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Case Study; Jennifer, tackling a triathlon but has hit a stumbling block with shoulder impingement.

Case Study; Jennifer

Jennifer has always been very active. Next year will be a milestone birthday and she has set a goal to compete in a triathlon before she turns 40. She has often competed in running and cycling, but Jennifer is a little apprehensive about swimming. Other than a few lessons as a kid and splashing around on holidays, she has no competitive experience. Determined to tackle the triathlon, she started distance swimming lessons and has a new found passion for it!

The coach is very encouraging and Jennifer has enjoyed getting to know both the veterans and novices in the class. She has learned the mechanics of the front crawl and is beginning to focus on speed and distance.

Pain Pattern and Posture Assessment

Unfortunately, Jennifer began having pain in her right shoulder. In fact, she is unable to sleep on her right side and experiences significant pain whilst swimming.

Recently, Jennifer has even had trouble putting dishes away into cupboards and washing her hair. As a result, she has visited your clinic.

Your evaluation revealed a painful arc of motion from 70–120 degrees during right shoulder elevation and a positive Hawkins- Kennedy test. Manual muscle testing revealed mild weakness of the middle and lower trapezius muscle bilaterally and pain with right shoulder external rotation. There was no evidence of ligamentous damage or significant muscle tears.

Jennifer was asymptomatic during examination of her left shoulder. During a follow-up appointment with her physician the following week, Jennifer was diagnosed with subacromial impingement.


  • Massage Therapists, Aromatherapists & Reflexologists - can you share any insights, treatment plans and advice that you would have for Jennifer when she visited your clinic?
  • Sports Therapists - where would you start with your assessment & treatment for Jennifer?
  • What anatomical tissues might be impinged and causing Jennifer’s pain? Why would swimming have been a contributing factor?
  • Shoulder impingement is fairly common, especially as one ages. Why do you think these structures are so prone to injury?
  • During the evaluation, the physical therapist noted a painful arc of movement typical with shoulder impingement. Why do patients with this condition characteristically have no pain with elevation below 70 degrees or above 120 degrees?
  • Despite being a very active adult, Jennifer has weakness in her middle and lower trapezius. Is that surprising to you? How do you think this weakness might be contributing to impingement of the shoulder?
  • Other than the trapezius, what other muscle group(s) will likely need to be strengthened? Brainstorm ideas for initial strengthening exercises for all weak muscle groups, as well as how they could be progressed as her pain lessons.
  • Will Jennifer need to stop her triathlon training completely? Are there recommendations the therapist could make that will allow her condition to improve without keeping her out of the pool?
  • Other observations and support...

Watch the recording of our Thursday Evening Online discussion of this case study...

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Case Study adapted from Dr. Tawny Chamberlain, PT, DPT, Department Chair and Program Director, Physical Therapist Assistant Program, South University, Richmond