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Mallory Owens had been to 300 doctors' appointments and undergone nearly 20 imaging scans by the time she arrived at Mayo Clinic in November 2017. Four years earlier, when she was 22, Mallory was involved in a devastating car accident that, among other injuries, left her with persistent shoulder pain that perplexed physicians.
The pain, says Mallory, felt like a lion mauling her left shoulder. The ever-present pain spiked when she coughed, raised her arms or sat up straight in a chair. Any effort to relieve the pain, such as physical therapy, only worsened it. While wearing back braces helped control the pain, it was never far away.
"I couldn't get dressed. I couldn't do my hair. I had to wear two braces to get in my car and drive," says Mallory, who lives in Raleigh, North Carolina. "I tried to conceal the world of pain that I was living in from other people because I didn't want my pain to define me."
When Mallory failed to get relief from local providers, she broadened her search for a remedy. Late at night, unable to sleep due to the pain and frustrated by a lack of answers, she read research studies. "I would look up medical journals for pain similar to my own," Mallory says. "I looked up authors, contributing doctors. I looked up where they practiced and their medical institutions."
As time passed, Mallory worked her way down the list of specialists she had compiled during her late-night reading. She visited medical centers in Florida, Illinois, Kentucky and New York. Near the end of the list was Bassem Elhassan, M.D., an orthopedic surgeon at Mayo Clinic in Rochester. During one Mallory's out-of-state appointments, she was referred to Dr. Elhassan. When she read about his pioneering work in scapular repair, she believed she might have found someone who could help.
A few weeks later, Mallory's phone rang. When she picked up, Dr. Elhassan was on the other end. "He said, 'Hi, this is Dr. Elhassan, and I heard you have some questions about tendon surgery,'" Mallory says. "Never in my life have I felt so relieved to know there was a doctor who was not only able to help me, but very compassionate about his patients and so devoted to work. It was a turning point in my long road to recovery."
At an appointment in Mayo Clinic's Department of Orthopedic Surgery several weeks later, Dr. Elhassan told Mallory he had experience with her kind of injury, and he offered a surgical repair to correct the problem. "I was proactively, on a daily basis, trying to find a doctor who could help me, and it took four years until I got to Mayo," Mallory says. "Without Mayo and Dr. Elhassan, I am convinced that I would have never recovered."
From the time Mallory was young, her shoulder blades, or scapulae, were different from other children. When she lifted her arms out in front of her body, her shoulder blades visibly stuck out like small wings. That condition — known as scapulo-thoracic abnormal motion, or STAM — is caused by abnormality in the muscles or bones around the scapulothoracic region. One of the most common reasons it develops is dysfunction or paralysis of the serratus anterior muscle — a large band of muscle that wraps around the rib cage and connects to the scapula.
While the condition can be debilitating and lead to limited upper body function, it didn't significantly affect Mallory's ability to exercise or work. But it did interfere with some activities. "I always thought I had a weak, small-boned upper body," Mallory says. "If you compare me to an average person, I have a harder time performing daily activities, such as opening doors, carrying groceries and driving a car."
"Every doctor I met with would say that something was definitely wrong with me, but they didn't have any answers or weren't able to help."Mallory Owens
When the car accident occurred, Mallory's obvious injuries, including bone and nerve damage to her left hand, wrist and arm, were treated promptly and slowly healed. After several months of recovery and rehabilitation, Mallory returned to work. Two weeks after resuming her job, however, her left shoulder blade, which had always stuck out, began hurting terribly.
"I'd be at work some days, and the pain would get so bad that I would have neurological side effects like hand tremors and slurred speech," Mallory says.
The specialists Mallory visited for help with her scapular pain ordered an array of tests, including, MRIs, CT scans and electromyographs, to assess the health of her muscles and the nerve cells that control them. The results all came back normal. While several specialists recognized that there was a unique aspect to Mallory's condition, none offered a solution.
