Rotator Cuff Tear
Age: years old
Gender:
HISTORY:
Presents with a - history of shoulder pain
Onset was , started
Location is
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Dominant hand:
Associated symptoms: *Try using right-click for negatives*
Contributing factors:
no history of: , , ,
EXAM:
Shoulder:
Inspection:
Palpation: on
Range of motion:
- Flexion:
- Extension:
- Abduction:
- Adduction:
- Int rotation:
- Ext rotation:
Strength: , except on
Neurovascular: , distal pulses , cap refill sec, sensation
Special tests:
- Neer sign:
- Hawkins:
- O'Brien test:
- Jobe test (empty can):
- Yocum test:
- Cross-body adduction:
- Sulcus sign:
- Apprehension test:
- Drop arm test:
- Speed's test:
ASSESSMENT:
DDx: rotator cuff tendinopathy, biceps tendinopathy, rotator cuff tear, shoulder impingement syndrome, adhesive capsulitis, glenohumeral osteoarthritis, acromioclavicular joint disease, labral tear, shoulder dislocation, shoulder subluxation, calcific tendinitis, septic arthritis, referred pain from cervical spine, brachial plexus injury, thoracic outlet syndrome, pancoast tumor, myocardial infarction, referred pain from liver pathology, referred pain from spleen pathology, humeral head fracture, clavicle fracture
PLAN:
Investigations:
- Shoulder X-ray
- Ultrasound of the shoulder
- MRI of the shoulder
Treatments:
- Remain active as tolerated
- Encouraged to stretch, keep good posture, and avoid lifting weight
- Physical therapy
- Heat or cold therapy
-
-
- Steroid injection
- for
Further care:
- Referral to orthopedic surgeon
- Follow-up in
- Return if pain worsens or if symptoms do not improve with treatment
HISTORY: Associated symptoms: EXAM: Shoulder: ASSESSMENT: PLAN: