An Unwelcome Development

I'm doing this in a blog so I can just send everybody the URL.

I've been having problems with my left shoulder off and on for the past three or four years now, mostly in the form of pain in my shoulder and aching down and around my upper arm just above the elbow. Finally, a couple months ago, it became so constant and so painful that I was routinely popping 8-hour Tylenol at bedtime just so I could get to sleep and I knew I needed to "see somebody" about it. Having been a medical transcriptionist for 22 years now come September (!!), I could think of several causes for pain in the shoulder, most of which have nothing to do with the shoulder per se.

I could be having problems with a pinched nerve: The "pinch" could be happening in my neck vertebrae where the spinal nerves that go to the arm branch off the spinal cord and come out between the vertebrae (I had been in a pretty hefty rear-end collision in my 20s and still have intermittent problems with a "catch" in my neck on turning my head to the left.) One of the branches (radial) of that nerve also has to go through the shoulder joint area, so the pinching could be happening there, called "thoracic outlet syndrome," or it could be a combination of neck and shoulder "pinching." I habitually sleep on my left side, and that could be causing misalignment in my neck, and making things worse. A pinched nerve seemed like a very reasonable explanation because, in addition to the pain, I was having numbness and tingling in my left ring and little fingers and in the "heel" of my hand, which I'd had intermittent problems with since I'd been a medical transcriptionist and which I attributed to neck/spine problems from the wreck. Neck exercises had usually solved the problem in the past, but they weren't working now. And, the thing about a pinched nerve: pinch it long enough and you get nerve damage, so that even when you relieve the pinch, the nerve will never fully recover its function.

Another cause that lurked ominously in the back of my mind was cholesteatoma, a tumor made of cholesterol that invades and eventually destroys the part of the ear behind the eardrum where the "hearing mechanism" is that transmits sounds from the eardrum to the nerves in the "inner ear." My dad had one that not only totalled his middle ear, but had significantly invaded into the mastoid bone, which is the part of the skull behind the ear. I knew that cholesteatomas tend to run in families and, even though they are in the ear, cholesteatomas can "refer" pain down into the shoulder. My dad had been having problems with pain in his shoulder on that side, which were "cured" when he had his ear surgery for removal of the cholesteatoma. A colleague who lives in Alabama had a cholesteatoma and she also had shoulder pain.

However, another thing that I had picked up from my years as a medical transcriptionist: Start with the problem that is easiest to get at. That would mean seeing somebody who find out if I had "done something" to my shoulder, and that would be an orthopedist. I had seen Dr. Harry Hall in 1989 who treated the fractured kneecap I suffered in 1989, and I'd been very pleased with the outcome. We had established a good rapport, and I felt comfortable with him. So, I hunted up his office number and set up an appointment. First crack out of the box, his office sent me for an x-ray of my shoulder -- logical. So Dr. Hall examined my shoulder, looked at the x-ray and noted that I had a small degree of impingement syndrome, and gave me a shot in my shoulder joint to knock down any inflammation that might be going on. Then he set me up for an EMG/nerve conduction study and an MRI.

Dr. Roger Wolcott did the EMG and nerve conduction study. The EMG was to test to see if the muscles in my arm were getting nerve signals, and if they were responding appropriately to them. The nerve conduction study tested the speed at which the electrical impulses traveled from one point in a nerve to another. If I did have impingement somewhere, and it was affecting the nerve, then it would show up as a slowing of the electrical impulse. I have a habit of telling my physicians right at the onset that I am a medical transcriptionist, and that I understand "docspeak." This makes communication a lot easier. And, like I told him, I've typed EMGs and nerve conduction study reports for years, so I understand the terminology. Although his tech performed the actual test, he took a look at their results while I was there, and told me what the findings were: There were no signs of nerve damage in any of the nerves of my left arm or hand, particularly in the radial nerve, which is the nerve to my little and ring fingers. That was reassuring.

