Initial Shoulder Consultation

Date of Consultation: 01 November 2024 Patient Name: Sarah Jenkins Patient Date of Birth: 15 May 1978 Diagnosis Rotator cuff tear, right shoulder, involving the supraspinatus tendon, approximately 1.5 cm in size, with associated subacromial impingement syndrome. Chronic in nature, without acute trauma history. Oxford Shoulder Score 38/48, performed on 28 October 2024. History The patient is a 46-year-old right-handed graphic designer who enjoys recreational swimming. She reports experiencing night pain that disrupts her sleep 3-4 times a week and rest pain rated as 4/10. She finds it impossible to lie on her right shoulder due to discomfort. Overhead activities are significantly difficult, particularly reaching for high shelves or styling her hair. She denies any associated neck pain or paresthesias/pins and needles in her upper limb. Her past medical history is significant for well-controlled hypertension and a previous appendectomy in 2005. There is no history of prior shoulder injuries or surgeries. Co-morbidities Patient has well-controlled essential hypertension, managed with daily ramipril 5mg. She denies any known drug allergies. She reports being a non-smoker for the past five years, having previously smoked 10 cigarettes per day for 15 years. Clinical Examination On observation, there was no obvious swelling, deformity, or muscle wasting. Palpation revealed tenderness over the greater tuberosity and subacromial space. Active range of motion was limited, particularly in abduction (to 90 degrees) and external rotation, with a painful arc noted between 60-120 degrees of abduction. Passive range of motion was slightly better but still restricted due to pain. Impingement signs were positive, including a positive Neer's and Hawkin's-Kennedy test. Supraspinatus strength was 3/5 with a positive Jobe's test. Deltoid and other rotator cuff muscles were 5/5. Neurovascular examination was unremarkable. Investigations Previous X-rays from October 2024 showed mild degenerative changes in the acromioclavicular joint but no significant glenohumeral osteoarthritis. A recent MRI scan performed on 25 October 2024 confirmed a full-thickness tear of the supraspinatus tendon, measuring approximately 1.5 cm, with signs of subacromial bursitis and mild tendinosis of the infraspinatus. Plan The patient has been counselled regarding the MRI findings and diagnosis. The initial management plan includes a trial of conservative treatment comprising physiotherapy focusing on strengthening the remaining rotator cuff muscles and scapular stabilisation, along with a subacromial corticosteroid injection for pain relief and inflammation reduction. She will be prescribed ibuprofen 400mg three times daily for pain, to be taken with food. A referral to the physiotherapy department has been made. The patient has been advised on activity modification, avoiding overhead movements and heavy lifting. A follow-up appointment is scheduled in 6 weeks to reassess symptoms and consider surgical intervention if conservative measures fail. Patient education was provided on the nature of her condition and the importance of adherence to the physiotherapy regime.