Reason: mechanical fall, concern for rotator cuff tear History: pain, limited ROM ROTATOR CUFF: Note is made of a near full-thickness tear of the supraspinatus at the level of its insertion on the greater tuberosity extending from the articular surface involving greater than 50% of the tendon width. This tear extends proximally approximately 3 cm from the level of the insertion on the greater tuberosity. There is no significant retraction. There is thickening and intermediate signal intensity within the supraspinatus indicating moderate tendinosis. There is partial thickness insertional tearing of the infraspinatus at the level of the greater tuberosity. There is no significant retraction. The subscapularis and teres minor muscles and tendons appear intact.SUPRASPINATUS OUTLET: There is a trace amount of fluid within the subacromial subdeltoid bursa. Mild osteoarthritis affects the acromioclavicular joint.GLENOHUMERAL JOINT AND GLENOID LABRUM: Mild osteoarthritis affects the glenohumeral joint. The glenohumeral joint alignment is anatomic. There is branching linear signal abnormality traversing the anterior inferior glenoid labrum indicating a tear which extends through the articular cartilage along the anterior inferior glenoid. There is heterogeneity and intermediate signal intensity within the superior labrum indicating a combination of degeneration and degenerative tearing. There is subchondral cyst formation within the greater tuberosity.BICEPS TENDON: The tendon of the long head of the biceps appears intact. ADDITIONAL
1. High-grade near full thickness insertional tearing of the supraspinatus tendon as well as partial thickness insertional tearing of the infraspinatus.2. Acromioclavicular and glenohumeral joint osteoarthritis.3. Degeneration and degenerative tearing of the glenoid labrum as described above. 4. Moderate to large glenohumeral joint effusion. Other findings as described above.