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CASE REPORT

IJSPT SUBSCAPULARIS SYNDROME: A CASE REPORT


Michael S. Thurner, PT, DPT, CSCS1
Robert A. Donatelli, PhD, PT1
Randa Bascharon, DO, ATC2

ABSTRACT
Dysfunction of the subscapularis muscle is introduced in this case report as a potential factor for consider-
ation in the etiology and/or consequential sequelae of subacromial impingement syndrome. Although
dysfunction of the supraspinatus and infraspinatus are implicated as being most commonly involved with
subacromial impingement pathology, the subscapularis is often overlooked and therefore undertreated.
Identifying the subscapularis’ potential involvement in patients with subacromial impingement pathology
may offer insight into shoulder impingement dysfunction and injury treatment options available to specifi-
cally address subscapularis dysfunction. In this manuscript, a case report is presented to highlight the signs
and symptoms of subscapularis pathology concordant with subacromial impingement syndrome and pro-
vide a clinical rationale for treatment. The purpose of this case report is not to suggest a new approach to
shoulder rehabilitation, but rather to prompt the consideration of subscapularis dysfunction when evaluat-
ing and treating patients with subacromial impingement pathology.
Key words: Subcapularis, subscapularis syndrome, subacromial impingement
Level of Evidence: 5

CORRESPONDING AUTHOR
1
Physiotherapy Associates Orthopedic & Sports Center,
Las Vegas, NV, USA Michael S. Thurner, PT, DPT, CSCS
2
Orthopedic & Sports Medicine Institute of Las Vegas, Physiotherapy Associates Orthopedic &
Las Vegas, NV, USA Sports Center
Acknowledgments 5920 South Rainbow Blvd. Suite 1
We would like to thank the participants for their time. Funding
for this project was provided by a grant from the United States Las Vegas, NV 89118
National Institutes of Health; K12 HD055931 Email: michaelsthurner@gmail.com

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 871
INTRODUCTION
Impingement syndrome is well defined in the litera-
ture as a pathological condition of the shoulder com-
plex associated with a clinical manifestation of signs
and symptoms altering normal motion and pain free
function of the affected upper extremity.1,2,3 In this
case report, the authors introduce the subscapularis
muscle of the rotator cuff as a plausible factor for con-
sideration as part of a cascade of potential causes and
subsequent sequelae associated with subacromial
impingement pathology. Relative scarcity of litera-
ture describing the relationship between subacromial
impingement syndrome and subscapularis dysfunc-
tion combined with numerous clinical observations
of improved outcomes with specific interventions
prompt the senior author to refer to the subscapu- Figure 1. Anatomy of the Shoulder complex.
laris as the “hidden culprit” of the rotator cuff.
fibers may potentially preserve the functional integ-
There are several cardinal signs and symptoms that rity of the rotator cuff’s dynamic stabilization role in
may implicate the subscapularis muscle of the rota- case of a partial tear or complete rupture due to this
tor cuff as a contributing factor to dysfunction and integrated anatomical relationship of the rotator cuff
functional limitations of the shoulder complex. Link- tendon fibers.9,11,12
ing underlying subscapularis soft tissue restrictions
to subacromial impingement syndrome with positive Histologically, some fibers of the subscapularis and
tests and measures may be helpful in gaining a more supraspinatus interlock and converge together as
thorough and broad understanding of contributions they course around and above the humeral head to
to shoulder impingement pathology and also have their respective insertion sites on the greater tuber-
implications for treatment to address subscapularis cle, thereby anatomically preserving the depressive
dysfunction. With early recognition and treatment, capability of the remaining cuff fibers.12 The force
patients presenting with subacromial impingement vectors of the subscapularis and the infraspinatus
and concurrent subscapularis impairments may be are biomechanically more optimally aligned to effi-
able to reduce time of recovery and enhance optimal ciently provide depression of the humeral head, com-
outcomes. pared with the supraspinatus.9,13,14 Specific exercises
of the rotator cuff and scapular rotators eliciting high
The subscapularis originates in the subscapular fossa EMG activity of the targeted musculature are later
on the costal surface of the scapula and courses ante- described in the interventions section of this case
rior and laterally to insert on the lesser tuberosity of report.8,15 Also, it is important to note when develop-
the humerus.4,5,6 (Figure 1) This is the largest of the ing a comprehensive rehabilitation or strength and
four rotator cuff muscles with nearly three times conditioning program for the cuff deficient patient
the physiological cross sectional area as the remain- or client, that the teres major and latissimus dorsi
ing three posterior cuff muscles combined.7 The sub- can also provide humeral depression forces second-
scapularis muscle primarily functions as a humeral ary to their anatomical alignment.9,13 Therefore, in
depressor and stabilizer along with its traditional role the case of rotator cuff dysfunction, the health care
as an internal rotator of the humerus.8 The histologic professional should carefully consider the develop-
architecture of the rotator cuff tendons fiber arrange- ment of an individualized program incorporating
ment is composed of multiple layers, which consist of specific therapeutic strengthening exercises and
crossover and interlocking of the fiber layers.9,10 The stretching or soft tissue mobilization in order to pro-
tendon fibers blend with and reinforce the glenohu- mote function of the patient or client by offsetting
meral capsule.10 This protective overlap of interlocking the deficiency or weakness that is present.

