Clinical Reasoning in Chronic Shoulder Pain Case Study
Original Editor - Ari Kaplan
Top Contributors - Ewa Jaraczewska and Jess Bell
Introduction
Clinical reasoning requires the clinician to hold multiple hypotheses simultaneously, weigh findings against one another, and progressively refine their understanding of what is driving a patient's presentation. In the shoulder, dysfunction at the glenohumeral joint, the scapula, or the thoracic spine can each produce overlapping patterns of pain and movement impairment.[1] A structured, region-by-region assessment can be used to identify the dominant impairments and guide a targeted, responsive treatment plan. This case study illustrates this approach in practice. It presents the case of a former competitive swimmer with shoulder pain, a common presenting condition in this population.[2][3][4]
Patient History
The patient is a former competitive swimmer who first developed shoulder and upper trapezius symptoms during high school. She attended physiotherapy (physical therapy) briefly and was able to continue swimming. At college, she continued with club swimming before transitioning to triathlon training. At this point, her symptoms worsened significantly, with both swimming and running provoking her pain. She had physiotherapy treatment for around four months at college, and with rest and treatment, her symptoms subsided. However, they returned each time she attempted to return to running or swimming beyond a certain training threshold. This has limited her ability to return to these activities.
Her pain is primarily right-sided, but she has also had intermittent left-sided pain. She describes her pain as anterior and deep. Occasionally, this extends to her posterior shoulder and into her upper trapezius. She is typically pain-free in her daily life, but she sometimes experiences acute cervical symptoms, which have been managed with manipulation and dry needling.
Postural and Breathing Assessment
The shoulder evaluation begins with the patient sitting. The cervical screen is unremarkable for symptom reproduction, though some stiffness is noted. The assessment then works through the thoracic spine, scapulae, humeral position, and breathing, with each finding informing the next.[5]
The patient has no significant hyperkyphosis in the mid- or upper thoracic spine. Her scapular position in the frontal plane is within normal limits bilaterally for abduction-adduction, elevation-depression, and upward-downward rotation. In the sagittal plane, anterior and posterior tilt appear normal at rest. However, both scapulae sit at approximately 15 degrees of internal rotation, reduced from the typical resting position of around 30 degrees.
The patient has an accessory breathing pattern. Shoulder elevation during breathing is subtle at rest, but becomes pronounced when asked to take a deeper breath. This pattern places increased demand on the sternocleidomastoid, upper trapezius, and scalene muscles, which can be exacerbated during high-intensity activities, like running or swimming.[6]
The postural assessment also reveals that the patient's humeral heads both sit anteriorly in the glenoid. This position can increase stress on the anterior shoulder, the biceps tendon, and the capsule. It can also create a pinching sensation in the posterior shoulder when reaching behind the body.
Active and Passive Range of Motion and Joint Mobility Assessment
Passive scapular mobility is assessed in sitting. There is resistance to retraction (adduction) and posterior tilting. Upward and downward rotation are unrestricted. These findings point toward the pectoralis minor as a primary myofascial driver, with possible contribution from the pectoralis major.
There is no visible dyskinesia initially on active shoulder flexion and abduction. However, at end range, there is significant bilateral upper trapezius activation and a visible scapular hike. There is also very little thoracic extension during active flexion, despite the lack of hyperkyphosis.
With the patient supine, passive glenohumeral motion is tested. Flexion and abduction are full and pain-free. External rotation at 90 degrees of abduction is approximately 85 degrees; this is a clinically meaningful deficit for a competitive swimmer. Internal rotation is restricted to approximately 15 degrees. Horizontal adduction with the scapula stabilised is approximately 5 degrees, well below normal and consistent with posterior shoulder tightness.
Glenohumeral accessory glides are normal in all directions (posterior, posterior-inferior, inferior, anterior, and anterior-inferior). This confirms the restrictions are muscular rather than capsular in origin. In prone, there is good overall joint mobility with thoracic posteroanterior glides, though there is some costovertebral stiffness around ribs five and six.
Palpation
Palpation is performed throughout the assessment in sitting, supine, and prone. The key findings are as follows.
In sitting, the infraspinatus is markedly hypertonic throughout. The teres minor and posterior deltoid are similarly affected. These findings are consistent with the internal rotation restriction and the anterior resting position of the humeral head. Hypertonic external rotators resist the posterior glide of the humeral head, which is required for both internal rotation and full external rotation.
The subscapularis, assessed in supine with the arm elevated to bring the scapula away from the thorax, is hypertonic and tender. This muscle is an internal rotator, and it resists external rotation. Subscapularis hypertonicity could also be contributing to the scapula sitting in a relatively externally rotated position.
The pectoralis minor is among the most restricted structures identified. This is consistent with the resistance to passive scapular retraction and posterior tilting. The pectoralis major is also notably hypertonic and may independently contribute to limited external rotation and restricted scapular retraction.
At the thoracic spine, the erector spinae are hypertonic through the mid-thoracic region. This hypertonicity persists in prone, confirming a passive tissue restriction rather than a postural holding pattern. The rhomboids and middle trapezius have increased tone. This is likely a compensatory response to chronic effortful scapular retraction against a tight pectoralis minor.
