Charles V. Toman, MD - 4/15/2009

Question
QUESTION: How long after surgery should I start filling
better I.e. No pain at night, when working, and
relaxing?
Some history I am a 37 year old female who
had a fall in 7-06. This fall I stepped into a
hole and injured my right wrist, right ankle,
right shoulder.  After having x-rays done that
showed no fractures at the time. I started with
my right wrist because that was the most
painful. After seeing the Ortho he splinted my
wrist for 3 wks. I went back still having pain so
I started therapy.  Pt falled and then a MRI
was ordered and that showed I had a TFC
tear. So I had surgery 3months after the fall.
The was repair of the TFC tear and
arthroscopic partial synovectomy, and open 1st
dorsal compartment extensor
tenosynovectomy. So my wrist heal and is
doing great now. So the next thing I focased
on was my right shoulder.  I had an injection
for impingement of my rt shoulder and started
PT. At first I got releaf then the pain came
back so I contued Pt and had a MRI of my rt
shoulder. The MRI showed distal rotator cuff
tendinosis or partial tear.  After having another
injection and going through Pt for 4 months I
had arthroscope surgery. There was no tear
but the doctor did a subacromial
decompression. I have to say I had a great out
come. I was using my arm that week and
working with out pain. I thought arthroscopic
surgery was the greatist thing. So I then turned
to the pain I had in my ankle. My ankle was
still swollen after 6 months of Pt and was
causing me to walk with my foot out ward.  So
after MRI I had arthroscope surgery to clean
up the joint with debridement. I have had a
good result from that I no longer walk
incorrectly which has helped my my back. So
after that long history everything sounds great
but in 7-08 I was attacked by a rottie at work.
So in that attack I had my right arm (bicept)
bitten. In that attack the dog got his jaw stuck
in my sleeve and the owner was pulling him of
me and I was resisting him so I would not fall.
So in the struggle I was pulled so hard my
shoulder started to hurt 3 days later and was
very swollen. I could not use my arm and it
was in so much pain all I could do was cry. I
also had a puncture in the middle of my bicep.  
So having now dealing with workmens comp I
was told that would have to see a different
Ortho than the one who did the first surgery.  
So I went and a new MRI was ordered and it
showed osteoarthritis of the AC joint and
subacromial bursitis and minimal evidence of
partial bursal tearing no full thickness tear.  So
at that time the new Ortho gave me an
injection and 4 weeks of PT. After that I did not
improve so a artheogram was ordered. The
artheogram showed a full thickness tear of the
rotator cuff so surgery was scheduled. I had
surgery in October 2008 to repair the tear. So
when I woke up the surgen tells me that there
was no tear and he can't explain why. He did
remove more bone and cleaned up the bursa.
So hear is the problem I have not gotten any
releaf from the surgery I have taken the Motron
and pain meds like clock work and gone to PT
3 times a week for the last 10 weeks. I had an
injection 2 weeks ago to take down the
swelling.  So I am in pain 24/7 when I am
using it. it  swells and is having sharp pain.
When I am resting the pain is throbing and rule
ach. When I sleep the pain is sharp stabbing
and throbing. I can't lay on my shoulder and if
someone tuches it I have pain run up my neck
and down my arm. One last thing when I use
my arm my whole arm swells and gets week.
This happens after 30 min of work.  So I am
wondering is this something I will have forever
or should it get better with time.  Also is there
another problem that could be going on? So when do you ask for s 2nd opion? also because this a work comp I have been passed to a Medical Reab specialist.  This doctor has told me that I have scar tissue with impingment of neuv. And that there is nothing that can be down. So I have been getting Acupucture for 3 weeks and I dont now if it is helping the pain has changed from ach to burning so I don't now what to think.  I still am having issues with the fact that I had a arthrogram that showed a tear then there was not one.   
Thank you for your time.



ANSWER: Janice,

First of all I am sorry that you are having to deal with all of these problems.

As for your shoulder, it is entirely possible for an MRI or MR Arthrogram to be wrong.  Typically with an arthrogram, though, the rotator cuff is either torn or not because you can actually see the contrast material pass through the disruption in the rotator cuff.  Without seeing the actual images it is impossible for me to tell you if there was or is in fact a tear. Also it would be unusual, but not impossible for a surgeon to miss a tear on direct examination of the tissue during arthroscopy.  Some tears are very small and can be covered by bursal tissue.  

When you said that one of the Doctors diagnosed you with AC joint arthritis, did they perform a distal clavicle resection at the time of surgery?  I don't think you mentioned this.

The pain that you describe as going up your neck can be caused by arthritis or inflammation in the AC joint.  My questions would be, do you have tenderness directly over the AC joint?  Do you have pain with cross body adduction - reaching your arm to the opposite side of your body?  Do you have weakness holding your arm in this position with resistance?  These are the typical tests for AC joint arthritis.

An easy way to see if your pain is coming from the AC joint is a diagnostic injection of lidocaine to see if your pain and symptoms resolve with numbing of the AC joint.  Your physicians should be able to do this for you in clinic.

The other possibility, assuming the surgeon who performed the arthroscopy did not miss the tear, is that you now really have a tear or a re-accumulation of bursal tissue.

