Yates Physio Initial

SE:// Consent to Heidi Ai: Yes Main Problem: Right shoulder pain and limited movement. Bodychart: Red flags (NIF TIV) Nil Smoking status Nil Altered sensation Nil Behaviour: Pain at rest - 2/10, ache, deep, right shoulder Pain on aggravation - 7/10, sharp, deep, right shoulder Other Sx - Clicking and popping in the shoulder. (If there are multiple pain areas include all, starting with main concern. Indicate if there is a relationship between symptoms IF the client indicates as such) Agg: * Overhead reaching - 2 minutes * Lying on right side - immediately Ease: * Resting - 10 minutes * Taking pain medication - 30 minutes Non-agg: * Walking * Sitting Non-ease: * Lifting Irritability: High 24 hr cycle: Pain worse in the morning and at night. Sleeping: Sleep is disrupted due to pain. HPC: Pain started 3 weeks ago after lifting a heavy box. Pain has gradually worsened with increasing difficulty with overhead activities. No specific injury. Past Hx: Nil PMHx (how they got better): Nil SHx: Occupation: Office worker General health: Good Activity levels - Walks 30 minutes, 3 times per week. Sleep - 6-7 hours per night, disrupted by pain. Stress - Moderate stress due to work deadlines, managed with relaxation techniques. Diet - Balanced diet, no specific dietary restrictions. Pregnancy - Not applicable. Drinking - Social drinker, 1-2 units per week. Home: Lives with partner in a two-story house. Are there any formal supports - Nil Informal supports - Partner provides emotional support. Medications: Ibuprofen 400mg, as needed for pain. Clinical flags: * Yellow flag: Fear avoidance beliefs regarding movement. Investigations: Nil What do you think is wrong?: Client believes they have a rotator cuff injury. Expectations: Client wants to reduce pain and regain full shoulder movement. They want to avoid surgery. Long term solution?: Client wants to return to full function and activities. Goals: * Reduce pain to 2/10 or less at rest within 2 weeks. * Improve shoulder range of motion to 90 degrees of abduction within 4 weeks. * Return to work duties without pain within 6 weeks. OE:// Outcome Measure AROM: * Shoulder flexion: 90 degrees * Shoulder abduction: 60 degrees * Shoulder external rotation: 30 degrees * Shoulder internal rotation: 50 degrees PROM: * Shoulder flexion: 120 degrees * Shoulder abduction: 90 degrees * Shoulder external rotation: 40 degrees * Shoulder internal rotation: 70 degrees Resisted static contraction when tested in consult * Shoulder abduction: 3/5, right, pain reproduced 6/10 * Shoulder external rotation: 3/5, right, pain reproduced 5/10 Assisted joint movements - PAIVMs/PPIVMs etc * Shoulder inferior glide, grade 2+ Neurodynamic - Slump/passive straight leg raise/ upper limb tensions test (1, 2a, 2b or 3) * Upper limb tension test 1, right, reproduction of pain with shoulder abduction. Neurological - upper and lower Neurological upper * Sensation: C5 - NAD, C6 - NAD, C7 - NAD, C8 - NAD, T1 - NAD * Strength: C5 - NAD, C6 - NAD, C7 - NAD, C8 - NAD, T1 - NAD * Reflexes: Biceps - NAD, Triceps - NAD, Brachioradialis - NAD * Upper motor neuron tests: NAD Provisional Dx:// * Rotator cuff tendinopathy * Shoulder impingement Differential diagnosis: * Acromioclavicular joint sprain * Glenohumeral joint instability Rx:// * Manual therapy: Soft tissue massage to the shoulder and upper back. * Home exercise program: Pendulum exercises, scapular retractions, and rotator cuff strengthening exercises. * Education/advice: Advised on activity modification and posture correction. * Taping: Kinesio taping to support shoulder. * Dry needle - consent given, infection control, and response to intervention: Nil * Intervention // effect: Soft tissue massage // improved pain levels Plan:// * Review in 1/52. * Re-Ax **shoulder range of motion and pain levels**. * Continue home exercise program. * Progress strengthening exercises. * Discuss work modifications. * No referrals required. * Next visit: 8 November 2024