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Things don’t add up

Exit forum ID Forum Discussion Things don’t add up

This topic contains 1 reply, has 2 voices, and was last updated by   William Brady, DC October 12, 2017 at 8:29 am.

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  • #3229

    Brandon Cohen DC, CSCS
    Participant

      60 old female

       with right  shoulder pain after falling onto a child’s bicycle onto that shoulder.

      Palliative: direct pressure (hmm…that’s weird)

      Provocative: movement/loading in front or above 90 degrees abduction.

      Intensity: 2/10, 8/10

      Quality: sharp and dull

      Just finished cancer treatment for breast cancer (Thank you ID for that 

      diagnosis), and has been declared cancer free. PET scan is scheduled 

      for later this month. Primary ordered plain film which were unremarkable.

      SA: 80 degrees on the right with pain in the lateral arm and shoulder.

      Pushup test: “Good luck with that.”

      Dx: Rotator cuff/labral tear, cancer, weakness, adhesion

      I ordered MRA, and in the meantime we did 2 treatments with the same 

      response. Improved ROM to 100 degrees, but back to 80 degrees for 

      follow 

      up visits. Biggest issue is that she cannot tolerate ranges of motion 

      required for movement. She can’t get to 90 degrees without pain which 

      makes infra and teres minimally effective. She can’t get past 90 degrees 

      on subscap either. Inferior capsule has a lot of protective tension 

      anywhere 

      past 90 degrees. She has adhesion in the deltoid where she fell, and 

      we’ve 

      made some change to that.

      MRA came back without a lot of degeneration, but no full thickness 

      tears.

      1. Supraspinatus and infraspinatus tendinosis with superimposed low-

      grade partial-thickness Bursal sided tears; no focal full thickness defect or 

      tendon retraction.

      2. Moderate acromioclavicular osteoarthrosis.

      3. Mild subacromial-subdeltoid bursitis.

      With the imaging, I was hopeful to have more answers, but now I have 

      more questions than before. What could be limiting her range of motion so 

      severely? Could the tendinosis be so severe that it creates all the 

      protective tension? I have not seen such

      intense pain and limited function without a big pathology.

      #3231

      William Brady, DC
      Participant

        Two big thoughts: 1. The shoulder could be very inflamed from the fall. 2. Stress is pro inflammatory and the opposite of a healing environment. Put these two together and she doesn’t need much pathology to have a high pain level and limited function.

        The symptom location strongly suggests symptoms are from glenohumeral inflammation or damage. MRI shows mild/moderate damage, the fall triggers inflammation and the stress (having cancer and cancer treatment will are not joyous occasions) perpetuates the inflammation.

        Has she tried ice? In a case like this it would be good to know if it’s palliative and may even be therapeutic.

        One last thought, you are the provider that diagnosed the cancer. Emotionally that might makes thing complicated. Keep this part in your back pocket for now.

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