Abstract
A 63-year-old patient with medical diagnosis of atraumatic partial left rotator cuff tear was seen for physical therapy treatment for 19 sessions over 9 weeks at an outpatient orthopedic clinic by a physical therapy student under the supervision of a licensed physical therapist.
The patient was evaluated at the initial encounter with observation, numeric pain rating scale, manual muscle testing, goniometry, the Quick Disabilities of Arm, Shoulder, and Hand questionnaire, and the Patient-Specific Functional Rating Scale. A plan of care was established to address the patient’s deficits of left shoulder pain, decreased active range of motion (AROM), diminished strength, reduced functional ability, limitations with activities of daily living, and restrictions with work and recreational activities. Main goals for the patient were to reduce pain, improve AROM, improve upper extremity (UE) function, and return to normal work and recreational activities. Main interventions used were manual therapy, therapeutic exercises, task-specific training, and patient education. The patient achieved goals of increased left UE AROM, increased strength, improved UE function, and decreased restrictions with work; however, most of the improvements did not meet the established minimal detectable change or the patient’s established level of goals. Therefore, the patient was discharged to further discuss other treatment options with his primary care physician.