Therapist: Dominika Gruszczyńska

Identification data: 22.03.2018

Name: Ricardo R.
Age: 43
Responsible physiotherapist: Sonia Couto Rodriges
Gender: M
Nationality: Portuguese

Job: Bussines owner, work on computer, sitting

Home situation: living alone
Hobby: swimming, surfing (shortboard), mountain biking, paddling

Living situation: living in block of flats, 1st floor

Dominance: righthanded
Weight: 83
Length: 183
BMI: 24,78 – correct weight

Reason for intervention: injury of rotator cuff during lifting furniture on 3rd March 2018

Clinical diagnosis: not stated, doctor made ultrasound scan but the inflammation process is too
big to see changes on the photo. Patient is waiting for reduction of inflammation process to
make another ultrasound picture

Actual history: Patient came to clinic because he has an insurance package. He felt pain in his
shoulder during lifting furniture, he heard a quiet pop and he couldn’t move his upper extremity.
He feels pain in anterior part of shoulder joint.

Medical/surgery history: there is not any surgery/medical history

Medication: non

Expectations from the patient and family:

- reduction of pain
- moving upper limb without any pain
- come back to sport
Personal factors:
- motivated (+)
- age (+)
- good health (+)
- active life style (+)
- type of work – computer (-)
- smoker (-)

Physical examination:

- General observation – posture a little bit bent to right side, because of pain in right
shoulder,
- Posture
Anterior view: right shoulder lower (+/- 1 cm)
head bent to right with left rotation (slightly visible)
Left waist triangle smaller

Lateral view: head protraction

shoulder protraction
retroposition of pelvic
hypolordosis lumbar - little

Posterior view: dyskinesia of scapula

- Palpation
low oedema around greater tubercle

- Sensibility:
patient feels pain when the area of grater tubercle is touching, Vas 8/10

- Analysis of the walking pattern:

correct
- Body chart

- Active and passive movements right upper limb [degrees]

Active Passive
flexion 40 60
extension 45 60
Internal rotation 50 85
External rotation 40 50
Abduction 15 30
Adduction 0 0

- Strength measure – right upper limb

flexion 3/5
extension 4/5
Internal rotation 3/5
External rotation 3/5
Abduction 3/5
Adduction 4/5

- Positive Jobe’s test

Left upper limb has active and passive movements and strength in correct range

Restriction level on participation:

difficulty during working,
stopped playing sports, working out at the gym

Restriction level on activities:

difficulty and pain during dressing up, eating, driving a car (gear change)
patient avoids activities which cause pain
the worst and most painful activity according to patient is dressing up – VAS 7/10

Restriction level on function:

 painful and low range of motion:

- flexion
- abduction
- rotation internal
- rotation external
- extension
 wrong biomechanics of movements in humeral joint due to scapula dyskinesia

Potential problems:
scapula dyskinesia – due to wrong position of scapula patient can’t stabilize scapula what
causes dysfunctional movements of humeral joint
Shorten muscles: pectoralis major, serratus anterior, subscapularis, supraspinosis
Weaken muscles: trapezius, teres minor and major

Physiotherapeutic diagnose:
Pain VAS 7/10 on the right shoulder ( insertion of rotator cuff) in the movements of the upper
limb above 40 degreases (abduction), 90 degreases (flexion) and external rotation (above 40
degreases) and instability of scapula due to rapture of cuff.

Prognosis:
Reducing pain in one week
Gain more range of motion in one week
Strengthen trapezius muscle and stabilize scapula in 3 weeks

TREATMENT
Goals:

- Short term goals

Reducing pain
Gain more flexion, abduction, rotation external and internal
Teach patient how to correctly stabilize scapula during movements

- Long term goals

Strengthen trapezius muscle
Gain scapula stabilization
Gain full range of motion
Come back to sport

Treatment plan (5 times a week, 1 hour a day):

1. Mobilization of humeral joint to gain more range of movements

2. Passive movements: flexion, abduction, internal and external rotation
3. Massage of muscles: superspinosis, subscapularis, trapezius, pectoralis major
4. Exercises:
- at the first few meetings exercises which stabilize scapule and teach patient corect
bimechanical movements
*contraction of trapezius, serratus posterior, and rhomboideus major with previous
shouler protraction
- passive external and internal rotation
- passive flexion - active extension
- passive adbuction

