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Orthopedics & Traumatology

Rotator Cuff Tear, Complete, Right Shoulder

ICD-10 Code
M75.121

Comprehensive clinical diagnosis and template for Rotator Cuff Tear, Complete, Right Shoulder.

Clinical Presentation & Protocol

Patient Usually Complains Of

Patient presents with chronic right shoulder pain, localized to the lateral deltoid, exacerbated by overhead activities and nocturnal discomfort. Reports significant weakness in abduction and external rotation, with a history of progressive functional decline and inability to perform activities of daily living. No history of acute trauma, or acute traumatic event noted.

Clinical Examination Findings

Physical examination of the right shoulder reveals atrophy of the supraspinatus and infraspinatus fossae. Active range of motion is limited in abduction and external rotation. Positive drop-arm test, positive Jobe’s test (empty can), and positive external rotation lag sign. Passive range of motion remains preserved. Neurovascular status is intact distally.

Treatment Protocol

Recommended treatment plan includes a trial of physical therapy focusing on periscapular stabilization and rotator cuff strengthening. Consider subacromial corticosteroid injection for symptomatic relief. If conservative management fails, surgical consultation for arthroscopic rotator cuff repair is indicated. Activity modification and NSAIDs as needed.

Detailed clinical guide coming soon.