As youth sports have become more specialized children are not playing multiple sports as much, and with that, I am beginning to see more sprain/strain injuries to muscles and tendons. In this particular case an 11-year-old volleyball player could no longer lift her left arm up in flexion and was limited by both pain and dysfunction.

According to William W. Briner Jr., MD and Robert Gallo, MD on the website Stop Sports Injuries, "Each year, more than 460,000 high school students including more than 410,000 girls participate in interscholastic volleyball. As participation has increased over the past two decades, as such the number of volleyball-related injuries has risen as well. While volleyball injuries rank lowest for all major sports, volleyball players are at risk for both traumatic and overuse injuries. Because volleyball involves repetitive overhead motions, such as spiking and blocking, players are prone to overuse injuries of the shoulder. The types of injuries that are most common in volleyball are rotator cuff tendonitis, finger injuries, ankle sprains, patellar tendonitis, anterior cruciate ligament and low back pain."

Interestingly, they don't mention the trauma that can happen to the nerves exiting the brachial plexus at C5,6,7,8. This would be the possible cause of my volleyball player's long thoracic nerve involvement with serratus anterior muscular weakness.

In the book by Travell & Simons — Myofascial Pain and Dysfunction: The Trigger Point Manual, they studied tennis and serratus anterior and found it essential to each of the three tennis strokes. In my experience volleyball players perform similar overhead repetitive movements.

In The Trigger Point Manual under "Activation and Perpetuation of Trigger Points" it is stated that serratus anterior trigger point may be activated by muscle strain during excessively fast or prolonged running, push-ups, lifting heavy weights overhead, or severe coughing due to respiratory disease.

Repetitive Trauma

My client was doing push-ups — an exercise that has become famously prescribed to kids, however this is the worst exercise they can do without first developing proper scapular stabilization. Most of these kids cannot even hold themselves in a plank position let alone a moving parts plank position (push-up) where their full body weight must be supported and moved.

Some days I just shake my head at the training methods used to gain strength in a sport. Have you ever seen a volleyball player solely play their sport from a plank position?

The plank exercise recruits core and shoulder stabilizers, which is a necessary exercise to establish before doing any push-ups. Unfortunately, that is rarely where the coaches begin. That is why it is critical for you as a massage therapist to understand personal training as one of your modalities.

This doesn't mean you have to be a personal trainer, but you do need to have an understanding of the modality, so you can better understand the injuries being presented to you from the various sports/sports training methods.

Case Study

This 11-year-old presented with pain along the lower medial border of the scapula. Which, if you look in Dr. Travell's book is a trigger point referral for serratus anterior. Her pain had been persistent since September of 2016, I first saw her in January of 2017. She had an MRI of the shoulder and had received six weeks of physical therapy. The MRI revealed supraspinatus tendonitis and subdeltoid bursitis, however she was not told to stop playing volleyball.

In-Gravity Functional Movement Screen

She complained of pain along the left lower medial border of the scapular when she did shoulder flexion or external rotation. Looking at the range of motion of shoulder flexion, she was at best 135 to 140, while normal is 180.

The Manual Muscle (MM) testing of flexion was weak and produced the pain along her scapula. MM testing abduction of the shoulder was weak but not necessarily painful. MM testing of the extension did not cause discomfort or loss of strength. MM testing of internal and external range of motion was weak and there was the same scapular pain on external range of motion. MM testing of supraspinatus was weak but without pain. MM testing of serratus anterior was weak and caused discomfort in her area of complaint.

Looking at her posture I could see a rotation of the pelvis with the right foot forward; rotation in the thoracic region with the left shoulder dropped and the right shoulder high; rotation in the cervical spine with the left ear lobe lower and the right ear lobe higher.

Editor's Note: Part two of this article will resume next month and will begin with the "Table Functional Movement" screen.