chronic mid/mid-lateral humerus pain

hiya guys and gals.

had this guy approaching me at the gym today, asking for a quick opinion. So my assessment was very brief, hence the lack of proper info, but I hope to get some ideas before I see him next.

~55yo physically active male, had a bilateral pain in his mid/mid-lateral humerus (ant. deltoid attachment, approximately) for almost 11 years. "deep", non radiating, not constant, exercise induced.

The pain is brought about by shoulder flexion exercises such as shoulder press, and lateral abduction, but almost always over 90 degrees. He recalls not being able to abduct at all at first, but improved during years, and now can do light weights.

• Direct palpation "sort of" brings vague pain, but nothing major.
• Subacrom. impingement neg
• speeds neg
• supraspinatus, biceps resisted painless
• Yergason neg

The injury, as he suspects, occurred on the pullover machine. Only x-rays have been done back then but showed nothing. no soft tissue imaging etc. ever done, and no diagnosis or proper treatment. though he says he had at least rested for couple of weeks.

I know this is very little info, but that's all I could get from him in those couple minutes. I will be seeing him later this week, and hope to have a "proper" look.

Any ideas? Educated guesses? all welcomed!

ok, had a thought, and my ideas so far include:

• despite primary negative test (it was quite floppy, to be honest..) - rotator cuff pathology (e.g. chronic suprasp tendinitis, calcification etc.)
• multiple rotator cuff trigger points?
• deltoid tendinitis?

Tests to follow:

• proper ROM and strength testing
• proper impingement tests (Hawkin's, Neer, empty can etc.)
• cross body adduction test for AC joint

I still think this might be a rotator cuff problem as primary obsevations somewhat point that way (over 40, pain and weakness with overhead activities, possible traumatic occurrence.. ) though 11 years of pain history..?!
supposing deltoid lesion at the insertion, is it possible to only cause pain at the mentioned angles, and not through full ROM?

ok, nice chatting with myself :)
but since I've had another couple of minutes with this guy yesterday, I thought I'd add to the story, maybe it will be of any use to somebody sometime. maybe not.

anyways, here are the findings so far:

• AC neg. -
• Transverse humeral neg.-
• Empty can +- (mild)
• Lateral abd. painful over 90deg.+
• Impingement relief pos. +
• Impingement (90deg GH fwd flexion, 90deg elbow flex.,forced int rotation) pos.+
• Resisted ext.rotation painful +

+ reports of pain at night, especially when changing sides etc.
after overhead activities with pain, 1-2 weeks of pain and symptoms consistent with flared up inflammation (pain, heat, loss of function)

therefore, my thoughts so far are:

• primary injury was poss. to external rotators, poss. including T.Maj.
• this in turn induced weakness and inability to properly control humerus tracking in glenoid resulting in subacr. impingement.
• having in mind extensive time frame (11 years), there should be a considerable amount of degeneration present,possibly calcification of cuff tendons, or even a formation of bone spur under acromium.
• Therefore an MRI would be very useful here

suggestions so far:

• stop overhand activities (stop weight training for upper body overall? suggestions?) and any other that places rot. cuff at risk at this point. (wide bench press, pull ups etc.)
• RICE for ~5 days (about the next time I'll see him)
• NSAIDs?

since he's a regular in the gym, I just said to come and see me every time he comes in, just to see how things are going.

if pain subsides after initial rest period, all the obvious rehab would start with MICE, stretching, cuff strengthening, scapular stabilisation, progressing to more global movements, improving GH translation, mobilisation to GH if necessary to improve distal translation etc.

Hey Zhgutas

sorry you haven't had any interaction here - probably the Xmas phenomenon with people not logging in.

First off I should say I am not really a sports physio. However from your description and analysis I would just make the following points which may or may not be useful:

* Yes you seem to have gathered some evidence now for it being an impingement problem
* The chronic nature of the pain - 11 years - i don't think you can rely on pain being closely related to organic impairments. The pain perception may have become a main feature the problem itself
* I would also query whether inflammation is a key process - wouldn't what we know about tendonosis more likely apply. The fact that he has pain at night gives some weight towards inflammation but that might just as well be to do with lying on the shoulder. As an index and test for inflammation one thing you could check if there is morning stiffness and pain on elevation and how long it lasts. +ve response to NSAIDs doesn't necessarily mean an inflammatory problem. RICE hasn't been shown to be effective for combatting inflammation except in the very acute so it is unlikely to reduce inflammation at this point and if you get a positive response to using ice it could just be neurally mediated analgesia or placebo. However working this out might be quite important in working out how to set and monitor exercise dosage.
*what about analysis of postern and presence of muscle imbalances? What are his thoracic spine, shoulder girdle and neck like?
Yes getting some imaging might be worthwhile - is an MRI and or a sonogram available?

Thanks for your response gcoe.

About the perception of pain - I've had the same thought at first. But the clue for me at the time was that the pain was not "just there" lingering as often seen in the "pain for the sake of pain", but rather is induced by a physical activity, and seams to follow an inflammation-type pain pathway more or less(as reported, not as observed though)

Well that's certainly food for thought about tendinosis.. That's pretty much an answer to what bothered me from the start, because of the time-frame (11y). therefore RICE would actually sound counterproductive here.. However as one of the goals for the shortest period of time (several forthcoming days) was to decrease pain flare-up after last workout, even some neural analgesia or even a placebo effect would hopefully be of some use. Whatever outcome will be valuable, though, in deciding on further options.

Didn't have the chance for a full postural analysis etc., but the observations so far suggest he's pretty well balanced, e.g. no excessive shoulder protraction or int. humeral rotation, no excess kyphosis and fwd.head, no complaints of pain, stiffness in the neck. Though I agree a closer look would be surely beneficial.

MRI is really expensive here, so I kinda doubt he'll be up for that anytime soon, though sonogram might be an option then. I will suggest that then.

Thanks again for your ideas and suggestions, really helpful and appreciated

Cheers Zhgutas

All the best with sorting it out .keep us posted with any progress

I'm new and a student but the the capsular pattern (pain on external rotation and abduction) and the location of the pain you say mid humerous (could it pass as deltoid insertion?), coupled with it being worse at night make me think adhesive capsulitus? If it is possible that it lasts that many years?