Hello there, I am a 23 year old Military Police Officer at Ft. Bragg, NC. I have been in the army 4 1/2 years, and participated in the Iraqi invasion in 2003, to give you a little background.

In Special forces training (PLDC/BNOC to be specific) I had a very heavy rucksack about a year ago, that hurt my shoulder very badly, to the point I couldn’t lift my shoulder the next day. Luckily it was the last week, so I finished training, then went on a break. I didn’t report the injury as I didn’t want to get ‘booted out’ of training. 3 months later, I started the next phase of training (small unit tactics). 4 weeks into training I couldn’t lift my shoulder anymore. I reported it to the medical personell out there, they put me on oral steroids and some advil and had me keep going (my shoulder was in intense pain at this time.) 3 days later, I could literally not lift it and had to drop training and go to the clinic. X rays were taken, and they gave me some advil.

Over the last year I have done 20+ weeks of physical therapy, had Xrays, MRI, dye injection MRI, and 3 cortisone shots, nothing has really helped. I was scheduled for surgery at one time, they told me they were going to smooth out a chunk of bone and scope it, when I came in for pre op, they told me the MRI’s showed there was nothing wrong, gave me another shot, and told me to come back in 6 weeks. There is a constant pain in the top back of the shoulder, it cracks when I move it in certain directions very badly, with loud, audible popping when I do this, there is some intense pain at night at times.

So far the army doctors have diagnosed me about 5 times, in order they are;
1. Join Effusion with tendonitis
2. Exterior Shoulder Impingement
3. Bone spur with tendonopathy
4. Nothing wrong with me
5. Interior, Anterior Impingement

I just got another new doctor, who is telling me I am too young to have these kinds of symptoms, and the MRI’s show him nothing. He doesn’t believe anything is wrong with me and that the cracking in my shoulder is normal. He started me on another 6 weeks of physical therapy.

Side note; in the army (at least 82nd) you cannot get promoted until you get off the profile (like a doctor’s note excusing you from excercising), so my entire career has been on hold the last 13 months.

Please give me any advice when I go into my next appointment, because I don’t feel like I can convince him that my shoulder is really hurting, and he is telling me the MRI’s show nothing is wrong with me. They are implying I am lying to them as of lately.

I have done a little research, and have discovered an MRI doesn’t show many injuries in the shoulder (bone spur, tendon frays, laberal tears, partial rotator tears) , and that many people get misdiagnosed quite a few times before the problem is found, through tests such as electrodiagnostic exam/arthrogram/scope.

Doctor Sinuhe Answers:

Thanks for your question. You describe a very complex situation - not only medically, but professionally as well. I repeat myself in these forums in saying I can’t be your attending surgeon, since I don’t have all the necessary information at hand. When speaking about shoulder problems, however, this is exceptionally true. When making a diagnosis, the main thing always is the physical examination (in addition to the details that the patient is telling), but in this case it is essential and crucial - no matter what the MRI reveals. Therefore, I hope and trust you have been examined, diagnosed and treated by a specialist - in this type of case often an orthopedic surgeon specialized in shoulder problems and sports injuries. Then again, as you well know by now, sometimes asking for a second opinion gives just that, and asking for five opinions gives you five different opinions. Therefore, I personally think the most important quality in any doctor is not only his level of expertise, but also his willingness to help and to try to solve the problem. This is why I often hesitate to advice to change a doctor, if you just basically get along with your doctor. If I were you, I’d choose a doctor who you like and who seems willing to help you. This may not be an easy task, unfortunately. I did my military service as a doctor, and I found the job very difficult from a medical point of view. It is one thing to treat a patient purely from a medical perspective - and another to determine whether the patient is qualified for training. The latter was, understandably, often the more important part of a doctor’s job there - and it seems it may be the same thing in the US as well.

Back to your problem. Being a neurosurgeon, I’m not hugely familiar with specialized shoulder problems. But I did discuss your case with a professor or orthopedic surgery.

In short, MRI does not show everything (although it is very accurate) and its interpretation may sometimes be difficult. For example, in my hospital they just this week successfully operated on a 16 year old, whose MRI was considered normal, but who eventually had a an excess cartilage causing impingement (obviously this was an exception, but in that case the clinical picture was clear). Therefore, you are not “too young” to have shoulder problems.

Since your symptom started by carrying a heavy rucksack, it may be worth considering performing an ENMG to rule out nerve impingement in the scapular area. This should, however, cause pain rather than not being able to lift one’s shoulder.

So far, all the suggested diagnoses you describe above have been reasonable options. More importantly, so have the treatment efforts. The normal start of treatment is rest. After the situation has been calmed down, the routine is to start to train the shoulder - exactly what has been done in your case. Since this has been tried in your case and your profession is at stake, the next option might be shoulder arthroscopy, even if the MRI is normal. Arthroscopy might be justified, since your professional career is on hold because of this.

In short:
1. If you can, choose a nice doctor who is willing to help you, preferably a shoulder specialist/orthopedic surgeon.
2. Ask whether ENMG might show any extra information
3. Ask about possibility to make an arthroscopy.

Hope this helps a little in your difficult situation.

Dr Sinuhe

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