Injuries and RehabTell us where it hurts! Do a quick search before asking about your shoulder injury to make sure your question hasn't already been answered (about 50 times), and read the sticky post first.
I used to be able to do 30 dips no problem, but now I can barely do 5 due to the pain in my shoulders. I've been diagnosed with cervical spinal stenosis. Is the stenosis the source of the pain? I'm also looking for any advice for treating/relieving the stenosis which has caused a lot of discomfort in my neck and also severely affected my training.
I think this is one issue that would probably be best addressed by your doctor. Spinal stenosis isn't always consistently the same between individuals and anything anyone is going to tell you on this forum is going to be pretty speculative anyways since cervical pathology is complicated. I think it's an important issue, and I don't to make it seem like you're getting a brush off, but treatment/therapy by someone who has significant experience in spinal stenosis would probably be your best bet.
Maxx,
I would recommend getting a differential diagnosis as to the origins of your pain. There are specific cervical tests and shoulder tests (after the c-spine is cleared) to perform to determine the tissue(s) at fault.
dfpt, what type of person would i go see for this. Currently I am just seeing a chiropractor who diagnosed the condition after requesting xrays and MRI's. He believes I've had the condition for quite some time, but no one had diagnosed. He uses a clicker to treat me instead of manual manipulation, but he refuses to work on the cervical area due to the bone spurs.
So, do you have stenosis or early osteoarthritis of the cervical spine?
Stenosis generally refers to a narrowing (and in the context of "cervical stenosis", it refers to the space that your spinal cord runs through. Bone spurs are generally more associated with osteoarthritis and also spondolytis/spondolysthesis, but I'm not entirely sure what your imaging looks like.
C2-3, C3-4, and C4-5 levels are normal. At C5-6, the disc is degenerated and there is some uncovertebral disease projecting into the left neural foramen. This causes mild stenosis. The central canal and right neural foramen are unremarkable. The C6-7 disc is degenerated and there is moderate left neural foraminal narrowing due to uncovertebral disease. The central canal and right neural foramen are unremarkable.
Cervical spondylosis with left neural foraminal compromise at the C5-6 and C6-7 levels as detailed above. No cord compression is seen.
XRAY REPORT:
There is a tilt of the cervical spine to the right. There is straightening of the cervical lordosis with anterior carriage of the head. There is a pseudo articulation of the posterior tubercle of C1 with the spinous process of C2. This is a developmental variation. Incidentally noted is a posterior ponticle at C1. Incidentally noted is partial ossification of the stylohyoid ligaments. There are disc space changes and degenerative bone formation at C4, C5, and C6. There is hypertrophy of the uncinate processes at C4/C5, C5/C6, and C6/C7. Incidentally noted is elongation of the C7 transverse processes bilaterally.
MAXX, definitely see an orthopedist ... he will be more qualified to determine if your shoulder pain is related to the cervical dysfunction or if it is a separate problem.
And if you can, I might also suggest a referral to a rheumatologist. Given, you might not have any other joint pain, but talk with your family physician whether he/she thinks this would be a worthwhile referral to make to possibly rule out ankylosing spondylitis. Your presentation would be an uncommon one, but it would be bad diagnosis to miss.
to possibly rule out ankylosing spondylitis. Your presentation would be an uncommon one, but it would be bad diagnosis to miss.
Really? I was under the impression that ankylosing spondylitis always started caudally and progressed cephalically ... plus it is very easy to diagnose on x-ray as the "bamboo spine" is pretty hard to miss ...
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I've seen a couple of very rare cases where the spondylitis appeared not-lumbar first. Again, it would not be the stereotypical presentation, but given that it would be such a horrible diagnosis to miss and given you can slow the progress down, why wouldn't you include it on your differential? I'm not saying that it's at the top of my differential, and I would definitely go through my family physician to ask about whether or not it would even be worth doing (I've never examined MAXX, nor have I seen his films), but it's not a difficult diagnosis to rule out either.
