Injured Shoulder: Rotator Cuff Supraespinatus Partial Tear

Patient

Q: Will summarize my case as quickly as possible: Last year at around this time I started an extensive workout program. Following this workout program I experienced twitching/fasciculations throughout my body, but didn't think much of it as I just related them to the demanding workout routine. Twitching became more obvious and I developed a tremor on my left arm/hand, especially noticeable upon exertion. Left arm seemed to fatigue rather quickly which made this tremor worse. Naturally, I looked up these symptoms online and bumped into ALS so I panicked. Stopped the serious working out around last August, but continued to test my strength (especially the left arm). I would normally do dumbbell curls with heavy weights, but important to note that since I was just testing my strength I didn't warm up my muscles at all. Around October I wake up in the morning and notice that a piece of my short head bicep running up to the anterior shoulder seems to have been torn off. Indentation on the bicep is very noticeable and I have what looks like fresh stretch marks at the site of concern. I realize stretch marks are caused by gaining muscle, but can also be caused by rapid loss of muscle which is what looks like happened in my case. Of course I panicked, thinking muscle twitching+visible muscle atrophy=ALS. I make an appt with my Dr. and still continue to test my strength. Strength doesn't seem too affected, but the arm tires unusually quick and I also get a mild pain at the bicep indentation and the shoulder area. I also notice that my deltoid is no longer round and has lost some mass. Not completely gone but definitely flattened. My Dr. examines me, does bloodwork, books me for an EMG and sends me to a Neurologist as he knows what my biggest fear is. I've had 2 EMG's on the left arm and 2 different neuro check ups. The EMG's were normal and the neuro appointment was also normal. GP sends me for an ultrasound of the left shoulder. Ultrasound says: "an irregular 8x4 partial tear, undersurface of the supraspinatus tendon insertion. Mild hyperemia on Doppler images shown. A small peritendinous effusion. The remaining rotator cuff, long head biceps and tendon and AC joint images are unremarkable. No impingement with movement." So here I am....with an atrophied left arm and now some scapular winging. Twitches are still felt and I am still concerned about an MND like ALS even though the Dr. says that both EMG's are reassuring that it isn't. I just want to know if it is possible for an injury like the one presented in the ultrasound can be responsible for atrophy of the shoulder, bicep, deltoid and scapular winging??? This has been giving me alot of grief and anxiety and I am sick of being worried, but I can't help but see the atrophy everytime I look in the mirror and take a shower. Any ideas on what is going on? I intend to request an MRI just to see if there is anything else going on in the upper arm. I apologize for the long message and thanks in advance for your advice and help.

Doctor

A:   There are several causes of arm-shoulder pain; one of the most common is the Rotator Cuff tendinitis and this seems to correspond with the description that you made of your pain. The rotator cuff is a group of tendons that support the shoulder. These tendons can be injured during weight lifting, when playing sports with a lot of throwing, after repetitive use over a long time or suffer degenerative changes with the aging process.
Typically, presents with an activity related dull ache in the upper outer arm and shoulder. Activity is commonly more difficult and painful above the shoulder level (more than 90 degrees). There is little or no discomfort with below-shoulder-level activities (less than 90 degrees) such as golf, bowling, gardening, writing, or typing. But, tennis, baseball/softball, basketball, swimming, and painting are more problematic and painful. The lesions of the rotator cuff represent a wide array of diseases, from acute reversible tendinitis to massive tears involving the supraspinatus, infraspinatus, and subscapularis, these are the muscles of the rotator cuff. The diagnosis is often made through detailed history and physical examination, and confirmed by imaging studies. You have an imaging study that confirms the incomplete tear of the supraespinatus tendon. Sometimes the healing process takes longer than expected and this depends on each patient in particular. It is very important before to do any exercise or straining physical activity to have an initial warm-up and stretching of the muscles, also when you start an exercise routine the demands have to be progressive and gradual, and the time and days that you dedicate to exercise must be consistent and regular to avoid injuries. There is a very well described entity in the medical literature called: Overuse Syndrome, which can affect any part of the body that is over stressed with movements or activities in a repetitive way, including occupational, recreational, and habitual activities. Repetition is part of the definition of overuse injury. The concept is that overuse injury is associated with repeated challenge without sufficient recovery time, and this is true for Body Building, Running, Jogging or any other sport or activity in which you exceed the guidelines and your own limits or capacities.
 
Conservative treatment of the Rotator Cuff tendonitis involves: physical therapy to control pain and keep range of motion of the shoulder, avoidance of painful movements and activities; anti-inflammatory drugs (i.e.: “Advil”, “Aleve”). If the patient shows poor or no improvement, then, local corticosteroid injection may be considered.

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