Rotation

    It was last November the 14th, one of the first days that you could feel the winter season approaching, a cold and blustery day.  I had an appointment at the medical complex in East Greenbush, and decided to wear  a warm winter coat, a leather one.  As I was getting ready to leave the building, I slipped the strap of my pocketbook up on my shoulder at the same time as I pushed the door open.  A gust of wind forced its resistance against the door, and I felt pain in my right shoulder, in the arm I used to open the door.  After I got to my car, I sat there a while, flexing my arm to alleviate the pain, and tried to rub the ache away.  I assumed I'd strained a muscle; I think something like that has happened in the past and had resolved in time. 
      The shoulder continued to bother me, though, making it so uncomfortable to put dishes away on a higher shelf that I began to use my left arm instead.  It didn't hurt to hold my toothbrush in my right hand, but brushing, or combing, my hair was a different story.  Raising my right arm to the side was difficult, and painful.  But more disconcerting was that I would be awakened during the night  with a rather sharp, localized pain centered across the top of my shoulder.
  The pain and restriction still had not dissipated three months later, so I contacted Ortho NY and made an appointment with Dr. Lee Kaback, an orthopedic specialist in shoulder repair.  My appointment with him was March 11, at which time my shoulder was x-rayed before the consult with the doctor. The exam consisted of raising my arm in different positions, and resisting while he applied pressure on the arm.  I could put my arm in any position requested, though in some with discomfort and or pain. Given my circumstances (meaning my age of course)  I am stronger than most would suspect, and my arm didn't fall down when he pressed on it. I have since read that if the rotator cuff tear is complete, the arm will drop instantly, with no tendons to support it.  I was not in that category.  If he had asked me to put my arm behind my back and then try to push it straight out, I would not have been successful, but he didn't ask that.
     Dr.K. said I probably was suffering from arthritis; he knew the history of my knees.  The pain is probably like that, he said, but I said no, it was much more localized.  He seemed to think a Cortisone shot would be a good idea, there and then, but I wasn't prepared for that at the time.  He asked if I would like to have an MRI to assess any possible damage, and I agreed.  I was not so concerned with the pain, though I'd like it to be gone, but more concerned that whatever damage was there could progress, and impede the use of my right arm.
     On March 15, I had an MRI at ImageCare in Latham, and on April 8, a follow-up appointment with Dr. K. for the results.   The first words he spoke after the requisite greeting were to say that I had "a very large tear in the rotator cuff," and that was where the pain was coming from.  And my options:   he loves to operate, he says, and he would do so right now, but there are issues.  Older tendons don't heal as well, and the recovery period is 5 months or so.  He again mentioned a cortisone shot for the pain, which he said could be effective by reducing the inflammation.  He said I could try Physical Therapy. I asked if the tear would improve on its own and he said he didn't think so.  I asked if the physical therapy would be helpful and he said it might be.  I opted for the P.T. and he wrote me a script.  I'm still thinking about pursuing that course. 
  4/17/2015
      At my F.U. visit,  Dr. K. said I had "a very large tear" in the rotator cuff tendon, and offered the above options.  He didn't go into detail as he knows patients are uninformed and he doesn't have the time to educate them.  After all, he had to spend much time and a great amount of money to gain his knowledge.  That's why he's the doctor: I'm just the damaged piece of clay that he can mold into some semblance of normalcy, or not.  He had seemed to think my problem was arthritis, but I didn't think it was.  The pain was too localized.  Anyway, I wanted  to know more than what he told me,  mainly because I want  to be informed of my condition before I begin physical therapy.  I plan to delay the start of P.T. until after the baby is born.  I  know that once the course of PT is started, it must run its course without interruption.  Medicare is very fussy about any alteration to the start and finish date.   So to clarify my condition, I requested a copy of the MRI report, which is a very simple thing to do, and to me, somewhat satisfying.  Following is a synopsis of the 3/19/15 report:
       The clinical indication was to evaluate for arthritis versus cuff tear. Finding were that while the other tendons in the shoulder, the subscapularis and teres minor, were pretty much normal, the same was not true for the supraspinatus and the infraspinatus.  Now I'm not a doctor, but besides seeing them played on TV, my  three years of high school Latin lets me know that the supra part is where my pain and loss of mobility is.  And the report reads:
          "Full thickness retracted tear of entire supraspinatus."  That has to run right across the top of the shoulder  because that's where the pain is.
        "Tear extends posteriorly to involve the infraspinatus, with full-thickness tear of the anterior 10 mm of the infraspinatus.  Posterior to this, tear extends another 10 mm posteriorly as an articular sided tear that delaminates into an interstitial tear extending to the myotendinous junction."  
         This taxes my cache of Latin, but helps me understand why the doctor would say only a very large tear.  It seems as if the supraspinatus ran amok and took everything nearby down with it.  I suppose retracted means what it sounds like----the same way  a snapped rubber band behaves, turning in on itself. 
      Adjectives pertaining to other structures are "mild, minimal, and moderate."   Somewhat jarring to see the report addresses "Bone Marrow"  status.  Who knew that would be on the table, but fortunately the finding was: "No evidence of fracture or pathologic marrow infiltration."  Phew!
    IMPRESSION: 
         "Full-thickness retracted tear of supraspinatus and anterior fibers of infraspinatus.  Further posterior extension of tear as articular surface and interstitial tear of the more posterior fibers of infraspinatus.    Probable full-thickness retracted tear of long head of biceps tendon."
         It reminds me of a night last summer when I was at the computer and heard a rushing and then crashing sound, as if a train had derailed at top speed.  A tall tree had suddenly snapped its trunk and its fall had impacted and thereby damaged all the structures in its vicinity.  As far as I know, though, nothing retracted.  I think I'll call on Monday* to check if it will be acceptable to wait until June to start therapy.  I do look forward to holding a little baby in my arms.
    * I never did get around to calling, so when I went to Seton and presented my script I found that it would need to be renewed.  A call to the Ortho office would do it, I was told.  It happens very frequently. In the meantime, they will do the assessment today.  They seemed confident it will work out.