Summary: Work Related Injury

Inspection of the right shoulder joint reveals atrophy. Movements are restricted with flexion to 90 degrees limited by pain and abduction to 75 degrees limited by pain. Hawkin’s test, Neer’s test, Shoulder crossover test, Empty Cans test, Lift-off test, and Apprehension test is positive. On palpation, tenderness is noted in the acromioclavicular joint and subdeltoid

Per PT treatment log dated 11/18/15, the patient has attended 19 PT visits for the thoracic and lumbar spine from 08/27/15 through 11/13/15.

O: Inspection of the right shoulder, no redness or edema noted; palpation of the right shoulder there was no warmth noted; on deep palpation TM reports in some tenderness

DOI: 9/30/2011. Patient is a 41-year-old male information technology computer support specialist who sustained injury while he was walking through a lobby when he slipped and fell. Per OMNI, he was initially diagnosed with lumbar intervertebral disc syndrome, myofasciitis and right arm strain. He underwent a right shoulder surgery on 07/16/13 and 12/22/15.

The patient notes that the injury happen when he was lifting some metal trash trays into a trash bin when he felt a sharp pain in his shoulders. Treatment history notes that the treatment to date has consisted of medications. Of note, the MRI done showed a large full thickness tear with retraction of the tendon. Physical examination of the left shoulder revealed that the range of motion has forward flexion of 0-175 degrees, external rotation of 0-40 degrees, and internal rotation to T12. There is positive Hawkins’ and Neer’s sign for impingement. There is weakness with abduction testing. Treatment plan notes recommendation, surgical intervention in the form of a left shoulder, subacromial decompression, rotator cuff repair surgery as necessary. A follow up of 2 to 3 weeks if surgery is authorized. As per medical summary and work status dated 6/14/16, it was noted that the patient has not improved significantly and would be needing surgery. The patient’s return to work date is 6/14/16 with no lifting over 10 pounds and no overhead reach. Follow up to clinic date is on

Current request is for 1 Right Shoulder Arthroscopy, Rotator Cuff Repair, Subacromial Decompression, Distal Clavicle Resection, Capsular Release, Debridement, and Biceps Tenodesis between 4/26/2016 and 6/25/2016.

DIAGNOSIS: Strain of muscle, fascia, and tendon at neck level; Carpal tunnel syndrome, unspecified right limb,;Carpal tunnel syndrome, unspecified left limb; Status post left carpal tunnel release; and Adhesive capsulitis of right shoulder (M75.01).

The patient is a 36-year-old individual who sustained an injury on 01/30/17 due to lifting.

Objective Functional Improvement shows that the patient is now able to get dressed with minimum assist. He is also now able to navigate 2 flights of stairs without pain, same as prior, now able to walk for 8 minutes, same as prior, can now lift 6.5 lbs. of weight, improved from prior, and push 6 lbs. of weight, same as prior. Therapy goals for this patient in the next 4 weeks are to reduce inflammation from moderate to minimal and increase cervical and lumbar spine flexion and bilateral rotation by 3 degrees. The patient in the next 4 weeks will be able to get dressed easier, navigate 2.5 flights of stairs without pain, walk 9 minutes from 8 minutes, lift 7 lbs. of weight, and push 7 lbs. of

DOI: 06/04/2007. Patient is a 66-year-old male baggage service agent who felt pain in his right shoulder after lifting bags. As per OMNI notes, patient is status post right shoulder decompression. Per the Orthopedic AME Supplemental report dated 11/05/19, IW has 3% whole person impairment rating for his bilateral shoulders. Per OMNI payment screen, last PT session was on 07/28/16.

DOI: 2/19/2014. Patient is a 53-year old right-hand dominant female production worker who sustained injuries to her neck, low back, right shoulder, and bilateral knees as a result of cumulative trauma. Per OMNI entry, she was initially diagnosed with cervical radiculopathy, lumbosacral radiculopathy, bilateral shoulders tendinosis/bursitis and knee tendinosis/bursitis.

IW was diagnosed with cervical strain with right arm dysesthesia with what appears lo he chronic regional pain syndrome of her right arm, right shoulder biceps tendonitis and subacromial bursitis with associated impingement, status post subacromial injection x 1, mild medial and lateral epicondylitis of her right elbow, carpal tunnel syndrome by EMG/nerve conduction velocity and reactive depression.

On 10/09/2017, the claimant was 4 months post reconstructive surgery. It was noted that he had been doing well. His incision was healed with a good mass of the biceps and good excursion with a range of motion of the elbow.

DOI: 4/27/2015. Patient is a 52-year-old male driver guard who sustained a work-related injury to his bilateral shoulders, hands, wrists, and back after being involved in a motor vehicle accident. As per OMNI, the patient was diagnosed with right shoulder labral tear, biceps tendonitis and impingement syndrome, acromioclavicular sprain, and lumbar disc degenerative disease.

S: In 10/22/2014, TM was seen for bilateral shoulder pain. Today TM is here complains of left shoulder pain. According to TM he was aligning a Santfa, a process involving reaching. When he was bring his arm down, he felt the sharp, tearing pain in his anterior of his shoulder. TM is here with left shoulder pain. TM reports his pain at 6-7/10. The pain was sudden, sharp at The pain was localized, and didn’t radiated to anywhere else. The pain was so sudden and so severe, it scared him. TM denies any tingling or numbness, loss of movement.