[Case Studies] Treating a surfer with anterior shoulder pain with Dr James Furness

In this episode with Dr James Furness, we explore an interesting case study on a real patient of his - a surfer who was suffering from anterior shoulder pain. We cover:

• Mechanisms specific to surfing
• Importance of a “working diagnosis” 
• Special tests of the shoulder 
• Treatment modalities for anterior shoulder pain

This episode is closely tied to James’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch James’s case study here with our 7-day free trial: https://physio.network/casestudy-furness

James Furness is a PhD graduate at Bond University with a background in musculoskeletal physiotherapy and research in water based sports. He is a Lead researcher within Water-based Research Unit at Bond University investigating the musculoskeletal and physiological adaptations in the sport of surfing. He has established a national collaboration with Surfing Australia and an international collaboration with universities within New Zealand and the USA. 

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Our host is @James_Armstrong_Physio from Physio Network

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Transcript

SPEAKER_01 0:02

Surfing is really broken down into the three primary components. So you sit for nearly half the time and you paddle for nearly half the time. The actual component of riding a wave is very, very small. So for example, if you do a two-hour session, you might spend about one to two minutes of actually riding the wave. The majority of that time is spent either paddling or sitting, so it's really intermittent in its nature. But what that means is that a two-hour surf session is about an hour of actually paddling. So there's a lot of load on your shoulders.

SPEAKER_00 0:36

Welcome back to case studies from Physio Network. In this episode, we're working through a detailed and clinically rich case of persistent shoulder pain in a surfer. This is a real-world presentation that many of us will recognise. A highly active individual with ongoing anterior shoulder pain, complex loading demands, and overlapping potential diagnoses. We take this case step by step, starting with the subjective assessment before zooming out to understand the specific demands of surfing, including paddling techniques, paddling mechanics, activity profiles and injury epidemiology. From there we move into the objective assessment, differential diagnosis, treatment progressions, and the clinical reasoning that underpins each decision along the way. Guiding us through his case is James Finesse. James is a physiotherapist and researcher with a PhD focused on the musculoskeletal and physiological profile of both elite and recreational surfers. His work has significantly advanced our understanding of shoulder injuries in surfing, including mechanisms of injury, paddling biomechanics, and sport-specific screening. James has published widely in peer-reviewed journals and is recognised internationally for his expertise in surf medicine and shoulder injury management. This episode is a great example of how understanding sport-specific loading, movement demands, and patient context can fundamentally shape assessment, diagnosis, and treatment decisions. I'm James Armstrong and this is Case Studies. So, James, great to have you on Case Studies episode today. We're talking through a really interesting case and we've got a lot to get through. So we're going to get straight into it. Talk us through the presentation of this patient. Sort of we're going to start with subjective work through to the sort of differential diagnosis, but let's kickstart with how this person presented and what are we looking at here.

