A Rare Case Of Shoulder Pain

Introduction

We are all aware of common causes of shoulder pain like general myalgia, muscle tendinitis/ tears, impingement syndrome, frozen shoulder, bursitis etc. Here is a different and interesting case

Case History

A 60 years old lady came with complaints of left trapezius/ neck pain radiating to the left elbow and progressively increasing for last few months.The pain was currently excruciating and it disturbed her sleep.

On examination

Cervical spine was clinically normal.
Left Shoulder examination revealed tenderness with reduced terminal movements.
Obrien's test, Speed test, Full can test and Empty can tests were positive.

Investigation

X - Ray

X-Ray was normal.

MRI revealed SLAP tear and labral tear with Supraspinatus fossae cyst pressing on the Suprascapular Nerve.

Treatment Plan

There is no medical Management for this condition, unlike regular rotator cuff tendinitis, frozen shoulder etc.

The patient was explained the nature of the condition and posted for shoulder arthroscopy.

Shoulder Arthroscopy

Hence the Arthroscopy revealed a SLAP with glenoid labral tear of the posterior labrum from 12 '0 clock and 5'O clock position which was partially reattached, but in a flimsy manner.

This poorly healed labrum was released with arthroscopic shaver and radiofrequency ablator and thick viscous fluid was found to come out of the Supraspinatous fossae. Manually the Supraspinatus / infraspinatus fossae were milked and the viscous fluid was thoroughly let out. The labrum and SLAP tears were repaired with suture anchors.

Slap Tear

Labral Tear

Suture Anchor For Repair

Final Repair Done

Immediate post operative status:

Within 3 days, the patient had 90% pain relief, indicating adequate decompression of the Suprascapular nerve.

The patient is on follow-up since 3 months and has complete recovery from pain.

Pathogenesis

How the cyst happened?

The patient must have torn her labrum long back.The unhealed labrum acts as a one-way valve allowing seepage of synovial fluid into the Supraspinatus and infraspinatus fossae. It may/maynot heal over time, but the valve mechanism traps the synovial fluid which forms a cyst. This process mechanically compression on the Suprascapular nerve, causing severe radicular (nerve) pain.In our case, the labrum had flimsly reattached. Hence it was taken down, fluid expressed and perfect labral repair was done.

This case is presented for rarity of diagnosis and need for advanced technological interventions.

Physiotherapy protocol followed:

1-2 weeks:

a) Use of a sling for 1-2 weeks postop
b) Maintenance of good postural positioning when performing all exercises.
c) Aerobic exercises along with rehabilitation.
d) Soft tissue mobilization and cryotherapy to surrounding tissues to reduce edema and pain.
e) Passive range of motion in all planes as tolerated.
f) AROM elbow flexion and extension
g) Wrist and forearm strengthening exercises.
h) Cervical stretches
i) Scapular squeezes
j) Lower trap squeezes

2-4 Weeks:

a) Continue soft tissue treatments
b) Passive range of motion
c) Scapula glides
d) Light joint mobilizations as tolerated
e) Begin isometrics in all planes
f) Initiate active range of motion in all directions as tolerated.
g) Scapular strength training exercises with theraband.

4-6 Weeks:

Progress strength training exercises including weight bearing exercises, theraband exercises.

6-8 Weeks:

a) Continue to advanced rotator cuff strengthening exercises.
b) Initiate functional activities.

8+ Weeks:

a) Continue strengthening exercises.
b) To do all day today activities.

Lesson learnt:

a) Think of common conditions, but don't forget other diagnosis
b) Don't be shy of asking for higher investigations. This is the era of technological medical advancements.
c) Arthroscopy of shoulder is a boon to many shoulder problems- rotator cuff tear, recurrent dislocation of shoulder, impingement syndrome, subacromial bursitis, rheumatoid shoulder, SLAP tears, unresolved calcific tendinitis, frozen shoulder, Suprascapular nerve compression by cyst etc.