Therapeutic Disorder Case Report
DOI: 4/25/2016. Patient is a 42-year-old female occupational medicine PT service representative who sustained injury to her right shoulder from repetitively pushing shelves/work duties. Per OMNI entry, she was initially diagnosed with right shoulder strain.
MRI of the right shoulder obtained on 08/12/16 demonstrates very mild subacromial subdeltoid bursitis and focally advanced tendinosis of the anterior supraspinatus tendon, but without lateral subacromial spur or high grade partial tear. Dense scarring of the biceps pulley is seen within the rotator cuff interval and suspected nondisplaced tear of degenerated anterior labrum above the equator, but without additional overt MR features of adhesive capsulitis.
Per the medical report dated 10/20/16, the patient was provided an injection to the biceps tendon sheath.
Per the PT note dated 11/14/16, …show more content…
Range of motion shows active forward elevation of 130 degrees and passive of 150 degrees, external rotation of 50 degrees, and internal rotation to the low lumbar spine. Rotator cuff strength is 5-/5 against forward elevation resistance.
The patient continues to have positive Hawkins, Neer, and Speed tests.
Patient was diagnosed with right shoulder impingement syndrome and biceps tenosynovitis.
She continues to be symptomatic following a course of nonoperative treatment, including two subacromial injections, a biceps tendon sheath injection, as well as a course of therapy. She has taken anti-inflammatory medications as well as Tylenol.
Based on persistence of symptoms, she wishes to proceed with surgical intervention. Plan is for right shoulder arthroscopy, subacromial decompression, and biceps tenodesis with possible rotator cuff repair.
Current request is for 1 Right Shoulder Arthroscopy with Subacromial Decompression and Biceps Tenodesis; and 12 Post-Operative Physical Therapy for the Right Shoulder between 12/22/2016 and
MRI of the right shoulder obtained on 08/12/16 demonstrates very mild subacromial subdeltoid bursitis and focally advanced tendinosis of the anterior supraspinatus tendon, but without lateral subacromial spur or high grade partial tear. Dense scarring of the biceps pulley is seen within the rotator cuff interval and suspected nondisplaced tear of degenerated anterior labrum above the equator, but without additional overt MR features of adhesive capsulitis.
Per the medical report dated 10/20/16, the patient was provided an injection to the biceps tendon sheath.
Per the PT note dated 11/14/16, …show more content…
Range of motion shows active forward elevation of 130 degrees and passive of 150 degrees, external rotation of 50 degrees, and internal rotation to the low lumbar spine. Rotator cuff strength is 5-/5 against forward elevation resistance.
The patient continues to have positive Hawkins, Neer, and Speed tests.
Patient was diagnosed with right shoulder impingement syndrome and biceps tenosynovitis.
She continues to be symptomatic following a course of nonoperative treatment, including two subacromial injections, a biceps tendon sheath injection, as well as a course of therapy. She has taken anti-inflammatory medications as well as Tylenol.
Based on persistence of symptoms, she wishes to proceed with surgical intervention. Plan is for right shoulder arthroscopy, subacromial decompression, and biceps tenodesis with possible rotator cuff repair.
Current request is for 1 Right Shoulder Arthroscopy with Subacromial Decompression and Biceps Tenodesis; and 12 Post-Operative Physical Therapy for the Right Shoulder between 12/22/2016 and