Patient With "Shoulder Tendinitis" Not Better After Medication

Can you guess what's wrong with my patient's shoulder?

Just by looking at the picture above, can you guess which shoulder was giving my patient problems? I also showed the picture to some of my staff and asked them "what can you see from this picture?"

Alright, for those who can't tell, here are some more clues. My patient came in with some neck pain and a very uncomfortable shoulder. He had seen his family doctor who told him he had tendinitis in his shoulder and gave him some NSAIDS (non steroidal anti inflammatory drugs).

However he did not get much better with the medication. He still had some neck discomfort and couldn't raise his arm above shoulder height. Lying on his affected side made his shoulder worse and he could only sleep supine.

At first I too thought the shoulder pain was referred from his neck. He mentioned that there was slight tingling sensation in his fingers occasionally too (which was why I thought the problem was coming from his neck). However I changed my mind after seeing he had trouble even lifting his arm sideways above shoulder height.

I told him that he probably had a tear in his L Supraspinatus muscle. If you look at the picture above carefully, you will see a hollowing above his left shoulder blade. There is also wasting in the muscle (or muscle atrophy) around the part where his neck on the left connects to his shoulder.

I was told later after an ultrasound scan that he had a full thickness tear in his left Supraspinatus muscle with retraction of the tendon! The doctor referred him for an MRI and said he may need surgery to repair the retracted tendon.

By the way, scientists have assessed biopsies from both people and animals with supposed tendinitis and found very few signs of inflammation in the tendons.

NSAIDs are commonly prescribed to reduce pain and inflammation of tendinitis. So if there is no inflammation, the medication is not going to help.

So the word tendinitis with the suffix "itis" means inflammation is misnamed since the condition has little or no inflammation. Researchers prefer the term "tendinopathy" meaning damaged or degenerating tendon.


Reference

Warden SJ (2009). Prophylactic Misuse And Recommended Use Of Non-steroidal Anti-inflammatory Drugs By Athletes. BJSM. 43(8): 548-549. DOI: 10.1136/bjsm.2008.056697.