Many patients perform repetitive overhead activities in sport and work, earning them the classification of overhead athletes. The literature abounds on treatment protocols for this demographic, and other than the inclusion of acceleration and deceleration activities needed for sport, the principles presented below apply to the wallpaper hanger and hairstylist, too.
Assessing Scapular Function
Optimal scapular function is integral for optimal shoulder function (Kibler). While not a true joint, the scapulothoracic junction is considered part of the shoulder girdle, along with the glenohumeral, acromioclavicular and sternoclavicular joints, and must be assessed statically and dynamically.
In shoulder conditions the scapula often protracts, causing aberrant shoulder girdle kinematics, dysfunctional muscular firing patterns, and an increased risk of injury.
Scapular dyskinesis is the term for this abnormal movement and position of the scapula. Kibler tests for scapular dyskinesis by having the patient actively raise and lower the arms in full flexion 3-5 times, with 3-5 lbs. in each hand, observing for medial scapular border winging, a positive sign.
In addition, the scapular assistance test is used to assess for anterior impingement syndrome and the scapular repositioning test aids in the differential diagnosis of dyskinesis versus glenohumeral or rotator-cuff involvement.
Global / Kinetic-Chain Assessment
Since finding the cause of the patient’s shoulder pain is our goal, a global assessment must be performed and include evaluation of the entire kinetic chain. Postural assessment for Janda’s upper-crossed distortion is a must, as is assessment of joint play in the entire spine, upper and lower extremities.
In addition, muscle firing patterns in the lumbopelvic hip complex, cervical spine and core need to be observed, along with evaluation for myofascial trigger points and soft-tissue imbalances. Finally, cervical nerve root or organic referral to the shoulder needs to be considered.
Exercise Corrections
Proper trunk movement and control are vital for the transfer of energy from the lower body to the upper extremity. In fact, the hip / trunk area contributes approximately 50% of the kinetic energy and force to the entire throwing motion. Loss of hip ROM, especially internal rotation, directly relates to inefficient energy transmission through the pelvis.
Ellenbecker advises stacking trunk and scapular stabilization exercises to create increased core stability while strengthening the deconditioned and/or injured upper-extremity muscles. For example, shoulder external rotation with elastic resistance can be done while in a side plank for simultaneous core activation.
Don’t Ignore the Lower Extremities
Considering the high energy forces created in the lower extremity during sports, it is understandable that lower-extremity (LE) injuries are the most common injury seen at all levels of play. In overhead sports such as baseball, tennis, volleyball, and even track and field events, LE injuries account for approximately one-third to two-thirds of all injuries. In addition, the cumulative rotational and extension sheer of throwing motions can lead to lumbar stress fractures, especially in youth athletes.
Shoulder Pain in the Cricket Bowler: A Clinical Case Study
Cricket is the largest spectator sport in the world after soccer, and is rapidly growing in the United States from youth to professional levels. The positions include fielders, batters, wicketkeepers (catchers), and bowlers (pitchers).
There are two types of bowlers: fast and spin. Fast bowlers accelerate along a pitch before releasing the ball in an overhand delivery involving shoulder counter-rotation in conjunction with rapid lumbar spine lateral flexion and rotation. An elite fast bowler throws up to 100 miles / hour.
Examination revealed a right-handed 15-year-old spin bowler with pain in his right anterior shoulder and upper arm that began while bowling two days earlier. The pain was worse at the top of his arc of delivery, yet throwing (as with a baseball) and batting were pain free.
He presented with kinesiology tape along the anterior aspect of his upper arm and a self-diagnosis of a strained biceps. There were no other comorbidities or significant abnormalities noted.
Clinical Tip: The biceps both flexes and eccentrically contracts the elbow during the cocking phase of bowling. It also prevents glenohumeral joint distraction and anterior subluxation during deceleration. Therefore, the patient’s “Dr. Google” diagnosis of a biceps injury is logical.
DTRs and sensation in the upper and lower extremities were WNL and symmetrical. Passive ROM of the right shoulder was unrestricted and pain free. Active ROM was full and locally painful in the anterior shoulder in full flexion and abduction only. Orthopedic testing for glenohumeral instability was negative.