If you're getting your diagnosis after a bamboo spine x-ray, it's because no one was thinking about it, and you're in the late stage. I've seen a lot of ank spondy, and not one bamboo spine x-ray yet--other than the textbooks.
Maxx,
I agree with UCONNJulie to see an ortho....another option which I'm biased towards are physiatrists (M.D.'s specializing in rehab), only b/c their last resort is surgery.
I've gotta admit, that's one hellova detailed MRI and X-ray report!...I'm impressed....I've not seen many MRI or X-ray reports mention the uncovertebral joints.
Bryanc: interesting you mentioned ankylosing spondy....what was it about the imaging that "red-flagged" it for you? My typical red-flag for A.S. is a subjective report of significant stiffness very temporarily relieved by stretching.
Maxx, I'd be curious to know your age, previous traumas or previous participation in contact sports. Maybe that's in your profile.....I'll check!
UConnJulie: what year did you graduate from UConn....1997 for me!
Bryan, interesting ... and I'm curious if you don't mind telling (just because we interact quite a lot on this forum and I've never asked) what kind of physician are you? I am assuming orthopedist since you talk about seeing films and your talk about other orthopedic injuries ...
dfpt, another UConn alum! Well, my first degree from UConn was in 1990 in athletic training. The program was shit and I never sat for my boards because I knew I couldn't pass them with the education I received (Ralph Mansell was the worst! The program is very good now, but it wasn't then!). Actually my senior year I decided to go into physical therapy but finished my degree first and then did prerequesites for a year or so (part time) then went back and graduated again in 1995. Were you in class with Jeff Kinsella-Shaw?
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I am 35 years old. My chiro also asked about previous trauma. He said my neck looked like a 60 year old neck, and he felt the damage had been there for quite some time. The only thing I could think of, I had a head on collision with a big guy on the football field my senior year in high school that left me with a very bad stinger--the right side of my upper body was paralyzed for about 2 minutes. Our trainer told me to tough it out.
After that, I always had trouble with pulled muscles in my neck. About 7 years ago, I had a severe pinched nerve in my back for about 2 months--nothing would relieve it. I started to do shoulder shrugs and within days, the pain went away and so did the pulled muscles in my neck--for good!
I have always been a neck cracker since high school. I can crack my neck two ways. One is general cracking that relieves stiffness in my neck. The other is more of a manipulation--I've always described the second type as bone clicking on bone. I used to do the second type a lot when I was younger, but stopped because it caused a lot of pain--it was a bad habit. I try not to do the first type much, because my neck feels a lot better when I don't crack it regularly. But when it gets stiff, I can't resist cracking it to get some relief.
I'm not sure if it is significant or not, but I also have lower back problems. I attribute them to working at a Sam's Club in college where I did a lot of heavy lifting. But my family has a history of back issues. Here's the xray report on the lumbar:
Pelvis and sacrum rotational malpositions are seen. There is a tilt of the lumbar spine to the left. The contour is flat in the upper region. There are disc space changes and degenerative bone formation at L1 thru L4. There is subchondral sclerosis of the facet joints at L4/L5. There are oseophytes seen across the margin of the sacroiliac joint on the left. The remaining osseous structures, joint spacing and articluar relationships are maintained. There is no evidence of osseous or joint pathology.
I feel great except for my lower back and especially my neck. My neck has kept me from doing serious weightlifting over the past year, which has taken it's toll on me mentally and physically. I live in a rural area, so there are not a lot of doctor options. I do not want to have surgery. But regular doctor visits or rehab would be difficult for me right now--my job really prevents me from seeing anyone on a regular basis, except during the summer months. Thanks for all of the input so far.
So, you've lost both lumbar and cervical lordosis...
You're 35 and you have degenerative changes in both cervical and lumbar/sacral vertebrae.
You have pain that wakes you up at night, which may or may not be related to a narrowing of the space that your spinal cord travels in.
None of this would be anything I would classify as "physiological variant of normal", because it's not. You should not have these changes at the age of 35, even if you BROKE your neck in high school.
