Assessing Overhead Arm Elevation - Video Case Study

Assessing Overhead Arm Elevation – Video Case Study

Assessing overhead arm elevation is one of the many things I look for during my integrated movement assessment.  This is a big part of the Champion Performance Specialist program.  The information you gather on the person’s ability to perform such a basic task is often invaluable when designing someone’s rehab or training program.

I have a video below of an assessment I performed that I wanted to share.  It’s an interesting case with a bunch of movement compensations.  I thought it would be nice to outline my thought process

But first, let me give you a little history…

The patient is a competitor high school swimmer with insidious onset of bilateral generalized shoulder discomfort and fatigue in the pool after prolonged swimming.  He had been seeing another clinician for soft tissue treatments in the past (hence the cupping marks.  His laxity was mostly posterior in nature, but certainly multidirectional.  The exam obviously reveals generalized laxity you would expect with a swimmer, however no significant structural pathology detected.

Here’s what I saw:

Pretty interesting, right?  Scroll down to the comments section and let me know what you think!

Let’s dig into some of my thoughts.

 Assessing Overhead Arm Elevation

  • I would first comment and state that this is one quick video in a long series of assessments.  I chose overhead elevation because it was simple and reproducible  and showed a bunch of interesting things!  I start my assessment off by simple asking them to raise their arms over head.  That is it.  No other instructions.  I feel that it is important to assess how “they” want to move, not how “I” want them to move. assessing overhead arm elevation
  • A test like overhead elevation in the sagittal plane, such as in this video, assumes two thing: symmetry and neutrality.  I don’t think either of these exist.  So it is inherently flawed.  Think about it, if his scapulae are off, then doesn’t that mean his glenoid is off?  Then technically the “sagittal” plane is just in relation to the ground, not to his body.
  • There is also a “chicken and the egg” concept here.  Did his pain create the dysfunctional movement or vice versa?  Unfortunately in retrospect we’ll never know.  Taking this into consideration I don’t think it is fair to assume that anything we are seeing is the “cause” of his pain.  Essentially it is all just the summation of where we are today.
  • Many people often want to jump right in and label specific muscles, such as being “tight,” “long,” “short,” or “weak.”  Remember all we know here is that he has a movement dysfunction.  I think it is appropriate to suggest these may be true, but you will need to take the next step and assess these assumptions.  I wouldn’t just jump in and treat based on assumptions.
  • I should also comment on the marks on his back.  One relevant, the other not so relevant.  The circles are cupping marks.  He is seeing another provider that performs this as part of his maintenance program while swimming in addition to massage etc, not for treatment of his symptoms.   However, the horizontal marks on his low back are relevant.  Those are stretch marks.  More on this later…

Static Scapula Position

  • I have commented on this before in my article on Myths of Scapula Exercises, but I don’t put a lot of emphasis on resting static scapular position.  Realistically, the scapula sits on the ribs, so it’s resting static posture is likely more a reflexion of rib and thorax position that scapular position.  I prefer to look at scapular dynamic movement quality.
  • Interestingly, you can see his dynamic concentric control of his scapulae doesn’t seem as bad as you would think based on his static resting position, especially as he gets high into elevation:

static and dynamic scapula position - assessing overhead arm elevation

The Head Wiggle and Scapula Wing

  • The first thing that really stuck out to me was his head wiggle.  I bet you missed it the first time!  A very interesting movement pattern.  In retrospect, you can find him shift his neck in this fashion quite a bit while observing him moving around and performing activities, even just talking to you sometimes.  It is not limited to just overhead elevation in the sagittal plane.  
  • We can’t really separate this from his winging scapula, they go together.  It sure looks like the head wiggles when the scapula wiggles.
  • To me, this looks like the levator scapula pulling the head with a complete lack of opposition from the lower trapezius and serratus anterior.  His head goes into side bend to the left and extension.  This is the cervical responsibility of the levator.  However, his scapula also shoots up into elevation and downward rotation.  This is my biggest indicator that levator is the one acting.  There could be more involved, like SCM, but I’m focusing on levator.
  • There is obviously some winging and lack of opposition of the levator by the traps and serratus.  This is really obvious on eccentric lower.  He also does not have a painful arc during this movement.  He is not shifting away from pain.

scapula winging - - assessing overhead arm elevation

  • So while the levator may be causing the head wiggle, it sure looks like the serratus and lower trap are not doing their job and creating the scapula wiggle.
  • See how everything plays together?

