Case Study: BURSITIS

Mr E came in with pain in his arm.  He was in his 50s and his pain was preventing him from doing much of his household chores, and prevented him from riding his bicycle for exercise.  He was feeling a bit depressed about the loss of function.  He had been diagnosed in the past with carpal tunnel syndrome on the same arm, but he had refused surgery.  He felt that shortly after the shoulder and upper arm pain started, his carpal tunnel got worse.  The shoulder pain didn’t bother him at night, but now he had burning in his hand that kept him awake.

A careful exam included special tests to determine if there was nerve root irritation in his neck, irritation and inflammation of the bursa in the shoulder, bad arthritis in the shoulder, weakness or tearing of the tendon in the shoulder, or compression of the nerves in the arm.   From an orthopedic/neurological point of view, there didn’t seem to be nerve issues in the neck or a tendon tear.  There was strong signs that the bursa was inflamed.  The associated muscles were also tight and tender.  And there was strain in the connective tissue going down the arm and toward the wrist.  The area of his burning pain was typical for carpal tunnel syndrome.

He said his other doctor wanted to give him anti-inflammatory medications and a cortisone shot in the shoulder, but he didn’t want one.

From an osteopathic perspective, there was alot going on.  There were numerous restrictions in his neck, the base of the skull, and the upper and lower back.  These seemed to be contributing to a posture in which his shoulders were rolled forward a bit, which can predispose to pinching of the shoulder bursa.  Also, there was strain–restriction and tightness–in the layers of connective tissue that travel from the trunk and neck out into the arm.  The nerves traveling through the shoulder and arm seemed to be tight and irritable.  (These are the same nerves that have branches going through the carpal tunnel at the wrist).

I prescribed him a low dose of a nerve stabilizing medication called neurontin.  The idea was to quiet the irritability of the nerves, so that he could sleep.  Neurontin’s main side effect is tiredness, so it’s often good at bedtime when there is pain.  I referred him to a physical therapist with very good biomechanical analysis skills, and I called her to tell her my impression of what he needed.

He came back the next week for osteopathic treatment.  He was sleeping well with the neurontin, without any daytime sleepiness.  I treated him with osteopathic manipulation three times.  There was significant improvements in the moblity of his neck and trunk, and in the tissues extending out into the arm.  The inflammation in the bursa, and the spasm and tenderness of the shoulder and arm muscles decreased significantly.  His burning pain in the hands subsided, though there was still tingling.  He was able to stop the neurontin.  He will come back in a couple of weeks after doing more physical therapy.  The goal there is to build on the changes that already happened, and do postural and strength training to help prevent recurrence.  And he didn’t need a potentially toxic cortisone injection!