Physical Therapist Initial

History of Present Illness

42 y/o male (MRN: 849-302-11) presents to PT on 21/10/2023 c/o R shoulder pain x 3 wks. Pain began immediately after attempting a heavy overhead press at the gym on 30/09/2023. Over the past 2 wks, he developed progressive stiffness and inability to sleep on his R side.

Acute onset while lifting 60 kg overhead at the gym; felt a sudden "catch" in the anterior-lateral R shoulder.

Signs and Symptoms

"Sharp, pinching pain" with overhead reaching; "dull, toothache-like throb" at night.

Pain at Present

4/10 at rest; 8/10 with overhead activity.

Moderate at rest, severe with movement.

Aggravating and Easing Factors

Aggs: Reaching overhead, reaching behind back, sleeping on R side, lifting > 2 kg.

Ease: Rest, ice, ibuprofen (Advil®) 400 mg PO TID PRN, supporting R arm on a pillow.

Activity Limitations

Unable to wash hair with R hand, fasten seatbelt with R arm, or lift boxes at work (warehouse supervisor).

Co-morbidities/Complexities

HTN, T2DM.

Prior Treatments / Surgeries

Subacromial corticosteroid injection on 10/10/2023 provided 4 days of partial relief. No prior PT or surgery for this issue.

Dr. A. Miller (Orthopaedics), Dr. S. Patel (PCP).

Prior Imaging /studies

R Shoulder XR (05/10/2023): Type II acromion, mild AC joint OA, no acute fracture or dislocation. R Shoulder US (10/10/2023): Supraspinatus tendinopathy with bursal thickening; no full-thickness tear.

Goals

"I want to sleep through the night without waking up in pain and get back to lifting weights at the gym."

Objective

Observation & Posture Forward head posture, bilateral rounded shoulders, R scapular anterior tilt at rest.

Palpation Tendor to palpation (TTP) over R greater tuberosity, subacromial space, and long head of biceps tendon.

Range of Motion (AROM / PROM)

• R Shoulder Flexion: 115° (painful arc 80°–115°) / 155° (empty end-feel)
• R Shoulder Abduction: 100° (pain) / 140° (pain)
• R Shoulder ER (at 0° abd): 55° / 65°
• R Shoulder IR (behind back): L4 (pain)
• L Shoulder AROM: WNL all planes.

Strength (MMT)

• R Shoulder Flexion: 4-/5 (pain)
• R Shoulder Abduction: 3+/5 (pain)
• R Shoulder ER: 4-/5 (pain)
• R Shoulder IR: 4+/5
• R Middle/Lower Trapezius: 3+/5

Special Tests

• Hawkins-Kennedy: (+) R
• Neer's: (+) R
• Empty Can (Jobe's): (+) R for pain and weakness
• Drop Arm: (-) R
• Speed's: (+) R (mild)

Assessment

42 y/o male presenting with 3-wk hx of R shoulder pain following an overhead lifting injury. Objective exam reveals decreased R shoulder AROM/PROM with a painful arc, weakness in the R rotator cuff and scapular stabilisers, and (+) impingement/rotator cuff special tests.

Likely diagnosis is R subacromial impingement syndrome / rotator cuff tendinopathy. Patient will benefit from skilled PT to reduce pain, restore full GH joint ROM, improve scapulothoracic mechanics, and increase rotator cuff strength to safely return to work and gym duties.

Goals

• Patient will report R shoulder pain ≤ 2/10 during overhead reaching to allow independent hair washing within 6 weeks.
• Patient will sleep through the night on R side without waking due to shoulder pain within 6 weeks.
• Patient will demonstrate R shoulder AROM flexion to ≥ 170° and abduction to ≥ 165° without a painful arc within 6 weeks.
• Patient will improve R shoulder abduction and ER strength to 5/5 MMT to support return to gym lifting within 8 weeks.
• Patient will independently lift a 10 kg box from waist to overhead shelf with proper scapular mechanics and 0/10 pain to resume full work duties within 8 weeks.

Plan

• No further imaging planned at this time; will monitor clinical progress over next 4 wks.
• Skilled PT 2x/wk for 8 wks: manual therapy (GH joint caudal/posterior glides, STM to pec minor/posterior cuff), scapular stabilisation exercises, progressive rotator cuff isometric to isotonic strengthening, and daily HEP.
• Ergonomic counselling provided regarding lifting mechanics at work and sleeping posture; follow up with Dr. Miller in 6 wks.