UConn Julie,
Yes, Jeff the neurology teacher! Is that how you know him? Sorry to hear about the athletic training, but career wise, P.T. has a lot more doors open for it.
None of this would be anything I would classify as "physiological variant of normal", because it's not. You should not have these changes at the age of 35, even if you BROKE your neck in high school.
I would have to respectfully disagree with this point. Bryanc, don't take this the wrong way. I think this is a great opportunity to share our viewpoints in relation to Maxx's condition. I do respect your input and I hope there's nothing I could say that would make you think otherwise.
Maxx,this is just my thought process and a lot is speculative b/c I didn't take a detailed history and I didn't physically examine you. Make sure you get evaluate by someone thoroughly.
Maxx, given your history of what appears to be significant trauma to your cervical spine in high school, you've already begun the acceleration in the degenerative process; your cervical spine is compensating to maintain proper alignment (by the way, how tall are you Maxx?). You're basically trying to balance a bowling ball with muscles that don't know how anymore (that's revealed by your constant "pulled muscles in the neck" report). If you kept on playing, I would imagine continued contact with your "unbalanced" head. Weight training in the presence of dysfunction promotes more compensation. As far as lumbar spine, a rotation (which accompanies a tilt) is more common than uncommon as well as sacral and pelvic orientation changes. Repeated contact in football may cause forced hyperextension (trauma=compensatory changes)...weight-training with compensatory changes as I mentioned earlier promotes more compensation. I think you'd go a long way with a lot of soft tissue work and corrective exercises. It's smart of your chiro not to manip with all that's structurally going on, but also, it won't resolve the neuromuscular component. Just my 2 cents.
UConn Julie,
Yes, Jeff the neurology teacher! Is that how you know him? Sorry to hear about the athletic training, but career wise, P.T. has a lot more doors open for it.
I know Jeff because I was his clinical instructor during his first affiliation ... then we worked together for many years at Windham Physical Therapy ... he's a great guy and probably the smartest guy I know! He's now on faculty at UConn full-time ...
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Ok, so the consensus is that I go see an orthopedist. But what do I do from there? Will the orthopedist prescribe treatment? I like the sound of soft tissue work and corrective exercises--will the orthopedist be able to refer me to those type of things, or do I need to see someone else for that? Cost is not an issue, as my insurance will cover everything. But time is a concern. I work 7:30-7:00 and sometime later throughout the week, and tho I can miss some work, I don't particularly like to. Plus I will probably have to travel at least an hour to go and see someone. I just want to make sure I get headed in the right direction and don't end up having to go to 3 or 4 different doctors.
Find a reputable orthopedist who specializes in spine treatment. You want a guy who has looked at a lot of spinal MRIs and XRays.
Bring your actual MRI and any other films you have had taken of your neck/back. (not just the report) He/she will want to look at the actual films.
Explain the current symptoms that you are experiencing. Be sure to detail what you CAN'T do as well as where your pain is.
Hopefully the orthopedist knows a reputable therapist in the area who can get you started on the way to a healthy spine. You might need more treatment initially, with visits tapering as you go along, so be prepared for two to three visits per week initially.
Although sometimes it's a crapshoot, you can find a PT from the APTA website ... it looks like there are a few in your area ... I would shoot for someone with sports medicine and orthopedic interests.
Best of luck ... keep us posted on what happens ...
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I know Jeff because I was his clinical instructor during his first affiliation ... then we worked together for many years at Windham Physical Therapy ... he's a great guy and probably the smartest guy I know! He's now on faculty at UConn full-time ...
Yeah, Jeff was one smart cookie....I don't think I understood much of his class; I'm actually more interested now than when I was a student. Are you still with him at Windham PT?
Maxx,
In addition to getting a PT recommendation from the orthopedist, feel free to "interview" PT clinics to get a feel of specialization and training of their staff. Best of luck.
I would have to respectfully disagree with this point. Bryanc, don't take this the wrong way. I think this is a great opportunity to share our viewpoints in relation to Maxx's condition. I do respect your input and I hope there's nothing I could say that would make you think otherwise.
