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Scapular pain after excision
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Scapular pain after excision - December 1, 2007 3:37:10 PM
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sam5935
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I moved this to this board as it seems to get a lot more traffic than the "manual therapy" board I had it on.
Hello,
First off, forgive me if my post is not entirely clear. Although I am about to graduate from nursing school, and thus have some medical knowledge, I may not be able to articulate mself as clearly as other posters here.
Two weeks ago I had two shallow excisions on my back to remove two moles. One was right over my left medial sacpular edge about halfway down and required two stitches. The other was over the spinal column between the shoulder blades and required 8 stitiches.
Two days after the procedure, I started to get left scapular pain in certain positions and when taking a deep breath. It was a deep muscle ache and I thought I must have strained something holding the neck oddly to avoid strain on the sutures and to keep the bandages from coming off.
The pain got worse and worse. Infection was ruled out. It was not responding to 500 mgs. Naprosyn twice a day. One doctor said it was a "pinched nerve" and another says that it is neuropathic pain of unknown etiology and prescribed Neurontin saying it might get better tomorrow or it might never get better!
I refused the Neurontin and, out of desperation took a loading dose of 1250 mgs. of naprosyn followed by 500 mgs. three times daily. The pain went almost completely away.
The pain originates in the lower medial edge of the scapula, which is an inch or two inferior to the nearest excision, both of which are almost completely healed now. However, the pain only appears in a few positions. When I sit down and my shoulders slump, the pain is excruciating. If I sit up and straighten my back, the pain completely disappears. If I reach down for something, like tying my shoes, the pain is terrible, but disappears as soon as I straighten up. Lastly, if I flex my neck forward, the pain appears at a certain angle, stays for 20-30 degress of the forward flexion, then disappears as I flex even forward.
It has seemed worse in the mornings and evenings the past few days and is starting to break through the high dose of naprosyn. As the day wears on, it starts to encompass the whole scapula at times, moving laterally in a line towards the tricep and down around the curve on the inferior edge of the scapula. For what it's worth, both traps. feel very tight as well, but no pain.
I realize it's difficult to tell by this description, but does this sound like a musculoskeletal issue? I feel like I did something in response to poor positioning after the procedure and that PT or massage may be the best approach. My doctor is very pessimistic and says that he doesn't know what it is and really refuses to do anything other than push the Neurontin. In short, I would really just like to get a consensus on whether or not this sounds like something that falls within the realm of PT or if I should start thinking more along the lines of some sort of Neuro./ chronic pain issue.
I am getting desperate as I can't keep taking the NSAIDS at this dosage forever and at the lower dosage, the pain was so bad that I was effectively disabled. I'm pretty scared at this point and don't know what is going on. Thank you so much for your time. I don't know if this is what this forum is meant for, but it would be EXTERMELY helpful to get your opinion. I know this is long but figure more information is better than not enough.Please let me know if you need any additional information.
Shayne
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RE: Scapular pain after excision - December 2, 2007 1:18:00 PM
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sam5935
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I'm wondering if my post is unclear.....is there any additional information that would help people evaluate this?
Thanks!
Shayne
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RE: Scapular pain after excision - December 2, 2007 2:19:56 PM
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SJBird55
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Yes, Shayne, you are a candidate for physical therapy services.
Were the stitches removed or did they dissolve? Anecdotally, I have seen patients have what appear to be neurological issues due to peripheral nerve sensitivity and the problem was because a stitch that was supposed to dissolve didn't.
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RE: Scapular pain after excision - December 2, 2007 2:37:13 PM
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sam5935
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The stitches were removed 5 days ago. More and more, I feel like the pain is related to the excision only in the sense that I compensated for the sutures and "messed something up." The pain feels muscular in nature and get worse and worse as the day progresses, especially if I have to sit a lot, which hurts it, as opposed to standing or being able to lay down. Also, as the day wears on the whole scapula begins to ache and get tired.
