PDA

View Full Version : shoulder injury



rebdwail
11-11-2004, 04:19 AM
My husband was an avid weightlifter and even trained for a bodybuilding show in March '03. During training he suffered an injury. We think it may have been while doing shrugs but we are not sure at all. The initial symptoms were pain, his left bicep was mushy and weak, and he could not extend his arm completely. His bicep is fine now but he has been in pain ever since.

His pain originates posterior near the armpit. That tendon is really tender. He definitely feels like its coming from the scapular region. He was a pulling sensation meaning his shoulder feels like it is being pulled up toward his neck. If he wears a close fitting shirt, it irritates it. He feels like when he rotates his body trunk to the right everything is free and flexible. When he rotates to the left, he feels like it is "locked up" and he can rotate as far. His left side is definitely weaker than the right and his muscle balance is off.

If he attempts a push up, he says it feels weakness from the scapular region and can not completely do one. He feels like his arm just kinds of hangs there an is not tight like the other side.

We have been to 3 orthopedic surgeons, a physiatrist, a few chiropractors, a few physical therapists, a neurologist, and several massage therapists, etc. We have exhausted all options. The MRI reports doesn't have a smoking gun but the latest one didn't sound pretty either. The EMG study came back normal but I do not think they covered the axillary area. He has tried cortisone shots, trigger point therapy, exercises, pain meds, heat/ice therapy, etc.

One of the orthopedic surgeons opted to do a surgery on his AC joint in March of 2004. The surgery did not do anything to relieve these symptoms. The doc now says he can just live with it and see what happens or have surgery...but of course, we have not received a diagnosis and we are not even sure if the first surgery should have taken place!!

The problem is my husband is 32 years old. We have 3 small children. He can not lift weights anymore. He is in pain everyday...some worse days worse than others. Some days are so bad he doesn't know how he can live with this forever if it never is fixed. I am to the point that I am trying to reach out to anyone who thinks they may have a suggestion!!!
Please help!!!

sydunisportsmed
11-11-2004, 01:35 PM
I don't normally like bagging doctors in their management of patients who I haven't examined, but I agree with your impression that it was pretty bad for the surgeon to have operated on the A/C joint without the diagnosis being made. Normally with a bone scan +/- MRI scan +/- repsonse to local anaesthetic and/or cortisone injections, you can be fairly certain whether the A/C joint is the source of the pain. It is disappointing that this surgeon, having had an opportunity to look inside the shoulder whilst your husband was under anaesthetic, can't at least be far more definitive about the diagnosis. Having said that, your husband won't be much worse off for having had the procedure (other than financially) because the A/C is a pretty unimportant joint, so it's not like the surgeon will have taken out an important structure.

The most important step for whichever doctor next sees your husband is to come up with a diagnosis, and this can start with even just isolating the region causing pain. In a case like this, I love to use local anaesthetic blocks. That is, pick an area of suspicion (e.g. the shoulder joint itself or the A/C joint, but not both) and infiltrate it with long-acting local anaesthetic to numb this spot. Then let the patient go to the gym and exercise, doing something that would normally hurt. If the pain is gone, then the region of pathology has been isolated, if it is still there then move on to another spot.

There have unfortunately been people over the years with disc prolapses in the neck pinching on nerves that have had shoulder operations and this should be ruled out as a diagnosis. In this case, none of the shoulder region local blocks would do anything. Your doctors hopefully would have suspected this if there is neck stiffness or signs anywhere of nerve block.

If local in the shoulder joint or subacromial space blocks the pain completely, you should just move on from the A/C surgery and perhaps consider a shoulder arthroscopy. I agree that having another surgery when the surgeons seem to have not much idea about diagnosis is not worthwhile, but if there is proof the pain is coming from inside the joint (because a local block numbs the pain) then this is a good reason to have surgery.

It is remotely possible that the pain could be coming from just underneath the scapula (the scapulothoracic bursa, which can rarely inflame) and then it isn't a shoulder joint problem, so don't operate, but this sometimes can be fixed with a cortisone injection to this spot.