Table 1 summarises the structures assessed and the clinical implications of hypertonicity in each muscle.
| Region | Structure | Clinical implication of hypertonicity |
|---|---|---|
| Posterior shoulder | Infraspinatus | ↓ Internal rotation; anterior humeral head migration |
| Posterior shoulder | Teres minor | ↓ Internal rotation; ↓ horizontal adduction |
| Posterior shoulder | Posterior deltoid | ↓ Horizontal adduction; stiffness at end-range flexion |
| Anterior shoulder (supine) | Subscapularis | ↓ External rotation; scapula in a relatively externally rotated position |
| Anterior chest | Pectoralis minor | ↓ Passive scapular retraction and posterior tilt |
| Anterior chest | Pectoralis major | ↓ External rotation; ↓ scapular retraction |
| Posterior thorax | Erector spinae (T4–T8) | ↓ Thoracic extension during overhead reach |
| Posterior thorax | Upper trapezius/levator scapulae | Scapular hike; cervical overload; accessory breathing |
Clinical Reasoning Synthesis
The patient has a pattern of posterior shoulder and posterior rotator cuff hypertonicity, centred on the infraspinatus and teres minor. This pattern has driven the humeral head anteriorly at rest and restricted internal rotation and horizontal adduction. The subscapularis contributes to the external rotation restriction and to the scapula's relatively externally rotated position. Anteriorly, pectoralis minor and major restrict scapular posterior tilt and retraction, limiting the scapular mobility required for overhead function. At the thoracic spine, erector spinae hypertonicity limits extension, resulting in compensatory scapular hiking and upper trapezius recruitment during overhead reaching. An accessory breathing pattern further loads the cervical musculature.
This is a soft tissue presentation, most likely established over years of repetitive overhead loading without adequate mobility management between training cycles.
Physiotherapy Management
The first treatment session focuses on the following interventions.
Self-directed infraspinatus release: the patient releases her infraspinatus using a lacrosse ball against a wall.[7] On retesting, passive internal rotation improves substantially, approximately doubling the available range. This confirms the hypothesis and demonstrates to the patient that her symptoms are amenable to change.[5] Passive external rotation is also retested. There is only a minor improvement, and the end-feel remains more solid than expected, indicating that other structures are contributing to the external rotation limitation.
Teres minor and major release: the patient releases these muscles using a foam roller in side-lying. On retest, internal rotation continues to improve, and the end-feel is now more normal. External rotation also increases to approximately 95 degrees. The scapular posterior tilt also improves, but retraction remains limited.[5]
Self-release to the anterior chest wall: the patient then releases her anterior chest using a lacrosse ball, targeting pectoralis minor and major. On retest, scapular retraction and posterior tilt improve markedly. External rotation does not change substantially, suggesting the remaining limitation may relate to the subscapularis, which is not directly treated in this session.[5]
Breathing exercises are also introduced. With the patient supine, the therapist applies a gentle inward pressure at the lateral mid-thorax and cues the patient to expand their ribs into the therapist's hands. The patient then replicates this using their hands to provide the tactile cue.[5]
The therapist plans to address the erector spinae in subsequent sessions. Once sufficient passive mobility has been restored, the plan is to progress to motor control and, eventually, strengthening exercises.[8] For a swimmer returning to significant training volume, a land-based programme should also be introduced to reduce the risk of recurrence.
Conclusion
Each intervention in this session is chosen based on a specific hypothesis, immediately retested against a measurable outcome, and either confirmed or revised. This iterative approach is what distinguishes targeted rehabilitation from generic protocols. It also builds patient confidence by demonstrating that their symptoms are amenable to change.
Resources
References
- ↑ Ludewig PM, Reynolds JF. The association of scapular kinematics and glenohumeral joint pathologies. Journal of orthopaedic & sports physical therapy. 2009 Feb;39(2):90-104.
- ↑ Edenfield KM, Olivas J, Garvin C, Robinson K, Krabak B. Swimmer’s Shoulder: An Update on Pathogenesis, Risk Factors, Clinical Assessment, and Management. Current Physical Medicine and Rehabilitation Reports. 2025 Dec;13(1):1-0.
- ↑ Preziosi Standoli J, Preziosi Standoli T. Scapular Asymmetries and Dyskinesis in Young Elite Swimmers: Evaluating Static vs Functional Shoulder Alterations. Osteology. 2025 Jul 3;5(3):22.
- ↑ Tavares N, Vilas-Boas JP, Castro MA. Effect of Preventive Exercise Programs for Swimmer's Shoulder Injury on Rotator Cuff Torque and Balance in Competitive Swimmers: A Randomized Controlled Trial. Healthcare (Basel). 2025 Mar 1;13(5):538.
- ↑ 5.0 5.1 5.2 5.3 5.4 Kaplan A. Shoulder Evaluation and Treatment Clinical Reasoning Case Studies Course. Physiopedia Plus, 2026.
- ↑ Bradley H, Esformes J. Breathing pattern disorders and functional movement. Int J Sports Phys Ther. 2014 Feb;9(1):28-39.
- ↑ Hoops JF, Hooper TL, Sobczak S, Kapila J, Dewan BM, Matthijs OC, Brismée JM. Participants with restricted dominant shoulder internal rotation range of motion demonstrate no side-to-side difference in humeral head translation; and no difference before and after joint mobilization: a pilot study. J Phys Ther Sci. 2024 May;36(5):259-266.
- ↑ Elder A, Powers CM. Scapular Stabilization for Shoulder Pain: Putting the Cart Before the Horse? Int J Sports Phys Ther. 2025 Feb 1;20(2):275-282.