PATIENT PROFILE:

Deb 16 yo Female
Patient was referred to PT for R shoulder tendinitis by PCP

Chief Complaint: Patient reports her primary complaint is pain with overhead motions in sport (swimming and volleyball).

Work: Patient does not currently work and is a student in high school.

Work limitations: Patient reports no limitations in school life.

Current exercise or activity level: Patient is currently in season for swimming and volleyball. Patient participates in freestyle for
swimming which reproduces symptoms and overhead swinging with her volleyball serve which also reproduces symptoms. Patient
states she has not decreased activity in sport since onset of symptoms a few months ago. Patient reports that she “tries to work
through the pain”.

Previous activity level: Patient’s symptomatic history has changed over the past few months. Symptoms initially began when
swimming season and volleyball were played at the same time. After swimming season ended patient noted she felt better and
experienced a decrease in symptoms. Patient resumed swimming a couple of weeks later and her symptoms got worse again.
Overall, patient has not expressed a decrease in activity since onset of symptoms.

PATIENT-CENTERED HISTORY

Area and behavior of symptoms:

P1 – pain in the anterior/posterior right shoulder. Patient reports that her pain can range from a 0/10 at its best to a 6/10 at its
worse. Patient reports her pain at this time is a 2/10 which she attributes to swim practice earlier this morning. Patient describes her
pain as localized to the shoulder, achy, intermittent based on activity, and variable.
P2 – N/A

Relationships between areas of symptoms: N/A – only one area of symptom(s) reported by patient at this time.

Aggravating factors or currently performed activities that provoke areas of symptoms: (one per each area of symptoms – document
type and dose of activity required to bring it on, how strongly the symptoms come on and time to ease)
 Brushing and fixing hair – immediate with overhead motion to put hair into ponytail is aggravating and goes away when
patient returns arm to neutral.
 Shooting a basketball – immediate with overhead motion above shoulder height and goes away dependent on amount of
repetition. The greater the repetitions the longer it takes the patients symptoms to dissipate.
 Swimming (freestyle) - immediate with overhead motion above shoulder height and goes away dependent on amount of
repetition. The greater the repetitions the longer it takes the patients symptoms to dissipate.
 Volleyball (overhead serve) - immediate with overhead motion above shoulder height and goes away dependent on amount
of repetition. The greater the repetitions the longer it takes the patients symptoms to dissipate.
 Patient reports no increases in symptoms with other ADL’s, dressing, or driving.

Easing factors or activities that ease areas of symptoms:

 Rest/Avoidance of aggravating activities
 Naproxen – Patient states that this can help a little but does not totally decrease her pain. Patient takes this intermittently
and not consistently.
 Patient reports her PCP urged her to ice her right shoulder but she did not find any relief with its usage.

24 Hour Behavior of Symptoms: Patient notes she experiences soreness and stiffness most mornings. The severity of these
symptoms in the morning is often dependent on the amount of activity she participated in the previous day. Patient reports no
difficulty or instances of awakenings due to shoulder pain since onset.

Detailed History of Present Episode: (at a minimum document the onset, progression over time, treatment to date, response to
intervention or self-treatment)

Patient has noted an increase in shoulder pain over the last few weeks to months since beginning volleyball this summer. Patient
cannot remember the exact date of onset but claims that this present episode began a few months ago when she was in season for
both swimming and volleyball. Patient claims that after initial onset her symptoms gradually increased until her swimming season
came to an end and she was only playing volleyball. Patient reports a decrease in symptoms once her swimming season ended.
Patient then reports an increase in symptoms again when she resumed her play in both sports with the next season of swimming.
Patient is currently participating in both sports with increasing symptoms. Patient saw her primary care physician who X-RAY which
showed normal results and she was referred to physical therapy. Patient states she has “not really” decreased her participation in
sport and “tries to work through the pain”. Patient has not previously sought out treatment for this episode. Patient does not report
any signs of self-management or treatment at this time other than icing “a few times” in the past few months and taking naproxen
as needed. Overall, patient ranks her general health to be a 6/10 due to limitations and pain with her right shoulder.

History of Previous Episodes: Patient does not recall a previous episode identical to the case she presented with today. Patient does
report a previous injury a 2 years ago where she fell onto her shoulder and felt an audible pop when diving for a volleyball. She
states that it felt like it went back into place. Patient does not report any other instance of shoulder injury or instability at this time.

PHYSICAL EXAMINATION
Outcome measure: DASH

Resting symptoms: Patient presents to therapy with resting symptoms of 2/10 today.

Demonstration of symptom or functional limitation producing activity: Patient’s functional * movement is reaching arm overhead in
flexion. This movement easily reproduces patients symptoms.

Observation/Gait: Slightly rounded shoulders in seated position. Patient exhibits right scapular dyskinesia with overhead flexion in
standing. Patient does not exhibit any signs of guarding of the right upper extremity or ataxic gait.

