Physiotherapy Protocol - RT Shoulder (Supraspinatus Tendinosis / Rotator Cuff Injury, Post-Trauma)

Phase 1: Acute / Pain Relief (Day 1-7, matches "rest for 1 week")

• Therapeutic Ultrasound (1 MHz, pulsed mode 1:4, 0.8-1.2 W/cm², 5-8 min) over the supraspinatus insertion/subacromial region - promotes local blood flow, reduces pain and soft-tissue inflammation without excessive thermal load on an acutely injured tendon (Firestein & Kelley's Textbook of Rheumatology; Pfenninger and Fowler's Procedures for Primary Care).
• Low-Level Laser Therapy (LLLT) over the supraspinatus tendon/subacromial bursa - reduces pain and inflammation, supports tendon healing; used as an adjunct in tendinopathy per current literature.
• Interferential Therapy (IFT) or TENS (80-150 Hz, 15-20 min) for analgesia if pain limits movement/sleep.
• Cryotherapy (ice pack, 10-15 min) after sessions, especially given the traumatic mechanism (blunt trauma), to control swelling/tenderness noted on exam.

• Sling/arm support for comfort only if needed (avoid prolonged immobilization - stiffness risk).
• Pendulum (Codman's) exercises - gentle passive mobility without loading the cuff.
• Passive/assisted ROM within pain-free range - passive external and internal rotation, scapular plane elevation.
• Gentle scapular setting/isometrics (pain-free submaximal) to maintain rotator cuff activation without tendon stress.
• Avoid overhead activity, weightlifting, throwing, driving (as advised).

Phase 2: Subacute / Mobility Restoration (Week 2-4)

• Continue ultrasound/laser 2-3x/week if tenderness persists, tapering as pain resolves.
• Phonophoresis (ultrasound with topical anti-inflammatory gel) can be used over the tender supraspinatus insertion for combined mechanical + drug delivery effect (Pfenninger & Fowler's Procedures for Primary Care, Fig 229-5 technique).

• Progress to active-assisted then active ROM in all planes.
• Rotator cuff isometrics (progressing to isotonic) - external rotation, internal rotation, abduction with resistance band, kept below shoulder height initially.
• Scapular stabilizer strengthening (rows, scapular retraction) - critical since scapulothoracic dysfunction perpetuates impingement.
• Posterior capsule/pectoral stretching if internal rotation or horizontal adduction is restricted.
• Manual therapy/soft tissue mobilization to the tendon and surrounding soft tissue lesion as noted on exam.

Phase 3: Strengthening (Week 4-8, contingent on symptom resolution and reassessment)

• Progressive resistance for supraspinatus (scaption in scapular plane, "empty/full can"), infraspinatus/teres minor (external rotation), subscapularis (internal rotation).
• Closed-chain and proprioceptive work (wall push-ups progressing to more dynamic loading).
• Eccentric loading for the tendon once acute pain has settled - supported for tendinopathy management generally.

Phase 4: Functional / Return to Throwing and Sport

• Sport-specific graded return (throwing progression) only after full pain-free ROM and near-symmetric strength are restored.
• Continue avoiding heavy weightlifting until cleared by the treating orthopedist, since chest pain and trauma mechanism raise the possibility of a broader soft-tissue/costochondral component that also needs to settle.

Notes tied to this specific chart

• Reassess at the 7-day follow-up (13-Aug): if swelling/tenderness/ROM restriction have not improved, the doctor has already flagged MRI RT shoulder to rule out a structural rotator cuff tear rather than tendinosis alone - physiotherapy intensity (especially loading) should stay conservative until that is clarified.
• The "RT sided chest pain" should be re-examined; if it persists despite improving shoulder signs, it may need separate evaluation (e.g., costochondral injury) since blunt trauma can affect an adjacent structure.
• Medications (Piroxicam/Dolonex DT, T-Well collagen peptide + hyaluronate + chondroitin) support the tendon healing environment alongside physiotherapy but do not replace graded loading.