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Dr. Andrew Rynne

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Suggest treatment for glenohumeral chondrolysis

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Dr. Prof. Kunal Saha

General & Family Physician

Practicing since :1954

Answered : 4312 Questions

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Posted on Wed, 31 May 2017 in Bones, Muscles and Joints
Question: I have a are condition called glenohumeral chondrolysis--not simply arthritic fraying but complete dissolution with toxic burn to the subacromial nerve area. I recently moved to XXXXXXX hoping to find some improvement. Instead, no one would renew my opioids. I can barely move my arms, am in non-supervised withdrawal after six years of oxycodone/oxymorphone and have no family alive and no support here. (Went to undergrad/grad school here, thought there might still be someone still around, duh) I have been taking an old rx of Mobic, naproxen, robaxin and occasional ibuprofen just to be able to get up to feed myself--the pain is beyond tolerance without this. I am, of course, bleeding rectally, but I need to function until I an get to a state with safer medical care. I started this 5 days ago. I was extremely fit until this happened (5/mile a day runner, never smoked, nor used illegal drugs, etc.) and have no systemic conditions at 71. I'm a bit concerned about the potential cardiac implications of what I'm doing, but the pain is enough to not want to survive, anyways, so I thought I 'd try this for the short run. Any thoughts on dealing with this? (Going to an ER is out of the question, already tried that and was treated like a drug addict--he actually used the ancient GOMER phrase......
doctor
Answered by Dr. Prof. Kunal Saha 4 hours later
Brief Answer:
Alternative therapies for pain relief need to be tried.

Detailed Answer:
Thanks for asking on HealthcareMagic.

I have gone carefully through your query and understand your concerns. As such the 5 mile per day running would not have damaging effects on your heart. Rather it is a good thing if you can carry on with it. However, you should try the same with proper pain relief measures. I understand that conventional treatments have not been very effective. Let me mention that acupuncture has been proved to be effective at least in knee osteoarthritis (using blinded placebo control randomized control trial - the best level of evidence of the day). It has also been demonstrated to depress the brain areas responsible for pain sensation. It is likely that acupuncture could provide you relief from the pain you are suffering from. I would suggest you to try acupuncture and hope that would provide relief.

Let me know if I could help further.

Regards
Above answer was peer-reviewed by : Dr. Remy Koshy
doctor
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Follow up: Dr. Prof. Kunal Saha 8 hours later
I'm sorry, the running and fitness activity disappeared with the shoulder injuries, seven years ago. I am in so much pain right now I am having trouble even dressing and had to pay someone to go get food for me. I had a revolver in my mouth twice recently due to the level of pain--not because I want to die, but because the pain is unbearable. I made the decision to gut it through this only because I will not let the doctors who caused this get away with it. (The damage was the result of a scheme to defraud Medicare ans compounded when they tried to cover it up. My work was Quality Review of Healthcare, and I am not speculating about that.)

My current concern, more concisely, is that, given my previous level of good health, is it possible to continue with what is a potentially risky level of multiple NSAIDS, Robaxin, etc., until I can find an MD who will trear my condition, which, per all those orthopods familiar with it, will require opioid treatment, or is there a way to adjust over the counter medications to be less risky? Mobic is the only prescription med I'm using out of the group. I am getting to the point of potentially just dying in my apartment. I worked in a mult-modality inpatient pain mgmt program years ago and would absolutely consider acupuncture, but the steps getting anyone to even treat me are insurmountable. Both arms arms are becoming useless from severe tendinosis--hence the choice of anti-inflammatory drug,s as I can barely hold a cup of water at present, and I can't meet the ever changing paperwork requirements.

