Right Shoulder Pain

Case Description: Pt is a 19 y/o female who arrived to physical therapy with reports of R shoulder pain which has been ongoing for about a year and a half. She has reports of pain down the R UE that seems inconsistent and her biggest difficulties are with reaching, carrying heavy objects, and driving. 

Objective Measures: The patient was seen for physical therapy 16 visits over a course of 2.5 months. 

Tests and Measures	Initial Evaluation	Day of Discharge from Physical Therapy
QuickDASH Scale	59.1% disability	5% disability
Shoulder strength  Scapular strength	R flexion, abduction 4/ 5  Mid/lower traps 3+/5 bilaterally	R flexion, abduction 5/5  Mid traps: 4/5  Lower traps: 4+/5
Shoulder ROM	Flexion: R 161 deg painful; L 180 deg  Abduction: R 148 deg painful; L 178 deg	All WNL and nonpainful
Special testing	Empty can on R	Negative empty can on R
Functional Capacity	Difficulty with reaching (especially overhead), driving, lifting heavy objects.	No longer issues with driving, now able to carry heavy objects without pain. No longer numbness or tingling in her arm. She is more conscious of her shoulder position with lifting/carrying. Reports her sleeping has improved as well.

Summary: The patient was discharged from physical therapy due to meeting goals of shoulder ROM, strength, and overall improved tolerance to daily activities including driving, reaching, carrying. She was educated on the use of her HEP to maintain gains in strength and ROM as well as manage any future flare ups.