Conservative Treatment

Pt is a 52 y/o M with PMH of right shoulder pain >2 years associated

with overhead activity despite conservative treatment with therapy and

injections who is now s/p R shoulder arthroscopy, subacromial decompression, and

biceps tenodesis on 1/8/15.

PM&R Diagnosis: s/p R shoulder arthroscopy

Past Medical History: Cubital tunnel syndrome, chronic low back pain, neck pain,

Depression, PTSD and anxiety.

Social History: Pt lives c wife and is part of the Wounded Warrior Program.

Precautions: No biceps strengthening (avoid resistive elbow flexion/supination)

Chief Complaint: Pain to R shoulder and tenderness around incision site.

S: Pt reported no new complaints.

O: -Pt received MHP to R shoulder x 20 min (S), tolerated well, skin intact.

Pt participated in 45 min therEx including:

- table slides x 3 x 10 each

- supination/pronation x 3 x 10

- shoulder stabilizing ball roll on wall clockwise and counter clock-wise x 2

min each.

- pendulum side to side, front and back, clockwise/counter-clockwise x 30 each

- upper trapezius and scalene stretch x 10 hold for 5 sec

- pulleys flex/abd x 3 min each

- elbow flex, shoulder flex, ext, abd, ER, c 0 lb therabar x 30 each

- shoulder elevation/depression, protraction/retraction and rolls x 3 sets x 10

each

Pt received ice pack to R shoulder x 10 min (S), tolerated well, skin intact.

A: Pt tolerated session well.

P:

...