SPEAKER_01 2:31

Thanks for having me on, James. We've got a male in his 40s. He's a really active surfer and also a foiler as well, which I'll talk about what that actually is. Really popular here on the Gold Coast. But basically, he has a right shoulder injury where he just goes to do what's called a dead hang, where you're just hanging from a chin-up bar. So didn't actually complete a chin-up, but he just feels a sudden sort of twin sensation in his right anterior aspect of his shoulder. He normally does a bit of a warm-up. So this day he doesn't do a warm-up. And he's also had this sort of little period of inactivity. Some of his aggravating factors were just these, those sudden arm movements, so trying to catch a ball. He experienced pain when he was duck diving. So duck diving is when you try to get underneath a wave. For those of you that aren't surfers, you're pushing the front part of the board down and then your knee pushes down on the back part of the board to take it under the wave. And that's when he had its he'd start to experience that anterior shoulder pain. Also the recovery aspect of surfing. Obviously, the entry point, all right. And then you got a propulsive phase, and then you've got a recovery phase. So during the recovery phase, he'd feel pain in the shoulder. He also sort of experienced some tightness in the back part of his shoulder as well. Also, things like lying on his right side created pain. Easing factors, so the pain was was intermittent. And he said he modified the way he did his workouts so he had like a neutral grip and changed some of his workout patterns as well. He had a similar injury a little while, so six months prior, which he didn't seek any treatment for, it just sort of settled by itself. Other things that I spoke to him about, things like lifestyle, there was nothing in there that sort of made me think that could be contributing to his symptoms. So things like sleep, diet, alcohol. He's a really active guy, works out a lot. The interesting thing is that while he had the shoulder pain, he continued to do really heavy weighted chin-ups. So putting 10 kgs on and then doing two to three sets of 10 to 12 chin-ups while he he never really stopped that, um, despite having this constant sort of shoulder issue. Before I jumped into objective, I I gave listeners a bit of a context to surfing. Um, and I think it's it's important to do that just so that you understand why I assess things I did. So just quickly, surfing is really broken down into the three primary components. So you sit for nearly half the time and you paddle for nearly half the time. The actual component of riding a wave is very, very small. So, for example, if you do a two-hour session, you might spend about one to two minutes of actually riding the wave. The majority of that time is spent either paddling or sitting, so it's really intermittent in its nature. But what that means is that a two-hour surf session is about an hour of actually paddling. So there's a lot of load on your shoulders. And so when you think about that, it makes sense that a lot of the sort of gradual onset injuries occur at the shoulder. And if we looked at observation, there's no sort of obvious muscle bulb differences between the sides. But he did have quite a sort of hitch when he came up into abduction at sort of 90 to 150 degrees. You did start to see this scapular sort of elevation happening on that right side, which wasn't happening on the left side. He was really stiff, so actively looking at his range of motion, hand behind back, sitting at the lumbar spine, where his the opposite side was getting up around T3. And then flexion and abduction, visually, there was a restriction there, about only 20-30 degrees. And end of range, overpressure didn't change his range of motion. Isometric testing, there was no reproduction of pain, uh, had full strength, and that was done uh at zero degrees of abduction. I did do some special tests, and and I'll just quickly discuss these. So the special tests, you know, I went through empty can, negative, but he did have a positive test with what's called the bear hug test, which does sort of target subscapularis, and that's where you're getting that the hand in this position, and then you're resisting internal rotation. Like you'll see that in the case study, but it is a relatively specific uh test, so it is it good at ruling in. So that did start to make me think that there could be some subscapularis presence