 

The Elbow Wiggle

  • Did you notice the elbow wiggle?  I don’t think this is really an elbow issue.  If you watch closely he keeps his hand in the same position.  He essentially fixes his hand on an imaginary sagittal plane track.  To me his shoulder and scapula want to move into adduction and internal rotation with the beginning of his scapula winging about to occur.  I feel like his glenoid may be the one the is not stabilized.  Since we have forced him to perform a strict overhead assessment in the sagittal plane, he is keeping his hand fixed and his elbow has to hyperextend to not allow his hand to horizontal adduct.  Again, just shows some of the flaws of assessments like this.

elbow compensation - assessing overhead arm elevation

  • So while this may be glenohumeral instability, I think it is still just the scapula as it occurs during the eccentric lowering and he has almost no ability to control winging.  And again, he does not have a painful arc.
  • This really illustrates a general point that I tend to make about humans in general, but even more so on high level athletes.  We are excellent at getting from point A to point B.  It’s all about how we get there.  Unfortunately the overhead elevation assessment uses an internal cue to “raise your hand up in front of you.”  Perhaps it would be better to give an external cue like “reach up and touch the ceiling.”

 

Thoracolumbar Flexion

  • So taking away all the interesting things happening from the scaps up, I also notice some interesting thoracolumbar compensations.  Remember, this client is a swimmer, and a high level swimmer.  Is it me or does his left latissimus look too small for a swimmer?
  • I mentioned earlier the stretch marks on his lower back.  When he tries to pull down with his arms with any resistance, his movement compensation was to go into a large amount of thoracolumbar flexion, which is a compensatory movement for the inability to extend his arms against resistance.  His lumbar paraspinals show hypertrophy.  So while this could be poor core control, I feel that may be too simplistic.  He goes into thoracolumbar flexion with minimal resistance.  Seems more compensatory rather than poor patterning.  In the photos below, that is not just paraspinal hypertrophy, that is also flexion:

latissimus - assessing overhead arm elevation

  • In looking at the photos above, see how he moves into thoracolumbar flexion?  These are fairly recent photos.  Here are a couple of photos from two months prior.  You can really see the thoracolumbar flexion compensation.  But also notice the dramatic increase in body composition in 2 months.  He put on 15 pounds of muscle mass in a 2-month program designed specifically for him:

thoracolumbar compensation - assessing overhead arm elevation

  • One thing I mentioned was that he feels symptoms with prolonged swimming.  He actually fatigues out well before his fellow swimmers.  Feels strong and swims well, then hits a wall quickly from 10-20 minutes in the pool, while everyone else is in there for 60-120 minutes without complaints.  While he looks a lot better.  There are still some muscles that are not coming back as expected, and he is still fatiguing out in the pool and feeling generalized symptoms.
  • This really makes me question a nerve issue that is just not allowing proper muscle function, and/or the fact that he is essentially swimming with his accessory muscles like his teres major and deltoids.  This is something we need to explore further.

 

Conclusion

Assessing overhead arm elevation is an important part of my overall movement assessment process.  There are many compensations that I typically see, but most don’t present as complex as this video case study.  I hope you enjoyed reading through my breakdown of how I assess overhead arm elevation and some of the things running through my mind!

Comment below if you think I missed anything!

Interested in learning my whole movement assessment system?  It’s a part of my Champion Performance Specialist program, where you’ll learn our exact system of assessing movement, then optimizing and enhancing performance.  It’s exactly what all the physical therapists and strength coaches follow at Champion when building our performance therapy and training programs.

