Case Study: Shoulder Impingement and Scapular Dyskinesis in a 28-Year-Old Male Athlete

Case at a Glance

A 28-year-old male with a history of extensive computer use and a recent transition from soccer to weightlifting presented with a two-year history of a mechanical 'blocking' sensation and audible clicking in his right shoulder during pressing movements, without significant pain.

Patient's Story

The patient is a 28-year-old male software developer who began a structured weightlifting program two years prior. His previous athletic activity was limited to recreational soccer. He presented with concerns about his right (dominant) shoulder. He first noticed an issue during the bench press, describing a need to make a 'swerving movement' at the end of the concentric phase, as if 'something in the shoulder was in the way.' This sensation is most prominent during overhead presses and, to a lesser extent, bicep curls. He reports no significant resting pain but can 'provoke' a dull ache with heavy, aggravating lifts. The patient observed a visible asymmetry, noting his right shoulder seems to sit slightly lower and more forward than his left. He also reports a consistent, audible 'crack' when he actively retracts and adducts his shoulder. He theorized the issue might stem from his occupation, which involves long hours at a computer with his right arm extended for mouse use, or from his habit of sleeping on his right side.

Initial Assessment

Upon presentation to a physical therapist, a postural assessment confirmed the patient's observation: a mild depression and protraction of the right shoulder girdle compared to the left. Dynamic observation revealed subtle scapular winging and dysrhythmia during arm elevation. Range of motion was full, but the 'blocking' sensation was reproduced during active abduction and forward flexion. A distinct, non-painful scapulothoracic crepitus (the 'cracking' sound) was noted with shoulder retraction. Special tests were performed: the Hawkins-Kennedy and Neer's tests were positive for impingement, eliciting a sharp pinch-like sensation in the subacromial space. There was no gross weakness in the rotator cuff, but endurance was diminished during resisted external rotation.

The Diagnostic Journey

The clinical picture strongly suggested a diagnosis of subacromial impingement syndrome, likely secondary to underlying scapular dyskinesis. The patient's history was highly relevant: the transition from soccer to upper body-intensive weightlifting without a focus on foundational stability, combined with the chronic poor posture associated with his desk job, created a 'perfect storm' for muscle imbalance. The periscapular muscles (e.g., serratus anterior, lower trapezius) were likely inhibited and weak, while larger muscles like the pectoralis minor and upper trapezius were overactive and tight, leading to poor scapular control. This dyskinesis altered the mechanics of the shoulder joint, reducing the subacromial space during overhead movements and causing the rotator cuff tendons to become compressed or 'impinged'. The patient was referred to his physician, who ordered an X-ray to rule out any bony abnormalities like a Type II or III acromion, which came back unremarkable. Further imaging was deemed unnecessary pending a trial of conservative care.

Final Diagnosis

Subacromial Impingement Syndrome of the right shoulder, secondary to Scapular Dyskinesis and associated muscular imbalance.

Treatment Plan

A multi-phase physical therapy program was initiated.

• Phase 1 (Unloading and Education): The initial focus was on activity modification. The patient was instructed to avoid provocative exercises (heavy bench press, overhead press) and modify others to be pain-free. He was educated on the mechanism of his injury and the importance of active correction over passive aids like 'back straps,' which he had inquired about.

• Phase 2 (Activation and Strengthening): The core of the treatment involved a targeted exercise program to address the muscle imbalances. This included:

  • Scapular Stabilization: Exercises such as wall slides, serratus anterior punches with a resistance band, and prone I-Y-T's to activate and strengthen the lower/mid trapezius and serratus anterior.
  • Rotator Cuff Strengthening: Focus on high-repetition, low-resistance external rotation and scaption exercises to improve endurance and control.
  • Stretching and Mobility: Pectoralis minor and latissimus dorsi stretching to improve shoulder posture.

• Phase 3 (Functional Reintegration): As symptoms improved, the patient was gradually reintroduced to pressing movements, with a heavy emphasis on proper form, scapular setting, and core engagement. Ergonomic advice was provided for his workstation to promote a more neutral posture.

Outcome and Follow-up

After eight weeks of consistent physical therapy, the patient reported a complete resolution of the 'blocking' sensation and a significant reduction in scapular crepitus. He was able to return to his weightlifting routine, including modified overhead and bench pressing, without symptoms. He demonstrated improved posture and an understanding of proper lifting mechanics. A home exercise program was established for long-term management. Follow-up at six months revealed the patient remained symptom-free and had successfully integrated the corrective exercises and postural cues into his daily life and workout regimen, preventing recurrence.