These are the things that I would think about if I were examining you.  

If all you had done was a subacromial decompression, you would have no restrictions after the surgery and would be released to full activities as soon as you could manage them.  Recovery time would be weeks with minimal therapy.

Hopefully, this has been helpful.  I feel you need further evaluation.  I don't think acupuncture will help in this instance.
Let me know if I can answer any other point which I may have missed.  I would be happy to try to elaborate on any point that I may have confused you on.

---------- FOLLOW-UP ----------

QUESTION: You asked did they perform a distal clavicle resection at the time of surgery.

They did not, What I understand is the surgen did a subacromial decopression with debridement of tendon that was frade. The surgen seamed to be upset after the surgery because there was no tear on exam. He has given an injection at the 6wk post-op point which for about three days gave some releaf. The doctor seamed to not have any answers for me after that other than my shoulder should be better. Also he gave me a script for Mobic 15mg which did help until I had a problem with my blood pressure going up. When that happed he decided to discharge me as a patient and send me to the rehab doctor. The rehab doctor has told me that I have scare tissue and there is nothing to be done and except it as it is. My only problem with this is that I had a good result with first Subacroial decopression on this shoulder I was back to all actevities in a matter of days, pain was gone in 2 months so I have a hard time excepting that this shoulder can't be better. That is why I asked for acupucture.  The one thing I dont understand is that no one has suggested to break up scar tissue or do injection under florascope. I am confused why the surgen and this rehab doctor don't wont to try more things to help my pain. I fill that I am being treated like I wont to have a perment injury. I have been asked to settal by the insurance which I dont wont to do. I have worked sense the injury the only time I have taken was the one week after the surgery. I have no intension of not working. I am to young and I enjoy my way of living I have also asked if I need to take off more time for healing and I am told no I need to use the arm. So that is why I asked if I should seek a 2nd opion to the Ortho?
I have tried the Gel for pain it did not work.
I have tried ahsaid patch it made my arm more painful in the surounding area except where the patch was.
I do excersises daily. The one good thing is I have my range of motion. It is painful when I take it though that range of motion. Even typing this e-mail is causing pain in my shoulder in front and the back part of shoulder. it fills like when you have over worked your arm swimming or tomany curls and you have to rest it to have the pain go away. I do have pain when reaching across and if I am holding something my arm gets very weak to the point I have to put the ideam down. I still cant lay on my shoulder and if anyone comes near that arm I get prodective of it. So I don't now how to get the work comp to give a 2nd opion with a ortho? well thank you for your time and the info you have given has been helpful.



ANSWER: I understand your feelings of frustration.  I have seen many patients who have been relegated to the "rehab doctor" who tells them that they have to live with it.  i am unsure of the procedure to get another opinion, but it probably requires lawyers and such. Based on your remaining symptoms it sounds like your distal clavicle arthritis may be contributing to your symptoms.  

I don't think a fluoroscopic injection would be helpful unless your doctors have some question regarding their certainty that they placed the injection in the correct place.  As for breaking up the scar tissue, you have excellent ROM and this means that you have limited scar tissue.

I would do what you can to seek out another opinion.

Again, sorry that you are having to go through this and hopefully this has been helpful.


---------- FOLLOW-UP ----------

QUESTION: So I have another question. If they missed a very small tear could I have made a bigger tear when I went back to work. There was a time two weeks post-op I was at work and I had been bathing a dog in a raised tub. I did not lift the dog or strugle with the dog, but after I was dune my arm was in as much pain that day as the day of surgery and I could not move my arm very well with out pain.  I called the PT and asked what I should do did I reinjury my arm he told me that I just flared it up and to ice it that day and keep my scheduled appointment.  I also called the surgen and he told me the same thing. So after a couple of days of icing and going to PT I could move my arm. But the pain contued. So could I have reinjured the arm at the time? another question is the lateral part of my shoulder is like a soft sponge is that normal?
And a new problem today I was holding a dog while putting the animal under general anesthia and while he was going threw the excitement stage I was holding him and win I now longer had to hold him my arm felt like it was not right so I stretched it and it was very painful. Then all day when I would go to reach for something my shoulder would fill like someone one was holding it forward and I would have to push on my shoulder to get it to fill normal is that when it becomes unstable. I have been having to take my other arm and push on the back of my shoulder area to getit to stop hurting. It was bothering me so much that I took part of my day off.
I dont now what it fills like to have a dislocated shoulder, but what I have read and heard I may have donne that could you tell me what that may fill like and if I should go and get an x-ray tomarrow? Thanks again for all your time I wish all surgens and doctors where able to discuss problems in this manor.

Answer
It is always possible to have a progression in a rotator cuff tear.  Could they have missed the tear - yes.  Could it have subsequently increased in size - yes.  Is it likely - No.

Yes you could have re-injured it.

I don't know why your lateral shoulder would feel like a sponge.

It is very difficult to imagine that your shoulder is dislocated or could have been dislocated in that manner.  You may have a subtle instability which leads to the sensation that the joint is out of socket.  

If you had a dislocation there is typically a significant amount of pain.  

If you have any question that it is dislocated you should see your physician and allow them to perform an X-ray.