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Case Study: When the Shoulder Won’t Heal

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.

Key takeaways:

  • The true cause of pain and dysfunction does not always fit familiar patterns.
  • Labels like “Type I, II, III dyskinesis” help to describe patterns — but they don’t explain the cause.
  • Every patient’s presentation is unique, and multiple factors should be considered. The classification is the map, not the territory.

 

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.

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About the Author

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.

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In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)

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Complete tear of rectus femoris
with large hematoma (blood)

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Separation of muscle ends due to tear elicited
on dynamic sonography examination

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