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 872
BACKGROUND & PURPOSE the subacromial bursa.1,2,3 Subacromial impingement
The glenohumeral joint is the most mobile joint pathology commonly affects the posterior rotator
present in the human body due to its osseous con- cuff tendons, most notably the supraspinatus. This
figuration.16,17 The articulation of the shallow gle- may induce a compensatory increase in activation
noid cavity with the relatively large humeral head of the subscapularis in order to accommodate for the
allows for extreme ranges of movement in all planes deficient or inhibited ability of the affected muscles
of motion, and thus inherently lacks stability.16,17 In to sufficiently counteract the superior shear force
the healthy shoulder, synchronous activation of the of the humeral head as the deltoid muscle contracts
dynamic stabilizers (acting as a force couple) provide during elevation of the arm.9 Although dysfunction
stability to this proximal link of the upper extremity of the supraspinatus and infraspinatus is commonly
chain. Proximal stability is crucial to influence dis- implicated as being associated with subacromial
tal functional mobility, allowing the hand to move impingement pathology, it is the assertion of the
freely in space. As a complement to dynamic sta- authors that the subscapularis is often overlooked
bility, the ligamentous and capsular tissue architec- and therefore undertreated.
ture of the glenohumeral joint provide tension at the Compensatory activation of the subscapularis may
extremes of available motion offering inherent static consequently lead to overuse over time secondary
stability relative to all planes of shoulder movement. to repetitive microtrauma, eventually resulting in
Dynamic stabilization of the glenohumeral joint is pathology of the muscle-tendon complex. Adaptive
affected by the rotator cuff and the scapulothoracic overuse without adequate healing time for the tis-
musculature. The rotator cuff muscles stabilize the sue to recover will ultimately result in fatty infil-
glenohumeral joint by acting to depress and com- tration of the muscle belly and/or degenerative
press the humeral head within the glenoid concav- scarring of the tendon consistent with tendinosis
ity.8,9 The scapulothoracic muscles control scapular pathology as may be evident through magnetic
movements allowing for optimal length-tension rela- resonance imaging (MRI).4 Fibrosis or scarring of
tionships of the rotator cuff musculature by prop- the subscapularis may present clinically as trigger
erly aligning the glenoid concavity relative to the points to palpation and adaptive shortening of the
humeral head.8 Neuromuscular control and adequate muscle belly and/or tendon, thus limiting shoulder
ratios of scapular muscle strength are essential to external rotation in the adducted position.19,20,21,22,23
shoulder complex function because the scapula and Cadaveric studies by Turkel et al indicate that the
humerus simultaneously move together in a com- subscapularis muscle is the most influential stabi-
plex yet coordinated fashion during shoulder move- lizing structure during passive external rotation of
ment, referred to as scapulohumeral rhythm.8 the glenohumeral joint at zero degrees of abduction
A disruption of this synergistic relationship may in the frontal plane.22,23 Furthermore, the integrity
occur secondary to a muscle imbalance, altering the of the muscle-tendon complex may continue to be
normal kinematics of this complex network of force compromised by adaptive shortening secondary
couples.3 Compensatory movement patterns may to protective shoulder postures of immobilization
subsequently present as scapular dyskinesis or con- in the adducted and internally rotated position.
comitant scapular asymmetry.3,18 The inability of the Travell and Simmons propose that a trigger point
rotator cuff to effectively offset the superior shear within the subscapularis muscle may sensitize
force of the deltoid may result in superior humeral adjacent muscles of the shoulder girdle presenting
head migration into the subacromial space.3,18 Conse- as secondary or satellite trigger points potentially
quently, this sequela of events may potentially lead leading to a heightened sensitization of pain and
to subacromial impingement. Subacromial impinge- motion restrictions of the shoulder complex.21 (Fig-
ment has been defined as mechanical compres- ure 2) Resultant scapular malalignment as a result
sion of the soft tissue structures that pass beneath of restricted mobility of the subscapularis may sub-
the coracoacromial arch as the shoulder is elevated.1,2,3 sequently cause poor length-tension relationships
The structures subject to impingement are the rota- of the scapular musculature, further accentuating
tor cuff tendons, long head of the biceps tendon and the muscle imbalance.

