Case study ( 4212 views as of May 23, 2019 )
Donald is a 65-year-old right hand dominant active gentleman who plays tennis regularly. He visits his family physician complaining of increasing pain to the right shoulder with associated weakness. He states that he can no longer serve or hit the ball overhead. He is having trouble sleeping at night and cannot lie on his right side. He has pain with raising his arm overhead and has clicking on occasion that can be painful. He localizes the pain to the anterolateral side of the top of the shoulder.
The physician's examination reveals some wasting of the supraspinatus muscle posteriorly. Donald's shoulder range of motion is full but he has a painful arc of motion. He has crepitus (crackling sounds) within the subacromial region with motion of the shoulder. He has pain with testing supraspinatus power and 4/5 strength. Infraspinatus and subscapularis power is full. He also had tenderness over the supraspinatus tendon insertion and a palpable defect. There was some tenderness to the biceps tendon.
Donald is diagnosed with an old rotator cuff injury and could benefit from having an MRI or CT scan on his shoulder to help physicians diagnose this injury and its severity. An orthopaedic surgeon may need to assess Donald for surgical treatment. He may also benefit from seeing a physiotherapist or sports medicine physician to help with strengthening and increasing range of motion again. Massage therapy may help to restore blood flow to the injury and relax tense muscles in the shoulder and neck area.Author: Dr. Jordan Leith