Small Partial Thickness Degenerative Rotator Cuff Repair - Arthroscopic Pathway Posted: 7/8/2020 ID: (C101520)

Partial-Thickness Bursal-Sided Rotator Cuff Tear in 67M

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CASE DESCRIPTION

AGE	67 / Male
CC	Right Shoulder Pain
HPI	A 67-year-old male, electrician, presents with a 1-year history of atraumatic right shoulder pain. His pain is worse with overhead and behind-the-back activities. He had an ultrasound-guided PRP injection and course of physical therapy 3 months ago with only minimal relief. He presents with persistent symptoms and disability.
PMH	Gall Stones Left Shoulder Rotator Cuff Repair
PE	A focused physical examination of the right shoulder reveals tenderness at the anterolateral bursa. His shoulder range of motion is: ER in neutral abduction to 45 degrees, IR in neutral abduction to L2, forward flexion to 165 degrees. His cervical spine range of motion is full. On strength testing: 4/5 supraspinatus, 5/5 subscapularis, 5/5 infraspinatus, and 5/5 biceps. Provocative tests reveal a positive Speeds, Hawkins and Neer's test. He is distally neurovascular intact.

AGE/GENDER:

67 / Male

CHIEF COMPLAINT:

Right Shoulder Pain

HISTORY OF PRESENT ILLNESS:

A 67-year-old male, electrician, presents with a 1-year history of atraumatic right shoulder pain. His pain is worse with overhead and behind-the-back activities. He had an ultrasound-guided PRP injection and course of physical therapy 3 months ago with only minimal relief. He presents with persistent symptoms and disability.

PAST MEDICAL HISTORY:	Gall Stones Left Shoulder Rotator Cuff Repair
PHYSICAL EXAM:	A focused physical examination of the right shoulder reveals tenderness at the anterolateral bursa. His shoulder range of motion is: ER in neutral abduction to 45 degrees, IR in neutral abduction to L2, forward flexion to 165 degrees. His cervical spine range of motion is full. On strength testing: 4/5 supraspinatus, 5/5 subscapularis, 5/5 infraspinatus, and 5/5 biceps. Provocative tests reveal a positive Speeds, Hawkins and Neer's test. He is distally neurovascular intact.
DIAGNOSIS:	Partial-Thickness Bursal-Sided Rotator Cuff Tear in 67M