Rotator cuff MRI results: partial RC tear

[RiderJen]

Finally got the MRI results yesterday (3-1/2 months after onset of pain): Partial RC tear

Back in October, the first ortho doc gave me the diagnosis "RC tendinitis", on which was based the PT therapy exercises (which only added more pain and new pain). At my request, the PT referred me to a sports ortho doc with an excellent reputation, and I saw him for the first time yesterday.

This sports ortho doc (whose specialty is shoulders and has a special interest in RC repair) read the MRI and determined that I have multiple partial tears just below the acromion, and noted the "very narrow" space between the acromion and the RC. He also checked neck function to verify the shoulder pain is not due to a neck problem.

This doctor prefers a conservative approach and does not rush into surgery. He feels I don't need surgery (at least not yet), and prescribed the following PT plan to be done in stages; if no improvement in 6-7 weeks, then he will discuss other options (including surgery):

1. Improve scapula function, then
2. Advance to RC activities when scapula function is improved and pain lowered; then
3. gradually advance to my regular activities (cycling, etc.).

He also showed me some things I can do on my own while driving, lifting etc by pinching my shoulder blades (in a natural form, not exaggerated), or just standing straight and pinching my shoulder blades.

My new PT regimen will begin on Monday; looking forward to learning the new exercises. I am hoping to be able to return to cycling, gardening, and other activities very soon without surgery, but will keep my mind open to whatever he thinks is best.

I searched and found this interesting article on scapular stability:
The Importance of Shoulder Mobility and Scapular Stability | Mark's Daily Apple

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[Dr Damien]

Rider Jen

Good for you that you now have what seems to be a definite diagnosis. Your ortho specialist is right in prescribng scapular control exercises prior to any shoulder exercises.
The question you should as yourself however is why did you have this problem in the first place. The anatomical site of your injury suggests you have a narrowing there already. Is this narrowing anatomic or due to insufficient scapulohumeral rythm?

I ask these questions only because, it would be a shame to go through all this trouble only for this same problem to reoccur...your age suggests that you might be susceptible to arthritic changes gradually..if all you did was raise your arm up and this problem occurred and its taking it more than two months for it to resolve...then possible the tendons are being stranguled. they are lacking oxygen and are changing in their physiologic properties. This problem is not a new problem, its something that has gradually happened over the years without you knowing...

before you start any scapular exercises, i would humbly suggest you get the opinion of your surgeon/specialist with regards any arthritic changes that might be causing the sspace underneath the acromion to be small... they should compare both your shoulders, if its not arthritic...your physiotherapist may want to reassess your scapulohumeral rythmn/ as well as any muscle imbalances and intraarticular motions of your shoulder joint properly. He/she should compare it to the other shoulder...

Its one thing to know the tissue damaged...we should ask why this happened? what do we need to do to stop it from happening again...

[taiger111]

Good that you have only partial tear.
Hope to see you get better!

After muscles are repaired, you need to break down scar tissues around joint.
Most of time, people have dysfunction in RC muscles and when they try to use shoulder, the exceed the load on muscles.
Your history showed us that when you raised your shoulder, you had a pain starting which suggest to me, that muscles that do opposites movements of shoulder raising is dysfunctional. As well as treating RC muscles, you need to check subscapuralis, teres major Lat, and lower trap. When they are dysfunctional, your raising shoulder movement is hinder and some muscles have to work hard than usual. That can exceed the capacity of loads on those muscle(which might be partially dysfunction) then injuries can occur.
Your injury is a result of your body's compensation. Also Upper extremity problem can be from compensation of lower kinetic chain.you need to see a body As a whole unit and treatment plan should be made accordingly.

Problems in manual medicines are facts that We tend to focus on treating Sites of pains. Sometimes it works and sometimes it does not. Recurring of problems are suggesting that treatments plans are not done to address the TRUE CAUSE of problems. If treatment plan is made well and skill of docs is enough,you will get better in shortly and you will be surprised. Most of people who do amazing jobs said that we should not focus too much on pains as practitioners. Pains are there to tell you that something is wrong in that area or it might be referred pains. Doing HOT pack, Electric and taping sometimes are just stimulating me chano receptors so that it override pain signals. Patients feel better but pains come back. We need to stay away as much as we can from doing this type of therapy as main treatments.


