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Help with MRI intrepretation for my 5th shoulder surgery...
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Help with MRI intrepretation for my 5th shoulder surgery...

Please help me intrepret my latest MRI.  Long history is apparantly leading up to surgery #5, will this ever end???  

I'm a 37 year old female, previous collegiate softball player.  Basic history...

Initially injured in '92 with (2) subluxations and undiagnosed issues.  Continued played all 4 years with a weak shoulder, basically trainer told me to pursue various Rotator Cuff exercises.  Graduated and gave up on playing ball when I started working.  

Over the years, due to continual headaches, back and neck issues and inability to reach for items, finally was diagnosed in 2003 with severe shoulder instability.  Surrounding back/neck muscles have compensated drastically.  Led to my first surgeries.

#1 - 05/2003 - Arthroscopic Bankart repair and Thermal Capsulorrhaphy.  Zero progress after extensive PT, excessive scar tissue build up leads to surgery #2

#2 - 01/2004 - Arthroscopic Manipulation - Tons of PT and massage, shoulder around 85%, basically let it go and gave up on playing ball.  Still couldn't reach for things behind nor above well, nor hook a bra well.  Headaches, back, neck issues continue and progressively worsen as years go by.  Had kids, so simply moved on with life.

A friend swore his surgeon was the best, had excellent results from a rotator cuff surgery, so decided to have a new evaulation.  First tried extensive therapy and stregthening but didn't change much, shoulder is essentially frozen now.  Daily headaches, terrible muscle knots and issues all over my upper back/neck.  Leads to surgery #3

#3 - 12/2009 - Arthroscopic SLAP repair.  More therapy and massage. Slightly better, but still unable to gain rotation up and behind me.  Headaches continue.  Introduced trigger point injections to address massive knot on my right trap which finally reduces from a baseball to a golfball. Headaches continue.  Diagnosed with severe bursitis, so tried a steroid injection to no avail.  Led to surgery #4.  

#4 - 04/2010 - Arthroscopic Subacromial Decompression, removed bursa (?) and several bone spurs.  Immediate results, finally gain full rotation of my shoulder.  External rotation is better than ever.  Started Trigger Point Dry Needling to address muscle knot issues.  After 6 weeks, start seeing progress, finally releasing some of the muscular issues surrounding neck/shoulder/traps, headaches are mostly gone, feel better than in years.  Then moved to MI.  Headaches are mostly gone.

By fall of 2010, I'm noticing a growing "bump" and tenderness at the A/C joint.  My bra straps, purses, backpacks, anything on that part of the shoulder is tender and growing worse.  Some days, can't lift my arm up to the steering wheel.  Headaches are beginning to reoccur.  Muscle issues are reoccurring.  

02/2011 Talk to a friend for a referral, back to a surgeon for evaluation.  Ordered MRI.

04/2011 - Doc was very hestiant for any additional operations, but based on MRI results, claims results show another surgery will resolve.  States he wants to "clean up" the A/C joint, which is severely inflamed, probably as a reaction to the last surgery.  Told him I'd wait until fall, as I was taking my last shot at playing softball now that rotation is back and since the tenderness is in a completely different location which doesn't seem to irritate my throw, figured I'd wait till fall.  Finally, I'm able throw a ball with decent rotation, but poor strength, so was very cautious.  But as the summer goes on, my shoulder is getting worse.  Made a few awkward throws that resulted stingers going down my arm, and now my shoulder is very aggravated, rotation is getting worse and have now severe tenderness behind shoulder, near suprascap.  Lifting my arm 60-120 degrees is diffiuclt and getting worse.  I know, I know, time to give up on ball.  Gonna call the doc to follow up and get something done, but would love an opinion on the MRI results.  

Anyway, here's results of the MRI from April....

- Postop changes presumable related to a subacromial decompression, without a distal clavicular resection.  Mild subcortical cystic change of the distal acrominon.  Mild to moderate dorsal capsuloligamentous thickening and edema of the acromicioclavicular joint.  Findings could be related to capsuloligamentous sprain as well as capsulititis. No full thickness capsuloligamentous tear, clavicular subluxaction, or abnormalities of the coracoclavicular ligament complex.

- Posterior downsloping orientation of the acrominon, wiht a slightly curved (type I-II) acromial undersurface. No abnormalities of the trapezius muscle insertion

- Surgical tracts within the glenoid, compatible with labral repair.  There is morpholoic and signal irregularity involving the glenoid labrum diffusely, butmost pronounced superiorly, anteriorly, and inferiorly.  Some of the labral signal and morphologic changes could be partially attributatble to post op change of the labral debridement and/or repair, though recurrent, nondisplaced surface tearing could also account for these imaging findings.

- There is mild subcortical cystic change and hyaline articular cartilage thinning of the central and anteroinferior aspects of the glenoid.  Mild fibrillation of the medial and superomedial aspects of the humeral head hyaline articular cartilage.  Mild glenohumeral joint fluid without conspicuous intraarticular loose body formation.  Mild thickening and minimal edema of the anterior band of the inferior glenohumeral ligament, which could be related to fibrosis in the setting of a capsuloligamentous sprainp; capsulitis could also account for this imaging appearance however.

