[Johnmpb]

#28342

Dear Dr. Corenman,

I am a 32 year old male with ongoing shoulder/upper scapula pain for the last 2+ years.

Here is some relevant history:
Four years ago I started getting a lot of anterior shoulder pain near my biceps tendon after physical activity. I had an MRI performed that showed bursitis and tendinitis. A series of cortisone injections and PT did not help and the pain only got worse. My ortho then had me do an MRI arthrogram which showed a small labral tear. Two more months of PT to address the labral tear was completed with only worsening of symptoms. Surgery performed on March 2016.

3 months after surgery all anterior shoulder pain is gone but posterior pain on the lower and upper scapula started shortly after surgery. Ortho said it may be a trapped nerve or fibromyalgia and recommended follow up with a rheumatologist and accupuncture for the nerve issue. Two rheumatologists ruled out fibro and accupuncture did not help pain.

Saw another ortho and he performed trigger point injections into the scapula which did not help. Did more PT with slight improvement (modalities focused on irritated nerve). Ortho then ordered an MRI to see if there was any cyst pushing on the suprascapular nerve causing the pain and weakness- results came back normal.

I would describe the pain as deep/throbbing. There is no burning, tingling, changes in skin, sensations, or any kind of electrical impulses. The pain seems to be negatively affected by lack of sleep, anxiety, and stress. There are times where I am pain free. Lots of sleep seems to decrease my pain. Minimal neck pain. Some upper trap involvement.

Three months ago I was diagnosed with scalp dysesthesia. Low dose antidepressants and antihistamines are the treatment for scalp dysesthesia and this has at least temporarily, helped my shoulder pain a little. My dermatologist had a study on his website titled “Scalp Dysesthesia Related to Cervical Spine Disease” by Laura A. Thornsberry MD and Joseph C. English III MD. What’s interesting to note is 14 out of 15 patients in this study had abnormal findings related to cervical spine imaging, more specifically DDD. I ran this study by my ortho and he had me undergo a cervical and thoracic spine MRI and referred me to a physical medicine specialist. I am scheduled to have an EMG test next week. Below are my MRI notes.

Your Neck:

FINDINGS:
There is slight reversal of the normal cervical lordosis. Minimal 2
mm anterolisthesis of C4 on C5 is noted presumably degenerative in
nature.
Incidental tiny hemangioma is seen of the T1 vertebral body. Bone
marrow signal appears otherwise normal.
Spinal cord and visualized posterior fossa are normal in signal.

C2-3: Unremarkable.
C3-4: Unremarkable.
C4-5: Unremarkable.
C5-6: A 2.5 mm broad-based posterior disc bulge causes mild central
stenosis. Mild left neuroforaminal narrowing is seen.
C6-7: A 3 mm broad-based posterior disc bulge causes mild central
stenosis. Mild left neuroforaminal narrowing is seen.
C7-T1: Unremarkable.

IMPRESSION:
Mild degenerative changes are seen in the lower cervical spine with
mild central canal narrowing and mild left neuroforaminal narrowing
at C5-C6 and C6-C7.

Your Upper back:
FINDINGS:

Spinal canal: No focal cord signal abnormality. No significant
spinal canal or neural foraminal stenosis.

Vertebrae: There is normal alignment and curvature. Vertebral body
heights are maintained. Unremarkable marrow signal.

Disc: Unremarkable No significant disc bulging.

Soft tissues: Prevertebral soft tissues within normal limits.

IMPRESSION:

1. Unremarkable MRI of the thoracic spine.

Please let me know your thoughts on these imaging results and my ongoing shoulder pain. What would be the next possible steps? Thanks in advance.

John

[Donald Corenman, MD, DC]

#28343

My suspicion is a mechanical disorder of your shoulder. Your statement; “Ortho then ordered an MRI to see if there was any cyst pushing on the suprascapular nerve causing the pain and weakness- results came back normal” means to me that the suspected compression of the supra scapular nerve was normal but there had to be post-operative changes so re-read the radiologist report of the shoulder.

You don’t note which side your shoulder pain and surgery was on so I will assume it was left. The report of C5-6 and C6-7: “Mild left neuroforaminal narrowing is seen”. probably means that this is not a cervical disorder. One simple test is to extend your head (bend it backwards) and hold for 20 seconds while keeping your shoulder at rest. This narrows the foramen and any significant increased pain can indicate a cervical nerve origin.

If however you keep your head still but move your arm overhead and reproduce pain, this is a shoulder issue. A simple office test is to do an intra-articular shoulder injection and look for temporary relief.

You can send your images to one of my shoulder experts at the clinic, Dr Millet, Dr. Provencher or Dr. Hackett and one of them will be happy to comment on your case.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[Johnmpb]

#28455

Hi Dr. Corenman,
Thank you for the quick and thorough response. I have asked my doctor to send me over a copy of my latest MRI report as we only reviewed the findings during my visit. It was a different facility however compared to my pre-op MRI since my insurance had changed. My pre op MRI reports made no mention of my suprascapular nerve as the main focus were the mechanical aspects of my shoulder joint.

Sorry I didn’t mention it but you are correct, the pain is on my left side. The pain is not affected by the position of the neck. I tried the test you recommended by extending my neck. Also, the pain is not affected much by raising my shoulder above my head. The dull deep pain remains within my entire range of motion, however there is specific angles above my head where there is definite weakness (shoulder/arm will shake when trying to hold in certain positions).

I have had several cortisone injections within my shoulder with no relief-in most cases worsening of symptoms.

Would it be ok to send the files from my MRI CD?

Thank you

John

[Donald Corenman, MD, DC]

#28457

Please contact one of the names I gave you directly. At least one of the three will evaluate your films if you ask.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[Johnmpb]

#28511

Hello Dr. Corenman,
Thanks again for your response. I am working on getting my latest MRI films through my doctors facility to send to one of your colleagues. Just one followup question:

What exactly gives the impression that this is a mechanical issue versus a neurological? Do the mild deviations in my cervical spine typically not cause ongoing pain/weakness like this?

John

[Donald Corenman, MD, DC]

#28527

Your notations indicate that this is probably not stemming from nerve compression in the cervical spine (“The report of C5-6 and C6-7: “Mild left neuroforaminal narrowing is seen”). Mild compression generally does not impinge upon the roots enough to cause dysfunction. Maybe the radiologist underestimated compression but all I have to go on is this report.

You also noted “3 months after surgery all anterior shoulder pain is gone but posterior pain on the lower and upper scapula started shortly after surgery” would indicate to me some unresolved issues with the shoulder. Another look at your images should be in order.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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