Right Shoulder Pain Case Study

DOI: 7/22/2015. Patient is a 43-year-old male flagger who sustained injury to his right shoulder while moving cones on a trailer. As per OMNI entry, he was initially diagnosed with shoulder strain.
He is status post right shoulder arthroscopic partial acromionectomy, resection of distal clavicle, resection of partial-thickness supraspinatus tendon tear, and intraarticular and acromial steroid Marcaine cocktail injections per operative report dated 7/11/16.
Per the PT note dated 11/16/16, the patient has attended 43 visits for the right shoulder. He reports fluctuating pain in his right shoulder. IW reports difficulty donning his shirt and states that he has been having on and off difficulty in lifting his right arm. Patient also reports continued right shoulder pain and difficulty sleeping. Pain is rated as 4-6/10. IW is unable to tolerate overhead activity at all without pain. Patient has problems with activities of daily living and is limited on his ability to perform housework, yardwork, or play sports due to shoulder impairments.

Flexibility of the sternocleidomastoid, pectoralis and upper trapezius is abnormal. There is tenderness and pain at the acromioclavicular joint and supraspinatus tendon. Shoulder active Range of motion reveals flexion of 140 degrees, glenohumeral external rotation to C7 and glenohumeral internal rotation to L4-5. Passive Range of motion shows flexion and abduction of 160 degrees, and external and internal rotation of 80 degrees. Shoulder strength testing demonstrates 4+/5 with right abduction, external/internal rotation and