Supraspinatus Case Summary
DOI: 6/17/2015. The patient is a 26-year-old female inventory associate/athlete who sustained a work-related injury to her hand/knees when she tripped on a cloth rack and fell down to the ground. As per OMNI entry, the patient sustained injury to her right ankle and right shoulder.
MRI of the right shoulder performed on 09/08/15 revealed supraspinatus tendinosis and slightly low lying acromion process without evidence of rotator cuff impingement.
Per the medical report dated 11/16/15, the patient still has a significant amount of right shoulder pain. She has a positive anterior apprehension sign. She can barely lift her arm up without pain. She has significant snapping in the shoulder. She has not improved with PT. MD has a suspicion for
a labral tear.
Based on the medical report dated 01/20/16, the patient presents for follow-up of her right shoulder pain. She is still in significant amount of pain. She is working and cannot lift anything. She feels her shoulder is disconnected. She was unable to get an MR athrogram. Her initial MRI was a stand up MRI which did not show a labral tear. MD has a very high suspicion for a labral tear. She has significant clicking and positive anterior apprehension signs in her right shoulder.
Recommendation was made for a right shoulder arthroscopic labral repair. She has tried activity modification, has had pain over six months and has tried anti-inflammatories. She wishes to proceed.
Per the IME report by Dr. Emmmanuel dated 11/30/15, the patient’s diagnoses include the following: status post right shoulder contusion, resolved; and pre-existing right shoulder injury. It was opined that there is no medical necessity for further treatment including PT. MMI has been reached.
MRI of the right shoulder performed on 09/08/15 revealed supraspinatus tendinosis and slightly low lying acromion process without evidence of rotator cuff impingement.
Per the medical report dated 11/16/15, the patient still has a significant amount of right shoulder pain. She has a positive anterior apprehension sign. She can barely lift her arm up without pain. She has significant snapping in the shoulder. She has not improved with PT. MD has a suspicion for
a labral tear.
Based on the medical report dated 01/20/16, the patient presents for follow-up of her right shoulder pain. She is still in significant amount of pain. She is working and cannot lift anything. She feels her shoulder is disconnected. She was unable to get an MR athrogram. Her initial MRI was a stand up MRI which did not show a labral tear. MD has a very high suspicion for a labral tear. She has significant clicking and positive anterior apprehension signs in her right shoulder.
Recommendation was made for a right shoulder arthroscopic labral repair. She has tried activity modification, has had pain over six months and has tried anti-inflammatories. She wishes to proceed.
Per the IME report by Dr. Emmmanuel dated 11/30/15, the patient’s diagnoses include the following: status post right shoulder contusion, resolved; and pre-existing right shoulder injury. It was opined that there is no medical necessity for further treatment including PT. MMI has been reached.