Neurological exam: Cleared. No deficits observed. Pain with right C6 myotome with elbow flexion due to stabilizing pressure applied
to right anterior/lateral shoulder by therapist. C6 myotome was tested a second time with different placement of stabilizing testing
arm and patient reported no complaints with testing position. C6 myotome was normal and in tact.

Range of Motion:
AROM (supine):
 Flexion: full in both right and left upper extremities; patient noted soreness at end range with right upper extremity
o Posterior tilt was applied to right scapula by therapist and flexion movement was repeated. Patient noted a very
slight decrease in symptoms with motion. Movement was still full range of motion and patient still experienced
soreness at end range.
 IR: full in both right and left upper extremities; patient noted soreness at end range with right upper extremity
 ER: full in both right and left upper extremities; patient noted soreness at end range with right upper extremity
 Abduction: full in both right and left upper extremities; patient noted soreness at end range with right upper extremity
AROM (standing):
 Flexion: full in both right and left upper extremities; patient noted slight pain at approximately 150 degrees of shoulder
flexion and soreness at end range with right upper extremity
o Posterior tilt was applied to right scapula by therapist and flexion movement was repeated. Patient noted
decreased symptoms with motion. Movement was still full range of motion and patient still experienced soreness
at end range.
PROM:
 Shoulder ER (90/90 position): full in both right and left upper extremities; patient noted soreness at end range with right
upper extremity
 Shoulder IR (90/90 position): full in both right and left upper extremities; patient noted soreness at end range with right
upper extremity
HAND BEHIND HEAD: Patient exhibited equal results bilaterally at about T2 spinal level.
HAND BEHIND BACK: Patient was more restricted with internal rotation in the right shoulder compared to the left. Patient noted
soreness, stiffness, and tightness at her end range with this movement.

Strength: (Manual Muscle Tests (MMT) – “make” tests)

 Lower Trapezius: 5/5 left shoulder, 4/5 right shoulder with soreness against resistance
 Middle Trapezius: 5/5 left shoulder, 4/5 right shoulder with soreness against resistance
 Upper Trapezius: 5/5 bilaterally
 Biceps: 5/5 bilaterally
 Rhomboids: 5/5 left shoulder, 4/5 right shoulder with soreness against resistance
 IR/ER MMT deferred to next visit.
  Myotomes from neurological examination were all within normal limits – no strength deficits identified at this time within
screen.

Joints cleared: Cervical spine was cleared and no deficits were identified.

Special diagnostic tests: none.

Palpation Findings: No findings in left shoulder. Slight pain and soreness identified in anterior/lateral right shoulder near rotator cuff
insertion (subacromial space). No findings with supraspinatus, upper trapezius, infraspinatus, sternoclavicular joint,
acromioclavicular joint, bicipital groove, or clavicle.

Passive Movement Assessment: See PROM in Range of Motion section.

Response to exam: Patient reported slight increases in symptoms with aggravating movements/activities but noted they all
decreased with shoulder return to neutral. Overall, patient reported pain/symptoms prior to examination and post examination to
be a 2/10.

Diagnostic hypotheses: Right rotator cuff tendinitis due to overuse and slight right scapular dyskinesia due to periscapular
musculature weakness.

Examination identified physical impairment list:

 Muscular weakness in rhomboids, lower trapezius, and middle trapezius

Examination identified functional limitations:

 Unable to reach overhead without pain

Prognosis/Rehabilitation potential: Patient is a good candidate for physical therapy. Patient is young and motivated to return to
sport without pain. Primary goal of rehabilitation is to reduce inflammation. Secondly, patient will begin a strengthening program to
increase strength and endurance of upper extremity(s) musculature to participate in multiple sports at one time without pain. With
adherence to established plan of care, patient shows good potential for rehabilitation.

Intervention performed today:

(be specific with in clinic treatment, home exercise program and activity advice. Be sure to include dose, frequency or any other
pertinent factors)
 Scapular Retraction:
o 2 sets, 20 repetitions, 2x/day, 3 second holds, slow and controlled eccentric release, seated
 Low Row with (red) TheraBand:
o 2 sets, 20 repetitions, 1x/day, emphasis on scapular retraction, slow and controlled concentric and eccentric
motions, standing
 Pendulums:
o Patient was encouraged to complete this exercise as often that she feels the need to. This exercise is an easing
activity that allows the joint to move and distract as a “feel good” exercise.
o 1 set each direction (side-to-side and forward-backward), 20 repetitions
 Patient Education:
o Discussed basketball tryouts in 2 weeks with patient and guardians. Patient was advised that increasing activity
further will not benefit her in any way. Discussed history of symptoms and how onset begins with multisport
interaction. Patient is currently in both volleyball and swimming so adding basketball into it will only worsen
symptoms. Informed patient it is ultimately her decision but strongly discouraged.
o Explained to patient limitations identified in examination and how these limitations are contributors to her
symptoms. Stressed the importance of strength and endurance especially for a multisport athlete.
o Discussed importance of rehabilitation to avoid less conservative actions for rehabilitation and its role in her
meeting her goals especially when it comes to being healthy for her summer swimming season.
o Discussed reduction in activity and giving tissue time to calm down. Used analogy of a scab for patient to
understand process of inflammation and how it will not decrease if it continues to be aggravated.
o Discussed importance of graded return to activity and appropriate loading of tissues throughout rehabilitation plan
of care.

