Patient History
69-year-old male with right shoulder pain and very limited range of motion after lifting and throwing injury 1-1/2 weeks ago.
Findings
ROTATOR CUFF: Full-depth and near full-length tear of the rotator cable and conjoined tendon involving the entire supraspinatus and the anterior portion of the infraspinatus footprint. The tear measures 4cm in width and 3.5cm in anteroposterior dimension.
SUBACROMIAL/SUBDELTOID BURSA: Mild to moderate diffuse peritendinobursitis.
MUSCLES (ROTATOR CUFF/DELTOID, TRAPEZIUS, PECTORALIS): Interstitial tearing of the infraspinatus myotendinous junction. Grade 3+ fatty infiltration and volumetric atrophy of their corresponding muscle bellies with associated edema.
Mild to moderate tendinosis and interstitial delamination of the superior subscapularis.
Intact teres minor.
BICEPS TENDON: Normal.
AC JOINT: Nominal AC joint arthropathy.
CORACOCLAVICULAR LIGAMENTS: Intact.
SUBACROMIAL ARCH/OUTLET: Type 3/hooked acromion with lateral downsloping.
Mildly thickened coracoacromial ligament.
SUBCORACOID ARCH: Normal.
GLENOHUMERAL JOINT: No arthropathy. Nominal chondrosis. No signs of capsulitis. Normal glenohumeral ligaments.
GLENOID LABRUM: Fraying of the superior labrum without displaced labral tears or paralabral cysts.
BONES: No fracture or dislocations. No intramedullary lesions.
SUBCUTANEOUS SOFT TISSUES: Mild diffuse periarticular soft tissue swelling.
AXILLA: Normal. No space-occupying lesions.
Impressions
1. Narrowing of the lateral subacromial arch due to a type 3/hooked, laterally downsloped acromion and a mildly thickened coracoacromial ligament.
2. A 4cm x 3.5cm full-depth and near full-length tear of the entire supraspinatus and anterior infraspinatus footprints with medial retraction.
3. Interstitial tearing with reactive edema of the infraspinatus myotendinous junction.
4. Mild to moderate diffuse peritendinobursitis.
