left shoulder coronal view
left shoulder sagittal view
left shoulder axial view
The next week, while I was cooling my heels in the doctor's office, I took a look at the MRI report which was open on a computer screen in the exam room. Here's what it said:
Examination: MRI study of the left shoulderThe MRI photos mostly looked okay to me, but what did I know? I had looked at some rotator cuff tears online already, and the bad ones had a lot of white areas. Mine only had some small white areas. So that was encouraging. But reading that I had a partial tear was alarming, and I feared the doctor would recommend surgery.
History: Left shoulder weakness and stiffness with history of earlier injury
Technique: Axial coronal and sagittal T1 and T2-weighted images of the left shoulder are reviewed.
Findings: Hypertrophic changes are seen around the acromioclavicular joint with small amount of fluid in the subdeltoid bursa consistent with bursitis and mild changes of tendinitis involving the most anterior portion of the supraspinatus tendon. There is a small partial articular surface tear involving leading edge of the infraspinatus tendon with adjacent synovial cysts seen at the base of the humeral head. The rotator cuff is intact and no abnormalities are seen in the biceps tendon which is located normally in the bicipital groove. Glenoid labrum is preserved. No fractures or bony contusion is seen. No bony destruction is identified. Normal study otherwise.
Conclusion: Mild degenerative changes acromioclavicular joint with subdeltoid bursitis and tendinitis in the supraspinatus region.
2. Partial articular surface tear of the leading edge of the infraspinatus tendon.
In fact, she did not. She told me that I almost certainly had adhesive capsulitis, and recommended physical therapy. I asked about the partial tear - wasn't that a concern? No, she said, it will eventually heal on its own. She also brushed aside the concerns I raised about the bursitis and tendinitis described in the report, saying that my main problem was adhesive capsulitis, end of story. At some point she also said something like "well you don't have any tendinitis" and I had to correct her, having read the report myself. (As you might imagine, my confidence in the doctor was not swelled by her remark.)
So two months after first seeing a doctor for the problem, I was on my way to PT. A good month of the delay was my own fault, and I wish I had not procrastinated so much.
I was able to obtain a copy of the MRI images free of charge, which was sweet. It's fun to run them as an animation, and I hope to create an animation for a blog post, but for now I've just posted one each from the different views. I wish the doctor had gone through all of the images with me. I'd like to know what parts of the image indicate the partial tear, bursitis and tendinitis.
Even though you may not have confidence in your physician. I would agree that the partial tear will heal on it's own. Our tissues get tears in them on a regular basis (ever got a paper cut) and they heal themselves every time as long as they have a good blood supply to them. Unfortunately the general public consensus is tear must mean surgery, which isn't usually the case. I think you have a good ortho since they weren't quick to do surgery. Remember surgeons make a lot more money doing surgery then an office visit. So be glad you found one that is not all over surgery.
ReplyDeleteThe busitis and tendinitis stuff is just inflammation, that is why the ice feels good. Your joint is not moving right and it's causing inflammation (also the inflammation is a primary cause of the trigger of the nervous system that your brain is recording as pain). This too will pass as the tissues heal and you regain your motion and strength. Plus realize MRI's are not 100% accurate all the time (also not common knowledge to most). So take the MRI results with a grain of caution as you should all the information you have been getting. You really have to piece all of it together to get the best answer. Don't rely on just one item, like the MRI report.
And your procrastination, not as bad as most, so don't beat yourself up. You'll do fine.
nice blog. very informative - may i ask what the differnce is between adhesive capsulitis and bursitis? thanks for the info..cheers!
ReplyDeleteHi Kory,
ReplyDeleteDon't get me wrong, I was relieved that the orthopedist had not recommended surgery. If she had, I would have looked for a second opinion.
My main problem was that she seemed to think that my problems were of no concern, not recognizing that they are of great concern to me (not the best bedside manner, a problem with many doctors). And she didn't seem to have read the report very well. I guess this can happen when you're seeing a new patient every 10 minutes. This made me wonder if she had "grokked" the situation correctly.
My understanding is that joints and tendons heal slowly because they do not have a good blood supply.
My initial fall was in late October. Assuming the tear occurred then, it's disturbing to think that it hasn't healed in 5 months. Or maybe the tear actually occurred later, perhaps as late as January when I fell while skiing... How long do these types of tears take to heal? My physical therapist told me 2-3 months.
I realize that MRIs do not always show the full picture. On the bad side, that may mean the partial tear is larger than suspected.
