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INITIAL EVALUATION — PHYSICAL THERAPY

Patient: 52-year-old female
Date of Eval: Today
Referring MD: Dr. R. Patel, Orthopedics
Dx (referral): Right shoulder impingement syndrome, s/p fall 3 weeks ago
ICD-10: M75.41 (Impingement syndrome, R shoulder), M25.511 (Shoulder pain, R)

SUBJECTIVE:
Pt reports falling on outstretched R hand 3 weeks ago. Pain localized to R lateral deltoid and AC region. Pain rated 6/10 at rest, 8/10 with overhead reach or sleeping on R side. Difficulty washing hair, reaching seatbelt, and donning a bra. Denies numbness/tingling, neck pain, or radicular symptoms. PMH: HTN (lisinopril 10mg), no prior shoulder injury or surgery. MRI 5 days ago: supraspinatus tendinosis with partial-thickness articular-side tear, no full-thickness tear, mild subacromial bursitis.

Patient goals: Return to recreational tennis (3x/wk), pain-free overhead reach, and pain-free sleep within 8 weeks.
DASH at eval: 54.2/100 (higher = more disability)

OBJECTIVE:
Vitals: BP 128/78, HR 72, no acute distress.
Posture: Forward head, R shoulder elevated and protracted, mild scapular dyskinesis on observation.

ROM (active / passive, R / L):
- Shoulder flexion: 125° / 145° (R) vs 170° / 175° (L) — painful arc 80–120°
- Abduction: 100° / 130° (R) vs 170° / 175° (L)
- ER at 0° abd: 55° / 70° (R) vs 80° / 80° (L)
- IR (behind back): R reaches L4, L reaches T10

MMT (R / L):
- Supraspinatus (empty can): 3+/5 with pain / 5/5
- Infraspinatus (ER at side): 4-/5 with pain / 5/5
- Subscapularis (lift-off): 4/5 / 5/5
- Middle / lower trap: 3+/5 / 4+/5
- Serratus anterior: 4-/5 / 5/5

Special tests (R shoulder):
- Hawkins-Kennedy: positive
- Neer: positive
- Empty Can: positive with weakness and pain
- Painful arc: positive (80–120°)
- Drop arm: negative
- Spurling, ULTT: negative (clears cervical spine)

Palpation: Tenderness over greater tuberosity and AC joint, mild trigger point in upper trap.

ASSESSMENT:
52 y/o female with R shoulder subacromial impingement and partial-thickness rotator cuff tear, presenting with pain-limited ROM, RC weakness, scapular dyskinesis, and functional deficits in overhead reach, dressing, and sleep. Excellent rehab candidate—motivated, no red flags, surgical management not indicated at this time.

GOALS:
STG (4 weeks):
1. Pt will demonstrate pain-free shoulder flexion to 150° to allow overhead reach for ADLs.
2. Pt will reach IR to T12 to don/doff bra independently.
3. Supraspinatus MMT will improve to 4/5 to support functional lifting up to 5 lbs.

LTG (8–12 weeks):
1. Pt will return to recreational tennis without pain (DASH < 15).
2. Pt will sleep through the night on R side without pain 6 of 7 nights.
3. Full pain-free AROM bilaterally (within 5° of L) with normalized scapulohumeral rhythm.

PLAN:
Frequency/duration: 3x/week × 8 weeks (24 visits), then re-evaluate.
Interventions:
- Manual therapy: GH joint mobilizations (grades II–III for pain, III–IV for motion), posterior capsule stretching, soft tissue mobilization to upper trap and pec minor.
- Therapeutic exercise (97110): scapular clocks, prone Y/T/W, serratus punches, sleeper stretch, pendulums progressing to band ER/IR at 0° then 90°, rhythmic stabilization.
- Therapeutic activities (97530): closed-chain UE on physioball, wall pushup-plus, gradual return to overhead reach.
- Neuromuscular re-education (97112) for scapular control.
- Modalities: Ice 10 min post-exercise PRN; no e-stim indicated at this time.
HEP issued today: Pendulums 2 min, scapular squeezes 3x10, doorway pec stretch 3x30 sec, wall slides 3x10. Will progress weekly.
Plan of Care will be sent to Dr. Patel for certification per Medicare guidelines.

PT signature: J. Reed, PT, DPT — Lic #12345