Wk 4, Case 3 - Review

Patient History
28 year-old female with neck and right shoulder pain after MVC.

Findings
ROTATOR CUFF: 10 x 10 mm partial thickness articular-sided tear of the infraspinatus footprint, with interstitial dissection/extension (PAINT lesion), anterior infraspinatus footprint. Mild insertional tendinosis of the supraspinatus without macrotear. Normal teres minor and subscapularis.

SUBACROMIAL-SUBDELTOID BURSA: Mild subacromial-subdeltoid peritendinitis.

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

BICEPS TENDON: Normal biceps long head tendon without dislocation or tear.

AC JOINT: Mild acromioclavicular joint capsulitis without hypertrophic arthropathy. Mild soft tissue swelling surrounding the AC joint and extending into the trapezius.

CORACOCLAVICULAR LIGAMENTS: Intact without tear. Normal coracoclavicular distance.

SUBACROMIAL ARCH/OUTLET: No outlet-related cuff impingement. Posterolaterally tilted type-2 acromion.

SUBCORACOID ARCH: No subcoracoid stenosis.

GLENOHUMERAL JOINT: No adhesive capsulitis. No Hill-Sachs or Bankart injury. Normal glenohumeral cartilage. Incidentally noted is anteroinferior capsular interponation, series 4 image 12

GLENOID LABRUM: Minimal superior labral fraying, SLAP 1.

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

SUBCUTANEOUS SOFT TISSUES: No superficial soft tissue swelling. No mass.

AXILLA: No lymphadenopathy.

Impressions
AC joint capsular sprain or grade 1 separation, without rupture. Soft tissue swelling surrounding the AC joint and extending into a mild strain of the trapezius. No trapezius avulsion or tear. No clavicle or acromion macrofracture.
Partial thickness tear, PAINT lesion (partial thickness articular-sided with interstitial extension) of the infraspinatus tendon at its anterior footprint, 10 x 10 mm, involving approximately 25% of the tendon thickness.
Superior labral fraying, SLAP 1.