I have seen so many cases that patients underwent Not well planned treatment and there have been no major change for years.
When i treated those people and spent 10-15min doing functional movement assessment and palpation, and treatment is done in 5-15min. (sometimes 20-30min if i am not good to find out what causes what)
Most of people see the dramatic change in functions as well as pain relief. usually takes 1-3 session of 5-10 min treatment. (it sounds too good to be true but we all can do the same.) Symptoms never come back. I also give a proper and easy specific stretch exercise as well as i recommend that they do Gyrotonics and pilatis. (i hate people coming back with the same problem)
Talking about pilatis and it focuses on CORE Muscles exercise. this should be done if all core muscles are function well but weak due to disuse of prolonged period.
When core muscles become dysfunctional, there will be compensation as i stated earlier in shoulder case.

People those in practice and school, there are so many things that we can learn outside of school and can make our treatment successful rate skyrokets.
Learning things in school is not Enough and people who just go through school will do midocre work. Schools teach foundations and let you get a license.
We need to additional extra work by ourselves(going to seminars, forming practice groups, keep up with current Research evidenced base practice, have mentors to guide you to become a better manual medicine practitioner, etc....)


I am saying this kind of things to open up minds of reader of this site, and hoping that some of people become better manual medicine practitioner and help those people who are not helped by other practitioners.

[RiderJen]

Thank you both for your comments.

I am in complete agreement that the source of the problem must be treated, not just the pain. I have been reading here and other places on-line, and am more informed about shoulder issues than ever before.

It's the weekend now, and PT begins Monday evening.

Meanwhile, I am practicing pinching my shoulder blades together (which, I'm assuming, means practicing excellent posture) when I reach, sit, drive, etc. As I do that, it's a little uncomfortable (not really painful though) and I feel a "popping" in the scapula area --- I wonder if this hints of instability or weakness in that area. I'm wondering if I should be using my arm at all, or if it is OK to use it (except for the activities that stress it) but only while pinching the shoulder blades.

So, to follow through on your advice: How can I ask my practitioners to check and use your suggestions without sounding like a know-it-all consumer whose head is full of information I get off the internet?

[Dr Damien]

Dear Rider Jen

use the word please, ask nicely and bat your eyelids...

that should work..lol

[RiderJen]

Dear Rider Jen

use the word please, ask nicely and bat your eyelids...

that should work..lol

I'll do my best. It is hard to believe that this could be treated and relieved in a few short sessions as taiger111 described, but I am keeping an open mind. However, knowing that, what can I say if the PT recommends two 1-2 hours sessions each week for several weeks??? All the $$$ I paid for the 10 prior sessions (all in vain, treating the initial dx of 'rotator cuff tendinitis' from the previous doc) is like money down the drain.

I believe this PT knows his stuff and seems to be up on latest protocols, along with the doctor. There's a point at which I have to trust him and see how things go.

[Dr Damien]

Dear Rider Jen

Lol, the overall management of tendinitis/tendinopathy, partial tendon tears are more or less the same...tendinopathy/tendinitis really will lead to a tendon tear because of scar tissue formed and the change in the properties of the tendon. The goals of physiotherapy would be to

1) reduce pain
2) maintain range of motion within pain limits
3) strengthen tendon

when you have a rotator cuff issue like the one you describe, really the cause of the narrowing should be identified first. This is what would determine what the manaegment would look like...otherwise you wuld keep having treatments with no real results...

for instance, do you have bone forming underneath the acromion narrowing the space below causing the tendons to rub on it? if this is the case, no amount of physiotherapy will help...some form of surgical decompression would be the answer...

or is your scapular not rotating effectively to free the space where the rot cuff tendons pass underneath the acromion? if this is the case, then assessing where your scapular is resting at rest, in comparison with the other scapular. The rythmn between the arm and scapular that occurs during active and passive movements (that is when you lift your arm or when someone else does this for you).
is this a combination of the inability for your arm to roll outwards during the movement of elevation?
All this may suggest tightness and weakness in some structures causing that pathological movement predisposing to a narrowing underneath your acromion...
so maybe some manual work will be needed first to get your scapular free and to be able to move within the plane it needs to be...then maybe some reeducation of proper rythmn may be needed...
or could it be in combination caused by tightness/lengthening with neck structures connecting to your scapular....?

