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SpecialistMichael
SpecialistMichael, MS, CSCS
Category: General
Satisfied Customers: 507
Experience:  Senior Information Specialist
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toCustomer Luck would have it you answered my decluttering

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toCustomer Luck would have it you answered my decluttering question and I actually have a question that deals directly with your degree and specialty. I had an injury at work last March, went to the dr had an MRI, was referred to specialist and sent to PT/OT. Almost a year later I am still having consistent problems and pain with the areas that were injured, is this common? If you need more details about the injury please let me know :)

Thank you.
Submitted: 2 years ago.
Category: General
Expert:  SpecialistMichael replied 2 years ago.

Customer:

Hi Bella, thank you for the request.

Customer:

Please tell me about your work injury. Keep in mind depending on the injury and the environment after that it can take upwards of 1-3 years to really start to feel better

Customer: replied 2 years ago.
Hi, my chat function has stopped working since I applied to be a specialist on the site, I apologize.
Customer: replied 2 years ago.
I was at work pulling a flat bed of merchandise through a swinging door, a box stuck on the door and instead of the box falling and the flatbed coming through, the metal handle jerked out striking my wrist/palm area and thrusting my shoulder back.

It's interesting you say that time span, because the specialist that I saw originally said I should be completely fine within 4-6 months at the most and any pain I have is "subjective". Given that it's a work related injury I was still having to work and restrictions were not followed as they should have been (injury was in March, I wasn't released from PT/OT til August) I am considering getting a second opinion from another specialist..some nights the pain is still so bad it keeps me awake. And I have trouble doing things above my head such as writing on boxes, for more than 5 minutes.
Expert:  SpecialistMichael replied 2 years ago.
There will be a few questions incoming so I can hopefully get an idea without a proper eval - something you should have again from another physical therapist. If you can provide a zip code i might be able to find someone through some networking.



Where is most of your pain located?

Also, what activities make it worse besides overhead box writing?
Customer: replied 2 years ago.
I still have pain in my wrist on the side from the base of my thumb up into my wrist primarily (sometimes can begin to include my entire hand and wrist, which stinks as I'm right handed and it's that hand) and in my shoulder it is on the front about 2 inches from the clavicle as well as on the very top of my shoulder joint approximately in the area where the bones of the arm meet the shoulder. A concern I have is that the MRI was done at the very beginning after the injury and there were several weeks where my shoulder was worked well past what it should have been and the dr that I saw did not see any purpose in getting a new MRI
Expert:  SpecialistMichael replied 2 years ago.
So why dont we look into this shoulder issue first and see if we can get an idea of it then we can move to your wrist.

If its easier I will ask some questions in bold and you can just copy them over with your answer so we can stay organized, if thats ok.

Does your shoulder ever feel unstable to you?


This shoulder pain, could you press on the painful area with a finger?



If you bring your arm up to shoulder height and bring it across you(as far as you can reach) in front of your body, does that make it worse?
Customer: replied 2 years ago.
Sounds good, I like organized :) I'm not sure why it didn't transfer over with the bold :/

Does your shoulder ever feel unstable to you?
Yes, my shoulder actually does feel unstable even though I have tried to keep up with exercises for it, it sometimes "pops" out of place (or it's the tendon/ligament popping, whichever it is my entire shoulder moves and there is an audible pop)


This shoulder pain, could you press on the painful area with a finger?
Yes, I can press on the painful area with a finger. Even at my worst with broXXXXX XXXXXmbs I have been able to tolerate at least that :)


If you bring your arm up to shoulder height and bring it across you(as far as you can reach) in front of your body, does that make it worse?

It does hurt more if I cross my arm across my body whether I am crossing it whether with or without utilizing my other hand to stretch (I did ballet and other dance in the past, so the flexibility is there but there is the pain still)
Expert:  SpecialistMichael replied 2 years ago.
The unstable feeling, does it feel like a "sliding" sensation?


This unstable feeling, is it worse with your arm in any particular position?


Describe the pain for me: sharp, dull achy, throbbing, sore etc..



The stretch you mention, its good that you are familiar with it - would you say that when you keep your thumb pointed toward the floor, and go into that stretch, does it hurt more.
Customer: replied 2 years ago.
The unstable feeling, does it feel like a "sliding" sensation?
I suppose the movement of the shoulder could possibly be construed as a sliding sensation, however it feels like a pop when I adjust my arm from other positions.


This unstable feeling, is it worse with your arm in any particular position?
Generally, it hurts/feels unstable just sitting still, it seems to hurt equally if my shoulder is forward or if I squeeze my shoulder blades together to bring my shoulders back more

Describe the pain for me: sharp, dull achy, throbbing, sore etc..
at the moment, a sharp pain on the top of the shoulder and more of a throbbing/aching on the front

The stretch you mention, its good that you are familiar with it - would you say that when you keep your thumb pointed toward the floor, and go into that stretch, does it hurt more.
OMG yes. I hadn't done that with my thumb pointed downward, that caused a very sharp pain in the front
Expert:  SpecialistMichael replied 2 years ago.
Well typically the shoulder joint shouldn't have a feeling of sliding unless it has some instability while moving.

