Dumped by physical therapist 4 weeks after radial fracture of elbow - long post

[Raksha2015]

I incurred a Type II fracture of my left elbow a month ago. The surgeon I consulted a few days after going to the emergency room (where I was x-rayed) examined my left arm and told me I would not need surgery, and to proceed with physical therapy; and to see him again in 4 weeks (tomorrow).

The first therapist was a nice young woman who gave me the option of continuing my P/T at a hospital that was closer to me, but in the same health network as the first hospital (a top hospital, one of the best in the U.S., where I get most of my medical care). I thought that was a good idea; and was given the phone# to call, which I did. She also showed me some exercises and gave me a diagram. The second hospital didn't have anything available until 2 weeks (actually 13 days) after my first appointment, which in hindsight I think was too long a stretch without seeing a therapist, but I didn't realize it at the time and none of the medical personnel mentioned it.

When I started P/T in earnest at the second hospital on 12/30, my new therapist told me I had been doing the exercises improperly and went over the right way to do them. (I have never been good at remembering exercises unless I do them on a few separate occasions under supervision) I did them 4x a day for the next 8 days. When I returned to therapy on 12/7; the therapist took measurements during our session and said I had improved in extension and bending of the elbow. She also made me feel extreme pain with her manipulation of my arm; and told me she didn't understand why I was feeling such pain, there was no reason for it. My questions prompted her to tell me that after an injury such as mine, the patient has 6 weeks until the elbow stiffens up.

I returned two days later, having continued the exercises at home. Again, the therapist's maneuvers were painful (even though she wrapped my arm and elbow in layers that included a hot wet towel), so much so that I begged her to stop for a minute. She took measurements, and seemed displeased; and refused to answer when I asked her what the measurements showed. She wanted to get me to be able to touch my left hand to my left shoulder by pushing the left forearm down toward the elbow-to-shoulder part of the arm (I couldn't do it) and also my left hand to touch the back of my neck (managed a fingertip for about 2 seconds). It was terribly painful and I could not sustain my endurance. I'm pretty sure she did the painful pushing for longer than 10 seconds, but I don't know how long, it seemed much longer than that. She advised me not to do any more specific exercises, but to "move the elbow" during the weekend, and throw a ball around, as well as do a barely specified bend-the-forearm-up-from-elbow-and-turn-palm-back-and-front exercise (she wouldn't tell me for how long/how often).

The originally prescribed exercises have been two: one that combines Elbow Flexion with forarm Pronation, and then Forearm supination (which has become easier). I did them first for 5 seconds apiece, later 10 (and frequently more, on my own initiative), usually 4x a day, though a few times 3x a day.

So I returned today; having thrown the ball (using the elbow, not the shoulder) with my left arm a lot over the weekend, and trying to touch the back of my neck with my hand (reached the back of my head). The therapist said she was going to try a splint to keep the arm bent, but then proceeded to do more of the pushing-my-forearm-back-to-get-my-left-hand-to-left shoulder, only with my lying down. It was agonizing, as usual. I tried to be brave, but it just hurt too much. (I had taken Tylenol Extra Strength - well, a generic equivalent, an hour before; it didn't help) The only thing that distracted me slightly from the pain was when I bit my lip quite hard, but that interfered with my regular breathing so I had to stop. It went on for at least 3 or 4 minutes, possibly longer. We did get my left hand to touch my shoulder, though only briefly. My therapist was annoyed with me, or at least was frowning most of the time, and seemed particularly annoyed when she said she was moving my shoulder, not the arm, and I was still in pain (I told her that it wasn't the shoulder that hurt, it was the forearm). Someone pulled a curtain around the area I was in, possibly to try to prevent me from terrifying the other patients, I don't know.

Finally, the therapist released me, and told me that she could not continue; I was "too difficult". She wrote a letter explaining it all to the surgeon (who I will be seeing tomorrow) and advised me to continue to do the exercises and "move the elbow". She asked how bad the pain was at that moment; I told her truthfully that there wasn't any more pain now (at that moment) but during her work on me, it had been either 9 or 10.

