The patient is a 64-year-old female who has been experiencing right shoulder pain for approximately six months. She was exercising and doing some weightlifting when she started to experience that pain in the right shoulder that radiated into the right forearm. She received an injection of steroid from an orthopedic surgeon who diagnosed her with tendonitis. She continued doing the physical therapy, but neither one of them help decreased the pain. Since she did not notice an improvement in the pain, she went to see another orthopedic surgeon who did an MRI of the shoulder and recommended rotator cuff repair. The patient is looking for a second opinion and also exploring the option of having a PIP injection done in the shoulder to help heal the tear. The pain is described as follows: Duration: Intermittent. She does have periods in which she is pain free. Quality and intensity: The pain ranges anywhere from 2/10 to 8-9/10 when she is actively using the shoulder. Radiation and distribution: Superior-posterior shoulder extending into the upper part of the forearm. Aggravating factors: Elevating and reaching behind aggravates the pain. Alleviating factor: Sitting still with the arm resting.
1. Right rotator cuff partial thickness tear.
2. Right shoulder enthesopathy.
1. I recommended the patient to continue physical therapy in terms of the range of motion, heat, and ultrasound to the right shoulder.
2. Voltaren gel to be applied up to three times to the right shoulder. Use of heating pads preferably moist heat to the right shoulder.
3. I discussed with her the use of the PRP in these situations. When it comes to the partial full thickness tear, the results of the PRP are not 100% or even 50%. The advantage of this therapy is that it gives approximately 32% chance of the muscle repair itself with minimal complications and fast recovery.
4. Surgery is not immediately needed since her symptoms are minimal. She does have discomfort only with certain maneuvers and she is able to function properly with her daily activities.
5. After discussion of the pros and cons of the PRP with this, she decided that she would like to try this therapy. She would be scheduled for the PRP injection of the supraspinatus. Prior to that, I would like to review the films.