Chiropractic Rehabilitation Methods for Shoulder Pain

Achieve lasting relief from shoulder pain through targeted chiropractic rehabilitation tailored to your needs.

Abstract: A Holistic Approach to Complex Shoulder Pain

In my years of clinical practice, I have seen countless individuals whose lives are compromised by persistent pain. One of the more enigmatic and often misdiagnosed conditions is suprascapular neuropathy, a nerve compression syndrome that can lead to debilitating shoulder weakness and atrophy. This educational post takes you on an in-depth journey into this condition, drawing on a specific clinical case we recently managed at our clinic. We will explore the intricate anatomy of the shoulder, the pathophysiology of nerve compression, and the diagnostic process. I will detail the procedural aspects of a targeted diagnostic and therapeutic injection into the suprascapular notch, explaining the rationale for each step, from landmark identification to medication selection. Furthermore, this post will illuminate the philosophy of our practice at Injury Medical Clinic, P.A. We will discuss how we integrate advanced diagnostic techniques with a multidisciplinary framework that combines the expertise of myself, Dr. Alex Jimenez, with the medical oversight of our esteemed Medical Director, Dr. Maria Guadalupe Cardenas, MD. Our collaborative approach, which synergizes chiropractic care, functional medicine, rehabilitation, and allopathic medicine, provides a comprehensive and patient-centered pathway to recovery, not just for shoulder conditions but for a wide spectrum of musculoskeletal and systemic health issues.

Introduction: The Integrated Care Model at Injury Medical Clinic

Welcome. I am Dr. Alex Jimenez, and I am honored to share insights from my practice and the broader field of integrative medicine. My healthcare journey has been driven by a passion for understanding the human body as a complete, interconnected system. This has led me to pursue a diverse range of specializations, reflected in my credentials: Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), Family Nurse Practitioner-Board Certified (FNP-BC), Certified Functional Medicine Practitioner (CFMP), Institute for Functional Medicine Certified Practitioner (IFMCP), Anti-aging, Regenerative, and Functional Medicine (ATN), and Certified in Chiropractic Spinal Trauma (CCST). This extensive training allows me to view patient health through multiple lenses, from the biomechanical and structural to the biochemical and metabolic.

At the heart of my practice, Injury Medical Clinic, P.A. (also known as Mission Plaza Injury Medical Clinic) in El Paso, Texas, is a philosophy of integrative and collaborative care. A cornerstone of this model is my professional collaboration with Dr. Maria Guadalupe Cardenas, MD. Dr. Cardenas is a highly respected physician, board-certified in Internal Medicine, with an impressive career spanning over four decades. Her NPI is #1164426749, and her Texas Medical License is #J2933. As our Medical Director and Collaborative Physician, Dr. Cardenas provides invaluable medical oversight, ensuring that our patients receive a standard of care that is both comprehensive and safe. This multidisciplinary setup, where a chiropractor and a medical doctor work in tandem, is crucial in modern injury and functional medicine care. It helps bridge gaps between healthcare disciplines, offering patients the best of all worlds.

Our team’s approach is multifaceted. We integrate:

• Chiropractic Care (Dr. Jimenez): Focusing on spinal and extremity joint biomechanics, nervous system integrity, and musculoskeletal health.
• Medical Oversight (Dr. Cardenas): Providing diagnostic expertise, managing systemic conditions, and offering medical procedural guidance.
• Functional Medicine: Investigating the root causes of disease by looking at genetics, lifestyle, and environmental factors.
• Personal Injury and Rehabilitation: Specializing in the recovery from accidents and injuries through targeted physical therapies and protocols.
• Advanced Diagnostics: Utilizing modern imaging and procedural techniques to achieve accurate diagnoses.

This collaborative environment allows us to create personalized treatment plans that address the patient as a whole person, not just a collection of symptoms. The case we will discuss today—an 18-year-old athlete with suspected suprascapular neuropathy—is a perfect example of how this integrated approach comes to life, from initial assessment to a precise, evidence-based intervention.

A Clinical Case Study: The Young Athlete with a Wasting Shoulder

This morning, a case presented that perfectly illustrates the subtleties of diagnosing complex shoulder pain. Our patient is an 18-year-old gentleman who came to us with a perplexing five-month history of vague, yet persistent, pain in his left shoulder. He described the onset as insidious—it didn’t start with a specific “pop” or injury but rather crept into his awareness and has been progressively worsening over time.

