4th Qtr 2016 Physician MSK (Joint) Case Study#4
Requested on 10/22/16
67yom- Arthroscopic Rotator Cuff Repair (29827) with Acromioplasty (29826)
CIGNA SI-PPO/OAP
C/O 14 week history of disabling shoulder pain on his initial office visit on 9/20/2016.
PE: Upon presentation to the orthopedist, he demonstrated significant restricted ROM of the right shoulder on physical examination with 3/5 abduction strength and a painful dysrhythmic arc of motion. Neer and Hawkins impingement signs were positive.
X-rays were unremarkable.
Treatment was initiated and included NSAIDs and home exercises after the initial visit.
An MRI was ordered.
Upon follow-up 4 weeks later, the MRI confirmed a full thickness Rotator Cuff tear.
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