Sports Medicine Review Consultation Notes

REFERRED BY: Dr. Eleanor Vance GP INJURY / CHIEF COMPLAINT: Right shoulder rotator cuff tear, ongoing pain and limited range of motion. REVIEW APPOINTMENT: 2 CURRENT HEALTH PRACTITIONERS INVOLVED IN PATIENT'S CARE: - Specialist: Dr. Anya Sharma, Sports Medicine Clinic - General Practitioner: Dr. Eleanor Vance, The Health Centre - Physiotherapist: Mr. Ben Carter, Active Rehab - Exercise Physiologist: Nil involved in care. - Chiropractor: Nil involved in care. CURRENT SYMPTOMS / PROGRESS: Patient reports a reduction in pain levels from 7/10 to 4/10 since last review. Range of motion has improved slightly, but still limited with overhead activities. Patient is able to perform ADLs with some modifications. Patient reports no change in psychological wellbeing. CURRENT THERAPIES / TREATMENTS: - July 2024, Physiotherapy, Physiotherapy, 4 sessions, Partial improvement, Ongoing - August 2024, Corticosteroid Injection, Injection, 1, Good improvement, 4 weeks INVESTIGATION HISTORY: - MRI, Right shoulder - July 2024 - City Imaging - Moderate tear of the supraspinatus tendon with associated bursitis. EXAMINATION FINDINGS: - Tenderness to palpation over the supraspinatus tendon. - Painful arc of motion between 60-120 degrees. - Positive Empty Can test. DIAGNOSIS: - Right shoulder rotator cuff tear. - Differential diagnoses: Acromioclavicular joint pathology, glenohumeral instability. TREATMENT PLAN: 1. Further Investigations: - None 2. Rehabilitation Protocol: - Continue physiotherapy focusing on rotator cuff strengthening and scapular stabilisation. - Home exercise program including range of motion and strengthening exercises. 3. Medications: - Continue with current pain management regime: Paracetamol 1g QID PRN. 4. Referrals: - None 5. Follow-Up Appointments: - Review in 4 weeks with Dr. Vance. 6. Contingency Plan: - If pain persists or worsens, consider referral to orthopaedic surgeon for further management.