Do you have any idea what muscle would be involved if the medial scapular edge hurts when I sit down, flex my neck forward when sitting, or reach forward?
Thank you so much for your help. I'm at wit's end!
Shayne
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RE: Scapular pain after excision - December 3, 2007 8:36:15 AM
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Shill
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The pain is likely still from mechanical strain as you flex your head forward, for prolonged periods, and/or lengthen the neural structures near or at the incision region. A safe thing to try until you get evaluated by your local therapist, is to sit with your shoulder blade in passive elevation, meaning to put as many pillows as you can under your elbow, so as to passively boost your shoulder blade up toward your ear. Then, you should also decrease the frequency of, and/or amount of time you spend in neck flexion and forward head position. This should reduce the strain until you can evaluated, with no risk of any injury.
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RE: Scapular pain after excision - December 3, 2007 10:01:02 AM
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sam5935
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SHILL-
Okay, I'll work on that. I'm really bad about "testing" if it still hurts avery five minutes by dong whatever hurts (dumb, I know.) After today, I can basically spend the greater part of each day resting it for several weeks if I need to. Would ice or heat be appropriate at this point? What about massage? And, as far as the whole scapula starting to ache as the day wears on, is this simply from guarding and flexing against the pain?
Thanks SO much for your time.
Shayne
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RE: Scapular pain after excision - December 3, 2007 12:39:35 PM
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Shill
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The aching is due to gravity further depressing the scapula as your day goes on. Brief periods of passive rest might make the end of your day far easier to tolerate. You wont likely need to rest it for the greater part of the day, but at least for longer than you are now. Truly, you should stay as active as you can, and you will probably find that sitting around doing nothing makes you far worse than returing to previous activities.
Generally ice will help with pain, but if you have nerve sensitivity, you can plan on this being a little annoying. Annoying but helpful that is. There are 4 stages of ice treatment that you may sense; Cold (go figure), Burning (not everyone notices this), Aching (the part you will hate), followed by Numbness. If you dont make it to the numbness part, you wont get the full effect. ALSO, make sure you have a wet cloth between your skin and the ice, and DO NOT use rigid commercial cooler packs, as these can freeze your skin. Use a flexible gel cold pack, or a bag of crushed ice.
And (another thing you already know!)...Stop testing it! You know it cant possibly heal in 5 minutes. Give it 6-8 weeks, then, under the direction of your PT, do some structured testing.
good luck, and let us know your results from your PT eval.
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RE: Scapular pain after excision - December 3, 2007 11:03:50 PM
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sam5935
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SHILL-
Thanks so much for your advice. I actually went to see a private PT today as, even though I got the referral, there was a 4 week wait. The PT couldn't find a lot wrong. But said that the scalenes are tight and that the muscles attached to my cervical spine (I think she said around C5-7) were referring pain to the area. She said that by looking at my posture, the shoulders were very slumped forward and could be causing the problem. She also said that the scalenes "pop up" when I breathe and that I'm using them far more than I should when breathing. She recommended a couple of exercises such as a small head nod and pinching the scapula back and down 10 times every half an hour to try to adjust my posture. However, she didn't seem to find much. I got a massage yesterday and had them work on that area. The pain when I flex my neck is much better, but the overall pain is much worse. However, there is pain all throughout the area today, I think from the massage. I also had 6 hours of tests today and since sitting is the worst position, I'm sure that didn't help.
I know that it's easy to miss things. Do you think I should talk to someone else? Or just continue with the exercises she gave me, ice, and lots of rest mixed in with regular exercise?
Also, she found a suture in the excision nearest the pain that apparently they missed. I'm going to have one of my peers in nursing school remove it tomorrow, but I doubt that's causing the pain.
Again, thank you SO much for your time and energy. It really helps as I'm feeling pretty hopeless right now!
