When direct access isn’t fun...
Being a physical therapist in the military comes with great pride and responsibility. Part of that responsibility is the amount of autonomy a military PT has to order imaging, prescribe meds, make referrals, and manage complex cases. It’s a really cool way to practice, but practicing in a form of primary care medicine, can certainly have its challenges…and some of those challenges don’t have happy endings.
Towards the end of my deployment, a young man presented to the clinic with a complaint of left posterior shoulder pain. He reported the onset of pain when he was lifting a ruck sack (military backpack) and throwing it on his back prior to a hike a few months ago. His exam was fairly benign. Almost all of his special tests were negative, his strength was normal, his neuro exam was normal, and he had no other complaints or red flag symptoms. On palpation, he had some discomfort at his teres major and minor. I could also feel a hardened area in that region which was tender to palpation. In my mind, I was thinking this could be something like ossification from a muscle tear. I wanted to send the patient for an ultrasound to evaluate the area and make sure it wasn't something worse, but on this deployment, ultrasound was not an option. I considered a CT scan but honestly didn’t want to subject the patient to that much radiation. I sent him for a plain film x-ray to evaluate for any ossification in the area. I saw him two days later and the imaging was completely normal. We talked about a CT scan, but the patient was leaving the deployment in three weeks and advised he could get an ultrasound when he returned to the US. I treated him for the muscle strain which of course included dry needling because…lets face it, that’s what I do. He had pain relief. I gave him a HEP and a few weeks later he left the deployment. I wish I could tell you that US just showed a muscle strain. But that isn’t how this story goes.
The US led to an MRI which led to a PET scan which led to some of the worst news anyone could get. Long story short, the hardened area was a Stage IV sarcoma which had already metastasized to the patient’s spine, abdominal mesentery, and lymph nodes. The patient had zero symptoms. He had a mechanism of injury for his shoulder pain. He had none of the red flag or constitutional symptoms they teach us to ask about during school…but he had metastatic cancer. Cancer.org says Stage IV sarcomas are rarely curable. You can read more about them here.
It is a hard story to tell. The diagnosis was a kick in the gut. It was a kick in the gut to most of the providers on this deployment. It just doesn’t seem right for an otherwise healthy young military man to be handed a death sentence when the only complaint was shoulder pain. That’s the nature of medicine I suppose. Fortunately, in the world of physical therapy, it isn’t typically an everyday experience.
Sometimes the shoulder pain you’ve evaluated a ton of times before is more complicated than that. Always screen for red flags. Sometimes things aren't as they seem. Please keep that in the back of your mind.