REFERRAL

Name: J.S.
Age/Sex: 17/M
Birthday: January 28, 2003
Address: Quezon City
Handedness: (L)
Civil status: Single
Contact No: +639 0633333333
Year/Course: 2nd/BSS student
Designation: Athlete - Baseball
Date: May 2, 2020

Respectfully referring J.S. for PT IE and intervention for (L) shoulder impingement. For follow up after 2
weeks. No baseball training drills that involves UE for now.

(signed)
Dr. A.M.

INITIAL EVALUATION
Name: J. S. Age / Sex: 17/M
Birrthday: January 28, 2003 Address: Quezon City
Course: BSS 2 year student
nd
Contact No.: 09063198868
Team: Baseball Position: Pitcher/Out Field
MD Diagnosis: Shoulder Impingement (L) Handedness: (L)
Date of Referral: May 2, 2020 Referring MD: Dr. A.M.
Date of IE: May 5, 2020

SUBJECTIVE ASSESSMENT

C/C: Pt. complains of intermittent pain on (L) shoulders (greater tuberosity, bicipital groove) which he
describes as “nangangalay” at “naiipit” (VRS = 8/10) after prolonged pitching (~45 pitches) and batting (after
~3 hours of training). Pt. reported that pain is decreased by rest (VRS = 2/10) and application of ice for 10-15
minutes (VRS = 6/10). Pt. also reports that he has observed a limitation in internal rotation of (L) shoulders.

Pt’s Goals and attitude towards PT Rehabilitation: Pt. expresses his fear that his shoulder pain might
progress to a point where injury may make him non-functional. He hopes to be able to go back to training and
compete s any discomfort. Pt. is willing and motivated to undergo therapy.

HPI: Pt. reported that pain at (L) shoulder started 2 weeks ago because training had been focused on pitching.
Pain is at same location, with same quality but of lower intensity (VRS=6/10). Pt. reported that pain may be
because he is always required to give 100% of his strength when pitching during training which lasts for ~4
hours.

Pt. reported that 1 week ago the said pain worsened (VRS: 8/10) and would not immediately decreased with rest
when his coach advised him to change his form when batting. Pt. reported that he used to bat with his arm close
to his body. Now, he practices batting with his (L) arm slightly abducted and elbow in slight flexion. Pt.
reported that his current pain may be due to his muscles not being used to new form and fatigue. Pain is
reported to be of same quality, location and intensity.
Pt. reported that LOM towards internal rotation was observed during assessment with MD done yesterday. He
added that he continued training for the past 2 weeks and just tolerated the pain being experienced. He would
just apply ice in between breaks (3-5mins) in training and after training (10mins on, 10mins off, 10mins on). He
reported that they don’t currently have team PT and he was also hesitant to have it checked as he might be
pulled out from the training. As stated above, he was finally checked by the MD yesterday and then was
immediately referred for PTIE and treatment.

PMHx:
● Previous fall, landing on (L) shoulder. Pt. experienced weakness and pain of his arm. Pt. reported that 2
weeks rest without intervention resolved the problem. (1 month ago)
● No other co-morbidity

FMHx:
● Unremarkable

P/S/EHx:
● 2nd Year BSS Student
● Varsity athlete, Baseball
● Pitcher and Out fielder
● (L) hand is used for pitching and batting
● Trains 3-4 hours every Monday, Wedenesday
and Friday (Team currently has no weight training,
all baseball drills but will start strength and
conditioning drills in a week)
● Enrolled to a PE class: football
● Non-smoker
● Does not drink alcoholic beverages
● Plays computer games during leisure time, no
other hobbies/routines that requires much physical
effort
● Has personal driver
● Has house help at home, does not perform any
household chores
● No overhead cabinet at home
● No shower, uses dipper when taking a bath

Medications: Arcoxia 60mg

Ancillary Procedures:
● None

OBJECTIVE ASSESSMENT
OI:
Mesomorph
(+) Postural deviation (standing)
(-) Gross deformity
(-) Gait deviation
(-) Swelling, erythema, wounds or scars on (L) shoulders

Palpation:
Grade 1 tenderness on (L) Greater tuberosity and bicipital groove
Normothermic

