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.