The Clinical Coach: Shoulder Cysts?

, over the last 7 years, I’ve seen over 150 shoulder presentations. From CrossFit athletes, to baseball players, swimmers and even cyclists.

It’s been one of my favorite regions of the body to treat as it can be quite simple, and complex at the same time.

While I’ve seen a variety of rotator cuff injuries, labral injuries, arthritic cases, fractures and even post-op surgeries. There’s been ONE pathology that I have yet to master when it comes to conservative care.

The Cyst.

And it’s not for a lack of trying.

From gentle mobilization, to graded mobility, dry needling, soft tissue work, e-stim, and even referrals to other chiropractors who have a class IV laser. I’ve tried it all with these cases.

All with less than 20% improvement.

The problem?

This space occupying lesion is non-painful, until it is.

And once it’s been aggravated, nothing conservative (even immobilization) seems to help it improve to the point where it’s not an issue for the patient.

Two cases come to mind.

The first one: A 67 year old lady presenting with shoulder pain after throwing the ball to her dog.

The second one: A 42 year old runner presenting with shoulder pain 5 years post-labral repair (on the same shoulder)

Both pain presentations at first glance could’ve been missdiagnosed for 1) impingement and 2) rotator cuff tear.

Specially if one were to skip the passive ranges.

Painful passive ranges of motion in my opinion point to a source of pain that is non-contractile. Yes, this could be a tendon, ligament or joint.

In the case of the shoulder, I’ve come to find out that performing the log roll test at the shoulder accentuates the labrum and GH joint itself while reducing the load of the tendons.

Now this is not a published test. There’s no confirmed log roll test of the shoulder, but it’s simply a motion that has come to be quite reliable (at my office) for this type of cases.

You are probably thinking - well let’s do a few test for labral injuries.

You are not wrong. We do them.

These tests usually result positive for pain if there is an intraarticular cyst present more than half the time, and out of the two paralabral cysts we’ve had it was 50/50.

Out of the 8 shoulders that I’ve treated with confirmed cysts, 7 had pain during passive IR/ER (shoulder log roll test), pain with active motion, and painful labral tests.

One had a deep sharp pain only with abduction of the shoulder. I like to think of this one as an outlier as it was a post-op patient with intraarticular cysts 1 year post op.

Sadly for all, the pain was significant enough to compromise not only their function, but their quality of life.

We had to do something.

If you are thinking that I recommended a corticosteroid injection to reduce the pain and therefore have a window of opportunity to improve their function.

That is exactly what I did.

I reached out to a local orthopedic (in Nixa) and a local neuroradiologist (while in St. Charles) for their co-management.

We agreed that this would be a short term solution, but could provide them with long term benefits, and if it failed they recommended surgical debridement.

I presented my recommendation to the patients, and five went through with the shot. The other 3 elected to have the cyst removed overall.

The three who elected surgery completed a 12 week shoulder rehab program and graduated with full recover, stronger shoulders and zero pain. One of them being our 67 year old female.

Out of the 5 who elected to go through with the shot, two ended up getting surgery within the year and the other three were able to keep their pain level low while increasing their function.

As a matter of fact one of them is the 44 year old runner I mentioned earlier. He is currently completing a longer rehab program as he has a few more things we need to work on.

While I’d love to tell you that you will be able to help every single patient conservatively. Your job is not to push a specific treatment onto them.

Your job is to provide them with the best quality care to help them maintain or improve their quality of life. That sometimes forces you to reach out and co-manage with other practitioners.

Make sure you take the time to understand all the treatment options available and make the best decision for your patient, not your bottom dollar.

The more you serve, the more you will receive.

Until our next issue!

In health and strength,

P.S. I am putting together a 7 week workshop where I will be covering business, technology and finance. I am only opening it to 10 participants. E-mail me if you want on the waitlist.