I was still on opioids when I saw local MDs, not one of which allowed me to participate in the 'discussion'. On the pain meds I appear stronger than expected for someone of my age. I'm totally out of them and have been trying just to get washed for the last three days, with no sucess. I don't want to develop an ulcer or heart issues, but I can't figure out a way to mitigate this pain without the opiates, which had almost minimal side effects, but are unobtainable. As much as I wanted to forego them, they allowed me to function, once my body adapted at an appropriate dosage. (I used to lie in bed crying and wishing someone would simply cut off my arms and shoulders, or simply shoot me, until that point.) I haven't even been able to get a monitored weaning here in XXXXXXX let alone help for the pain.
doctor
Answered by Dr. Prof. Kunal Saha 40 minutes later
Brief Answer:
Pain medications usually have serious downsides

Detailed Answer:
Thanks for writing back and for clarifying. Although I do not know the specifics of the medical intervention that subsequently led to your pain, let me remark that it is not always the doctors fault when things turn in the wrong direction. Being in the profession for so many years I have seen how things go wrong at nobody's fault. I understand that it is a bad practice when people try to cover up. I would not promote that. But more often than not, it can be really hard to make the patient get to understand how things went beyond control.

Coming to your query, over the counter or prescription, NSAIDs are usually gastric irritants and prolonged intake can result in troubles like gastritis. On the other hands opioids are addictive/habit forming and grow tolerance leading to requirement of higher and higher doses for equivalent amount of pain relief. Robaxin (methocarbamol) is a muscle relaxant and not a pain medication but can be used. I know the limitations of palliative medicine at present scenarios. However, it is based on evidence that I have suggested you acupuncture. You can give it a try. The choice of continuing with the pain medications or trying acupuncture lies upon you.

Regards
Above answer was peer-reviewed by : Dr. Kampana
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Follow up: Dr. Prof. Kunal Saha 14 minutes later
I'm sorry, the running and fitness activity disappeared with the shoulder injuries, seven years ago. I am in so much pain right now I am having trouble even dressing and had to pay someone to go get food for me. I had a revolver in my mouth twice recently due to the level of pain--not because I want to die, but because the pain is unbearable. I made the decision to gut it through this only because I will not let the doctors who caused this get away with it. (The damage was the result of a scheme to defraud Medicare ans compounded when they tried to cover it up. My work was Quality Review of Healthcare, and I am not speculating about that.)

My current concern, more concisely, is that, given my previous level of good health, is it possible to continue with what is a potentially risky level of multiple NSAIDS, Robaxin, etc., until I can find an MD who will trear my condition, which, per all those orthopods familiar with it, will require opioid treatment, or is there a way to adjust over the counter medications to be less risky? Mobic is the only prescription med I'm using out of the group. I am getting to the point of potentially just dying in my apartment. I worked in a mult-modality inpatient pain mgmt program years ago and would absolutely consider acupuncture, but the steps getting anyone to even treat me are insurmountable. Both arms arms are becoming useless from severe tendinosis--hence the choice of anti-inflammatory drug,s as I can barely hold a cup of water at present, and I can't meet the ever changing paperwork requirements.

I was still on opioids when I saw local MDs, not one of which allowed me to participate in the 'discussion'. On the pain meds I appear stronger than expected for someone of my age. I'm totally out of them and have been trying just to get washed for the last three days, with no sucess. I don't want to develop an ulcer or heart issues, but I can't figure out a way to mitigate this pain without the opiates, which had almost minimal side effects, but are unobtainable. As much as I wanted to forego them, they allowed me to function, once my body adapted at an appropriate dosage. (I used to lie in bed crying and wishing someone would simply cut off my arms and shoulders, or simply shoot me, until that point.) I haven't even been able to get a monitored weaning here in XXXXXXX let alone help for the pain.
doctor
Answered by Dr. Prof. Kunal Saha 56 minutes later
Brief Answer:
Take the medicines in full stomach. Drink plenty of water.

Detailed Answer:
Thanks again for writing back. A good idea to reduce the risk of gastritis from the pain medicines is to take them in full stomach. It greatly diminishes the risk of gastric irritation. Mobic (meloxicam) is a good medicine can be taken. It is good to know that you are considering acupuncture. I am certain that you would get someone easily to offer the therapy on you. In addition you may also visit a psychologist. He can offer you cognitive behavioral therapy which will help you to cope better with the present level of pain.

