Shoulder Surgeon's Note

Name: John Smith Thank you for referring John who was seen in the Shoulder clinic today. Diagnosis: Right shoulder impingement syndrome. Rotator cuff tendinopathy. Plan: Continue with physiotherapy exercises and stretches. Start a course of oral anti-inflammatory medication for 2 weeks. Review in 6 weeks with an updated X-ray and MRI of the right shoulder. John is a 48-year-old right-handed male, working as a carpenter. He presented today with a 3-month history of right shoulder pain, which began gradually without any specific injury. The pain is primarily located over the deltoid region and radiates down his arm, exacerbated by overhead activities and sleeping on his right side. His wife, Sarah, was in attendance during the consultation. He is currently employed full-time, and his work involves frequent overhead lifting. His leisure interests include gardening and playing golf, both of which are currently limited by his shoulder pain. He reports associated stiffness in the shoulder, particularly in the mornings, and occasional clicking sensations. There is no numbness or tingling in his arm or hand, and no significant weakness noted during daily activities, though he struggles with reaching for items on high shelves. His functional limitations include difficulty with dressing (putting on a coat), washing his hair, and reaching into the back seat of his car. He finds it challenging to perform his work tasks without pain and has reduced his golf playing due to discomfort. To date, John has tried over-the-counter paracetamol and ibuprofen with limited relief. He has attended 4 sessions of physiotherapy, which have provided some temporary improvement in range of motion but no sustained pain relief. Past Medical History: Relevant medical history includes controlled hypertension, diagnosed 5 years ago, for which he takes medication. Surgical history includes an appendectomy 20 years ago. His father had a history of heart disease. He is a non-smoker and occasionally drinks alcohol. He has no known drug allergies. Medications: Amlodipine 5mg once daily. On Examination: On inspection, there was no obvious swelling or deformity of the right shoulder. Palpation revealed tenderness over the greater tuberosity and subacromial space. Range of motion was limited in abduction to 120 degrees and external rotation to 45 degrees, both movements being painful, particularly in the mid-arc. Neer's and Hawkins-Kennedy impingement signs were positive. Strength testing demonstrated mild weakness in abduction (4/5) and external rotation (4/5) against resistance, but internal rotation and adduction were full strength. Neck examination was unremarkable. Imaging findings and any relevant interpretations: Previous X-rays of the right shoulder, taken 2 months ago, showed no fractures or significant degenerative changes, but mild acromial spurring was noted. An MRI is still pending but has been requested. Discussions were held with John regarding his diagnosis of shoulder impingement and rotator cuff tendinopathy. The options for management, including ongoing conservative therapy, corticosteroid injection, and potential surgical intervention if conservative measures fail, were explained. He was advised on the importance of adhering to physiotherapy and medication. The potential benefits and risks of each option were discussed, and he expressed understanding. Investigations planned: An updated X-ray of the right shoulder. An MRI of the right shoulder. Treatment planned: Continue with current physiotherapy regimen. Prescription for a short course of oral anti-inflammatory medication. Relevant other actions such as counselling, referrals: A referral for a subacromial corticosteroid injection will be considered if symptoms do not improve with the current plan. Thank you for referring John. Dr. Thomas Kelly Consultant Orthopaedic Surgeon