 

Champion Performance Specialist - laptop mockup

 

 

70 replies
  1. Michael Powell
    Michael Powell says:

    With his postural distortion in the upper T/lower C spine, I would suspect a thoracodorsal nerve impingement/lesion, potentially long term issue for which he has created dramatic “work arounds” as he has grown and developed.

    • Mike Reinold
      Mike Reinold says:

      Michael, this is a great thought for sure. Believe it or not, he did not have any nerve injuries. Just instability of the shoulder, which created all those compensations as he tried to control his shoulder!

  2. Michael Gonzalez
    Michael Gonzalez says:

    Hey Mike,When he is just about finished reaching full elevation there is a downward shift that occurs in the left GHJ that does not appear to happen on the R side. Whats your opinion on why that is happening? I think that as he is elevating that Humeral head is shifting inferiorly due to the instability. Is it possible the elbow wiggle is caused by the humeral head sliding back to center as he brings the arms back down?

  3. Nic Larson
    Nic Larson says:

    This is a scapular detachment. My opinion is rhomboid tear from intense weight training and swimming.

  4. Melissa A, PT, CSCS
    Melissa A, PT, CSCS says:

    I wonder if the cervical wiggle is indicative of scalene issues and possibly a thoracic outlet compression that is preventing restoration of good symmetrical motor control. Maybe check on pec minor flexibility and address withsoft tissue work, stretching to release pec and the scalenes. Great case study.

  5. Zack Johnson
    Zack Johnson says:

    I’m not sure I put much stock into his scapular kinematics. Nice article: “Is There a Relationship Between Subacromial Impingement Syndrome and Scapular Orientation? A Systematic Review”
    Elizabeth Ratcliffe et al. Br J Sports Med. Aug 2014

    Great article on kinematics and if it’s relevant to SIS. Although it sounds like he may not have SIS the article quotes research how there is a wide variety in kinematics with injured and no injured pt’s. It would be interesting to see if his movement pattern is the same after rehab, also would be nice to see if there was a change in movement with his swimming pattern. Also would be nice to know what stroke he does mostly. Either way crazy looking kinematics that may not resolve but he can reduce his symptoms with proper therex principles!

    • Mike Reinold
      Mike Reinold says:

      I don’t know Zack, I think this is one of those areas where the jaded opinions on social media are influencing people the wrong way.

      This case has nothing to do with SIS. He has instability. And that meta is so broad it’s hard to draw any conclusions. Of course, detecting a mild scapula dyskinesis is not abnormal and just one of the many factors related to SIS.

      But significant dyskinesis absolutely can impact shoulder pain. Careful not to throw the baby out with the bath water. It’s common to just be cynical and say nothing works on social media right now, but my guess is nothing works everything and everything works for something.

  6. Sean langan
    Sean langan says:

    Right arm is further from the head at end range and throughout the whole motion. Abnormal neck and distal arm/forearm movement on the first rep. Definite scapulothoracic dysfunction on the left side.

  7. Samantha Kidd Pittsford
    Samantha Kidd Pittsford says:

    The asymmetry and decreased stability is obvious, but the cervical motion blew my mind. Upward rotation doesn’t look too bad to me, most of the dykinesia occurs on left side when lowering to neutral. This is coupled with left cervical side bending. Left Levator? I’m not too sure.

  8. Bill Weissert, PT, OCS
    Bill Weissert, PT, OCS says:

    Interesting stuff. Excessive scapular movement in the first 1/3 of elevation tells me that scapular stability is lacking. Winging and tilting on return on left. Poor scapular elevation at end ROM, or he is already so elevated at the outset (common with swimmers) . I doubt his serratus is weak, just he has poor timing, esp on left. Without looking at Mike’s assessment, I would definitely be following up with an assessment of trap function and scapulohumeral stiffness. Does he swim butterfly?

  9. Bruce J. Fellows
    Bruce J. Fellows says:

    Moving through the saggital plane the most glaring component in this video, in my opinion, is that during L shoulder flexion and at about 90 degrees the arm, for lack of a better term sort of wiggles (why is this? Laxity? Instability? Prior injury to elbow/shoulder?), this occurs at the same degree of motion during both concentric and eccentric phase of the movement. Also as the patient comes back to neutral position the scapula wings mostly at the medial border, but some posterior tilting seems to occur as well. This is highly suggestive of shoulder girdle instability, thus predisposing to injury.

