1 November 2024
Thank you for referring Mr. Smith, a 35-year-old male who works as a software engineer, for assessment and management of right shoulder pain.
This review was performed in co-consultation with Specialist Sport and Exercise Physician Dr George Pitsis.
History of Presenting Complaint:
Mr. Smith presents with a 6-week history of right shoulder pain, which began gradually after a weekend of playing tennis. The pain is located in the anterior and lateral aspect of the shoulder and is exacerbated by overhead activities and reaching. Initially, the pain was mild, but it has progressively worsened, now interfering with his work and sleep. He denies any specific injury or trauma. He reports no history of similar symptoms.
Investigations:
* MRI Shoulder, 20/10/2024, Imaging Centre ABC, Radiologist Dr. Jones: Moderate-sized tear of the supraspinatus tendon with associated tendinopathy and mild subacromial bursitis.
Current Therapies/Treatments:
* Paracetamol 1g four times daily as required for pain.
* Regular ice application to the shoulder.
Background Medical History:
* No significant past medical history.
* Medications: Paracetamol as above.
* Allergies: NKDA (No Known Drug Allergies).
* Non-smoker, occasional alcohol consumption.
* No relevant family history.
Examination:
On examination, Mr. Smith's right shoulder showed a reduced range of motion, particularly in abduction and external rotation. Palpation revealed tenderness over the supraspinatus tendon insertion. The Neer's and Hawkins-Kennedy tests were positive. Strength testing was mildly reduced in abduction and external rotation. No neurovascular deficits were noted.
Diagnosis:
Mr. Smith presents with clinical and radiological features consistent with a rotator cuff tear.
Differential Diagnoses:
* Rotator cuff tendinopathy: Less severe presentation.
* Acromioclavicular joint pathology: Pain localised to the AC joint.
* Glenohumeral joint instability: History of instability.
Management:
I have discussed Mr. Smith's problems with them today, and recommended the following management of their condition:
* Continue with paracetamol for pain relief.
* Commence a course of physiotherapy, focusing on range of motion exercises and rotator cuff strengthening.
* Avoid activities that exacerbate the pain.
Further treatment options were discussed including optimisation of non-operative management with ultrasound-guided injections, and referral to an Orthopaedic Specialist for consideration of operative management of this injury.
Follow-Up Plan:
I would appreciate the opportunity to review Mr. Smith in 4 weeks to assess their response to the recommended treatment plan and to assess their progress with the physiotherapy-based rehabilitation program.
Once again, many thanks for giving me the opportunity to assist with management of your patient. If you have any further questions, please do not hesitate to reach out to me.
Warm regards,
Dr Jonathan Attia
MBBS; MSpMed
Co-Consulted with Specialist Sport and Exercise Physician Dr George Pitsis
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