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 873
Figure 2. Subscapularis Trigger Points (x’s) & projected referral pain pattern. The essential referred pain zone appears as solid red with the
spillover zone illustrated as stippled.

Scapular malalignment or asymmetrical scapulae, the diagnosis of impingement.25,26,27,28 Although ana-


often referred to as S.I.C.K. (Scapular malposition, tomically the subscapularis does not pass under
Inferior medial border prominence, Coracoid pain, the subacromial region, it has been shown to limit
Scapular dyskinesia) scapula, may present as a pro- glenohumeral external rotation, which may lead to
tracted scapula on the side of the affected extremity subacromial impingement pathology as previously
in patients presenting with shoulder impingement.24 described.22,23 Secondary to the characteristic nature
Through clinical observation, the author’s note adap- of overuse, the subscapularis muscle will usually
tive shortening of the subscapualris often occurs in present as weak and painful upon muscle testing
conjunction with an internally rotated scapular pos- illustrated by the belly press and/or lift-off test.26,29
tural abnormality, associated with lengthened and The clinical presentation of limited external rotation
subsequently weakened posterior rotator cuff and in the adducted position, pain to palpation of trigger
scapular musculature. points within the subscapularis muscle belly and/
or tendon, and dysfunction of the subscapularis on
Limited and painful active elevation of the shoul-
strength testing should be considered in the etiology
der in the plane of the scapula is a classic sign of
of subacromial impingement. The concept of label-
subacromial impingement syndrome. This may be a
ing or categorizing specific shoulder impingement
consequence of a lack of disassociation between the
pathology helps identify the relationship between
scapula and the humerus and/or the diminished gle-
clinical findings and shoulder dysfunction. Iden-
nohumeral external rotational capacity preventing
tifying the subscapularis’ potential involvement in
sufficient clearance of the greater tuberosity under
patients with subacromial impingement pathology
the coracoacromial arch during elevation of the
may be helpful in gaining a greater insight into shoul-
shoulder.19 The lack of disassociation will inherently
der dysfunction, and expand intervention options to
disrupt the normal biomechanics of the shoulder
address subscapularis dysfunction. Further research
complex and could potentially limit the depressive
is warranted to determine the cause and effect rela-
capability of the already compromised subscapu-
tionship between the subscapularis and subacromial
laris muscle, resulting in superior migration of
impingement syndrome pathology.
the humeral head, due to the previously described
muscle imbalance in relation to the deltoid. Repeti-
CASE REPORT
tive overhead activity may result in subacromial
impingement pathology with the associated pain- Patient History
ful shoulder movement into positions of glenohu- A 22 year old right hand dominant female tennis
meral joint elevation. The Hawkins-Kennedy, Neer, player was sent to physical therapy with a physician
and Yocum impingement tests will usually confirm diagnosis of right shoulder pain secondary to sub-