however, pain relief has to be achieved first...so maybe you would need a continual treatment of Ice or heat/cold...for as long as is necessary to reduce pain/inflammation...before any true active movement is practiced...

when the partial tear/tendinopathy is painless, then you can start reeducating and eccentric work...using at first a gravity eliminated plane....

these are just some methods of addressing this issue, some clinicians skilled in acupuncture may want to use this as well...

but again if you have a bony spur/osteophyte within that space...trust me, no form of physiotherapy will help....

So again...you need to suggest to your clinician about any arthritic changes and this has to be ruled out first...to determine whether physio is the way to go...

this would save you money on wasted treatment time...

see that i am thinking about how to save you money....lol

[RiderJen]

Thank you for all the info.

Going back to the clinician (sports ortho doc) before going to PT would mean canceling the PT appointment (no big deal), scheduling a new appt. with the doctor and waiting a couple of weeks, then asking him for further evaluation to inspect these issues before going further. I'm afraid he'll think I'm overly analytical and not trusting his initial judgement, or wonder where I became so informed to ask for this.

Is that common and reasonable? I completely understand your advice, and want to get the best possible rehabilitative and preventative treatment now, rather than having to return time and time again over the years.

This doctor is reputable in his field, and has a special interest in RC repair, so it seems he'd have covered everything..... but, perhaps not. He did ROM and other tests that my initial ortho doc did not.

[Dr Damien]

Dear jen

Your point understood...the reasonable thing as you suggest , is to start your physiotherapy, if no improvements then consider the above issues...at least you are getting some care...
you are right, i wouldnt go back to the ortho man, he would think you dont trust him...which I know you do,...

well get your physio and see how it goes, if its going well then the problem isnt anatomic most likely...

cheers

[RiderJen]

Thank you, Dr. Damien.

I hope this new round of physio will work and enable me to avoid surgery. The previous round of PT, gentle as it was (based on the original diagnosis -- RC tendinitis) only caused more pain and new symptoms --- during those weeks, pain spread to upper shoulder, popping sounds in back of shoulder over scapular area when pinching blades or shrugging shoulder, etc. I guess they were the "wrong" exercises since they were working with a different diagnosis. I'm hopeful this new round will work.

[RiderJen]

Back to PT tonight; basically same exercises as first round but gentler and fewer to focus on scapular strength while avoiding pain.

The most upsetting thing about this is the disruption in my training as a volunteer member of my employer's Urban Search and Rescue (USAR) team. We're just beginning to learn to rappel, and other activities requiring my shoulder including cribbing and shoring structures, confined space rescue, and such. The doctor's order implies NOT doing any cycling, gardening, or rappelling until the 3rd stage of his plan.

My PT seemed surprised the doctor didn't recommend surgery since my shoulder worsened during the first round of PT and seems stubborn to recover.

I am wondering what's the worst that could happen if I complete my USAR training activities unless they cause pain, while continuing with PT to improve shoulder strength. If pain worsens, then stop ---- but I'm wondering if it's worth trying this, or foolish.

[RiderJen]

It's been several weeks since I started PT in late November, 2010. The exercises are gentle and I was told to not do anything if it hurts. I'm concentrating on squeezing the scapulas during the exercises, and now also while driving or while reaching. I'm still not doing any exercises or activities that hurt or may aggravate it. My desk at work was ergonomically evaluated to allow me to work at the keyboard with good posture.

Nevertheless, I now have referred pain below my elbow, and more tearing-type pain in the front of the shoulder where the humeral head meets the acromion. In addition, I now feel a little more fatigue in this shoulder, and now more mild pain (of the same type) in the other shoulder.

Pain still flares up the day after any exercise sets, no matter how gentle. The ONLY time I have NO pain is if I skip the exercises for 1 or more days.

My PT feels that surgery seems very likely since my symptoms have progressively worsened during the course of PT. My next appt. with the sports ortho doc is late Februrary, and the PT suggested I could continue doing the exercises on my own at home but terminate going to PT for now until rehab begins after surgery, since I am not progressing while continuing to pay $. I'm considering doing just that.