Soooo. Am I a total wimp or just cursed with a heavy-handed physical therapist? If I can get my surgeon to authorize future P/T with a different therapist, should I expect more of the same? I had expected discomfort and a certain level of pain during my P/T sessions, but not pain so intense that I could not endure it for more than a minute or two (sometimes less, maybe). I am not a coward;having endured multiple operations and "aggressive" chemotherapy in the past; but this experience has been exhausting and I am scared and rather depressed. Will I have to put up with torture in order to regain more range of motion? Right now, the dexterity of my left hand and fingers has increased since the accident, but not the bending and extension of my elbow (except, briefly, in that one session on 1/7).

Will I have to choose between suffering extreme physical pain in P/T that has so far been unendurable and not regaining the range of motion I need to have a normal life back (be able to drive properly, walk my dog on-leash, lift something heavier than 5 lbs., etc.)?

Any insights or opinions would be welcome. Thank you for reading.


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[gcoe]

I have two responses:

Fractured elbows can be notoriously prone to stiffness. The nature of the joint is that the two bone ends are very "congruent" meaning that the two are tightly shaped and in close contact (as a tight fitting glove as a metaphor) - this means that if there is a disruption of the surfaces there often can be problems with the movement between the surfaces hence a lot of stiffness. It isn't possible to give specific advice as I don't know the exact nature of the fracture. Pain is also a common problem when trying to improve the range of motion. However there could be other complications. For example it may be that there is some involvement of the nerve complex (known as adverse neural tension) and this can cause a lot of pain and may need examining. You described getting the pain in the forearm when the therapist moved the shoulder and this could indicate such a problem.

My second response is more about the way the therapist communicated to you. It is clear there is no empathy there. In my experience having someone who can build rapport with you is essential for the smooth progression of your rehabilitation. For example if a procedure is particularly painful being understood with a sympathetic ear and having some problem solving for dealing with the pain is really important. It may be necessary (and by the way I don't know this) to have the joint moved in such a painful way but there are such things as pain management options. All in all if the therapist behaved the way you said - well it wasn't very professional and I don't think you were treated with dignity and respect that you should be accorded with.

The best answer is to may be seek help from another therapist whom you can have a good working relationship with. you may also need more of a team approach - perhaps a physician could help with the pain management side of things. Whatever, it is true that you do only have a limited window of opportunity to get things moving so I would persist with help now.

I wish you well with our recovery.

[Raksha2015]

Thanks for answering.

Actually, the therapist moved the left arm, not the shoulder. The injury was a radial head fracture of the elbow, type II. I knew that there would be some discomfort and pain with the exercises and therapy; but I did not expect that pain to be so excruciating that I could not bear it for very long.

This past Wednesday, I saw the orthopedic surgeon who I had originally consulted (back on 12/17). He said that I was where he expected me to be at this point (after x-raying me again and evaluating the x-rays as well as my left arm) and could start a home exercise program.

I am seeing another therapist, though not as frequently, just enough to check that I'm doing the exercises (including the 2 new ones she assigned me) correctly. I may not continue after the next two sessions; she didn't seem to think I would need more. She said I was doing well, as expected in terms of flexion/bending and slightly ahead of the curve in the dexterity/flexibility of my left hand (I think that's what she said). She was much nicer and more positive than the other therapist. Both she and the surgeon took measurements that indicated improvement from the first time they had done so, 4 days after the injury. The therapist did imply, when I questioned her, that I would not be able to ever touch my left hand to my shoulder again, but it is not yet impossible, and she did say I will be able to straighten the left arm more than I can right now.

And my surgeon cleared me to drive as of early February. My left hand is stronger, though it still has a way to go (I can open soup and soda cans again with just the left hand). I hadn't expected to regain full function in all things within two months; my therapist says it could be several months to a year.

I'm coming to the end of that 6-week window after which the elbow stiffens. I have been moving it throughout most of the time, regardless of twinges or discomfort, and am doing the exercises 3 or 4 times a day (trying for 4, but the last several days my sleep cycle has been poor and messed up my timing). I hope I will still be able to continue the recovery; my therapist indicated I would, though it might not continue at the same pace.

If I find out that my prior physical therapy was mismanaged and that this had an impact on my ultimate recovery, I will be displeased. Probably there's no way to know for sure. I wonder whether I would have done better to chance the surgery, though I've also been told that it is very painful and can cause infections and arthritis.

[toddchaney]

Good to hear that you are seeing a physiotherapist. I would also suggest you to go for a rehab program for speedy recovery. Eat properly and exercise regularly.

[Jeff04]

I suggest you see another therapist.

[mathewvarghese]

See an expert physiotherapist well versed in Anatomy and Biomechanics.