Clinician Specialty: Massage Therapist
PATIENT DETAILS
Patient age: 45
Patient sex or gender: Female
Patient main occupation: Office Administrator
Any other relevant demographic patient particulars: Lives with husband, 2 children. Non-smoker. Social alcohol use.
SUBJECTIVE HISTORY
Presenting complaint and patient's goals or expectations for attending: Pt presents with chronic L shoulder pain, gradually worsening over 3 months. Goals: reduce pain, improve range of motion (ROM) for daily tasks, return to gardening.
Site of pain or complaint with specific anatomical location: L deltoid, supraspinatus, and upper trapezius.
Onset of pain or symptoms including mechanism of injury and timing: Gradual onset, no specific injury. Started after increased desk work. Worse in evenings.
Character and nature of pain or symptoms: Dull ache, occasional sharp pain with overhead movement. Feels stiff.
Referral pattern of symptoms: Refers occasionally down L arm to elbow, no hand paresthesia.
Aggravating or exacerbating factors: Prolonged sitting at computer, lifting objects, reaching overhead, sleeping on L side.
Easing or relieving factors: Heat pack, gentle stretching, rest.
Timing and pattern of symptoms: Constant dull ache, 5/10 severity, sharp pain (7/10) with specific movements. Worse in pm.
Severity rating and Patient Specific Functional Scale scores: Current pain 5/10 (resting), 7/10 (aggravated). PSFS: gardening (initial 4/10), lifting (initial 3/10), reaching overhead (initial 2/10).
Irritability level assessment: Moderate irritability; symptoms settle within 30-60 mins after aggravation.
RELATED HISTORY
Occupational history and activities of daily living impact: Office administrator, 8 hrs/day computer work. Difficulty reaching for items on high shelves, doing laundry, gardening (pruning).
Current activity, sport and exercise history: Sedentary, walks 30 mins 3x/wk. Stopped yoga due to shoulder pain.
Previous treatment for this condition: Self-managed with heat and OTC analgesics (paracetamol) with minimal relief.
Current medications and supplements: Paracetamol PRN, Multivitamin daily.
Relevant radiology, scans and tests: None recent. Previous X-ray 5 yrs ago for different issue, clear.
Recent general health status: Good. No recent illness or fever.
Injury, medical or surgical history: L clavicle fracture 20 yrs ago, fully recovered. No other relevant medical hx.
Relevant family history: Mother had similar shoulder pain, unspecified diagnosis.
Other relevant information: Reports increased stress at work recently.
FLAGS
Red flags indicating serious pathology: None identified.
Yellow flags indicating psychological, behavioural or social factors: Moderate stress at work, fear avoidance for overhead movements.
Blue flags indicating workplace factors: Prolonged sitting, ergonomic setup at desk not optimal.
Pink flags indicating positive prognostic factors: Motivated to return to activities, good general health.
OBJECTIVE ASSESSMENT
Observations of demeanour and movement patterns: Guarded L shoulder movement, mild forward head posture, rounded shoulders. Wincing with overhead reach.
Active range of motion findings: L shoulder Flexion 120° (painful end range), Abduction 110° (painful end range), External Rotation 45°. R shoulder full ROM, pain-free.
Passive range of motion findings: L shoulder Flexion 130°, Abduction 120°, External Rotation 50° (less pain than AROM, but restricted end feels).
Resisted range of motion findings: L shoulder Flexion, Abduction, Ext Rotation: Weak & painful. Internal Rotation: Strong & pain-free. Elbow Flexion/Extension: Strong & pain-free.
Palpation findings: Tenderness and hypertonicity L upper trap, levator scapulae, supraspinatus, deltoid. Trigger points in L upper trap and supraspinatus. Mild warmth L shoulder joint.
Neurological and neurodynamic assessment results: Sensation intact C5-T1. Reflexes normal LUE. Neural tension tests (ULNT1) negative.
