Consultant Referral

Created by

Laura Evans

Specialty

Osteopath

Last edited

10/20/2026

Uses

0 times

History

Mr Pendelton presented to the physiotherapy clinic with a 4-month history of right anterolateral shoulder pain and weakness following a fall onto his outstretched arm. He reports significant night pain that disrupts his sleep and difficulty with overhead activities. He has completed 12 weeks of structured physiotherapy with minimal improvement in function or pain levels.

His past medical history includes hypertension and type 2 diabetes mellitus. His previous surgical history includes an open appendicectomy in 1998.

His current medications are ramipril 5 mg PO OD, metformin 500 mg PO BID, and naproxen 500 mg PO BID PRN. He also takes an over-the-counter glucosamine sulphate 1,500 mg PO OD supplement.

He works as a self-employed electrician, is right-hand dominant, lives with his wife, and is a non-smoker who drinks approximately 6 units of alcohol per week.

He has a documented allergy to penicillin, which causes a generalised maculopapular rash.

Examination Findings

On physical examination, there is mild wasting of the right supraspinatus fossa with no acute deformity. Active range of motion of the right shoulder is limited to 80 degrees of abduction and 90 degrees of forward flexion due to pain and weakness, while passive range of motion is full with pain at end-range elevation. External rotation is 45 degrees and equal bilaterally. He demonstrates 3/5 strength on empty can testing and external rotation against resistance, alongside positive Hawkins-Kennedy and Neer impingement signs. Cervical spine screening and distal neurovascular examination are unremarkable.

Investigations

An ultrasound scan of the right shoulder performed on 10/10/2023 demonstrated a full-thickness tear of the anterior supraspinatus tendon measuring 1.5 cm with mild subacromial bursitis, while a plain radiograph showed a type II acromion and mild acromioclavicular joint osteoarthritis.

Impression

The clinical presentation and imaging findings are consistent with a symptomatic full-thickness right supraspinatus tear and subacromial impingement that has failed conservative management.

Management Plan

Treatment to date has consisted of a 12-week progressive rotator cuff strengthening and scapular stabilisation programme alongside posture modification and oral analgesia. Given his ongoing functional deficit and occupational demands as an electrician, he has been advised to avoid heavy overhead lifting while awaiting your review regarding potential surgical repair.

I would value your assessment and management of this patient. Please contact me if you need any additional information.

Yours sincerely,

Sarah Jenkins Senior Musculoskeletal Physiotherapist Southbank Physiotherapy Clinic 020 7946 0821 | s.jenkins@southbankphysio.co.uk

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