mtomaino
12-02-2013, 01:54 PM
This is a great question---and very relevant nowadays where, for many insurance plans, preapproval for an MRI is often required, and these delays may cause one undue anxiety as well as delay in treatment.
I recently saw a 69 yo patient who is healthy and very active. She had no previous problems with her shoulder until she slipped and fell over the weekend. She was seen at an Urgent care and told she might have a rotator cuff tear because of severe pain--with a normal xray (no fracture).
When I examined her she was unable to raise her arm above horizonal---in fact, when I positioned her arm out in front of her body, she could not hold it there. We call this a positive "drop arm" test, which typically means that the Supraspinatus tendon is torn.
However, sometimes pain from a cuff strain or acute bursitis can result in a similar finding. Absent trying Physical therapy and a cortisone shot---with a re-evaluation in a few weeks, to see if there is any improvement--only then to get an MRI (if it is approved), I often recommend trying a LIDOCAINE INJECTION TEST.
This is performed right in the office. Numbing medicine--lidocaine---is injected into the subacromial space to take away the pain that may be inhibiting an accurate assessment of muscle strength. If this injection transiently takes away all of the pain, and yet weakness and a "drop arm" finding persist, then there is a very strong probability that the rotator cuff is indeed torn. By contrast, if one can then raise the arm overhead, there may not be a tear--or it might be very small.
These issues commonly arise in the office in patients with acute pain. In such cases, one might push an MRI sooner particularly if a patient is intent, because of activity demands etc on proceeding with a repair asap.
Even though a trial of PT is often feasible, and in many cases, advisable, if a tear is present, an MRI provides valuable information about tear size, whether it is retracted, and whether there is any evidence of muscle atrophy------each of which may impact on when and if to operate sooner than later--or at all.
MMT
I recently saw a 69 yo patient who is healthy and very active. She had no previous problems with her shoulder until she slipped and fell over the weekend. She was seen at an Urgent care and told she might have a rotator cuff tear because of severe pain--with a normal xray (no fracture).
When I examined her she was unable to raise her arm above horizonal---in fact, when I positioned her arm out in front of her body, she could not hold it there. We call this a positive "drop arm" test, which typically means that the Supraspinatus tendon is torn.
However, sometimes pain from a cuff strain or acute bursitis can result in a similar finding. Absent trying Physical therapy and a cortisone shot---with a re-evaluation in a few weeks, to see if there is any improvement--only then to get an MRI (if it is approved), I often recommend trying a LIDOCAINE INJECTION TEST.
This is performed right in the office. Numbing medicine--lidocaine---is injected into the subacromial space to take away the pain that may be inhibiting an accurate assessment of muscle strength. If this injection transiently takes away all of the pain, and yet weakness and a "drop arm" finding persist, then there is a very strong probability that the rotator cuff is indeed torn. By contrast, if one can then raise the arm overhead, there may not be a tear--or it might be very small.
These issues commonly arise in the office in patients with acute pain. In such cases, one might push an MRI sooner particularly if a patient is intent, because of activity demands etc on proceeding with a repair asap.
Even though a trial of PT is often feasible, and in many cases, advisable, if a tear is present, an MRI provides valuable information about tear size, whether it is retracted, and whether there is any evidence of muscle atrophy------each of which may impact on when and if to operate sooner than later--or at all.
MMT