Patient presents with pain and swelling 3 months status post MVA. Patient reports that the right shoulder collided with the passenger window during the accident, and has been experiencing severe pain and limited range of motion since the incident.
1. Full-thickness, partial-width tear of the anterior fibers of the supraspinatus tendon at the footprint and a moderate-grade, articular-sided tear of the posterior fibers near the footprint with medial retraction of both portions of the fibers as described above.
2. Focal, moderate-grade intrasubstance and articular-sided tearing of the upper fibers of the subscapularis tendon with associated medial shifting of the long head of the biceps tendon at the level of the pulley.
3. Tenosynovitis of the long head of the biceps tendon.
4. Intrasubstance delaminated tear of the infraspinatus tendon, extending from the footprint to the myotendinous junction.
5. Low-grade tearing of portions of the anterior labrum.
6. Edema of the distal end of the clavicle, likely stress-related and reflecting posttraumatic osteolysis.
