This is a 53-year-old male patient, who presents to the center today complaining of left shoulder pain. The patient had a biceps separation in the left shoulder in 2008. He had two surgeries and then during physical therapy had a re-separation. Initially, it began while he and three other guys were lifting a 300 pounds box. Within few month of the first biceps separation on the left side, he had right-sided biceps separation. He does not have any significant pain on the right side at this point. He does have some pain in the neck intermittently as well, but denies any radicular pain in the upper extremities. He denies any numbness or tingling in the upper extremities. Pain level is 5/10 in the left shoulder. He describes it aching and sharp in nature. It is constant. Pain is made worse with lifting. He has some pain intermittently in both knees to mild-to-moderate level. He was seen by an orthopedist doctor who wanted to do surgery. He is not interested having surgery at this point. He has had no treatment otherwise for his symptoms. He occasionally will take Vicodin for pain when it becomes severe. He denies any other injuries.
Rotator cuff syndrome.
Right shoulder pain.
Biceps tendon separation.
Dr. came and spoke with the patient and clinical findings, assessment, diagnoses, and treatment recommendations were discussed with the patient. We would recommend trigger point injection to the left deltoid area for the pain. We have discussed other treatment options for his rotator cuff tear including PRP. The patient will think about this and we will schedule him for the procedure as soon as he is ready. I believe this will be a good non-surgical option for his left shoulder. He also has some issues with neck and his knees on an intermittent basis, but not causing significant problem at this time. We will see the patient back in one-week period of time.