Case Study of the Week- Protracted Shoulder

Updated: Mar 13

WHO- Keith H

  • Keith is a 66 year old dad and rockstar orthodonist who came to me with mild shoulder pain after years of two accidents involving his right shoulder.

Keith’s movement screen looked like this:

  • ASLR- 1/2 Shoulder mobility- 1/1 Glute bridge- 2/2 SL stance- 1/1 <— Poor balance on right side Overhead squat- 1- Forward lean Passive testing- Shoulder flexion (poor bi-lateral), internal rotation (poor bi-lateral/worse right), scapular protraction, hip external rotation (poor bi-lateral)

While I could have chosen to go after ASLR as it seems to be the most glaring screen, Keith’s primary complaint was his shoulder.

Though not currently in pain, what was immediately apparent in Keith’s initial screening was the marked protraction of his right shoulder in comparison to his left.

Because of Keith’s accident and the nature of his work (leaning over people daily), the issue I suspected was a forward gliding of the humerus. Sahrhmann defines this as the humerus being a third in front of the acromion and/or the humerus being positioned anteriorly in the glenoid cavity. This deformity is commonly seen alongside an anteriorly tilted scapula which may contribute to their association. This article details this issue in more detail.

The other consideration with Keith was his age. At 66, his body has laid down considerable connective tissue in the direction of repetitive positions he has assumed for many years (kyphosis due to leaning over patient’s for one) while his muscles lack the elasticity/hydration to respond as quickly to mobility drills. For me, prolonged static stretching is a no-no with older clients for the same reason.

With Keith, the first step was to refer out to a manual therapist to mobilize his shoulder posteriorly.

From here, the first step for us was to improve thoracic spine mobility (a more proximal structure) which will usually in turn provide the shoulders (a smaller structure) a better base of support to move from.

Keith had very little background in resistance training and so a big part of our program in this first phase has been teaching him basic upper body mechanics via band presses, pulls and modified deadlifting.

I love the band press exercise to teach shoulder protraction and retraction because they are open chain and allow the therapist/trainer to stand behind the client and cue scapular mechanics.

In addition, the deadlift is a great “bang for the buck” exercise to strength scapular retractors while teaching him to organize his upper body.

What was also interesting about Keith is that he is a diligent student of his work. A prolific speaker and author in his field, he loves to study, understand and execute.

I knew this would allow me to assign him a more detailed home program that he would perform diligently. I also assigned him a copy of “Move your DNA” by one of my favorite authors, Katy Bowman, and asked him to read the chapter on upper body mechanics. With this in mind,

Keith’s initial program looks like this:

1. Refferal - Manual therapy on R shoulder

2. Alignment - Assigned “Move Your DNA” upper body mechanics chapter

3. Gym program

  • Passive Mobility - Crocidile breathing - Roll- Lats, Pecs, posterior rotator cuff, peanut for T-spine - Voodoo floss band- Shoulder internal rotation mobilisation - Band distraction- Shoulder flexion

  • Active Mobility - Floor slides - Arm sweeps - Rib rolls

  • Pattern Re-training - Deadlift - Band press - Band row

  • Isolated strengthening - Forward facing wall slide - Band internal rotation

  • Home program - Floor slides - Arm sweeps - Rib rolls

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