1. Rotator Cuff related shoulder pain

This is common in bowlers due to repetitive stress.

Rule Out:

• No weakness in external rotation
• Pain is not aggravated by resisted external rotation or pressing movements.
• MRI does not report rotator cuff pathology.

2. Biceps Tendinopathy

• Involvement in SLAP tears.
• Pain in the anterior shoulder.

Rule Out:

• No pain on palpation of the bicipital groove.
• No clear pattern of pain with resisted elbow flexion.
• All special tests are negative.

3. AC joint pathology

• No history of trauma or injury
• No difference in scapular positional changes
• Negative active compression and horizontal adduction test

 Diagnosis:

• Suspected Slap 2 tear, which has healed or potentially improved within this 1.5years
• Doubted MRI predictability as well and suggested to repeat MRI 
• Progressed for RTS

Validation for the diagnosis: 

Diagnosis: Post SLAP Type II Tear status

Validation:

• Being an overhead athlete who is involved in repetitive high-velocity sport (bowling-130 kmph) predisposes him to SLAP tear.
• He has GIRD (Glenohumeral Internal Rotation Deficit), which is a common adaptation seen in overhead athletes and serves as a risk factor for SLAP tear. 
• Symptoms match with SLAP pathology, including:
  • Pain with overhead movement (bowling)
  • Had mobility restrictions at the onset of pain
  • Gradual onset after high workload
• The MRI confirms a SLAP II tear

However, the O’Brien test, biceps load test I, and biceps load test II are negative. So either the SLAP tear is healed now, or the MRI report may be wrong (Normal adaptation in overhead athletes looks like SLAP tear in MRI).

Other factors to consider: 

1. Patient’s perception of pain: He has a good understanding of the pain and the importance of exercise. We need to give the right course of RTS rehab.
2. Psychosocial Factor analysis: Not affected
3. Belief and expectation: He believes that he can bowl the same as before if he undergoes a proper return to the sports program.

Treatment Planning

1. How long it takes – Usually, non-surgical management of SLAP tear takes around 5-6 Months to return to play
2. How many sessions are required – The average session required is 20 (18-28 sessions)
3. How many days in a week – 2,2,2,1,1,1,1,0,1,0,1,0,1,0,1
4. Things need to focus during treatment

• Mobility exercises 
  • Shoulder overhead mobility like Foam Roller Lat stretch, sleeper stretch
  • thoracic extension mobility like Foam roller thoracic extension, wall-supported thoracic exercise
  • scapular mobility exercises like Wall angels, scapular pushups, Prone V, T, and A exercises

• Strength training for Upper body like Single arm DB chest press, kneeling shoulder press, Landmine Shoulder Press chest supported rowing, Lateral raises, biceps and triceps strengthening exercises

• Strength training for core muscles like Banded rotation and lower body muscles

• Stability exercise like Turkish getup, Thread a needle

• Power-based movements – to produce force development during bowling
  • Explosive pushing and pulling like Pendlay rows, Push press, explosive Smith machine bench press
  • Rotational power training like Woodchops, Med ball rotational throw, Med ball overhead rotational slam
  • Upper body Plyometrics like plyo pushup, clapping pushup

• Sports-specific conditioning- Bowling-specific movement like med ball overhead, bowling with a weighted ball in half kneeling, Bowling-Specific Resistance Band exercise.

• Progressive bowling program (including workload tracking) 

1.     Shadow bowling with low intensity
2.     Partial effort bowling (50-60%)
3.     Progress to full-effort bowling
4.     Return to competitive-level bowling