This topic contains 5 replies, has 2 voices, and was last updated by 
Christopher Stepien March 21, 2018 at 8:47 am.
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Scott Glidden
46 year old female
L shoulder pain that started December 2017 and drastically worsened the last week of February where her shoulder just “froze up”. No trauma that she can recall. Its a sharp pain that ranges from 1-2/10 base ache to a sharp 7/10 pain with activity. She cannot abduct her arm past 90 degrees. She tosses and turns at night, which flares up her shoulder as well. Rest makes it better. Speed’s was negative and supraspinatus press test was positive on right. Resisted internal and external rotation also produced symptoms. Adhesion of infraspinatus, teres minor, and subscapularis, along with significant inflammation over infraspinatus and supraspinatus. R shoulder has full range of motion, minimal adhesion.I suspected she has a rotator cuff tear, so I sent her to get an MR Arthrogram. She didn’t want to get one because she has had imaging done several times with contrast, and she stated she has an allergic reaction to the dye. After some back and forth I relented, thinking an MRI without contrast is better than no imaging at all.
The impression of the MR was as follows:
“1. Considerable tendinosis of the supraspinatus
2. A fluid signal 4mm in diameter in the supraspinatus tendon. This may represent a near-full thickness bursal surface tear or a full-thickness tear.”Do I send for an MR Arthrogram for more clarity? Do I treat the tendonosis? She also has a family history of autoimmune diseases, so that complicates things as well.
Christopher Stepien
Hey Scott, good stuff.
Do you have a smoking gun here? (HINT: MR findings)
Before you get an arthogram or treat the tendinosis, what is your diagnostic list?
Arthrograms are the most sensitive tests for labrum pathologies.
While it’s possible you could have a labrum issue that wasn’t found on MRI, it occurs to me like you already have a testing procedure that makes sense of your symptom presentation and exam findings.
James Phipps
I agree with Chris, the MRI findings support your clinical findings.
There is clearly a lot of inflammation so you will want to keep your dose really low on the treatment end to see how she tolerates it.
She may have to go into first aid mode where she just rests it and takes NSAIDS until the inflammation decreases enough for you to treat the adhesion.
Brandon Cohen DC, CSCS
Agreed, I wouldn’t have her go through the MRA at this point. You have a long road already, even without a labral tear.
Scott Glidden
My diagnosis is that she has:
1) supraspinatus tendonosis
2) adhesion on infraspinatus/teres minor
3) autoimmune condition that exacerbates both conditions.After I saw her today, she saw her PCP and is got a referral to a rheumatologist to get checked out. She complained that even the positioning from the MR flared up her shoulder, so tx isn’t going to be an option at this time. She really wants to avoid surgery, so if the rheumatologist finds that she has an autoimmune condition we are going to let that tx get underway before any tx of adhesion will happen.
Christopher Stepien
How do you explain this MR finding with your diagnosis?
“A fluid signal 4mm in diameter in the supraspinatus tendon. This may represent a near-full thickness bursal surface tear or a full-thickness tear.”
How does the autoimmune condition relate to her current symptoms?
Does the autoimmune condition cause her to recover more slowly?
Does the autoimmune condition cause multiple joints to be in pain uncorrelated with load?
Is the autoimmune condition something the PCP is looking at to grab at straws?With your #1 priority on your diagnosis, what does she need treatment-wise, right now, that is in the best interest of her health?
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