Describe in detail how this CIP was implemented into your

clinical assignment. Be sure to describe the scenario(s) (real or

mock) thoroughly and address all aspects of the CIP. You may
attach supporting evidence as necessary.

An athlete came into the training room complaining of pain in their left
shoulder. I performed an upper extremity evaluation and documented
a SOAP note in vivature. I also constructed a day-to-day rehab protocol.
S: Ath reported today c/o L shoulder pain. She is a Freshmen thrower at IU. R
hand dominate. Ath stated P has been occurring since junior year of HS. She
stated that the P is not tender to the touch. She feels it more when she is lifting or
does over head press, wide press, and bench press. The P occurs as she is
going up in weight and reps. Ath. stated she felt a pop after too many reps when
lifting. Level of P yesterday was 7/10. Level of pain today is a 2/10. The pain is
sharp and achy. Ath took Ibuprofen last week for P, has not since.
O: No swelling or discoloration w/ L shoulder. P with palpation of the biceps
tendon. RROM/AROM: normal. PROM limited w/ internal and external rotation at
end of range. MMT: Shoulder flexion 4/5, Shoulder scaption 4/5, Shoulder Ext.
Rotation 3/5, Shoulder Shoulder Int. rotation 4/5. (+) Hawkins-Kennedy, Neers
Test (+), Rents Sign Test (+) w internal rotation. Speeds Test (-). Ath. completed
rehab consisting of bent over rows w/ weight 2x10, I's/Y's/T's w/ weight 3x8
(difficulty noted with Y's ROM limited), Shoulder stability 3x, corner stretch 3x30
seconds, Towel Curl AB/ADduction w/ wall band 2x10 (fatigue noted with
abduction), internal rotation w/ cane 3x30 second hold, and game ready for 15
minutes medium pressure w/o c/o.
A: Dx: L biceps tendonitis. ST/LT Goals: athlete being able to do rehab exercises,
being able to increase ROM, moving through rehab with less pain, perform
exercises with weights. Also, lifting weight functionally over-head with no pain
and no pain at 180 degrees of shoulder flexion, to be able to return to play being
pain free
P: Treat symptomatically and begin w/ conservative rx. Rehab addressed to
improve increase flexion and ext/int rotation of anterior structures. - Jabari
Adkins, ATS