I'm not sure I understand. You think that his X-ray and MRI _are_ within the range of "physiological normal" for a 35 year old?
Either way, however, the primary symptomological issue is the shoulder pain, which, I think we can agree on (with the limited history we have) is likely related to his neck. He has a documented stenosis of the cervical vertebrae. Even if it's not ankylosing spondylitis (and it very well may not be; I'm just strongly suggesting that it be ruled out definitively--whether by physical exam or biochemistry), soft tissue work is NOT going to solve the stenosis problem. Bone remodels to biomechanical stress over time. I'm not even sure what biomechanical force could even cause a stenosis (i.e. uncovertebral--inappropriate growth of the bone _inwards_), but I'm pretty sure it's not going to be dysfunctional "pulling" of discoordinated neck muscles.
A 35 year old neck does not look like at 60 year old neck from a single traumatic episode 20 years ago. This is a _degenerative_ change. Even under the abnormal biomechanical forces you propose, from the imaging reports, this sounds like a much more accelerated deterioration that can be explained by "dysfunctional muscles" alone. I don't deny that "soft tissue work" may be beneficial, and a component of rehabilitation, but I think it would be leading MAXX down the garden path to lead him to believe that just because it happens to be the most appealing solution, that it's going to be the panacea of his condition. The possibility of a metabolic, endocrine, auto-immune or other systemic condition MUST be ruled out if any physician/therapist is going to do their due diligence. And I don't think anyone (including me) is able to do that over the internet. But I think there is sufficient evidence from the imaging reports alone that this needs to be done by someone qualified and in-person.
I'm not sure I understand. You think that his X-ray and MRI _are_ within the range of "physiological normal" for a 35 year old?
Bryanc,
I guess I'm interpreting "physiological normal" as someone whose not had any physical trauma or does not subject their body to daily repetitive abnormal postural stresses. Am I off in my interpretation?
Bryanc,
I guess I'm interpreting "physiological normal" as someone whose not had any physical trauma or does not subject their body to daily repetitive abnormal postural stresses. Am I off in my interpretation?
Sorry, I edited my post up there while you responded herel.
I made an appointment with a local orthopedist who deals with sports injuries. Some others who have used him said that he has referred them to other doctors who were really good. Should I print out some of the things discussed here so that I can ask questions?
Bryanc, great points. I've commented after some of your quotes.
Quote:
soft tissue work is NOT going to solve the stenosis problem.
I agree, soft tissue work will rarely change radiological findings. The goal is to "normalize" biomechanical forces.
Quote:
Bone remodels to biomechanical stress over time. I'm not even sure what biomechanical force could even cause a stenosis (i.e. uncovertebral--inappropriate growth of the bone _inwards_), but I'm pretty sure it's not going to be dysfunctional "pulling" of discoordinated neck muscles.
Wouldn't dysfunctional "pulling" be considered a biomechanical stress? Isn't there anything definitive in the literature that suggests what may cause degeneration?
Quote:
A 35 year old neck does not look like at 60 year old neck from a single traumatic episode 20 years ago. This is a _degenerative_ change. Even under the abnormal biomechanical forces you propose, from the imaging reports, this sounds like a much more accelerated deterioration that can be explained by "dysfunctional muscles" alone.
I'm proposing that the traumatic episode(s) started and accelerated the degenerative process...the resultant "dysfunctional muscles" would presumably facilitate this process. I just don't put a lot of weight into radiological films without the correlation to the complete clinical examination. Too often I've had patients improve significantly despite their involved radiological reports and some patients will not improve despite radiological films that show no abnormalities.
Quote:
I don't deny that "soft tissue work" may be beneficial, and a component of rehabilitation, but I think it would be leading MAXX down the garden path to lead him to believe that just because it happens to be the most appealing solution, that it's going to be the panacea of his condition. The possibility of a metabolic, endocrine, auto-immune or other systemic condition MUST be ruled out if any physician/therapist is going to do their due diligence. And I don't think anyone (including me) is able to do that over the internet. But I think there is sufficient evidence from the imaging reports alone that this needs to be done by someone qualified and in-person.
