Abstract
A 51-year-old female patient with a partial-thickness tear of the right rotator cuff was seen for 12 physical therapy sessions over a period of 6 weeks at an outpatient physical therapy clinic. Treatments were provided by a physical therapist student under the supervision of a licensed physical therapist.
The patient was evaluated at the initial encounter with the numeric pain rating scale, goniometry, manual muscle test, Shoulder Pain and Disability Index and the Patient Specific Functional Scale. A plan of care was established to address right shoulder pain, decreased shoulder range of motion and strength, right upper extremity functional limitations, and restriction with work-related duties. Main goals for the patient were to decrease right shoulder pain, increase right shoulder range of motion, increase right shoulder strength, improve right shoulder functional mobility, and return to work without restrictions. Main interventions used were patient education, manual therapy, muscle stretching, therapeutic exercise, task specific training and modalities. On discharge, the patient achieved the goals related to pain, range of motion, strength, and functional mobility. She was able to return to work without restrictions.
The patient was discharged to home under her own care and to progress independently with an individualized home exercise program.