Patient Information – Case Study

Shubhash Mishra

52 Years Old | Male

🩺 Relevant Medical History

The patient sustained an injury following a road traffic accident involving a collision with a truck while riding a two‑wheeler, resulting in a direct fall onto the left shoulder.

Presenting Complaints

  • Left shoulder pain, specifically exacerbated by overhead movement.
  • Significant difficulty with activities of daily living requiring reaching or lifting above shoulder height.

Medical Diagnosis

  • Left shoulder rotator cuff tear.

Mechanism of Injury

  • Direct impact on the left shoulder due to a road traffic accident while riding a two‑wheeler.

Surgical / Medical Management

  • Medical management as advised by the orthopedic surgeon
  • Pain‑relieving medications and activity modification

Assessment & Clinical Findings

Clinical Findings

  • Pain: Present over the left shoulder, aggravated during overhead movements
  • Mobility: Reduced active range of motion of the left shoulder
  • Strength: Decreased shoulder muscle strength affecting functional activities

Physiotherapy Intervention Plan

Pain Management

  • Pain management techniques including ice/heat therapy and TENS

Shoulder Mobility

  • Shoulder mobility exercises to restore range of motion

Strengthening

  • Progressive strengthening exercises for rotator cuff and scapular stabilizers

Treatment Outcomes

Significant reduction in shoulder pain

Improved shoulder mobility and strength

Able to perform overhead activities independently

Clinical Conclusion

This case highlights the effectiveness of a comprehensive physiotherapy approach in managing cervical spondylosis with lumbar radiculopathy. The treatment plan successfully addressed the patient’s symptoms through a combination of therapeutic exercises, pain management techniques, and postural correction strategies. The significant improvement in pain levels and functional abilities demonstrates the value of targeted rehabilitation in managing work-related musculoskeletal disorders. The patient’s ability to return to prolonged two-wheeler driving without significant discomfort underscores the success of the intervention in restoring functional independence and quality of life.