Reassessment of Primary History and Physical Examination Findings Following Intervention (SE* & OE*):
  SE: Increase in symptoms experienced with freestyle swimming, overhead volleyball serve, shooting a basketball, and fixing
hair in the morning. Reassess in 2 weeks.
 OE: Patient shows weakness in right scapular muscles. Patient MMT for lower trapezius, middle trapezius, and rhomboids
were 4/5 on the right shoulder and 5/5 on the left shoulder. Patient unable to get past 150 degrees of standing shoulder
flexion pain-free.
o Next visit, MMT shoulder IR and ER in neutral position and 90-90 shoulder position. Deferred initial visit.

PLAN OF CARE AND GOALS

Plan of care: Patient plan of care will be approximately 6-12 weeks pending patient response to treatment before discharge from
therapy to an independent home exercise program. Patient will come to therapy 2x/week for 2 weeks and will reassess at that time
for future scheduled appointments. Patient requires therapy to decrease pain, increase strength, increase endurance, increase pain
free ROM, and begin a home exercise program.
Patient education:
 Discussed basketball tryouts in 2 weeks with patient and guardians. Patient was advised that increasing activity further will
not benefit her in any way. Discussed history of symptoms and how onset begins with multisport interaction. Patient is
currently in both volleyball and swimming so adding basketball into it will only worsen symptoms. Informed patient it is
ultimately her decision but strongly discouraged.
 Explained to patient limitations identified in examination and how these limitations are contributors to her symptoms.
Stressed the importance of strength and endurance especially for a multisport athlete.
 Discussed importance of rehabilitation to avoid less conservative actions for rehabilitation and its role in her meeting her
goals especially when it comes to being healthy for her summer swimming season.
 Discussed reduction in activity and giving tissue time to calm down. Used analogy of a scab for patient to understand
process of inflammation and how it will not decrease if it continues to be aggravated.
 Discussed importance of graded return to activity and appropriate loading of tissues throughout rehabilitation plan of care.

Patient goal:
 Patient would like to be healthy for her summer swimming season which begins in a couple of months (May)
 Patient would like to be able to participate in sport (volleyball, swimming, basketball) without an onset of shoulder pain
 Patient would like to be able to participate in basketball tryouts in 2 weeks
Short term goal:
1. Patient will obtain full ROM in all directions without pain or soreness at end range in 2 weeks in order to decrease inflammation.
2. Patient will increase right scapular strength (Middle Trapezius, Lower Trapezius, Rhomboids) to a 4/5 in 4 weeks in order to
decrease load on rotator cuff muscles and increase overall stability of the shoulder joint.
Long term goal: Patient will decrease symptoms to a 0/10 with overhead movements (freestyle swim, overhead serving, and
shooting basketball) in order to return to sport (volleyball and swimming) without pain or limitations in 8 weeks.
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FOLLOW-UP NOTE

1) Items to reassess – include subjective and objective measures:

 Reassess MMT in 4 weeks
 Assess shoulder IR strength and shoulder ER strength in neutral and 90-90 shoulder position nest visit
 Reassess overhead motion and when symptoms come on each visit
 Reassess ROM and symptoms at end range in 2 weeks
 Reassess patient goals
 Reassess symptoms with swimming and volleyball with restricted sport participation time

2) Plan for continued treatment if symptoms continue to improve:

 Continue strengthening program
 Progress exercises as indicated
 Initiate new exercises as indicated
 Continue patient education
 Begin total body exercises
 Phase out of symptom modification phase and move more into strengthening phase and then move into return
to sport without restriction phase

3) Plan for continued treatment if symptoms stayed the same:

 Add new exercises and try to target different things than previously targeted – goal is to exhibit some sort of
effect within first few visits to obtain buy-in
 Continue with current program and progress as tolerated
 Reassess as necessary

4) Plan for continued treatment if symptoms are worse:

 Move back into symptom modification phase and out of management and strengthening phase until symptoms
calm down
 If no progress and symptoms worsen in 3 weeks, will refer back to physician

5) Trigger for additional tests/measures/imaging/referral:

 Monitor for presence of red flags not identified in initial evaluation – will refer as necessary
 Continually monitor for changes in symptoms
 If no progress noted and/or symptoms worsen in 3 weeks, will refer to specialist (orthopedics) for
imaging/consult