Supraspinatus Tendon Case Study

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DOI: 11/16/2015. Patient is a 57-year-old right hand dominant male mechanic who sustained injury while he was lifting a metal roller when he lost his balance and fell backwards. Per OMNI, he was initially diagnosed with head laceration which required 7 sutures and right shoulder full thickness supraspinatus tendon tear, confirmed by 12/29/15 MRI.
MRI of the right shoulder obtained on 12/29/15 showed limited portions of the study due to motion artifact. There is a full thickness tear of the supraspinatus tendon. The torn tendon is indistinct but appears to be retracted to the level of the acromioclavicular joint. Mild arthritis changes are noted.
Based on the progress report dated 01/21/16, the patient complains of intermittent and worsening right shoulder pain, rated as 8/10. Pain radiates to the left arm, described as aching, burning and sharp. Pain is aggravated by lifting and movement, and relieved by rest. Associated symptoms are decreased mobility, and joint instability and
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He was assessed to have a full thickness rotator cuff tear of the right shoulder which has failed PT, time, rest and medications. Plan is for arthroscopic repair.

Per verification to the provider’s office, the IW has a history of prior spontaneous proximal biceps rupture in 1985 and no PT notes are available as this has been requested by another MD. For the discrepancies with ROM testing, a corrected report was requested, however, no medical records received at the time of submission of the review to PA.
Current request is for 1 Right Shoulder Arthroscopy, Debridement, and Rotator Cuff Repair; 1 Preoperative Consultation; and 1 Polar Care Circulating Cold Pad with Pump (E0218) between 1/26/2016 and

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