Obviously pretty hard to manage via email, but I hope these pointers are helpful. Also if you reveal which city you are in, there is a chance I may be able to recommend someone in the US.

rebdwail
11-11-2004, 02:23 PM
Thank you for your response. First off, I will tell you that we are in Tucson, AZ. I would like to clarify that prior to his surgery on the AC joint (which was the third orth. surgeon we had seen) diagnosed impingement. Like I said the surgery did nothing for him. Hindsight is 20/20 and we think that if it was impingment, the second orth. surgeon would have diagnosed it (because they were both using the same MRI). Make sense? The second orth. did not ever make a clear diagnosis.

My husband has had a few shots in and around the AC joint and that has never done a thing for him. It seems like we can't get any doctors to explore further or sit down and really listen to all of the symptoms and problems. It's been so frustrating!

I have his MRI reports, one from 7/03 and the most recent from 9/04. I think the second one sounds worse than the first but am not a doctor...
There is a 5mm lesion in the proximal humerus. Is it possible a lesion in this particular spot could throw off the whole mechanics of his shoulder thus causing secondary issues and a lot of pain? The supraspinatus tendon is mentioned in both MRI reports. The first one talks about tendinosis. The second one says there is an irregularity of the bursal surface of the supraspinatus tendon which may represent a paritial-thickness bursal surface tear. The second MRI also aso reports of an irregularity of the glenoid labrum but evaluation of the labrum for a tear is limited without significant joint effusion or intra-articular contrast. What does that mean? Could there be more there than what meets the eye? Is it possible to fax you these MRI reports to just peek at to see if we are missing something? I obviously know you can not disgnose anything. I was just hoping you may be able to stir up some new avenues to investigate...or even just define some of the jargon.

I truly appreciate your response! Thank you!!







I don't normally like bagging doctors in their management of patients who I haven't examined, but I agree with your impression that it was pretty bad for the surgeon to have operated on the A/C joint without the diagnosis being made. Normally with a bone scan +/- MRI scan +/- repsonse to local anaesthetic and/or cortisone injections, you can be fairly certain whether the A/C joint is the source of the pain. It is disappointing that this surgeon, having had an opportunity to look inside the shoulder whilst your husband was under anaesthetic, can't at least be far more definitive about the diagnosis. Having said that, your husband won't be much worse off for having had the procedure (other than financially) because the A/C is a pretty unimportant joint, so it's not like the surgeon will have taken out an important structure.

The most important step for whichever doctor next sees your husband is to come up with a diagnosis, and this can start with even just isolating the region causing pain. In a case like this, I love to use local anaesthetic blocks. That is, pick an area of suspicion (e.g. the shoulder joint itself or the A/C joint, but not both) and infiltrate it with long-acting local anaesthetic to numb this spot. Then let the patient go to the gym and exercise, doing something that would normally hurt. If the pain is gone, then the region of pathology has been isolated, if it is still there then move on to another spot.

There have unfortunately been people over the years with disc prolapses in the neck pinching on nerves that have had shoulder operations and this should be ruled out as a diagnosis. In this case, none of the shoulder region local blocks would do anything. Your doctors hopefully would have suspected this if there is neck stiffness or signs anywhere of nerve block.

If local in the shoulder joint or subacromial space blocks the pain completely, you should just move on from the A/C surgery and perhaps consider a shoulder arthroscopy. I agree that having another surgery when the surgeons seem to have not much idea about diagnosis is not worthwhile, but if there is proof the pain is coming from inside the joint (because a local block numbs the pain) then this is a good reason to have surgery.

It is remotely possible that the pain could be coming from just underneath the scapula (the scapulothoracic bursa, which can rarely inflame) and then it isn't a shoulder joint problem, so don't operate, but this sometimes can be fixed with a cortisone injection to this spot.

Obviously pretty hard to manage via email, but I hope these pointers are helpful. Also if you reveal which city you are in, there is a chance I may be able to recommend someone in the US.

sydunisportsmed
11-11-2004, 02:45 PM
Sounds like the diagnosis is supraspinatus (rotator cuff) tendinopathy, non responsive to cortisone injections.

This could be confirmed by an injection of local anaesthetic into the sub-acromial space (just under the A/C joint) which should block the pain temporarily.

If the first surgery didn't enter the shoulder joint (and was confined to A/C joint) then perhaps a shoulder arthroscopy might help.

Some tendinopathy is resistant to all treatment however.

I would try to get a confirmation that this is the diagnosis on the next visit, then at least you can start researching this topic (shoulder tendinitis etc.)

