An educated shoulder question

[anhospog]

After struggling with regular shoulder pain in both AC joints for the past 18 months which included orthopod visits, xrays, MRI, steroid injections, 2 different physical therapists, NO bench or overhead pressing and consistently following the movements from both the Inside/Out DVD and the shoulder articles from T-Nation, I am down to one question. My xrays show a couple small osteophytes on the clavicular part of one of my AC joints. PT thinks if we get just the right angle we'll see osteophytes on the other AC joint also. The first PT suspected impingment but after 6 weeks of his exercise regimen and following Inside/Out I was still having substantial bilateral AC pain. The second PT does not suspect impingement but simply AC arthritis. This makes a certain amount of sense since even simple range of motion across my body leads to shoulder pain. My question is how many times have you seen AC arthritis as a primary disease with no impingment syndrome? If this is really my problem surgical intervention seems inevitable. The problem I'm having with accepting this is my muscle function evaluations by the orthopod and first PT took all of 1 minute and the second PT took all of 30 seconds. That is no exaggeration. I'm really uncomfortable sucuumbing to surgery after such cursory exams but if I can't perform range of motion it is very hard to follow the Inside/Out exercises. By the way, as far as pain, the steroid injections were miracle cures which lasted a month or so. I do not seem to have a type 3 acromion so I can't help but think if I knew exactly which muscles were short and which are long perhaps I could know which rehab exercises are helping and which are hurting any potential imbalance. Anyone know of a top notch PT in the New Orleans or Mobile, AL area? I would be more than willing to drive a few hours for a thorough evaluation and some educated advice.

[UConnJulie]

Well, if you have osteophytes, I don't see how he/she would say that you don't have impingement! Any time there is anything compromising the rotator cuff tendons, whether it is a type III acromion, or osteophytes, or poor mechanics resulting in decreased subacromial space, and they cause pain with shoulder movement, in my book, that is impingement. Here is some good info from the AAOS.

The problem with letting it go too long when you have osteophytes is that the tendons eventually get "worn down" by the bone rubbing on them, leading to further rotator cuff pathology and eventually tears. If there are no tears, the surgery to trim away the spurs is frequently done arthroscopically, and recovery is fairly easy.

Have you seen another surgeon for a second opinion?

You can search for a PT on the APTA website, which is not always a guarantee of a quality therapist.

Here are some things to look for in a good physical therapist ...

[anhospog]

Julie, your info was very helpful. I found a local PT from the APTA list who teaches at a PT school and who seems to have an interest in shoulders. He's the first I've talked to who mentioned me needing a thorough hands on eval and to expect the visit to take more than a few minutes. I am trying to find a radiology clinic to perform an outlet Y view since all the other views have been standard AP views. Thank you for your help.

[UConnJulie]

Glad to be of help ... please keep us posted on your experience and how things turn out!

[bryanc]

Herein lies the problem with plain-film x-rays in what is essentially a soft-tissue problem:

Plain film x-rays show soft-tissue problems very poorly, if at all.

The presence or absence of "bone spurs" or osteophytes is not a reliable indicator of shoulder pain, particularly if they are small. There are many people who have osteophytes who never experience any pain or problems, so don't be so quick to blame it on the poor osteophyte. Just because you have a radiologic abnormality doesn't mean that it is the causative factor of your problems. There are several ways in which an osteophyte could have absolutely nothing to do with your impingement symptoms--the most obvious one being that the osteophyte might not be in the subacromial space at all! Not having seen your images, I would not speculate that you have de-facto impingement just because you have osteophytes.

Primary AC osteoarthritis is VERY uncommon. And same-time-onset bilateral osteoarthritis is equally as uncommon, if not more so. I agree that you possibly need a more thorough assessment of your shoulder function, but don't hang your hat on surgery fixing your problems either. The story you present here is not a classic osteoarthritis story; and I would be leery in leading you to believe that that's where your answer lies.

[anhospog]

Bryan, thank you for your input. As a veterinarian, much of my day is spent with my arms forward and my chest/sternum flexed forward either doing surgery or examining patients on exam tables. I think it is this "taco" position for the past 15 years that has caused my problem. I have finally developed enough range of motion to perform face pulls and seated rows to try to offset my 10 hours of daily "taco" position. I agree it is hard to believe both of my AC joints developed primary arthritis at the same time. My MRI and AP rads do not give a view allowing visualization of the subacromial space. I'm trying to gain access to an outlet Y shoulder view which may help with the osteophyte question. Each piece of information allows me to make a more informed decision. One of the decision making problems is we go to orthopedic surgeons to get musculoskeletal advice and surgical repair tends to get recommended. Surprise. For me personally, surgery was offered with NO recommendation for physical therapy. Hopefully, my next physical therapist will spend a little time evaluating my problem. I'm a veterinarian and I'm able to give each patient a full 30 minute appointment so I can give each case the time it deserves. I can't imagine spending 1 or 2 minutes doing a patient evaluation. Each time I'm exposed to the human side of non catastrophic illness I'm thankful I chose veterinary medicine. We certainly have time and financial pressures but they pale in comparison to the human side.

[LisaS]

if you are wary of surgeons seeing surgical solutions, have you considered consulting a physiatrist with an interest in sports med?

[UConnJulie]

Or an osteopath who specializes in non-surgical interventions ... I personally see this group ... Valley Sports Physicians