Today I bought the book Treat Your Own Rotator Cuff from Amazon.com to see if the exercises it contains might help. I'll continue the exercises on my own, and include pendulum swings in the mix, hoping for improvement when I return to the doctor in February.

What also makes my head spin is reading that surgery can be avoided through exercises --- so, what do I do but go from one PT to another until something works (if it does)? It seems like there must be something else wrong in addition to the tears, if I am doing exercises designed to improve this but my shoulder only continues to get worse.

I'm 54 and active. I'm wondering if I should give the PT more time to work before considering surgery. How much time is reasonable? When I read stories about someone's pain improving or disappearing after only a few PT sessions, I wonder if I'm doing the wrong exercises, or if my shoulder has issues that won't improve without surgery.

[gcoe]

Hi Rider.jen

Three things I noted in your update:

Referred pain below the elbow
Similar pain ( but more mild) in the other shoulder
Highly irritable nature if the pain that has failed to settle at all.

Rotator cuff symptoms are unlikely to produce theses sorts of symptoms. In fact these seem suggestive of possible neck invovement and possibly pain from the nervous system. Rotator cuff pain is usually more localised, doesn't spread past the elbow and should remain in one shoulder! Neck symptoms are famous for mimiclking shoulder pathology. Even though the MRI showed a RC tear these symptoms are contradictory

This is very important to sort out before proceeding with surgery- otherwise if the diagnosis is wrong the result will bedisappointing. I think you need to go back and have it diagnosed with a fresh clinical eye.

[Dr Damien]

Dear Rider jen

Gcoe is very right, your update throws a different light unto things...definitely worth another assessment

Good luck

[RiderJen]

Thank you.

If there is a bone spur on the acromion rubbing on the RC, wouldn't the RC continue to be irritated by movement? I think one of you said if this is the case, no amount of physiotherapy would help.

Assuming my pain is entirely due to my RC tear, and it is due to the very small space between the RC and acromion, wouldn't it be likely that the same pathology would be in the other shoulder?

The pain below my elbow is nothing like the pain in my shoulder... it's like a mild throbbing, occurs much less often, and doesn't affect my ROM or ability to use my arm at all.

My sports ortho doc did do a neck exam in the office; I moved my head from side to side and up and down, but none of that caused any discomfort in my shoulder.

[Dr Damien]

Dear Rider Jen

It is quite difficult to really say whats going on without seeing you in person. It may be you are having two different conditions happening at once...or it may just be one condition. If we focus on a hypothesis that it is one condition, then its likely that the trouble is from the neck... (only speculating now), my hypothesis is you are having two conditions happening at once now...

I am presuming this because you have said the pain below your elbow does not affect your ability to use your arm...

Does your below elbow pain occur at the same time with the shoulder pain...? does any neck movement bring about any of the pains you've described?

It is quite rare to have bilateral rotator cuff tears...although i have noticed that a lot of people who get surgical decompression done, soon often require another surgery on the other shoulder...maybe because the same arthritic changes are responsible or perhaps they now use the other arm more making it susceptible to injury...really true shoulder problems rarely(if at all) radiate past the mid arm...if you are getting pain below the elbow, really you would need another look at your neck/spine...

What are the exercises you are doing? you describe them as gentle but what are they...?
Do you get any pain when you move your arm...or does this pain remain in intensity irrespective of any arm movement

perhaps injections to the subacromial area will help clarify what is happening...if you are still getting pain after such a treatment then the more likely problem is the neck however if the shoulder pain reduces but the below elbow pain remains then you have two conditions happening at once,if all the symptoms reduce then its probably a rare presentation of a shoulder problem,

Sometimes this is the only way to help make a certain diagnosis...If i took an MRI of my muscle after doing strenous exercises, it possibly will show up as multiple tears as well...what i mean is that MRI's are pretty accurate but they do not identify pain generators just pathology...you may have had these tears all along...besides an osteophyte encroachment would have likely been picked up by this anyway...

This sounds like going around the net really...

i dont know how thorough your neck exam was, but a good neck exam goes beyond simply looking up/down, side/side...