Movement Analysis:
ACTIVE PASSIVE RESISTED
(L) Shoulder
Findings:
Pt. reports pain at end-range of Pt. reports pain at end-range of Pt. reports pain at end-range of
abduction (ipit and pangangalay, abduction (naiipit, VRS = 2/10, flexion (ipit and pangangalay,
VRS = 4/10, greater tuberosity) greater tuberosity) and internal VRS = 2/10, greater tuberosity),
and internal rotation (stretch-pain, rotation (stretch pain, VRS = 6/10, mid-range (~90o) abduction (ipit
VRS = 2/10, greater tuberosity) greater tuberosity) and pangangalay, VRS = 6/10,
greater tuberosity) and inner range
(~60o) abduction (ipit at
pangangalay, VRS = 7/10, greater
tuberosity).
Significance: Mild to moderate stretch pain (VRS 2/10) was felt during outer range of active, passive, and
resisted in all motion that indicates the element affectation (e.g. muscle and tendon). Problems could be
temporarily addressed via ice pack, ms strengthening such as isometric exercises to relieve pain and
numbness.
(L) Elbow

Findings:
Full active ROM Full Passive ROM Pain at end-range of elbow flexion
(Naiipit, VRS = 2/10, bicipital
groove)
Significance: Mild intermittent pain (VRS 2/10) was felt during end range of resisted elbow flexion that
indicates the element affectation (e.g. muscle and tendon) on biceps tendon. Problems could be temporarily
addressed via REST and AROM exercises.
Legend:
0 = VRS = 0/10
+ = VRS = 1-4/10 (Minimal pain)
++ = VRS = 5-7/10 (Moderate pain)
+++ = VRS = 8-10/10 (Extreme pain)

MMT:
Muscle strength of the upper extremities and was found to be WNL except:
● (B) Rhomboids = 4/5

Significance: (B) scapular retractors decreased in strength is only due to lack of scapular weakness that leads to
poor scapular positioning during flexion. Problems could be addressed via strengthening and stretching the
protractors and retractors.
ROM:
Active and Passive ROM were grossly assessed and was found to be WNL. However, pt. reported stretch pain
at end-range(full) of both active and passive internal rotation

Significance: AROM and PROM assessments are all within normal limits. But pt. also reported stretch pain ate
the end range of active and passive internal rotation.

Postural Assessment:
All land marks seen anteriorly, posteriorly and laterally are WNL except:
● Slouched posture in standing and sitting
o Scapula protracted
o Lumbar vertebra flexed excessively
o Weight bearing on area between ischial tuberosity and PSIS (sitting)

Significance: Pt. has postural deviations that may cause for predisposing factor for his therapy. Slouched
posture in standing and sitting may cause of muscle weakness such as scapular protractors (trapezius,serratus
anterior, pectoralis major) lumbar flexors and extensors. Mobility impairment in the abdominal muscles and
lower lumbar extensor muscle. It also affects pt. performance in playing baseball. Problem could be
temporarily addressed via postural correction techniques.

Scapular mobility Assessment:

Left Right
At Rest ● Distance from vertebral ● Distance from vertebral
spine WNL spine WNL
● No scapular winging ● No scapular winging
● No excessive protraction/ ● No excessive protraction/
retraction/ rotation/ elevation/ retraction/ rotation/ elevation/
depression depression

With active shoulder movement
(flexion)
With active shoulder movement,
scapula restricted from moving
(upon instruction)
Scapula starts to move at early
range of motion (less than 60 o,
starts to rotate at ~15o)
Scapula can be held in place until
~60o
Scapula starts to move at early
range of motion (less than 60 o,
starts to rotate at ~15o)
Scapula can be held in place until
~60o

Significance: Pt. presents poor scapular rhythm and restricted active flexion from moving that indicates weak
scapular stabilization. Problems can be temporarily addressed by scapular stabilization and correction
techniques for scapular rhythm.

Functional Assessment: (as pt reported)

