Shoulder Clinic Outpatient Letter

Name: Sarah Jenkins Thank you for referring Sarah who was seen in the Shoulder clinic today. Diagnosis: Right Rotator Cuff Tendinopathy with secondary impingement. Left Bicipital Tendinopathy. Plan: Continue physiotherapy with focus on rotator cuff strengthening and scapular stabilisation. Review in clinic in 6 weeks with a view to consider subacromial corticosteroid injection if symptoms persist. Sarah Jenkins, a 45-year-old right-handed office worker, presented to the clinic today experiencing chronic right shoulder pain for the past six months, which has been progressively worsening. She works as a data analyst and spends most of her day at a computer, which exacerbates her symptoms. Her primary reason for the visit is persistent pain and reduced range of motion, particularly with overhead activities. She enjoys gardening and swimming, both of which are currently limited due to her shoulder pain. She attended the appointment alone. She also reports occasional sharp pain radiating down her left arm, which is worse with lifting objects. Her functional limitations include difficulty with dressing, reaching overhead to cupboards, and a significant impact on her ability to perform her job duties and engage in her hobbies. To date, she has undergone a course of non-steroidal anti-inflammatory drugs (NSAIDs) prescribed by her general practitioner and has completed eight sessions of physiotherapy focusing on general shoulder mobility and strengthening, with limited improvement. Past Medical History: Sarah has a past medical history of essential hypertension, well-controlled with medication. There is no significant family history of musculoskeletal conditions. She is a non-smoker and consumes alcohol socially. She reports no known allergies. Medications: Amlodipine 5mg once daily. Paracetamol 500mg as required. On Examination: 1. Cervical spine movement was full and pain-free, with chin to chest range of 45 degrees and lateral rotation to both sides of 80 degrees, symmetrical bilaterally. 2. General shoulder inspection revealed no overt swelling, bruising, or muscle wasting on either side. 3. Right shoulder range of motion showed external rotation of 60 degrees, internal rotation to T10, and forward flexion of 140 degrees with a painful arc of abduction between 90 and 120 degrees, consistent with stiffness rather than frozen shoulder. The left shoulder had full, pain-free range of motion. 4. Palpation over the right AC joint was mildly tender. Palpation along the long head of biceps tendon in the bicipital groove was significantly tender on the left, but non-tender on the right. 5. Resisted supination of the forearm on the left produced pain in the bicipital groove. Speed's test was positive on the left, eliciting pain in the bicipital groove. Yergason's test was also positive on the left, reproducing pain and detecting instability. 6. Rotator cuff assessment on the right showed 4/5 strength with pain during the belly press test for subscapularis, 4/5 strength with pain on resisted external rotation for infraspinatus, and 3/5 strength with significant pain on the empty can test for supraspinatus. Left rotator cuff assessment was 5/5 strength for all tests with no pain. 7. Impingement provocation tests on the right revealed a positive Neer's sign and a positive Hawkins-Kennedy test, both eliciting significant pain. 8. The Scarf test for AC joint pathology was negative on the right, despite mild tenderness on palpation. Radiology findings from a recent plain film X-ray of the right shoulder showed no acute bony pathology or significant degenerative changes. A comprehensive discussion was held with Sarah regarding her symptoms and the findings from the examination. The options for future management, including further physiotherapy, potential corticosteroid injections, and surgical intervention were explained, detailing the risks and benefits of each. She was provided with an opportunity to ask questions and expressed understanding of the proposed plan. Investigations planned: Magnetic Resonance Imaging (MRI) of the right shoulder to further assess the rotator cuff and other soft tissue structures. Ultrasound scan of the left shoulder to assess for bicipital pathology. Treatment planned: Continuation of current physiotherapy regimen, with specific exercises targeting rotator cuff strengthening and scapular stability. Consideration of subacromial corticosteroid injection for the right shoulder if symptoms do not improve following MRI results and continued physiotherapy. Many thanks again for the referral. Kind regards