Wk 4, Case 2 - Review

Patient History
54-year-old female with complaint of slight pain, popping and decreased range of motion in shoulder for years.

Findings
ROTATOR CUFF: Mild tendinosis of the supraspinatus and infraspinatus with interstitial microtearing of the insertions, no macrotear. Normal subscapularis and teres minor.

SUBACROMIAL/SUBDELTOID BURSA: Mild subacromial subdeltoid peritendinitis.

MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): No muscle atrophy, strain, or tear.

BICEPS TENDON: Intact biceps long head tendon without dislocation or tear. Mild extra-articular tenosynovitis.

AC JOINT: Moderate acromioclavicular arthropathy without separation or coracoclavicular ligament injury. No medial arch stenosis.

CORACOCLAVICULAR LIGAMENTS: Intact without tear.

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

SUBCORACOID ARCH: No subcoracoid stenosis.

GLENOHUMERAL JOINT: Convex anterior glenoid, posterior tilt of the glenoid relative to the long axis of the scapula. Slight depression or coronal downsloping of the inferior one-third of the glenoid consistent with dysplasia.

Blunting of the posterior glenoid rim with retroversion angle of 24 degrees (normal less than 8) also consistent with dysplasia. 1.5 cm osteochondral defect/remodeling of the glenoid cup. No effusion.

GLENOID LABRUM: Essentially circumferential (sometimes referred to as a a SLAP 9) but primarily posterior labral tearing. Tiny noncompressive paralabral cyst.

BONES: No acute macrofracture. No infiltrative or destructive bone lesion.

SUBCUTANEOUS SOFT TISSUES: No soft tissue mass. No muscle atrophy or tear.

AXILLA: No lymphadenopathy or vascular abnormality.

Impressions
Dysplastic glenoid cup with retroversion, posterior glenoid insufficiency, near circumferential but primarily posterior labral tearing, and tiny noncompressive paralabral cyst.
Mild rotator cuff peritendinitis and tendinosis without tear.
Mild acromioclavicular arthropathy.