Shoulder pain doing dips/spinal stenosis

[MAXX]

So there may be some treatments that relieve the pain and discomfort. But is there anything that halts or reverses the degeneration? Is surgery the only option? I've read a little bit about laser surgery--is that an effective technique?

Thanks for all of the input. I know a lot of your posts are speculative, so I keep that in mind. But I am worried that I am never going to be as physically active as I once was or as I'd like to be.

My appointment is tomorrow (Friday) at 4, I'll keep you posted......

[UConnJulie]

MAXX, I have treated many people with similar radiographic findings who responded favorably to treatment and end up pain free or very nearly so. I have also treated people with unremarkable x-ray and MRI findings for whom we were never able to alleviate symptoms. What it boils down to is that it is possible that you will respond to treatment and can live a normal, pain-free life. Keep us posted on how your appointment turns out ...

[dfpt]

What it boils down to is that it is possible that you will respond to treatment and can live a normal, pain-free life.

I second that statement. Just like UconnJulie stated, very frequently, we successfully treat people with involved radiological films like yourself. You'll never know until you try it; but only after getting cleared by a physician.

[dfpt]

Bryanc, thanks for the reply. You've given some food for thought, but I'm still hungry, so here's my take on some of your comments.

So first off, if soft tissue work isn't going to fix the radiological findings (which for MAXX's concern if we were to speculate, would be that his shoulder symptoms are being caused by compression of the spinal cord in a narrowed spinal canal), then what good, exactly will "normalizing biomechanical forces" though soft tissue work do in terms of alleviating this primary complaint?

I'm not convinced, given his primary c/o, that his symptoms ARE caused solely by compression of a narrowed spinal canal. I would speculate that IF his symptoms are primarily related to compression, then we would be able to reproduce his symptoms (bilateral shoulder pain) with movements or positions which physiologically narrow the spinal canal, i.e. cervical extension, sidebending and/or rotation. In any event, is there any other option, besides surgery, that will truly fix the radiological findings?

There is the possibility of axial loading causing remodelling of bone thickening in an annular pattern, but if a trauma is the trigger for an otherwise normally weighted head, we would not expect to see loss of both the cervical AND lumbar lordosis on radiological exam

.
Let me expand on this possibility: we know according to Maxx's films that he has a forward head carriage and loss of cervical lordosis. So instead of a well-balanced "bowling ball", we have muscles trying to keep this bowling ball from falling forward. The force needed to keep his head from falling forward would create an axial load on his straight, but forwardly tilted neck. Look at the line of force of the upper traps, levator scap and scalenes. The SCMs posteriorly rotate his cranium, thus facilitating constant upper trap tone due to their neuro relationship. Wouldn't this constant axial load be sufficient stimulus for bone remodelling? As far as his loss of lumbar lordosis, we don't have a way of determining when that occurred; but clinically, I've never seen a normal lumbar lordosis in the presence of a flat upper T-spine (I can see it on his avatar) and forward head carriage or vice versa.

if this was a case of "accelerated degeneration" in the face of abnormal biomechanics rooted in repeated neck trauma (and MAXX reports only one trauma he can remember), we would not expect there to be both loss of cervical and lumbar curvature as an adpatation to "balance his head properly".

MAXX recalls one major trauma b/c he experienced brief paralysis, but in my mind, he's gotten several per every day of football practice and game day; unless he was the kicker. Plus, what's the weight of those helmets.

Yes, trauma can be a triggering factor, but in order for abnormal degeneration to take place, there has to be an underlying pathology; and muscles that pull dysfunctionally doesn't cut it.

How about repeated small traumas (football games and practice, weightlifting, powerlifting, prolonged static positioning (probably slouched) 6-8hrs/day) on top of dysfunctionally pulling muscles?

I've treated many people with heel spurs for plantar fasciitis and they've gotten better, despite still having a heel spur (and I guess this a poor example, because the presence of a heel spur doesn't actually mean much of anything at all--EXCEPT that the heel spur grows in the direction of the pull of the plantar fascia), so yes, you can spurious radiological findings which may never improve with any kind of therapy (but usually because the radiological finding has nothing to do with the causative factors of the symptoms, as in the case of the heel spur).

So why wouldn't/couldn't this be applied to the spine, or any joint for that matter. Bone spurs in the shoulder, herniated discs, spondylolisthesis and retrolisthesis....many people have gotten better with soft tissue work with these underlying pathologies without causing changes to the radiological films.

but that the signs he's reporting are enough to warrant a comprehensive investigation--not just medical clearance for conservative management

. I'm totally with you here; I'm not trying to dilute the possible seriousness of his case, I'm letting you see inside my head if MAXX were to walk off the street into my clinic; and I wouldn't let him leave without hearing me say, "Have it checked out by your doctor".

[MAXX]

I've never seen a normal lumbar lordosis in the presence of a flat upper T-spine (I can see it on his avatar) and forward head carriage or vice versa.

prolonged static positioning (probably slouched) 6-8hrs/day)

dfpt, it's interesting you've brought up my avatar. I've been reading the Neanderthal series among other articles by Mike Robertson--not sure how familiar you are with those articles. I've always had a hunched standing posture and slouched sitting posture--they are the postures that offer the most comfort unfortunately these days.

But I've always wondered about a diagnosis such as yours dfpt, just from a picture. Can you explain more specifically what you see in my avatar? By the way, that photo is 4 years old--I have some recent shots from front, side and rear views that I could post.