Activity Current performance Previous performance Findings
ADLs
Bathing Slower compared to previous WNL ● Pain with overhead
performance especially when activities even with minimal
washing hair due to ‘naiipit resistance
na pain’ (VRS: 4/10) with
overhead activities
Desk-top Pt. is able to tolerate desk-top
activities activities (writing, reading
etc.) for up to 20 mins. After
which, pt. reports
pangangalay and would need
to reposition himself
PE Same as previous
Class(football) performance, no any
affectation/limitation
Training Drills
Pitching (as Able to perform ~45 pitches
reported) before pain (VRS: 7/10)
becomes bothersome.
Pt. reports apprehension due
to fear that something might
happen to his shoulder if he
continues and moves it too
forcefully
Throwing (as Pt. reports compensating with WNL
reported) increased force generation
from the wrist due to pain
(VRS: 8/10) with movement
from the shoulder. Pt. reports
being able to throw as far as
necessary.
Batting (as Pt. reports that he experiences
reported) a decrease in power because
he is unable to bat with
appropriate follow through
due to pain (VRS: 8/10).
Donning and doffing clothes, ambulation, sit-ups, sprinting, diving and sliding is reported to be unaffected by
current condition.
Significance: Difficulty doing ADLs due to pain, decreased endurance, power, improper timing of scapular
muscles. Problems could be temporarily addressed by scapular stabilization, patient education about proper
posture, and functional training.
Special tests:
Special Test Indication
Yergason’s (+) Bicipital tendinitis
test
Empty Can (+) Supraspinatus affectation
test
Neer’s Sign (+) Impingement at subacromial
Pt. is able to tolerate desk-top ● Decreased
activities (writing, reading endurance of scapular and
etc.) for up to 45 mins. After shoulder muscles
which, pt. reports
pangangalay and would need
to reposition himself
Plays all football drills and ● No limitations
position except for goal
keeper (only 6 classmates
were the chosen goal keeper
after 2 sessions)
Able to perform ~90 pitches ● Pain with repeated
before fatigue starts movements over prolonged
periods of time
● Possible improper
firing and timing of
scapular muscles as
observed in the scapula-
humeral rhythm assessment
● Apprehension
● Learned
compensations to painful
shoulder
● Decreased power
● Absence of follow
through
Findings
(+)
(+)
(+)
 space

Significance: Pt. presents tendinitis, supraspinatus affectation, and impingement of the subacromial space of
shoulder. These results may led to pt. injury and decrease in performance. Bicipital tendinitis could be
addressed via cross fiber massage and rest. Supraspinatus affectation could be addressed via relative rest and
avoid activities that will aggravate the pain. Impingement at subacromial space could be addressed by pt.
education and all these should focus on PT session because of acute phase.

A. REFINED PROBLEM LIST.

IMPAIRMENTS ACTIVITY LIMITATION PARTICIPATION

RESTRICTION
PIP’s limitation in internal Pt. will have a limited Cannot perform his
rotation of (L) use of (L) UE in baseball role as baseball player
shoulders. training such as
Pitching throwing and
Pain on (L) shoulders bathing
(greater tuberosity,
bicipital groove)

NPIP’s Grade 1 tenderness Pt. will have limited use Cannot perform his
on (L) Greater of (L) UE while playing role as a student
tuberosity and games on computer
bicipital groove
Pt. will have limited use
mild to moderate of (L) UE while bathing
stretch and
intermittent pain on (L)
shoulder

Pain elicit while

performing overhead
reaching activities even
with minimal
resistance

Decrease endurance of
the scapular and
shoulder muscles

ROM of the shoulder

are Normal but there’s
a stretch pain on the
internal rotation
motion
B. Prioritized problem list

1. Pain on (L) shoulders (greater tuberosity, bicipital groove)

2. Pain elicit while performing overhead reaching activities even with minimal resistance
3. Grade 1 tenderness on (L) Greater tuberosity and bicipital groove

4. ROM of the shoulder are Normal but there’s a stretch pain on the internal rotation motion
5. Pt. will have a limited use of (L) UE in baseball training such as Pitching throwing and bathing
6. Pt. will have limited use of (L) UE while bathing
7. Pt. will have limited use of (L) UE while playing games on computer
8. Decrease endurance of the scapular and shoulder muscles
9. mild to moderate stretch and intermittent pain on (L) shoulder

ANTICIPATED PROBLEM

ANTICIPATED PROBLEM JUSTIFICATION PREDICTIVE CRITERIA

Weakness of UE muscles
decreased in muscular
endurance and power of UE
Decreased motivation and
increase fear
due to no baseball workout and
strengthening of UE
Due to no other physical activity
such as weight trainings
Due to stress of no training and
becoming non functional
Pt. will perform multiple angle
isometric x 6 sec hold x 10 reps
x 2-3 sets x O.D.
Pt. will perform intensive
walking, sit ups, sprinting
PT will have a positive self-talk
and goal setting.

PT DIAGNOSIS

Pt. has limited performance in baseball training, bathing, and computer activities. Due to the intermittent pain (VRS
8/10). Pt. has limitation in performing his role as an baseball player and a student due to the shoulder impingement.

PROGNOSIS

POSITIVE PROGNOSTICATING FACTOR SIGNIFICANCE:

-Patient has no other associated pathologies Patient will have a faster recoveries
involved or gross deformities.

-Patient have good health there is no other condition so treatment is more

prioritized

-Patient is young Younger people have faster healing process