Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic/acute shoulder pain, localized to the lateral deltoid region, exacerbated by overhead activities and night pain. Reports significant weakness in abduction and external rotation, with a subjective feeling of "giving way." No history of recent trauma, or history of specific injury event [Date/Mechanism]. Failed conservative management including physical therapy and NSAIDs.
Clinical Examination Findings
Inspection reveals atrophy of the supraspinatus and infraspinatus fossae. Active range of motion (ROM) is limited by pain and weakness. Passive ROM is preserved. Positive Drop Arm test, positive Empty Can test (Jobe's), and positive External Rotation Lag Sign. Neurovascular status is intact distally.
Treatment Protocol
Plan: 1. MRI shoulder to confirm tear size and retraction. 2. Corticosteroid injection for symptom management if indicated. 3. Referral to Orthopedic Surgery for evaluation of arthroscopic rotator cuff repair. 4. Continued physical therapy focusing on periscapular stabilization. 5. Activity modification: avoid overhead lifting.