low shoulder

[Coley6]

Hi there,

I have a bad right shoulder for the past 3-4 years. It subluxes a lot and can be a real pain. I saw a physiotherapist a few months ago after being officially diagnosed with ehler's danlos syndrome hypermobility type by a rheumatologist who specializes in these types of disorders. In the physio's report she wrote: "poor scapular dynamic control with weakness particularly to serratus anterial the cuff external rotators." I'm not exactly sure what that means, but she told me I have poor proprioception, and I understand that my shoulders, especially my right, is very weak and unstable. She taught me some exercises that I do religiously and the pain is starting to decrease !!. It subluxes less and it feeling a lot better. I've been able to increase the weight I'm using, so it must be getting stronger. My concern is that my right shoulder sits much lower than my left. I had noticed it before but over the past two weeks it seems to much more noticeable! The straps on my summer tops are always falling down on my right shoulder, I have to pin the straps! And I look crooked. Will it ever go back to being level with my left shoulder or will it permanently be a lot lower? I have always carried my bag/purse on the left shoulder because the right is too sore, so that can't be causing the problem on the right. I have really terrible posture that I'm working on as well, and I am doing several other exercises for other hypermobile areas of my body. I have a lot of tension on the right side of my neck and top of my shoulder still. If anyone can explain why my shoulder is so low, and if there are any physio treatment options I should seek, please let me know! I like to deal with these things as soon as I can

Coley

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[Dr Damien]

Dear Coley6

If your therapist is right (and Im sure they are) , then the weakness in your serratus anterior is causing some lengthening of your trapezius muscles on your right side...the tension you are feeling is this muscle working hard to keep the shoulder blade elevated, it normally shouldnt work this hard...this lengthening is giving the illusion of a depressed shoulder...I dont want to say actual depression.

Ask your therapist what he/she thinks about taping? maybe relocating the shoulder blade and given some support to the serratus anterior will make it work more effeciently (given there are no neurological causes of course) and reduce the stress on the trapezius muscle...in the mean time massage is good in getting rid of some of that tension...

Best to do this with a skilled therapist- a good test...keep your arm in a position it is not likely to dislocate in (internally rotated, slight abduction elbow on the table palm facing down...ask someone to gently to lift your shoulder blade on the right up gently until its in the same position as the left, then let them hold it against your chest wall...if the tension in your neck eases off, then this is the problem.

Best of luck

Best of luck

[Coley6]

Just in follow-up: I saw my physiotherapist and she helped my shoulder back into the joint and taped it a few times for me. Last week I saw my physiatrist and was unable to fully shrug my right shoulder (I didn't realize this). She did an xray and ultrasound on my shoudler. She's also sending me for a nerve conduction study/emg July 25 which makes me really nervous. She said that the upper trapezius on my right side has atrophied. I'm confused about how it happened, I didn't feel any pain until a few weeks ago. I was using the arm like normal, and doing all my physio exercises. Now I have a low-grade burning pain on the top of my shoulder/side neck. Will I be able to rehabilitate the muscle? I sort of want to avoid the nerve conduction/emg, I thought if I can get it better I can ask my doctor to cancel it. My physio is away but maybe I should book with a different physio. If anyone can explain all this further I would really appreciate it!

Thank you,

Coley

[Dr Damien]

Dear Coley6

Thank you for the updates, its unfortunate that your symptoms seem to be getting worse. I think a nerve conduction test is necessary, from what you are saying ...there are possibly neurological causes that have been overlooked. My earlier texts had that clause in it about that possibility. I think your physio has helped you long enough but if infact there are neurological causes, then its time to have a specialist look at it...I can understand your frustrations and fears with regards having further tests done, but delaying it further is not going to be of any help in my opinion.

your initial diagnosis of the hypermobility syndrome may be playing a part particularly in how the blood supply to these nerves are functioning, so sustained positions of your neck etc may be contributing to all this...i would suggest holding off phsyio and getting assessed by the neurologist/vascular specialist first...

but if you have to see a different physio, bear in mind you want to avoid any fixed postures now and you want to possibly improve the blood supply to these areas, so sleeping postures, postures in your daily activities are going to be important to look at...

if you could describe how the taping was done this could be also helpful to know...

keep us updated

many thanks

[Coley6]

Thanks again: your input is helping me understand what's going, and giving me good questions to write down to ask my physiatrist.

