Ky patuent have pain in shoulder from past 1 month ..rom of is full.. and kenedy testis positive ..also she have pain when I did ultrasoubd in shoulder . Some knots on internel side near chest

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Clinical Analysis - Badar Bakht, 69F, Right Shoulder Pain (1 month)

Findings Summary from Documents

Clinical Picture:

Feature	Finding
Pain duration	1 month
Pain VAS	5/10
ROM	Full (no restriction)
Hawkins-Kennedy test	Positive
"Knots" near chest (medial)	Likely subcoracoid bursitis / myofascial trigger points
Ultrasound right shoulder	Supraspinatus near-complete tear + subcoracoid bursitis + secondary OA + cortical erosions
Comorbidities	HTN, hypothyroidism (thyroxine 100mcg), H/o right knee replacement

Interpretation

1. Positive Hawkins-Kennedy Test This test is performed by forward flexing the humerus to 90 degrees and forcibly internally rotating the shoulder. A positive result indicates subacromial impingement syndrome. Its sensitivity is ~71.5% and specificity ~66.3% for impingement of any degree. When combined with a positive painful arc and positive infraspinatus (Jobe) test, the probability of impingement syndrome exceeds 95% (Campbell's Operative Orthopaedics, 15th Ed).

2. Ultrasound Findings

Supraspinatus near-complete tear: This is a high-grade partial-to-near-complete full-thickness tear. At 69 years of age, this is very common (prevalence of full-thickness tears is ~25% over age 60, increasing to 50% over age 80). The fact that she has full ROM is consistent - many patients with even large chronic tears retain functional ROM through deltoid compensation.
Subcoracoid bursitis: The "knots" or palpable nodules on the internal/medial chest-side area are highly consistent with subcoracoid bursitis - the subcoracoid bursa lies between the coracoid process and the subscapularis, medial to the shoulder joint. This bursa can enlarge and feel like a mass. It causes anterior/medial shoulder pain.
Secondary OA shoulder + cortical erosions: This indicates degenerative joint disease secondary to the chronic cuff tear (cuff tear arthropathy). Cortical erosions can also be seen in inflammatory arthritis, but given her age and history they are most likely degenerative.

3. "Knots" Near Chest (Internal Side) These most likely represent:

Subcoracoid bursitis (confirmed on US) - inflamed/thickened bursa
Possibly myofascial trigger points in pectoralis minor or anterior deltoid
Less likely but worth noting: in a 69F with HTN + hypothyroid + OA at multiple joints (shoulder + knee replacement), consider calcium pyrophosphate deposition or an underlying inflammatory process

Current Management (Dr. Saba Samreen's Prescription)

The treating rheumatologist has prescribed:

Cap Arthra Celebex 100mg (Celecoxib 100mg) - COX-2 selective NSAID - appropriate for pain + bursitis + OA flare with lower GI risk than non-selective NSAIDs
Cap Eskem 20mg (Esomeprazole 20mg) - GI protection alongside the NSAID - appropriate
Shoulder support + light movements - conservative rehab

This is a sound conservative regimen. Note: Celecoxib requires caution in HTN patients (monitor BP, prefer lowest effective dose).

What Should Be Considered Next

Conservative management is the appropriate first-line approach in this 69-year-old with a chronic near-complete rotator cuff tear. Evidence supports nonoperative treatment leading to successful outcomes in ~60% of patients, and for patients over 65 years of age with chronic tears, conservative treatment is generally preferred (Campbell's Operative Orthopaedics, 15th Ed).

Recommended steps:

Local corticosteroid injection - subacromial or subcoracoid bursa injection (triamcinolone or methylprednisolone) would provide significant relief for the bursitis component. The note mentions "Daxuil gel for LA" (likely lidocaine as local anesthetic for an injection procedure).
Physiotherapy - pendulum exercises, progressive strengthening of the deltoid and remaining cuff muscles, scapular stabilization. Full ROM now is a good sign.
MRI shoulder - given near-complete tear on US, MRI would better characterize the tear size, retraction, fatty infiltration (Goutallier grading), and help plan further management.
Rheumatology workup for erosions - cortical erosions on US warrant:
- RF, Anti-CCP (to exclude RA)
- ESR, CRP
- Uric acid (crystal arthropathy)
- In the context of her hypothyroidism, check for calcium pyrophosphate deposition disease (CPPD)
Cervical management - she also has cervical radiculopathy (right-sided), which can contribute to shoulder pain. EMG/NCS and cervical MRI may be indicated.
Surgical consideration - if conservative treatment fails after 3-6 months, arthroscopic rotator cuff repair is an option. However, in patients >65 with chronic tears and fatty degeneration, a reverse total shoulder arthroplasty may ultimately be more appropriate if progression to cuff tear arthropathy occurs.