    Additionally, it would appear, that upon initiating and completion of the movement that the head laterally translates from L to R. This may due in part to an overactive upper trap on the right. However I had trouble seeing any glaring differences in the upper trap during movement.

    The L arm when hanging at the patients side seems to be closer to the torso than the left. I am surmising that this patient has some R to L muscle imbalances (not based on this finding alone). Perhaps found in the Lats, Rhomboids, upper trap, maybe even pecs or serratus (is he more stroke dominant on the right? Just curious.)

    Anyway, this was an interesting video as you mentioned, and a lot of fun to try and assess and critique. Thank you for the opportunity Dr. Reinold, I look forward to reading your interpretation!

  10. Daniel Maggio
    Daniel Maggio says:

    Hi Mike, I just got accepted into PT school beginning fall 2015, so these videos are really going to help train my eyes!

    From my limited knowledge I see slightly more internal rotation of the left humerus….whether or not it is the cause of the excess scapular winging on the left side – almost looks like over-compensation of the winging because of an acromio-humeral impingment (possibly a secondary issue caused by the scapula).

    It almost looks as though there is an underlying scoliosis that could be the root of all secondary symptoms. maybe not scoliosis but a sufficient enough asymmetry in the thoracic spine. Especially upon the athlete raising the arms into flexion, there is a noticeable cervical shift.

  11. Mike Reinold
    Mike Reinold says:

    Thanks so much everyone, love the thoughts, comments, and discussion! I am just finishing up my summary of the video and will post it up tomorrow as a new post for everyone to see.

    • Leanne Teron
      Leanne Teron says:

      Hi Mike
      Did you check him for Scheuermann’s Disease with an upper thoracic scoliosis? Those stretch marks on his back could indicate that his bones were becoming wedge shape.

    • Leanne
      Leanne says:

      Hi Mike
      Did you check him for Scheuermann’s Disease with an upper thoracic scoliosis? Those stretch marks on his back could indicate that his bones were becoming wedge shape.

      • Lisa
        Lisa says:

        When I see stretch marks, I think connective tissue disorder such as Ehlers Danlos, likely hypermobility classification. These patients tend to have significant joint instability, difficulty building muscle, and some have neurologic funkiest that doesn’t look quite right. Stretch marks are common even without significant weight gain.

  12. Michael Zweifel
    Michael Zweifel says:

    Definite scapular dyskinesia, left elbow hyperextension, also seems to be some poor patterning or rhythm. Would be nice to see side or front view to see what the ribs are doing. Also are those paint ball marks or some cupping therapy?

  13. Aline T.
    Aline T. says:

    Great post Mike. Like others, I would appreciate a different view or 2! What are his CS movement like….I agree with Darryl Elliott…I would want to check out his mid CS and upper TS.

  14. Evanthis Raftopoulos, PT
    Evanthis Raftopoulos, PT says:

    Ruben, if the problem is the experience of B shoulder pain, you cannot really see that with xray’s or any imaging studies. You can make a lot of assumptions thought from studying mechanics (see above).

  15. Evanthis Raftopoulos, PT
    Evanthis Raftopoulos, PT says:

    Primary complaint:
    “bilateral generalized shoulder discomfort”

    1. Cannot rule out that motor function on the L is pre-existing, who knows why

    2. any rationals for primary complaint (see above) solely based on variable movement patterns of L scapula or other bodyparts are more likely based on speculations (confirmation bias) and less likely based on what is established in the literature.

    3. If 1 and 2 are true and the goal is helping eliminate symptoms, then attempting to correct what has been mostly suggested so far as “dysfunction” does not make much sense.

    • Ruben
      Ruben says:

      You won’t find knowledge of normal and abnormal kinematica of the shoulder girlde in static images and text from literature. Try x ray cinematografic examination and you’ll learn to see the problem.