"Every doctor I met with would say that something was definitely wrong with me, but they didn't have any answers or weren't able to help," Mallory says.
What was wrong with Mallory was quite difficult to identify, says Dr. Elhassan. "Sometimes when the scapula is not working well, and patients have a lot of pain, the nerve exam and testing might look normal, and nothing in imaging shows muscle damage," he explains. "Scapulo-thoracic movement is very unique, and in my opinion, a detailed physical examination based on very good understanding of anatomy and biomechanics of this movement is much more important than imaging and other testing."
During Mallory's exam, Dr. Elhassan looked at whether the muscles surrounding her scapula were functioning normally. While Mallory's individual muscles didn't show evidence of paralysis or damage, that didn't necessarily mean her muscles were activating in a normal sequence for movement. "If the muscles are working in an abnormal sequence of activation, then this will cause STAM and, in this case, cause dysfunction of the shoulder and pain," he says.
The car accident caused Mallory's serratus anterior muscle to stretch and further disrupt the stability and motion of the scapula on her chest wall. When the muscle healed, even though it had relatively normal contraction, it retained the abnormal elongated shape and motion. "By the time I saw her, the muscles were recovered," Dr. Elhassan says. "But the muscle anatomy, the length of the muscles, the position of the muscle, and the way they activate around the scapula were abnormal."
As a result, the sequence of muscular contractions required for movement was out of order. Instead of the scapula being stabilized on the chest wall, the persistently elongated serratus muscle, and its inability to maintain the scapula's position on the chest wall, led to ongoing STAM and winging of the scapula off the chest wall.
To restore function and eliminate pain, Mallory needed surgery. The repair would reanchor the muscles responsible for scapular movement to her chest wall. Surgery also would encourage the distorted muscle to regain its earlier shape.
Mallory's operation, which took place in March 2018, was one of the first such repairs that Dr. Elhassan performed at Mayo Clinic. During the procedure, Dr. Elhassan made a hole in the bottom tip of the scapula bone. Inserting a donor tendon through the hole, he wrapped the tendon around one rib and fastened it on itself. "If we pull the scapula in and force it to stay on the chest wall for a while, then the muscle will shorten over time," Dr. Elhassan says. "Over three, four, five months, the scapula will be able to move freely. By that time, the brain will be able to give the sequence of movements that are more organized to restore normal mechanics of the motion."
Mallory's shoulder was immobilized for three months after surgery. She moved back home with her family and depended on caregivers to help her through her days. "It was a really tough recovery, but it was well worth it," Mallory says.
When her restrictions were lifted, she moved her left arm in ways that were impossible before. Some motions that should have been pain-free, however, continued to cause discomfort. That pain was related to inflammation of the bursa — a lubricating tissue beneath the scapula, between the scapula and the chest wall.
"Mayo Clinic, with its holistic approach and exceptional level of care for your well-being, is everything that a patient could ever imagine."Mallory Owens
In September 2018, Mallory underwent a second operation, also performed by Dr. Elhassan. This surgery, a scapulothoracic bursectomy, involved removal and debridement of the inflamed bursa, as well as removal of a small portion of scapular bone that typically causes bursitis.
After that, the change in her shoulder pain was like night and day, Mallory says. Unfortunately, as the shoulder pain diminished, other accident-related pain became more apparent. "When I look back to two years ago when I had a lion mauling my shoulder, I also had other underlying sources of pain. I wasn't able to feel that due to the intense pain I was constantly enduring," Mallory says. "Although the lion was tamed through surgery, I'm still working with Dr. Elhassan on resolving the few lingering sources of pain."
There is no question in Mallory's mind that Mayo Clinic is the place that will give her the best chance at a full recovery. "Mayo Clinic, with its holistic approach and exceptional level of care for your well-being, is everything that a patient could ever imagine," she says. "Mayo is a truly special place, and I will always hold it very close to my heart. Whatever happens in the years to come, I know I'll always be in good hands, thanks to Mayo Clinic."