What’s wrong with this patient?

Posted: February 7, 2013 in Uncategorized

I want to share with you a patient who I’ve seen 5 times over the past 7 weeks for right shoulder pain. He is an avid volleyball player and want’s to get back to his sport. I saw him earlier on in 2012 and diagnosed him with a SLAP tear. He was referred for an MRI which showed just what I suspected. Unfortunately conservative care could not fully abolish this patients pain and clicking in the joint. He had labral repair surgery 10 weeks ago and while in surgery, his surgeon noticed substantial anterior capsule laxity and decided to do a capsular resection and shift…meaning they cut into the anterior capsule to pull it tighter together preventing excessive humeral head anterior migration.

Initially treatment consisted of gentle PROM and scap setting stuff. He was told he could not go past 90 degrees abduction and over 10 degrees ER in neutral for the first 8 weeks (seems excessive to me). We have done lots of manual therapy work in the form of gentle PNF stretching, myofascial release (or whatever you want to call it), passive scapular mobilizations  and are now starting both anterior and posterior capsule stretching. I am also starting gentle proprioceptive drills with him in supine. His exercises to date have included:

  • Pendulums (codmans)
  • AAROM into flex, abduction, ER in neutral using a golf club
  • Proprioceptive drills leaning the arm into a rubber ball against a wall and making figure 8’s
  • Scapular rows
  • Prone glenohumeral joint centration exercises using a 10 pound weight… think “suck the ball back into the socket”I had him doing scaption with a band but stopped this exercise due to what I was seeing in the video you can see below. Can you guess why I decided I didn’t like it for him?

Based on the one video you are about to see of this gentleman doing bilateral shoulder abduction can you tell me what you see? Based on what you see can you give me some reasons for it and what you would do about it? I would be curious to get other perspective as I have my ideas and will share them in part 2 of this post but I always like knowing what other clinicians would do.

Shoulder video

Thanks!

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Comments
  1. Decreased inferior glide of humerus (from long period of post op immobilization) in ABD increases UFT activation and inhibits proper scap-humeral patterning. If allowed by protocol I would mobilize humerus in ABD and ER inferiorly, (release inf structures first), then continue repatterning exs.

  2. Right serratus anterior is lazy on return from scaption. I would love to see a supine view of this patient from the top. Look where his AC joint is sitting to see if his pec minor is tight. Then look at rib 4-5 mobility on the right.
    I agree with Nora also. Mobs might help, but look at internal rotation strength as the sub scap is usually the culprit here. Upward rotation could be better too on the right. Look at upper trap strength and rhomboid dominance, although with that winging in return from scaption, it may not be a problem.
    Cool video. Great job Jessie.

  3. julio says:

    If you check the deltoid creases not exist at all in the right shoulder, so that’s means that there’s not movt. in the GHJ? If the surgeon did an anterior capsular repair could be possible that now the patient has a post. “instability” o excessive post translation of HOH?. Everybody mention the way UT, serratus aneterior, and so on work but how was before the surgery.

    • Steve says:

      Are you familiar with the work of Dr. Evan Osar and his book “Corrective exercise solutions for common shouder and hip dysfunction?” I think some of the strategies in this book would be beneficial to this patient.

  4. Adam says:

    Looks to me like he has GH stiffness post op – giving him the initial appearance of good upward rotation. You can see it is not driven by a proper muscular pattern because the centre of rotation is about the acromion right away rather than starting at the base of the spine of scap and only finishing with rotation about the acromion. Also – there is an obvious lack of eccentric control of serratus.

    • jessephysio says:

      Thank you Adam, I appreciate the feedback. You’re absolutely right. He used to drive his upward rotation from his levator scap as apposed to serratus and upper/lower traps. We have since corrected this. His anterior capsule is still tight, which is pushing his humeral head posterior with external rotation. This is probably due to the capsular shift surgery and is something that will hopefully resolve with time.

      His eccentric scapular control is much better. Thanks!!

  5. Trish says:

    Hi Jesse, I’ve been following this post for a little while now I agree with the observations about your patient’s pattern, especially in regard to the lack of serratus anterior control. I’m wondering how you progressed your exercises since the initial set you had listed above.
    I’m hoping that you will do a follow up post, as I have a patient with a similar pattern (due to a period of immobilization) and I need some new serratus and repatterning exercises!
    (sorry if this posts twice, I think my earlier comment deleted itself!)

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