Physio Initial MSK outpatient

HOPC - Patient presents with a 3-week history of right shoulder pain following a fall while playing tennis. - Pain is aggravated by overhead activities and eased with rest and ice application. - Pain is described as sharp during movement and dull at rest, with intensity varying throughout the day. Radiology: - MRI of the right shoulder shows a partial tear of the supraspinatus tendon. Past Medical History - Hypertension, managed with Amlodipine 5mg QD. - No known allergies. Social History - Patient is a non-smoker and consumes alcohol occasionally. - Lives with spouse and has a supportive family network. - Works as an accountant, involving prolonged sitting and occasional lifting of heavy files. Goals - Short-term: Reduce pain and improve range of motion within 4 weeks. - Long-term: Return to playing tennis without pain within 3 months. Objective - Active Range of Motion (AROM): Right shoulder flexion 0-120 degrees, abduction 0-90 degrees, external rotation 0-45 degrees. - Strength: 4/5 in right shoulder abduction and external rotation. - Palpation: Tenderness over the supraspinatus tendon. Treatment - Education: Discussed pain management strategies and importance of adherence to home exercise program. - Hands-on: Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper R) shoulder. - Active therapy: 3x10 Single leg calf raises, 3x10 R) shoulder external rotations with resistance band. - Home Exercise Program (HEP): 3x10 R) shoulder pendulum exercises, 3x10 R) shoulder wall slides, to be done daily. Assessment - Diagnosis: Partial tear of the supraspinatus tendon with associated inflammation. - Differential Diagnosis: Rotator cuff tendinopathy. - Progress: Patient has shown slight improvement in pain levels and range of motion. - Barriers: Patient's work schedule limits time for exercises. Plan: - Continue current treatment plan with emphasis on strengthening and range of motion exercises. - Review in 2 weeks. - Likely therapy: Progress to more advanced strengthening exercises. - Referral: None required at this stage. - Communication: Will send a progress report to the patient's GP before the next session.