A neighbor of mine was walking and ran into my wife, she told her she had trouble with her right shoulder brought on and worsened by tennis. It has not been improving for the last 4 months.
Terminology refresh!
Subjective: Pt reports onset of R shoulder pain while trying a new tennis serve in July 2012. Since then, Sx have been unchanging and return each time she plays tennis. Sx worse with serving, R sidelying, throwing. Sx better with rest, ibuprofen. Sx are intermittent and rated 3-7/10
Objective:
ROM
Cervical
flexion FN
extension DN, mild loss
Rot/flex Left DN, mild Right DN, mod
breakout FN in PROM NWB
Thoracic
Rotation Left DN, mod Right DN, mod +
Shoulder
LRF Left DN, mild Right DP, sev
MRE Left FN Right DP, sev
MSR Left DN, sev Right DN, mod
hip IR Left DN, sev Right DN, mod
MSE DN, sev
hip flexed, shoulders crossed Left FN Right DN
Myofascia: moderate restrictions in R cervical paraspinals, upper trap, lateral upper arm, thoracic paraspinals, L > R ITB, L psoas
Assessment: Signs and Sx consistent with right shoulder impingement syndrome
The assessment part is formal, normally I write it for the doc or the insurance company, because I look at it much more than just a shoulder problem. Even the patient asked, "So what's the diagnosis?" I stated her shoulder is not moving well, along with her mid-back and left hip. These are contributing to some r/c impingement which is accentuated by her new slice serve, and not by the mechanics of her normal flat serve. She was happy with that, and saw the benefit in working on things other than her shoulder. Do I have to treat all those things? No, but if you have the means, why wouldn't you make someone's movement more efficient? There is a reason why tennis pro's, coaches etc, teach the correct form. It baffles me when someone does not correct biomechanics, despite all the terrible asymptomatic movers out there.
Treatment:
Day 1: IASTM to cervical paraspinals, upper trap, levator scapula, right lateral upper arm. Instruction on repeated shoulder extension in standing and open book for thoracic mobility.
Day 2: She came back after playing tennis (I told her she was ok to play, as she was not better or worse from recent playing) stating she was 100% pain free. Her LRF and MRE were still moderately limited as was thoracic rotation. Hip extension and IR on the left were still DN and severely limited.
Treatment was as on day 1, but added psoas release, QL, ITB on the left along with hip LAD, MWM to improve hip IR. We reviewed HEP from day 1 and she was instructed on repeated hip IR for HEP.
That's it for now, she's coming back for a few more visits this week. As she still has some motion limitations, I want to clear as much of those up as possible prior to discharging her. However, I don't require 100% mobility in all those areas as she may have not had that for years. Once her mobility is improved, I'll check rolling patterns. I estimate she'll be discharged to HEP in 3-4 more visits.
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