Abstract
A 25-year-old female patient with suspected left glenohumeral instability was seen for 8 sessions in a 10-week period at an outpatient physical therapy setting. Treatment was provided by a student physical therapist (PT) under the supervision of a licensed PT. The patient was examined at the initial encounter with shoulder range of motion, shoulder and scapular manual muscle tests, observation of scapular motor control, functional tests such as reaching overhead and reaching behind the back, the sulcus sign, apprehension, and relocation, tests, the Patient Specific Functional Scale (PSFS), and the Western Ontario Shoulder Instability Index (WOSI). The patient’s pain was monitored for each examination item. A plan of care was established to address left shoulder and scapula weakness, improve functional capabilities of the left shoulder, and decrease work and sport restrictions. Main goals for the patient were to decrease shoulder pain, increase shoulder and scapula strength, improve the ability to lift, carry, push, and pull objects greater than 20 pounds, reach overhead, and improve exercise, jiu jitsu, and work restrictions. Main interventions used were scapular neuromuscular control, shoulder strengthening, and shoulder stabilization exercises. The patient achieved the goals of decreasing her pain, improving her shoulder and scapular muscle strength, capacity to lift, carry, push, and pull resistance, reach overhead, and decreasing her shoulder symptoms when performing upper extremity exercises at the gym, during jiu jitsu, and at work. The patient was discharged to continue living independently at home and with a home exercise program.