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Answer 4
  1. Initiate a course of physical therapy. The clinical presentation and radiograph are consistent with a rotator cuff tear. Initial management of partial tears and complete tears in the older patient should be conservative initially. In a younger patient with an acute tear, the next step would be to order an MRI scan to confirm the tear and a referral to an orthopaedic surgeon. Intra-articular injection should not be performed in the setting of acute injury. Physical therapy emphasizes maintenance of range of motion; immobilization would be counterproductive. Ultrasound examination can detect both full- and partial-thickness rotator cuff tears, but the readings are operator dependent, and in most centers, an MRI scan is the most reliable test.

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