Hello: Thank you Gail and Michael-You have both brought up valid questions that I will look into for my client as far as receiving a definitive diagnosis for him-As far as the records he has submitted to me,
Client’s submitted synopsis of injury:
December 3, 2021 (Massage therapy injury):
‐‐ I had told Dr many times not to work on my abdomen, he continued anyhow.
‐‐ I felt painful thrusting and tearing in abdominal wall.
‐‐ Hiatal Hernia, hernia through rectus muscle, nerve damage, impaired diaphragm, GI shut down.
‐‐ Diastsis recti, linea alba tear, damage along chest wall. Multiple layers of soft tissue damage.
‐‐ Debilitating pain for over a year. GI dysfunction for over a year. This was the initial injury.
Synopsis of Appointments:
Date of injury as seed by client: 12/3/2021 as stated by client: The client stes this is where he felt the tearing- The client has some mental health issues where he is his own worst enemy when communicating with the doctors due to his belief in his misdiagnosis. I have educated him on communication with self advocacy and limiting his focus on the priority of the appointment at hand. He is very set in his ways as to what he wants and doesn’t want-
Point Info obtained from reports and not by this advocate:
1)Sport Med: 6/29/2023:
MRI: Magnetic Resonance Imaging Results -abdominal and chest MRI without contrast
Upon my limited review of the superficial musculature of the MRI examinations, noted that there is a defect within the left upper rectus. The defect is black on T1. I recommend a 2nd opinion from an orthopedic or physical medicine rehabilitation specialists.
Ultrasound Exam USUltrasound Examination of the Rectus In the left upper rectus region, there is a region of hyper-echogenicity suggestive of previous and incorrectly healed defect. There is hypo echogenicity on the patient’s left lower ribcage region lateral to the rectus abdominis origin, approximately at the midclavicular line. This is suggestive of a defect of the muscle detached from inferior ribcage. In the left upper rectus region, there is a region of hyperechogenicity suggestive of previous and incorrectly healed defect
Plan: Patient has a complex history of injury to his abdominal wall that appears to be worsening. Ultrasound examination and MRI examination as above. Patient’s history is complicated by Ehlers-Danlos syndrome.( Client states that should not be on his record-he doesn’t have it and wants to move on) I do recommend the patient follow up with an orthopedic specialist, physical medicine and rehabilitation specialist, or reconstructive surgeon to further evaluate the patient’s treatment options. We can attempt prolonged therapy versus platelet rich plasma within the defect of the rectus muscle, but the patient continues to have the diastasis recti on ultrasound examination. Patient will follow up with me after his evaluation with the specialists
2) Liddy Healthworks:(Chyropractic)
Upon visual inspection of his abdomen, I found mild redness. Palpation revealed mild to moderate swelling, warmth and the feeling of ropy tissue that was variant from the typical rectus abdominis. The patient’s ribs and sternum flared. In an effort to rule out diastasis recti, fascial tears, muscle tears and solar plexus injury, the patient has been referred to radiology, gastroenterologists, and orthopedists and has not received any answers.
3) 6/29/2022: General Surgeon
assessment of Abdomen: Flat, soft. No scars. 6mm fascial defect at midline superior umbilicus. Moderate rectus diastases noted from typhoid to Umbilicus. Mildly TTP in upper midline and costal margin including over the typhoid, though no fascial defect palpable in this area.
Longstanding supraumbi hernia, not involved in symptoms. Small diastisis
PLAN: NSAIDS And encourage second opinion from PT or PM&R
-Offered repair of asymptomatic supra-umbilical hernia repair: recommended to delay this to avoid confusion about overlapping symptoms from surgical pain and current pain
Discussed small hiatal hernia on CT from Cedars: No intervention recommended
4) 3/20/2023- Bariatric-Referred by GI
Patient will be scheduled for a celiac nerve plexus block for diagnostic imaging studies and constellation of symptoms. Patient would like to proceed with surgery.
Surgical treatment of MALS involves resecting the median ligament, which is causing compression of the celiac ganglion, as well as resecting the celiac ganglion and nerve plexus. Operation is done robotically
****Suspicious for MALS*****
Additional studies recommended to rule in or out MALS:
EGD with Dr Shamsi
4-hour Gastric Emptying Scan
He wants the Nerve conduction study to see if how his nerve conduction is hindering his muscle recovery. The complicated part of this case is the client’s direction:
Although he wants the MALS ruled in or out and states he has a diagnosis of MALS, I have reiterated to him that he will not have a definitive diagnosis unless recommended testing is completed. I have to advocate for what the client wants but, at the same time I am being honest and realistic with educating him on his goals and outcomes.
He agreed with the recommended surgery at the time of appointment consult but now he has stated his muscles have improved somewhat, so, he wants to move on from there. I do not believe there was ever testing prior because he didn’t feel the injury until the deep tissue massage. However, when reading the notes it states, “suggestive of previous and incorrectly healed defect.”
He is considering nerve plexus block for diagnostic imaging studies and constellation of symptoms and has stated he does not want surgery- But, in the next breath talks about surgery. I agree with you that it had to be quite the deep tissue massage to cause injury. My goal is to be real with him about his diagnostic results, his goals and expectations. I have offered him to meet with another advocate with experience in connective tissue disorders but, he would like to continue on with me at this point and may consider that later. You bring up good questions to ask him about- On initial consult, I thought maybe he had bariatric surgery but he stated he did not.
I can’t thank you enough for your input. I have found both of your questions and direction very helpful .