Long story short, two shoulder surgeries and an elbow surgery later I'm being put out, got the exams back and just trying to see what I'm looking at.
First the Shoulder
Diagnosis-Other
Left glenohumeral osteoarthritis and rotator cuff tendinopathy, status post surgery with residual pain, scars, decreased ROM, Side affected-left
ROM is as follows
Flexion- 0-60
Abduction- 0-60
External Rotation- 0-40
Internal Rotation- 0-65
Pain with weight bearing, localized tenderness, objective evidence of crepitus
They then went on to check the box for no ankylosis however in the comments section wrote this "SM's decreased ROM is contributed to by mechanical restriction, CONSISTANT WITH ANKYLOSIS in a favorable neutral position. (that's the part I'm confused about because if I did my math right that would go from 20% to say around 40)
Hawkins impingement test-positive
Lift off Subscapularis test- positive
Shoulder instability, dislocation or labral pathology is suspected.
History of mechanical symptoms such as clicking and catching.
History of recurrent dislocation of the glenohumeral joint
-Frequent episodes
-guarding of all movements
Arthritis has been documented
Now onto the elbow
diagnosis-left cubital tunnel syndrome, status post surgery with residual ulnar neuropathy, left arm pain, scars, decreased ROM
ROM
Flexion 0-75
Extension 75-0
forearm supination 0-80
forearm pronation 0-70
pain with weight bearing
Marked tenderness involving the medial and posteromedial aspect of the elbow moderate tenderness of the distal medial upper arm and of the proximal posterior forearm, consistent with diagnosis
One other question, in both of these the list my scars in the condition itself, shouldn't these be rated separately, they measured them and wrote them down but the are not on the from sheet with the rest of conditions. Thanks for the input, sorry about the lengthy post.
First the Shoulder
Diagnosis-Other
Left glenohumeral osteoarthritis and rotator cuff tendinopathy, status post surgery with residual pain, scars, decreased ROM, Side affected-left
ROM is as follows
Flexion- 0-60
Abduction- 0-60
External Rotation- 0-40
Internal Rotation- 0-65
Pain with weight bearing, localized tenderness, objective evidence of crepitus
They then went on to check the box for no ankylosis however in the comments section wrote this "SM's decreased ROM is contributed to by mechanical restriction, CONSISTANT WITH ANKYLOSIS in a favorable neutral position. (that's the part I'm confused about because if I did my math right that would go from 20% to say around 40)
Hawkins impingement test-positive
Lift off Subscapularis test- positive
Shoulder instability, dislocation or labral pathology is suspected.
History of mechanical symptoms such as clicking and catching.
History of recurrent dislocation of the glenohumeral joint
-Frequent episodes
-guarding of all movements
Arthritis has been documented
Now onto the elbow
diagnosis-left cubital tunnel syndrome, status post surgery with residual ulnar neuropathy, left arm pain, scars, decreased ROM
ROM
Flexion 0-75
Extension 75-0
forearm supination 0-80
forearm pronation 0-70
pain with weight bearing
Marked tenderness involving the medial and posteromedial aspect of the elbow moderate tenderness of the distal medial upper arm and of the proximal posterior forearm, consistent with diagnosis
One other question, in both of these the list my scars in the condition itself, shouldn't these be rated separately, they measured them and wrote them down but the are not on the from sheet with the rest of conditions. Thanks for the input, sorry about the lengthy post.