Then I had the MRI -- on my birthday actually. (Not really what I wanted for my birthday.) The reason I was having an MRI is that x-rays can only show bones. MRIs can show soft tissues as well as bones -- organs, muscles, tendons, cartilage -- and can show them in great detail and in three dimensions. If I had a torn ligament or cartilage, it would show up on MRI. And, let me tell you. If you are even the slightest bit claustrophobic, you will have trouble having an MRI! If they offer you sedation, take it! First, they shot contrast dye into my joint, and then had me lie on the table, and "inserted" my head and shoulders into the scanner -- a huge metal donut with a very narrow "donut hole. " They have to "magnetize" the part of the body they want to look at, which means they have to rotate magnets around you very fast for a long time. The machinery that does this is noisy. It thumps and bangs and tweeps and sounds like it's going to come flying all to pieces. There's no chance you are going to be able to doze off for the nearly thirty minutes it takes to do the scan. I couldn't take my tunes in with me. I just had to think calm thoughts and wait it out. Since the radiologist has to view the scan images and interpret them, I didn't find out any results. But my mom took me out to eat at Anna's Asian Buffet for my birthday afterward, and a heaping helping of Chinese food "made it all better. "

So Wednesday, July 30, I went back to Dr. Hall to get the MRI results and find out what, if anything, needed to be done next. His verdict: Full-thickness rotator cuff tear. Since there was no actual injury involved, it had probably happened gradually over time as a result of impingement syndrome. Naturally, I asked Dr. Hall for a copy of the MRI, which he provided. His office uses an electronic medical record system, so all he had to do was have his nurse get on the laptop, access the report and print it, and in a matter of minutes, I had the report in hand. So, for those of you who understand "docspeak," here's the MRI report by the radiologist, Dr. Lee Johnson:

"POST CONTRAST MRI, LEFT SHOULDER

Multiplanar, multisequence MRI of the left shoulder is performed following intra-articular contrast administration. There are no bone contusions or trabecular microfractures. There is a full-thickness tear of the supraspinatus tendon proximal to the greater tuberosity. Contrast extends into both the subacromial and subdeltoid bursae. (note: the MT who transcribed the report transcribed "bursa" as singular when it should have been plural) There is no significant musculotendinous retraction. There is no atrophy of the supraspinatus muscle. The subscapularis is intact. Biceps tendon unremarkable. The biceps labral complex is maintained. There are no labral tears. AC joint is maintained. There is no significant inferior spurring. Para-articular soft tissues are unremarkable.

IMPRESSION:
1. Full-thickness tear, supraspinatus tendon, just proximal to the greater tuberosity with no significant musculotendinous retraction or muscular atrophy.
2. No definite labral tears. "

So what exactly does this mean. The shoulder joint has got to be the worst joint to injure of any joint in the body because it's the hardest to repair. The problem is that the shoulder is a ramshackle affair made up of three bones, the shoulder blade (scapula), the end of the clavicle, and the upper arm bone (humerus), all lashed together with tendons and ligaments. The tendons are hooked to the muscles that control the wide range of movements of which the arm is capable. Tn fact, the shoulder joint has the widest range of motion of any joint in the body.

You hear the term "rotator cuff" bandied about, but what exactly is it? The rotator cuff is made up of the tendons that attach the four main shoulder muscles to the arm bone: the subscapularis, supraspinatus, infraspinatus, and teres minor. It's called "rotator" cuff because these are the muscles that enable you to rotate your arm (move it around in a circle). A rotator cuff tear is a tear in one of these tendons. Tear it bad enough and you tear the muscle loose from the bone. When that happens, you can no longer make whatever movement that muscle enabled you to make.

So I've got a tear in the supraspinatus tendon which is what attaches the supraspinatus muscle to the upper arm bone. Here's the supraspinatus muscle. It's one of the muscles that helps you raise your arm. I've got a full thickness tear in the tendon that attaches it to the top of my arm bone (humeral head). So I have pain when I try to raise my arm straight out from my body and lift it above shoulder level. And the tendon didn't actually tear from injury. It was worn through by impinging (rubbing) against the acromion -- and being caught between the acromion and my arm bone (humeral head) -- classic impingement syndrome.