Its an incredibily complex joint and during motion, there is not a lot of "spare" space, so any inflammation would actually take up less space when the arm is moving. For the extreme range of motion, the shoulder is inherently a bit prone to being unstable and prone to injury.

When the door took your arm back when you were first were injured, were there any other sensations during that?

Are there times of the day when it hurts worse?

If you turned your thumb down( as if you have poured a glass of water out at arms length) and tried to lift your arm up toward the ceiling not directly in front, not to the side but at an angle would that cause anything better or worse?


Customer: replied 2 years ago.
When the door took your arm back when you were first were injured, were there any other sensations during that?
Oh it was a metal handle of a flatbed, not a door. at the time it was time to go home so it wasn't until I came to work the following day and began using my arm that the pain became increasingly worse. It's been almost a year so honestly I don't remember the exact moment of the injury if it was a sharp pain or if it was the repetitive movement afterwards that made it worse.

Are there times of the day when it hurts worse?
There are no specific times it hurts more than others and it is not necessarily a daily pain but it's frequent enough that after almost a year it's concerning me.

If you turned your thumb down( as if you have poured a glass of water out at arms length) and tried to lift your arm up toward the ceiling not directly in front, not to the side but at an angle would that cause anything better or worse?
The shoulder feels slightly more pressure with the pain in the front and same pain on top; in this position it causes sharp pain in the thumb/wrist area
Expert:  SpecialistMichael replied 2 years ago.
For the shoulder: Have you tried complete rest from work, ice and a regime of an NSAID? For at least 7-10 days, but with gentle range of motion to ensure it doesn't stiffen up?


How long after the intial insult did you see a doctor, then how long after that did you start PT?


Was this a worker's comp case?


Had you been dealing with any shoulder issues before the insult with the metal cart and door?
Customer: replied 2 years ago.
For the shoulder: Have you tried complete rest from work, ice and a regime of an NSAID? For at least 7-10 days, but with gentle range of motion to ensure it doesn't stiffen up?
I tried to take complete rest from work and have rested and done the whole regime with basic exercises. Whenever I am having flare-ups I always have icepacks near and anti-inflammatory med etc.

How long after the intial insult did you see a doctor, then how long after that did you start PT?
The incident happened on a Thursday, I wanted to see a doctor that Friday but was convinced by one of the persons in charge of those reports at work to wait until Monday. I worked both days that weekend and by Monday it was significantly more painful.

It took probably at least 2-3 weeks to start PT because it is a worker's comp case, so the approval process is a pain in the toochis. I'd get 4 visits approved, then it would take 2 weeks to approve 4 more, but all good done in the 4 visits would be undone by being pushed past my limits at work during the time.

Was this a worker's comp case?
Yes it is actually still a pending case unfortunately.

Had you been dealing with any shoulder issues before the insult with the metal cart and door?
Prior to this incident I had actually had physical therapy for the shoulder a year prior to strengthen it and after stopping that PT I had no problems with it whatsoever (that previous round of PT was when I went in for voluntarily just to make it stronger as I never had PT after an injury as a teenager about 15 years ago)
Expert:  SpecialistMichael replied 2 years ago.
Thank you so much for all the patience and answers to all the questions, being over the internet makes this very hard without a manual exam trying to figure this out

Were you given an answer of any sort of diagnosis of either injury?

Did the MRI show anything or say anything in the radiology report?


Do you remember any of the names(I know its hard here) of any of the exercises, or do you remember the PT telling you any of the goals you were going to work toward with them, aside from the obvious reduction in pain?
Customer: replied 2 years ago.
Thank you for your time and patience! I'm sure this is probably one of the most in-depth questions you've had and I do apologize for that.

I actually received paperwork from my attorney that was previous Orthopedic doctor's office.


Were you given an answer of any sort of diagnosis of either injury?
the diagnosis: R shoulder strain, R wrist tendonitis (this was from a report dated in June)

Did the MRI show anything or say anything in the radiology report?
According to the report in June (which I believe my MRI was actually done in April or early May) there was no evidence of cuff pathology no labral pathology. Tendons intact and PT/OT continuation recommended.

Please note that up until about June/July I was unable to even lift a full gallon of milk let alone normal tasks.
Expert:  SpecialistMichael replied 2 years ago.
You don't have to apologize at all. I had a nasty traumatic shoulder injury that dragged on for a very long time that actually was a career changing situation..and if you guessed that injury was the thing that got me into rehabilitation science, you would be right! I am happy to assist you.


