Orthopaedic Review Letter to GP

Diagnosis Right rotator cuff tear. Management * Advised on conservative management including physiotherapy and activity modification. * Discussed the option of arthroscopic rotator cuff repair if symptoms persist. * Scheduled a follow-up appointment in 6 weeks. Detailed history of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, trauma, any previous treatments (e.g., physiotherapy, medications) and responses, etc. Current medications, including any pain management medications, anti-inflammatories, supplements, etc. Patient, a 58-year-old male, presented with a 3-month history of right shoulder pain. The pain was initially mild but gradually worsened, now rated 7/10 on the visual analogue scale. It is exacerbated by overhead activities and at night, disrupting sleep. There is no history of trauma. The patient has tried over-the-counter analgesics with minimal relief. Current medications include paracetamol as needed. Social history, focusing on occupation, sports, physical activities, and lifestyle factors that may influence musculoskeletal health The patient is a construction worker. He participates in recreational golf once a week. Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc. Inspection revealed no obvious deformity or swelling. Palpation elicited tenderness over the supraspinatus tendon. Active range of motion was limited in abduction and external rotation. Strength testing showed weakness in external rotation. The Neer and Hawkins tests were positive. Insert summary about diagnostic imaging results x-ray and MRI, do not use lists, only 2 sentences X-rays were unremarkable. MRI revealed a full-thickness tear of the supraspinatus tendon. Insert diagnosis, Patient education on the diagnosed condition, surgical procedures and non-operative management, potential complications. Any specific patient or family concerns addressed during the consultation The patient was informed of the diagnosis of a right rotator cuff tear. The options of non-operative management (physiotherapy, activity modification, and analgesia) and surgical repair (arthroscopic rotator cuff repair) were discussed. Potential complications of surgery, including infection, stiffness, and re-tear, were explained. The patient expressed concerns about returning to work, which were addressed by discussing a staged return to activity.