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shoulder pain, shoulder pain diagnosis and shoulder pain treatment

Shoulder pain diagnosis - the puzzling tale of a national-level javelin thrower with shoulder pain

It's a bit predictable, I suppose, for a javelin thrower or baseball pitcher or big server or free-styler to develop shoulder pain, but boy, what a challenge they can be for health and fitness professionals! To develop confidence in managing shoulder pain requires more persistence, more willingness to learn from mistakes, and more exposure to different injury types than many other joints of the body. I hope you will find in this case study some important principles for assessment/treatment and prevention that all the above over-use shoulder problems will have in common, yet also see how the sports-specific demands are unique.
This mid-twenties female javeliner reported that her right throwing shoulder first gave her problems two months before coming into the clinic, during a weights session doing clean and jerk. With a heavy weight on the bar, late into her set, and in the full elevation position, she felt a tearing sensation and a strong sharp pain, and had to drop the weight backwards. Since then she had had to avoid doing that movement quickly (ie, rapid abduction/external rotation) as well as front squats and wide-grip bench press. The pain was described as deep, sharp, and on the top and back of the point of the shoulder.
She was able to continue technique work and normal throwing training up until a few days ago when she also started to get a diffuse aching pain in her shoulder - she then realised the problem wasn't resolving on its own.
On further questioning, she also complained of a worsening pain in her rib cage on the right side for the past two months, a recurring clunk in her shoulder when stretching her posterior cuff muscles, difficulty lying on her shoulder - after a short while she would need to click it to relieve a pressure building up - and a three-year unsolved history of right elbow pain (MRI changes with medial epicondylitis). There was no report of any neural symptoms, neck pain, or outright instability. She had no previous history of shoulder problems in four years of competing at national level.

This began with observation: well-developed upper trapezius bilaterally, thoracic kyphosis (rounding of upper back) pronounced, forward located head of humerus right side, and poor control of her scapula on two active movements. In descending from elevation at about 90 degrees, slight winging occurs, and at end of shoulder external rotation with her arm at 90 degrees abduction, the inferior angle of her scapula rotates away from the centre. This tells us that a component of the problem is related to the poor positioning of her scapula, which will force the rotator cuff to work harder to try to stabilise the head of the humerus ('ball') in a central position in the glenoid fossa ('socket').
All passive movements were found to be totally pain-free, with no evidence of labral ('cartilage') damage - this was a very important factor for her as it might make the difference between needing surgical intervention and physio being successful on its own. Neural tension tests and cervico-thoracic joint stressing were similarly negative, as were resisted muscle tests in neutral positions.
However, a number of things came up with instability testing: positive 'sulcus' test on right (possibly evidence of some multi-directional laxity in the capsule), negative apprehension test, slightly excessive translation of the ball in the socket joint in neutral position, posterior laxity at a very specific angle of abduction, and a slightly positive 'relocation test' - ie, a posterior glide of the ball in the socket with active external rotation at 90 degrees abduction would make that movement suddenly pain-free. Trigger points and pain inhibition were found in the rotator cuff muscles with evidence that the larger-power muscles were over-compensating; pec minor tightness was holding the scapula into protraction, and gross restriction of thoracic joints, especially on trunk rotation to the right, was evident.

A later factor
In summary, we can hypothesise (at this point, because another important factor was missed until a few weeks later) that numerous biomechanical issues were causing a muscle imbalance over time which was resulting in over-work of her rotator cuff musculature. Eventually, in a very heavily loaded situation doing the jerk movement, with fatigue present, excessive 'translation' (shearing movement) of the ball in the socket took place. Due to the weight on her shoulder, her subscapularis/infraspin-atus/teres minor/supraspinatus muscle could control the head of the humerus no longer and it slid perhaps only .5 cm forward and down beyond what it would normally do. This likely over-stretched the anterior-inferior capsulo-ligamentous structures, and possibly even tore the posterior capsule and/or pinched the rotator cuff tendon under the sub-acromial arch.
Once our understanding of the essential nature of a problem is clear, it is not too hard to ascertain how to solve it and to begin to draw up a plan with the elite sports person we are helping for return to training and finally competition. With muscle-imbalance problems, the time-scale depends on a number of factors; for instance, if damage has been done (hence do they need surgery first?), their psychological status and maturity as an athlete, availability of their coach, and, of course, how deeply ingrained the imbalance is in their movement patterns of daily life.

This involved releasing and massage of trigger points and deep-tissue massage of pec minor, mobilisation and manipulation of thoracic spine, and beginning (initially simple) scapular-control exercises and rotator-cuff strength/control work. Gradually over a few weeks the exercises were moved up to positions where the problems were - ie, abduction and external rotation - particularly focusing on improving rotator-cuff control of the ball in the socket while still keeping the scapula 'set' in a retracted position.
Treatment progressed very well and she was able to throw pain-free very soon after. However, we struggled to return to doing the clean and jerk at any useful weight, and after a while her pain with throwing began to return. In addition, she was still complaining of her rib/thoracic pain. It forced me to wonder what I had overlooked. It couldn't be a technique error specific to her javelin throw since it was centred around the clean-and-jerk action. Had I properly assessed the length of her power muscles? Which power muscle would be tight in the 'jerk' position?.... Latissimus dorsi - of course! Assess-ment revealed gross tightness of it on the right side - the missing piece of the puzzle. If tight, it would restrict the thoracic/rib cage movement, and shear the head of the humerus inferiorly to destabilise the ball in the socket at the top of the 'jerk'. Equally, an overly-active 'lat' would prevent the subscapularis muscle from working effectively to control the ball in the socket.
She required only one session of firm deep-tissue massage and stretching, and suddenly she was able to begin increasing the weight on her clean and jerk. We reviewed all her control exercises and narrowed them down to a small number of essentials, with the expectation that she should keep them going as part of her weekly routine. This would especially be the case if she became sick or injured again, or during off-season mainten-ance work - she must understand that she would always be at risk of re-injury if she had not done her exercises for a few weeks, since a degree of laxity (not instability - important difference) would always remain in her 'golden shoulder'.

Ulrik Larsen



shoulder pain, shoulder pain diagnosis and shoulder pain treatment