[/quote] I whole-heartedly agree, which is why I stressed that I was speculating in his case. My speculation was based on the assumption that he would see a specialist and be cleared for conservative management.
Looking forward to your comments Bryanc.
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?
Secondly, I think we need to understand a bit more about bone growth and remodelling in reaction to stress. Bone growth occurs in the direction of force, not against it. If you bend a bone, or pull on it, the bone becomes thicker on the "stretch" side of the bend, or the "pull" side of the pull; not on the other side. So if you consider that MAXX has growth _inwards_ into the spinal canal, the forces necessary to generate that growth would require either a bend _inwards_ or a pull _inwards_. Additionally, if we're referring to the neck muscles pulling "dysfunctinally" on the vertebrae, we would expect to see remodelling at the point of force, as opposed to remodelling of the spinal root canals or spinal canal itself. 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. We would also expect there to be a regular _increased_ axial loading (i.e. MAXX's head would have to get heavier; or he would have to be putting weights on his head as part of his weight training). And we would also expect him to be exposed to this increased load for a prolonged period of time each day to such an extent that the bone never quite reaches a homeostatic point of formation/turnover--since he has theoretically recently developed the shoulder symptom, which means that the bone must be turning over due to a ever-changing stimulus (similar to the training principle that if you don't increase your stimulus in weight lifting, i.e. load, tempo, reps, sets, etc; the muscle will only grow to a certain size)
In terms of the etiology of abnormal bone degeneration, we're looking mostly at metabolic factors such abnormal bone turnover, abnormal bone formation (not that I think MAXX has osteoporosis, but it is one example of abnormal bone formation and turnover); endocrine factors (hyper/hypocalemia, parathyroid hormone disturbances) and usually, other systemic factors (autoimmune being one example, and congenital being another--but I'm assuming that MAXX isn't Marfanian). The fact of the matter is that MAXX is having shoulder dysfunction which may be related to his cervical pathology AND has concommitant stuctural changes in his lumbar and sacral spine. Again, 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". We would also not expect the degeneration to occur so rapidly (MAXX is only 35!)--if the radiology reports are as severe as they appear to be. 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.
Neither of us as a complete clinical correlation in this case (I mean, every radiology report ends with "requires clinical correlation") This is limitation of the online forum. However, if someone asked, "I have a burning pain in my chest after I eat spicy foods," I would still likely answer, "Sounds like it could be heartburn, but I would still recommend getting checked by your doctor because it's possible that this a presenation of angina, or a heart attack, or a panic attack." "You need to stop eating spicy foods" might be a part of that answer, but I would definitely not leave it there, nor would I want to give the impression that spicy foods is the primary solution. So yes, we are both speculating, just from two different directions here. 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).
Again, I'm not saying that MAXX should NOT engage in soft tissue work, or corrective management to correct his posture, but that the signs he's reporting are enough to warrant a comprehensive investigation--not just medical clearance for conservative management. I think we're on the same page there.
Bryan, correct me if I'm wrong, but I think MAXX's MRI report did not mention central canal stenosis, but rather foraminal stenosis (at the level of C5-6 due to uncovertebral joint degeneration). So talking about central canal stenosis is moot.
Clinical experience in treating hundereds of clients with neck pain and degenerative changes encroaching upon the nerve roots tells me that if MAXX were to come to me for physical therapy, it is likely that he would benefit from an array of techniques including Maitland mobilizations, soft tissue work (as his muscles will have compensated for this problem and if we hope to restore full painfree movement, ALL tissue needs to be treated), scapular stability training, postural re-education ... etc etc etc. Because each individual is just that - individual ... what works for him specifically might be slightly different than what works for someone else. A good clinician will continually evaluate the effects of the treatment to determine if that particular treatment is effective ... and if not, make appropriate adjustments ... sometimes what works is surprising or unexpected. Do what works.
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Shoulder pain doing dips/spinal stenosis
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