Hi. My right shoulder has been bugging me for YEARS. No diagnosis. X-rays seem to show nothing of note. I had a car accident YEARS ago (like 25 years ago), after which I had physical therapy on this shoulder for quite a while. I have a bunch of joint pain that led my Primary Care Doc to send me to a rheumatologist. The rheumatologist hasn't figured out exactly what's going on with me, but doesn't think my shoulder problem is related to my clearly inflamed hand joints (and occasional clearly inflamed toe joints). The rheum-doc and primary care doc suspect I may have psoriatic arthritis because I have psoriasis. That's the background.The rheum-doc sent me for physical therapy for my hand, my lower back, and my shoulder. The physical therapy has greatly reduced the pain in my lower back and my hand. But the shoulder remains a problem.The physical therapist wonders if (a) the shoulder pain is because of the car accident injury from 25 years ago, (b) the shoulder pain is a reaction of funny movements I've used to spare pain in my hand, (c) the shoulder pain is a labrum tear. It seems the more we do to try to improve the shoulder, the worse the pain gets. We've done heat, TENS, exercises, ice. The shoulder pain is really awful. So my questions are:- would a labrum tear not be visible on x-rays?- what would you suggest I try next? - should I continue with PT on the shoulder? After a month or so it just seems worse, rather than better. (The PT *HAS* taught me some tricks that have reduced the pain a little bit for some tasks, like reaching over my head.)Any and all thoughts welcomed.
(I limit NSAIDs due to colitis. Rheum doesn't want to do cortisone shots because of diabetes.)
Tylenol 3 when the pain is at its worst.
PT, heat, ice, TENS, ultrasound, exercises
Hi there. I'd be happy to answer your question. Are you still online?
I am an Orthopedic Surgeon and would like to help answer your questions. Please understand that the information that I provide is for educational and informational purposes and is not treatment or meant to substitute for being treated by a live physician. I get online once a day and therefore please bear with me if you post and I haven't responded yet. I will in due time. Please do not accept until you have had your question answered in a satisfactory fashion.
How old are you? Are you otherwise healthy? Do you participate in any sports or work activities that involve the shoulder?
Here are answers:
A labrum tear is not visible on xray. Xray detects bony abnormalities. I can also detect arthritis if the joint spaces are narrowed on xray.
I suspect that you either have a tear of the rotator cuff or arthritis. As I mentioned the arthritis would be seen on xray. Did a physician mention osteoarthritis to you? If you are under the age of 45 or 50 arthritis is less likely.
The rotator cuff is a series of 4 muscles that originate on your scapula (wing bone) and terminate on the head of your humerus (arm bone). The cuff powers your shoulder and allows you to elevate your shoulder and rotate and turn your shoulder. Tear of one or more of the tendons is very common the older that you get.
Are you able to elevate your shoulder to touch the ceiling with full strength?
Evaluation by an Orthopedic doctor or Sports medicine doctors would be recommended as they would be able to detect weakness of the cuff on exam.
An MRI of your shoulder would be the logical next step. It would tell you the status of your rotator cuff, labrum, and cartilage.
One other diagnosis that I forgot to mention is tendonitis or impingement syndrome of the shoulder. Essentially this is when your rotator cuff gets impinged or irritated by the undersurface of part of the scapula (wing bone). When the impingement is severe sometimes a tear of the rotator cuff can develop.
Please see a specialist to get the right diagnosis because obviously your current treatment has been unsatisfactory.
Please let me know if I have answered your question. If not, please let me know what else you would like to know. Thanks.
Hi. My apologies for my long delay. I, too, don't log into the computer very often. I'm 49. Mostly healthy, although you if you read the long list of my ailments you'd wonder how I'm still ambulatory! (Asthma, diabetes, hypertension, migraine, depression, celiac disease, psoriasis, colitis, glaucoma, basal cell skin cancer, and probably more.) I'm slightly overweight (about 10 pounds). Been diabetic for 17 years but still managing with just diet (A1C 5.5)I'm an at-home mom of four kids, so my activities that involve the shoulder are mainly just daily-life kinds of things. No special work or sporting activities that involve the shoulder. I am a lector at Church, and have to carry the Bible over my head when I lector. That's heavy. That's been very hard for me until lately. The tricks that the PT taught me has helped me carry that book over my head more easily. Oh, and the therapy the PT has done for my hand has helped tremendously, too.No, I cannot press towards the ceiling with full strength. As a matter of fact, just dressing and undressing is a true challenge. I cannot wear a regular bra because I cannot hook it in the back. Just pulling T shirts over my head on/off is a REAL challenge. Very painful.I will see the PT again this afternoon. I am going to ask him to repeat his initial evaluation process to see if he still thinks he's on the right track. I will see the rheumatologist again next month, but I'm unsure of the date. I'm not scheduled to see my primary care doc until October. So if I'm going to get an MRI of the shoulder or a referral to an ortho, I guess the rheumatologist would have to set that up. I guess I could make a "sick call" to my doctor. But honestly, this has been going on for SO LONG with no forward progress towards healing that I'm beginning to despair that any one takes it seriously except the physical therapist.Thank you for your input! If you have additional ideas, I'm eager to read them.
