Physical Therapist Identification of an Undetected Rotator Cuff Tear via a Telehealth Evaluation: A Case Report

Abstract

Background The COVID-19 pandemic has highlighted the need to explore alternative methods of health care delivery, including telehealth. Minimal evidence is available regarding telehealth as a diagnostic tool for suspected orthopaedic pathology. Case Presentation A self-referred 66-year-old man presented with left shoulder pain that had been present for 6 weeks. Mechanism of injury included 2 falls 2 weeks apart. His physician diagnosed him with adhesive capsulitis and referred him to a physical therapist near his home. No imaging studies were performed. Initial management did not improve his status, so the patient requested a second opinion. A telehealth evaluation was chosen, as he resides 220 miles away. Live 2-way video conferencing was utilized throughout the evaluation. Visual motion observation noted marked active, but not passive, limitations. Pain in active external rotation was 8/10. Special testing noted positive drop arm test and impairments in external rotation. Outcome and Follow-Up A rotator cuff tear was suspected and the patient was referred for a surgical consultation, with subsequent surgery completed for a full-thickness supraspinatus tear. During follow-up 3 months after surgery, the patient reported that the telehealth visits were very convenient and more effective than prior management. Discussion A telehealth evaluation performed by a physical therapist was able to identify and manage, via referral, an undetected full-thickness rotator cuff tear. JOSPT Cases 2021;1(1):29–33. doi:10.2519/josptcases.2021.9990