Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic left shoulder pain exacerbated by overhead activity and nocturnal discomfort. Reports progressive weakness in abduction and external rotation. No history of acute trauma, though symptoms have worsened over the past [X] months. Failed conservative management including physical therapy and NSAIDs.
Clinical Examination Findings
Left shoulder examination reveals significant atrophy of the supraspinatus fossa. Active abduction is limited to [X] degrees with a positive painful arc sign. Strength testing demonstrates 3/5 power in abduction. Positive Empty Can (Jobe) test and Drop Arm test. Passive range of motion is preserved. Neurovascular status intact distally.
Treatment Protocol
Recommend surgical intervention for arthroscopic repair of the complete supraspinatus tendon tear. Pre-operative plan includes MRI confirmation of tear size and retraction. Post-operative protocol involves immobilization in a shoulder sling for 6 weeks followed by a structured physical therapy program focusing on range of motion and progressive strengthening.