As a shoulder surgeon, there are a few diagnoses you hope you never have to make… and today’s story is about one of them. A 54-year-old man sat in the exam room, seeking a second opinion. Only a handful of diagnoses in my world cause someone to look that miserable. Tim was holding his arm tight against his side, and he looked like he hadn’t slept more than an hour in two weeks. He described his pain as someone driving a hot spike through the top of his shoulder and down the outside of his arm.
His history was simple … there was no fall, no gym injury, and he didn’t spend a weekend painting a ceiling. He’d had a mild respiratory illness about five weeks earlier, and then one night the pain came on and hasn’t receded in weeks.
By the time he reached my office, the machine had already done what the machine does. He’d been to the emergency room, where his X-ray was normal. He’d had a shoulder MRI that showed “tendinosis and a partial-thickness rotator cuff tear.” He’d had an ultrasound-guided cortisone injection into the bursa above the rotator cuff, which did nothing, and he’d recently started physical therapy, but he could barely tolerate it. A well-meaning surgeon looked at the MRI, watched him struggle to lift his arm, and scheduled him for surgery.
This story doesn’t add up, and I suspect you can already feel it too. As I have always said, your story, exam, and imaging studies have to tell the same story. Otherwise, we might be treating imaging findings and not the cause of pain.
A partial-thickness cuff tear doesn’t produce the worst pain of someone’s life overnight, and when a patient’s pain is that far out of proportion to the MRI images, we should look for another cause. Furthermore, if you inject the space you believe the pain is originating from and get no response at all, you probably shouldn’t be planning to operate in that space.
From the moment I saw him, I knew it was one of a small handful of possible diagnoses. His X-rays were normal, so it wasn’t calcific tendinitis. His MRI was pretty normal for his age, and there was no evidence of a frozen shoulder. His exam findings showed subtle scapular winging, and he had some weakness around the shoulder— not unexpected given the severity of his pain, but he also had some hand weakness that you shouldn’t see with ‘shoulder’ issues. And no… his neck didn’t hurt either.
Now his diagnosis was clear…
For Members, I’ll walk you through this gentleman's diagnosis, why it’s missed so often, and the handful of simple exam findings that should make any of us stop and think... certainly before scheduling surgery. We’ll cover which tests help and which ones mislead, what treatment actually works, how long recovery really takes, and the questions to ask if you, or someone you love, wakes up with shoulder pain that nothing seems to touch.