kayakers shoulders

[ugandanphys]

Hi

Just wondering if anyone could throw some light on a patient I have at the moment. He's a white water kayaker and its also his profession - very high level, with lots of crazy forces being put on the shoulders.

He came to me about 3 months ago, with right shoulder trouble, with 2 distinct areas of pain - postero-superior pain catching at 70-110 degress, and also minor pain around anterior capsule. He had an ultrasound which said small sub deltoid bursitis and minor bicipes calcification, but I've since been told that that report was unreliable...He looked pretty straightforward rotator cuff trouble with secondary impingement, bad scapular control, winging etc. He got a low grade injection and lots of stability excs and rotator cuff control work. Pain in rotator cuff insertion area quickly resolved but over the past 2 months the anterior capsule pain has gotten much much worse - now in BOTH shoulders. Even simple ADLS, computer, writing etc are flaring his pain he says.

He has been out of action now for nearly 4 months and this is his livlihood. Sports musculoskel is not my area of physio, which I've told him. We're in Uganda and resources are not great so really I'm all he's got - HELP!

I did refer him to a good ortho surgeon here to have him look at them, I was thinking labral tears, even though the 3 clinical tests were coming up negetive. MRI revealed nothing, doc thought it was bicipital tendinitis bilaterally and did another injection anteriorly into the right to see if it would help before doing the left, but no improvements.

I dont really know what else to do. He's a really good patient, adhereing to physio totally. We've been mostly doing posterior capsular stretching coz poor internal rotation, lots of scapular work, thoracic extension work and rotations - he does have 2 small scoliosis which I know is having impact on technique. lots of core work. But we've had to cut out biceps stretching which was flaring too much. Anterior capsule seems a bit lax,

ANy further advice would be greatly appreciated.
Any other suggestions for diagnosis?

thank you!

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[gharris29]

Hi, i'm not sure about alternative diagnoses, however have you tried myofascial trigger pointing to the rotator cuff? if you combine this with pendular exercises and active assisted ROM that might working quite well. Kayaker's tend to get impingement type injuries and so pendular exercises will help distract the humeral head from the ghj and then scapular setting, postural control exercises may help.
Hope this helps.

[maverick]

Hey buddy,

May be you should assess his Cervical Spine/Thoracic Spine. And also check if any myofascial involvement is seen...!!?!

Good Luck...

[marj]

I would also check his glenohumeral position. No more than 1/3 of the humeral head should be anterior to the anterior edge of the acromion. Even if he is starting from a good position he may be translating anteriorly with load, so palpate the humeral head with resisted isometric and active movements. Good luck. Marj

[nasde]

does sound a bit odd - reduction of kayaking, and now pain in both shoulders? Pain with ADL's and light activity?

Consider what the others have written e.g humeral head position, Cervical spine; but also look at what he's doing on a day to day basis - there must be something he is doing - bilaterally (i would guess) that is irritating him. Is it possible that the exercises you have given him are the source of the irritation?

A lot of athletes are very driven and I find sometimes do not get the whole concept of exercise that does not cause pain (esp if their livelihood depends on it) Does he tend to overdo exercises (through pain etc) - thinking that if it's sore it will get me better faster? Could that be the reason his shoulders are sore? Has he been doing the rotator cuff strengthening etc on both sides? (that would possibly indicate the reason pain has appeared bilaterally) have you got him strengthening flexion/lifting weights/bench press? (i find that they can irritate the anterior structures of the shoulder)

I found manual release to the posterior capsule one of the most effective treatments for shoulders in general.

Cheers