Understanding and Managing Shoulder Pain with a Focus on Subscapularis Dysfunction

Dear Readers,

Welcome to our latest newsletter, where we dive into the multifaceted world of shoulder pain, shedding light on the often overlooked role of the subscapularis muscle in subacromial impingement syndrome (SAIS) and its management.

What is the subscapularis muscle?

The subscapularis is one of the rotator cuff muscles that stabilizes the shoulder joint. It plays a crucial role in internal rotation and depression of the humeral head (upper arm bone) within the glenoid cavity (socket of the shoulder blade).

Unraveling Subacromial Impingement Syndrome (SAIS): SAIS is a prevalent shoulder condition characterized by pain and impaired mobility, often attributed to the supraspinatus and infraspinatus muscles. However, the subscapularis muscle's involvement is frequently underestimated, leading to suboptimal treatment outcomes.

Weakness, tightness, or trigger points in the subscapularis muscle can disrupt shoulder mechanics and lead to pain. This can happen due to overuse, repetitive motions, or imbalances in other shoulder muscles.

Insights from Clinical Practice: In our recent case study, a 22-year-old tennis player presented with deep shoulder pain and restricted mobility, indicative of subscapularis dysfunction. Through a comprehensive treatment regimen encompassing targeted exercises, manual therapy, and sport-specific training, she achieved remarkable recovery and resumed tennis activities without limitations.

What are the signs and symptoms of subscapularis involvement in shoulder pain?

• Limited external rotation of the shoulder, especially at low angles (arm by your side)
• Pain with overhead activities
• Weakness during internal rotation movements
• Trigger points within the subscapularis muscle belly

S.I.C.K. Scapula: Scapular malalignment, known as S.I.C.K. Scapula (Scapular malposition, Inferior medial border prominence, Coracoid pain, Scapular dyskinesia), may contribute to shoulder impingement syndrome.

Diagnostic Tests: Positive findings on impingement tests like Hawkins‐Kennedy, Neer, and Yocum tests can confirm the diagnosis of impingement.

Treatment options for subscapularis dysfunction:

• Manual therapy techniques: Soft tissue mobilization and trigger point release can help address tightness and pain in the subscapularis muscle.
• Low-load prolonged stretching: This technique gradually stretches the muscle to improve flexibility and range of motion.
• Therapeutic exercises: Strengthening exercises targeting the subscapularis and other shoulder muscles can improve stability and function.
• Low-Level Laser Therapy (LLLT): This modality may promote healing and pain relief by increasing cellular metabolism.

Treatment Focus: The primary objective of therapy was to restore scapulohumeral rhythm, enhancing shoulder strength and mobility for the patient's return to tennis without restrictions or symptoms.

Phase I (Weeks 1-4):

• Progressive Resistive Exercise (PRE): Implemented a regimen of high-repetition exercises (12-15 reps × 2-3 sets) with moderate to light weights. Emphasis was on pain-free motion to stimulate muscle activation, promote strength, endurance, and improve blood flow to facilitate tissue healing.
• Targeted Exercises: Selected specific exercises targeting the rotator cuff and scapular rotators, identified during examination as exhibiting suboptimal strength.
• Soft Tissue Mobilization: Utilized low-level laser therapy (LLLT) with deep sustained pressure to alleviate trigger points in the subscapularis muscle belly.
• Stretching: Employed low-load prolonged-duration (LLPS) stretching into external rotation to enhance mobility of the subscapularis muscle.

Phase II (Weeks 5-6):

• Progression of Exercises: Transitioned to increased weight with fewer repetitions (8-12 reps × 3 sets) to focus on targeted muscular strengthening of the shoulder complex.
• Continued LLLT: LLLT with deep sustained pressure was continued in phases I-II using a pulsed (905 nm) laser to target trigger points identified during examination.
• Illustrative Figures: Referenced illustrative figures (6-10) demonstrating specific exercises targeting the rotator cuff and scapular rotators eliciting high EMG activity of the targeted musculature.
• Pressure Application: Pressure was applied over trigger points identified in the examination and adjusted according to the patient's tolerance and response to treatment.

Phase III (Weeks 4-6):

• Progressive Strengthening: Advanced the resistive strengthening program following ACSM guidelines, increasing resistance according to patient tolerance and proper technique demonstration.
• Return to Sport Program: Introduced a tennis-specific return to sport program to prepare the patient for resuming play optimally.
• Low Repetition Exercise: Emphasized low repetition exercise (6-8 reps × 3 sets) with adequate resistance to enhance overall muscular strength.
• Sport-Specific Exercises: Integrated sport-specific exercises for tennis players, focusing on overhead movements such as the tennis serve in a controlled environment.
• Neuromuscular Control: Incorporated lateral bounding, agility drills with sport cord resistance, and tennis swing exercises to enhance neuromuscular control and spatial awareness.
• Strength and Power: Introduced internal and external rotation exercises performed above 90 degrees of abduction at varying speeds to improve strength and power in the overhead position.
• Interval Training: Initiated interval training using ten-second intervals of high-intensity lateral movement interspersed with submaximal low-intensity active rest for thirty seconds on the dynamic edge to progress the patient/athlete's conditioning status.

Outcome Assessment:

Quick DASH: Performed again, revealing a zero percent disability/symptoms at discharge with no deficits or dysfunction reported.

Return to Tennis: The patient/athlete successfully returned to unrestricted tennis, symptom-free, following the aforementioned six weeks of physical therapy.

This integrated approach encompassed progressive strengthening, sport-specific training, neuromuscular control exercises, and interval training, facilitating the patient's smooth transition back to tennis with improved strength, function, and symptom resolution.