I just had an MRI done on my head/neck just yesterday because I was getting bad headaches, though that's resolved now, but maybe that imaging will come in handy to solve this mystery. I just really hate the sound of the nerve conduction study and emg. I understand it's probably important to do I would just prefer a miraculous recovery and avoid this whole thing!!

The taping was sort of like a triangle around the top of my arm. My physio said something was happening with my scapula and humerus, I think she said it was 'dumping', so her taping was trying to prevent that. I really liked the taping because it made my shoulder feel so much more secure, and I felt like I could use it without worrying that it would dislocate, but we discontinued it when the doctor learned that I couldn't shrug.

In the meantime I'm being careful not to do anything silly to hurt my shoulder, but I'm trying not to over-protect it either. It just feels like someone's pushing on the top of my shoulder; it's so heavy, so it is really hard to write and type, I'm using my elbow as an anchor. I'm still able to do most things (dress, wash hair, cut food etc), it just hurts.

What I don't understand is how the upper trapezius muscle atrophied without my realising. How does a muscle just all of a sudden not work like that? It's just strange because I was on such an good physio program to try to sort out my hypermobility and my shoulder was doing great. I'm glad I've been able to maintain my 30 mins of cardio and lower body exercises/stretches each day.

I will keep you updated. Thank you again!!

[Dr Damien]

Dear Coley6

Thanks again for your updates,

ill try to give an explanation to what i think is going on however bear in mind that you are not being seen and what is being said here is in response to the information you have given so far therefore anything you get like you say is for your physician/doctor/consultant/physio to ultimately take charge of.

the trapezius muscle is mostly innervated motor wise by the spinal accessory nerve, this nerve runs underneath the trapezius muscle and can be injured in multiple cases of dislocation when there is excessive stretch to the trapezius (a kind of traction injury) or during compression when something pushes down on the trapezius muscle for prolonged periods. because you have a diagnosis for hypermobility which is a dysfunction of connective tissue, this is more likely to happen because the blood vessels are also affected.

nerves generally get damaged in three stages...ill summarize in simple terms.compression stage (gets better almost immediately the compression is taken off), mild post compression stage (some aspects of the nerve is damaged but it still conducts), and total compression or nerve snapping when the nerve is cut off... you might hear terms like neuropraxia, axonotmesis and neurotmesis to define these classifications.

howver prior to any of these stages, there is a stage that is not even noticed on a cellullar level...this has to do with the blood supply to the nerves, even a mild compression can cut of the blood supply thats starts the whole process...

because the spinal accessory is a motor nerve, you wont have any sensory perceptions i.e numbness, parasthesia, burning sensation etc in the beginning something that would cast your mind to a nerve issue....hence the only sign that you may notice is atrophy and weakness, so dont be surprised at how you didnt notice this until now

maybe the problem has been the trapezius muscle the entire time, giving the illusion of a serratus anterior weakness because both tend to couple in shoulder elevation tasks and a severe trapezius muscle weakness can give the illusion of serratus anterior weakness (scapular winging)

now muscles generally maintain their tone because of a trophic influence given to them by the nerves that supply them even when they are not active.

like a hose pipe that allows water flow through, if you block the hose slightly some water will pass but slowly , block it totally and no water passes at all. same thing happens with nerve transmission/conduction

headaches are quite a complex issue...ruling out other medical causes is necessary...however on a musculoskeletal level, there is an indirect relationship with trapezius muscle stress and headaches. often the headaches are one sided, are related to activity and usually present at the back of the head all the way to the eye level. this is usually muscles in the neck under tension working hard to maintain alignment in the light of deep flexor weakness.

MRI results are unremarkable and in the elderly radiological exams will show at best arthritic changes of the cervical vertebrae paticularly the facet joints of the superior ones.

the nerve conduction test will check to see if the nerves are the problem here and if they are how bad the situation is...only then can a good treatment plan be made...

shoulder shrugging is a good test but it has its own problems, the trapezius muscle is not the only muscle that carries out this action.

