Shoulder Clunking - what's the cause?

[alophysio]

Hi - thanks for the information. More is still better (S/E, O/E, Agg, Ease, 24 beh etc)

Ok, I would look at his scapula MOTION during his Pull ups - does it downwardly rotate? He should be staring in a position of nearly full abduction (i am assuming pull ups with palms forward to work the lats). If it does, then it is probably an overactive levator scapula and he probably has been doing his shrugs improperly - upper trapezius is a scapula lateral rotator since it attaches to the distal 1/3 of the clavicle and has horizontally aligned fibres, which is why your clavicle is designed with a twist to generate more torque etc etc.

An improper shrug technique would lead to him focusing on lifting his shoulders with too heavy a weight and his scapulae will lead from his superomedial corner instead of his acromion - he may be starting in downward rotation leading to inhibition of the lower traps - lower traps is a stabiliser since it attaches onto the medial edge of the spine of the scapula. Its role is to ensure the axis of rotation is started at the medial edge of the spine of the scapula when the arm is at its side.

During arm motion like abduction, the axis of rotation moves along the spine of the scapula until it reaches the lateral edge of the spine of the scap, behind the acromion process. During this whole motion, the thoracic fibres of trapezius cannot exert a downward/medial rotation of the scapula.

That is all looking at the orientation of upper traps and lower traps. THey act as a team to produce the lateral rotation of the scapula to clear the humeral head. Serratus anterior also plays a role in there as well.

People who go to the gym and try to have "good form" sometimes mistakenly think that pulling their shoulders down and back is also good for their shoulders. This can lead to overactive rhomboids and levator scap which downwardly rotate the scapula in an effort to "keep the shoulder down" - it is called a "dumped" scapula.

The reference for the above material can be found in CLinical Biomechanics, Johnson G et al (1994) 9: 44-50.

As for friendlypain's positional humerus, infraspinatus is not the only culprit. The posterior band of the inferior glenohumeral ligamant can cause anterior translation of the humeral head when in full ER. The research was done on baseball throwers but i have found the theory applies to all my overhead patients. There are 3 papers from Arthroscopy by Burkhart SS et al (2003) 19 (4):404-420.

An assessment of the mans internal rotation in supine with shoulder at 90deg ABD and elbow at 90deg ABD with scap prevented from lifting off the bed is a good way to assess. If they can't get close to 30deg from the bed (60deg ROM measured from start position), then they may have glenohumeral internal rotation deficiency (GIRD - don't you just love the americans and their names for things??!?). Capsule stretches then lead to improved performance.

I have a State/National level swimmer who had shoulder pain during her butterfly stroke. She had GIRD but she presented with the shoulder clunking anteriorly, anterior shoulder pain and classic impingement signs. Within 2 weeks of the stretches (no other exercises, decrease in her training of painful activities) her pain had disappeared, she knocked 1.2secs off her time setting a PB (personal best)and everyone was happy. The stretches allowed her arm to complete the stroke more fully since she essentially had 25% less time pulling through the water and shortening her stroke.

BTW, the stretches i give are lying on the affected side (e.g. right side), shoulder-over-shoulder so the weight is down holding the scap position of the right shoulder. The shoulder is in 90deg F, the elbow in 90deg F and so the radius/ulna should be parallel to the line of the shoulders. The patient then uses his free left arm to pull the wrist into IR and GENTLY hold the stretch there. THey should not feel their impingement pain, if so, decrease the amount of F - if you do that, the angle of the stretch will come back towards the patient's tummy. I usually get them to do about 5 mins of this morning and evening for 30s-5mins at a time. You can then progress them with other stretches and address any other dysfunctional muscles.

Hope that helps... THe references listed have been a big help for me. It also makes you look at the SC joint more closely because it has to bear the weight of the upper arm when upper traps is working...i wasn't taught the above at uni until my masters degree but i would assume that is what undergrads are taught these days since the research is 1994 and 2003???

Good luck - let us know more info please!

[edited text from here]
P.S. the level that you start with your patient is the level of function he can do without pain and with good form. If he cannot lift his arm from his side without dumping his scap (unlikely since he can do heavy weights) then i would start with scap positioning then lifting an unweighted arm until he can get it. The worse thing to do would be to pull this guy too far back because losing muscle bulk is expensive and time consuming. You will have to show him why he has to pull back and give him a time limit in which your treatment will work - e.g. 3 weeks. Then assure him he can do certain exercises to maintain his bulk and you can tell him that research has shown that one hard set per week taken to fail at 8-12reps, particularly with eccentric load failure (a higher load than concentric contraction) will be enough to maintain most of his bulk - the difficulty is making sure the exercises chosen do not adversely affect his shoulder.

Good luck!