Shoulder Muscle & Tendon Tear - Left Adhesive Capsulitis

[bernardb201]

Hi,

I recently had an MRI of my left shoulder after the pain recurred about a month after a 2 sets of rehab/therapy sessions (total of 12 sessions).

Prior to the rehab/therapy sessions and the MRI, I've experienced a dull pain on the left shoulder.

I used to lift weights at the gym & stopped about 2 years ago. In fact, months before I stopped going to the gym I already noticed that when I do military presses, the barbell tends to tilt towards the left. At the time, there was very slight pain.

The MRI findings are as follows:

MRI examination of the left shoulder in the oblique coronal, oblique sagittal and axial planes shows the following
"findings:
1. Moderate fluid collec1ion is seen distending the joint capsule with fluid accumulation likewise seen along the
bicipital tendon sheath.
2. The proximal biceps tendon exhibits minimal in1rasubstance increased signal. The biceps tendon is within its
normal position within the bicipital groove.
3. There is in1rasubstance hyperintensity likewise noted at the supraspinatus tendon near the musculotendinous
junction. There are signal changes further seen at the supraspinatus attachment site to the greater tuberosity.
Minimal bright fluid signals are detected surrounding the tendon.
4. The subscapularis tendon superior tendon slips are thickened and heterogenous. Minimal fluid signals
surround the tendon.
5. The infraspinatus-teres minor tendons are Slightly thickened. The muscles comprising the rotator cuff show
normal course and configura1ion.
6. The anterior-inferior glenoid labrum appears detached but undisplaced, with intermediate signal soft tissue
that may represent fibrosis. There is likewise intermediate signal at the superior labrum posterior aspect that
may be due to degeneration or partial tear.
7. The humeral head shows normal configuration and articulates properly with the normally developed glenoid.
There is minimal osteophyte formation at the greater tuberosity. The articular surfaces are smooth and show
norma! cortical thickness.
8. The glenohumeral joint space is normal in width. The bone marrow segment is normal in signal.
9. The acromion-clavicular joint space has normal configuration. The acromion shows slight inferolateral tilting.
Its inferior margin is slightly convex.
10. There is no fluid accumulation in the subacromial-subdeltoid bursa. The peri bursal fat planes are intact.
11. The other muscles around the shoulder joint appear normal, as do imaged portions on the lung and soft
tissues.

Impression:
Moderate joint and biceps sheath fluid collection.
Consider proximal biceps tendon intrasubstance tear.
SuggesTIve tear with fibrosis, anteroinferior glenoid labrum.
Consider small partial superior labral tear or degeneration at its more posterior portion.
Intrasubstance tear of the supraspinatus tendon and possible tear at the greater tuberosity insertion.
Subscapularis tendinosis with partial tear of its upper lhird.
Infraspinatus-teres minor tendinosis.
Slight infero-lateral-1ilting acromon process.
Osteophyte forma1ion at the humeral greater tuberosity.

My doctor suggested surgery. Problem is, I'm diabetic & my blood sugar control is unstable. Given the above findings & impression, is there hope for a non-surgical treatment?

I would appreciate your opinions and suggestions.

Thanks ...

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[nmarman]

question:

Did you have ultrasound therapy to increase healing around the tendons?

The easy answer is surgery is a big indication here. However i would seek a ultrasound examination first to confirm some of the findings.

Saying that, you could try shock wave therapy to accelerate the tendon repair while immobilise for 1 month. I have had great success with this protocol but you do have a lot going on - prognosis would be better if we had either ultrasound to confirm soft tissues involved or even X ray to see positioning and instability measurements. Traditional techniques wont work - sorry.

also even if the shock wave reduces pain you will still be unstable and will have to limit movement and activities. meaning that almost any activity you would have to invest in good strap.

degeneration has also started and is likely to progress which may cause more pain in some time to come.

does that help?

[theshoulderguy]

Hi Bernard, in the absence of a significant injury, the structural lesions reported on MRI could be explained by normal age and activity related changes e.g cuff tendinopathy, partial thickness tearing, degeneration labrum.

This is not an indication for surgery in my opinion.

However, this sort of degenerative changes can in my experience lead to an adhesive capsulitis which may be made worse by being an insulin dependent diabetic.

I am not clear as to what your diagnosis is so difficult to comment.

Additionally, what we know about shoulders that start to show signs of wear and tear is that as time progresses so too does the size and extent of the tears i.e partial tears become full thickness tears and so on.

In my experience, persistent pain and shoulder dysfunction that you cannot live with is usually the number one reason to consider a surgical option not because an MRI says you have some potential age related degenerative changes.

However, if your doctor/surgeon has exhausted all conservative measures (injections and physiotherapy) and completed a thorough shoulder examination (considering MRI findings in light of what he/she sees clinically) and has an operative diagnosis, and you understand what he/she is trying to achieve/fix surgically then I would suggest that you at least consider it.