My suggestion is to consider injection therapy, that would help bring things into better light, offer you some temporary relief, and perhaps help with your physiotherapy...do you like needles? have you been icing that shoulder?

[RiderJen]

Thank you, Dr. D.

To answer your questions:

-- To explain the pain below my elbow, I took a closer "look" at it. As with the initial pain in my upper arm (near the shoulder), the pain there is difficult to pinpoint. But if I palpate the area, the pain is actually right AT the elbow, not below it. I feel it ONLY while moving my arm, but not always. I was assuming that it could be the result of the now-increasing fatigue in my upper arm and perhaps some other muscles having to compensate.

-- Neck movement does NOT bring about ANY of the pain I've described anywhere in my shoulder or arm.

-- If the cause of my RC cuff is anatomical, and is bi-lateral, then it stands to reason that my dominant arm would feel the pain first, followed by the non-dominant arm.

-- The exercises are to improve scapular strength/function, and include (always while keeping shoulder blades pinched): (1) Holding a short resistance band with both hands, elbows at 90 degrees and at my sides, gently pulling band from each end; (2) with one hand at my side and bent 90 degrees, pulling the handle attached to a resistance rope(?) until there is only gentle resistance, holding for 20 seconds, repeat several times, then repeat in other direction (gentle internal rotation / abduction, but always keeping my hand straight out in front with elbow bent 90 degrees; (3) full planks for 15 seconds; (4) gentle circles with arms at my sides; (5) small movements to wiggle a body blade. ***ALL OF THESE EXERCISES ARE DONE WITHIN MY LIMITED PAIN-FREE RANGE OF MOTION AND ONLY IF I AM PAIN-FREE WHILE DOING THEM *** However, even when these exercises don't cause pain while doing them, my shoulder hurts more the next day (by "hurt", I mean more intense sharp/tearing pain).

-- I have used ice after the exercises, but not always. The PT center sometimes offers ice after the exercises, but it's not always offered (however, it's always given if I do ask). About a month after this began, I iced the shoulder several times/day, but I did not feel any relief or improvement so I have not continued as often. Besides, I've read conflicting things about inflammation ---- some say it promotes healing, and others say it doesn't!

-- When I raise my arm close to 90 degrees or above, I feel intense/sharp/tearing pain about 4 inches from the top of my shoulder as well as the front of the joint (around the glenohumoral joint). If I raise it even once with some pain, the next attempt is even more painful and more limited. (i.e. each successive movement makes the next one even more painful and limited.) External rotation beyond about 20-40 degrees is very painful (again, each successive attempt is more painful and limited than the previous one).

-- Oh, one more thing.... if I pinch the shoulder blade (apply excellent posture) while raising my arm, I can raise it higher with less pain. The doctor and PT encouraged me to do this to put less strain on the RC.

[Dr Damien]

Dear Rider Jen

All is not lost, there are still a variety of conservative treatments that can be tried. Again we can only go by what you say,...

my thoughts (please take them as suggestions alone as I would never undermine another professionals judgement)

We will start with the exercises... you are doing resisted exercises... this is fine, but we only advised when you are totally pain free in active range before considering resisted exercises...these exercises sound like there are aimed at improving scapular adduction and humeral lateral rotation...no issues with that except you still arent painfree without resistance there they shouldnt really be coming up just yet...this is just my opinion nothing more...if you have a tendon issue like this it builds up scar tissue and fills up the already narrow space...concentric exercises (like the ones you describe-this means causing muscle shortening) adds strength, builds fiberes but isnt good for flexibility really...exercises aimed at tendons should be eccentric in design (this means allow lengthening)...this adds strength as well as flexibility...that is what you need to start off with (i feel) when strengthening is to be considered...

