Need medical advice

Billson

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My 65 year old mother had a fall a few weeks ago and most of the force was absorbed by her arm so she has been having difficulty moving her arm from the shoulder. I had her arm x-rayed fearing that it may have suffered a fracture or something. The results came back negative but her condition doesn't seem to be improving and the pain is still there.

Another possibility that occured to me is that she may have torn some ligaments but I don't know if this will show up on the x-rays or if she needs to undergo another type of scan to determine this.

Do we have any flashaholic doctors around here that can help me out?

Thanks.
 
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raggie33

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ok im not a dr but could it be pyshlogical? i only say this cause xray didnt see anything
 

rayearth

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I am a doctor, but without a physical examination, I cannot tell anything for sure, so take this with a grain of salt.

There is a good possibility that she could have suffered a rotator cuff injury, muscle sprain, or microfracture. The first is probably the most likely if the xray is okay. The only way to tell for certain is an MRI, which is quite expensive. The treatment, unfortunately, is even more expensive, potentially surgery. She should go to her primary care physician for a more thorough examination.
 

Billson

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rayearth,

Thanks for your suggestion. I'll take her to a doctor for a more thorough examination and take it from there.
 

Santelmo

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So sorry to hear that pare, in lieu of medical advice, my prayers instead. . .
 

Hookd_On_Photons

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If her health insurance doesn't require a referral from a primary care physician, take her directly to an orthopaedic surgeon.

I'm not dissing internists, but they're not very familiar with musculoskeletal injuries and you'll save some time and do your family doc and your mom a favor by going to the specialist right off the bat. You wouldn't trust an orthopaedic surgeon to manage diabetes or asthma, would you?

Do the orthopaedic surgeon a favor and bring the *original* radiographs to the appointment. You might have to sign them out from the hospital or clinic where they were taken. Copies might not be exposed properly.

It's possible that the radiographs did not demonstrate any findings because they may not have been adequate to obtain the correct diagnosis due to under/over-exposure, improper positioning, or failure to adequately demonstrate the site where the problem is. (For example, a radiograph of the humerus - the "arm bone" - might miss problems with the shoulder or elbow because the view is not centered on those joints)

There could be soft tissue problems that might require an MRI or another study to diagnose, as radiographs will not demonstrate them (they're only useful to evaluate radio-opaque structures, such as bones).

Your mom could have a shoulder dislocation or a nondisplaced fracture.

She could have a rotator cuff tear, as mentioned previously.

A stiff shoulder is a common problem, even without major damage to the bony or ligamentous structures. Your mom could have adhesive capsulitis of the shoulder, commonly known as "frozen shoulder". This can often be addressed with physical therapy, but sometimes requires surgical intervention.
 

bwaites

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HOP,

While the advice is generally good, in this age of managed care, I don't know a single orthopod in my state that takes self referrals!

I'm sure there is one somewhere, but I haven't found him.

I would disagree that an internist might not be familiar enough to make the diagnosis. I work in an Internal Medicine specialty, and only big city internists don't make these diagnoses. The rest of us see ortho problems daily, and deal with them appropriately.

I have 2 patients having MRI arthrograms of joints today, as a matter of fact.

Methinks you paint with too broad a brush, my friend!!:)

Bill
 

legtu

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Do also consider that those kind of injuries can sometimes really take a long time to heal, especially at that age.

My mom had a fall around 2+ months ago and it took around a month for her arm to get back to normal. The swelling lasted around a week and although it has already subsided, the pain was still present whenever she tried to move her arm till around the 2nd-3rd week.
 

James S

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People's experience with docs is so widely varying ;) Yes, some internal medicine docs might not be able to make a full diagnosis of this sort of thing, but if they are at all worth their salt they will recognize it enough to send you to someone who can.

Most important thing about doctors is that the first one you pick out at random from your insurance company paperwork or the yellow pages might be a moron. The joke goes something like:

"You know what they call the person who graduates last in their med school class?"

...

... wait for it...

...

"DOCTOR!"

And invariably when you most need a good one, you get that guy. So if he isn't able to give you a reasonable diagnosis and recommendations for treatment and isn't referring you where you feel you need to go, ask him to recommend someone for a second opinion. There is no bad feelings about this sort of thing, at least there shouldn't be. There are many excellent doctors out there that can help you, but you can't get that help if you're not seeing one of those. Dont take it too much to heart the general negative statements about docs in places like this as anything more than an anecdote about a specific lousy doc that person was seeing :)
 

Hookd_On_Photons

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Bill and James:

I apologize for sounding like a specialist snob. I'm not, really.

My area is fortunate enough to have a number of specialists that take self-referrals, despite high managed care penetration. As a result, the family docs are not accustomed to managing a broad range of problems. It's very easy for them to pick up the phone and get a same day referral to an orthopaedic surgeon, a plastic surgeon, a cardiologist, and so forth.

I *have* seen some problems with primary care docs not recognizing a red flag, and having things go suboptimally as a result. I've seen missed fractures and joint subluxations/dislocations. I've seen complications of nondisplaced fractures, such as nonunions, joint contractures, growth plate problems, and so forth that went unrecognized for a while.

I'm not saying that internists, pediatricians, and family practitioners are dummies. You know the definition of a double blind study... two orthopods reading an EKG (or chest X-ray). And I know several family practitioners who practice excellent sports medicine (as well as any orthopaedic surgeon, except that they don't do surgery).

