Shoulder SOAP Notes & Documentation

Patient reports "my shoulder feels stronger this week" and rates pain at 2/10 at rest, 4/10 with end-range motion. Patient states she is sleeping better without the sling. Denies any sharp pain or catching sensations. Motivated to progress exercises. Reports performing home exercise program 2x daily as instructed.

ROM (PROM): Shoulder flexion 145 degrees (from 130 degrees last visit), abduction 120 degrees, ER at 0 degrees abduction 40 degrees, IR at 0 degrees abduction 45 degrees.
ROM (AROM): Flexion 120 degrees with good scapulohumeral rhythm, abduction 100 degrees.
Strength: Deferred per protocol. Isometric ER/IR 3+/5 pain-free.
Special Tests: Deferred per protocol. No apprehension with passive motion.
Observation: Minimal swelling, well-healed portal sites, improved scapular positioning at rest.
Treatment: PROM all planes, AAROM with wand and pulleys, scapular stabilization exercises (rows, serratus punches), isometric ER/IR at 0 degrees abduction, pendulum exercises, cryotherapy x 15 min post-treatment.

Patient progressing well within post-operative protocol expectations. PROM improved 15 degrees in flexion since last visit. AROM developing appropriately with good scapulohumeral rhythm. Isometric strength improving without pain provocation. Patient demonstrates understanding of precautions and home program compliance. Continues to require skilled PT for ROM progression, gradual strengthening, and neuromuscular re-education to achieve functional use of R UE.

Continue PT 2x/week per surgeon protocol. Progress to Phase 2 exercises: initiate AROM in all planes, begin light resistance band exercises for ER/IR at side, continue scapular strengthening. Maintain PROM stretching at end ranges. Next visit: reassess AROM, begin submaximal isometrics in neutral if appropriate. Patient to follow up with surgeon at 8 weeks. Continue HEP with updated exercises.

Patient reports "reaching overhead is getting easier" and rates pain at 3/10 with overhead activities, down from 6/10 at initial evaluation. States he is more aware of his posture at his desk job. Denies night pain. Patient notes he can now reach the top shelf without significant discomfort.

ROM (AROM): Shoulder flexion 170 degrees (WNL), abduction 165 degrees, painful arc noted 80-120 degrees (improved from 70-130 degrees).
Strength: R supraspinatus 4/5 (from 3+/5), ER 4+/5, IR 4+/5, lower trapezius 4/5, serratus anterior 4/5.
Special Tests: Neer test positive (reduced pain vs initial), Hawkins-Kennedy positive (reduced pain), Empty can mildly positive.
Posture: Forward head posture improved, reduced thoracic kyphosis, improved scapular positioning bilaterally.
Treatment: Soft tissue mobilization to upper trapezius and pectoralis minor, joint mobilization Grade III posterior glides, rotator cuff strengthening (ER/IR with resistance band), lower trap and serratus strengthening, thoracic extension exercises, postural education, activity modification review.

Patient demonstrating good progress with reduced painful arc and improved rotator cuff strength. Posture improvements noted with carryover to work environment. Scapular mechanics improving with better lower trapezius and serratus activation. Patient responding well to manual therapy combined with therapeutic exercise. Continues to require skilled PT for progressive strengthening, manual therapy, and functional training to return to full overhead activities without pain.

Continue PT 2x/week for 4 more visits. Progress resistance band exercises, add overhead strengthening in pain-free range, continue manual therapy as needed. Begin sport-specific exercises if patient wants to return to tennis. Progress HEP with increased resistance. Reassess special tests at visit 6. Goal: return to full overhead activities with NPRS 0-1/10 by discharge.

Patient reports "it's not getting worse, but not much better either" which is consistent with frozen phase. Pain rated 4/10 at rest, 6/10 at end-range. Night pain continues to disrupt sleep 2-3x/night. Patient frustrated with slow progress but understands the natural history of condition. Performing HEP consistently. Difficulty with bra fastening, hair care, and reaching back pocket.

ROM (PROM): Shoulder flexion 95 degrees (stable from last visit), abduction 70 degrees, ER at 0 degrees 15 degrees, IR at 0 degrees hand to sacrum level. Capsular end-feel in all directions.
ROM (AROM): Flexion 90 degrees, abduction 65 degrees with shoulder hiking compensation.
Strength: Unable to fully assess due to ROM limitations. Grip strength WNL bilaterally.
Observation: Guarding with passive stretching at end-range. Compensatory thoracic sidebending with abduction.
Treatment: Grade I-II joint mobilizations for pain modulation, gentle PROM within tolerance, sustained stretching at comfortable end-range, scapular mobility exercises, cervical and thoracic mobility, compensatory movement pattern correction, patient education on frozen phase expectations, modalities for pain management.

Patient remains in frozen phase of adhesive capsulitis with ROM plateau as expected. Pain levels stable. Capsular pattern restrictions persist with firm end-feel. Patient educated that this phase may last several more weeks before thawing begins. Focus remains on pain management, maintaining available ROM, and preventing compensatory dysfunction. Continues to require skilled PT for joint mobilization, stretching techniques, and education to optimize recovery trajectory.

Continue PT 1-2x/week during frozen phase. Maintain gentle mobilization and stretching program. Monitor for signs of thawing phase (spontaneous ROM improvements, decreased night pain). Continue HEP focusing on pendulums, table slides, and pulley within available range. Consider referral back to physician if no progression in 4-6 weeks. Reassess ROM and pain levels at each visit to identify transition to thawing phase.