Case of the Week 9-10-12: Overhangs Hurt! | Modern Manual Therapy Blog

Case of the Week 9-10-12: Overhangs Hurt!

Today's Case of the Week is a Quick Case, one of my close friends was in town for a few days and had time to stop by for 1 visit.

History: One year ago, the patient had insidious onset of right anterior and lateral shoulder pain while bouldering on an overhang. Since then, Sx have remained unchanged and she is only top roping at this point, being unable to boulder (due to the overhangs in the routes). Sx are intermittent, with moderate amount of pain, worse with reaching overhead, and sleeping on right side.


  • Cervical extension, DP, mild loss
  • Shoulder LRF Right DN, min loss
  • Shoulder MRE Right DN, sev loss
  • MSE DN
    • breakout - right hip flexed, and hands behind head, FN - indicating shoulder elevation, thoracic extension, hip extension limits
  • MSR LN DN, mild loss Right DN, mod loss
    • breakouts - hip IR DN, mod loss on right, upper and lower body rotation (lumbar locked) was FN, indicating lower body restriction and possible motor control issue
  • Deep Squat - DN

Treatment: What do you focus on when you only have 1 treatment before your patient goes back to NYC? I chose the one I could make the most amount of difference in, that would also change her function the fastest.

  • IASTM in cervical posterior patterns to upper trap, and levator scapula right > left, lateral upper arm
  • 1st rib mobs
  • thoracic spine thrust manipulation (1 upper, 2 mid)
  • psoas release with pelvic tilts, hip slides, and deep breaths as functional release
  • FR to the right shoulder, with emphasis on release of external rotators
  • LRF right FN
  • MRE right DN, mild loss
  • MSR right FN
  • MSE DN, improved extension with more segmental movement, right hip extension improved as well
I didn't bother retesting the DS, as I didn't have time for a rolling breakout and full instruction on that. She was instructed on repeated shoulder extension in standing for shoulder mobility, and open book for thoracic rotation. 

She texted me the next day saying that sleeping on her right was completely pain free as well as reaching overhead. She still needs to test bouldering on overhangs. She will need a few more treatments to clear up any remaining DNs, progress her corrective exercise, and assess rolling patterns.

Discussion: Climbing on overhangs and negative incline require more core strength, coordination, not to mention thoracic mobility and shoulder elevation. Her lack of thoracic extension and shoulder mobility combined to strain her shoulder during these activities. I wish I had more time, but someone else needs to follow up with her in NYC! Any readers or any recommendations? 


  1. Dr. E,
    I like how you integrate the SFMA into your daily practice! I think the system really works for assessing movement change. I have taken the course but I haven't worked it in to my practice yet. Do you use this as your only ROM assessment including the breakouts?

  2. It's easy to integrate into your practice, you should already be assessing movement, this just streamlines it! I use it and repeated motions (depending on history and my intuition), I use about 50% of the breakouts and the rest are my own active and passive movement testing (which most of the breakouts really are).