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  • Alice
    Client ID 018

  • Name:
    Alice
    Age:
    39
    Primary Diagnosis:
    R rotator cuff repair
    Gender Identity:
    Female
    Insurance: 
    BCBS
    Pronouns:
    She/her/hers
    Referring Physician: 
    T. Mohr, MD
    Race/Ethnicity:
    White

  • History of present illness:
    39yo WF reported gradual R shoulder and hand weakening and altered sensation in R shoulder. While attempting to lift suitcase into plane overhead bin 6 months ago, heard pop in R shoulder and experienced acute weakness and pain. 2 days later, fell and caught herself using RUE. After fall, was unable to use RUE. Had outpatient physical therapy before deciding to proceed with surgery. MRI revealed full thickness complete tear of the supraspinatus and partial tear of the infraspinatus tendon. Arthroscopic R rotator cuff repair and R carpal tunnel release surgery were performed 2 weeks ago.

    Past medical/surgical history:
    L rotator cuff repair 3 years ago, carpal tunnel B wrists

  • Marital status: Married 16 years

    Primary language: English

    Prior level of function: Independent with ADL/IADLs, including driving prior to current injury. Shoulder weakness required activity modification (e.g., requiring a second assistant for transferring patients at work and avoiding overhead reaching at home). Difficulty typing for long periods of time while charting.

    Employment/work/school: College education. Part-time nurse (two 12-hour shifts weekly). Work duties involve prolonged walking and standing, frequent lifting up to 50 pounds when positioning patients, and fine motor coordination for placing IVs and using syringes.

    Play/leisure/interests: Enjoys gardening and crafting (primarily paper crafts) in her spare time.

    Environmental factors: Lives with husband and two children in two-story house with no STE, no handrails. 15 steps to second level, L handrail. Walk-in shower (2” ledge), sliding door, shower chair, and handheld shower head.

  • Weeks 0-6: Wear sling continuously (may be removed for exercises, showering, and dressing). Pain medication PRN. Complete given HEP 4x day, scar massage 4x day. PROM only. No joint mobilization.

    Weeks 6-12: No lifting more than 5 lbs or overhead reaching. AAROM progressing to AROM. No strengthening exercises.

    Weeks 12+: Progress to strengthening exercises as tolerated.

  • Tylenol 650 mg TID PRN

  • MRI: full thickness complete tear of the supraspinatus and partial tear of the infraspinatus tendon

  • Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.

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