This 27-year-old man came to the Injury Clinic complaining of left-sided thoracic pain and occasional low-back problems, both of a mechanical and postural nature. He mentioned 'by the way' that he had a left-shoulder problem that had prevented him doing any freestyle swimming for a number of years as part of his general fitness regime, owing to sharp pain and a clunk which his GP said 'could not be helped'.
It was decided to investigate his shoulder as the major issue and as a secondary issue deal with the spinal pain.
His shoulder pain was reproduced at 90 degrees abduction with internal rotation, coinciding with the out-of-water phase (recovery phase) of freestyle. There was no pain on 'catching' the water with the arm or during the pull-through phase. On observation, active movements of flexion and abduction were pain-free; however, quadrant position and the inclusion of internal rotation to elevation brought on pain and a clunk. Poor scapular control on descent from elevation at 90 degrees and segmental stiffness at thoracic spine levels were evident.
Closer examination revealed an anteriorly displaced head of humerus (HOH) by .5 cm in resting position, mild posterior capsule tightness (clear from stiffness on a post-glide of HOH and marked decrease in internal rotation through range of elevation), tightness with trigger points in infraspinatus, teres minor, pec minor and subscapularis muscles.
In prone, internal rotation with the therapist retracting the scapula and holding the HOH centrally, confirmed the noticeable external rotator tightness and inner-range weakness of subscapularis. These factors are central to under-standing why he has gradually lost scapular control and why the axis of rotation of his HOH has been shifted anteriorly. (Trigger points in infraspinatus and teres minor will weaken the ability of these muscles to eccentrically hold the HOH centrally in the glenoid fossa). Finally the pec minor becomes shortened and overactive and pulls his scapula into downward rotation and protraction; consequently his thoracic spine loses its extension mobility.
This is what then has resulted in sub-acromial impingement, with thickening of the rotator-cuff tendon, possibly explaining the audible clunk on the recovery phase. However, it is commonly very difficult to ascertain which factor is the chicken and which the egg in multifactorial chronic injuries such as this.
Treatment progressed on three levels:
1. Flexibility. Deep-tissue massage, trigger-point releasing and stretching were employed with gradual progression towards the impingement directions, eg, firm massage of infraspinatus with the arm abducted to 90 degrees and in 45 degrees of internal rotation (scapula held in place by a seatbelt) or pec minor massage in 90 degree abduction or the quadrant position (as tolerated). Home stretching with due attention to scapular position is crucial.
2. Control and Re-education. As flexibility returned in the rotator cuff and pecs, lower trapezius setting exercises with infraspinatus activation (through a co-contraction in the shoulder) were progressed gradually towards the prone recovery movement of freestyle. Subscapularis had to be taught how to work in inner range and thereby stabilise the HOH with infraspinatus.
3. Technique. This needed to be evaluated in the pool, and two factors needed to be changed: (a) he was encouraged to drop his elbow to a sufficient degree and lead with his hand (still keeping the elbow above the hand, however) early on in his return to freestyle; (b) there needed to be increased body roll when his right arm pulled through the water, and he was encouraged to learn how to breathe bilaterally, not just to the right side.
All these factors have been critical in his full return to freestyle as part of his routine, but they will require constant monitoring and maintenance of flexibility to prevent recurrence.