- There is supraspinatus tendinosis extending into the anterior infraspinatus fibers, and associated with mild bursal and articular sided supraspinatus fraying, and no full thickness tear.  Mild subscapularis tendinosis and bursal and articular sided fraying, and no substantial tear.

- No fatty atrophy, edema, or volume loss of the supraspinatus, infraspinatus, or subscapularis muscles.  Teres minor tendon and muscles are normal.  Normal deltoid muscle.

- Tendinosis involves the intracapsular portion of the biceps long head tendon.  No discrete tear or frank tendon subluxation.

- Mild gelohmeral joint fluid with synovitis.  Mild fluid within and synovial thickening of the subacromial subdeltoid bursa.  No conspicuous intraarticular osteochondral bodies.

- Normal quadrilateral space.  No abnormal fluid collections.  No soft tissue masses.

Impression:
- Postop changes related to labral repair.  Morphologic and signal irregularity diffusely involve the glenoid labrum, most pronounced superiorly, inferiorly and anteriorly.  While some of the morphologic and signal changes could be partically attributal to postop change from labral repair and debridement, recurrent surface tearing would have a simliar imaginig appearance, and cannot be excluded.  No displaced labral fragment.

Thickening and minimal edema of the anterior band of the inferior glenohumeral ligament, which could be related to fibrosis in teh setting of prior capsuloligamentous sprain, as well as capsulitis.

Mild glenohumeral joint effusion with synovitis.  Mild subacromial subdeltoid bursal fluid thickening.  Mild to moderate dorsal AC joint capsuloligamentous thickening and edema.  Findings could be related to capsuloligamentous sprain as well as capsulitis.

Rotator cuff tendinosis.  Surface fraying of the supraspinatus and subscapularis, without a full thickeness tear.

Am I done with ball.  Do I give up on any sport with overhead motion?  My daughter is finally old enough to play ball, and I have hard time calling it quits.  I'm all for doing what it takes to fix once and for all.....PT/massage/chiro, whatever it takes.  But it's certainly been a long journey.  Any advice out there?  Thanks for listening.
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3 Comments Post a Comment
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1711789_tn?1361311607
Hi there!

Well to be precise, it would be difficult to say. As you already know, the joint doesn’t look in the best of shapes and there are a number of issues involved. While movement may improve gradually, I wouldn’t typically advise professional sports, since these may be associated with increased trauma to the joint. I would suggest keeping the movements within a comfortable range and not overstressing the joint. You may seek a professional opinion from your orthopedician after a clinical evaluation as well.
Hope this is useful.

Take care!
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Avatar_f_tn
First, thanks for taking the time to read my "novel" and post.  

As you can tell, I'm rather detailed and like to know the specifics (I find it fascinating) but i have no idea of what the above MRI language means.  My orthopaedic surgeon read the results and basically told me I have lots of various "itisis", but what exactly that means, I'm not sure.  Irritation, inflammation, damage, all of the above?  The term "chronic" shoulder was in the conversation, and I'm not sure if that means it's simply something I'll have to learn to live with?

He did say the MRI indicates severe inflammation at the A/C joint which clearly appears on the MRI like a "white hot poker" and hence the growing "bump" and tenderness.  He said that's the specific area he knows he can repair via surgery by "cleaning it up".  He says this joint "doesn't respond well" to arthroscopic surgery, which is what occurred last time while addressing the bone spurs and shaving the end of the collar bone during the Subacromial decompression.  Does this make any sense?

I understand it's time to hang up the old competitive softball glove and am accepting of that.  And for the most part, day to day activities don't bother me, although certain sleeping positions are more comfortable than others, etc.  However, overtime, will the joint stiffen to the point of being frozen again?  

Any suggestions on addressing the golfball knot on my trap?  Still doing massage and constant stretching.  I've also been given muscle relaxers (flexeril), which help me sleep, but aren't the best during the day.  Can these be used long term?  

Thanks!

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1711789_tn?1361311607
Hi again!

Well, the shoulder joint is a complex joint with a few ‘sub-joints’ involved within the shoulder, along with a number of tendons, muscles and connective tissue structures, aside the bone and cartilage. The suffix ‘itis’ is used for inflammatory conditions e.g. the inflammation of the bursa is called bursitis, inflammation of the tendon is called tendonitis and so on. Your MRI describes chronic inflammation of a number of structures within the joint. Chronic irritation as well as injury/ damage can lead to inflammation. ‘Chronic’ means something that is constant or has been present since a long time. Chronic conditions are unlikely to resolve in a short span and may take considerable time and treatment effort. While acute tears and injuries respond well to an arthroscopic repair, inflammations tend to take their time. Removal of spurs (bony outgrowths) and similar structures, that may cause irritation and retard healing (cleaning the joint), may help with resolution.
          Aside massage, physiotherapy and stretching, you may try warm compresses on the knot over trapezius. I wouldn’t advise using muscle relaxants for a long term or even regular use; though you may use them occasionally when the symptoms get severe.
Hope this is helpful.

Take care!
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