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05-18-2013, 10:52 PM #1
AC Joint Issues: MRI & Subsequent Treatment
Thought I might record this process for posterity and hopefully a few people will find some help in reading this.
A little history:
I've been lifting since 1981, I'm currently 47 years old and have been competing on & off in FBB over the last 12 years. Last show was Oct, 2010 As far back as the early 90s I recall having pain in my right shoulder when I used one of those seated (chair-like) pec decks, but that was really the only thing I ever noticed. Around 2005 I was doing too-heavy behind-the-head barbell presses and went too low on a rep and tweaked my shoulder. An MRI just showed bursitis and no tears.
After a show I did in 2007, I started noticing a lot of pain in the right shoulder, and a weird feeling that later I found out was arthritis in the joint. I decided to get an MRI because it was really getting painful. The result of that was a suspected pinhole tear in the rotator. A month of PT did nothing, so I asked for a second opinion and surgery. Following arthroscopic surgery, they never found any tears but removed the arthritis, cleaned up a bunch of frayed tendons and scraped down my clavicle a little to reduce inflammation when the area got irritated.
After a month of PT, I was back to 100%. I competed 3 more times across 2009-2010 w/ fantastic results and no pain ever. Then I got the brilliant idea to do 30 lb Arnold presses a week out from my last show in 2010, too heavy, too depleted, and tweaked it. It has been off & on sore every since, not painful but just sore, and gets tired pretty quickly during lifting. The result of a back day is all the little muscles around the shoulder end up doing all the work, my scapula gets pushed out and frequently I have a rib or two out of place, so I visit the chiropractor regularly.
Since then, I've been started experiencing more of that shitty aging thing and w/ the inception of Women's Physique, I've decided to begin downsizing and focus on that category for competition. However training has been near non-existent because of the plethora of tendonitis I have at this point + age + the shoulder + a boatload of foot problems. Mostly I just gave up for a while and focused on diet. I've gotten the foot issues hopefully on the mend, and decided to tackle the shoulder now.
First step: MRI to get a baseline and confirm that there's no tears
Conditions the MRI was taken under: no shoulder or upper body training for several weeks. I did happen to roll over and sleep on my right side the night before so it was a bit sore. So this is a fair representation of my shoulder in a "normal every day state". I figure if it only takes sleeping on it to make it annoying, prep training is going to screw me. Thus this whole effort to fix things.
The humeral head is normally located within the glenoid (or as my chiro likes to correct - it isn't "within" but rather "hangs off of" because the shoulder is not a true ball & socket joint, e.g. like the hip). There is a no joint effusion. There is a large amount of fluid signal in the acromioclavicular joint (more commonly known as the "AC joint") with widening of the AC joint space. The widening measures approximately 7 mm. The acromiom is slightly curved downward. There is a small amount of fluid within the subacromial bursa.
There is no muscle atrophy. Mild tendonosis (scar tissue build-up around the tendon) of the supraspinatus tendon is seen, with mild intramuscular strain of the supraspinatus at its myotendinous junction. (Basically there is some seperation / compromise of the point where tendon & muscle attach.) There is no tear. (Yay!) There is mild tendonosis of the infraspinatus. The teres minor and subscapularis tendons are intact.
The biceps tendon is normally located within the bicipital groove. The biceps labral anchor is intact. There is no paralabral pathology on this non-arthrographic study. (So good news - no tears, no compromise of the biceps connections.)
1. There appears to be abnormal widening of the AC joint with a large amount of fluid and edema in the AC joint space. This could be confirmed with weight-bearing plain radiographs for AC joint injury. (Basically testing ROM & strength holding out the arm and lifting various weights - at what point does it become weak. I don't expect to actually do this - it is expected that weakness can be easily demonstrated.)
2. Mild tendonosis of the supraspinatus tendon with intramuscular strain at its myotendinous junction. (Commented on this above.)
3. Mild tendonosis of the infraspinatus tendon. A small amount of fluid within the subacrimonial / subdeltoid bursa.
05-18-2013, 11:15 PM #2
I'll update this thread as I go thru the process. I'm working w/ my chiropractor as opposed to a shoulder specialist. After reviewing the above MRI results w/ my chiro, I am starting w/ two things on Monday:
- full x-ray of torso (mostly because I don't have anything recent on record)
- evaluation of push /pull balance, ROM and mobility of various structures of the upper body (e.g. pecs, supra / infraspinatus, clavicle, rib cage, etc.)
An high-level description of the process I'm anticipating is establishing an understanding of the push/pull balance I currently have, and hopefully identifying the source of the imbalance that is driving my shoulder issue. An example would be a dominant pec muscle, or even the pec muscle being driven by a "short" muscle in my abs. In other words, looking at how far down the trunk of my body does the imbalance start? This whole idea is based on establishing balance. The body's structural job is simply to keep the brain from hitting the ground. So over time, under the various influences of our lives, wear & tear on the body, repetitive motion issues, injuries, posture, daily "habits", the body arrives at some way of keeping your head upright, but the way it does it won't necessarily be optimal and sustainable. An illustration of this survival tactic is - even w/ someone with cerebral palsy may have all sorts of strange limb contortions, but the head is still upright. But the functional capability of everything south of the head may have all sorts of compromises. And those compromises, over time, will continue to affect peripheral structures and generally propagate that degradation over time.