of an additional issue going on. But it wasn't what I was primarily thinking is his main diagnosis. Even though things like speeds test was negative, I still was starting to think that this was more of a bicep sort of tendinopathy based on um the understanding that I have around surfing and paddling and also his the things he was telling me he was doing subjectively, but not to say that you could have these other issues going on. So yeah, just something to for the listeners to think about. You know, you have that sort of lift-off test, we've got the belly press test, they're good tests for subscapularis, but also be aware of that what's called the bear hug test as well. It's quite a specific test. And when we talk about specificity, think about it's good for ruling in. So if it's positive, there's a high chance that it could actually be that condition. I always like to use the word working diagnosis rather than you know, what is my primary diagnosis? Because in physio, I believe that it is always working, it's always changing depending on you know the development of the patient's progress. And you might find out new things as well as time goes on. And you know, with our initial assessments, we don't have a huge amount of time to determine you know everything that's going on. So things can develop as time goes on. But my work into diagnosis was that some kind of biceps teninopathy and this associated stiffness, which was probably due to this increased demand with the loading that he was putting on the the shoulder through his gym workouts, which I don't know if I mentioned at the start. He was working out about four times a week and he was surfing a similar amount of times, so a decent amount of load going through his upper body. His workouts didn't have a huge amount of lower body exercise in it, and he wasn't doing anything else. Like he wasn't running or cycling or anything like that. So it's a lot of load just on his shoulder pedal region. And so my initial treatment, I always use a bit of a mixed approach. I use both exercise therapy, obviously, and manual therapy. And so for me, initially it was looking at can I change his range with some manual therapy? And I often use more active approaches of manual therapy, like movement with mobilization, MWM, and just using a simple AP glide and getting the patient to move into flexion. And there was subjective reporting of decrease in and stiffness with movement and a visual improvement. And you know, I didn't get out the doniometer and measure. And often in those first sessions, I'm not always doing that because you know, we try to cover so many things. But there was a change. And so when I see changes like that, like instant changes, you start to think that okay, this approach will be effective for this patient. And it's not to say that this approach will be effective for every patient. So I probably want the listeners to be aware of that. And if I had time, I would talk about mechanisms and neurophysiology and things like that. I don't have the time, but you guys can go back and listen to that aspect of the case study. If you're interested in that side of things, what are the mechanisms behind manual therapy and things like that? One of the big things that I'm a big believer in is obviously education with patients and talking them through load management. And so for him, explaining to him about provocative loading and restorative loading, the first thing that we needed to do with him was to have a little period of deloading. He was, in my opinion, just loading that shoulder up way too much, never allowing it to have any time for recovery. So he was never really building up that tissue capacity. He was just gradually decreasing it with the constant load. And so talking to the patients about even a period of ral, I'll use the word relative rest. Often I don't say to patients this to stop everything. We just might modify the amount of what they're doing. And so for him, it was looking at his workouts. We did remove chin-ups because he just we just needed to delo that tissue. And then we looked at some other modifications in his workout just to reduce the total volume. And I think that's something to think about with all your patients is that is it a volume issue? Is there just too much load? Is there never a chance for recovery? So yeah, don't be afraid to almost do nothing. Like really, you're taking things out, which is hard for us as physios. We always want to put things in.

