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Supraspinatus Tendon Case Study

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DOI: 6/9/2015. Patient is a 55-year-old right hand dominant male breakfast host employee who sustained injury when he picked up a box of milk when he felt pain on his right shoulder to neck and radiating to the right forearm. Per OMNI, he was initially diagnosed with right shoulder impingement, cervical train and benign hypertension.

Per PT daily note dated 01/20/16, the IW has tended 5/6 sessions for his right shoulder.
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.
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Per the initial orthopedic evaluation report dated 02/09/16, the patient’s pain is worsened when he attempts to elevate the arm. Pain and weakness in his arm make it difficult for him to perform activities such as dressing, grooming and bathing. He is taking
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