Feel free to write back.

Regards
Above answer was peer-reviewed by : Dr. Nagamani Ng
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Follow up: Dr. Prof. Kunal Saha 40 hours later
Thank you very much for your suggestions--and, if I am able to get sufficient opioid tx to get dressed and see someone I will most definitely attempt to utilize acupuncture. I am trying to take the NSAIDS as you've suggested, full stomach and plenty of water. I worked in pain management, and was responsible for utilizing behavior modification, relaxation techniques, etc., with patients and found them, along with the other modalities that inpatient program offered to be very successful for that patient population. The orthopod who did my surgeries remarked on how extreme the damage to my shoulders was, and what a 'mind over matter'person I had to be.

The rest is more of a clarification of my remarks. If you're busy, please don't concern uyourself.

While I'm very aware, after several decades of working teamed with MDs (and living with a few) of the inadvertent medical mistakes, given the lack of perfect knowledge and perfect human beings, my own condition was not only the result of deliberate fraud. This clinic did 2.5 years of an obscene amount of Kenalog injections--I have an allergy to lidocaine which was contained in the appr 52 injections, done despite my protests, while they repeatedly refused to do an MRI.

When the MRI revealed the degree of cartilage damage, with surgery scheduled for 3 weeks away, they forced me to go back for even more 'if you want us to do the surgery', which was bizarre. This was done so they could document they were placing them in the subacromial space--NOT-the primary care they sent me to insisted he had to get them into the joint, or 'they wouldn't be effective'. (Although journals were indicating severe, intractable pain and cartilage loss in a percentage of patients having had large infusions of local anesthetics via pain pumps, there had been a study indicating that the subacromial space seemed impervious to that risk, so the orthopod thought this fake documentation would cover his 'back'..)

The condition is referred to as PAGCL, and, in addition to global loss of cartilage, rather than the smaller local lesions of arthritic conditions, there is a 'chemical burn' to the subacromial nerve area. The pain is exacerbated by any movement or pressure and I understand no one can tolerate it without serious pain medication. Worse, the common variable is of highly physically active patients, almost all young athletes. The only recourse is total shoulder replacement, and the MDs involved have stated, 'these patients hurt no matter what you do'. (David Bailie, MD) It is commonly referred to as devastating.(Raffi Mirzayan, MD and author of a multitude of texts on cartilage.

Since I didn't have access to the relevant journals at the time I was clueless re the risks. Two months earlier, several multi-million dollar settlements were made in an urban area fifty miles from the town I was then in in Oregon. Subsequent to the surgery, these docs ordered a 50 mc Fentanyl patch, when I was opiate-naive and 100 lbs. Luckily, the pharmacist warned me of how dangerous it would be, or that clinic would have solved any potential discovery of the type of fraud that prompted their inappropriate treatment (The fraud due to a form of reimbursement in the US--capitation--with the incentive that, from a global monthly pmt per patient, the medical group gets to keep as profit what they don't spend on patient treatment. I worked on a pilot program for this and saw more despicable violations of proper medical care than could fill the book I'll never write.)

For the last 6.5 years I had been on the opioids I mentioned, finally arriving at the right dosage level in 2014, allowing me some ability to have a life, albeit nowhere near my previous one. I had weaned down a bit before moving to XXXXXXX to comply with the current political pressures on my most recent and trusted doctor. All of my labwork, vitals, kidney, liver functions, etc., have been fine.

I've always been drug-adverse, and, when I saw the leading specialist for this still rare condition, I asked if there would be a chance I could get off them. He responded with an abrupt laugh, then said, 'no, you'll be on those for the rest of your life'.