In my practice, this usually is how we come to have a conversation about surgery, when all other avenues have been exhausted, there is ongoing pain and dysfunction and a clearly defined structural cause (which is sometime difficult in the shoulder).

Finally, you need to get your blood sugar under control, I don't really see it as a contraindication for shoulder surgery unless it is way off the charts, again check with your doctor.

I hope this helps.

Luke

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[inty]

Hi
I would suggest to you to try a Kinesio taping and manual therapy-Mulligan concept. Bouth therapy metouds are very effective in MSK.

Good luck

[bernardb201]

Hi Luke,

Thanks for your response.

So far I have sought only my ortho's opinion since he's the person who requested the MRI exam, & surgery was his suggestion. Hence, no further alternative was given. Asked if muscle/tendon tears heal, he said it has to be isolated w/ very minimal movement.

I will consider the surgery but currently I have economic issues. Though my health insurance will cover the procedure, confinement, & professional fees, the screws which he said will be needed (4 pcs) will not be covered & so w/ the machine that will be used to fix the torn tissues. Plus, I have to be out of work for at least 3 weeks for complete recovery. That is a challenge.

My next step is to exhaust alternatives to surgery hoping that something may correct my condition.

Thanks again,
Bernard

Hi Bernard, in the absence of a significant injury, the structural lesions reported on MRI could be explained by normal age and activity related changes e.g cuff tendinopathy, partial thickness tearing, degeneration labrum.

This is not an indication for surgery in my opinion.

However, this sort of degenerative changes can in my experience lead to an adhesive capsulitis which may be made worse by being an insulin dependent diabetic.

I am not clear as to what your diagnosis is so difficult to comment.

Additionally, what we know about shoulders that start to show signs of wear and tear is that as time progresses so too does the size and extent of the tears i.e partial tears become full thickness tears and so on.

In my experience, persistent pain and shoulder dysfunction that you cannot live with is usually the number one reason to consider a surgical option not because an MRI says you have some potential age related degenerative changes.

However, if your doctor/surgeon has exhausted all conservative measures (injections and physiotherapy) and completed a thorough shoulder examination (considering MRI findings in light of what he/she sees clinically) and has an operative diagnosis, and you understand what he/she is trying to achieve/fix surgically then I would suggest that you at least consider it.

In my practice, this usually is how we come to have a conversation about surgery, when all other avenues have been exhausted, there is ongoing pain and dysfunction and a clearly defined structural cause (which is sometime difficult in the shoulder).

Finally, you need to get your blood sugar under control, I don't really see it as a contraindication for shoulder surgery unless it is way off the charts, again check with your doctor.

I hope this helps.

Luke

Follow me on Facebook

---------- Post added at 09:01 AM ---------- Previous post was at 08:59 AM ----------

Thanks. I will discuss that with my ortho.

Hi
I would suggest to you to try a Kinesio taping and manual therapy-Mulligan concept. Bouth therapy metouds are very effective in MSK.

Good luck

[bernardb201]

Prior to consultation w/ the ortho, I saw a rehab doctor who initially suggested 6 therapy sessions. Each session I was subjected initially to an ultrasound therapy around the affected area where a gel (Vi-Gel - Indomethacin) is applied. That's for about 15 mins. Next electrodes are placed on the area & electric current flows to it. The therapist would cover it w/ a hot compress. That's another 15 miins. For the next 25 mins, I'll do stretching exercises & some very light weight lifting targetted on my shoulders. After the 6 sessions, there's still some pain when I try to stretch as if reaching something from my back, so the rehab doctor ordered another 6 sessions. After these, the pain has been minimized substantially. I was then advised to apply hot compress & do the stretching & weights routine 2x a day if possible, and apply Vi-Gel as needed.

Unfortunately, about a month after the therapy sessions, the pain started to come back & this time I think there's an increase in intensity. I admit though that I can only do the routines once a day in the morning & at times I skip it since I felt no pain.

I'm seeking a 2nd (or maybe 3rd opinion) & I will suggest what you said. I'll update my post after my consultations.

Thanks for the response.

question:

Did you have ultrasound therapy to increase healing around the tendons?

The easy answer is surgery is a big indication here. However i would seek a ultrasound examination first to confirm some of the findings.

Saying that, you could try shock wave therapy to accelerate the tendon repair while immobilise for 1 month. I have had great success with this protocol but you do have a lot going on - prognosis would be better if we had either ultrasound to confirm soft tissues involved or even X ray to see positioning and instability measurements. Traditional techniques wont work - sorry.

also even if the shock wave reduces pain you will still be unstable and will have to limit movement and activities. meaning that almost any activity you would have to invest in good strap.

degeneration has also started and is likely to progress which may cause more pain in some time to come.

does that help?