Tenonitis Case Study: Left Rotator T

Based on the progress report dated 03/28/16 by Dr. Bakhos, the patient presents for follow-up of his right knee

Attached are chiropractic and PT notes. Patient has been previously denied with same request on 12/01/15 (Review

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.

On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The

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

DIAGNOSIS: Impingement syndrome, right shoulder; full-thickness rotator cuff tear with retraction, right shoulder; adhesive capsulites, right shoulder; post-op pain, right shoulder; Right elbow strain/sprain; Right wrist strain/sprain; Right upper extremity overuse syndrome.

Based on the medical report dated 12/29/16, the patient is having flare-up in his bilateral shoulders with pain on the left 6/10 and on the right 8/10. It is worse with reaching up and certain other activities. He is avoiding medications. He has had very good experience with physical therapy in the past and would like some sessions to treat his flare-up. He also needs

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.

Based on the latest medical report dated 11/05/15, the patient had a minimally displaced “GT” avulsion fracture, nondisplaced incomplete fracture at the surgical neck and nondisplaced anterosuperior glenoid fracture. He had a rotator cuff tendonitis without full thickness tearing. There is some

A 22-year-old male triple-A baseball pitcher presents with gradual pain in the right shoulder area. Pain is dull, with occasional sharp pains with overhead movement and backward motion of the right arm. Pain radiates from the shoulder down into the right elbow. No numbness or tingling of the right arm. No perceived weakness of right arm. You inform the athlete that he likely has a rotator cuff injury. Which one of the following tendons is NOT likely to be injured?

Had an X-ray done and has to wear a boot at nights. When he came into the appointment, he rated his pain as a 4.

As per medical report dated 4/21/16, patient returns for re-evaluation. He is not doing well and with current instability of the left shoulder. It was noted that the patient wanted to have more time and continue to exhaust any benefits of therapy; however,

O: On inspection, no edema or discoloration noted to her right shoulder. TM reports pain with deep palpation of her AC. Full active ROM, limited passive ROM. Reports increased pain with posterior rotation of her right shoulder; No impairment of neurovascular system; radial and ulnar pulse +3; brisk capillary refills.

Based on the medical report dated 05/02/16, the patient states that he is experiencing more pain in his left shoulder on this visit than he has in a while. He reports relief with the steroid injection. He continues to attend PT 3 times a week. He states that he feels some improvement with PT.

Patient continues using pain medications. Patient has modified activity level. Treatment received includes activity modification, medications, shoulder arthroscopy and therapy. Tests performed include X-rays, MRI x 2, and MR arthrogram.