Although cognitive behavior therapy might be a useful adjunct for some, I can't even care for myself without help from the meds, I've barely left my bed since I ran out, couldn't get dressed for a med appointment I desperately wanted to go to,.Given the current mindless inability of lawmakers and enforcement (and I once worked for the feds and am very aware that meeting political agendas rather than bettering social conditions is their only objective),

I am not making bets on my survival. There are those of us whose injuries are such that opioids allow us to live, rather than induce addiction and, unlike statistics borne of those with predilection to addiction or irresponsible thrill-seeking, we do not develop sharp increases, if any, in our dosages. I have been able to reduce and might be able, with activity modification, to minimize further, but without treatment soon, I would prefer death to feeling like I'm being burned alive on a continual basis. I wouldn't force an animal to live like this, and I now regret that I may have underestimated what my last dog endured in his intensely loyal refusal to leave me, knowing my need for him.

***You might be able to help me by letting me know how treatment might be in your own country, as leaving the US may be my only option if things don't improve personally and nationally very quickly***
doctor
Answered by Dr. Prof. Kunal Saha 4 hours later
Brief Answer:
Local anesthetics are toxic to the cartilages

Detailed Answer:
Thanks for the updates. Although intra-articular administration of pain medication along with local anesthetics had been a practice, it is now known that these anesthetic agents are toxic to cartilage and the likely cause of PAGCL. In other words, the attempts to relieve your suffering have actually made it worse. In our country it is not a standard practice to administer such agents routinely. Anyway, it is no use crying over spilt milk. As of now we need to deal with the after effects. My personal experience as well as my review of medical literature indicated the benefits that acupuncture could provide and that was the reason for my suggestion. The conventional methods in palliative medicine (pain medicine) are still to go a long way and lets hope for the best.

Feel free to write back.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Prof. Kunal Saha 5 hours later
Thank you very much for your recommendations, kindness, and knowledgeable response. I wanted to thank you more last night but had reached my limit of typing.

I had practiced meditation when younger, as well as following Stoic philosophy in grade school and need to return to these, separate from more specific address Given your knowledge of this--which appears absent from the US MDs I've been interacting with, your recommendation carries even more weight and I'll do my best to access this. I have so little of my life left and it's hard to weigh the massive loss of function, combined with pain, the loss of opioid tx is resulting in so I know how miserablely self-focused I sound--not that you in any way made me feel that. Given the intensity and long history of my post meningitis migraines, I'd tried to learn as much as possible about pain, but it took this situation to teach me how limited our current methods and understanding are.

(I do think I would be less bitter if, in my case, this wasn't the result of greed with even more damage resulting from an attempted cover up, but I had been warned not to go to them, and, since I haven't yet protected others effectively, I imagine this is some form of karma. I realize that this site is nm ot an arena for discussion of issues which involve culpability or dead litigation, but focuses on available and safe address of medical problems, and you have been very helpful in this respect. I'm happy for the patients in your direct care, as it is becoming increasingly rare in the US to receive both the level of expertise and compassion you have demonstrated. Thank you :)
doctor
Answered by Dr. Prof. Kunal Saha 2 hours later
Brief Answer:
There is evidence that acupuncture works in migraine

Detailed Answer:
Thanks for writing back. I am glad to know that you find me to be knowledgeable and helpful. I would definitely do my best to alleviate you of your pain. You can also feel free to discuss things that could come within my domain of knowledge.

I would not really blame karma for all things that happen. Things go wrong. Some people have to suffer more. It is not what comes in our way that defines us. It is how we react to them and how we deal with the adversities that defines us. If we cannot deal with the adversities THAT is the karma and we would have to suffer accordingly for not being able to find a way out.

Coming to the context of meditation, the mind is a power tool. Meditation tries to gain control over it. Cognitive behavioral therapy tries to achieve the same although from a different angle. Opioids and NSAIDs have their limitations. But the gap can be bridged by will power by making the mind strong and if the mind can prevail over the body, the bodily sufferings are much easier to deal with.

Coming to the context of your migraines, once again there have been randomized control trials (although not placebo controlled) that have demonstrated the efficacy of acupuncture in migraine. In other words, you may rely on the evidence and may try out acupuncture for that indication as well.

Let me know if I could help further.

Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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