So my thought on your shoulder goes a couple of ways. But I want you to think of an MRI as trying to purchase a house by looking in through the windows - it gives a solid idea of whats going on in the house but there would be no way to tell UNLESS you walked around inside the house. Same idea with MRI's, it gives you a picture.

The other thing is remembering how complex this shoulder joint and all its musculature actually is. All the range of motion the should has(3 planes) leave it open for instability issues. The other thing is, because of all the things crossing the joint and surrounding it, there is not a lot of space. Any inflammation, takes up space, not enough space creates a situation of rubbing and inflammation, this becomes a cycle unless a regime appropriate care is taken. This is called impingement syndrome, which might not limit activity but can be a serious nuisance. Major league baseball players develop this from throwing, they can play with it at the limit of progression, but sometimes if it gets worse and worse can be season ending.

Overhead sports and activities because of the way the shoulder is built can actually promote overuse injury simply because of that "space issue", every "Kinda sorta" wants to rub so if my shoulder has a little less space than yours, and we are both doing overhead things all day, or lifting overhead, I might develop some inflammation and irritation and you might not. Or even vice versa, its so highly variable.

The other thing that can happen with repetitive activity(again even just because of the way a shoulder is built in one person) is small tearing fraying of the rotator cuff, the muscles that control your arm's deceleration when throwing something like a ball. These muscles(3 out of the 4) act to basically "suck" the head of the humerus(your upper arm) into the socket, they provide control and stability. If these are weak even when not injured, can leave the shoulder unstable. Sometimes the fraying mentioned at the top of this paragraph can happen, and someone will be absolutely functional and completely pain free.

The glenoid labrum(labrum for short) is a dish shaped cartilage that adds depth to the joint, when this is injured, its common for people to experience instability.

Now remember its so hard to come up with an idea of the injury without doing an exam and doing some special tests and manual muscle testing with you. But I will give you my thoughts based on all these questions' answers.

I think the metal cart incident may have been the initial insult that may have caused an involuntary contraction of those rotator cuff muscles(they contract as a "safety" reaction to protect the joint) that may have either irritated them or at the least caused a strain of the muscles initially. I think that initial insult would have probably lead to the start of inflammation(as with any injury). The fact that you returned to work, but noticed it getting worse as you did more and more activity partially confirms that there was at least some inflammation that the repetitive use of the overhead work would progress that inflammation.

The instability feeling you have, coupled with some pain I would imagine be resultant from from the starting weakness of those muscles(remember the body works on a use it or lose it basis) that was made worse from all the discomfort caused by the inflammation and initial strain from the cuff muscles. Using an inflamed shoulder, because of all the inflammation(fluid and "tissue expansion") can also create a feeling of inflammation. If you shoulder is indeed instable, that might explain the feeling of it sliding out when you do certain things.

In all of these situations, a solid dedicated RICE routine(rest, ice, compression, elevation) + NSAID(taken breakfast, lunch, dinner with doc recommendation) is needed to try to see what problems were really there after the initial inflammatory response happened.

I would suggest getting another opinion(though I am not sure how it would work with comp in your case's progression) and I think you need some rotator cuff targeted therapy to get those muscles firing strongly. From working in injury rehab, treatment stages are similar, however I can tell you all therapists(respectfully) are not created equal. Some just give you a list of exercises and say "do this at home" and some actually work along with you, doing manual therapy while you're in your appointments but actually give you "homework" - like classes in school. The issue is, if you have that inflammation still in there from regular use(or a slight fray or tear of any of the muscles) if its constantly re-aggravated from use, its hard to get a handle on the inflammation so you can progress to ranging it, then strengthening it so you can actually feel better.

Without doing any examination and eval, and without being able to do those tests it sounds like you have some impingement issues resultant from the metal cart traumatic insult, and some resultant instability from the weakness of those essential stability muscles being inactive(inflammation can shut them off as well). This needs a thorough evaluation by someone who deals with younger, active populations, so you can get an unbiased answer that sometimes is biased from clinicians seeing worker's comp being abused.

For example, the first time my injury was properly diagnosed was when someone who wasn't being paid, and whom I did NOT know evaluated it... just a thought.

Does this all make sense?
SpecialistMichael, MS, CSCS
Category: General
Satisfied Customers: 507
Experience: Senior Information Specialist
SpecialistMichael and 67 other General Specialists are ready to help you
Customer: replied 2 years ago.
Yes that makes a lot of sense actually, and not all of my work is overhead-thank goodness--though I do work in retail as well as another customer service job so I'm either at the computer a lot or lifting/pushing/pulling/etc.

In my state you're entitled to a second opinion on worker's comp cases (I did have to retain an attorney, as you can imagine this has been both a literal and figurative pain). I requested the paperwork because I have been considering getting a second opinion--actually at a sports medicine clinic where it is not common for them to see worker's comp people at all, but I know the doctors there are excellent.

