DON’T ASSUME; ALWAYS ASSESS

• Duration: Acute- 2 Weeks
• Type of Pain: Nociceptive pain
• Character of pain: Mechanical 
• Irritability: High – The pain starts as soon as he lifts his shoulder above 90 degrees
• Lifestyle Impact: Minimally affected due to pain – he stopped playing badminton for the past 1 week.
• Fear of Movement Analysis: He has a pain-related fear of movement because of the sharp and sudden pain.  

Understanding the Patient’s Problem Based on History and Pain Analysis:

Without proper guidance, he had been playing badminton for the past 1 year, and suddenly started playing an intensive game two weeks back, which might be an overload. We suspect that his tightness and pain in the right side pec region might have started due to improper load management. 

Further, assessing the shoulder mobility and muscle strength can give us more clarity about the cause of pain. 

Physical Examination

• Observational Findings: He was feeling that his right side pectoral region was swollen, but while we assessed, we didn’t find any visible changes like swelling, redness, bruising, or muscle atrophy. 

• Range of Motion (ROM) Analysis and Mobility Screening:

Right side Internal rotation ROM and also the total arc are reduced. A reduction of 20° is significant.

Shoulder Overhead flexion mobility: Highly restricted beyond 90 degrees on the right side, and was painful. 

Thoracic rotation: Highly restricted on the right side and was painful. 

Strength Tests:

BREAK TEST for shoulder muscles: 

 The right external rotators and internal rotators are weak and painful.

Palpation: 

During palpation, the pec region felt tight and painful. 

Special tests: 

• Speed test – negative 
• Yergason’s test- negative 

(Note: we mentioned only the significant findings; other tests were negative or had no significant findings)

Investigation: no X-ray, MRI has been taken

Differential Diagnosis

AC joint pathology:

• No history of trauma or injury. 
• No differences in scapular positional change 
• Negative active compression and horizontal adduction test

Bicipital tendinopathy:

• No pain on palpation of the bicipital groove
• No pain during resisted elbow flexion 
• Speed test & Yergason test – negative. 

Pec muscle  strain:

• There is no discoloration in the chest region
• No bruising around the chest region
• No history of tear or strain occurred

Soft tissue injuries of the shoulder: 

• Only one plane of movement is affected. The internal rotation ROM is restricted; the strength test also revealed that the internal and external rotators are weak and painful.

• No restriction in the ROM of other movements.   

• Pain is reproduced only during the movement. 
• With these findings, we ruled out the soft tissue injuries around the shoulder, which eliminated the need for an MRI or any other imaging. 

Diagnosis

1. Patient’s perception of pain

He has a good understanding of the pain. We need to give confidence and proper rehab for shoulder muscle strengthening.

2. Psychosocial Factor analysis: Not affected
3. Belief and expectation:

He believes that he can play again the same as before if he has proper strengthening, and he also requires adequate knowledge about load management.

4. Diagnosis: Muscular tightness was noted in the pec region; Internal rotators are weak and overloaded, which was evident from the ROM and strength testing.  Along with that, improper load management and inadequate strength in posterior shoulder muscles caused him pain.   

He was playing racquet sports for almost a year, and GIRD is common in overhead sports. So there is a chance of having lesser internal rotation (IR) on the dominant side, along with greater external rotation (ER). 

But since his ER has not increased, and also the total arc is reduced, it is concluded that the internal rotation ROM is reduced. A reduction of 20 degrees in the total arc is significant, making the person prone to shoulder injury.  

The diagnosis is concluded to be : 

Rotator cuff-related shoulder pain due to Pec overload and poor load management

Treatment Planning

1. How long does it take? 

It’ll take around 2-3 months for him to get back to playing as intensely as before. 

2. How many sessions are required?

He requires an average of 12 sessions (12 to 14 sessions) over 6-8 weeks

3. Weekly 3 sessions plan
4. Things to focus on during treatment:

1st and 2nd week- Mobility exercises 

• Shoulder overhead mobility, like Foam Roller Lat stretch, shoulder range of motion exercise
• Thoracic extension mobility, like Foam roller thoracic extension, wall-supported thoracic rotation
• Scapular mobility exercises, like scapular push-up, Prone V T A exercises 

 3rd and 4th week- Progressive Strengthening exercise

• Strength training for the upper body, like banded chest pull, banded face pull, chest flies in eccentric, and Lateral raises
• scapular mobility exercises like scapular push up, Prone V T A exercises with dumbbells 1kg and 2kg

5th and 6th week- unilateral strengthening exercises and core strengthening: 

• Inclined single arm DB chest press in eccentric, bent over horizontal rowing, banded lat -eccentric, and land mine Shoulder Press. 
• Also, Strength training for core muscles like Banded rotation, wood chop, and lower body muscles

7th and 8th week- Force development

• Focus on the rate of force development.
• Med ball throws, clapping pushups, and he can be encouraged to play, gradually increasing the intensity. 

Advice to the patient:

• Educate about Load management- demand  and capacity, 
• Incorporate proper strength training in routine- at least 2 days /week
• Advice on nutrition intake, hydration, and sleep, which allows for proper recovery