Sunday, October 31, 2010

Shoulder update

It has been many months since the last post regarding some shoulder problems. Here is an update on the situation after many months and several mistakes taken on the diagnostic pathway. I'd have liked to make these updates in real time, but I continue to live in another world of family/full time work/part time school that has isolated me from many other activities.

While the exact trauma can be traced to a particular day, I think that I've got a particular physiology that makes this type of injury harder to recover from and easier to to get on my right shoulder. I naturally have bad posture, and participate in an activity that contributes to slouching and rounded shoulders (ie biking). Not just cycling but mountain biking with several years of falling and rolling probably a few landings on outstretched arms all leading to stresses on the AC joint. The bad posture contributes to shoulder impingement by decreasing the amount of space in which shoulder ligaments have between the shoulder socket and the AC joint. The smaller this AC space the easier it is for the ligaments to get caught or impinged. This right shoulder has always seemed to have a strength imbalance compared to my left side, even though I am right handed.

For years I've easily 'thrown my shoulder' out when tossing a ball or a football. When doing turkish get ups with my right arm, I was fine when the arm was totally vertical in plane. But, if it got off angle at all, my arm would almost buckle when compared to my left arm. When viewing my trap muscles from the front, my left side is noticeably bigger and stronger.

I'd been working out 2x a week at crossfit, and really loving it. I loved the combination of high intensity, camaraderie, and time efficiency. 1 hr in and out, endorphin rush, and full body workout. We'd been doing some pushpresses . Light weights, high reps. The problem was my bony AC joint. I've got a point bump there, I think I've always had it. But every rep, I kept landing the bar onto this bump.

The next few days it was sore, but didn't think much of it. At first, while my bony AC joint was tender to the touch, it was my shoulder muscles that really felt bad. Any motions that caused isometric contraction of the front of the deltoid, such as pushing, sanding, RIDING MY BIKE hurt. The muscle just felt engorged or overloaded. And the bicep tendon running up the shoulder was tender and swollen. Additionally, and in hindsight the really telltale signs, were pain in movements where the arm crossed the chest and when moving the arm in an arc to overhead, the last third of the motion hurt.

I followed the natural course of action of rest, and ice, and ibuprofen. Combine being very busy with inherent desire to not go see doctors and I waited much much to long before doing something.

Several cycles of this and it really never went away. Finally, I went to my family doctor.
1) Mistake 1: Not going to go see an orthopedic specialist the first time. They took and xray and he prescribed high strength naproxen. The staff radiologist said the X ray was in spec and that the AC spacing was ok and there as no separation.

Several weeks go by, some improvement but not that much. Then I went to see a sports doctor.
2) Mistake 2: not going to see an orthopedic specialist. He prescribes PT. I go to PT and the PT assessment shows significant strength imbalance in my internal and external rotators on my right arm, and bad posture consisting of shoulders rolling forward which contributes to decreased AC spacing and potential for impingement. A combination of tight chest muscles and weak back muscles helped perpetuate the hunched forward position. The exercises several for internal/external rotators, stretching the chest. Plus some ultrasound and icing using the game day machine

After weeks of little to no activity, the PT was welcome. My whole shoulder system was so weak. We started with the lightest band and the smallest weights. My deltoids were just blown. afterwards.

Over the course of a few weeks, my strength definitely increased and the stability of the whole shoulder improved, but the pain the certain movements continued. The reassessment showed the improvement but still some significant weakness compared to the left arm.

Finally went to go see the orthopedic specialist. He does his assessment and history and then looks at the first xray I'd gotten months ago. The same xray that had originally come in as being fine. He takes one look at it and says AC osteolysis.
Also known as weight lifter's shoulder. Also known as arthritis of the AC joint. This issue is common with people who weight lift for a long time or do lots of overhead work. Ironically, bench press is also known to cause this problem and bench places significant stress on the AC joint. Along with dips. Pull ups also can aggravate it. I have been lifting off/on since highschool. But rarely did overhead work till this year.

The next step was either a cortison injection right into the joint. Which would be a definitive diagnostic more so then any sort of cure. But I wanted an MRI just to be sure that there wasn't anything else going on, because so much of my issues seemed to involve muscles and tendons.

As part of the MRI they also retook xrays.

If you look close in the XRAY you can see some black spots where there should be bone. This is the part of my clavicle that has eaten away. Healthy bone would remineralize back.

You can see the bump I speak of in my AC joint. The MRI was so weird. It was a contrast MRI which involved injecting dye into the shoulder area. The whole MRI experience was interesting but not something I'd like to go through on a regular basis by any means. Thankfully I'm not too claustrophobic. Here are some of the shots of the dye being put in:

And the MRI with the dye

The MRI came up fine, maybe a little bit of tendinitis, so the next step was the cortisone shot. He'd said that it may cause temporary relief or it may be all I needed. Several cortisone shots could be taken over the course of a year. Though there are some negatives of multiple injections. Surgery, an arthroscopic technique known as Distal Clavicle resection aka mumford procedure would be a final step if the cortisone didn't offer enough relief and I didn't want to continue dealing with the pain.

Getting the cortisone shot hurt like all get out. Like someone was taking a hammer to the joint. It was sore for a few days, and then all was good. The pain is virtually gone, it still hurts in certain places especially when puttting on/taking off a shirt. But the important thing is that I can bike again. I still ice it afterwards but other than that very little issue.

Who knows how long the shot will last. But I will put off any surgery as long as possible.

It was a bad summer/fall. School was/is very bad, combined with being unable to do much exercise at all and riding just made for some generally negative vibes. I felt like I lost out on a whole summer. But now that I'm back on the bike I feel much better.

I guess like many things in life, I took for granted the ability to ride. I've realized how much I miss it, and the social interactions of riding with friends. Missing all that time wasn't fun, but coming back to it helps me value this time much more. Plus starting over is good. I can relearn good habits instead of ingraining bad ones. It's taking several rides, but I'm amazed at how well the legs are starting to come back and how well the feeling of moving with the bike is coming back.

I still am gun shy on the downhills, and I can tell I don't have total shoulder stability like when I was lifting a lot. As soon as I can get past this class I'm going to restart the Morris lifting plan and stick with that into winter and ride when I can. Doubtful that I'll go back to the other xfit even though I miss the style of working out. But I think that the highrep workouts aren't the best thing for my joints. I'd like to do some yoga maybe as the one thing I can really feel from returning to the bike is lower back fatigue.

Lesson's learned.
1) the shoulder is very very complex, and not to be messed around with. If it feels bad go see an ortho w/o waiting.
2) cycling is a wonderful sport. Road riding, mountain biking, doesn't matter. For me, it is more than just an activity.
3) while different types of working out provide more balanced body development, there is no substitute for time on task and actually pedaling your bike to get better at actually pedaling the bike.

It's not over yet I'm sure. I've heard lots of people's cortisone stories so we'll just see the next step.


At 4:32 PM, Blogger DrG said...

Good to see you're back on the blog and your shoulder isn't getting the best of you ;)

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