Joe A Shaw PA-C - 3/25/2008

Question
QUESTION: Hi - I injured my left shoulder 8 months ago when I awkwardly lifted two 40 lb. bags of dog food - I felt deep pain in shoulder and down my bicep. I continued to have pain/problems, mostly with bringing my arm across my body, supinating (could never really get my palm flat), and reaching up or out to side (pain would increase if I contracted my bicep while reaching). I also had bad pain with internal rotation against resistance, like pushing a sliding door. I did PT, cortisone injections, and acupuncture with no benefit. X-rays showed some spurring and MRI arthrogram was negative for tears, but showed some OA of AC joint and a very narrow subacromial space.
Three weeks ago I had a subacromial decompression and clavicle debridement. Labrum was fine, as was rotator cuff, including the subscapularis; bicep tendon was "pristine."  My doc felt that the pain in my bicep was referred/compensatory and that surgery should take care of the pain I was having before.
I have started PT and am getting my ROM back.  My concern now is that I am feeling the pain that I was feeling before the surgery - most especially when I bring my arm across my body and with internal rotation against resistance.  Do you think it's too soon after surgery (i.e. things have to start working again), or should I be concerned that the original problem hasn't been diagnosed/addressed?  Any thoughts as to why I might be having this pain since the main structures of the shoulder looked ok? Sorry for the long question; thanks for your time!   Sue

ANSWER: Sue,
You give a great summary and it looks like the ortho covered all the regular kind of things. The subacromial decomp. surgery is quite common. Some of what you are going through I would say is still too early to tell if it is normal or not..I think at 3 months you will know if it is the old pain or not.

If it is coming back I think they need to really look at the bicipital tendon/groove etc..There are several articles which point to the fact that this can cause chronic anterior shoulder pain and is misdiagnosed as rotator cuff type of pain. I have attached a rather lengthy article but based on your note I think you can understand the bulk of it..I skimmed through it...and 3/4 down they talk about bicipital groove type of pain and how it is much more common in women etc.. I know the ortho said the BT looked good..but I don't know if he can tell how well it glides and what not during movement. This article also talks about the BT and the different grooves,flat grooves,angle grooves etc..this is what the BT moves through as it is used...a canal or groove of sorts.
Ignore the potator typo in title and it is from the Chinese journal of clinical medicine..but Im sure they are quite familiar with shoulder injuries etc..with all the world class gymnast they produce...again just something to study.  

http://www.cjmed.net/html/20061217_6.html?PHPSESSID=4ad6cf901c06805a25d0c0377237

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

QUESTION: Thanks for your quick response Joe. I, too, have wondered about the bicipital groove. At times when I have felt pain when contracting my bicep while reaching (especially overhead), I have also heard/felt a painful "pop" or "clunk." Could this be the tendon popping out of the groove?

Answer
Yes..it could be..also the labrum tears can "clunk"..but ortho said labrum was okay?...again the BT may look okay as well, but if you have a congenitally shallow groove it may pop in and out with certain movements. google test for subluxing biceps tendon. And see if this reproduces the sensation or pain.

Also look up Yergason's test--This is more for tenosynovitis of the BT (ie the sheath around the BT is inflammed causing it to move in and out of groove).
But if you rec'd a cortisone inj to this area it should have helped I would think..and you should have more anterior shoulder pain with these bicep conditions more so than other shoulder cond's.