Shayne
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RE: Scapular pain after excision - December 4, 2007 9:01:41 AM
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jlharris
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Shayne,
I don't want to sound rude, but I do want to be direct: Take a deep breath and let the thing heal. You are NOT going to develop some chronic pain syndrome. Go back and read in your nursing text about tissue healing. 3 phases - 1. Inflammatory: usually about 3 days but in my experience if the injured tissue keeps getting irriatated (say, by "testing" it to see if it's painful) this period can be prolonged. 2. Proliferation: This will take, depending on the tissue, 4-6+ weeks from the initial injury (oh, and surgery is an injury, just a nice clean one). You are still in this phase, at the very least. You will have discomfort especially with the constant passive stress of gravity pulling your shoulders forward and your head down. There is nothing "wrong" with you structurally (as your PT pointed out) but that doesn't mean you can't have pain. Simple analogy many of us use: Take you index finger and pull it backwards until you feel a stretch. No problem at first, but after about 5 minutes it will begin to hurt. Now nothing is "wrong" with you finger, but you need to quit bending it backwards! ie you need to be aware of gravities effect on your posture and your surgical incisions and position yourself occasionally to release the stresses on those tissues. Finally 3. Remodelling - this can take upwards of 12-18 months depending on the tissue. This phase is after the tissue is "solid" but not really like the other tissue around it. Your body attempts to replace, we'll call it scar tissue, with more normal tissue for that area.
Summary, have patience, follow Shills positioning recommendation, your PT's recommendations, and ICE and you will be fine. I'd say in 2-3 more weeks you'll be having very infrequent problems.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Scapular pain after excision - December 4, 2007 10:23:40 AM
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Shill
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I concur completely with Jason's excellent description and advice.
Steve
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RE: Scapular pain after excision - December 4, 2007 10:42:43 AM
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Alex Brenner PT MPT OCS
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Shayne,
I don't think your thoracic pain is directly related to the surgical removal of your moles but instead I think it is just coincidental that you are having mechanical thoracic pain after the procedure. In my opinion, I also don’t think that waiting 6-8 weeks is also acceptable. If you are no better with trying what others have suggested I would consider letting a manual therapist manipulate your t-spine. I have treated thoracic pain almost exactly like you describe and there is a good technique that is easy to perform and is well published in the literature that has a real good chance of getting you better a lot quicker than 6-8 weeks. Ask your therapist if they know of such a technique. If you can’t find a PT, (and I may take a lot of crap for this) I would consider going to an evidenced based orthopaedic chiropractor, not one of the subluxation model chiros.
Hope this helps.
Alex
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RE: Scapular pain after excision - December 4, 2007 12:17:27 PM
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Chocco
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Sounds like it could be a facet joint. I would still wait even if it is a facet joint could remedy itself, still early
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RE: Scapular pain after excision - December 4, 2007 4:10:36 PM
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Alex Brenner PT MPT OCS
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What do you mean wait? Meanwhile your patient has moved on to someone who will help them.
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RE: Scapular pain after excision - December 4, 2007 7:03:41 PM
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jlharris
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I disagree with you Alex. I don't think her pain is coincidental. I think it is a secondary effect of the inciscion around periscapular and postural muscles. It is normal to have pain from the incisions and to have muscle inhibition around the site of the incisions. Shayne then sits in class all day in (I'm assuming but most likely correct) forward head and stooped shoulders that are difficult to conteract as a result of the scapular and postural muscle being inhibited. It's the classic McKenzie analogy: pull your finger back and wait 5 minutes. It'll begin to hurt until you release the strain on those tissues. There is nothing wrong, structurally, the positioning (prolonged) just irritates the tissue. Throw on top of that, the tissue is still in the proliferation phase, one will get posture related pain.
