Case Study: Geoff Ogilvy Shoulder Injury
During relatively passive activities Geoff experienced discomfort when he moved the left shoulder, slept on his left side, and when breathing deeply. When performing the golf swing his movements in the upper extremity were limited, as the scapula could not guide the desired movement of the left arm and shoulder, resulting in pain and limited range of motion, particularly during deceleration (eccentric loading) of the golf club at the end of the backswing. Put simply, Geoff was anticipating the onset of pain and stopped so that only 95% of range of motion was achieved. However, his loss of perceptual awareness because of the injury had him ‘feeling’ like he was always at full swing. A concern then was if he began to over strive in the initiation of his golf swing, then instability and lateral shift may develop and promote poor movement patterns.
Radiologic evaluation was determined to be necessary for the correct diagnosis of Geoff’s injury. Magnetic resonance imaging (MRI) was used to confirm the injury as a grade-1 strain of the left rhomboid major, occurring at the musculotendinous junction between the rhomboid and medial border of the scapula.
Grade 1 strain to left Rhomboid Major.
The Rhomboid Major connects the medial border of the scapula to the spinous process of T2-T5 vertebrae. It acts to stabilize/position scapula by keeping it pressed against the ribcage, and to retract the scapula toward the spine. A grade-1 Rhomboid Major strain causes pain in the upper back between the shoulder blade and spine, consistent with the symptoms that Geoff experienced.
All muscle strains should be rested and allowed to heal fully. If Geoff had continued to practice/play, the condition would have worsened dramatically. If ignored, a grade-1 strain has the potential to become a grade two strain or even a complete rupture.
The immediate treatment was aimed at limiting the amount of inflammation by complete rest, repeated bouts of ice therapy and anti-inflammatory medication. The ice therapy continued at regular intervals (10 minutes ice, 30 minutes off) for a 72-hour period. It is important to stop bleeding into the affected area as the blood will act as an irritant and increase inflammation. Blood must be cleared from the injury site and surrounding tissue so that the healing process can begin.
Contrast baths or hot/cold immersion therapy were introduced following the first 72-hours period. This is a form of treatment where the whole body (or individual limb) is immersed in ice-cold water followed by immediate immersion in hot water. The process is repeated several times, alternating between hot and cold. The ratio of heating time to cooling time is adjusted as the individual acclimatizes to the temperature extremes. Geoff started the treatment with 1 minute in cold water at 10þC and 4 minutes in hot water at 35þC, and progressed to 2 minutes in cold water at 5þC and 3 minutes in hot water at 38þC. Heat dilates the blood vessels (vasodilation) and cold causes them to get smaller (vasoconstriction). Therefore, hydrotherapy treatment helps to increase blood flow in the immersed area and is beneficial for treating swelling and reducing inflammation. Contrast baths may also increase the elasticity of muscle and connective tissue, which help with improved range of motion as rehabilitation proceeds.
As pain and swelling began to subside, and in conjunction with the contrast baths, ultrasound and electrotherapy were added to the treatment process as methods to further speed up recovery.
Of primary importance in the rehabilitation process is the restoration of full range of motion and elasticity of the damaged tissue. Geoff’s rehabilitation was broken down into three areas:
Corrective Movement and StretchingGeoff starts in side lying posture injury side up. This position negates the influence of gravity on neural excitability, thus reducing the inputs required to control movement. Both his legs were straight with knees slightly bent and his head is supported (by a pillow or yoga prop) in a neutral position. Geoff then reaches out with the left arm and places an object (a golf ball) on the floor. The reach is far enough that the shoulder and rhomboids lengthen. He then returns the left hand to touch mid chest, then reach out and gathers the object – repeating the movement several times, placing and gathering the object.
His spinal rotation is limited early, but gradually increased (so that reach is increased) each day of rehabilitation. The movement must be directly horizontal and perpendicular to the lie of the spine.
The next movements were performed in a small series from the quadruped position. Geoff starts with knees directly under hips, and hands directly under shoulders. His left hand was placed on a small mat that would slide on the hard floor.
In the first exercise in the series Geoff slides the left hand forward, so that he is extending the left arm fully, ending directly in front of the right hand. He then returns the left hand to its starting position. He repeated the movement several times.
The second exercise in the series has Geoff sliding the left hand under the torso and behind the right hand. He is extending the left arm fully before returning to his original position. This movement allowed for increased shoulder rotation and lengthening of the left rhomboid.
To further assist in the promotion of blood flow and alignment of muscle fibres, in conjunction with the movements illustrated above, the gentle palpation of the left rhomboid major was added. This involved the application of light pressure over the rhomboid following the direction of the muscle lengthening while Geoff performed each movement.
Geoff then moved into standing postures so that the rehabilitation moved towards being more functionally relevant. He began in a sharpened Romberg’s position with controlled mid-range rotation only. Again, range of motion was gradually increased over a few days. By holding the golf club across the top of the chest and shoulders a further lengthening of the rhomboid was achieved.
The Romberg’s exercise was followed by a resistance band activity. The band provided diagonal resistance while Geoff slowly rotated through the swing plane. Again, as Geoff completed this movement palpation over the rhomboid muscle was provided. He performed this exercise at a range he was comfortable with so that there was little risk of developing compensatory movements such as lateral pelvic shift, and gradually increased range of motion over the next few sessions.
High point resistance:
Low point resistance:
The long-term outcome following muscle strain injury is usually excellent, and complications are few. This proved to be the case for Geoff and he was able to return to play after a short period with no discomfort or awareness of the left rhomboid strain.