Case study ( 3607 views as of September 21, 2018 )
Tom is a 25-year-old right hand dominant snowboarder who presents to his doctor for evaluation of his left shoulder. He injured it one week ago after failing to land a large jump and consequently landing directly on his left side. He described having immediate and significant pain to the left shoulder. He was unable to actively move the arm without significant pain. It has failed to improve to date and although the pain has settled considerably he still is unable to lift the arm. He says it feels very weak.
On examination, the doctor notices Tom is holding the arm close to his side. There is no deformity or muscle wasting. Passive range of motion is full with some discomfort. Active range of motion is very limited and he is unable to actively elevate the arm beyond 45 degrees. There is tenderness to palpation over the supraspinatus insertion and a palpable defect with crepitus present. There is grade 3 power testing supraspinatus, 5/5 power for infraspinatus and subscapularis testing. There are no other findings with the examination.
A diagnosis of a young rotator cuff tear is made. Tom may benefit from having an MRI on his shoulder to confirm the exact severity of his injury. He may also benefit from seeing a physiotherapist and possibly a massage therapist in order to improve the range of motion again in his shoulder. He may also benefit from seeing an orthopedic surgeon for assessment.Author: Dr. Jordan Leith