Posterior Labral Tear: My Shoulder Pain Experience Without Surgery.

Well, it's been awhile but my shoulder is now pain free.  And it turned out to be a posterior labral tear.  I wrote months ago about my physical therapy experience with electrical stimulation to my shoulder.   I self referred myself to get PT on my persistent shoulder pain.  I made it to eight therapy sessions and had a significant improvement in my range of motion, but not the pain component.   I was only a no show for one appointment as I got my dates and times mixed up.  These visits  consisted mostly of  a resistance training  component and an E-stim component.  On two occasions the thereapists performed ultrasound with topical steroid therapy on my persistently painful right shoulder.

Then came baby Zachary.  With his birth and delivery, we met  our $3,500 total out of pocket HSA  plan deductible for the year.  So I figured, what the heck.  With a zero copay for all medically necessary services for the rest of 2011, why not get an MRI of my shoulder to see if more clarity of my shoulder's pathology could be defined.   Unlike physical therapy service, my Blue Cross Blue Shield insurance required preauthorization  for an MRI.   So I caught one of the orthopaedic surgeons in the hall and he had his office call me directly to fill out the paperwork.  

Within minutes I had my MRI scheduled at my hospital of choice for the next morning.  Here  is a picture of me strapped into a Siemens 3T-MRI for my MRI  The scan I got was an EXT JNT UPP W/O CONT/RT MRI to indicate extremity joint upper without contrast routine.   I must say, the MRI tech was perfect in their implementation of the  Studer Group AIDET method of customer service.  Great job! I'm, certain the hospital will pay you oodles of  extra cash that will start rolling in once Medicare starts paying for health care based on patient satisfaction surveys in 2013.

3T MRI of right shoulder.
I figured I'd follow my own HSA tips and get my MRI this year while my deductible was met. Free MRI, at least free for me.  We all pay for it one way or another.  It doesn't get any better than that.  After making sure I didn't have any metal on me I entered the MRI suite for my MRI.

I went through  the MRI with no problem.  It had a larger diameter than older models.  Unlike Grunt Doc, I didn't feel the least bit claustrophobic.  I almost fell asleep in a state of complete relaxation.   Within minutes of completion, I headed to the radiology department to get my first glimpse of what turned out to be a posterior labral tear.  I have no idea how my labrum tore.    Here's a screen shot of my shoulder MRI showing my posterior labral tear and paralabral cyst formation.  It's no wonder my shoulder has been hurting for so many months.  I also had rotator cuff tendinitis/tendinosis without tear.

With this result in hand, I decided to officially schedule an actual office appointment with the surgeon.  I picked a day I was actually working so I could just head down the hallway to get things done.  It was a 1 PM appointment for the following Monday.  I showed up several minutes early to complete the new patient paperwork.

Do you ever wonder why all those questions are asked on the new patient documentation, especially why an orthopaedic surgeon is asking you if you have any problems with nasal drainage?  They may tell it's for thoroughness.  It's not.   It's to make sure you fill out all their paperwork so it complies for the highest possible billable code for a new patient appointment in the office. With that PMFSH and complete 10 point  review of systems performed by you, the patient, they can now bill the highest level new patient clinic E&M code.

I showed up and  filled out the paperwork.  1 PM came and went.  Four or five people checked in after me.   Three people were called in before me.  I'm not sure if they all had 1 PM appointments or not.  1:15 pm came and went.  I got paged about a new admission in the emergency department.  I told them to park them there for awhile or send them to the floor and I would see them when I had time.  If you ever wonder why it's taking so long for your physician to show up and evaluate you, it might just be that they themselves are at the doctor's office also waiting to be evaluated.

Twenty minutes after my appointment I was taken back to a room where the nurse took my vitals asked me a few questions and then I sat again.  Ten minutes passed.  Twenty minutes passed.  Then the nurse poked her head into the room.  I explained that I had a patient I needed to go see and if the surgeon was unable to make it to their appointment, I could always reschedule when it was more convenient for them.

The nurse apologized and indicated that the physician was called away.  Funny stuff.  I know what that means.  It's code for I don't know where the doctor is.  I indicated that I was perfectly OK rescheduling because I know how things are.   I was then offered the services of the nurse practitioner.