  16. Darryl Elliott
    Darryl Elliott says:

    Mike,
    Great format to present something like this. Would like to discuss with you more on this style.

    Given the brief onset history and watching the video would want to look at C5-T1 to for anything that could be causing nerve irritation that would affect the muscles that are being affected in the shoulder.

  17. jfreyou
    jfreyou says:

    Severe scap instability L. Serratus ant not stabilizing at all but lots of other muscles compensating. Early upward rot L scap significant during GH flexion, scap slips into stabilized position near EROM L sh flex as shoulder flexors torque on scap lightens up once a overhead. During return to neutral from L sh flexion , scap goes way past normal downward rotation and with no stabilization slips upward and adducts also. This lack of stability at scap causes the cervical stabilizers (lev, UT etc.) not to be able to assist as much at cervical spine causing significant R lateral Side bend/shift at mid cervical. Excessive c spine motion likely leading to diffuse ache B upper back, sh, neck etc? Am I close? Likely all coming from Long thoracic nerve damage L. Is there a history of trauma here. Could the swimming mechanics of certain strokes have caused an over stretch injury to L long thoracic Nerve?

  18. jessephysio
    jessephysio says:

    Aside from the obvious poor eccentric control of the left scapula, look at his left elbow on the way down…it does a weird wiggle/hyperextension type thing. Could this be related to him avoiding a painful position at the shoulder or generalized laxity at the ulnohumeral joint?
    Also, he looks as though his scapula bilaiterally sit in a downwardly rotated position at rest..this could be a function of tight lev scap/rhomboids, weak lower traps or a combination of the above. I also noted a mid cervical spine right side bend on the way down..hard to know what that means without a few other tests.

    Looking forward to your thoughts mike!
    Jessephysio

  19. melissa messervy Physio in Jersey
    melissa messervy Physio in Jersey says:

    I’m guessing long thoracic nerve palsy (as mentioned by Patrick) probably due to compression from hypertrophy of muscle or traction from swimming, & then medial & upward migration of scapula compresses it more or other way round migration of scapula from muscle imbalance causing compression of nerve.
    Thanks for this mike, I enjoy your posts & this time I felt compelled to interact!

  20. john power
    john power says:

    Question about nerve palsy. wouldn’t the scapula wing with significant downward rotation and up trap facilitation from the onset of shoulder flexion if the long thoracic nerve conduction/SA was impaired? I see pretty good concentric SA activation, not so good eccentric. The SA is working. To me the muscle impairment is due to joint dysfunction and inhibition

  21. Sebastian
    Sebastian says:

    Thanks for posting Mike.
    I can only say that if their is a perception in the patient of a problem and pain in the shoulders, we are probably looking at “defense” patterns versus “defecty”.
    IOW, analyzing his present moevement patterns is interesting, but does not provide us with anything solid to focus on for treatment, does it?

  22. Marion
    Marion says:

    Obvious scapula stability issues as mentioned in detail above, in addition to loss of thoracic flexion in neutral. At the limits of glenohumeral flexion, there is a distinct over accentuating of thoracic extension. General loss of thoracic extensor bulk and over development of lumbar extensors. Piece it all together for us MIKE!!!

    On a social media note, this format of post is obviously a WINNER, look at the levels of engagement? A social media managers JOY. Congratulations.

  23. john power
    john power says:

    Left GH joint lesion, labral tear, instability, begins just before 90º of concentric flexion. The various dysfunction muscle firing patterns are compensatory for primary joint dysfunction.

  24. Paul Randles Melbourne Aust
    Paul Randles Melbourne Aust says:

    Hi everybody from Australia.
    To my mind this video would suggest winging scapula Left with other compensatory movements just that. I think our swimmer friend needs to be cleared of neurological injury. A likely prolonged conservative management seems likely.
    Thanks MIke.

