Initial Detailed Consult

Presenting Complaint: Right anterolateral shoulder pain and mild right lateral epicondyle ache.

• 34yo male recreational swimmer and CrossFit athlete. 6/52 Hx of insidious onset R shoulder pain, aggravated by overhead pressing, kipping pull-ups, and freestyle swimming catch phase. Associated 2/52 Hx of R lateral elbow ache during heavy gripping. Nil pins and needles, numbness, or night pain.

Medical History: R ankle inversion sprain (2019, fully resolved). Appendicectomy (2015). Nil significant medical conditions.

Medications: Ibuprofen (Nurofen®) 400 mg PO PRN for shoulder pain.

Examination

SFMA

Cervical Flexion: FN. Cervical Extension: FN. Cervical Rotation: L FN, R DN (mild end-range stiffness, nil pain).

Multisegmental Flexion: FN. Multisegmental Extension: DN (limited thoracic extension). Multisegmental Rotation: L FN, R DN (decreased thoracic rotation).

Upper Extremity #1: L FN, R DP (pain at R anterior shoulder, fingers to L3).

Upper Extremity #2: L FN, R DP (pain over R lateral deltoid, unable to touch spine of scapula).

Single Leg Balance: L FN (eyes open 15 s, eyes closed 10 s), R FN (eyes open 15 s, eyes closed 12 s).

Overhead Squat: DN (arms fall forward, limited thoracic extension and R shoulder flexion).

SFMA Breakouts: Supine passive R shoulder ER DN (limited to 70 degrees), prone active thoracic rotation R DN.

Muscle Testing

SERRATUS ANTERIOR: L 5/5, R 4/5 (delayed activation onset, winging noted, nil pain)

LATISSIMUS DORSI: L 5/5, R 5/5 (normal activation, nil pain)

UPPER TRAPEZIUS: L 5/5, R 5/5 (early dominant activation on R)

MIDDLE TRAPEZIUS: L 5/5, R 4/5 (nil pain, fatigues quickly)

LOWER TRAPEZIUS: L 4/5, R 3+/5 (poor endurance, compensatory lumbar extension, nil pain)

PECTORALIS MAJOR - TRANSVERSE: L 5/5, R 5/5 (nil pain)

PECTORALIS MAJOR - OBLIQUE: L 5/5, R 4+/5 (mild anterior shoulder tightness)

MID DELTOID: L 5/5, R 4/5 (pain 3/10 over lateral subacromial space)

ANTERIOR DELTOID: L 5/5, R 4+/5 (mild ache 2/10 on resistance)

POSTERIOR DELTOID: L 5/5, R 5/5 (nil pain)

BICEPS: L 5/5, R 4+/5 (mild discomfort at bicipital groove)

TRICEPS: L 5/5, R 5/5 (nil pain)

WRIST EXTENSORS: L 5/5, R 4/5 (reproduces mild R lateral elbow ache 2/10)

EXTENSOR CARPI RADIALIS: L 5/5, R 4/5 (pain 3/10 at lateral epicondyle, slow onset)

Cervical Testing

C COMPRESSION: - (nil pain or radicular symptoms)

C DISTRACTION: - (nil change in baseline symptoms)

C KEMPS: L -, R - (smooth movement, nil facet pain)

FORAMINAL COMPRESSION - LAT FLEXION: - (nil pain)

FORAMINAL COMPRESSION - ROTATION: - (nil pain)

FORAMINAL COMPRESSION - KEMPS OVERPRESSURE: L -, R - (nil symptom reproduction)

UPPER LIMB TENSION TESTS: RADIAL NERVE: L -, R - (mild forearm stretch bilaterally, symmetrical, nil reproduction of lateral elbow pain). MEDIAN NERVE 1: L -, R - (normal).

Thoracic Testing

1st RIB RESTRICTION: L -, R + (elevated and stiff on R, tender to palpation, nil radiating pain)

ADAM'S FORWARD BEND: - (nil structural scoliosis or rib prominence)

ADSON'S TEST: L -, R - (radial pulse maintained, nil paraesthesia)

RESPIRATION: Apical chest breathing pattern dominant; decreased R lower rib cage lateral expansion, nil pain.

