Magnetic Immaging Case Study

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REHAB 570 ASSIGNMENT 3: DIAGNOSTIC IMAGING CASE STUDY
Sulabh Singh

PERSONAL (10 Marks)
Age: 51 years Sex: Female Employment: Employed as a full time Sign board Painter with City of Greater Sudbury
Interests: This client likes to play golf recreationally. Likes to work in their backyard garden.
ENVIRONMENTAL
Living Situation: Patient is living with spouse and 19 year old son. Actively participating in cooking cleaning and other daily chores.
Environment: Patient is living in 2-storey home. This patient drives car for commute to work. This patient was off work for 12 weeks from the day of onset of shoulder problem.
HEALTH CONDITION
Primary Complaint: Right shoulder pain and inability to move the right arm away from the body Physiotherapy
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Magnetic resonance imaging- Right shoulder
MRI scan of the right shoulder was performed with this department’s rotator cuff tendon protocol.There is full thickness (complete) tear at the junction of supraspinatus tendon and infraspinatus tendon. It measures 7.7 mm AP x 9.8 mm proximal to distal. There is no retraction of myotendinous junction. A separate longitudinal tear measuring 5.7 mm in length is identified at infraspinatus myotendinous junction. There is severe supra and infraspinatus tendinopathy. The long head of biceps tendon is intact and normal in appearance. The subscapularis tendon is intact and normal in appearance.
There is a small effusion in subacromial subdeltoid bursa communicating with the shoulder joint through the rotator cuff defect.
This exam was not optimized to assess the glenoid labrum; however, no obvious labral pathology is detected. There is severe osteoarthritis at the acromioclavicular joint.
Impression
Intermediate sized full thickness tear at junction of supraspinatus and infraspinatus tendons. Severe supraspinatus tendinopathy. Severe infraspinatus tendinopathy associated with small tear in myotendinous junction. Small to intermediate sized shoulder joint effusion communicating with subacromial subdeltoid

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