Infraspinatus Arthritis Case Summary

DOI: 2/24/2016. Patient is a 31-year old female server who sustained a work related injury when carrying out large tray of food.
The patient is subsequently diagnosed with sprain of right rotator cuff capsule, initial encounter.

MRI of the right shoulder revealed mild to moderate right acromioclavicular joint arthropathy; minimal supraspinatus and infraspinatus tendinopathy; and signal intensity morphologic changes of the posterior superior labrum consistent with a small area of fraying or tearing. As per medical note dated 6/27/16, it was noted that the patient did physical therapy but without relief. She also had taken ibuprofen but still continues to be symptomatic. Physical examination revealed that she forward elevates to about 130 degrees, externally rotates to 50 degrees, and internally rotates to the low lumbar level. Acromioclavicular joint is tender.
Acromioclavicular joint is mildly tender. Greater tuberosity and proximal biceps are mildly tender. Rotator cuff strength is 4/5 in the infraspinatus, supraspinatus and subscapularis. Impingement test is positive. Assessment includes right shoulder impingement with possible rotator cuff or labral tears. As per plan, it was noted that the patient will proceed with cortisone injection under sterile conditions with double Betadine prep and 2 cc of local lidocaine infiltration. A 1 cc of betamethasone was injected with 2 xx of Marcaine and 1 cc of lidocaine. It