Supraspinatus Tear In Suspected Labral Pathology Highlights Importance Of Pocus In Clinical Decision Making

HISTORY: A 53-year old male presented to the clinic for a long history of right shoulder pain, which has been ongoing since he dislocated his shoulder in high school. The patient owns a welding business, and frequently engages in heavy lifting. He also describes a fall from a ladder 1 year ago which injured his right arm. The patient describes sharp, non-radiating pain with lifting his right arm overhead, lifting objects, and with making a throwing motion. He also describes his shoulder “locking up” when reaching for objects, and has a degree of weakness particularly with lifting his right arm above his head. He has been addressing the pain with massage and ice. PHYSICAL EXAM: Vitals were within normal limits. The patient’s right shoulder showed no obvious swelling or deformity, and there was tissue tenderness to palpation located along the biceps tendon and posterior shoulder, however there was no tenderness along the acromioclavicular joint. Pain with abduction over 90 degrees and with flexion, with general right sided weakness appreciated with strength testing. Patient had negative empty can and Hawkins tests, positive speeds test. Positive O’Brien’s test. Some uncontrolled descent from 120-90 degrees on drop arm test. DIFFERENTIAL DIAGNOSES: Labral tear, supraspinatus tear, osteoarthritis TEST AND RESULTS: POCUS of the right shoulder showed the bicipital long tendon in bicipital groove, and some subcortical changes noted suggesting potential early osteoarthritis. Notably, a full thickness supraspinatus tear was visible in 2 views.MRI of his right shoulder without contrast scheduled for December 13th 2023. FINAL WORKING DIAGNOSIS: Supraspinatus tear, osteoarthritis TREATMENT AND OUTCOMES: 1.Given POCUS findings, an MRI w/o contrast was ordered. Surgical options versus more conservative measures can be discussed pending the results of this testing .2.With the patient’s long history of shoulder pain and a previous dislocation, combined with frequent manual labor, labral pathology as well as osteoarthritis are also likely and will be addressed with physical therapy. 3. Patient referred to OMM clinic to receive myofascial, counter-strain and other indirect techniques. 4. We have also counseled patient to continue massage therapy, and to rest shoulder at work. Patient instructed to use lidocaine gel or patches as needed.