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 874
acromial impingement. The patient reported a three-
month history of ‘deep’ shoulder pain without being
able to identify specific physical boundaries. The pain
was elicited when she was serving overhead or dur-
ing the follow-through phase of a forehand swing. She
reported an insidious onset of symptoms with no his-
tory of specific trauma to the right shoulder. Magnetic
resonance imaging (MRI) results suggested tendinop-
athy of the supraspinatus and subscapularis tendon
with a possible partial tear of the supraspinatus tendon.
The Quick DASH outcome measure with the optional
sports/performing arts module was completed at the
initial evaluation and the patient scored fifty percent,
and twenty-two percent disability/symptom scores in
sport and overall function, respectively. Figure 4. Lift-off Test for the Subscapularis.
Examination
The patient tested positive on the Neer and Yocum supraspinatus in the ‘full can’ position and the sub-
impingement tests. An internally rotated right scap- scapularis while performing the lift-off test. (Figure
ula, medial border prominence, and a mild lack of 4) Mild deficits were also noted during testing of the
disassociation of the scapula and humerus were infraspinatus and teres minor, which were graded
identified during active elevation of the arm in the with a 4/5 and 4-/5 respectfully. The serratus ante-
plane of the scapula through visual observation in rior, middle and lower trapezius were also tested via
comparison with the opposite extremity. Passive manual muscle testing and were graded as 4-/5, 4/5,
external rotation (ER) at zero degrees of abduc- and 4-/5 respectfully. Subjective complaints of pain
tion was limited to 30 degrees with the total inter- 4/10 were noted during manual muscle testing of the
nal/external rotation arc of motion at 90 degrees of lower trapezius. The authors note that the test posi-
abduction equal to the left shoulder. (Figure 3) tion in question requires the test subject to abduct
and externally rotate the glenohumeral joint, which
The opposite extremity was measured for compari- also recruits the supraspinatus and may biomechan-
son at zero degrees of abduction and was found to ically result in impingement due to faulty mechan-
be within normal limits, at 75 degrees of external ics of the injured shoulder, thus irritating the already
rotation. Prominent weakness (3-/5) and pain (7/10) compromised soft tissue structures. Trigger points
were noted during manual muscle testing of both the were identified upon palpation of the superior and
inferior lateral aspect on the anterior surface of the
subscapularis muscle belly with the patient posi-
tioned in supine with the humerus supported in an
abducted and externally rotated position. (Figure 5)
At the conclusion of the physical examination, the
identifying signs and symptoms were enough to sus-
pect involvement of the subscapularis.

Intervention & Outcome


The focus of treatment was to re-establish scapulo-
humeral rhythm by improving strength and mobility
of the shoulder complex allowing the patient/athlete to
return to tennis unrestricted and symptom free. Dur-
ing the first four weeks of physical therapy, treatment
Figure 3. Restricted External Rotation in the Adducted Position. consisted of a progressive resistive exercise (PRE) pro-

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 875
Figure 5. Trigger Points to palpation of the Subscapularis Muscle
Belly and/or Tendon.

gram to address weakness and postural adaptations


of the rotator cuff and scapula rotator musculature,
low-level laser therapy (LLLT) with deep sustained Figure 6. Subscapularis Diagonal Exercise.
pressure to relieve trigger points in the subscapularis
muscle belly, low load prolonged-duration (LLPS)
stretching into external rotation and soft tissue mobili-
zation to improve the mobility of the subscapularis.