At left is what it looks like from above, looking straight down on the shoulder. That little hook thing pushing between the muscle fibers at the top is the acromion. It's part of the shoulder blade. The end of the clavicle butts up against the acromion to form the acromioclavicular joint. The thing is, while a small percentage of tears will heal themselves, most of them require surgery, and the longer you put it off, the worse the tear is likely to get, and the more likely the surgery will not be successful. If it goes long enough, the tendon will lose its elasticity and will shrink up, and then you cannot re-attach it to the bone because it will be too short to reach.

I go back to see Dr. Hall in six weeks to see if I have any improvement, which I doubt I will. What it looks like is that sometime in the fall (October?), I'll be having surgery on my shoulder. The implications of the surgery will be that my whole left arm (and hand!) will be out of commission for weeks because I will be in a shoulder immobilizer -- exactly how long I don't know yet. And once I come out of the immobilizer, there will be rehab, again I don't know for how long. I will be coming back to my house after the surgery because I'll have the cats to take care of, most of which I can do one handed. It'll be a little tricky giving Jett his insulin injections one-handed, but I'll work it out. I'll be able to keep working because I "mouse" a lot more than I type, and what little I do need to type, I can type one-handed. It will slow me down, but I can still do what I need to do. I won't be able to fix my hair one-handed. It's very long and takes both hands just to comb it, never mind put it in a braid or a pony tail. I'll probably end up cutting it before the surgery to a length that I can comb with one hand. I'll probably end up cutting it way short. I'll hate it, but there it is. I won't be able to drive (even if I didn't have a two-handed car -- it's got a stick shift), maybe for months. The only thing I'll really need to drive for, though, will be doctor's/therapist's appointments, for a while anyway. Hopefully, my mom will be able to drive me to those. I'll stock up on food I can microwave and that comes in pull tab cans that don't require a can opener to open, and get bread and lunch meat I can freeze until I need it. I'll also have to stock up on cat litter. I'll need to get somebody to come in at least once a week to empty my garbage and change the bag on the Littermaid and take it all out to the alley, and to set my water bottles up on the counter. It won't be my mom. Those water bottles weigh 40 lbs and she'd never figure out how to do the Littermaid. However, I can operate the TV one handed, and read books one-handed, and listen to music one-handed, so there's that.

So, in the meantime, I'm going through the whole house and collecting stuff for the garage sale mom and I are having in three weeks. It'll be at her house, so I'll have to schlep everything over to there except one computer desk which I want to sell but which I'm not even going to try to move. My friend Jean has graciously offered me the use of his pickup for schlepping purposes and most of the stuff will be in plastic garbage bags. Once that's over and done with (big sigh of relief), I'll be able to move the desk I'm keeping about a foot farther from the western wall of my office, and put down a piece of half-inch plywood over all the exposed carpet between the desk and the cabinets behind it -- I am so sick of having to pull this stupid plastic chair mat back into position because it has migrated north -- which it does very quickly. Once the desk is moved and the plywood is down, I'll be able to move one of my burgundy recliners in from the living room (I've already put casters on it, so it rolls) and I'll have my work computer back in my office. Right now, my work computer is on a rolling table, which I push to and from the living room every day. I'm working 10-hour shifts so I can have three days off in a row, but my ankles puff up like a balloon after even a couple hours of sitting in my desk chair. Reclining in the recliner while I work has eliminated my ankle swelling, and is a lot easier on my neck and shoulders. Being able to move the recliner into my office will allow me to use my recliner to work at my personal computer as well as my work computer.

After that, I really need to get some yard work done this September -- irises transplanted and thinned, a brick border put in around the crepe myrtles, drip hoses laid and/or reconfigured, and that last little bit of sifting done. I've saved back some of Jett's syringes and next week, I'm using them to inject herbicide into the trunks of all those (expletive deleted)"volunteer" tree seedlings that are the unwanted gift of my neighbors, and kill those suckers once and for all. With all the stuff I have to do between now and then, by the time I have my surgery, I'll be ready to take it easy and rest up.

