First Orthopaedic Shoulder Consult and Ultrasound

Patient is a 55-year-old female, referred by Dr. Sarah Jenkins, General Practitioner, presenting with left shoulder pain. History of Presenting Complaint - The patient complains of a 3-month history of dull, aching pain in her left shoulder, insidious in onset, with no specific injury mechanism. Symptoms are exacerbated by overhead activities. - Pain is described as 6/10 at its worst, interfering significantly with dressing, reaching for objects, and sleeping on her left side due to night pain. She finds it difficult to lift her arm above shoulder height. - Previous Treatments: She has tried paracetamol and ibuprofen with minimal relief. She completed a 6-week course of physiotherapy which provided temporary improvement but symptoms quickly recurred. No injections were previously administered. Past Medical History - Relevant orthopaedic or systemic conditions: Mild osteoarthritis in knees, otherwise healthy. - Allergies: Penicillin (rash). - Medications: Ramipril 5mg OD, Atorvastatin 20mg OD. - Social History: Non-smoker, rarely consumes alcohol (socially, 1-2 units/week). Works as an administrative assistant, low activity levels outside of work. Examination - Inspection: Mild atrophy noted in the left deltoid and supraspinatus fossa. No swelling or erythema. Old, well-healed appendectomy scar on the abdomen. - Tenderness: Moderate tenderness to palpation over the left greater tuberosity and anterior aspect of the acromion. - Active Range of Motion: Left shoulder: FE 120/180, AB 110/180, ER 40/90, IR L3. Right shoulder: FE 180/180, AB 180/180, ER 90/90, IR T7. - Special Tests Rotator Cuff: - Biceps: Yergason's test negative, Speed's test negative. - Subscapularis: Push Off test weak and painful, Belly Press test weak and painful. - Supraspinatus: Jobe's test positive and painful on the left. - Infraspinatus: External Rotation Pain test positive on the left, External Rotation Lag test negative. - Teres Minor: Hornblower's sign negative. - Impingement Tests: Neer's and Hawkins-Kennedy tests both positive on the left, reproducing patient's pain. - Special Tests Laxity/Instability: - Sulcus Sign: Negative. - Anterior Drawer Test: Negative. - Posterior Drawer Test: Negative. - Apprehension Test: Negative. - Relocation Test: Negative. - O'Brian's Test: Negative. - Grind Test: Negative. - Posterior Labrum Traction and Slide Test: Negative. - Kim's Lesion Test: Negative. - Neurovascular Status: Radial, ulnar, and median nerve sensation intact and motor function normal. Capillary refill brisk in all digits. No neurovascular deficits noted. Special Investigations X-Rays - Left shoulder X-rays (AP, Y-view, Axillary) show mild superior migration of the humeral head and subacromial spurring. No glenohumeral arthritis. Ultrasound - Biceps Tendon: Mild tenosynovitis with a small amount of fluid in the sheath. - ACJ: Minor degenerative changes, no significant effusions. - Subscapularis: Partial thickness tear, 5mm x 3mm, with fraying. - Supraspinatus: Full thickness tear, 1.5cm in maximum anteroposterior dimension, involving the anterior fibres, with retraction to the level of the glenoid. No muscle atrophy noted. - Infraspinatus: Tendinopathy, no tear identified. - Teres Minor: Normal. - Subdeltoid Subacromial Bursa: Moderate bursitis with fluid collection. - Dynamic tests showed impingement of the supraspinatus tendon under the acromion during abduction. - Posterior Labrum: Intact. - Posterior Glenoid Notch: Normal. - Posterior Inferior Capsule Thickness: 2.1mm. - Additional Comments: Overall findings consistent with significant rotator cuff pathology and impingement. Assessment - Rotator cuff tear (full thickness supraspinatus, partial thickness subscapularis) left shoulder. - Subacromial impingement left shoulder. - Biceps tenosynovitis left shoulder. - The condition significantly impacts her quality of life, limiting her independence in daily tasks and causing sleep disturbance. Plan - Discussion included non-surgical options (further physiotherapy, corticosteroid injection) and surgical repair. Patient prefers a surgical approach given the chronicity and severity of symptoms and failure of conservative management. - Recommended surgical procedure: Arthroscopic rotator cuff repair of the left shoulder with subacromial decompression and biceps tenodesis. The procedure, implants, rehabilitation protocol, and potential benefits and complications were discussed in detail. Patient provided informed verbal consent for surgery and wishes to proceed. - Potential Risks of Surgery Discussed Included But Is Not Limited To infection, deep vein thrombosis, stiffness, persistent pain, nerve or vessel injury, re-tear, and major systemic risks such as cardiac events or pulmonary embolism. - Patient education materials regarding post-operative care and rehabilitation protocols were provided. - Referral made for pre-operative assessment with the anaesthetist and to the specialist orthopaedic nurse for pre-admission counselling. - Surgery Planned For 1 November 2024. Other Investigations Tests Not Performed or Discussed: MRI was discussed but not deemed necessary at this stage due to clear ultrasound findings and the patient's strong preference for surgery, making it unlikely to change the management plan. Additional Comments - Patient mentioned recent relocation, which has added some stress but is not directly impacting her physical symptoms. - A billing discount for early payment was discussed: 10% discount for payment within 7 days.