Summary

This 69-year-old female has a classic presentation of near-complete supraspinatus tear with subcoracoid bursitis and secondary glenohumeral OA, likely chronic given her age and full ROM. The Hawkins-Kennedy positive confirms subacromial impingement. The "knots" near her chest/medial shoulder represent the inflamed subcoracoid bursa. Current management with celecoxib + PPI + shoulder support is appropriate. Addition of a US-guided corticosteroid injection into the subcoracoid bursa and physiotherapy would likely provide significant benefit. Workup for the cortical erosions (inflammatory markers, RF, anti-CCP) is important given the rheumatology context.

Source: Campbell's Operative Orthopaedics 15th Ed 2026, Physical Examination of the Shoulder & Full-Thickness Rotator Cuff Tears sections.

Give ne physiotherapy ttestment full

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physiotherapy treatment protocol rotator cuff tear conservative elderly phases exercises

Here is the complete physiotherapy treatment plan for this patient - Badar Bakht, 69F, Right shoulder: near-complete supraspinatus tear + subcoracoid bursitis + secondary OA + cervical radiculopathy, full ROM, VAS 5/10.

Full Physiotherapy Treatment Plan

Goals

Pain reduction
Maintain full ROM (she already has it - protect it)
Strengthen intact cuff muscles (infraspinatus, subscapularis, teres minor) + deltoid to compensate for torn supraspinatus
Stabilize scapula
Improve function for daily activities
Prevent tear progression

Phase 1 - Acute Pain Control (Week 1-2)

Electrotherapy / Physical Modalities

Modality	Dose	Purpose
TENS	80-100 Hz, 20-30 min/session, daily	Pain relief (gate control)
Therapeutic Ultrasound	1 MHz, 0.8-1.5 W/cm², pulsed 1:4, 5-7 min over bursa + cuff	Reduce bursitis inflammation, promote tissue healing
Hot pack / Moist heat	15-20 min before exercise	Muscle relaxation, increase tissue extensibility
Ice/Cold pack	10-15 min after exercise	Reduce post-exercise soreness
IFT (Interferential Therapy)	4000 Hz carrier, 80-120 Hz beat, 15-20 min	Deep pain relief, reduce inflammation in joint

Exercises - Phase 1

1. Codman (Pendulum) Exercises

Patient leans forward, arm hangs freely
Small circles clockwise + anticlockwise, 10 reps each
Forward-backward swing + side-to-side swing, 10 reps
Do 2-3x per day
Purpose: gentle distraction, synovial fluid circulation, maintains ROM without active cuff loading

2. Cervical exercises (given she also has cervical radiculopathy)

Gentle cervical ROM: flexion, extension, lateral rotation
Chin tucks (deep neck flexor strengthening): 10 x 10 sec holds
Cervical traction (manual or mechanical if available): 5-7 min

3. Hand, wrist, elbow AROM

Full active motion to prevent disuse stiffness

Activity Modification

Avoid overhead reaching, lifting, behind-back movements
Wear shoulder support (as prescribed) during the day
Sleep on unaffected side with pillow supporting right arm

Phase 2 - ROM Restoration + Gentle Strengthening (Week 3-6)

Criteria to enter: VAS reduced to ≤3/10, pain controlled at rest

Continue Modalities

Continue ultrasound + TENS as needed
Add laser therapy if available (830 nm, 3-5 J/cm², over cuff and bursa) for additional anti-inflammatory effect

Stretching Exercises

1. Cross-body (horizontal adduction) stretch

Pull right arm across chest with left hand
Hold 12-30 seconds, 5 reps, 2x/day
Stretches posterior capsule

2. Doorway stretch (anterior capsule)

Place forearm on door frame at 90 degrees
Lean body gently forward
Hold 20-30 sec, 5 reps

3. Sleeper stretch (posterior capsule)

Lie on right side, right arm at 90 degrees forward flexion
Use left hand to gently push right forearm toward bed into internal rotation
Hold 20-30 sec, 5 reps

4. Towel-assisted internal rotation stretch

Towel behind back, lower hand pulls upper (right) arm into internal rotation
Hold 20 sec, 5 reps

Active-Assisted ROM (AAROM)

1. Pulley exercises

Overhead pulley: use left arm to assist right arm in forward elevation
3 sets x 10 reps, 1-2x/day

2. Wand/stick exercises

Supine forward flexion with stick (left arm drives)
External rotation with stick in supine (elbows at sides)
3 x 10 reps

3. Wall climbing

Face wall, fingers "walk" up as high as comfortable
3 x 10 reps

Scapular Stabilization (IMPORTANT - often neglected)

1. Scapular shrugs: 10 reps up and hold 5 sec 2. Scapular retraction: squeeze shoulder blades together, 10 x 5 sec hold 3. Scapular depression: push shoulder down away from ear, 10 x 5 sec hold 4. Scapular protraction + retraction: full range, 15 reps

These are done with the arm at the side, low cuff loading.

