , you have to see a neurologist ".
    I went to a neurologist and was diagnosed " neuritis " and he prescribed some medicine and I quit practicing and just rested for 2 months till the nerves turned pretty Good now .
    few days I tried to go downstairs and my knees started hurting me like hell (I can say,worse than before the PT )
    What Happened , I don't know
    Please Please
    Is it a curable case I mean Maltracking ? I'm shedding tears , I'm just 27 years old and I quit my job :'(
    I see it's not logical at all to strengthen my muscles while the kneecap is not tracking well in the groove , I have to use knee's tape while exercising else I will irritate the cartilage more (what do you think about that ? "
    Sorry for my poor English it's not my first language

    1. I'm rather doubtful that maltracking kneecaps are that curable, but I'm skeptical that they're usually the cause of knee pain. You may be an exception to that rule. I don't know; I haven't examined your knees (not that I'm qualified to do that anyway). Sometimes taping the knee does help alleviate symptoms (though I'm not sure it has anything to do with correcting any maltracking).

      You sound like you're in a bad place, and you're getting a bunch of diagnoses that aren't very helpful. Honestly, the first thing I'd do is try to find a better doctor. Reading on this site might give you some ideas about strategies for beating knee pain, but getting a good doctor (or physical therapist) is the best place to start. Good luck, and try not to lose hope.

  2. Hi Richard, I am 29 years old and I am experiencing Chondromalacia Patella as well. As you wrote here, PT has not helped me and caused more pain in the end.

    I am reading your book and it is great that you actually healed from this knee pain, great book btw. People talk about their knee pain in these forums but I don't get the full story because I don't know how old they are. Knee pain and cartilage wear is a very common thing for older people, unfortunately I am experiencing this too early :(

    You have had several discussion with different people about knee pain. I am curious to know how many people that you talked to actually healed and on average how long did the healing process took?

    Thank you very much,

    1. Honestly, I couldn't even begin to tell you. I've just collected anecdotes here and there. My best suggestion for you is to jump into one of the open comment forums (there's one up right now) and ask the people there. Some are definitely getting better, though not fully healed. It's hard. And it can take a long time.

  3. Hi Richard.
    Here is my experience with PT:
    I'm 44 years old and underwent to a microfracture surgery at the throclea and lateral condyle at my right knee because I had a full-thickness cartilage failure (bare bone). And my lateral discoid meniscus was re-shaped to a regular form.
    The OS performed the surgery very well.
    As you wrote, the young PT was always pushing hard on execises until the day he prescribed me a deep squat that wrenched a chunk of fibrocartilage formed due to the surgery and torn my lateral meniscus.
    This is the result of PT for me.
    Sorry for my poor English it's not my first language.

    1. Sorry to hear. I wish your story were the exception, but it's all too common. Physical therapists are too aggressive, in general, when they're trying to rehabilitate bad knees.

  4. Thank you Richard, but that's true.
    The muscle focused approach is a really bad idea.
    Now, the OS told me that I need another surgery.
    The worst thing is that I had no pain and was capable to run in a slow rhythm. Now, I feel pain even during an easy walk.