This blog post is the first of a two-part series authored by Marissa Rescott, SPT. It is intended for clinicians who are treating CrossFit athletes with shoulder injuries. This first post focuses on assessment and treatment of the shoulder using the Shoulder Symptom Modification Procedure, while the second post focuses on load management strategies for rehabilitation and return-to-CrossFit.

PART I

Are you...

a healthcare provider who has seen an uptick in your patients with shoulder pain caused by CrossFit?
a clinician who is unsure exactly how you can create buy-in while tailoring your shoulder assessment and treatment to the CrossFit population?
somebody who is open to integrating a pain science and biomechanical approach to the shoulder that might seem counter intuitive?

Enter the Shoulder Symptom Modification Procedure (SSMP)

WHAT IS IT?

The SSMP is a method of examination developed by Dr. Jeremy Lewis in an attempt to simplify the shoulder exam and treatment for patients with rotator cuff tendinopathy and subacromial impingement syndrome (SAIS). Due to the lack of evidence surrounding pathoanatomy of SAIS and the relatively poor diagnostic accuracy of our special tests, Dr. Lewis needed another way to conceptualize shoulder pain.

The SSMP does not seek to identify “pain generating structures”, but rather to strategically identify modifications to provocative movements that can reduce symptoms and inform treatment.

Here are the four step-wise procedures used to modify painful movements:

Thoracic Extension
Scapular Repositioning
Humeral Head Repositioning
Manual Therapy: cervical or thoracic

WHY DO I USE IT?

The SSMP is particularly useful for our CrossFitters as many of the shoulder injuries encountered are a result of poor mechanics or overuse. It provides clinicians with options to modify lifting around an injury and more importantly, it decreases the pathologizing of movement flaws. For example, where traditional physiotherapy would dictate that the shoulder blade should be down and back during pressing to decrease impingement, the SSMP allows any position of the shoulder blade that would reduce the patient’s symptoms.

Which way should the shoulder blades be cued for pain relief?

HOW DOES IT CREATE BUY IN?

It can be adapted to the patient's CrossFit-specific movements! Rather than traditional assessment methods that use unweighted and awkward provocative movements, this method of shoulder assessment uses the specific movement that is the CrossFitter's "goat", or weakness. For our patients, this could be a barbell press, a hang on the rig, a snatch, etc.

Even more important is that the purpose of the assessment is to find a way to make those CrossFit movements DOABLE, a way to continue their participation despite injury. This is contrary to many approaches that remove the provocative movement from a patient's repertoire rather than alter the movement.

Lastly, it makes use of resistance bands, which any CrossFitter knows is the ultimate mobility aid.

WHY IS IT COUNTER-INTUITIVE?

The SSMP ultimately takes principles from pain science and minimizes the importance of traditional biomechanical mantras, like "Shoulder blades down and back when pressing overhead," or "cue the thoracic spine into extension for overhead movement." This assessment acknowledges biologic variability and allows movement modifications that reduce pain during the provocative movement.

HOW DO I USE IT?

The full text of the "Assessing and Treating the CrossFit Shoulder: Use of the SSMP and Load Monitoring to treat pain" is available here along with how-to pictures, references, and additional clinical insights provided by Dr. Sarah Haran DPT, OCS of ArrowPT.

Marissa Rescott, SPT, CF-L1

The Ohio State University '18

Marissa is a Doctor of Physical Therapy student and CrossFit coach who is completing a specialized 6-week internship experience with ArrowPT before she graduates with her license in May. She is focusing on learning the elements of a successful cash PT practice, conservative treatment strategies for hip impingement, and injury rehabilitation for the CrossFit population. Marissa describes herself as a neuro nerd, lunge lover, and adventurer who believes in the benefits of one-on-one care to return her patients to an active lifestyle!