Rotator Cuff Tears Pathway Posted: 4/20/2021 ID: (C101749) Shoulder360™ The Comprehensive Shoulder Course

Chronic Massive Rotator Cuff Tear in 69M

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CASE DESCRIPTION

AGE	69 / Male
CC	Right shoulder pain
HPI	A 69-year-old male, with a history of prior right rotator cuff repair in 2001, presents with progressive right shoulder pain. He worked as a carpenter for 40 years before retiring earlier this year. For the past 2 years, he has had progressive worsening of right shoulder pain with associated weakness and difficulty with overhead activities. A trial of NSAIDS and physical therapy did not improve his symptoms.
PMH	Hypertension Prior rotator cuff repair (2001)
PE	1. Tenderness to palpation laterally below the acromion and anteriorly over the bicipital groove. 2. Right shoulder range of motion reveals - active/passive abduction to 80/120 - forward elevation to 110/160 - external rotation at side to 30/50 - internal rotation to L5 vertebra 3. There is a positive Jobe's test with a negative belly press test. 4. He is neurovascularly intact.

AGE/GENDER:

69 / Male

CHIEF COMPLAINT:

Right shoulder pain

HISTORY OF PRESENT ILLNESS:

A 69-year-old male, with a history of prior right rotator cuff repair in 2001, presents with progressive right shoulder pain. He worked as a carpenter for 40 years before retiring earlier this year. For the past 2 years, he has had progressive worsening of right shoulder pain with associated weakness and difficulty with overhead activities. A trial of NSAIDS and physical therapy did not improve his symptoms.

PAST MEDICAL HISTORY:	Hypertension Prior rotator cuff repair (2001)
PHYSICAL EXAM:	1. Tenderness to palpation laterally below the acromion and anteriorly over the bicipital groove. 2. Right shoulder range of motion reveals - active/passive abduction to 80/120 - forward elevation to 110/160 - external rotation at side to 30/50 - internal rotation to L5 vertebra 3. There is a positive Jobe's test with a negative belly press test. 4. He is neurovascularly intact.
DIAGNOSIS:	Chronic Massive Rotator Cuff Tear in 69M