So, you actively work on conteracting gravities effects, help with positioning when able, and let healing do it's thing. No need to make a big deal out of it. Not saying manual therapy is contraindicated, but also would argue a manip won't help with postural and incisional pain. And I'm a huge proponent of manipulation.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Scapular pain after excision - December 4, 2007 7:10:35 PM
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Chocco
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Sorry I misread your post sam I thought you were 2 days post surgery. Still sounds mechanical and postural to me. I agree with Jasons post, but if you are that dependant on meds and you are 2 weeks out of surgery ( a minor surgery at that) I don't see the harm on trying to speed things along with therapy.
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RE: Scapular pain after excision - December 4, 2007 8:45:03 PM
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Chocco
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Okay i am still feeling like a toll fromo my first post, so i will try to elaborate in hopes of redeeming myself a little'
The more I think about it the more I agree with alex on this. Jason is correct with his description of the healing process, but I think that its a little much to say suck it up for 3 weeks, meanwhile your downing naprosyn like there is no tomorrow. There are also signs that there may be a mechanical source, whenever flexion is intoduced in the thoracic spine the pain increases. If there is a positional fault or hypomobility in your t-spine( facets joints, post rib articulation etc) when shayne slouches and the thoracic spine segments flex he gets pain, sits up straight segments extend pain goes away. Structurally there isn't anything wrong, mechanically there is. At the very least Shayne would benefit from education on sitting maintaining a neutral pelvis to improve his posture for longer periods of time. If someone in my family came to me in the same situation I wouldn't tell them to wait 4 weeks before I tried to help them. Maybe Alex is right or maybe jason is right as to the cause of the problem ( none of us evaluated shayne we are only going off subjective) but I would feel better Trying to treat it first especially when the patient is that dependant on meds
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RE: Scapular pain after excision - December 4, 2007 9:43:44 PM
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jlharris
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quote:
There are also signs that there may be a mechanical source, whenever flexion is intoduced in the thoracic spine the pain increases.
Point taken. I didn't mean to come off as so polar. Treatment is warranted, but simple education on natural healing progression, postural re-education, and avoidance of pain provoking activities without labeling the pain with complex structural/mechanical/medical diagnosis should suffice. Case study. Grab a chair, duck the crappy grammer and spelling mistakes:
Yesterday I had a 40ish year old woman walk into my office with Bilteral cock up splints complaining of horrible (9/10) pain at rest in her left wrist - radial - that then radiated proximally up the ULNAR aspect of her forearm and then up the LATERAL aspect of her upper arm. She held her L UE in a guarded position and was observed to make no voluntary movements with L hand/wrist. Overreaction and generalized pain with light touch. Began to cry with Tinnels at the wrist; but w/o a positive test. Pain began 1 month ago after building a deck using a drill with R hand and holding the screws steady with the L hand. MD thinks CTS but presentation doesn't fit. I really had no idea, but I knew she shouldn't be having 9/10 pain this far out from a non-traumatic episode.
PLAN OF CARE: Educated on natural EXPECTED healing time and phases. Told her she needed to begin moving her wrist and that by doing so it WILL FEEL BETTER EVERYTIME, and worse if she continues to not move it. HEP of pain free wrist flex-ext AROM and Elbow PRO-SUP AROM.
F/U today: No splints, no pain meds, pain 4/10, cleaned kitchen in the morning before PT for first time since onset of pain with no increase in pain.
Point: When pain symptoms and pain behaviors fall outside of the "norm" or expected, r/o systemic causes of pain, and then quite trying to find some structural or biomechanical reason for it. It's probably not there. Educate the patient as to what IS EXPECTED. Tell them what WILL happen with your advise, and emphasize that - at this point - their pain is no longer correctly indicating injury or possibility of injury.
Now, if Shayne had come to me with neck pain that worsened as the day went on and with cervical flexion; but did not begin with surgical incisions along the spine between the shoulder blades, I'd manip the T-spine along with all the rest. But IMO, choosing to manip and explaining the rationale the the pt for the manip, implies more going on than hypersensitization on postural related tissue stress causing pain that is being interpreted to be more than it is (which is common and not meant to imply some sort of psychosomatic problem).