THORACIC ROTATION/EXTENSION, HAND ON OPPOSITE SHOULDER: L FN, R DN (stiff mid-thoracic spine, nil pain)

THORACIC ROTATION/EXTENSION, HAND BEHIND LOWER BACK: L FN, R DP (anterior R shoulder pain 3/10, restricted thoracic extension)

THORACIC ROTATION/EXTENSION, HAND BY EAR, ELBOW OUT: L FN, R DN (restricted R pectoralis minor and thoracic rotation, nil pain)

Shoulder Testing

EMPTY CAN: L -, R + (positive with thumb down; pain 4/10 in subacromial space and weakness)

BEAR HUG: L -, R - (strong, nil pain)

HORNBLOWERS/INFRASPINATUS: L -, R + (pain 3/10 posterolateral shoulder and mild weakness on R)

SPEEDS: L -, R + (mild tenderness 2/10 localized to R bicipital groove, no weakness)

O'BRIENS: L -, R - (nil deep joint pain with thumb down or palm up)

YERGASONS: L -, R - (nil pain or snapping)

BICEPS LOAD TEST: L -, R - (nil apprehension or pain)

NEERS: L -, R + (reproduces familiar R anterolateral shoulder pain 4/10 at end range)

ACROMIOCLAVICULAR JOINT: L -, R - (nil local ACJ pain on horizontal adduction)

STERNOCLAVICULAR JOINT: L -, R - (normal glide, nil pain)

SULCUS SIGN: L -, R - (nil inferior instability or pain)

GLENOHUMERAL AP GLIDE: L -, R + (excessive anterior translation of R humeral head with posterior capsule tightness, mild anterior ache)

PAINFUL ARC: L -, R + (pain 4/10 between 80 and 120 degrees of active abduction)

ARM DROP TEST: L -, R - (smooth eccentric control, nil pain)

Elbow, Wrist and Hand Testing

LATERAL ELBOW PALPATION: Tender over R common extensor origin and ECRB tendon (VAS 3/10).

GRIP: L 52 kg (pain-free), R 46 kg (reproduces mild R lateral epicondyle ache 2/10).

Functional and Structural

HANDEDNESS: Right hand, right foot, and right eye dominant.

GAIT - WALKING: Normal heel-toe gait, reduced R arm swing.

SQUAT - BODYWEIGHT: Good depth, neutral knee alignment, heels remain down.

SQUAT - OVERHEAD: Dowel drifts forward at 90 degrees hip flexion due to R shoulder tightness and thoracic stiffness.

NECK FLEXION MOVEMENT PATTERN: Normal segmental rolling, nil chin poke.

DEEP NECK FLEXOR ENDURANCE: 28 s hold prior to sternocleidomastoid dominance.

SHOULDER ABDUCTION: R scapular dyskinesis noted (early scapular elevation and reduced upward rotation at 90 degrees).

PUSH UP: R medial scapular border winging on eccentric phase, nil shoulder pain.

WEIGHTED SHOULDER FLEXION: 5 kg dumbbell reproduces R anterior shoulder catch at 130 degrees.

Range of Motion Testing

SEATED NECK RANGE OF MOTION: Flexion 50 deg, Extension 65 deg, Rotation L 80 deg, R 75 deg, Lat Flexion 40 deg bilaterally.

SEATED TRUNK ROTATION: L 45 deg, R 35 deg (restricted end-range R thoracic rotation).

SHOULDER ABDUCTION: L 180 deg, R 165 deg (painful arc 80-120 deg).

SHOULDER FLEXION: L 180 deg, R 160 deg (anterior pinch at end range).

SHOULDER EXTENSION: L 50 deg, R 45 deg (nil pain).

SHOULDER ROTATION SEATED: @ 90 deg abduction: ER L 90 deg, R 75 deg (tight); IR L 70 deg, R 45 deg (significant posterior capsule restriction).

WRIST FLEXION: L 80 deg, R 75 deg (mild tight pull over R lateral epicondyle at end range).

WRIST EXTENSION: L 75 deg, R 70 deg (nil pain Passively).

Working Diagnosis: Right subacromial pain syndrome (supraspinatus/infraspinatus tendinopathy) secondary to scapular dyskinesis, posterior glenohumeral capsule tightness, and thoracic extension/rotation restriction; concurrent mild right lateral epicondylalgia.

Treatment: Soft tissue massage and myofascial release to R pectoralis minor, infraspinatus, teres minor, and R wrist extensors. PA and rotational joint mobilisations (Grade III) to T3-T8 and R 1st rib. Mulligan MWM for R shoulder flexion and R lateral elbow gripping. Kinesiotape applied to R scapula for lower trapezius facilitation.

Home Care:

• Thoracic extension over foam roller: 2 mins daily.
• Sleeper stretch for R posterior capsule: 3 x 30 s holds daily (pain-free).
• Serratus anterior wall slides with resistance band: 3 x 12 reps daily.
• Isometric R shoulder external rotation at neutral (towel under arm): 5 x 30 s holds @ 50% effort daily.
• Activity modification: Avoid overhead barbell pressing and kipping pull-ups for 2/52; substitute with landmine presses and ring rows.

Treatment Plan: Review 1x/week for 3 weeks to progress rotator cuff and scapular stabiliser loading (moving from isometric to isotonic eccentric/concentric control), monitor R lateral elbow load tolerance, and gradually reintroduce overhead CrossFit movements and swimming volume.