Wk 1, Case 5 - Review

Patient History
56-year-old male with right shoulder pain and decreased ROM.
Findings

ROTATOR CUFF: Mild tendinosis of the supraspinatus and infraspinatus followed by teres minor. Interstitial delamination microtear of the subscapularis. No full-thickness or retracted rotator cuff tear.

SUBACROMIAL/SUBDELTOID BURSA: Mild subacromial-subdeltoid peritendinitis.

MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Mild teres minor strain without tear. No quadrilateral space mass.

BICEPS TENDON: Thin intra-articular segment of the biceps without dislocation or tear. Mild biceps tenosynovitis.

AC JOINT: Mild active acromioclavicular arthropathy, including bony hypertrophy, spurs, periarticular marrow reaction but no separation. Small inferior spurs but no impingement of the traversing cuff.

CORACOCLAVICULAR LIGAMENTS: Intact without tear. Normal coracoclavicular distance.

SUBACROMIAL ARCH/OUTLET: Posterolaterally tilted type 2 acromion without lateral arch stenosis.

SUBCORACOID ARCH: No subcoracoid stenosis.

GLENOHUMERAL JOINT: Posterior decentering of the humeral head. Articular surface flattening on both sides of the joint. Large humeral head spur directed inferiorly. Mostly preserved glenoid bone stock but mild posterior glenoid bone loss and glenoid retroversion noted. Intracapsular debris/bodies including in the subcoracoid bursa.

GLENOID LABRUM: Chronic nondisplaced degenerative posterior and superior labral tear.

BONES: No macrofracture. No infiltrative or destructive bone lesion. Impingement-related pseudocyst formation within the humeral head adjacent to and beneath the infraspinatus insertion. Chronic remodeling of the humeral head with flattening from 12 o’clock to 3 o’clock.

SUBCUTANEOUS SOFT TISSUES: No soft tissue mass.

AXILLA: No lymphadenopathy or vascular abnormality.

Impressions
1. Severe glenohumeral arthropathy including extensive cartilage loss, large humeral head spur, posterior labral tearing, glenoid and humeral head remodeling, complex capsulitis, and debris/bodies in the joint space.
2. Posterior humeral head decentering with greater than 20 degrees of glenoid retroversion.
3. Mild rotator cuff and biceps peritendinitis and tendinosis without tear.
4. Mild active acromioclavicular arthropathy.