Clinical Intake — Complete rotator cuff tear or rupture of right shoulder

This 54-year-old male presents with a 6-month history of progressive right-sided periscapular pain and proximal arm weakness, rated 6-7/10 at rest and significantly worse with overhead activities and at night. Advanced imaging obtained in November 2025 demonstrated a large full-thickness tendon disruption with nearly 3 cm of retraction involving both the supraspinatus and infraspinatus, along with moderate labral fraying and mild glenohumeral degenerative changes. He completed 12 weeks of structured physical therapy without meaningful functional recovery, and a subacromial corticosteroid injection provided only transient relief before symptoms returned to baseline. Given persistent limitations in activities of daily living — including inability to dress independently or perform overhead tasks — Dr. Tanaka recommends further evaluation for definitive management.