Case study Rotator cuff tear PDF

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Adrianna Parra Clinical Experience II Case Study #3 December 10, 2010 Rotator Cuff Tear

Adrianna Parra December 10, 2010 Clinical Experience II Case study #3 Rotator Cuff Tear To begin, a rotator cuff is made up of four muscles that help move and stabilize the shoulder joint (Emedicinehealth, 2010). Any damage to any one of the four muscles, Supraspinatus, Infraspinatus, Teres Minor, Subscapularis, or their ligaments can occur because of an acute injury, chronic overuse, or gradual aging. There are a variety of issues that arise if the rotator cuff is damaged: pain and spasm limiting shoulder range of motion, fluid accumulation with in the joint do to inflammation, arthritis and calcium deposits that form over time limiting range of motion, and muscles not able to make the small adjustments within the joint to allow the humeral head to move smoothly (Emedicinehealth, 2010). Rotator Cuff injuries are classified into 3 grades; Grade 1 strains involve stretching of the fibers without any tears, Grade 2 injuries involve partial muscle or tendon tearing, and Grade 3 injuries are defined as a complete tear of a muscle or tendon (Emedicinehealth, 2010). According to Emedicinehealth some symptoms that may accompany a rotator cuff tear are; severe pain, inability to abduct the arm or life above head, gradual onset of weakness, and point tenderness. An MRI arthrogram is usually ordered to be sure an apparent tear is there and needs fixing. After surgery simple rest and ice are the first treatment that is necessary. A sling and anti-inflammatory medication may also be helpful to help decrease pain (Emedicinehealth, 2010).

Emedicinehealth,. (2010). Rotator cuff injury . Retrieved from h t t p : / /w w w. e m e d i c i n e h e a l t h . c o m / r o ta t o r _ c u ff _ i n j u r y /a r t i c l e _ e m .h t m S.O.A.P NOTES Subjective: A Lakeview high school student came in complaining of the inability to lift his left arm past 90 degrees of range of motion in either direction. He is a defensive lineman on the football team and repeatedly goes to block the opposing team placing stress on his shoulder. He has point tenderness on the posterior side of his left shoulder. Objective: He is guarding the shoulder, being careful not to move it to an uncomfortable position. Assessment: First testing range of motion in all planes, he has a significant lost of motion in flexion, extension, and abduction. He is not able to extend past about 80 degrees without experiencing pain. Apprehension Test was positive as was Empty Can and Gerber’s Lift Off.

Plan: To get an MRI to find out if there is a tear to the rotator cuff before the injury gets worse without treatment....