- after reducing pain adding:

*active external and internal rotation
*active flexion
*resistance flexion
*active external and internal rotation
*resistance external and internal rotation
*active abduction
*resistance abduction

5. Mobilization of diaphragma to gain more ROM in humaral join

6. Ultrasound
7. Coldpack – till the oeadma and inflamation will be reduced

DAILY TREATMENT

19.03.2018

Painfull: active and passive flexion and abduction, external and internal rotation

1. Passive movements of humeral joint till pain border: flexion, abduction

2. Mobilization of humeral joint
3. Massage of supraspinatus, subscapularis muscles
 4. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient positioned in lying position with belly up, arms flexed in
90 degrees position, holding Swedish ball, knees and hips bended in 90 degrees position
20reps/3 sets
- passive internal and external rotation 10x/3sets
- active internal and external rotation 10x/3sets
5. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
6. Coldpack on shoulder – 15 minutes

21.03.2018

1. Passsive movements of humeral joint till pain border: flexion, abduction, rotation
external and internal
2. Mobilization of humeral joint
3. Traction of humeral joint (few abduction position to gain more ROM)
4. Massage of supraspinatus, subscapularis muscles, pectoralis major
5. Exercises:
- scapulae contraction – 10 repetitions with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient is laying down, upper limbs flexed in 90 degrees,
resistant band used to support – 20 repetitons/3 sets
- trapezius contraction – patient in supported kneel position – 20 repetiotion
6. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
7. Coldpack on shoulder – 15 minutes

22.03.2018

1. Passsive movements of humeral joint till pain border: flexion, abduction, rotation
internal and external
2. Mobilization of humeral joint
3. Massage of supraspinatus, subscapularis muscles, pectoralis major,
4. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient is laying down, upper limbs flexed in 90 degrees,
resistant band used to support – 20 repetitons/3 sets
- external rotation – patient keeps in his hands resistance band, forearms in supination
position, patient does external rotation with resistance, slowly coming back to central
forearm position – 10 repetiotion/3 sets
- trapezius contraction “cat’s back” – patient in supported kneel position – 20
repetiotion
5. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
6. Coldpack on shoulder – 15 minutes

23.03.2018
1. Passsive movements of humeral joint till pain border: flexion, abduction, rotation
internal and external
2. Mobilization of humeral joint
3. Massage of supraspinatus, subscapularis muscles, pectoralis major,
4. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient is laying down, upper limbs flexed in 90 degrees,
resistant band used to support – 20 repetitons/3 sets
- external rotation – patient keeps in his hands resistance band, forearms in supination
position, patient does external rotation with resistance, slowly coming back to central
forearm position – 10 repetiotion/3 sets
- trapezius contraction “cat’s back” – patient in supported kneel position – 20
repetiotion
5. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
6. Coldpack on shoulder – 15 minutes

26.03.2018

1. Passsive movements of humeral joint till pain border: flexion, abduction

2. Mobilization of humeral joint
3. Mobilization of diaphragma
4. Massage of supraspinatus, subscapularis muscles
5. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient positioned in lying position with belly up, arms flexed in
90 degrees position, holding Swedish ball, knees and hips bended in 90 degrees position
20reps/3 sets
- pulling down theraband (band handed above patient’s shoulder)– start position of arms
– 90 degrees and pulling band to extension with scapulae contraction and depression of
scapulae (depression – really difficult movement to perform by patient)
6. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
7. Coldpack on shoulder – 15 minutes

27.03.2018

1. Passsive movements of humeral joint till pain border: flexion, abduction

2. Mobilization of humeral joint
3. Massage of supraspinatus, subscapularis muscles
4. Mobilization of diaphragma
5. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient positioned in lying position with belly up, arms
flexed in 90 degrees position, holding Swedish ball, knees and hips bended in 90
degrees position 20reps/3 sets
 - pulling down theraband (band handed above patient’s shoulder)– start position of
arms – 90 degrees and pulling band to extension with scapulae contraction and
depression of scapulae (depression – really difficult movement to perform by
patient)
6. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
7. Coldpack on shoulder – 15 minutes