Resisted muscle testing of the individual muscles of the rotator cuff was pain free and graded at 5/5. Biceps tendon load testing and instability tests of the tendon within the bicipital groove were negative. Labral tests were negative. There were no signs of sub-cromial or subdeltoid bursitis.
Chiropractic examination revealed a loss in the cervical lordosis and thoracic kyphosis, rounded shoulders and a protracted scapula. Overactivity of the upper trapezius was noted in abduction bilaterally. Loss of joint play was noted in the cervicothoracic spine, right sacroiliac and sternoclavicular joint.
Scapular repositioning and assistance tests were negative. Dynamic Trendelenburg test was positive for gluteus medius weakness bilaterally. Myofibrosis was found in the subscapularis, infraspinatus, teres major, latissimus dorsi, pectoralis minor and subclavius muscles. Cervical ROM and orthopedic tests were negative. Radiographs were negative.
A working diagnosis of scapular dyskinesis and sternoclavicular joint dysfunction with a resultant grade 1 rotator-cuff strain was made and care began.
Treatment Protocol
Manual myofascial release and instrument-assisted soft-tissue mobilization with movement provocation were performed over the region. The subclavius was especially tight. CMT of the dysfunctional spinal segments and the sternoclavicular joint were performed.
Clinical Tip: The subclavius depresses the clavicle and stabilizes the sternoclavicular joint. It is within the clavipectoral fascia along with the pectoralis minor, coracobrachialis, and short head of the biceps. The sternoclavicular joint and subclavius dysfunction were directly related to the anterior shoulder pain in this patient.
Strengthening of the scapular stabilizers (mid and lower trapezius) was performed with elastic resistance and began prone. Once the patient was able to limit upper trapezius firing, the exercises progressed to standing and included external rotation, extension and horizontal abduction.
Prone external rotation at 90 degrees of abduction was also performed. Strengthening of the serratus anterior was achieved with supine protraction and wall push-ups, and progressed to dynamic hugs and push-up-plus exercises.
Clinical Tip: A classic dysfunctional firing pattern observed in shoulder pain is hyperactivity and early activation of the upper trapezius, decreased activity and late activation of the middle and lower trapezius, and reduced strength of the serratus anterior, scapular retractors and depressors.
Clinical Summary
All patients who perform overhead activities are vulnerable to shoulder injuries, whether in sport or ADLs. As doctors of chiropractic we are uniquely suited to be the go-to provider for assessment and management of shoulder pain and dysfunction.
Our ability to assess and correct imbalances in the entire kinetic chain with a chiropractic multimodal approach is superior to exercise or modalities alone. This is the key for symptomatic resolution, as well as the ticket for prevention of recurrence.
Resources
- Constable M, et al. Quantification of the demands of cricket bowling and the relationship to injury risk: a systematic review. BMC Sports Sci Med Rehab, 2021;13:109.
- Dinshaw N, et al, Injuries in cricket. Sports Health, 2017;10(3):217-222.
- Ellenbecker TS, Aoki R. Step by step guide to understanding the kinetic chain concept in the overhead athlete. Curr Reviews Musculoskel Med, 2020;13:155-163.
- Edwards PK. Exercise Rehabilitation in the non-operative management of the rotator cuff tears: a review of the literature. Int J Sports Phys Ther, April 2016:11(2):279-301.
- Farhart P, et al. Intrinsic variables associated with low back pain and lumbar spine injury in fast bowlers in cricket: a systematic review. BMC Sports Sci, Med & Rehab, 2023;15:114.
- Koscso JM. Lower extremity muscle injuries in the overhead athlete. Curr Reviews Musculoskel Med, 2022;15:500-512.
- Pote L, et al. Strength and conditioning practices of franchise-level cricket trainers. S Afr J Sports Med 2020;32:1-5.
- Saini SS. Scapular dyskinesis and the kinetic chain: recognizing dysfunction and treating injury in the tennis athlete. Curr Rev Musculoskelet Med, 2020 Dec;13(6):748-756.
- Singla D, Hussain ME, Bhati P, et al. Reliability of electromyographic assessment of biceps brachii and triceps brachii in cricketers. J Chiropr Med, 2018 Sep;17(3):151-159.
- Walter S, et al. Effect of Indian clubbell exercises on cricket fast bowlers’ shoulder kinematics. S Afr J Sports Med, 2023;35:1-7.
