Shoulder Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 45y/o RHD male with gradually worsening shoulder pain over several years. Severity: 3-7/10. Pain localized to anterior shoulder / AC joint. Duration: gradually worsening over several years. Exacerbating factors: overhead activity and reaching behind the back or across the chest. Ameliorating factors: rest, arm at side. Night pain: none. Previous treatment: NSAIDs, no injections, no PT, no surgeries.
PMH:none
PSH:none
Medications:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Inspection: shoulders symmetric, no atrophy, no scars
Palpation: AC tender, reproduces pain.
Active Forward Elevation (R/L): 160 / 160
Passive Forward Elevation (R/L): 160 / 160
External Rotation at side (R/L): 50 / 50
Internal Rotation (R/L): T9 / T9
Cross Arm (R/L): AC joint pain / -
Neer (R/L): - / -
Hawkins (R/L): - / -
Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien (R/L): - / -
Yergusons (R/L): - / -
Speeds (R/L): - / -
Sulcus (R/L): - / -
Apprehension (R/L): - / -
Generalized ligamentous laxity: none
C-spine: non-tender, full ROM
Abduction: 5/5 External Rotation: 5/5 Internal Rotation: 5/5
Biceps: 5/5 Triceps: 5/5 Wrist Extension: 5/5 Wrist Flexion: 5/5 Interosseous: 5/5
subjective normal m/u/r/ax sensation
2+ radial pulse
Xray: Type II acromion, >7mm acromiohumeral space, no GH arthritis. There is spurring, sclerosis and narrowing of the AC joint.
MRI: none
ASSESSMENT: Acromioclavicular Arthritis (715.11)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
1/1 = lidocaine / kenalog AC joint injection. Sterile technique. No complications.
NSAIDS
Information sheet given
Follow-up 6-8 weeks