And just for a wider view of things - at least for me - the shoulder is the point I'm interested in, but the peripheral weaknesses and imbalances that have been part of my general chiropractic adjustments and massages include things like thoracic immobility (not very mobile rib cage). This, in particular, can eventually affect the health of the lymphatic system, lungs, digestive tract. (I'm regurgitating some of the stuff my chiro talked about today..) But generally we're looking at potential considerations as I get older, and ultimately the quality of my life.
The specific recommendations that will come out of the evaluation I'm thinking will be something like ratios of work on different areas in terms of developing or not over-developing the push or pull strength of different structures in getting to a natural balance. And specifically to the treatment of a widened AC joint space - that is basically saying the AC ligament structure has been overstretched. Ligament tissue takes 36 months to regrow so we're looking at a 3 yr timeline in terms of correcting this particular structural issue - or allowing "non-stretched" AC ligaments to replace the currently stretched ones.
Let the fun begin!
05-20-2013, 08:42 PM #3
5/20/13 - Physical Therapist Evaluation & X-rays
This was a 1 hr session w/ the physical therapist running thru a variety of checks on ROM and strength of my arms (shoulders) at different angles as well as looking more closely at the upper thoracic vertebrae.
- My ROM in my neck - forward / backward, side to side (rotationally) is normal.
- The ROM on ear-to-shoulder - average is 45 degrees. My left side is 50 degrees (yay!), right side 38 degrees (boo!). This is saying its not a tightness that is symmetric but rather there's stuff going on in the right.
- Mobility of my rib cage is a little tight, but normal. But noted is tighter in the upper thoracic area.
- Shoulders tend to get pulled forward, right more than left. Implying pec-dominant but also other things like the muscle that should be holding the scapula down is weaker so it all drifts forward, esp on the right.
As a start - general guidance is going to be study up on tissue & fascia in context of rehab. Not really issues w/ muscles as much as at the fascia level. Pay attention to the pull back. Suggestions for training will come up more next week when I start working w/ her.
The treatment is going to be 2x/week sessions consisting of 1/2 hr w/ the PT & 1/2 hr w/ the massage therapist. The PT portion will consist of body-weight stuff like push ups at certain angles that encourage the weaker muscles to do what they are supposed to do. A lot of this is simply retraining my body to function the way it should instead of the way I've ended up to date.
This is really just getting a baseline set of x-rays with this chiropractor - it has been a long time since I've gotten them. So ... when the guy doing the x-rays comes out saying "... WOW!" after getting them processed ... what do you say? Yikes. Here's the rundown just after 5 min of looking at them:
- I have some scoliosis going on
- my neck has 2 curves in it when it should only have 1. There's also some disc degeneration on the lower part (or back to the upper thoracic vertebrae that are tight from the PT eval) and he said it would be from something traumatic like a car accident from a long time ago. The only whiplash event in my life I can recall was the one car accident I had when I was hit on the passenger side of my car. My car's chassis was essentially bent, the tires blew out on the driver side and the windshield shattered. All that happened to me was some whiplash and a few scratches from flying glass. Apparently it might've been a little more whiplash-y than I thought.
- Looking at the AC joint, not holding a 15 lb weight, compared to holding a 15 lb weight -there's seperation - so again something isn't doing the right work.
- My 'vertical axis' is basically twisted - as indicated by basically the tailbone not lining up in the center. There's also a bunch of disc degeneration on that lower vertebrae as well, also resulting from something probably when I was kid. He was saying it didn't need to be a traumatic impact but something as simple as throwing my back out - which I've done a few times over the last several years.
So .. looks like there's a whole boatload of stuff going on and my chiro is all excited! (Eh... I'd rather be boring...)
Next step is a follow up to discuss all of the above on Friday.
06-01-2013, 11:02 AM #4
6/1/13 - Sort of an update
Since the initial evaluation, the Rx for the next 4-6 weeks is:
- adjustments 3x/week - focusing on progressively increasing mobility of my rib cage / thoracic spine and continuing to work on general rebalancing of the spine and clavicles to reduce the torque from right to left. (Right side front is loose / left side front is tight / back side right is tight / left side back is loose.)
- PT - arm ROM and shoulder mobility / ROM in all dimensions.
- Post-PT Massage - lots of ART ... ow! Followed by a lot of icing.
During the last PT session, probably because of all the issues w/ my feet, it was called out that my ankles appear weakened as well (e.g. hard to balance on 1 foot for a DB DL). So I'm starting to formulate my gym protocol around all the comments. That is one of my goals for this weekend.