Wk 3, Case 2 - Review

Patient History
52-year-old male with pain and decreased ROM in his left shoulder after a fall on an outstretched hand at work.

Findings
ROTATOR CUFF: Full-thickness complete supraspinatus tear, retracted to the 10 o’clock position of the humeral head, 1.3 cm lateral to the glenoid rim. Full-thickness complete retracted infraspinatus tear, similarly retracted. Teres minor tendinosis and strain without tear. Full-thickness complete subscapularis tear retracted to the glenoid rim.

SUBACROMIAL/SUBDELTOID BURSA: High-riding humeral head abutting the undersurface of the acromion with marrow reaction in the acromion.

MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Moderate volume loss and fibrofatty infiltration of the supraspinatus, subscapularis and mild involving the infraspinatus. Normal teres minor muscle bulk.

BICEPS TENDON: Previous biceps tenotomy and tenodesis in the bicipital groove. Attenuated proximal biceps without re-rupture.

AC JOINT: Moderate acromioclavicular arthropathy and capsulitis. Os acromiale with mild swelling at the synchondrosis.

CORACOCLAVICULAR LIGAMENTS: Intact without tear. Normal coracoclavicular distance.

SUBACROMIAL ARCH/OUTLET: High-riding humeral head but no bony or ligamentous lateral arch stenosis. Auto-acromioplasty due to the craniocaudad humeral microinstability.

SUBCORACOID ARCH: Coracohumeral stenosis or impingement with mild anterior decentering of the humeral head.

GLENOHUMERAL JOINT: Glenohumeral joint space loss and bony spurring. Complex capsulitis. Large joint fluid collection. No adhesive capsulitis.

GLENOID LABRUM: Blunted superior labrum, no acute tear.
BONES: No macrofracture.

SUBCUTANEOUS SOFT TISSUES: 1.8 x 1.0 cm lipoma at the posterior surface of the teres minor near the myotendinous junction.

AXILLA: No vascular abnormality. No lymphadenopathy.

Impressions
Massive rotator cuff tear including full-thickness complete retracted tears of the supraspinatus, infraspinatus and subscapularis. Moderate volume loss and fibrofatty infiltration of the supraspinatus and subscapularis, mild atrophy and fibrofatty infiltration of the infraspinatus.
Moderate acromioclavicular arthropathy. Os acromiale.
Mild glenohumeral arthropathy and complex capsulitis. Blunted chronically frayed superior labrum.