Therapeutic exercises were initiated using high


repetitions (12-15 × 2-3 sets) and moderate to light
weight with an emphasis on pain free motion in
Phase I. The overall goal of therapeutic exercise in
the initial phase was to stimulate appropriate muscle
activation, promote muscular strength and endur-
ance, and increase blood flow to the healing tissue in
order to enhance the recovery process. The exercises
were selected to target specific musculature identi-
fied during the examination as having less than opti-
mal strength. Specific exercises of the rotator cuff
and scapular rotators eliciting high EMG activity of
the targeted musculature are illustrated in figures 6- Figure 7. Dynamic Hug, using pulley system.
10.8,15 (Figures 6-10) The exercises were progressed
side-lying position with the upper extremity relaxed
in Phase 2 using increased weight with fewer repeti-
at the patient’s side. The physical therapist performs
tions (8-12 reps × 3 sets) in order to transition to a
a distraction force to the scapula with a sustained
more focal emphasis on muscular strengthening of
hold to patient tolerance with oscillatory mobiliza-
the shoulder complex. LLLT was utilized in phases I-
tions performed intermittently between manual
II using a pulsed (905 nm) laser with deep sustained
stretch holds at the therapist’s discretion. (Figure
pressure utilizing a laser probe for three sets of five-
12) A low-load prolonged stretch into glenohumeral
minute cycles. (Figure 11) Pressure was applied over
external rotation was applied continuously for 20
the trigger points identified in the examination and
minutes in phases I-II. The patient was positioned in
modified according to patient tolerance.
the supine position with the shoulder supported on
Manual mobilization of the scapula was also initiated a foam wedge in zero degrees of abduction allowing
in the initial phase and progressed into phase II based gravity to produce the intended stretch into external
on patient tolerance. The patient was positioned in a rotation. (Figure 13) By the end of the fourth week of

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 876
Figure 8. Biodex Eccentric Loading Internal/External Rotation. Figure 11. Low Level Laser with Deep Sustained Pressure Over
the Trigger Points.

Figure 9. Prone Horizontal Abduction with External Rotation


@ 90 & 135 Degrees of Abduction. Figure 12. Scapular Tilt & Distraction.

Figure 10. Prone External Rotation and Horizontal Abduction


@ 90 Degrees of Abduction & Elbow Flexion. Figure 13. Low Load Prolonged Stretch of the Subscapularis.

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 877
treatment, the patient demonstrated full active ele- in this phase to reintroduce the overhead movement
vation without evidence of compensatory movement including the tennis serve in a controlled environ-
patterns, symmetrical scapulae, pain free grades of ment. Lateral bounding and agility drills with sport
5/5 during manual muscle testing of the rotator cuff cord resistance were incorporated with the tennis
and scapular rotator musculature, improved passive swing in order to enhance neuromuscular control
range of motion to 75 degrees of external rotation and spatial awareness. Internal and external rota-
at zero degrees of abduction, and no pain 0/10 to tion performed above 90 degrees of abduction at
palpation of the subscapualris muscle belly or ten- varying speeds was also introduced in this phase to
don.30 Table 1 highlights the clinical deficits present improve strength and power in the overhead posi-
and the proposed corrective therapeutic exercise or tion. Interval training using ten second intervals
treatment as depicted in figures 3-13. (Table 1) Table of high intensity lateral movement inter-dispersed
2 identifies the prescription of therapeutic exercise with submaximal low intensity active rest for thirty
and phase in which specific therapeutic interven- seconds on the dynamic edge was also initiated at
tions were implemented in relation to this case this time to progress the patient/athlete’s condition-
report. (Table 2) ing status.

