Expert: Dr. J. Shawn Leatherman - 11/28/2006

Question
Thank you for your reply. I have had numerous x-rays, 2 MRI's of the shoulder and 2 nerve tests. I've had shoulder stabilization surgery and have a oouple anchors and sutures in my shoulder joint. Surgery was June 2003. I've also had 6 rounds of physical therapy from 2002 until present. The therapists always say that there is something more going on, but they never say what it is. The doctors say that all the tests have been normal aside from the last nerve test which reveales the nerve damage. None of the x-rays were weighted. I am currently on doctor #8 with trying to figure out the problem and he is the one who discovered the nerve damage. I am a 29yr old f who relies on physical activity to relieve stress and who has lost a career in Law Enforcement due to the injury. Do you have any additional suggestions or advice? It's really very frustrating. Thanks again for your time.
vic

-------------------------------------------
The text above is a follow-up to ...

-----Question-----
While doing weight training / military presses something snapped on the inside of my right scapula up toward the top of the shoulder. The shoulder immediately dropped down and has been about 6cm lower than the other for about 4 years now. At first they thought it was shoulder instability and they did surgery but it did not take away the pain or fix the drooping. January of 2005 they discovered that i had about 91% nerve damage for the R long thoracic nerve and scapular winging. I had a few months of physical
therapy to help strengthen the serratus anterior and the trapezius. I am still doing the exercises but there is continued pain which i have been told is not from the nerve damage because the long thoracic nerve is strictly a motor nerve. The exercises don't seem to be getting those muscles any stronger and the continued drooping feels like it plays tug of war on my spine and pulls on my neck. Other than doing exercises to try to strengthen the muscles doctors do not know what to do. Sometimes the weight of the shoulder drooping down feels like it interferes with getting deep breaths in and the muscle on the inside of the scapula and the side of my neck is very tight and usually in a spasm. Do you have any suggestions as to how to correct the problem and / or relieve the discomfort. Thank you for your time.
-----Answer-----
Dear Vic,

WOW, sorry to hear about your ongoing complications.  From what you have described, it sounds as though you also have disruption of the acromioclavicular joint (AC) of the shoulder.  Has this been evaluated...with shoulder x-rays, weighted and non-weighted?  IF not, then it needs to be evacuated.  If you have a full tear of the ligaments that provide stability to the AC joint, the only fix is surgical repair (wiring) of the joint. For a comprehensive description of the AC joint and injury to it, check out this website:  http://www.physsportsmed.com/issues/2001/11_01/johnson.htm

You see the only time we hear a snap in a sports injury is when something has been torn or broken.  It only leaves three structures to worry about:  bone, muscle/tendon, and ligament.  Ligaments and muscles are the most common.

Now if the AC joint is functionally complete, and the shoulder is not dislocated, which I know they would have found, the only other explanation would be a full thickness tear of an associated muscle...possibly the levator scapulae, supraspinatus, or an isolated head of the deltoid tendon.  A functional examination of muscle strength should have been performed to evaluate the possibility of this along with an MRI for confirmation.  With your continued loss of strength, a more thorough examination of all of the muscles of the shoulder joint, specifically testing the ability to maintain a contraction in the muscles range of activation would be appropriate.  Unfortunately, if there is a full thickness tear of any of those muscles/tendons, then surgical repair is again the only option for full correction.  Concerning the long thoracic nerve, the 91% nerve damage is probably due to a stretch injury from the initial trauma and the fact that there is a 6cm drop of the affected shoulder.

Vic, what I think you need to due is get another orthopedic opinion from a sports medicine doc, who has not evaluated your case before.  A fresh look at the problem can many times find the actual anatomical problem.  

Continued pain can easily be explained by sensory nerve dysfunction/over-activation by continual stimulation of pain nerved dues to the uncorrected injury as well as a condition called Neoneuralization/Synaptic Arborization/Wind-up (new nerve growth of pain fibers in the area of injury along with scar tissue formation) Manual therapy such as deep tissue massage and active release techniques, and tissue mobilization have been found effective in the reduction of pain from this type of cause.
in my opinion, the spasms you have described will continue unless the loss of shoulder height is corrected.  You may also find temporary reductions in shoulder pain/muscular pain with chiropractic care, but it will not specifically fix the problem from what information you have given me about the injury.

Good luck Vic, Let me know how things turn out.
Respectfully,
Dr. J. Shawn Leatherman  

Answer
Dear Vic,

At this point I am at a loss.  With all the diagnostic testing you have been through, I am surprised that you have no definitive diagnostic impression from any of your doctors.  If there have been no damaged structures found on MRI, and nerve testing has only revealed Long Thoracic Nerve dysfunction, this only leave pain as an ongoing issue...and of course the shoulder inequality, which may be due to postural changes in response to your pain levels.

I do believe that you have scar tissue formation in the affected area which continues to exacerbate your pain and decrease function.  Remodeling of scar tissue can be affective with manual therapies...although, with added soreness.  With that said, again active release techniques (ART) would be a good avenue for you to pursue.  I would recommend that you find an ART Certified Doctor and schedule a consultation. Check out this website for more information on the technique and to locate a doctor close to you with advanced training:  http://www.activerelease.com/about.asp

If the ART doctor doesn't think that you will gain additional benefits from treatment, then the next step would be to check into pain management.  This is more invasive, but when there are no other answers, sometimes just controlling the pain is the best option for daily function so that you can progress with career, personal, and family matters.

I wish you all the best Vic.
Respectfully,
Dr. J. Shawn Leatherman