Isometric Strengthening (Phase 2, weeks 4-6)

Begin pain-free isometrics with arm at side, elbow at 90 degrees:

Isometric external rotation: push hand outward against wall/doorframe
Isometric internal rotation: push hand inward against wall
Isometric abduction: push arm outward against wall
Isometric flexion: push arm forward against wall
10 reps x 10 sec holds each, 1x/day

Phase 3 - Strengthening (Week 6-12)

Criteria to enter: pain-free AROM through full range, no compensatory shrugging

Isotonic / Resistance Band Exercises

Use Thera-band (start with yellow/lightest resistance):

1. Side-lying external rotation (infraspinatus + teres minor - MOST IMPORTANT)

Lie on left side, right elbow bent 90 degrees at side
Rotate forearm upward against gravity / band
3 x 15 reps, slow controlled movement
This strengthens the intact posterior cuff to compensate for supraspinatus

2. Prone horizontal abduction (middle and lower trapezius, posterior deltoid)

Lie prone on plinth, arm hanging down
Lift arm to shoulder height with thumb pointing up
3 x 12-15 reps

3. Prone row (rhomboids, middle trapezius)

Prone, elbow bent, pull hand toward armpit
3 x 12 reps

4. Resisted internal rotation with band

Stand, band fixed to wall, pull inward
3 x 15 reps (strengthens subscapularis)

5. Resisted external rotation with band

Elbow at side, rotate outward against band
3 x 15 reps

6. Resisted shoulder flexion with band (below 90 degrees only initially)

Forward raise to 90 degrees against band
Do NOT go above 90 degrees until pain-free
3 x 15 reps

7. Deltoid strengthening

Side lateral raise, start with 0.5-1 kg dumbbell
Only to shoulder height (90 degrees)
3 x 12 reps
Critical because deltoid compensates for torn supraspinatus in this patient

8. Biceps curl (supports anterior shoulder stability)

3 x 12-15 reps with light weight

Manual Therapy (by physiotherapist)

Glenohumeral joint mobilization (Maitland Grade I-II initially, progress to III-IV): anterior-posterior glides, inferior glides to maintain joint mobility
Soft tissue massage: cervicothoracic junction, upper trapezius, pectoralis minor (addresses the myofascial component of her "knots")
Trigger point release on pectoralis minor and anterior deltoid (the "knots" on medial/chest side)
Thoracic spine manipulation: improves scapulothoracic rhythm

Phase 4 - Functional Training (Week 12-16+)

Criteria: Full pain-free AROM, strength 4+/5 in all planes

1. Closed chain exercises

Wall press-ups (hands on wall, lean and push)
3 x 15 reps

2. Progressive overhead activities

Gradually introduce reaching overhead in functional context (shelf placement, hair combing)

3. PNF patterns (Proprioceptive Neuromuscular Facilitation)

D1 and D2 flexion/extension patterns
Improves neuromuscular coordination

4. Functional ADL training

Dressing, grooming, cooking activities
Energy conservation techniques for this 69-year-old

5. Postural correction

Address forward head posture (worsens cervical radiculopathy)
Thoracic extension exercises
Cervical retraction against resistance

Home Exercise Program (Daily)

Time	Exercise	Sets x Reps
Morning	Pendulum exercises	2 x 10 each direction
Morning	Cervical chin tucks	3 x 10 sec
Morning	Scapular retractions	3 x 15
Afternoon	Cross-body stretch	5 x 30 sec
Afternoon	External rotation with band	3 x 15
Evening	Hot pack + gentle ROM	15 min
After any exercise	Ice pack	10-15 min

Important Precautions for This Patient

No overhead lifting until Phase 4 - protects the near-complete supraspinatus tear from progressing to complete rupture
No behind-the-back movements with force
No push-up position (full open chain push)
Monitor BP - she has HTN; avoid Valsalva during exercises (breathe continuously)
Hypothyroidism - these patients have slower tendon healing and increased risk of tendinopathy; progress slowly
Knee replacement (right) - avoid exercises requiring stance on right leg; use chair/plinth support

Frequency & Duration

Phase	Duration	Sessions/week
Phase 1	2 weeks	5 days/week
Phase 2	4 weeks	3-4 days/week
Phase 3	6 weeks	3 days/week
Phase 4	4+ weeks	2-3 days/week
Total	~16 weeks	-

Expected Outcome

Conservative physiotherapy for chronic near-complete rotator cuff tears in elderly patients (>65 years) shows successful outcomes in approximately 60% of cases, with sustained improvement at 10-year follow-up. The primary goal is deltoid and intact cuff recruitment to compensate for the torn supraspinatus - not repair of the tear itself. If no improvement after 3-6 months of diligent physiotherapy, referral back to orthopedic surgeon for consideration of surgical options.

Sources: SICOT-J 2023 Rehabilitation Trends; Physiopedia Rotator Cuff Tears; Campbell's Operative Orthopaedics 15th Ed 2026

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