Abstract
A 52-year-old male patient who was 4 weeks post-operative for a left rotator cuff repair was seen for physical therapy treatment for 12 sessions in 6 weeks at an outpatient physical therapy setting under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter with observation, numeric pain rating scale (NPRS), range of motion (ROM), strength, upper extremity (UE) function via the QuickDASH, participation restrictions via the patient specific functional scale (PSFS) and screened for the presence of a deep vein thrombosis. A plan of care was established to address moderate to severe pain, severe range of motion (ROM) and strength loss, moderate activity limitations, and severe participation restrictions. Main goals for the patient were to decrease left shoulder pain, improve range of motion, strength, ability to perform activities of daily living (ADL), participate with hobbies, and to return to work again. Main interventions used were manual therapy, modalities, patient education, and therapeutic exercise. The patient achieved the following goals of range of motion, strength, and functional capacities. The patient was discharged to continue his individualized home exercise program independently in the home, while awaiting authorization for more outpatient physical therapy visits.