  25. Patrick Davin
    Patrick Davin says:

    Looks like significant inferior angle dysfunction (Type II scapula dyskinesis) with eccentric shoulder elevation most likely due to serratus anterior weakness. With the amount of anterior scapula tipping and assumed serratus weakness, I would wonder about a long thoracic nerve palsy. Would be interesting to see what patient would look like with wall push-ups. I would also be interested in checking patient’s symptoms with scapular retraction test as well as ability to stabilize in closed-chain.

    Patrick Davin MSPT, ATC, CSCS

  26. Danielle Reiss
    Danielle Reiss says:

    1. Poor eccentric control: scapular winging on return from flexion
    2. Overactive levator scap (L>R). And on L side shldr flexion is initiated by scap elevation (levator) not GH motion
    3. C-spine lateral flexion L on return for flexion (most likely upper trap/levator compensating for weak eccentric control of GH muscles)
    4. R shoulder more ER and R forearm more supinated than L (weak biceps and rot cuff on L)

  27. Walter A. Murphy
    Walter A. Murphy says:

    What’s up with those red patches?? I see obvious weakness in the serratus anterior with obvious scapula winging. Also poor recruitment of the lower trapezius.Since he is a swimmer he might be tight in his lattisimus as well. I would start treatment in those areas.

  28. Manoj
    Manoj says:

    Hi Mike,

    Thanks for posting such an unique video. I feel his L shoulder has RC muscle deficit especially supraspinatus. He is using two joint muscles(triceps , Biceps) to bring about the elevation and his depression is controlled by Trapezius and Levator. All those red patches also indicates some thing which you would have obtained through history..

  29. Paul G
    Paul G says:

    I agree with all the comments about the left scapular but think that there is something going on with the right that is forcing the movement pattern to occur. There is a left lateral shift in the upper thoracic region through the movement.
    The work mentioned to solve the left scapular issues are required but the right side looks tight at the top of the movement, and as someone has mentioned, does not go through to full scapular elevation.
    The neck wiggle, the hyperextension of the left elbow all look like compensations for this movement fault.
    I look forward to hearing more about the case and how it develops, plus some other movement angles and tests.

  30. Ruben
    Ruben says:

    It’s a motor control problem on the left side. Because there’s insufficient upward rotation of the scapula he makes use of his GH laxity and this leads to GH instability. The mediorotation of the scapula when lowering the arm is a just a way to center the caput in the cavitas glenoidalis. It has nothing to do with weak traps or rhomboids. He needs to learn how to upward rotate and stabilize his scapula by motor control training.
    @Mike: I think the marks on his back are from cupping, is that right? Why do you make use of that? He won’t learn to move his shourdle girdle with that kind of therapies.

    • Travis M.
      Travis M. says:

      I would tend to disagree with the patient not having weakness surrounding his left scap. If he did not have weakness, he would have a 5/5 Midtrap, low trap and serratus anterior MMT. I would bet the farm this is not the case based on his function. I think he has a neuromuscular component to his lack of function or poor mechanics and he can be taught to function in an improved fashion but at this point it would have to be considered a strength deficit. I also think you are going to

      • Ruben
        Ruben says:

        I do not think this problem has anything to do with strenght of certain muscles. If you don’t know how to move / stabilize there’s no indication of strentght training. Btw the rhomboid is a retractor. The patient needs to upward rotate not retract. Rhomboid training (retraction excerices) will increase the GH instability!

        • Travis M.
          Travis M. says:

          Ruben,

          If you read my post again I state that I believe the rhomboids are TIGHT and are possibly a cause of him not achieving full scapular upward rotation. I did not say to strengthen rhomboids as this would tend to increase downward rotation and retraction. I also believe that, as I said, there are two components of strength. One is neuromuscular activation and recruitment of muscle fibers, the second is muscle cross sectional area. That is why you will see two types of strength gains in patients. First six weeks is neuromuscular strength gains where a patient learns to recruit a muscle better. Second which is after six weeks of consistent strength training you can see increased cross section area. In both cases a MMT or dynamometer will show an objective increase in strength. So with this in mind I would guess that he has less than 5/5 strength in Low Trap, serratus, mid trap and possibly rhomboids. I would choose to strengthen mainly low trap and serratus, and mid trap due to the fact that they are scapular stabilizers but also upward rotators. During the strengthening process he will hopefully improve both neuromuscular activation as well as cross sectional area.

