Health and Exercise Science

HLEX 3233 Injury Evaluation & Recognition – Upper Extremity

Case Study Summary Report

Case Study 3 – Shoulder and Upper Arm

By Austin Tummons
1. Describe the clinical signs and symptoms that your patient is experiencing.

Signs: No effusion/edema, discoloration, or deformities present

Symptoms: Immediate pain in shoulder after a pitch, pain was high right after motion but went
down later that night from 8/10 to 6/10.

2. Based on your patient’s complaints and your physical exam, what CONDITIONS (at least 3)
would you include in your initial assessment? Why?

Subacromial Impingement Syndrome: It could be this because patient is complaining of pain

when pitching, which I an overhead motion and there is discomfort with overhead motions with
this. Another thing the patient complained of is clicking in the shoulder. Tender around and
under the acromion process. Abduction causes pain in shoulder.

Rotator Cuff Tendinopathy: Patient talks about a clicking in shoulder which is consistent with
this condition. Along with that it is condition that is caused from overhead motions causing pain.
Tenderness is also observed in this condition with pain in abduction. Also makes sense that it
could be this because the pain described seemed like it was a tendon. His pain would be greater
with working of the shoulder and motion, but pain would decrease with rest but come back.

SLAP Lesions: The main indicators that it is this condition is the fact that all the special tests
that tested positive all pointed towards SLAP Lesions. Anterior Slide and Compression-Rotation
Tests are all direct indicators of SLAP lesions, O’Brien test also indicates SLAP lesions but can
also point to other conditions. This condition can also be caused by overhead throwing motions
so it is consistent for someone like a pitcher along with clicking in shoulder.

3. Using the answers from question 2, determine through differential diagnosis the appropriate
medical assessment.

I am confident that the patient has SLAP Lesions. The special tests all point towards a SLAP
Lesions and all his symptoms are also consistent with SLAP Lesions. All the ROM and MMT
also indicate SLAP Lesions. So, everything is pointing towards SLAP Lesions and the special
test are a pretty good indication of this.

INJURY EVAL & RECOGNITION - UE | Case Study Summary Report

 Health and Exercise Science
HLEX 3233 Injury Evaluation & Recognition – Upper Extremity
4. Based on the information given and the information you’ve gathered, what would be your best
course of action for your patient? Describe in detail.

I would refer my patient to go see a doctor to get an imaging done on his shoulder to confirm
SLAP Lesions and move onto treatment options. Depending on how bad, the doctor may
recommend just anti-inflammatory medication but if that doesn’t improve it then surgical options
will be put into consideration. With surgery, full recovery can be anywhere from 2-6 weeks.

INJURY EVAL & RECOGNITION - UE | Case Study Summary Report