Physio MSK Initial Assessment

Physiotherapist Note - 1 November 2024 Consent was obtained for the session and for the use of Heidi AI Health Scribe. Family members, clinicians or students present during the session: Patient's spouse, Mrs. Sarah Smith, was present during the initial subjective assessment. PC: * Right shoulder pain and stiffness HPC: * Patient reports that the pain began approximately 3 months ago after an unaccustomed gardening session involving heavy lifting and overhead pruning. * Initially, the pain was intermittent and mild, exacerbated by reaching overhead. Over the past month, the pain has become more constant and has started to affect sleep. * Current presentation: Constant dull ache in the right shoulder, sharp pain with specific movements, particularly abduction and external rotation. Subjective information related to the presenting condition: * Patient reports difficulty with daily activities such as dressing (putting on a coat), washing hair, and reaching for items in high cupboards. * Describes the pain as a deep ache, sometimes sharp with movement. * Experiences morning stiffness lasting approximately 30 minutes. NRS: * Current pain: 5/10 (at rest) * Worst pain: 8/10 (with overhead movements) * Best pain: 3/10 (after rest and pain medication) Special Questions: * Clicking, popping or grinding: Reports occasional clicking with movement but no grinding. * Sensation changes: Denies any numbness or tingling in the arm or hand. * Giving way: No episodes of the shoulder giving way. * Power: Reports perceived weakness with overhead tasks. * Dizziness: Denies dizziness. * Double vision: Denies double vision. 24 Hour Pattern: * Morning: Stiff and painful for the first 30 minutes, gradually eases with gentle movement. * Day: Pain fluctuates, worse with activity and prolonged static positions. * Evening: Pain increases, making it difficult to find a comfortable sleeping position. Often wakes up due to pain. Aggs: * Reaching overhead * Lifting objects, even light ones * Sleeping on the right side * Prolonged computer use Eases: * Rest * Applying heat pack * Over-the-counter pain relievers (ibuprofen) PMH: * Hypertension, managed with medication (diagnosed 5 years ago). * No previous shoulder injuries or surgeries. Imaging Results: * MRI Right Shoulder (dated 15 October 2024): Mild supraspinatus tendinopathy with no full-thickness tear. Minimal subacromial bursitis. Medications: * Lisinopril 10mg once daily (for hypertension) * Ibuprofen 400mg as needed for pain (up to 3 times daily) * Glucosamine and Chondroitin supplement once daily Social History: * Home setup: Lives in a two-story house with husband. No stairs directly impact daily activities but difficulty reaching upper shelves in kitchen. * Falls history: No recent falls. * Support systems: Strong support from husband. * Employment: Retired primary school teacher. * Role in home and community: Active in local gardening club, which has been impacted by shoulder pain. * Hobbies, interests and mobility: Enjoys gardening, walking, and reading. Walks daily for 30 minutes without issue for legs, but arm swing is restricted on the right side. Goals: * Short-term: Reduce pain to 3/10 or less at rest and improve sleep quality within 2-3 weeks. * Long-term: Be able to reach overhead to put away dishes and resume gardening activities without pain within 8 weeks. Return to full pain-free range of motion. Objective: * Observational findings including postural observations: Mild right shoulder protraction. Apparent guarding of right arm movements. No obvious swelling or discolouration. * Objective assessments divided by joint including range of motion assessed at each joint: * Right Shoulder: * Flexion: 120° (painful end range) * Abduction: 110° (painful end range) * External Rotation: 30° (painful end range) * Internal Rotation: L4 level * Left Shoulder: Full pain-free range of motion. * Power assessed using MRC scale at each relevant joint: * Right Shoulder: * Flexion: 4/5 * Abduction: 4/5 * External Rotation: 3/5 * Internal Rotation: 4/5 * Left Shoulder: 5/5 all movements. * Special tests performed and findings: * Hawkins-Kennedy Test: Positive for right shoulder pain. * Neer Impingement Test: Positive for right shoulder pain. * Empty Can Test: Mild weakness and pain in right supraspinatus. * Speed's Test: Negative. * Yergason's Test: Negative. Treatment: * Manual therapy: Gentle posterior and inferior glides to glenohumeral joint to improve capsular mobility. * Soft tissue release: Myofascial release to upper trapezius and levator scapulae on the right side. * Therapeutic exercises: Initiated pendulum exercises, wall slides, and isometric rotator cuff exercises (submaximal). Advice, education or advisories given to the patient for future attention: * Education provided on activity modification, posture correction, and pain management strategies. * Advised on ergonomic setup for computer use and strategies to reduce overhead reaching. * Encouraged regular, gentle movement within pain-free limits. * Provided home exercise programme sheet and demonstrated exercises. Analysis: * Diagnosis presented as a problem list using medical terminology: * Right shoulder supraspinatus tendinopathy. * Subacromial impingement syndrome, right shoulder. * Impaired glenohumeral joint mobility and strength, right shoulder. * Differential diagnoses or contributing factors identified during the session: * Possible cervical spine referral (ruled out by cervical assessment). * Postural imbalances contributing to shoulder mechanics. Plan: * Plan including next appointment and any tasks agreed upon during the session: Continue home exercise program. Focus on pain reduction and improving range of motion. Next appointment scheduled for one week. * Timeline of next review: Review in 1 week. * Likely therapy to be provided at the next appointment: Progress manual therapy, advance strengthening exercises, and reassess pain and range of motion. * Letters, phone calls or communications the treating therapist will complete before the next session: None required at this stage.