Scapula and shoulder in an archer: Kim 2018 case

The case is a 31-year-old Korean archer, right-handed, world-class and with about twenty years in the sport, who for five years had felt a popping in his right shoulder, the drawing side, while holding at full draw. The noise could be heard by others; the discomfort was slight and did not stop him competing, but it distracted him while aiming and made him anxious. MRI showed a tear of the posterosuperior glenoid labrum and tendinosis of the supraspinatus, subscapularis and long head of the biceps; CT showed an altered scapular position, rotated upwards, protracted and tilted.

After 8 weeks of scapular stabilisation exercises (24 sessions of 40 minutes, three a week) scapular position on CT had improved by between 3.75% and 12.88% depending on the measure, with the upward rotation angle changing by 16.4 degrees. Strength measured with a dynamometer had risen in all four muscles: upper trapezius from 31.18 to 33.89 kg, middle from 21.20 to 25.39, lower from 22.13 to 28.46 and serratus anterior from 32.61 to 38.35. The questionnaire on apprehension about the noise (an adapted FABQ) fell from 51 to 22 points and the sports module of the DASH (SM-DASH) from 75.00 to 6.25. According to coaches and teammates the popping could no longer be heard.

At one year strength was higher still (35.00, 30.67, 30.33 and 43.67 kg), the FABQ was at 19 and the SM-DASH still at 6.25. CT was not repeated because, judging by the distance between the scapulae and the spine, alignment looked close to normal.

This is a single case, with no control and with assessors who knew about the treatment. Scapular position was measured by three-dimensional CT lying supine with the arms by the sides: three angles (upward rotation, superior translation and protraction) and the distance between the inferior angle of the scapula and the ribs. Strength of the upper, middle and lower trapezius and serratus anterior, on the right side only, was measured with a handheld dynamometer in standard manual muscle testing positions, averaged over three trials. Apprehension about the noise was assessed with the Fear-Avoidance Beliefs Questionnaire, designed for low back pain, with shoulder joint noise substituted for back pain; disability with the sports module of the DASH.

The programme consisted of five exercises with increasing load: prone scapular retraction with the arms at 90 and 120 degrees, push-up plus, retraction and depression against an elastic band, lifting the body off a chair on the arms, and leaning forwards onto a therapy ball, later progressed to a sling. Each exercise was twenty repetitions with 5 or 10 second holds, and load was recalculated every two weeks with a 20-repetition maximum test. The first six weeks focused on awareness of a neutral scapular position, the last two on the ball exercises. The archer also had a daily home programme, with a booklet.

With one archer and no comparison, the improvement cannot be attributed to the exercises: over eight weeks the shooting load, the point in the season and the attention paid to the problem can all change. It is not even stated whether, or how much, the archer kept shooting during that time. Assessors were not blinded, and the noise, the main complaint, was not measured with any instrument: its disappearance is reported by coaches and teammates. The FABQ was adapted by the authors without validation for this use.

The improvements in scapular position are calculated from angles measured lying down at rest, not during the draw. At one year CT was not repeated and position was judged by a different method, so the follow-up position data cannot be compared with the baseline. The authors note that the SM-DASH may not separate problems well in high-level athletes, and they did not measure shooting performance. The labral tear seen on MRI was not re-examined, so it is not known what changed in the structure of the shoulder.

For an archer with a popping drawing shoulder, the case describes a course that in this athlete coincided with improvement: exercises for the muscles that hold the scapula, centred on the middle and lower trapezius and serratus anterior, with the gains still there a year later. It is a clinical account, not evidence that it works for others, and the starting point was a diagnosis by an orthopaedic specialist with MRI and CT, which had found a labral tear. In the case described the exercises came after this full assessment, and that is the context in which they should be read.

The link with shooting is indirect. The noise appeared at full draw, when the scapula has to stay still under load, and the discomfort of hearing it distracted the archer from aiming: by his account, once the problem eased the movement felt smoother through draw, aim and release. Score was not measured. Joint noise in an archer can have different causes, and the study says nothing about archers who have the noise without pain or without an altered scapula.