WHAT ARE FULL PLANKS? (PARDON MY IGNORANCE)


PInching your shoulder blade is good...this improves the pain and better elevation...I generally will start you off on scapular exercises only... the exercises you have got build up strength but really from you description there might be timing issues affecting scapulohumeral rythmn...this may be due to imbalance or abnormal firing of muscles..you need training on how to organise how the muscles work to give good scapulohumeral rythmn

there are several reasons why poor scapular motion causes an impingement...(im sure you've had this lecture before)
1) a depressed scapular...this means the scapular is low in position, it may rotate well but because its low it still impinges...if this is what you are I would be looking at the length of your trapezius and its timing
2) a downwardly rotated scapular...this means the scapular may be in a good position but its tipping forward so when you raise your arm its not rotating fully so its not creating enough room...in this cause i would be looking for pecs tightness...
3) and abducted scapula/ winging: scapular is so far out and fans out...this suggests serratus weakness, may come with pecs tigtnessand rhomboid weakness...in this case...there would be poor setting of the scapular...so pinching scapular together would make a difference perhaps to how much room you will get..
3) an adducted scapular: sometimes suggestive of subscapular adhesions or tight scapulospinal muscles...so there isnt much room for some level of abduction and rotation...impingment the occurs...

The other issue is with your arm...is the humerus head too far foward within the joint or is it too high up, is it rotating maximally during arm elevation to clear the subacromial space...if it is this can be another reason why impingement happens (anterior displaced humeral head)...the biceps tendon could be involved this may explain the anteror shoulder pain you are getting, may be kinesio taping will help...to give you feedback about where to place the humerus for good and painless motion before you move...

I generally will be teaching you how to set you scapular and practice external rotation (slowly in return from external rotation to give eccentric phase) without resistance until we are able to get a full and painfree movement (some tapes might be needed to show you what your scapular is meant to be doing until you master it)...

you can have a combination of these factors...the question is which/or ehich combinations are happening to you? maybe you need some manual therapy work, to equalize the tissues, maybe you need exercises that are specific to correct the problem...i wouldnt be going strengthening with resistance just yet...

You mentioned you were icing the shoulder...but no effect, the problem is the shoulder is still mobile if the space is narrow and the lesion is very irritable..then repeted use may not make this effective...in this case...injection therapy maybe helpful...although there are sideeffects, pain relief is often dramatic but the steroids delay healing so you may have to stay exercise free for about 1-2wks...acupuncture may be another adjunct therapy that can be used...

I still stand to have the space checked out for bony spurs...this if there is is just likely to grow bigger and physiotherapy may be futile...

Other considerations are what your activity of daily libving is like, is it the dominant hand that is trouble some...(do you forget and lift things up that might be too heavy)...
While the arm is still irritable active assisted movements may be what you need to do to prevent any muscle contraction...it may be good to also take gravity away from the equation for some exercises

Cheers

[RiderJen]

Thank you so much. Let's see....

1. Could you give me 1 example of an eccentric exercise I could do? That would give me an idea of whether or not I'm on track with what I'm doing.

2. Planks are done by lying face down, then resting on forearms and toes (or, on knees) and holding body in a straight line from feet (or knees) to the head, while supporting the body with the forearms, and holding for seconds to a minute (I hold for 5 seconds, and repeat several times). Sideways plank is doing this on one side, then the other. I'm unable to do a sideways plank on this arm for longer than 10 seconds without pain. The PT believes that the sideways planks are key to getting the humerus head to sit lower. [Prior to onset of this problem, I was doing sideways planks for almost 1 full minute on each side, and a full plank (face down on forearms) for 1 minute.]

I forgot to mention that I get manual therapy during each appointment, after a hot pack and several minutes on the "arm bike" machine.

3. With respect to having the space checked out for bony spurs: Do you mean to have that done arthroscopically? or how else can the space be checked out? I've had 2 different sets of x-rays; the ones requested by doctor #2 were much more complete (from different angles) than the first.

4. In my activities of daily living, my dominant arm is the troubled one, and I sometimes forget and use it a little more than I should or move it in a direction it doesn't like ----- but, 98% of the time I am very careful. Perhaps I should not be using it at all(??), but I'd just be sitting and doing nothing at all, or letting it dangle at my side ---- perhaps this is what I should be doing!?? I also drive a car with a manual transmission, and have been looking after my mom while she was in the hospital during the holidays (doing my best to hide my shoulder problem from her and not lifting anything heavy).

One more bit of information that may prove helpful: 5 years ago when we bought our car with the manual transmission, I noticed that when I shifted away from me I felt a mild but sharp tearing/prickly type pain in the spot on the front of my shoulder. At that time, it was so mild that I didn't even consider going to a doctor. However, that same pain is one of the pains that has flared up and worsened since starting PT, and I feel it even when not driving.