Don't know anyone who is an expert in Tuczon. The closest shoulder guru to you may be Richard Hawkins in Colorado:

http://www.steadman-hawkins.com/clinicInfo.asp

Rod Whiteley
16-11-2004, 01:27 PM
because the A/C is a pretty unimportant joint, so it's not like the surgeon will have taken out an important structure.


That certainly had been the prevailing thought amongst many practitioners, however there is increasing evidence that the AC joint certainly is an important structure and that its dysfunction can cause a lot of problems.
For example:
Mouhsine E, Garofalo R, Crevoisier X, Farron A. Grade I and II acromioclavicular dislocations: results of conservative treatment. J Shoulder Elbow Surg 2003;12(6):599-602.
This group followed up a series of Tossy Grade I and II AC joint injuries for an average of 6.3 years finding that 48% still complained of 'symptoms' and that 27% had thought these symptoms sufficiently bad to seek surgery for their problem. I hardly think that the structure is unimportant if injury is likely to warrant seeking surgery in about a quarter of subjects.
You may also be intersted in the work of:
Gerber C, Galantay RV, Hersche O. The pattern of pain produced by irritation of the acromioclavicular joint and the subacromial space. J Shoulder Elbow Surg 1998;7(4):352-5.
In essence this group showed that hypertonic saline injection produced patterns of pain referral from the ACJ which could easily be mistaken from a subacromial source.

Good luck with your husbands problem.

injuryupdate
16-11-2004, 06:17 PM
Taken out of context, I agree that this statement is wrong. In terms of propensity to cause pain, the A/C joint is very important. In terms of ability to live without the joint, it is not nearly as important.

It might be trivialising it a bit to compare the A/C joint to the appendix, as in weightlifters, baseball pitchers, etc. the joint probably has a significant function.

Analogies in the rest of the body might be prepatellar bursa, sacroiliac joint, iliotibial band, plantar fascia, sesamoids. In certain athletes these structures might be very important. In many other people these structures are the source of a lot of pain and annoying but you could live without them functioning fully if you could just get rid of the pain they are causing.

I wouldn't want to excuse a surgeon who operated on an A/C joint where the problem was misdiagnosed. We don't know enough about the case to know whether this occurred. Hopefully, even if it happened, it would turn out to be a waste of money rather than making the problem worse.

Rod Whiteley
16-11-2004, 09:20 PM
Analogies in the rest of the body might be prepatellar bursa, sacroiliac joint, iliotibial band, plantar fascia, sesamoids. In certain athletes these structures might be very important. In many other people these structures are the source of a lot of pain and annoying but you could live without them functioning fully if you could just get rid of the pain they are causing.


I'm old enough to remember when the cruciate ligaments of the knee were 'a useless evolutionary redundancy' and therefore injury to them was to be ignored (at the time menisci were being wantonly removed with quite good short term results). I don't know about the pre-patellar bursa, but if you've bumped your shin and your patella on something, I reckon you might have an idea why it's there. In the shoulder there's good evidence that the subacromial bursa is a significant structure in terms of nutrition for the subjacent cuff, and that removing it unnecessarily is a potentially hazardous option. Elderly people with fused SIJ's who fall and suffer a longitudinal fracture of their sacrum will tell you why you have a small amount of shock absorbing movement available at the sacro-iliac joint. If I removed my iliotibial band, my vastus lateralis might have something to say about it, and there's a nice mathematical proof I'm aware of that shows that the restraint of the axial expansion during muscle contraction which fascia (such as the thoraco-lumbar fascia, and the ITB) afford increase the subsequent tensile force generated. I'm not sure how the windlass mechanism of the foot would work without the plantar fascia, or how the FDL would get to the undersurface of the distal phalanx unhindered without the sesamoids (or did you mean sesamoids like the patella perhaps?)
I'm just saying that we often remove things we don't really understand at our peril.
As for the appendix - well how do you think the carrot always ends up in your vomit?

hhh
17-11-2004, 12:23 PM
In terms of living without the joints and anatomical strucutres, I think that is a fair call if you have no requirement for the functional demands of the kinetic chains involved with each structure and if performance is not a priority. Amputees seem to manage without an ITB, prepatellar bursa, numerous sesmoids and a whole lot more.

However - you make Nikolai Bogduk look like a conservationist!