So at this point, basically I need to keep icing the shoulder take my naproxen etc then ice my wrist.

I did have great physical therapists who worked with me during sessions and gave homework. I still do the exercises that they gave me as "final homework" a couple of times a week, but often it doesn't seem to really feel like it's doing much good.

You'd mentioned rotator cuff issues, now with the initial MRI i had actually questioned when I got to the specialist's office if we could do a reevaluation of that but they felt it unnecessary. I know I have a friend that had a CT with contrast to see more what was going on when she had an injury. I always thought that they were just trying to push me through get me well quick and try to shut out the case. I don't deal with that, I believe that an injury needs full and complete treatment rather than rushed treatment due to pressure. :) that's just me.

I'm glad to hear that your injury got properly diagnosed--even if it wasn't on the first try. And you have been of great help in giving me more details on the situation. To be honest, I had been so frustrated with the process I was getting ready to cave in but you have made me realize that I really do owe it to myself to get double checked...because it could be worse than they originally diagnosed (and really this kind of pain after a year, is the impingement common??)

Thanks so much for all of your help!!
Expert:  SpecialistMichael replied 2 years ago.
Thank you for the opportunity to assist you.

Remember what I said about MRI: they are pictures that give a REALLY good idea of whats going on, but its just a picture you would have to be inside the house to see what its really like.

With injuries like impingement I worked with a patient in a PT clinic with someone who had been symptomatic for nearly 8months... it was a very slooww progression of the inflammation very slowly getting worse and worse until the person couldn't do anything then decided to get checked out... just for that impingement the person had to rest, range and rehab for 12-15 weeks before they could return to work.. it was that bad. The other thing is a tear of the rotator that an MRI just can't see, you would have to have exploratory surgery to even find it.. but you would want to avoid surgery unless absolutely last resort.

If your shoulder is inflamed, from an old injury or a semi-healed injury, that inflammation can stick around for quite a long time in some cases. So to be brutally honest, I would expect it to be at least a little better, but if it was never give a situation to get better than I wouldn't be surprised if its still bothering you.

The other thing to remember is that some people can have some slight instability naturally(if they were a volleyball player, pitcher, quarterback etc..) as long as function and structural integrity is still there it is not a concern. If you get a second opinion , they should be doing those special tests to check for instability. Unless there is something easy to spot like a tear, an MRI can't technically see instability.

While I can't recommend medications or drugs to you I can tell you a common progression used to actively try to calm inflammation in the shoulder.

-Ice - 20 minutes out of each hour as many times as you can in a day
-Ibuprofen - a common recommendation I have seen is 800mg 3x a day(so 800mg at breakfast, lunch, dinner) , taken each day for 7-10 days. The pain relief on this is usually within 20-30min, but the anti-inflammatory properties actually take some time to build up - and this is where people don't quite get full potential. They stop taking it a couple days after. NSAIDs can be cause some stomach irritation and be hard on the live in the very long term, but again if you are healthy these are generally not an issue.
-GENTLE passive range of motion to help assist the inflammation out while not creating the same situation that irritated it. Sitting at the kitchen table, using your hand "crawling" across the table away from you being careful NOT to use the shoulder muscles, but then draw your arm back carefully. Keep your hand on your shoulder so you can feel the muscles contract, that way you know you aren't supposed to contract them and you can stop yourself, maybe a couple sets of 10 to start.
-Pendulum exercise - stand up, bend at the waist, let your arm hang down to the floor, relaxed. Use your body to gently initiate a mild swing and do a couple sets of these for roughly 30seconds each - again making sure you use your body instead of your shoulder muscles to let the arm dangle and move. This is not a violent swing, just a gentle rocking, hence the name pendulum.
-Activity mod, if you can not do something that you know will fire up your shoulder then don't do it. If you must do something, once you feel some irritation building up switch your task and ice. Pushing through irritation will only make it worse.

See what happens when you adopt this, for only a week - it should be a pretty significant difference. When looking at another opinion, I tended to notice the most thorough, most considerate ones(in regards to symptoms and full evals) are the ones who deal with elite athletes, because the athlete "must have a career" ahead of them so choices are often well thought out.

You are very welcome for all the help on this complex situation(made worse by doing over the internet). I wish you the absolute best and just remember, the body heals..but it takes the right situation and time, which is key.

If I can help with anything, answer any questions in the future, don't hesitate to request me Bella.
-Mike
Expert:  SpecialistMichael replied 2 years ago.
and Bella, with the pendulum, its not a large circular "swing" to start, its just a light small passive rocking swing to start(possibly even only a couple of inches to start), if its uncomfortable lessen it until you're more mobile. RICE! :)

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