I guess on a clinical level, the challenge will be to see if the trapezius has any activity at all...the EMG is more accurate in answering this question. therefore if you dont want to go for this yet, your clinician may need to try different positions with and without gravity affecting with palpation to see if its active at all... if if it is, probably the site (and im assumming that it is a nerve issue now) of the nerve problem is within the trapezius muscle because thats where it becomes superficial...

neurodynamic tests may be necessary ( care to be taken not to stretch the nerve but to aim to glide instead), gentle massge may be necessary, keeping the trapezius in a shortened position without compression is neccessary...therefore any exercises that might stretch this should be avoided...

fixed postures that causes stretches of compression should be avoided....

it may be necessary to assess the neck too as the trapezius muscle has its origin from there....

not the most ideal situation, however a forearm sling cuff may be needed...the only downside to this is the risk of compressing the trapezius on the other side...

best of luck and keep us updated

[Coley6]

Thank you so much for explaining all of that to me. I really appreciate it! I really like having a better understanding of these things. I saw my massage therapist today who spoke with a physio before doing any work on my shoulder. The physio came in and had me lie on my left side, put a pillow under my right arm and put her finger at the back of my shoulder. With a lot of cueing and intense concentration I was able to sort of slide my shoulder up. She said I should absolutely have it investigated further. She told me to practice activating it on my own (she went over the correct movement several times) to see if I could bulk up the muscle. She said my bicep was really knotted and said its doing a lot of work to keep my shoulder in. She said the left side of my neck is also really tight and she said its compensating for the right. I forgot to ask about using a sling as I keep finding my left arm holding my right arm for support, but I worry a lot about using a sling for the reasons you already mentioned. Quite lucky this physio was around to take a look.
It certainly feels worse as the days go on, today it is making me nauseous and I have such a headache that is one-sided and feels like pressure behind my eye. I think if it's still like this tomorrow I'll contact the physiatrist for further direction as its a very miserable feeling. I'll let it you know how it's going, I actually just wish the nerve conduction was earlier to know what's going on! Thanks again for your knowledge, it's been very helpful.

[Coley6]

Hi again,

I think it's recovering now. I have been working hard on the exercises the Physio gave me. My neckline is still asymmetrical and shoulder is weak but I can do a shoulder shrug Not sure if I'll still have to do the EMG, hoping for not! Will let you know how it's going. Thanks again for all the info!

[Coley6]

Hi again,

I think it's recovering now. I have been working hard on the exercises the Physio gave me. My neckline is still asymmetrical (though better) and shoulder is weak but I can do a shoulder shrug Not sure if I'll still have to do the EMG, hoping for not! Will let you know how it's going. Thanks again for all the info!

Coley

[Dr Damien]

Dear Coley6

Getting better is definitely what we like to hear...

best of luck

[Coley6]

I had my nerve conduction and EMG today. The nerve conduction was normal. The doctor said that the EMG revealed "neurogenic changes" to some of my muscles (sternocleidomastoid, rhomboids, upper trapezius, and I can't remember the names, but there were two spots in the back of my neck). She's not really sure if it's just a really old injury causing these results, or if it's the winging improving. She's going to consult with my regular physiatrist and give me a clearer idea of exactly what's happening in August. I wasn't too sure what she meant by neurogenic changes, she tried to explain it but I didn't fully get it, but whatever was going on it doesn't sound too terrible and they'll monitor it (though I don't think I'd ever agree to an EMG again!!). I can continue with physio. Also, my MRI results are normal! Now to curl up with a cup of tea and an ice pack for these very sore muscles!

[Coley6]

Another quick follow-up. I saw my physiatrist last week to discuss the EMG. She said that the issue was actually noted in my cervical spine, from C3-5. She said that she thinks something is causing pressure on a nerve there. She said the MRI was clear, so she's not sure what is happening. It's getting better, but still annoys me with pain. The hardest thing to do is write. I have to do a lot of handwriting in my work. I have been working really hard to strengthen, but it doesnt seem to be helping. I'm wondering how much control I have over it. At any rate, I'll keep up my exercises because I'm sure it can't hurt, and maybe it's helping in very small ways and making me more aware of my shoulder.

They are re-doing the EMG in November The doctor also offered some type of injection to help with the pain, but I didn't want to. I didn't ask for any details about the injection, but I am worried if I couldn't feel pain there that I might hurt my shoulder more.

We'll see how it does!