I just had PT. We started with heat and TENS. Then I did the shoulder bike. (gosh, six minutes can feel like FOREVER.) Then he massaged the shoulder. Today I didn't leap out of the chair in pain from the touch. Then I did pulley exercises (hate those) and pendulums arm swings. Then he re-evaluated the shoulder. He no longer suspects a labrum tear. He's pretty sure it's impingement of the rotator cuff / tendonitis. Then I ended with ice. I am not in a lot of pain at the moment, but I still wouldn't be able to change my clothes without a lot of pain. Even doing the exercises at PT makes me queasy from pain, especially doing the pulleys. Everything sound about right? The PT says middle aged women & diabetcs are particularly prone to this. So a middle-aged woman diabetc is perhaps doomed. Your thoughts appreciated.
Hi there. Thanks for the additional information. It sounds like PT is helping. Rotator cuff tendonitis/impingement syndrome is very likely. What concerns me however is the weakness and that it is painful at times. There is a spectrum of pathology starting from capsulitis/bursitis to tendonitis/impingement to partial tear of cuff to full thickness tear. Your age puts you in the tendonitis/impingement/partial tear category. Diabetes put you also at risk for what we call a frozen shoulder or adhesive capsulitis. The treatment of all of the above first and foremost if PT to regain full range of motion and strength.If however the cuff is torn that can be painful and the natural history is progression of the tear. However some patients do not want aggressive treatment (surgery) so we don't order an MRI and we just go nonoperative with PT and possible a cortisone injection.Given that it has been bothering you for a very long time, I would go with PT while waiting for an Ortho referral or MRI.I hope that helps and that I've answered your question. If I haven't feel free to let me know what other questions you have. Thanks.
Grateful if you could put this a bit into English!Here's what the MRI says without and with contrast (please forgive typos):Most notable change is amorphous increased T2 with enhancement involving the ventral deltoid ligament and muscle at its insertion on the distal acromion. There is adjacent subcutaneous edema. Appearance is consistent with strain/partial tear. Note is also made of edema and enhancement involving the chronic navicular joint consistent with sprain. There is mild focal tendinosis superior tendon of subscapularis. There is no evidence for synovitis. Glenoid labrum and biceps tendon are unremarkable. There is no rotator cuff tear. The femoral head has normal signal and morphology.Impression: Partial-tear versus high grade strain ventral deltoid muscle and tendon at its attachment on distal acromion with adjacent subcutaneous soft tissue edema. Small subacromial effusion. Edema consistent with sprain at the acromioclavicular joint. Mild tendinosis anterior suprasinatus tendon and superior fibers of the subscapularis tendon.
Hi there. Thanks for following up with me. Here is what your MRI reports means in plain English:Most notable change is amorphous increased T2 with enhancement involving the ventral deltoid ligament and muscle at its insertion on the distal acromion. There is adjacent subcutaneous edema. Appearance is consistent with strain/partial tear. Note is also made of edema and enhancement involving the chronic navicular joint consistent with sprain.***this means that the front of your deltoid muscle has a strain in it as indicated by fluid or swelling in the muscle attachment on your scapular bone (called the acromion).There is mild focal tendinosis superior tendon of subscapularis. There is no evidence for synovitis. Glenoid labrum and biceps tendon are unremarkable. There is no rotator cuff tear. The femoral head has normal signal and morphology.***this means that the front rotator cuff tendon (the subscapularis) is thickened from some chronic irritation and strain. The labrum is a gasket around the cup of the shoulder and it is normal. The biceps tendon is anchored to the cup of the shoulder and it is normal. There is not tear of the rotator cuff and the humeral head is normal. This is good news and means that the muscles that power the shoulder (the rotator cuff) is normal.Impression: Partial-tear versus high grade strain ventral deltoid muscle and tendon at its attachment on distal acromion with adjacent subcutaneous soft tissue edema. Small subacromial effusion. Edema consistent with sprain at the acromioclavicular joint. Mild tendinosis anterior suprasinatus tendon and superior fibers of the subscapularis tendon.***essentially the front of your deltoid muscle is strained and partially torn. There also is some thickening or chronic irritation of the rotator cuff tendons (supraspinatus) and (subscapularis) but both pretty normal.So your injury is the front of your deltoid muscle where it attaches to bone. This is a rare type of injury and generally surgery is not recommended for deltoid injuries.I hope this interpretation is clear for you. Thanks.
Thank you so much! If I were in your office, and I had already done PT for 3 months, and the pain and problem is YEARS in duration, what would you suggest?
Hi there - I think with this MRI and history of failed PT I would offer a patient a series of injections starting first with the anterior deltoid attachment to the acromion, which the MRI indicates is where there is a tear/strain. The purpose of the injection would be first to determine if this is the exact spot that causes the pain. Secondly, it may provide relief because the injection would contain numbing medication and anti-inflammatory medication. I hope that helps. Thanks.
THANKS! TWO more little questions:- Would a rheum-doc do such injections, or do I need PCP to send me to an ortho?- Did I bring this injury onto my myself by knitting/crocheting/tatting lace too much?Thank you so very much!
I think an Orthopedist or a Primary Care Sports Medicine physician could to the injection. In some areas the rheum docs are skilled enough to do it.It is difficult to say how the injury happened. It is a rare location to have an injury and is typically seen after surgical decompression of a bone spur from that acromion process of the scapula. Anything causing repetitive forward lifting of your arm could have caused it. Thanks.