Special and orthopaedic test results: Neer's Impingement Test (+ L). Hawkins-Kennedy Test (+ L). Empty Can Test (+ L, weak). Cross-body Adduction Test (-). Speed's Test (-).
Functional movement test results: Difficulty reaching overhead for functional tasks. Pain with initiating push-up position.
Vital statistics and other measurements: BP 120/80 mmHg. HR 72 bpm. RR 16. Temp 36.8°C.
DIFFERENTIAL DIAGNOSIS ANALYSIS
Primary tissue involvement: Myofascial structures (upper trap, levator scap, supraspinatus, deltoid), rotator cuff tendons (supraspinatus).
Main symptoms analysis: Localised pain, stiffness, limited ROM, pain with specific movements.
Symptom drivers identification: Postural strain from desk work, muscular imbalance, potential supraspinatus tendinopathy/impingement.
Supporting evidence: Positive impingement tests, palpation findings, aggravation with overhead activities.
Differential diagnoses with justification and rationale:
• Rotator Cuff Tendinopathy (Supraspinatus): Positive impingement tests, pain with overhead, tenderness over tendon.
• Myofascial Pain Syndrome: Presence of active trigger points, hypertonicity in surrounding musculature.
• Subacromial Impingement Syndrome: Positive Neer's & Hawkins-Kennedy, pain arc.
Patient consent to treatment: Verbal consent obtained for soft tissue therapy and dry needling to L shoulder region.
TREATMENT INTERVENTIONS
Soft tissue manipulations performed: Deep tissue massage L upper trap, levator scap, rhomboids, supraspinatus, infraspinatus, deltoid. Trigger point release L upper trap and supraspinatus.
Dry needling interventions: L supraspinatus, upper trapezius, posterior deltoid. Target MTrPs (myofascial trigger points). Patient tolerated well.
Joint mobilisation techniques: Grade I/II GHJ (glenohumeral joint) distraction and caudad glide. Scapulothoracic mobilisation.
Myofascial cupping treatments: Applied to L upper back/shoulder region (upper trap, deltoid) for 5 mins to increase local circulation and release fascia.
IASTM treatments: N/A
Hot stone therapy: N/A
Taping or strapping applications: Kinesiology tape applied to L shoulder for postural support and pain relief.
Education provided regarding lifestyle, dietary, cognitive or environmental adjustments:
• Ergonomic advice for desk setup (monitor height, chair position).
• Postural awareness education (shoulder retraction, chest open).
• Pain education: explanation of tendinopathy and muscular pain, reassurance about activity.
• Stress management techniques (deep breathing).
Self-efficacy level assessment and support requirements: Pt moderately confident in managing symptoms at home. Requires regular check-ins and encouragement to adhere to HEP.
Treatment plan: Course of 6 weekly sessions. Reassess at 3rd and 6th sessions. Focus on pain reduction, ROM improvement, strengthening.
HOME EXERCISE PROGRAM PRESCRIPTION
Overall strategy of home exercise program: Pain-free ROM exercises, gentle stretches, scapular stabilisation exercises.
Program details with periodisation and updates:
• Pendulum swings 3x10 daily.
• Wall slides 3x10 daily.
• Scapular squeezes 3x10 daily.
• Doorway pectoral stretch 3x30s daily.
• Progress to light resistance band exercises in 2 weeks.
Future reassessment measures and milestones: Reassess L shoulder AROM, pain levels (VAS), PSFS scores for gardening/lifting/reaching at next appointment.
OUTCOMES
Subjective response and relevant comments: Pt reports feeling lighter in L shoulder, reduced stiffness post-treatment. Initial pain score reduced to 3/10.
Validated surveys or questionnaire results: N/A
Patient Specific Functional Scale short-term goals: Reduce pain during gardening to 2/10, increase lifting tolerance by 2kg within 2 weeks.
Patient Specific Functional Scale long-term goals: Return to full pain-free gardening, resume yoga classes within 6-8 weeks.