< Message edited by jlharris -- December 4, 2007 9:47:59 PM >
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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RE: Scapular pain after excision - December 4, 2007 10:39:50 PM
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sam5935
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Hey everyone!
Wow, a whirlwind of posts! The pain was much better today, and the pain upon flexion and reaching forward was not happening, just an overall pain if I sit too long. However, I am still on 500 mgs. of Naprosyn 3 times daily. I've been doing the exercises that the PT I saw mentioned, where I throw the sholders back and pinch the shoulder blades together. I have no idea why the pain is better today. I did get a massage two days ago, yesterday the pain was really bad, but I could tell that part of that was from the massage because the whole back hurt to some degree.
I'm just really concentrating on, as soon as it starts to ache, laying down and icing it, one or a combination of which makes the pain go completely away for a while. Meanwhile, trying to stay active as possible without carrying lots of stuff with that hand and shoulder.
As far as being more aggressive in treatment, I'm not sure what to do as the PT I saw yesterday didn't find much, although she did say that she thought that any problems I might have had to do with muscle connections in the C-spine as opposed to the thoracic area. I do notice that twisting at the trunk definitely stretches the left scapular area more than the right and is a little painful.
I am in San Francisco. Does anyone know a good PT here they would recommend? Also, if you need more information or more specific information, please let me know.
And to the poster who was afraid of being rude: No problem! I appreciate your straightforwardness. I honestly would be near as freaked out if my doc didn't basically say, " I don't know what it is and I don't know if it will ever go away." Your point about me needing to take a breath and calm down is well-taken and good advice.
Some of the language that is being used is out of my realm. However, what I'm hearing is: Rest and ice it but stay active. Don't do things that hurt it. Have realistic expectations and realize it's not going to go away tomorrow. And consider being more aggressive and getting a 2nd PT opinion.
Does this sound accurate?
Thank you SO much for your input. I'm sure you're all very busy and I really appreciate it. Any further thougths are most welcome!
Shayne
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RE: Scapular pain after excision - December 5, 2007 11:21:12 AM
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Alex Brenner PT MPT OCS
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Jason,
You make some good points about pain education and fear avoidance behavior; I understand that and agree with it. I don't think his pain is coming from the sutures. According to Shayne's history he had very shallow incisions to remove a mole. Do we really need to go into the phases of healing with him for two tiny incisions? It’s not like he had spinal fusion surgery or something. I fell off my 4-wheeler this past weekend and gashed my leg deeper than his incisions probably were. My leg hurts a little but I don't need to pound the Naprosyn to ease the pain.
My point is that he seems to have mechanical spine pain unrelated to the sutures. The fact that his thoracic pain gets worse with cervical flexion and eases with extension make him a good candidate for the thoracic manipulation that has been presented in several research articles published by Josh Cleland. This guy has a very good chance at being much, much better in a very short time; very similar to the building evidence we have for manipulation for patients with acute lumbar pain. If we keep waiting and waiting for the pain to resolve without doing something then I would argue that we would be contributing to the potential for this patient to have chronic pain. THEN you have a problem. I would certainly follow the manipulation with pain education, advice to keep active etc. and some directional preference exercises to help ease the pain. In the words of Tim Flynn, "Move it and move on!"
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RE: Scapular pain after excision - December 5, 2007 12:50:19 PM
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jlharris
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I think you have very valid points Alex. And, as said before, I'm a proponent of manipulation for NMSK pain. I think Cleland, Fritz, Childs, Flynn and them are doing great things with spinal pain research. I have no argument that your sugested POC is appropriate. My point is just tackling the "hypersentive" pain complaints with education (as you agreed with) and to be careful to not cloud it with attributing misrepresented pain with a mechanical explanation.
Thanks for the conversation Alex and Shayne.
_____________________________
Jason L. Harris, PT, DPT
My PT Blog
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