When diagnosing pain syndromes, it is logical to look for familiar patterns. In the case of shoulder pain, we typically check the rotator cuff, treat ruptures or tendinopathy, and follow up with physical therapy. During physical therapy, we may look for scapular dyskinesis, retrain motor control, and strengthen the rotator and scapular muscles. But not everything fits into this tidy recipe.
In overhead athletes like pitchers, volleyball players and swimmers, it is easy to overlook disruptions to fascial continuity and gliding. When the fascial layers between key scapular stabilizers lose their ability to glide — from overuse, microtears, rib misalignment or adhesions — the scapula force couple breaks down. Shoulder movement becomes inefficient, not because of weak muscles, but because the mechanical bridge connecting them has been damaged.
When fascia is damaged, muscle strengthening won’t fix the problem. No matter how strong the muscles, fascia that won’t glide is unable to effectively transfer force loads, and movement remains dysfunctional. For that reason, focused clinical examination is critical — including assessment of fascial tensegrity, scapular ultrasonography, and Showmotion kinematic analysis. These tools help to uncover the true cause of shoulder dysfunction, so that our intervention matches the cause of pain.
Pain syndromes are rarely linear. Sometimes you never fully know which came first — muscle imbalance or fascial tear. But with the right tools and a broader lens, you can identify the underlying cause of pain and dysfunction, and intervene in the most effective way.
Dr. Lev Kalika is a world-recognized expert in musculoskeletal ultrasonography, with 20+ years of clinical experience in advanced rehabilitative medicine. In addition to operating his clinical practice in Manhattan, he regularly publishes peer-reviewed research on ultrasound-guided therapies and procedures.
Dr. Kalika is an esteemed member of the International Society for Medical Shockwave Treatment ((SMST), and the only clinician in New York certified by the ISMST to perform extracorporeal shockwave therapy. He is also an active member of the American Institute of Ultrasound in Medicine (AIUM), and has developed his own unique approach to dynamic functional and fascial ultrasonography.