Initial Shoulder Consultation

Date of Consultation: 01/11/2024 Patient Name: John Smith Patient Date of Birth: 15/03/1975 Diagnosis: Based on our discussion today, you have been diagnosed with rotator cuff tendinopathy in your right shoulder. This condition typically involves inflammation and irritation of the tendons in your shoulder, leading to pain and weakness, especially with overhead movements. Oxford Shoulder Score: 32/48 (performed on 28/10/2024) History: You are 49 years old and right-hand dominant. You work as a carpenter, which involves frequent overhead reaching and heavy lifting. You enjoy playing golf and swimming in your spare time. You have been experiencing significant pain in your right shoulder for approximately six months. You report that the pain is often present at night, making it difficult to find a comfortable sleeping position, and you often wake up due to the pain. You also experience some pain at rest. You find it impossible to lie on your affected right shoulder due to the discomfort. Your sleep is severely disturbed, and you rate your pain as 7 out of 10 at its worst. You are having significant difficulty with overhead activities, such as reaching for tools on a high shelf or performing swimming strokes. You have not experienced any associated neck pain. However, you have noticed occasional pins and needles in your right hand, particularly in your thumb and index finger, but no altered sensation. Regarding your past medical history, you have a long-standing history of mild hypertension, which is currently well-controlled with medication. You also had a minor knee arthroscopy five years ago, which is unrelated to your current shoulder issue. Co-morbidities: Hypertension, controlled No known allergies Non-smoker Clinical Examination: During your examination today, we observed some mild asymmetry in your right shoulder, with subtle atrophy of the supraspinatus muscle. Palpation revealed tenderness over the greater tuberosity and along the biceps tendon. Your active range of motion was restricted, particularly with abduction and external rotation, due to pain. Passive range of motion was slightly better but still painful at end ranges. Special tests performed included a positive Neer's impingement sign and a positive Hawkins-Kennedy test, both reproducing your shoulder pain. The empty can test elicited weakness and pain, particularly in your supraspinatus. Your neurological examination of the upper limb was otherwise unremarkable. Investigations: An MRI scan of your right shoulder performed on 25/10/2024 showed evidence of significant supraspinatus tendinopathy with partial-thickness tearing and subacromial bursitis. X-rays taken on the same date showed no significant degenerative changes or fractures. Plan: Our plan is to initially manage your rotator cuff tendinopathy conservatively. You will be referred for a course of physical therapy to focus on strengthening your rotator cuff muscles, improving scapular stability, and restoring your range of motion. We will also prescribe a short course of anti-inflammatory medication to help manage your pain and inflammation. We will review your progress in six weeks, and if your symptoms have not significantly improved, we will then discuss the option of a corticosteroid injection or consider surgical intervention. In the meantime, please try to avoid activities that aggravate your shoulder pain, especially overhead movements, and continue with your prescribed exercises diligently. You are expected to attend all physical therapy sessions and take your medication as directed.