28.03.2018

1. Passsive movements of humeral joint till pain border: flexion, abduction

2. Mobilization of humeral joint
3. Massage of supraspinatus, subscapularis muscles
4. Mobilization of diaphragma
5. Exercises:
- scapulas contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- shoulder protraction – patient positioned in lying position with belly up, arms flexed in
90 degrees position, holding Swedish ball, knees and hips bended in 90 degrees position
20reps/3 sets
- pulling down theraband (band handed above patient’s shoulder)– start position of arms
– 90 degrees and pulling band to extension with scapulae contraction and depression of
scapulae (depression – really difficult movement to perform by patient)
6. Ultrasound applied at the area of greater tubercle – 4 minutes, 1 W
7. Coldpack on shoulder – 15 minutes

09.04.2018
1. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
2.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
3. Mobilization of diaphragm
4. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- internal/external rotation laying on a side
right side up – external rotation 10x/3 sets
left side up – internal rotation 10x/3sets
- overhead press with a wooden stick – 15x/3 sets
- external and internal rotation with a wooden stick 20x/3sets
- isometric internal rotation 5s/10x/3sets
- cats back 20x/3sets
5. Ultrasound – 4 minutes, 1W
6. Coldpack 10 minutes

10.04.2018
1. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
2.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
3. Mobilization of diaphragm
4. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- isometric internal rotation 5s/10x/3sets
- cats back 20x/3sets
5. Ultrasound – 4 minutes, 1W

11.04.2018
1. Deep tissue massage around insertion point of cuff
2. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
3.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
4. Mobilization of diaphragm
5. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
-internal and external rotation with 1kg weight – patient felt pain  change for theraband
10x/3 sets
- isometric internal rotation 5s/10x/3sets
- cats back 20x/3sets
6. Ultrasound – 4 minutes, 1W

12.04.2018

1. Deep tissue massage around insertion point of cuff

2. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
3.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
4. Mobilization of diaphragm
5. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- internal/external rotation laying on a side
right side up – external rotation 10x/3 sets
left side up – internal rotation 10x/3sets
- overhead press with a wooden stick – 15x/3 sets
- external and internal rotation with a wooden stick 20x/3sets
- isometric internal rotation 5s/10x/3sets
- cats back 20x/3sets
6. Ultrasound – 4 minutes, 1W

23.04.2018
1. Deep tissue massage around insertion point of cuff
2. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
3.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
4. Mobilization of diaphragm
5. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- internal/external rotation laying on a side
right side up – external rotation 10x/3 sets
left side up – internal rotation 10x/3sets
- overhead press with a wooden stick – 15x/3 sets
- external and internal rotation with a wooden stick 20x/3sets
- isometric internal rotation 5s/10x/3sets
- extension and protraction exercise with theraband attached high 15x/3sets
6. Ultrasound – 4 minutes, 1W

Patient feels more pain because of doing too much effort – biking, surfing

24.04.2018

1. Deep tissue massage around insertion point of cuff

2. Tension release massage of subscapularis, supraspinosis, rhomboideus, pectoralis major
3.Passive movements – flextion, abduction, external rotation, abduction + external rotation,
movements till the end of patient’s range of movements
4. Mobilization of diaphragm
5. Exercises:
- shoulder protraction – patient lays with belly up, keeps resistance band in both hands
20x/3 sets
- scapulae contraction – 10 repetition with holding contraction 5 seconds/ 3 sets
- internal/external rotation laying on a side
right side up – external rotation 10x/3 sets
left side up – internal rotation 10x/3sets
- overhead press with a wooden stick – 15x/3 sets
- external and internal rotation with a wooden stick 20x/3sets
- isometric internal rotation 5s/10x/3sets
- extension and protraction exercise with theraband attached high 15x/3sets
- plank 30 seconds
- plank on knees 30 seconds
- plank on knees plus activation of scapulae 5x/3sets
6. Ultrasound – 4 minutes, 1W