[bryanc]

I think this has perhaps gone a bit past simple debate here df, because we're starting to come full circle in our arguments. Can MAXX have experienced bone remodelling as a result of improper skull carriage? Sure. Can the bone remodelling he's experienced caused his symptoms? Sure. Can "dysfunctional" muscle pulling cause bone remodelling? Yes. My argument still hasn't changed. I don't think I am disagreeing with any of these issues. My argument is, and has remained that I still hold a suspicion that the bony changes in MAXX's neck COULD have an underlying systemic pathology that, if present, could require pharmaceutical or other non-physiotherapy intervention. And I hold this suspcision based on the radiology reports and MAXX's description of the history of this problem.

We are both speculating on many factors. I've never met MAXX. I've never seen his ACTUAL radiographic images. Neither of us actually has any clinical correlation. I think I've already mentioned this fact already.

I feel like what you're arguing has now gone past MAXX's actual problem. In fact, I honestly don't know what issues we're actually arguing at this point. In fact, I really think this debate has only served to confuse rather than clarify anything for anyone.

[dfpt]

But I've always wondered about a diagnosis such as yours dfpt, just from a picture.

Whoa MAXX, you could get me in trouble by using the word diagnosis. Static posture is just a piece of the puzzle in your clinical picture. There are many more pieces that need to be evaluated and put together. The static posture portion will clue me in to where your possible stress points are, as well as possible dysfunctional areas. From your avatar, I can clearly see the medial borders of your scapula as well as the inferior angles....I assume flat back and forward tilt of your scapulas. Looks like your right shoulder is lower than the left. Also can questionably see exaggerated lordosis in the lower lumbar and a slight scoliotic curve in the same area. Of course, I could be cheating with my observation as you've already revealed your radiologic findings. It's a very rare day if and when I see perfect static posture.
I've read MR's NNM series a while back. Did you follow his recommendations?
BTW, how did your M.D. appointment go?

[MAXX]

Ok folks, I'm back. Sorry about the delay....

I wasn't really impressed with my 2 visits to the ortho. On my first visit, I had my neck evaluated. He wasn't sure what the cause of the degeneration was--possibly the football injury started it. He believes that the ligaments are all stretched out, especially those to the scapular area on my right side. He used some type of term that had to do with "tension." Basically, he referred me to a back surgeon because he claims that though I do not need surgery now, I eventually will, and I should get acqauinted with a surgeon now. He didn't believe that my posture had anything to do with my problems. He believes that poor posture is a result of people getting in a position that feels good and comfortable.

I had a really tender spot just above my scapula--I jumped when he touched it. He gave me a steroid shot to relieve trigger area. It loosened up the muscles, but did nothing for my neck discomfort.

I attempted to talk to him about some of the back exercises I had been doing that are from the Neanderthal series of articles on T-Nation by Mike Robertson. He promptly dismissed anything I said about it, stating that I should be careful of getting things from the internet, because people just wanted to sell books and DVD's to make money.....

Today, I went to get my lower back checked--he wouldn't evaluate both areas on the same visit. He thinks that the abnormal bone growths in that area are do to weakened ligaments. So, he said instead of going the time-consuming route of PT, "let's try the easiest treatments first." He gave me a series of prolotherapy shots.

I really dislike the idea of getting shots. Not because I don't like shots, but because I do not like to put things into my body unless it is absolutely necessary.

I just didn't get a good sense that this guy was leading me down a path to a corrective treatment. On top of it all, after I signed a release form for the shots, I read the fine print highlighted at the bottom of the form that says the shots aren't covered by insurance. I thought that was pretty underhanded to not mention it to me personally and just hope that I read that on the form.

Suggestions? I really want to go the route of corrective exercises, but how do I find someone with that thought process? Someone who doesn't just want to prescribe medicines, shots, or surgery......

[UConnJulie]

When you have a hammer ... everything looks like a nail ...
Are there any osteopathic physicians in your area? If you can find a good one who specializes in sports medicine, that may be your best bet ...

[bryanc]

Hell, I'm unimpressed. Sounds like you got "lucky" and drew the short straw of orthos. Yeesh.

[MAXX]

Julie is there an online directory for osteopathic physicians? There aren't any listed in my phonebook.

[MAXX]

I found the following site, but only one physician is listed in sports medicine for the entire state of Ohio. Which of the other categories should I look under? I also searched orthopedics, but all of them were surgeons.

http://www.ohioosteopathic.com/index.cfm

[UConnJulie]

I found this one here ...


Darlene Snider, DO

60360 Patton Hollow Road

Cambridge, OH 43725

(740) 439-3901 (tel)

(740) 439-7251 (fax)
dsnid@seormc.org

Here's her profile from the SouthEast Ohio Regional Medical Center ...

[Chrisatc]

MAXX, look for someone who has a DO after their name. You may also want to look for a chiropractor or a PT who specializes in spinal health. And my oh my, that physician was quick to pull the syringe, all while disregarding "internet filth?" Maybe you should bring him MR's CV?

[LisaS]

or look for a physician who is a physiatrist or has the specialty of Physical Medicine & Rehabilitation.
http://www.physiatry.org/

from that site, I see four residency programs in PM&R in Ohio - maybe start there for a referral

[MAXX]

That's awesome Julie, I'm going to call her tomorrow!!! I was going to look on Southeast Med's site, but figured they wouldn't have anyone (it's a tiny hospital).