The athlete's shoulder

Hi guys, good luck for your new placements. I have just completed my musculoskeletal outpatient’s placement and I thought I would share with you a patient that I was treating. A 23 year old male presented with right shoulder pain which was diagnosed as sub-acromial impingement with GHJ instability, after a fall during basketball 6/5 ago, and resultant ongoing shoulder pain. On observation of his scapulohumeral rhythm, it was evident that the way tipping of the inferior angle of the right scapular, due to tight an overactive pec minor, and under active lower traps.

My plan was to work on the patient’s ability to stabilize his scapular through lower traps activation (scapular retraction exercises), but first I needed to release his pec minor. With pec minor released, the pt’s impingement tests all became negative, but I still needed to address the underlying factor of impaired scapular stability.

I tried some basic lower trap exercises in prone, however as this patient had large superficial muscle bulk, there was massive teres major activation and not even a flicker of lower traps. In sitting, I had a little more success, but there was still mass compensation by surrounding muscles. So I trialed the use of EMG biofeedback, over lower traps, and performed the same scapular retraction exercises. After a few attempts, he got the hang of it, and eventually was able to isolate lower traps. Once he could isolate the muscle group in a few different positions, I began to incorporate scapular stabilization during all of his upper body exercises in his gym program, such as lat pull down, seated rows, pull ups and bicep curls. As this allowed the pt to continue going to the gym and doing the exercises that he enjoyed, he was highly compliant.

Over the four weeks, the patient’s pain levels significantly reduced and his scapulohumeral rhythm became much more symmetrical and aligned, which I thought was a positive rehabilitation outcome.