Giana H. Johnson, BS
Medical Student
St.George's University School of Medicine
Miami, Florida, United States
Jasmine Sidhu, MD
PGY 4 PM&R Resident
Larkin Community Hospital South Miami PM&R Residency Program
Miami, Florida, United States
Hein Linn Thant, MD
PGY III PM&R Resident
Larkin Community Hospital
West Palm Beach, Florida, United States
Puja C. Shah, DO
PGY3 PM&R Resident
Larkin Community Hospital South Miami
Lutz, Florida, United States
A 61-year-old disabled male presents with chronic right shoulder pain. His medical history includes uncontrolled hypertension and, in 2012, a brown recluse spider bite that led to necrotizing fasciitis, requiring multiple surgeries, including the removal of the proximal humerus bone. Post-surgical intervention, the patient experiences debilitating pain, which is significantly impacting his quality of life and daily functioning.
Case Description:
On physical examination, multiple surgical scars and severe atrophy of the supraspinatus and infraspinatus muscles was observed. Imaging with coronal proton density fat saturation MRI confirmed severe muscle atrophy, significant arthritic changes in the acromioclavicular joint, and marked deformity with heterotopic ossification. The rotator cuff tendons could not be evaluated due to the extent of the resection.
Discussions:
The patient reported persistent and severe pain, rated at 9/10 on the pain scale, exacerbated by movement and when lying on the affected arm during sleep. He described electric-like pain radiating down his right arm to the fingertips. Despite long-term opioid therapy, including oxycodone and gabapentin, pain relief was only partial (around 20%). A recent trigger point injection (2cc 6 mg ketorolac, 4cc 1% lidocaine, and 4cc sarapin) reduced his pain by approximately 10% for a day but provided no lasting relief, indicating traditional pharmacotherapy was insufficient. Physical therapy, including cold packs and e-stim, helped alleviate some pain. The patient had limited range of movement and was unable to flex or extend the shoulder due to excision of the humeral head. Despite his condition, he remains active in daily activities, such as driving and household chores, though he is unable to lift heavy objects.
Conclusions:
This case underscores the intricate challenges involved in managing chronic shoulder pain. The profound muscle atrophy, arthritic changes, and potential chronic infection highlight the complexity of the patient’s condition and the need for multidisciplinary pain management.
