Date:
Patient:
Reason for Visit:
Follow-up for rotator cuff injury
Assessment of pain and functional limitations
Evaluation of progress with treatment plan
Management plan discussion
History:
Presenting Illness:
Date of initial injury or symptom onset
Mechanism of injury (acute trauma, overuse)
Initial symptoms (pain, weakness, clicking/popping sensation)
Current symptoms and any changes since last visit
Past Medical History (PMH):
Underlying medical conditions (e.g., diabetes, arthritis)
Prior surgeries or injuries to the shoulder
Social History:
Occupation and activities that may aggravate symptoms
Physical Exam:
Inspection: Assess for shoulder posture, swelling, bruising, or atrophy of muscles.
Palpation: Evaluate for tenderness over specific rotator cuff muscles or tendons.
Range of Motion (ROM): Measure active and passive range of motion in all directions (flexion, abduction, external rotation).
Strength Testing: Assess strength of rotator cuff muscles (internal and external rotation).
Special Tests: Perform specific maneuvers (e.g., Neer impingement test, Hawkins-Kennedy test) to help diagnose specific rotator cuff injuries.
Diagnostic Tests (may be ordered depending on clinical suspicion):
Imaging Studies:
X-ray: May show bone abnormalities (e.g., calcifications) but not tears.
Ultrasound: Can visualize fluid collections and some tendon tears.
MRI scan: Provides detailed view of soft tissues (muscles, tendons) and is the most accurate for diagnosing rotator cuff tears.
Assessment:
Type of rotator cuff injury: Based on history, physical exam findings, and imaging studies (if available). Consider specific muscles involved (supraspinatus, infraspinatus, etc.) and the severity of the tear (partial vs. full-thickness).
Pain level and functional limitations: Evaluate the impact of pain and weakness on daily activities and range of motion.
Progress with treatment plan: Assess response to previous interventions (rest, medications, physical therapy).
Plan:
Treatment approach based on severity and chronicity:
Non-surgical management: First line of treatment for most rotator cuff injuries. Includes:
Rest: Reduce activities that aggravate symptoms.
Ice and pain medication: To manage inflammation and pain.
Physical therapy: Exercises to improve strength, flexibility, and range of motion.
Corticosteroid injection: May be considered for pain relief in some cases.
Surgical referral: May be indicated for large tears, persistent pain despite conservative management, or significant functional limitations.
Patient education: Provide information about the type of rotator cuff injury, healing process, and importance of treatment adherence.
Discuss activity modifications and proper use of pain medication.
Instruct on performing prescribed physical therapy exercises at home.
Follow-up:
Schedule for follow-up appointments based on treatment plan:
More frequent visits for patients with initial injury, physical therapy, or considering surgery.
Less frequent visits for patients with improvement and ongoing physical therapy program.
Encourage patients to report any worsening symptoms or difficulty performing exercises.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of rotator cuff injuries.