Weeks 4-6 comprised of advancing the progressive The Quick DASH was performed again, and the
resistive strengthening program using the principles patient scored a zero percent disability/symptoms at
of muscle strengthening established by ACSM guide- discharge with no deficits or dysfunction reported.
lines.31 A return to sport program specific to tennis The patient/athlete was able to return to unrestricted
was also integrated at this time on order to optimally tennis, symptom free, following the aforementioned
prepare the patient for return to play. The resistance six weeks of physical therapy.
of the therapeutic exercise targeting the rotator cuff
and scapular rotators was increased accordingly to the DISCUSSION
patient’s tolerance and ability to demonstrate proper Clinically, over the past 20 years the senior author
technique throughout the exercise. The emphasis of has consistently observed a clinical relationship
the Phase III, during weeks 4-6, was low repetition between a loss of glenohumeral external rotation
exercise (6-8 reps × 3 sets) with adequate resistance in the adducted position and signs and symptoms
to enhance overall muscular strength. Sport specific of subacromial impingement pathology. Further-
exercises for the overhead athlete were also initiated more, these patients concurrently exhibited near

Table 1. Clinical presentation and proposed intervnetions.

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 878
Table 2. Phased Intervention used during treatment of the subject in the case report.

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 879
Table 2. Phased Intervention used during treatment of the subject in the case report. (continued)

equal (+/- 5 degrees) total internal/external arc of restrictions of the shoulder characteristic of the sub-
motion at 90 degrees of abduction when compared scapularis’ involvement.
to uninvolved side. According to Turkel et al, the
Godges et al recently demonstrated a positive correla-
most influential stabilizing structure during passive
tion between soft tissue mobilization with propriocep-
glenohumeral external rotation at zero degrees of
tive neuromuscular facilitation to the subscapularis
abduction is the subscapularis muscle.22 Thus, the
muscle belly and an increase in external rotation
authors of this case report believe that a restriction
and overhead reach.34 In the current case report, the
of external rotation at zero degrees of abduction with
treating clinicians utilized a deep pressure soft tissue
normal passive external rotation range of motion at
mobilization technique in conjunction with LLLT, as
90 degrees of abduction may be indicative of the sub-
illustrated in figure 11. LLLT is a modality treatment
scapularis as the primary restricting tissue. Elkstrom
used to facilitate recovery by attempting to promote
et al and Donatelli et al describe external rotation at
a healing response at the cellular level. Several
zero degrees of shoulder elevation as the selective
authors suggest that LLLT with a high power level of
stretch or testing position for the subscapularis.20,32
impulse or biphasic dose response has the capacity
A more recent cadaveric study suggests varying
to drive photons (light energy) to the target tissue at
angles of abduction in conjunction with external
depths of up to 10-13 cm or 4-5 inches.35,36,37 The pro-
rotation induce strain on different portions of dis-
posed healing effects revolve around improvement
tinct fiber arrangements within the subscapularis
of microcirculation at an adequate depth of pen-
muscle.33 Turkel et al also note that no single struc-
etration to reach the targeted soft tissue structures
ture solely stabilizes the glenohumeral joint in any
and increase cell metabolism (which is proposed to
one plane of motion, and the position and tightness
influence ATP production or energy used to enhance
of anterior structures vary with abduction and exter-
recovery at a cellular level). This may may assist
nal rotation angles.22,32 This anatomical concept of
in returning the damaged cells to a stable, healthy
stability has been well established in the literature
state.38,39 LLLT has been cited as a safe and effective
although the contributions of specific stabilizing
modality to accelerate pain relief and healing.38,39
structures remains controversial. The authors of this
case report acknowledge the anatomic variance of Also, a subscapularis tilt and distraction soft tissue
the orientation of fibers comprising the subscapu- mobilization technique was used to provide oscilla-
laris muscle and thus promote stretching at multiple tory mobilization stretch in an attempt to alleviate
angles of elevation if the subscapularis is identified any soft tissue restrictions present within the sub-
as the predominately restricted tissue structure. The scapularis muscle as illustrated in Figure 12. Low
subject of this case report presented with mobility load prolonged-duration stretch (LLPS) has histori-

