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Abstract

Introduction: Posterior impingement, also known as internal impingement, is a type of secondary impingement that is caused by overuse and repetitive movements of the shoulder overhead during motions such as throwing, spiking, etc. A combination of shoulder abduction and external rotation produces impingement of the infraspinatus and/or of the supraspinatus against the posterior-superior glenoid. Posterior impingement is common in overhead athletes, and this mechanism is usually seen during the cocking phase of throwing. Someone suffering from posterior impingement may complain of posterior shoulder pain, posterior stiffness and decline in performance. Patient Information: In this case study, a 15- year-old male high school baseball pitcher seeks medical help after dealing with posterior shoulder pain, elbow pain, and tingling in his elbow to 4th and 5th fingers for 3 weeks. The athlete complained of feeling weak while throwing. He states that does not recall doing anything specific to his shoulder, such as falling on it or subluxing/dislocating it. The pain is the highest during throwing and after throwing but eventually would cease as he rested. The symptoms he is experiencing are not isolated just from pitching but arise when throwing any ball. He also has pain from reaching overhead to grab things from shelves or stretching with his hands overhead. Differential diagnoses include posterior impingement, SLAP tear, rotator cuff tendonitis, UCL tear, and cervical radiculopathy. These diagnoses have similar signs and symptoms, so the objective examination was important in determining the diagnosis. Cervical radiculopathy was tested to rule in or out the paresthesia symptoms he was experiencing. Posterior impingement was ruled in through location of pain and when he was getting pain. Additionally, I tested multiple tests for the same condition to aid in ruling. Intervention: The athlete was removed from participation to prevent further damage to structures and decrease pain and tingling symptoms. Rehabilitation focused on shoulder stability, rotator cuff strength, serratus anterior strength, and proper scapulohumeral rhythm and throwing mechanics. Posterior mobilizations, scapular framing, and scapular upward rotation mobilizations were utilized before exercises to help decrease pain and improve shoulder and scapular joint mobility, and soft tissue massages were done on the biceps, upper traps, forearm, rhomboids, and lats to help release tension. Return to Play protocol is broken up into phases. Phase 1 is general stabilization and strengthening, phase II is advanced stabilization and strengthening, phase III is plyometrics, and phase IV is sport specific activities (return to throw). The athlete progressed through the program based off location of pain, type of pain, and change in symptoms. The throwing motion was also utilized to gauge progress. The goal for the athlete was to be able to return to strength and conditioning camp in 6 weeks. Outcomes: The patient made progress through his program. He was re-tested on MMTs for IR, ER, flexion, and protraction, specifically the serratus anterior. He reported no pain through the first two weeks with any of the exercises. General muscles soreness is expected as he continued to increase strength gains. He has not been cleared to participate at this time, and he is currently continuing in phase II. Clinical Bottom Line: This case report demonstrates how posterior impingement goes beyond the shoulder musculature and glenohumeral joint. There are many impairments that can arise due to the impingement. Muscle imbalances and improper scapulohumeral rhythm are expected in overhead athletes. One may note scapular dyskinesis as a sign of muscle imbalances often presented with posterior impingement. The current research harps on evaluation of the glenohumeral joint, scapulohumeral joint, and humeroulnar joint, including the cervical spine, and how to rule in and out their involvement.

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