Perhaps the Most Beautiful Pix My Mom Has Ever Taken

Photo of the view from my cousin John and his wife Sheila's place outside Capitan, NM.

Jazz Improvisation on a Theme by Birds on a Wire

I am a part of the first television generation. We both became available to the general public at about the same time, and some of my earliest memories (age 3) involve watching TV. Back then, television only came in two networks, NBC and CBS, and had only two colors, black and white. When I was 7 years old, one of the more popular shows on television was "The Steve Allen Show." (It was very popular with me.) Steve Allen was a TV personality who, besides being witty and hilariously funny, was the original host of "The Tonight Show," the author of more than 50 books, and, more to the point, was also a very accomplished musician, jazz pianist and composer. The list of talented people that man brought to national attention (including a young comedian from Nebraska named Johnny Carson) is mind-blowing. Back in 1956, the year his show debuted, the whole nation, not just the South, was still very much segregated and most of white, mainstream America considered jazz "race music." But Allen was a TV pioneer in more ways than one. Not only did he perform jazz himself on his nationally televised show, but he also showcased many talented black jazz artists in a time when showing a "colored" person doing anything on TV was risky, let alone allowing black musicians to play their music. The jazz Allen played was the new, "cool jazz," that had been "pasteurized" and "intellectualized" by white musicians like Dave Bruebeck, Stan Getz, Bill Evans, Chet Baker and others, many of them formally trained, who were too cool for Big Band and too radical for the Doris Day set, having crossed over to the "dark side," after being seduced by the music of Miles Davis, John Coltrane, Thelonius Monk, Charlie "Bird" Parker, Dizzy Gillespie, et. al.

The madeleine that triggered the above spasm of "recherche du temps perdu" happened when I was outside watering the yard last night. I always water after dark during the hot months to minimize evaporation losses, and I time the sprinklers by the TV -- which was why I was in the back yard at 11 o'clock at night resetting a sprinkler to water the lavender end of the climbing rose flower bed, which is next to the back gate. I was also "kind of" watching a show on the Ovation channel about the photographer Sally Mann, that I was recording to DVR with plans to transfer it to DVD (sans commercials) later. Her photographs had gotten me in the "artsy photographsy" mode, so while I was adjusting the sprinkler, I was checking out various views of the yard with a "photographic eye" and so happened to look up at the night sky above me. Since I was right by the back gate, I was close enough to the alley that the power lines were directly above me, and there were several bright stars visible through the spaces between the individual wires.

Stay with me now. Here's the point where this whole piece comes together like an asterisk of intersecting lines of thought: I flashed on the visual image of the power lines and stars and thought: Power lines = lines of the musical staff; stars= notes on that staff, notes that could be interpreted as music and played, that could become a theme/motif for a piece of music. That's where Steve Allen comes in. That visual image was primed by a memory of one of the old Steve Allen shows where he did a "jazz improvisational thing" -- What stuck in my 7-year-old mind about that particular show segment was that Allen used "found melodies" from a series of photographs as the themes he would improvise on. The only one of the several photographs that I remember, and I remember it very clearly, was a picture of some birds roosting on the wires strung between two telephone poles. There happened to be five wires, which translated to the five lines of the treble clef, and the birds perched on them became the notes. He played the bird "notes" on the piano, and that became his theme. Then he took that theme and improvised on it. Brilliantly.

The idea of using stars as notes and telephone wires as the musical staff to provide a "celestial" melody is going to turn up in one of the stories from the "Johnny B." universe, just you wait and see. And I think I know exactly where. It'll involve at least one of Sam's cousins (whom he reckons by the dozens) -- definitely Fionnuala, the lady that's half seal (selkie), and almost certainly the harpist named Taliesin, and it will probably involve Wuffa's harp. Stay tuned.