  31. Travis M.
    Travis M. says:

    I see tight lats bilateral that are trying to compensate for lack of stability. With the left he has resting posture of downward rotation which could indicate tight rhomboid and levator. He also has anterior tilt of left greater than right, which would make me test pec minor length. In elevation on the left he shows more signs of scapular instability therefore increasing the distal movement of hand and elbow. He also has obvious poor eccentric strength of mid and low trap as well as serratus which leads to the winging and control faults in the eccentric phase. I feel that he tries to over compensate with upper trap on left for stability and gets the resultant ipsilateral cervical side bend. I would therefor like to see both strength and endurance tests of Low trap, mid trap and serratus. As for the right resting he has downward rotation, scapular internal rotation. His right scapulae does not achieve enough upward rotation in full flexion and he deviates to scapular plane to try to achieve full elevation. His eccentric faults are not as marked on the right. I would also be interested in core strength and stability since swimming consists of a lot of open chain motions. I think he could become much more efficient with his stroke if his deficiencies are addressed. I also feel he would be a perfect candidate for red cord due to the nature of full suspension like he functions in the pool. Interested to hear how he progresses and possibly some of the other results of tests and measures that you did.

  32. Bill
    Bill says:

    Great discussion here and thanks for posting this interesting video Mike.

    My initial thoughts:

    If you took a representative sample of 100 swimmers matched for age, gender, and ability level and perhaps predominant swimming stroke, would you be able to tell who had pain versus no pain by watching a video of them performing bilateral shoulder flexion? In other words can we say that the movement patterns we see on this video, and the theorized impairments that are attributed tothem, are causally related to his pain?

    I just attended a one day seminar with L. Moseley. So given my acknowledged recency bias I suggest that this is a cortical issue:) Perhaps this swimmer’s neurotag for shoulder extension and cervical rotation are now inextricably linked given the repetitive nature of these actions occurring together during a sport that is notorious for a high volume of training?

    Bill

    • Luke
      Luke says:

      Bill is onto something critical IMO.

      You’ve taken a fish out of water and asked him to move on dry land, with no environmentally relevant feedback and using a movement pattern that he would not normally use (in training).

      Your focus is the shoulder and that’s fine for assessment but what enters the water first?

      Look at how he postures the hand during arm elevation in this video- this is abnormal and not functional for a swimming stroke. This type of movement pattern that moves from the shoulder IMO is probably not meaningful to this athlete nor functional.

      Skilled hand use/feedback/drills in an elevated position would IMO be a better assessment/treatment direction test.

      Great post.

  33. Leanne
    Leanne says:

    I agree with the comments above & would like to add there appears to be a lack of mobility/stability, week core with abs/glutes not firing in the right sequence, need to breath deep into the diaphragm to help engage the mid & low traps first. If this swimmer which appears to be breathing shallow would activate the mid & upper traps & neck muscles first as a compensation for muscle imbalances.

  34. Marty
    Marty says:

    Firt a question: Did he receive a cupping treatment, acupuncture? Left side significant weakness in serratus and rhomboid weakness. Definite levator scap involvement and lat tightness some thoracic extension compensation. Right sided involvement as well scap dyskinesis. I would like to see some different views.

  35. Debbi B
    Debbi B says:

    Primary issues I see are:
    1. Left sided serratus weakness/rhomb major weakness (he was able to stabilize for only one rep.)
    2. Left: levator/rhomboid minor tightness: likely elevating the scap, and causing left lateral cervical flexion when returning to neutral.
    3. Other compensatory issues noted at ribs difficult to asses with the info curious about SC joint, SCM may also be part of the problem.
    Nice video I am looking forward to your assessment.

  36. Steve Edling D.C.
    Steve Edling D.C. says:

    Long thoracic nerve paralysis causing serratous on left to be weak. forward head posture. T-L area very hypertonic looking. Would like ot see his movement at 90 degrees.