The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 880
cally been utilized in physical therapy as an effec- 3. Ludewig P, Reynolds J. The association of scapular
tive means to induce lengthening of soft tissue.40 kinematics and glenohumeral joint pathologies.
The emphasis of the stretching technique applied in J Orthop Sports Phys Ther. 2009;39(2):90-104.
this case report is to restore tissue length by way of 4. Morag Y, Jamadar D, Miller B, et al. The
subscapularis: anatomy, injury, and imaging. Skeletal
gradual application of tension over time to produce
Radiol. 2011;40:255-269.
a permanent or plastic remodeling of the connective
5. Cleeman E, Brunelli M, Gothelf T, et al. Releases of
tissues allowing increased range of motion over the
subscapularis contracture: an anatomic and clinical
course of time. LLPS was implemented at the onset study. J Shoulder Elbow Surg. 2003;12:231-6.
of treatment to promote tissue lengthening with-
6. Warwick R, Williams P, Gray H. Gray’s Anatomy (35
out inducing pain. In this case, the patient was able ed). Philadelphia. Saunders Company. 1973;532-540.
to fully tolerate treatment and ultimately regained 7. Ward S, Hentzen E, Smallwood L, et al. Rotator cuff
full mobility of the shoulder. The patient was also muscle architecture: implications for glenohumeral
introduced to a progressive resistance exercise pro- stability. Clin Orthop Relat Res. 2006;448:157-163.
gram early in the rehabilitation process in order to 8. Reinold M, Escamilla R, Wilk K. Current concepts in
develop neuromuscular control, improve overall the scientific and clinical rationale behind exercises
strength, and facilitate optimal ratios of strength of for glenohumeral and scapulothoracic musculature.
the rotator cuff and scapular rotator musculature J Orthop Sports Phys Ther. 2009;39 (2):105-117.
for promotion of normal scapulohumeral rhythm. 9. Millet P, Wilcox III R, O’Holleran J, Warner J.
She responded well to physical therapy intervention Rehabilitation of the rotator cuff: an evidence based
approach. J Am Acad Orthop Surg. 2006;14(11):599-
progressing as appropriate under the discretion of
609.
the physical therapist, ultimately returning to tennis
10. Cooper D, O’Brian S, Warren R. Supporting layers of
without residual pain or limitation.
the glenohumeral joint. An anatomic study. Clin
Orthop Relat Res. 1993;289:144-155.
CONCLUSION
11. Sakurai G, Ozaki J, Tomitta Y, et al. Incomplete tears
Patients frequently present or are referred to physi- of the subscapularis tendon associated with tears of
cal therapy with a non-specific diagnosis relating to the supraspinatus: cadaveric and clinical studies.
shoulder ‘pain’. Any patient presenting with shoulder J Shoulder and Elbow Surg. 1998;7(5):510-515.
pathology may present with some or all of the signs 12. Thompson W, Debski R, Boardman N III, et al. A
and symptoms that implicate the subscapularis as a biomechanical analysis of rotator cuff deficiency in a
part of the dysfunction. Manual therapy techniques cadaveric model. Am J Sports Med. 1996;24:286-292.
and exercise prescription as illustrated in this case 13. Halder A, Zhao K, O’Driscoll S, Morrey B, et al.
report may be implemented once a treatment plan Dynamic contributions to superior shoulder stability.
is established based on the clinical examination. Fur- J Orthop Res. 2001;19:206-212.
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Shoulder Complex. St.Louis. Churchhill Livingstone.
presentation of patient with subacromial impinge-
2002:91-132.
ment syndrome. Higher-level studies are needed to
15. Decker M, Tokish J, Ellis H, Torry M, Hawkins R.
establish parameters for ‘significant’ external rotation Subscapularis muscle activity during selected
range of motion loss, to objectively quantify strength rehabilitation exercises. Am J Sports Med.
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The International Journal of Sports Physical Therapy | Volume 8, Number 6 | December 2013 | Page 882

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