SOAPIE - Physiotherapy

Subjective

• Lives in 2-storey house with spouse; retired carpenter. Recreational golfer.
• 62 yo M presenting with 4-wk hx of R anterolateral shoulder pain, insidious onset after painting ceiling. Pain 6/10 on overhead reach, 2/10 at rest. Disturbs sleep when lying on R side.
• HTN, T2DM. Previous L total knee arthroplasty (14/05/2021).
• R shoulder US (02/10/2023): Supraspinatus tendinopathy with mild subacromial-subdeltoid bursitis; no full-thickness tear.
• metformin (Glucophage®) 500 mg PO BID, ramipril (Altace®) 5 mg PO daily, ibuprofen (Advil®) 400 mg PO PRN.
• Penicillin (rash).

Objective

• Posture: Mildly protracted R scapula. R shoulder AROM: Flexion 130° (painful arc 80–120°), Abduction 110° (pain 6/10), ER 45°, IR to L3. PROM: Full, mild end-range pain in flexion/abduction. MMT: R supraspinatus (Empty Can) 4-/5 with pain, ER 4/5 with pain, IR 5/5. Special tests: Hawkins-Kennedy (+), Neer's (+), Drop Arm (-). Palpation: Tender over R greater tuberosity and subacromial space.

Assessment

• Clinical presentation consistent with R subacromial pain syndrome / rotator cuff tendinopathy, correlating with recent US findings.
• 1. R shoulder pain limiting overhead ADLs and sleep. 2. Decreased R shoulder AROM in flexion and abduction. 3. R rotator cuff weakness (supraspinatus/infraspinatus).

Plan

• Initiate 6-wk conservative rehab program focusing on scapular stabilization, progressive rotator cuff loading, and pain modulation.
• Discussed tendon load management and relative rest from aggravating overhead activities.
• Follow up in 1 wk (18/10/2023 at 10:00 America/Halifax). Co-manage with Dietitian for T2DM glycemic optimization to support tendon healing.

Intervention

• Grade III inferior and posterior glenohumeral joint mobilizations (3 x 30 s). Soft tissue release to R pectoralis minor and upper trapezius (5 mins).
• Demonstrated R pendulum exercises, scapular retractions (2 x 10), and submaximal isometric shoulder ER at 0° abduction using towel roll (5 x 10 s holds).
• Reduced isometric hold intensity from 75% to 50% MVC due to mild pain reproduction during initial trial.
• Advised to avoid sleeping on R shoulder (use pillow support under R arm) and apply ice for 15 mins post-exercise if sore.

Evaluation

• Post-treatment R shoulder AROM abduction improved to 125° with pain reduced to 4/10. Tolerated manual therapy and modified isometrics well.
• Good initial buy-in; patient able to independently perform HEP with correct form.
• Patient expressed concern about missing upcoming autumn golf tournament; advised to hold off on full swings for 2–3 wks.
• Will maintain isometric loading for 1 wk before progressing to isotonic TheraBand® exercises, contingent on pain levels remaining ≤ 3/10.