Right Shoulder W/O Contrast

Client reported this week she is having shoulder pain. She also submitted MRI Rx. With the following findings:

As per office notes dated 5/4/16, the patient is seen for bilateral elbow pain and bilateral wrist pain. She rates the pain as 3/10 with medication and 7/10 without medication. She is active for at least six hours a day and has energy to make plans. Her activity level has

On physical examination of the right knee, the patient is tender at the joint line and lateral meniscus.

The clinical evaluation of labrum pathology can be difficult to diagnose due to each type of SLAP lesion having different mechanisms of injury, pain, and area that is affected. Type 1 SLAP lesions can usually be associated with rotator cuff pathology with a partial thickness tear of the supraspinatus ligament due to micro-tears. ^1,5 This is quite common in baseball players and other overhead athletes. Type II lesions can vary based on age; younger patients have more instability than older patients who tend to have rotator cuff pathology. ^1,6 Type III and IV lesions are more commonly associated with traumatic instability. ^1 As with all injuries, the evaluation should start with the history making sure to include the exact mechanism

Until the last decade, diagnostic arthroscopy was the only possible way to clarify a doubtful diagnosis. Unfortunately, it is an invasive and expensive procedure, and its overuse has produced unnecessary comp-lications, such as infection, neurovascular lesions and damaged intra-articular materials. ( 86 ) It is preferably performed only for treatment purposes, provided that alternative non invasive diagnostic modalities such as MRI are available. ( 87 )

MRI of the left ankle and foot obtained on 01/26/16 showed evidence of moderate to high-grade partial tear of the anterior talofibular ligament and moderate partial tear of the calcaneofibular ligament. There is evidence of mild partial tear of the deltoid ligament. Mild to moderate osseous contusion of the talar body is seen. There is a mild sinus tarsi edema. There is a minimal subtalar and tibiotalar effusions.

The shape or thickness of the acromion sometime plays into effects of the rotator cuff. In some people the space between the undersurface of the acromion and the humeral head is very narrow, which can lead to being more likely to pinch the supraspinatus tendon. In some cases, there are people who have bone spurs on the front of the acromion, which increases the risk of impingement syndrome. Muscle imbalance is another situation

It is crucial to rule out other differential diagnoses such as lateral collateral ligament injury , osteochondritis dessicans, posterior interossesus nerve syndrome , radial head fracture , capitellum fracture and synovitis. (1)

However, plain films were not obtained. There is no clear rationale for the indication of shoulder MRI with unequivocal objective findings and absence of plain films. In addition, there is no focal neurological deficit on the exam. There are no sensory or motor deficits noted. Medical necessity has not been established. Recommend non-certification.

O: Inspection of right elbow - No edema, discoloration, or swelling noted; tenderness with palpation near the lateral elbow when the wrist is bent forward; right hand Grip strength: Right +4, Left +5

MRI of the right shoulder obtained on 01/09/16 revealed a complete supraspinatus tendon rupture with tendon retraction to the level of the mid humeral head. There is a suspicion for full-thickness tears involving anterior substance infraspinatus tendon at the junction with the supraspinatus tendon. There is an underlying infraspinatus distal tendinosis. There is volume loss of the supraspinatus and infraspinatus muscles with mild edema in the infraspinatus muscle. Moderate subacromial/subdeltoid bursal fluid is seen contiguous with joint fluid through the supraspinatus tendon tear defect. There is osteoarthrosis of the acromioclavicular joint. Heterogeneity of the intraarticular long head biceps tendon segment is seen likely due to motion artifacts positive/negative tendinosis.

An abnormally shaped acromion will also cause impingement on the cuff tendons. Three types of acromions have been identified. They are: type I (flat), type II (curved), and type III (hooked). In a study performed by Morrison and Bigliani, 70% of rotator cuff tears were associated with type II and III acromions. None had type I. Although the causal relationship between the shape of the acromion and rotator cuff tears or impingement can be concluded, the clinical findings support Neer's theory of impingement occurring primarily along the anterioinferior acromion (Donatelli 2004). Haig (1996) describes shoulder impingement as producing an atrophic, "worn away" appearance of the cuff tendons, which are frequently retracted.

Shoulder impingement syndrome may also be referred to as "subacromial" impingement syndrome because the tendons, ligaments, and bursa under the "acromion" can become pinched or compressed.

2. He has a full-thickness tear of the supraspinatus tendon, which measures approximately 3 cm with a positive full can test.

DOI: 8/23/2012. Patient is a 59-year-old male longshoreman who sustained an injury when allegedly attempted to sway cables that were being lowered and hurt his left shoulder. As per OMNI, he sustained a left shoulder rotator cuff tear/superior labral anterior-posterior tear/impingement, acromioclavicular joint arthritis and bicipital tenosynovitis. On 11/21/2012, he underwent left shoulder rotator cuff repair, debridement of glenohumeral joint, distal clavicle resection and subacromial decompression via acromioplasty.