Left Shoulderer Case Study

Patient is a 67-year-old right hand dominant female maintenance who sustained injury to her left shoulder due to continuous trauma from 04/04/00 to 04/04/01. Per OMNI, she was diagnosed with rotator cuff tear of the left shoulder. She is status post left shoulder arthroscopy and one manipulation. She was declared P & S by Ortho AME Dr. Fernandez on 06/11/04 with 28% permanent disability rating. Future medical care includes doctor visits, medications, PT, injections and no additional surgery anticipated.
X-ray of the left shoulder performed on 10/21/16 revealed progression of degenerative osteoarthritis of the left glenohumeral joint of the shoulder, compared to prior study. Anterior cruciate ligament is relatively well-preserved.
Based on the progress report dated 10/21/16, the patient was referred for left shoulder arthritis. She ultimately underwent rotator cuff repair in 2001, 2002 and a left shoulder arthroscopy, shortly thereafter manipulation. Over the ensuing years, treatment has been intermittent, including PT, use of pulley and multiple injections including cortisone. At this time, there is chronic pain both with activity and at rest, with marked loss of motion.

There is deltoid detachment on the lateral aspect of the acromion, well-healed arthroscopic and an extended lateral incision of the acromion likely related to the index surgery in 2001. The shoulder has a marked capsular pattern stabilizing scapula, 25 to 30 of abduction, 40 to 45 of flexion, and external rotation to 5. She internally rotates to L5 left flank. Coarse crepitate is palpable through the limited motion arc. Both pain and weakness is demonstrated in resisted internal and external rotation from neutral and attempts to isolate the calf away from the