Shoulder injury rehabilitation exercises - the importance of a tailor-made rehabilitation program

Meet Jennifer, a 15 year-old state-level tennis player, who almost had to be forced by her coach to attend her initial physiotherapy consultation. She didn't see the need because her shoulder 'only hurt when she served'! When asked how it affected her serve, she said that she couldn't serve as hard, and that sometimes she just didn't practice at all when it hurt. This response immediately suggested to me that to gain Jennifer's compliance in any sort of rehabilitation program, education was going to be vital.
Assessment
The initial assessment was quite straightforward. Sharp pain had been present on serving for two months in the anterior superior region of her right shoulder, when she made contact with the ball. Overall, the pain had been progressively getting worse. Pain was reproduced at end of range flexion and on an impingement test (horizontal flexion, then internal rotation of her shoulder). Her humerus was sitting anteriorly and she also demonstrated slight capsular laxity anteriorly on her right shoulder with ligament testing and gently gliding the head of humerus forward in sitting. Internal rotation was decreased by approximately 45 degrees on her right compared to her left, suggesting significant posterior capsule and external rotator cuff tightness. Her scapular control was very poor through abduction, especially on sustaining the 'stop sign' position. In summary, we can conclude that the supraspinatus tendon was 'impinging' (pinching; getting inflamed) under the bony arch of the acromion process, a situation exacerbated during serving.
Ask the athlete
An important, but often-overlooked, aspect of assessing an athlete's injury, is asking the athlete whether or not any technical changes have been made/ are being made in their training. Often technical changes can result in injury because the patient cannot cope with the physical requirement of the technique. If no real changes are being made, then it may help to see if the patient can explain the aspects of their technique they are working on. This could clue you in to the type of injury and what you may need to work on. In this case, Jennifer had been working on the same thing for the last six months ­ trying to keep her elbow high as she reached the cocking position on her serve. In tennis or throwing, the shoulder should be abducted to approximately 90 degrees at the end of the cocking phase. Jennifer was letting it drop well below this. But no matter how much she was cued by her coach or how hard she tried, Jennifer couldn't do it, and no doubt the effectiveness of her serve was being affected because of this lack of control and strength.
Treatment
Our first treatment session consisted of trigger points to infraspinatus and teres minor. This allowed the humeral head to sit back in a better position and to improve her range of internal rotation. Kinesio-Taping the humeral head posteriorly then reinforced a better shoulder posture. This was obviously not going to remedy a chronic shoulder problem, but it served a very important purpose: it proved to Jennifer that we could significantly decrease her pain.
She could now roll her arm over in a service motion without pain ­ a feeling she had not had in a while! In addition, it began to teach her where the correct 'normal' position for her shoulder should be: much less rounded and closer to a 'neutral position' ­ the centre of rotation for her 'ball and socket' joint. Jennifer then realized how much better she could feel when serving on court. It also gave her confidence in me, which was vital if we were to have a good outcome.
The rest of the session consisted of further education ­ thoroughly explaining to Jennifer her injury and using some 'scare tactics'. For Jennifer, that meant giving her some examples of other tennis players who had had similar injuries as juniors but were not handled properly and had subsequently not had continued success in the sport. This definitely had an impact on the keen young tennis player. At following sessions, she presented to the clinic with her folder in which she kept her list of exercises and reassured me that she had been doing her exercises religiously. Compliance was no longer a problem.