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Tuesday, July 28, 2009

Richard's Shoulder

Note: Of course, we are not medical professionals, or spelling experts nor do we have perfect memories. What follows is the best of our recollection of what the doctors have said thus far.

Richard had an MRI of his right shoulder which showed a "Nonspecific atrophy of supraspinatus and infraspinatus" and a "globular intermediate high signal seen in the supraspinatus and infraspinatus near the tendon insertions." The orthopedic doc said this is bad because it basically means they (the MRI techs) see a "something" but don't know what it is. You don't want to stump them. The MRI "result code" was "Abnormal, Immediate Attn Needed". They did say it definintly is not a rotator cuff tear. This is good. There is much "degenerative atrophy" meaning his muscles are rotting. Not ever good.

The orthopedist, Dr. Bischoff, referred him for an EMG test to be done by a Neurologist to hopefully clarify what damage has been done, and where.

His EMG was today at Portsmouth Naval Hospital.

We had a great doc, a neurologist, who performed both parts of the test. The first part involved shocking various parts of R's hand, wrist, arm, shoulder and neck and recording the results. This part was uncomfortable and mildly painful. The second part of the test involved sticking needles into the muscles, starting at the hand and working all the way up to the shoulder, recording first with the muscle resting, and then with the muscle engaged. This part was mildly painful at the begining (the hand/wrist/arm) but became extremely painful when the doc neared the damaged areas of the shoulder and neck.

The doc gave us several answers:
1. The damage was absolutely, positively a result of the motorcycle accident Richard had in February (yes, really, FEBRUARY).
2. The subscapular nerve was damaged due to blunt force trauma (ie hitting the pavement) but the damage is "incomplete" which means it is not completely broken, just damaged.
2.5. The subscapular nerve feeds impulse signals to two muscles, one above it and one below it. The one below is severely damaged, the one above, not as much, but still significant damage. The upper muscle controls the lower 15% lifting power of the arm, the lower muscle controls the movement as if you have your arm in a sling position and then are pushing outward as if pushing a door open with your forearm.
3. The nerve damage happened immediately but was not evident until weeks later when the muscle stopped geting impulse signals from the nerve. (See straw analogy below.) This was the time during March when Richard had such severe pain that he was in two ERs and a doctors office, all within two days.
4. The muscle not getting whatever it gets from the nerve is the reason the muscle is atrophying (rotting). Richard has a severe concave hole in his shoulder, where that muscle used to be.
5. If it was a "complete" tear, surgery would absolutely be required.
6. Since it is "incomplete" damage, it may or may not require surgery. Sometimes these things heal on their own, although they take "a very long time-six months to a year" to do so. It has already been six months.
7. The neurologist said the next step is to make an appointment with the orthopedist, Dr. Bischoff, to review the EMG results and decide what the next step is. The neurologist's guess was that Dr. Bischoff would refer Richard to a surgeon.

It seems that we can wait another six months and it may heal on its own, still requiring physical therapy after that time. Or, we can opt to do surgery, which may or may not be able to help, and would also have an extensive recovery time and would require much physical therapy afterwards.

The straw analogy. The nerve is like a straw. When Richard hit the pavement it flattened the straw, but did not tear it. So there were some impulse signals still left in the first portion of the straw that was able to feed into the muscles. However, a few weeks later, all the impulse signals were either already in the muscle, or on the other side of the damage to the straw. That is when the huge pain happened and the muscles started to rot. Now, we are waiting for the straw to re-inflate, which may or may not happen on its own.

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