Author: Dr Michael Quasney
Several years ago I got into a heated debate with some friends and fellow chiropractic students over the value of experiencing what our future patients would be experiencing. In order for us to really understand how to help someone we should try to feel their alternative and experience so we can know the solution.
There are many times in my clinical career where I have stumbled across a significant clinical paradigm just by paying attention to what I am doing in a specific movement or moment. This came to a noteworthy headway recently when I started to have significant pain in my left wrist and in my left shoulder.
Below are my MRI results and, as a general rule, you really don’t want to have a lot of words on any MRI you ever get. As you can see below there are a lot of words which means there are a lot of structural problems going on.
EXAM: MR ARTHROGRAM SHOULDER LEFT
FINDINGS: Osseous structures: No Hill-Sachs lesion or bony Bankhart. No fracture, dislocation,
or malalignment. No AVN. No significant glenoid or humeral head osteophytes. Type II acromion in neutral position, The acromiohumeral interval is normal, Normal coracoacromial ligament. Normal coracohumeral interval. Articular surfaces/joints: Intact glenohumeral joint articular cartilage. No significant acromioclavicular joint degenerative change. No tear of the
acromioclavicular ligaments/capsule or malalignment of the AC joint. No erosions or other secondary signs of an inflammatory arthritis.
Subacromial/Subdeltoid bursa: Normal.
Rotator cuff:
Supraspinatus: Mild tendinosis at the humeral attachment without tear.
Subscapularis: Mild tendinosis at the humeral attachment without tear.
Infraspinatus/teres minor: Mild infraspinatus tendinosis at its humeral attachment without tear. Normal teres minor tendon.
Biceps tendon: Intact. Normal biceps pulley and rotator cuff interval.
Labrum: Anterior superior sublabral foramen. Torn mid to posterior superior labral body and its glenoid attachment (images 13-15, series 6). Superior anterior sublabral foramen. Torn mid to inferior anterior labral glenoid attachment. On the Aber images, there is a tear of the mid posterior labral body and its glenoid attachment (images 6-8, series 13) over a craniocaudal distance of 12 mm.
Capsule: Intact shoulder capsule. Intact glenohumeral ligaments. No glenohumeral joint synovitis. No evidence of adhesive capsulitis.
Neurovascular structures: Normal.
Other soft tissues: Normal.
IMPRESSION:
1. Multifocal labral tears including the mid to inferior anterior labrum.
2. Mild rotator cuff tendinosis without tear.
3. Intact shoulder capsule.
MRI OF THE LEFT WRIST WITHOUT CONTRAST
FINDINGS: There is significant inflammation in and around, and fragmentation of, the abductor poilicis longus tendon and extensor pollicis brevis tendons as they extend from the level of the distal radius to the base of the thumb, with peritendinous fluid but no retraction. Inflammation and ligamentous thickening of the dorsal radial ligament and the anterior oblique ligament of the first metacarpophalangeal joint. Fluid is seen around the extensor digitorum longus tendons but no tear. Tendons are otherwise intact. The scapholunate ligament is thickened, irregular and indistinct with greater than expected fluid in the scapholunate joint. Lunotriquetral ligament appears to be intact. The triangular fibrocartilage is normal in size, shape and signal except for a small focus of linear signal adjacent to the radial attachment (coronal image 11, series 7) with a small amount of fluid in the distal radioulnar joint. Except for some degenerative subcortical cyst, bone marrow signal is normal. Alignment is normal. Carpal tunnel structures are normal. No masses, cysts or bursae
IMPRESSION:
1. Partial tears and tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons
2. Strain or partial tears of the dorsal radial ligament and anterior oblique ligament of the first metacarpophalangeal joint
3. Scapholunate ligament tear.
4. Question small perforation of the triangular fibrocartilage near the radial
As with most of our patients, there was no singular moment or accident or fall or anything that really made me feel that I was injured all of a sudden. What I did feel was that my left wrist and left shoulder were feeling worse and worse. What I can say is that, for several years, I felt my left arm was weaker in pushing motions, and with some pressing positions I would have a 3/10 pain for a brief moment at a specific part of the movement. That was really all the warning I had. Just a little bit of weakness and a little moment of pain. But that was enough for me that I should have paid more attention and really felt what was very obvious in hindsight. I have much less control over my left shoulder blade than my right.
Once pain started, things began to unravel pretty quickly. It first started at the wrist, then it was the left elbow, then finally the left shoulder. At some point, I would have 10 out of 10 pain when trying to grip things with my left hand, so much so that I would literally fall to the ground and grab my wrist out of pain. I would try to sleep with a splint on my wrist. I even had to learn to wipe my bum with my opposite hand as that precise motion was impossible to do with my left wrist. Becoming an ambidextrous bum wiper is a very weird skill to acquire in your 40s.
Despite all of this, I was still able to build a fence that involved a crazy amount of digging and heavy machinery and took several weeks if not the entire summer to complete. I was able to do handstands with my friend’s daughter. I was able to ski for several seasons. I was able to do jiu-jitsu with some mindful modifications and lots of early tap outs. I was able to treat and adjust patients in many different ways with many kinds of forces. I could deadlift 1.5 times by body weight almost the whole time. I was eventually able to get back to our staff standards and do 20 gymnastics pushups and almost do 5 chin ups. I was able to work out and run and enjoy a lot of my life. There are definitely things that I had to temporarily give up. Duffing a shot in golf was excruciating and I had to leave that sport for about a year. Push-ups and overhead pressing are still very hard and are uniquely challenging positions to my shoulder. My left wrist still has a little loss of extension which makes it tricky to push off the ground with that hand at times.
Through all of this, I really doubt many of my patients knew anything was wrong. From their perspective, it was just another work week for me. It was just another appointment where I was constantly demonstrating lots of movements for them to perform. This is not to say there weren’t bad days and some times where I really had to modify my work environment. At no point, however, did I feel like I could not do my job safely and still provide the care that patients needed.
All of this is to say that function and control are really important. I know there is no way I could’ve done any of these things without knowing how to brace my trunk, use my hips, and stabilize my shoulder blade. There were so many times where I was able to spare my shoulder and wrist by using other parts of my body more and I fully know that if I were not able to do that, I would have had much more pain and not been able to do much in my life or profession. This is just another example among many moments in my life where I felt that the skills I had really protected me from a lot of pain and a lot of worry.
To be transparent, I would absolutely prefer not to have any of these structural problems. I would have preferred to find out why this was happening in the first place and fixed it ahead of time. I would prefer not to potentially get surgery in the future. I would prefer to have made the perfect evaluation system that would have shown me that I was vulnerable to injury. I would have liked those options to what I have now. But this experience does let me confidently tell our patients that the option on how you use your body is extremely important to how you experience pain and how well you can function.