The Clinical Coach: The Missing Link in Anterior Shoulder Pain

Happy Friday!

Welcome to another clinical issue of The Performance Doctor!

In this issue we are going to focus on one muscle specifically that tends to be forgotten by 90% of clinicians when dealing with anterior shoulder pain, and could be the missing link for your patient to reach 100% improvement.

What is anterior shoulder pain?

Anterior shoulder pain has been described as deep, achy and in some instances as a sharp pin point pain in the area over the anterior deltoid. Just like with lateral shoulder pain, anterior deltoid injuries are not very common in the general public - and are mostly secondary to biomechanical injuries in sports and exercise. Yet, everyone wants to treat the anterior deltoid immediately for every anterior shoulder pain.

If you missed the lateral shoulder pain issue, read it here.

Anterior shoulder pain has a variety of causes like:

• Proximal bicipital tendionpathy

• Pectoralis major strain

• Rotator Cuff injury

• AC joint pain

• Bursitis

Muscles and structures you should be assessing during your examination.

• Anterior Deltoid Muscle (it’s the area of pain)

• Biceps Brachii Muscle (proximal insertion)

• Infraspinatus Muscle

• Supraspinatus Muscle

• Subscapularis Muscle

• Subdeltoid Bursae

The assessment of these structures should involve observation and palpation on your part. Remember that 90% of your history taking, should give you enough information to arrive at your top two differential diagnosis, and give you an idea of which structures are most likely involved.

In this issue we are going to focus on the Subscapularis muscle.

The subscapularis is a muscle that sits on the front of your shoulder blade and helps you with internally rotation of your arm. It’s the larges muscle in the rotator cuff, and the most forgotten muscle in clinical practice.

Just like all the other muscles of the rotator cuff, the subscapularis can strain, tear and develop tendinopathy from overuse, trauma or age-related conditions.

Subscapularis tears are RARE with only 4% reported in young patients after a traumatic injury. In older popluation, degenerative subscapularis tears are quite common and asymptomatic, with one study showing that 50% of patients aged 50+ years old had asymptomatic subscapularis tears.

Subscapularis strains are most common in athletes who participate in repetitive internal rotation mechanics, like throwing or participate in sports like Brazilian Jiu-Jitsue or gymanstics where the arm can be forced into external rotation and abduction.

Acute subscapularis tendinopathy may make your patients feel they have frozen shoulder as they may not be able to lift their arm due to pain.

The most common mechanism of injury of the subscapularis are:

• Forced internal rotation with adduction (e.g. baseball throwers)

• Forced external rotation with abduction (e.g. bjj athletes)

• Forced extension (e.g. gymnasts)

There are few orthopedic examinations specific for subscapularis injury. In most cases, at The Athlete Spot, we utilize the following orthopedic examinations:

• Lift-Off Test

• Bear Hug Test

• Deep Palpation with Resisted Internal Rotation

There aren’t many tests specifically designed for the subscapularis muscle. We really like the bear hug test and the lift-off test as they have been quite reliable for us in the assessment for subscapularis weakness.

PRO Tip: Don’t be surprised if after a couple of treatments (weeks) function, mobility and your objective findings have improved overall, but the patient still feels pain upon palpation. This means there is still sensitivity present and you may need to be more localized in your passive treatment.

Throwing

Throwing is a full kinetic motion that starts at the feet, involves rotation and flexion of the spine and other various structures at various velocities. For this reason we don’t introduce, or assess throwing mechanics until the patient’s pain and function have improved 60% or better.

Because throwing requires the acceleration and deceleration of the scapulo-humeral and scapulo-thoracic complex we choose to discuss throwing dynamics once the patient is able to complete concentric, eccentric and isometric movements with confidence and with any increase in pain lasting less than a day. Preferably less than a couple of hours.

Not every throw is the same. Pitching is much different than throwing a football. In most instances it is smart, and I highly recommend, to refer out your patient to a throwing coach who will be able to work with you and your patient to improve their throwing mechanics for their specific sport. If you are working with general population,

It’s important to note that every single one of my patients learns how to brace properly to meet the demands of the exercise/movement they are participating in.

50% of anterior shoulder pain in the office have involved the subscapularis muscle. Therefore I can’t tell you with true accuracy how many of your patients will show up with a subscapularis injury. However, now you should be able to incorporate one of the orthopedic examination into your assessment and be able to determine wether or not the subscapularis muscle needs to be treated.

Don’t be surprised if the first couple of session you don’t treat the subscapularis and on your 3rd or 4th visit you do. You may just be peeling the layers of the onion.

How do we treat these muscles?

You already know I am a fan of a combination of passive and active care to provide my patients with what they want and what they need.

Passive approach:

It’s no surprise that I am going to tell you that the first thing I’ll do is dry needle the subscapularis muscle. Dry needling has been a part of my practice since I was in school and after I graduated it’s been the main soft tissue treatment that I use. Specially when I am dealing with deep muscular tissues like the subscapularis muscle or the piriformis.

Dry needling the subscapularis musce on patients has results in a reduction in pain almost 75% faster than those whom I’ve had to treat with pin and stretch technique

*There are patients who are not treated with needles for personal reasons or contraindications. 

It doesn’t mean that IASTM, Pin and stretch, ART, or other manual therapies won’t help your patient. I’ve just seen faster results with dry needling in my office.

Active approach:

At the office I still utilize a few DNS movements to help patients improve their motor control. The 3 month prone DNS position is one that to this day I still utilize with patients dealing with a subscapularis injury.

This position allows them to focus on maintaining joint centration at the GH joint.

Additionally we utilize a variety of isometric positions that allow the patient to load internal rotation exercises at various degrees of GH abduction before we move into concentric and eccentric loaded movements.

With this approach I can progress a variety of exercises/movements that target the subscapularis muscle that become part of my patients rehab program.

As I mentioned in our previous clincial issue, my approach involves providing patients with a dedicated progressive strength and conditioning program broken down into four phases:

• Pain Management Phase

• Strength Phase

• Conditioning Phase

• GPP Phase

If you made it to the conclusion give the post a like.

You have no excuse now. Your assessment for anterior shoulder pain should include assessing the subscapularis muscle.

How you choose to treat the subscapularis muscle and which movements to focus, will depend on your patient’s goals, wants and needs as well as your experience developing a program that will meet them where they are and will progress them accordingly.

If you found this issue helpful, share it with a friend.

If you find that there’s something missing, or you’d like me to dive into deeper areas, let me know too.

Until our next issue!

In health and strength,

If you are ready to take it to the next level here are three ways I can help:

1. Subscribe to my free newsletter, The Performance Doctor, where I share practical and actionable fitness, rehab, and business education for Fitness-Forward Doctors.

2. Join over 260 Certified Dry Needling Practitioners and enroll in an upcoming Dry Needling Course

3. Master diagnosis, treatment and rehab for upper and lower extremity injury and dysfunctions. Enroll in our upcoming Extremity Rehabilitation Masterclass.