SPEAKER_00 10:40

Yeah, definitely. Ever wished you could see how experts treat real patients of theirs? With case studies by Physio Network, you can watch presentations where top clinicians break down real life patient cases step by step, showing how they assess and treat even the trickiest of conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click link in the show notes to start your free trial today.

SPEAKER_01 11:08

It's that kind of principle of inaction. And sometimes that might be the thing that actually gets them better. You might do some manual therapy, you might give them an exercise, but the one key thing you get them to stop doing might be the thing that actually changes their recovery trajectory. Just something I guess is a lesson, a takeaway from this case study. Just a simple posterior capsule stretch and then what I call restorative loading. Provocative loading for him was the chin-ups and things like that. Restorative loading for in this case was just to try and gently load the biceps tendon. And that was just done in a simple sort of scaption plane. And I just gave him just a really low weight, just at a sort of a to eight to twelve rep range, three or four sets. So that you know, just a stimulus that was going to be enough, but was not going to really clear him up. But also getting him to note what his pain was like 24 hours. Are we getting a massive increase in pain or not? And if we're not, then we know we're in this sort of right rep range and weight range and things like that. So make sure you you do go through that with patients and really go through the rep range that you're setting them. And then the other thing that I got him to do was what we did in the clinic, which was a simple posterior glide with shoulder elevation. And that's just a technique that you'll see in the case study where the patient can actually perform that technique on themselves using a little simple about and then the shoulder in a sort of a posterior inferior direction and coming up into flexion. And what we're really trying to do there is encourage pain-free movement and normalize that pain-free movement with the patient as well. Also, you may see some changes in range of motion as well. Thoracic mobility is really important. And I guess this is again where if you've watched the podcast, you'll look at what happens when you lie on a surfboard and you have minimal amounts of thoracic mobility, what the shoulder and how the shoulder has to compensate. When you fatigue, often you'll fall into more of a flatter position, which just requires the arm to be in more of an abducted position. And if we think about physics and biomechanics, you're gonna be more loaded on the shoulder and those sort of positions as opposed to when you're upright, then you can clearly reach forward. But again, obviously this is just a short sort of 15-20 minute recap. So it's something to go back to and have a look at. But I think as a clinician, treating surfers, don't neglect the thoracic spine, just like you wouldn't when you're treating a shoulder, you know, for any athlete, and make sure you do target some of the treatment around that, specifically if they do have reduced movement there, increased muscular tone and things like that. That started to come into my treatment regime with this patient. I also taught him how to do that, some of those trigger point release techniques. So just to self-manage, so getting him to do that at home was really important. Because that's a big one for me as well, is helping him in this initial stage of pain, but really his pain may come back. And what tools am I going to give this patient so that he can manage his pain or his symptoms when they do come back? It's potentially very likely if you've had one injury, you're very likely to have another injury in the same location. I guess that's another I'm sprinkling these lessons throughout for me and for the listeners. Reduction in pain isn't necessarily the goal, it's trying to improve his function, which by doing that, by addressing all these things, we're going to improve his pain. But I'm also giving him tools that he can use long term. So yeah, so first one was you know simple trigger point release techniques around that scapulothoracic region, and then a simple mobilization technique over a foam roller. So teaching him how to mobilize different aspects of that sort of mid and lower thoracic spine, actually his whole thoracic spine, but getting him to find spots that feel stiffer than others and then moving around. So that was what we implemented. And then as time went on, that the diagnosis developed a little bit further around, we got most likely a biceps teninopathy, but also this associated posterior shoulder tightness. There was definitely, you know, posterior shoulder tightness in conjunction with some kind of anterior biceps teninopathy. I did speak about posterior shoulder tightness and sort of the mechanisms behind that and things to look out for, retroversion, or is it more of a splenochumeral capsule tightness, or is it more of a posterior muscle tendon issue? The third one is what we can really have effect on. Not necessarily the capsule. The capsule requires a huge amount of load to actually change tissue length, and that's never going to happen in our mobilization techniques. And I do talk about some of the mechanisms at play in those techniques and what we're actually doing. And if you're interested in that sort of thing, go back and have a listen to the mechanisms that are occurring when we're doing those mobilization techniques.

SPEAKER_00 15:37

No, definitely worthwhile looking, you know, go back to the case study and getting this much more in depth than we can even possibly go into today.

SPEAKER_01 15:44

And then yeah, I saw him again another month later, which is two months post that initial. He's not experiencing those burning sensations during surfing or with quick arm movements. He's able to surf, no problems at all. He's not experiencing any sort of tightness during that paddling, the recovery aspect, which was happening right at the beginning. The only thing he sort of said that he had some difficulty, which was reaching the arm across. So it was that initial sort of bear hug test of he was still experiencing a little bit of pain, and that was when he was trying to pull his wetsuit off. That was one thing that you said he still struggled with. And so we continued actually the current plan, the current management. So I was still mobilizing the joint. I was using some mobilizations into sort of external rotation, trying to improve that range. And then yeah, I guess finally, if there's any physios out there that are interested in doing any higher degree research, I am looking for masters and or PhD students that are interested in surfing and shoulder injury specifically, looking at mechanisms of shoulder injury and then you know treatment techniques and things like that. So if any of you listeners out there are interested in that, just feel free to reach out to me. If you just Google my name, Bon James Finness at Bon University should be up there. It should take you to my research and profile page, which you have my email address.

SPEAKER_00 16:59

Brilliant. Yeah, that but that sounds great. Great, great call to action to finish on there, James. And uh, if anyone's listening is is interested in that that area, that field, then get in touch with James and get cracking on some new research and get involved. Sounds brilliant. Really good opportunity. Brilliant, James. Thank you so much for that. There's tons to unpick there. I really highly recommend listeners do check out the case study because, as you've mentioned several times there, there's much more detail that you've not been able to go into in in today's podcast that you did go into in the in the case study, and more for listeners to dive into and get their teeth stuck into. But thank you so much for your time today, James. No worries. Thanks, James.