It's just that I don't know how well general practitioners in the Phillipines are trained to deal with orthopaedic injuries. I also figured that managed care probably hasn't spread its taint to the Phillipines, so if Billson has a choice he might as well take his mother to somebody who frequently sees this type of problem, rather than potentially take extra time to see a general practitioner who might have to subsequently refer her to the specialist. Generally, the sooner therapy is initiated for a frozen shoulder (my completely unfounded guess of the diagnosis), the better the prognosis.

That's my free advice, and it's worth every penny. :nana:
 

Billson

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Thanks for all the suggestions.

One thing I've noticed from doing some research and reading this thread is that all of them mention swelling. I don't believe my mom suffered any swelling. Is that possible?

FWIW, her symptoms seem to point to her rotator cuff but I'm still trying to find a good doctor for her. We tend to have many quack doctors here so I have to be more careful than usual. I just realized we don't have a family doctor because we've never had to see a doctor for as long I can remember.
 

nikon

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If you can't get your mom to good internist right away, you would probably do well to take her to a hospital emgency room ASAP. A shoulder injury is not something to take lightly. I speak from experience.
 

oldgrandpajack

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I took my Grandmother to the hospital a few years ago, with pain and minor swelling of the left arm. She had a catscan, and it showed she had a disecting anurism of the descending aorta, behind her heart. Because of her age (94) and health, it was inoperable. I never would have guessed it was something that serious.

oldgrandpajack
 

James S

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Thats true, the longer you let something heal wrong, the harder it's going to be to put it right again. It's not a bad idea to go to the ER and get her started up the chain of consults till you get to someone who can do something about it.

You might want to call ahead first though and not go when they are swamped. They should be happy to tell you over the phone that this is or is not a good time to come in with a non life-threatening injury.
 

Hookd_On_Photons

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Billson said:
One thing I've noticed from doing some research and reading this thread is that all of them mention swelling. I don't believe my mom suffered any swelling. Is that possible?

Many people will develop degenerative changes to the rotator cuff as they age. Sometimes a weakened rotator cuff can become torn without minor trauma. Sometimes large degenerative tears occur without any trauma at all. That could account for the lack of swelling.

Also, shoulder injuries may not cause swelling of the shoulder. Patients commonly develop dependent edema of the arm, forearm, and hand (i.e. those parts swell up because they hang down, so fluid collects there because the venous/lymphatic system can't transport the excess fluid out of the limb, so fluid collects there due to gravity).

It may be difficult for an inexperienced examiner to differentiate between a frozen shoulder and a rotator cuff injury. The patient will exhibit pain with joint motion, and limited active motion. Passive motion should be spared more with a rotator cuff injury than with adhesive capsulitis... but patients with rotator cuff injuries commonly develop adhesive capsulitis because pain prevents them from moving their shoulders. An MRI or arthrogram might be ordered to image the rotator cuff (arthrograms are rarely performed in the USA these days, as MRIs have become readily available - they might still be the standard imaging procedure in the Phillipines).

It is very important to get your mom assessed and treated as soon as possible. The longer the shoulder remains immobile, the more difficult it is going to be to rehabilitate it. If there is a traumatic tear of the rotator cuff, it will become more difficult to repair it the older it is, and some tears cannot be repaired after just a few weeks. If there is a degenerative tear, it could be irreparable. If the rotator cuff is intact but has become stiff (frozen shoulder), waiting too long could necessitate surgery to restore joint motion.

In a worst case scenario, the shoulder could be dislocated, and gone unrecognized because of inadequate radiographs. Or the lack of shoulder motion could be due to a neurologic injury, rather than being a primary musculoskeletal problem (unlikely, since you haven't mentioned burning pain, numbness, or tingling as symptoms).
 

Hookd_On_Photons

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I'm not sure taking her to the ER is a good idea. She's not in extremis, as she's had the condition for a few weeks already.

In the USA, ERs are obligated to arrange for follow-up, so if it were impossible for her to get evaluated through other means then going to the ER might get her referred to an orthopaedic surgeon on call. I'm not sure how the system works in the Phillipines.

Otherwise, the ER might not be the best place to have the shoulder treated. The ER doc may or may not know anything about musculoskeletal problems. Most likely, the ER would get an X-ray, rule out anything immediately life- or limb- threatening, and assuming there wasn't an infection or something that required immediate attention your mom would be discharged. You might not necessarily get referred for a follow-up appointment with the best qualified doctor, either (you get whoever's on call that day).

BUt who knows, maybe there is an orthopaedic surgeon sitting around in the hospital waiting to see ER consults. That's typically *not* the case around here.

If you know any nurses, physical therapists, athletic trainers, or coaches, ask them who they think the best orthopaedic doctors are in the area. After all, they see how patients do in the long run after the docs have worked on them, and they figure out pretty quickly who's good and who's a hack.
 

cobb

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If the x ray showed nothing, that just means it wasnt broken. It could be a stress fracture that wont show up til the bones start to calicify or they do a bone scan with the radioactive injection.

Soft tissue and muscles wont show on x ray. It heat helps its muscles, cold its inflimation.

I use to have shoulder pain that went down my arm like the classic heartattack symptons. Doing shoulder exercises without and with weight helps.
 
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