  37. Dr. Seth Burke
    Dr. Seth Burke says:

    Some of my thoughts while watching:

    Initial alignment- depressed scap bilat, L>R downward rotation, adducted scap bilat, C/S rot R, L>R GH adduction, L>R elbow hyperextension

    Conc mvmt- relatively greater GH movement vs. scap (GH hyper), L GH IR, decreased/late scapular upward rotation bilat, R scap does not posteriorly tilt and/or ER at end-range, and excessive anterior humeral head glide at end-range likely due to stiff pec minor (note creases).

    Eccentric phase- his R RTC mm are clearly stiffer than the scapular mm (literally “pushing” the scap into the winging) and there is a motor control issue since his rhomboid fired near the end of motion (improperly), and the RTC was unable to properly lengthen giving him that “hitch” at the end. The serratus anterior is long on the L (unable to generate enough force to maintain proper scapular alignment against the ribs).

  38. Rod Y PT (MN)
    Rod Y PT (MN) says:

    + L scapula inferior angle and superior border instabilty. I would have the patient stop the cupping treatments he is getting…. :)??? Stick with motor control exercises of L scapula. Good video. I ask patients if they would like to see what their scapula is doing and offer them to watch the video – they really enjoy seeing what their shoulder/scapula complex are doing.

  39. Conrad Stalheim
    Conrad Stalheim says:

    Really cool video and love that you posted this up!I’m excited to see what you have to say about it Mike!

    Shoulder flexion and thoracic extension range of motion look really good. Ability to control left scapula is clearly flawed. It appears to wing when challenged indicating a serratus ant. issue. The neck waggle looks very funky. My first thought would be some kind of levator scap. involvement.

  40. Kristy
    Kristy says:

    The first thing I saw was the obvious dyskinesis of the left scapula and the winging, as Nick already pointed out. Can’t wait to see your thoughts on this one.

  41. Nick Rainey
    Nick Rainey says:

    L scapular dyskinesia is greater than R.

    Scapular winging indicative of inhibited serratus anterior.

    It’s difficult to tell, but it doesn’t look like his lower traps are kicking in as much as I would expect after 120 deg of flexion.

    Trunk motion on eccentric phase indicative of poor eccentric control.

    I’ve found great success with focusing on lower traps, serratus anterior, and upper traps. I would definitely start there with treatment. Other findings will likely fix them selves. The ones that don’t should be addressed as needed.

  42. Leslie Salmon
    Leslie Salmon says:

    It’s challenging to evaluate without seeing a side and front view. I see the movement in left arm and neck, as well as protrusion and elevation of the left shoulder blade. From the rear, he appears to be tipping his chin towards chest – perhaps habit, but not optimal. Again, a side view would be helpful.

    Where will we be able to see your evaluation and suggestions for this young man?

  43. Stephen Thomas, PhD, ATC
    Stephen Thomas, PhD, ATC says:

    Nice post Mike. Videos of cases are always fun! First I would like to point out that he should stick with swimming because he clearly sucks at paintball!!! Kidding aside if you look at his static position you can see that the right scapula is more anterior tilted and protracted compared to the left side giving that typically impression that it is depressed. The left side has a worse type I scapular dyskinesis pattern with the inferior angle protruding, although it is slightly observed on the right. There also seems to be hyperextension of his left elbow as you can tell from the minimal distance between his lats and elbow. During dynamic motion the right has slightly more upward rotation. The wiggle is interesting and I think might be caused by a combination of the laxity in his left elbow and the lack of neuromuscular control during forward flexion of his scapular stabilizers and rotator cuff. This is why its very clear during the mid range of motion when the capsule is not engaged. He clearly has inhibition of his lower trap and serratus as you can tell from the eccentric phase as well as how the pattern gets worse with more repetitions. I also agree with the others that he has a tight levator on his left that is most likely in spasm. It seems that this is purely a neuromuscular control issue with some typically structural tightness (pec minor, levator, etc) and the combination of time off from the pool and rehab should alleviate his pain.

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