By: Joe Halbert

A 27 year old male ice hockey player has spent most of his athletic career incorporating a physical style of play into his game.
He reports having a history of bilateral shoulder tendinitis with "clicking" while raising his arms overhead.
About two weeks ago he reports missing a check on another player and slamming his right shoulder into the corresponding tempered glass.
Since that time he complains of not quite being able to use his shoulder the same as before and feels stiff and weak when attempting to shoot the puck.

Observation:
There is no ecchymosis observed at the shoulder

Palpation:
Mild tenderness is elicited over the right proximal humeral tuberosities and bicipital groove.

Range of Motion:
Some guarding, otherwise normal

Special Tests:
Negative Ludington's, Yergason's, Allen's, Impingement, Speeds and Adson's, Positive Drop Arm Test.

Neurological Test:
Normal

Injury:
Partial tear off the right rotator cuff

Modalities to be used:
A. Deep transverse massage
B. Cryotherapy
C. Therapeutic Ultrasound
D. Transcutaneous Electromagnetic Neurological Stimulation (TENS) (i guessed)

Phase One
Range of Motion Phase (Weeks 1 to 4)

Modalities:

1. Increase ROM

2. Decrease Pain and Inflammation

a. Cryotherapy
Ice bag applied to right shoulder for approximately ten minutes before and after practice

b. TENS
Help decrease pain. May promote organization of collagen alignment because of the piezoelectric effect within the tendon during the healing phase.
Protocol
Current Intensity: To tolorance without muscle contraction
Pulse Duration: 75 to 150 seconds
Frequency: 80 to 125 pps
Modulation: Continuous
Treatment Time: Fluctuates with pain. Until pain stops. Approximately 30 minutes

c. Transverse Friction Massage (alternating days)
To aid in the absorption of local edema or effusions and reduce local muscle spasm
Treatment Time: 7 to 10 minutes
Therapeutic Exercise: External and internal rotation concentric and eccentric strengthening using wall weight
Tubing exercises: External and Internal rotation, flexion, abduction and horizontal abduction

Phase Two
Intermediate (weeks 4 to 6)
Goals: Continue to decrease pain and inflammation and to improve muscle strength.
Criteria to progress to phase two:
1. Full ROM
2. Minimal pain and tenderness

Modalities:

a. Cryotherapy
Same as Phase one, Ten minutes before and after practice

b. TENS
Continue to help decrease pain depending on where athlete is, will determine if TENS will be used after activity as well.

c. Thermotherapy
Hydrocollator pack secured to anterior and posterior aspects of the shoulder. Ten minutes after Cryotherapy treatment to increase metabolism and healing

d. Transverse Friction Massage
Ten minutes before activity to continue to aid in the absorption of local edema

3. Therapeutic Exercise
Continue same protocol from phase one with increased intensity if applicable

Phase Three
Dynamic Strength Phase (weeks 6 to 8)
Goals: Improve strength, Power and endurance
Criteria to progress to phase Three
1. Full non-painful ROM
2. No pain or tenderness
Strength 70 percent compared with contralateral side

Modalities:

a. Cryotherapy
Same as Phase one

Therapeutic Ultrasound
Increase blood flow after cryotherapy treatment
Protocol:
Frequency: 1.0 MHz
Intensity: 2.0 to 4.0 CW
Treatment: Up to 5 minutes daily, three times, then alternating days

Therapeutic Exercise
Tubing exercises for biceps
Initiate diagonal patterns (PNF)

Phase Four
Return to activity phase
Goals: Preogressively increase activities to prepare athlete for full functional return
Criteria to progress to Phase 4
1. Full ROM
2. No pain or tenderness
3. Satisfactory Clinical exam

Modalities:

a. As needed

Therapeutic Exercise
Tubing exercises for biceps
Initiate diagonal patterns (PNF)