Talk about an awkward position to be put in. 
Nurse:  If you don't mind we have the nurse practitioner here now who could see you immediately and discuss the options.
Happy:  That's OK.  Dr Ortho and I looked at the films together this weekend in the doctor's lounge and indicated he thought I needed an injection.
Nurse:  Our nurse practitioner has done many injections.  She is quite qualified to provide that for you.
Happy:  That's OK.  Dr Ortho also indicated he was going to perform some bedside maneuvers on my shoulder to document the stability of my joint.
Nurse:  Our nurse practitioner has been trained to do those as well.
Happy:  You know what.  If Dr Ortho is not available, I am quite happy rescheduling when he is.  We have already discussed my case and he is well up to speed on the details and specifics.
Here I am a medical physician who has discussed my case  and reviewed the films together in the doctor's lounge with the orthopaedic surgeon and the office nurse, with good intentions, was trying to push the services of their nurse practitioner my way.  No offense to nurse practitioners, but I made an appointment to be seen by an orthopaedic surgeon, not a nurse with  generalized practitioner training who has received an unknown and undocumented amount of on the job training.   That might go over well with a public that accepts health care at face value, but it's not OK with me.

I signed up for and  expect to get the expertise of an orthopaedic surgeon, not a nurse  with general practitioner training, who, for all I know could have been the best pediatric lactation specialist ever trained on the job three weeks prior.  Nurse practitioners must be trained on the job, whatever that job may be, because the length and intensity of their formal education is insufficient to practice any independent scope  similar to medical school and residency trained physicians.

They could be the best pediatric nurse practitioner one week and be doing post op checks on a craniotomy patient the next.   I'm not about to ask for the resume of the nurse who has decided to pursue additional broad training in practitioner school.  I asked for a consultation with an orthopaedic surgeon.  I expect an orthopaedic surgeon's opinion.  It's not about getting the injection.  Heck, I could give my self the injection.   It's about getting an orthopaedic surgeon's evaluation and medical opinion.

Remarkably, he showed up within minutes after I suggested to the RN that  we reschedule my visit for a time more convenient for him.  He did his beside evaluation, manipulated my shoulder to clarify its stability, talked about options expectations and prognosis and then numbed up my skin with some topical spray anesthetic.  He then proceeded with a 10cc intraarticular injection of steroid and anesthetic.  He told me, for a few days,  my arm would feel like someone punched it.  He told me not to do any therapy for 3-4 weeks.

The injection itself was a combination of pain and pressure.  It wasn't horrible.  Just uncomfortable.  Less than a minute later and the procedure was complete.  I had almost immediate relief of pain and for the first 4-5 hours after injection for my posterior labral tear, I had no pain at all.  He was right, however.  Over the next several days I felt a soreness, not where my posterior pain usually was, but superior, over my AC joint, where the injection was administered.  During this time I had absolutely no pain posteriorly where my labrum had been torn.

I am now 18 months out from that appointment and I am happy to report that I continue to have no pain anywhere in my shoulder, except with motions involving extreme posterior extension of my shoulder joint and occasional mild stiffness.    I am hoping with post injection rest and time for my shoulder to heal without constant inflammation that I can avoid surgery.

How much money has all this cost my insurance company on my self referred evaluation and management of my posterior labral tear?  The following are all the expenses associated with my work up of my shoulder pain, including both the charges and the actual allowable charge after run through my Blue Cross Blue Shield insurance.  While I can't say anything about  hospital costs, the hospital charges are quite remarkable as you shall see:
  1. PHYSICAL THERAPY SERVICES: Initial visit of physical therapy, seven follow up physical therapy visits, six E-Stim sessions, two ultrasound treatments to my shoulder and the cocktail of steroid cream used for the ultrasound therapy  
      1. Hospital Charge: $1,799.00
      2. Allowable Charge: $1,241.31
      1. Hospital Charge: $2,662
      2. Allowable Charge: $1,836.78
      1. Radiologist Charge:  $256
      2. Allowable Charge: $130.50
      1. Orthopaedic Charge: $355
        1. Injection ("Surgery"): $165
        2. Drugs (steroid/anesthetic): $20
        3. Office visit: $170
      2. Allowable Charge: $264.10
        1. Injection ("Surgery"): $111.06
        2. Drugs (steroid/anesthetic/supplies): $3.03
        3. Office visit: $150.01
What were my total charges for the evaluation and management of my many months of shoulder pain?
Total charges:  $5,072
Total allowable charges: $3,472.69

My Blue Cross Blue Shield paid 68% of the billable charges.  Medicare probably pays less than 1/2 this amount, or $1,700 and Medicaid probably pays 1/2 of Medicare, or $900.   We, as private citizens in the open insurance market are essentially subsidizing the Medicare/Medicaid population for their smorgasbord of undervalued, centralized government pricing and Ponzi scheme. If it was not for us, the private citizens of America putting our hard working insurance premiums to work, while our employers divert thousand of dollars in  wages to pay for our health insurance  benefits, our hospitals would simply close.

So America, it's time you sent a thank you to your employer for their help in keeping your hospital alive and well. Without their premium support, you'd be traveling 60 miles for the nearest hospital, like our vets do. And I'm not sure you're ready for that.

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