EVALUATION
Objective responses to treatment: Immediate improvement in L shoulder AROM by approx 10-15 degrees in flexion/abduction. Reduced tenderness on palpation of upper trap/supraspinatus.
Updated overall impression: Pt presents with chronic L shoulder pain likely due to myofascial dysfunction and early supraspinatus tendinopathy/impingement exacerbated by occupational posture. Positive initial response to treatment.
Plans for next treatments including methods, timing and scheduling: Continue weekly sessions. Next session focus on further soft tissue release, dry needling, and progress HEP. Schedule next appointment for 1 November 2024.
Referral plans: Consider referral to GP for imaging if no significant improvement in 3-4 sessions or if red flags emerge. Consider ergonomic assessment of workplace.
CLINICIAN REFLECTIONS AND LEARNING MOMENTS
Clinical reflections on treatment delivery: Pt responded well to combination of manual therapy and dry needling. Education on ergonomics and posture was well-received.
Key takeaways from the session: Importance of addressing both local tissue dysfunction and contributing postural/occupational factors for chronic shoulder pain. Patient engagement with HEP crucial for long-term success.
(Use standard medical abbreviations in line with Australian medical notation conventions and clinical myotherapy abbreviations. Write in concise bullet points or brief statements focused only on clinically-relevant elements, not full sentences.)
PATIENT DETAILS
[Patient age] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient sex or gender] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient main occupation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Any other relevant demographic patient particulars] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
SUBJECTIVE HISTORY
[Presenting complaint and patient's goals or expectations for attending] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Site of pain or complaint with specific anatomical location] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Onset of pain or symptoms including mechanism of injury and timing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Character and nature of pain or symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Referral pattern of symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Aggravating or exacerbating factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Easing or relieving factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Timing and pattern of symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Severity rating and Patient Specific Functional Scale scores] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Irritability level assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
RELATED HISTORY
[Occupational history and activities of daily living impact] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Current activity, sport and exercise history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Previous treatment for this condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Current medications and supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Relevant radiology, scans and tests] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Recent general health status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Injury, medical or surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Relevant family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Other relevant information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
FLAGS
[Red flags indicating serious pathology] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Yellow flags indicating psychological, behavioural or social factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Blue flags indicating workplace factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Pink flags indicating positive prognostic factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
OBJECTIVE ASSESSMENT
[Observations of demeanour and movement patterns] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Active range of motion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Passive range of motion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Resisted range of motion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Palpation findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Neurological and neurodynamic assessment results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Special and orthopaedic test results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Functional movement test results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Vital statistics and other measurements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
DIFFERENTIAL DIAGNOSIS ANALYSIS
[Primary tissue involvement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Main symptoms analysis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Symptom drivers identification] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Supporting evidence] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Differential diagnoses with justification and rationale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient consent to treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
TREATMENT INTERVENTIONS
[Soft tissue manipulations performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Dry needling interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Joint mobilisation techniques] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. Use arrow symbols for direction such as '↑' for superior glide.)
[Myofascial cupping treatments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[IASTM treatments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Hot stone therapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Taping or strapping applications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Education provided regarding lifestyle, dietary, cognitive or environmental adjustments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Self-efficacy level assessment and support requirements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Treatment plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
HOME EXERCISE PROGRAM PRESCRIPTION
[Overall strategy of home exercise program] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Program details with periodisation and updates] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Future reassessment measures and milestones] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
OUTCOMES
[Subjective response and relevant comments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Validated surveys or questionnaire results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient Specific Functional Scale short-term goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Patient Specific Functional Scale long-term goals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
EVALUATION
[Objective responses to treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Updated overall impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Plans for next treatments including methods, timing and scheduling] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Referral plans] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
CLINICIAN REFLECTIONS AND LEARNING MOMENTS
[Clinical reflections on treatment delivery] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)
[Key takeaways from the session] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)