Shoulder Clunking - what's the cause?

[Physio33]

PROBLEM:
A clunking sensation in one shoulder while doing pull ups in the gym.
What is the cause of this?

Comments appreciated.
Thanks,
Physio33

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[alophysio]

Probably a shoulder that clunks! More info please!

Given that it is the shoulder, a muscle imbalance is the most likely cause but how can we help with such limited information???!?!

[friendlypain]

Shoulder clunking on pull ups.... tough one unless I know how the exercise is being done. A clunking is usually a muscle's tendon strumming against a boney projection much like a guitar pick on a guitar string. Needless to say it is not a good situation for the tendon.

My guess would be a supraspinatus tendon due to an improperly set GH joint. My area of interest is the position of the humeral head and if it is more anterior (by => 2 inches) at rest. If it is I would suspect an anterior humeral glide due to a very tight infraspinatus and a shortened bicep setting the head of the humerous outside the "normal" position, leaving the supraspinatus tendon vulnerable to strumming.

If it isn't then I would look to the boney structures of the shoulder with special interest given to the active movements and positioning of the scapula. Since I can write a small book on this, and is nothing but a review of your education, I will save my keyboard from my index finger assault.

Treatment would be based on the history of trauma of the shoulder, the speed to return to activity, and the discipline of the person to do their self care.

[Physio33]

Thanks a million “friendlypain” and “alophysio” for your valued insight into the shoulder clunking problem……The ideas on shoulder instability, boney structures of the shoulder and positioning of the scapula have left me with plenty to work on. I have had limited clinical experience with shoulder injuries and so wasn’t sure where best to start with the examination of the individual.

I could write a book on this individual so will keep it brief (But please ask if you require more information):
Client with the clunking shoulder does a lot of weight lifting and has excellent muscle development globally. So, I was a bit daunted as to where to start my physical examination. Now, have been well guided by your suggestions. Pt has ANTERIOR SHOULDER INSTABILITY. THANKS!

A further question:
Can an athlete of this calibre still have a weakness of the Rotator Cuff muscles, yes? And if so,is this due to them developing their SECONDARY MOVER muscles of the Rotator Cuff (Ant and Post Deltoid) to a much larger degree than the PRIME MOVERS (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis)?
Weight lifters are prone to falling into the “trap” of developing and exercising the LARGE MUSCLE groups as they achieve visual results of muscle development quicker. Can this then have a knock on effect of making them more prone to developing joint problems as they are neglecting to strength the stabilising muscle groups?

Finally, What level of exercise rehab would be suitable for this individual? (LEVEL meaning, this athlete has a very good baseline shoulder strength level) Does one start with:
• Scapular setting
• Isometrics (of Internal and External Rotators of the Shoulder Jt.)?
• Resisted Int/Ext Rotators with T-Band progressed onto weights

Since doing pulls ups is the aggravating activity, late stage rehab should involve exercises done in outer ranges of shoulder ROM?

Thanking you in advance of any feedback.

[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!

[jwilso]

Any history of previous shoulder trauma? if he has had previous dislocation he could have a Hill-Sachs lesion or a Bankart lesion. is the clunking painful anyway? is it only pull ups that cause the clunking?

[reem101]

dear physio33
do you perform special test for the patient?
if it become -ve.replay

good luck

[jwilso]

what special test? there are loads for the shoulder

[kara1983]

what a great answer! real nice to hear your indepth reply.

[neurospast]

Thank you Alophysio for your reply, very usefull.
I would like to take one step further back. Just go with the patient to the gym and look how he performs. Or just do a thorough observation in "resting postion" and in action. Do not focus on the glenohumeral joint. I have had a patient with a clunk which disapeared when mobilising the thoracic spine. Movement is about balance between muscles, joints etc. Activity of muscles is depending on (to a larger degree) the nervous system which puts things in motion. Therefor any false imput by the nervous system will effect movement.
Stretch as Alophysio mentioned in his example could alter the muscle tone and restore the right balance.
Look at things like internal rotation of the arms (quite likely thumbs pointing inwards or even backwards, while normally they should point forwards in rest) this means an overactivity p.e. pectoralis major.
Decreased thoracic movement will effect scapula movement. (extreme shoulder movements are accompenied by high thoracic rotation)
I meant to give just some examples so you understand why I say; back to the drawing board.

[alophysio]

All true, all true! With resting position, it can give clues but observation of dynamic function is better. I know because i have poor starting positions but functionally not that bad.

Lets face it, if the guy is an amateur, he is probably doing too many chest press/pecs exercises and not enough "back" and shoulder exercises to balance it all out.

In addition to the T/S and nervous system as neurospast has pointed out, consider also his cervical multifidus and longus coli - the easiest test for this is to lie supine, hold the articular pillar on both sides (anywhere you want, you will eventually cover all levels), then get the patient to flex 90deg to the ceiling then horizontally extend so they end up in 90deg abd. Throughout the movement, there should not be any lateral displacement of the cervical vertebrae to the moving arm side. If there is, cue them to grow 1mm higher and see if that stabilises the vertebra. If it does, then i would focus on motor control and retraining his cervical stabilisers.