My biggest fear at this point is that any painful manipulations being done in PT might be causing the partial tear to enlarge. If I could know for sure that this is just not possible, it would make me feel more patient about the pain I'm experiencing during PT.
missy,
ReplyDeletethank you. Keep in mind all the info here is from the patient's perspective, and it's mostly drawn from what I've found online; I have no expertise.
Bursitis is an inflammation of the bursa. I have subacromial bursitis, an inflammation of the bursa in the shoulder, which is basically a sac of fluid sitting below the acromion, a bone at the outer end of your shoulder blade.
In contrast, adhesive capsulitis is a condition affecting a "capsule" of tissue which surrounds the shoulder joint. Nucleusinc has a somewhat gory illustration and in contrast here's the normal capsule. I am still trying to understand exactly what the shoulder capsule is; it's not something that's familiar to me like tendons and bones.
Your concerns are very valid. If the tear does not have good blood supply it may never heal. But also realize that tear may have been there for many years as well. Often times we hear tear and assume that has to be the problem, many times it is not. I know this is counter-intuitive to what is thought. But studies show in many injuries that if we take MRI's of "normal" joints we can find many problems, but the patient will not have pain. Remember the body is an amazing healer and compansator. It is often the inflammation that is stirring things up. I use an example of a bees nest. If you have a bees nest outside your house you may not even know it is there. But if someone goes and wacks it with a stick, you realize real quick that you have bees everywhere and that you have a problem. That is what the inflammation does...it stirs things up and makes the nervous system more sensative to everything and it decreases the effectiveness of the muscles that can help assist the injuried tissue.
ReplyDeleteYour concern about further tear is very valid. But realize the force needed to actual cause further tear is very significant. The therapist would have to apply extreme amounts of force to actually cause a tear. Studies show the risk of further tear or damage with manual therapy techniques is very, very low.
The 2-3 month time period is pretty accurate. Once you can control the inflammation and gradually rebuild strength and motion all will return to normal.
Again I commend you on your study and understanding of what is going on. Keeping asking questions of your physicians and therapists, so you have a better understanding. Yes, they often are too quick in and out, but you are paying them -- force them to do their job.
Hi Kory,
ReplyDeleteBut studies show in many injuries that if we take MRI's of "normal" joints we can find many problems, but the patient will not have pain
I've read some surprising statistics about this. The AAOS says:
"Rotator Cuff Tears increase in frequency with age, are more common in the dominant arm, and can be present in the opposite shoulder even if there is no pain. The true incidence of rotator cuff tears in the general population is difficult to determine because 5% to 40% of people without shoulder pain may have a torn rotator cuff. This was determined by studies using X-rays, CT Scans and MRIs to assess the shoulders of patients with no symptoms. One study revealed a 34% overall incidence of rotator cuff tears. The highest incidence occurred in patients who were older than 60 years. This study supported the concept that rotator cuff damage has a degenerative component and that a tear of the rotator cuff is compatible with a painless, normal functioning shoulder."
Hm. It's no fun to hear that tendons degenerate of their accord. But I'm well under 60, and I have an infraspinatus tear on my non-dominant arm, so I'm inclined to think that this is not a long-standing injury, and that it's due to trauma, although of course anything is possible.
I believe the pain I'm feeling comes from several sources, because I feel different kinds of pain with different movements. As you say, inflammation is certainly a problem (tendinitis and bursitis are presumably both due to inflammation), but I think the tear is also causing pain.
There are several "hot spots" around my shoulder which cause intense pain when moved the wrong way. This is different from the pain of adhesive capsulitis, which I've seen described as very general, not specific to one area.
It's good to hear that it's unlikely that PT will worsen the tear. I hope the stimulus will help get some blood flow to the area and get it healing.
I did ask my physical therapist if he had any articles to recommend, but so far he only could suggest a search at pubmed, and it will probably take way too much time to find something really useful there.
Can someone give me some advice on rotator cuff surgery then the shoulder being froze?
ReplyDeleteAnnette, surgery is a serious thing. You should really consult with a doctor (and get a second opinion if possible).
DeleteIve had surgery aug 7 2013 I still can't raise my arm up I have another MRI on monday with a very good ortho dr that takes care of our sports in Michigan dr. Dr says my bursa is froze from being in a sling for 6 weeks. It's not that simple sling this was a 800 $ sling it was terrible
ReplyDelete