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Case of the Week: Atraumatic Lateral Shoulder Pain in a 59F

case of the week case study rotator cuff related pain subacromial impingement
Rotator Cuff Impingement Radiographs Xrays Shoulder

Case of the Week: Atraumatic Lateral Shoulder Pain in a 59F

CC: Atraumatic Lateral Shoulder Pain in a 59F.

HPI: This 59-year-old female has had a 1 year atraumatic history of lateral shoulder pain. She has difficulty lifting her arm overhead. She has maintained good strength but pain is her primary concern. She has tried physio and oral NSAIDs without much benefit. 

What is this patient’s most likely diagnosis?

PMH: RHD financial institution desk job worker. Non-smoker. NKDA. Insulin-dependent diabetic - well controlled. 

PE: Physical exam shows no muscle wasting on visual inspection. Rotator cuff rated 5/5. Hawkins and Neers re-creates pain complaint. Mildly tender bicipital groove on palpation. Yergason’s was negative. Cervical spine was unremarkable for shoulder pain. 

Imaging: MRI demonstrated a 8 mm x 6 mm x 3 mm articular surface partial thickness supraspinatus tear. Radiographs are seen here.

Diagnosis: Chronic rotator cuff related pain with subacromial impingement and a degenerative small partial-thickness supraspinatus tear. 

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