Have fun! Sounds interesting.

[reem101]

iam sorry but iam still in internship year and the lack of experiance make my judgment wrong.sorry and i appreciate your help and support

[salsaqueen99]

It's interesting to see what people have said to cause the clunking because I have clunking of the right shoulder which happens when I move my arms both to the side and in front of my. My sports doc has told me to ignore it. I do however think that the clunking came as a result of my dance injury. The clunking has been reduced from doing stabilisation exercises of the shoulder girdle (protraction and retraction in different positions) along with abduction and adduction exercises with a theraband.

I just thought i'd add some insight from a patient's perspective.

[mattd8a]

Poor rhom strength and lack of serratus control, can lead to hypertrophy of Lat Dorsi, match that with too much anterior strength (Delt and Pec Minor/major) and you can end up with clunking shoulder. Assess bulk of Lat Dorsi, as he may have developed a shoulder stabilisation strategy where he utilises lat dorsi to clamp downlimiting the rotation of scapula. Is it bilateral or unilateral? Any indication of nerve problems (long thoraccic, dorsal scapula control rhoms and serratus I think]?) Any other muscle wasting/hypertrophy (e.g. traps and delts) major protraction in shoulders? greater unilaterally? Evidence of scapula winging?
Am sure you have it sorted by now but just a few ideas

[Physio33]

Thanks a million to everyone who replied to the Shoulder Clunking Problem.

The pt. I had was incidently my brother, so he only let me assess/treat him on and off over the past few weeks. He didn’t allow me to fully assess his as he wanted a quick fix treatment exercise program! So I apologise for my lack of objective findings from my physical exam. Any future patients will not be family members I assure you all.

His progress to date has been pretty good.
The main agg. factor for his clunking shoulder was
- doing high reps of lat pull downs in the gym ie 10 in a row.
- Shoulder clunked when he started to fatigue, so was clunk free at rep 6-7.

Currently his mgmt to date has included
- Scapular setting exercises (He had a Winging Scap)
- Internal rototor strengthening exercises
- Reduction of reps of pull downs
-Some thoracic joint Grade 3 mobs for the stiffness there.


I’m a fairly new member to this forum and am well impressed with it.
Look forward to being in touch with ye all again. It's great bouncing ideas off each other. This Forum is blessed having regular input from many physiotherapists with years of clinical experience behind them in this field.

Thanks for all the discussion and brainstorming about the Clunking Shoulder.
A topic not touched on at college these days!
Physio33

[linbin]

hi guys
i would like to add something more.as everybody knows shoulder,especially the glenohumeral joint depends on muscles more for stability.during movements,dynamic stability is mainly provided by rotator cuff muscles.concavity compression action my rotator cuff,help to maintain the integrity of the joint .so that other superficial muscles can act.when rotator cull is functioning properly it reduces translation to a minimum,bcos of its force couple action with deltoid in the vertical direction and force couple between subscapularis anteriorly and infraspinatus and teres minor posteriorly in transverse direction.so rotator malfunctioning leads to abnormal translation -clunking-ligament,capsular stress and lesions.so our management should give primary importance to causes of rotator malfunctioning and strengthening of rotator cuff muscles.

[alophysio]

Hi limbin,

Agreed.

I also saw a patient last night who presented ith clunking shoulders but when i looked at him, his upper traps development was low comapred to his chest and shoulder muscles - he was seriously strong - able to do dumbell shoulder presses of 45kg in each hand, used to be 50kg!

When i taught him simple upper traps activation patterns using a 5kg weight, his clunking disappeared.

i surmised that upper traps attaches to the distal 1/3 of the clavicle and so by making it work a little better, it balanced out some of the forces anteriorly displacing the clavicle - it was more of an AC joint clunk.

Whaddya reckon?

[112inky]

The clunking has been reduced from doing proper exercises of the shoulder girdle

[bikelet]

"His progress to date has been pretty good.
The main agg. factor for his clunking shoulder was
- doing high reps of lat pull downs in the gym ie 10 in a row.
- Shoulder clunked when he started to fatigue, so was clunk free at rep 6-7.

Currently his mgmt to date has included
- Scapular setting exercises (He had a Winging Scap)
- Internal rototor strengthening exercises
- Reduction of reps of pull downs"

Hi, sorry to come in late on this thread. My suggestion is external rotators. Generally, these tend to be weaker than internal rotators so if he needs to be strengthening anything it should be this. I read an article in a gym magazine (sorry don't know the ref) about training for doing chin ups. The trainer said that building up external rotator strength is critical to the successful performance (and good form) of this skill. Trying looking up articles about this on the net.

Also has he tried setting his scapula prior to pulling down on the lat pull downs? It's easy to get lazy and not move properly, especially when fatigued. Teaching general body awareness may help. Also look at hand position on the lat pull down bar and in pull ups- a wide grip generally stresses the shoulder more