While searching the internet, I found the website of an orthopedic surgeon with an article about rotator cuff tears; on this page he wrote "In most patients, these exercises initially increase pain. However, if they are performed regularly, they appear to result in symptomatic relief in 60 to 70% of patients. It has been our opinion that patients with hooked acromions are less likely to respond to an exercise program than those who have relatively small curves in their acromions." In my x-rays, my acromion appeared flat.

I won't give up! However, I do feel very frustrated, and feel like my life is on-hold. Thank you for offering your advice and suggestions --- I appreciate it very much.

Finally --- I'm very active and my activities are currently very restricted. I am not afraid of surgery, but I am afraid of making the wrong choice. If surgery is needed, I'll do it. Needles -- OK, but I don't want to get a shot, then wait weeks (again), and try something else followed by more weeks of waiting, and finally end up with surgery when it might have worked months earlier.

[Dr Damien]

Dear Rider Jen

probably best to carryon with your physiotherapy...things may improve in a few weeks to months...glad to hear ou arent giving up.have a good weekend...

cheers

[RiderJen]

Someone recommended that I apply ice to my injured shoulder prior to stretching, saying that it helps the injured parts to get moving. Not an ice pack per se, but a frozen cup of ice held on the spot until it is well-iced. She said the person who told her about this swears by it.

If this technique does work, then I'm assuming the ice reduces any pre-exercise inflammation and allows the part to move easier.

I've never heard of icing before stretching. Is this a non-standard treatment recommended under only certain circumstances?

[RiderJen]

Dear Rider Jen

probably best to carryon with your physiotherapy...things may improve in a few weeks to months...glad to hear ou arent giving up.have a good weekend...

cheers

Thank you, Dr. D. I anxiously await the book Treat Your Own Rotator Cuff which I expect to arrive tomorrow -- looking forward to seeing how the exercises in that book differ from the ones I've been doing, and if anything will change for the better after doing them. I'll post any progress or changes here.

Thanks again...

Rider Jen

[RiderJen]

Recently diagnosed with RC tear, pain has steadily worsened each day and week since PT began in late November. I now have pain all the time in my shoulder (except when I take days off from the exercises) and am able to do less and less without pain.

Starting this week, and on the advice of my PT, I will take a break from going to the PT facility until I return to my sports ortho doc in late February to discuss other treatment options (my PT believes surgery is inevitable). I ordered the book Treat Your Own Rotator Cuff to see if it might help, hoping to return to the doctor with some good news.

Meanwhile, I read about trigger point therapy and wonder if it might be effective in my case. Has anyone successfully treated a patient (or been treated) with this diagnosis and obtained successful results from trigger point therapy alone, or along with effective PT?

[Vanc_WA_PT]

A couple thoughts on RCT: the long head bicep and supraspinatus tendons seem to be most often symptomatic in the cases i've treated; when the bicep tendon is aggravated it aches down the front of the arm (the bicep) and when the supraspinatus is irritated it aches down the side of your arm and occasionally into the elbow; so if your arm aches then the tendons are getting irritated; my care plan of choice is to minimize pain through rest, ice and meds; stop aggravating factors - stay out of impingement positions when your elbow is away from your body and hand is turned down like shifting a car, pouring coffee or using computer with arms unsupported; instead try and keep your elbow at your side and lift with palm up; get full passive shoulder rom through man ther like soft tissue work, joint stretch and surrounding muscle stretch; lastly add painfree strengthening exercises and in my book if your shoulder is painful after exercise then they aren't painfree exercises. You should be able to do resisted shoulder adduction and extension (do adduction in scapular plane, not straight out from side), scap depression and retraction (try bypassing GH joint and loop Tband around your shoulder joint so you're pushing with the back of your shoulder). Iontophoresis is a dexamethasone patch where anti-infl meds are passed into the AC area using electricity - your PT can do that; steroid injection to subacromial space could also be done by ortho, but i'd let him/her bring up that idea Lastly, I would not push through with rescue training as it may turn a non-surgical condition into a surgical one. Good luck.