His complaints were twofold: diffuse, nagging pain and noticeable, progressive weakness. One of the classic red flags he reported was nocturnal pain—discomfort in his left shoulder that was significant enough to disrupt his sleep. This symptom often points toward an inflammatory or compressive process, as the static position of sleep can exacerbate pressure on sensitive structures.

My physical examination revealed the most telling signs. On visual inspection and palpation, I noted clear atrophy, or wasting, of the left infraspinatus compared with the robust, healthy right muscle. A similar, though perhaps slightly less pronounced, atrophy was also visible in the supraspinatus muscle on the same left side. These muscles are two of the four crucial components of the rotator cuff, and their wasting is a significant clinical finding. It immediately tells me that the nerve supply to these muscles is compromised. A healthy muscle with an intact nerve connection does not simply waste away.

The patient’s history provided a vital clue: he has been an avid weightlifter for the past seven or eight years. This long-term, high-demand activity places immense and repetitive stress on the shoulder girdle. He specifically noted increasing difficulty in the gym with two key movements: abduction (lifting the arm out to the side) and external rotation (rotating the arm outward, as if preparing to throw a ball).

Putting these pieces together—the insidious onset, the progressive weakness, the nocturnal pain, the visible atrophy of the infraspinatus and supraspinatus, and the functional deficits in abduction and external rotation—my clinical suspicion converged on a diagnosis of suprascapular neuropathy.

Understanding Suprascapular Neuropathy: A Deeper Look

To fully grasp this condition, we must first understand the anatomy involved. Suprascapular neuropathy is a compression neuropathy, meaning a nerve is being pinched or entrapped somewhere along its path. In this case, the affected nerve is the suprascapular nerve.

The Path of the Suprascapular Nerve

The suprascapular nerve is a critical structure that originates from the brachial plexus, the complex web of nerves in the neck and shoulder that controls the arm and hand. Specifically, it arises from the upper trunk of the brachial plexus, formed by the C5 and C6 nerve roots (with occasional contributions from C4).

From its origin, the nerve embarks on a winding journey:

1. Across the Posterior Triangle of the Neck: It travels laterally, deep to the trapezius muscle.
2. Through the Suprascapular Notch: This is the first and most common site of entrapment. The suprascapular notch is a small, U-shaped indentation on the superior border of the scapula (shoulder blade). The superior transverse scapular ligament stretches across the top of this notch, converting it into a foramen (a tunnel). The suprascapular nerve passes through this tunnel, while the suprascapular artery and vein pass over. This tight, unyielding space is a prime location for compression.
3. Into the Supraspinatus Fossa: After passing through the notch, the nerve enters the supraspinatus fossa, a depression on the upper part of the posterior scapula. Here, it gives off motor branches to innervate the supraspinatus muscle. This muscle initiates the first 15-30 degrees of arm abduction.
4. Around the Spinoglenoid Notch: The nerve then continues its journey, wrapping around the lateral edge of the scapular spine to reach the spinoglenoid notch. This is the second potential site of entrapment. It’s a broader passage connecting the supraspinatus and infraspinatus fossae.
5. Into the Infraspinatus Fossa: Finally, the nerve terminates in the infraspinatus fossa, the large depression below the scapular spine. Here, it provides motor innervation to the infraspinatus muscle, which is the primary muscle responsible for external rotation of the shoulder.

Why Compression Occurs

Compression of the suprascapular nerve can result from various causes. In our patient’s case, the most likely culprit is repetitive microtrauma from years of heavy weightlifting. Overhead movements, heavy lifting (like squats with a barbell resting on the shoulders), and bench pressing can all create dynamic forces that stretch or compress the nerve, particularly at the unyielding suprascapular notch.

Other potential causes include:

• Anatomical Variations: A congenitally narrow notch or a thickened or ossified (turned to bone) transverse scapular ligament can predispose an individual to entrapment.
• Direct Trauma: A fracture of the scapula or a direct blow to the shoulder can damage the nerve.
• Space-Occupying Lesions: Cysts, particularly paralabral cysts extending from a tear in the glenoid labrum (the cartilage rim of the shoulder socket), can form near the spinoglenoid notch and press on the nerve.
• Repetitive Overhead Activities: Common in sports like volleyball, tennis, and swimming.

The Clinical Picture of Suprascapular Neuropathy

The symptoms directly correlate with the nerve’s function.

• Pain: Often described as a deep, dull, aching sensation in the posterosuperior aspect of the shoulder. The patient may find it difficult to pinpoint the exact location.
• Weakness and Atrophy:

• If the compression occurs at the suprascapular notch (proximal entrapment), both the supraspinatus and infraspinatus muscles will be affected. This results in weakness in both abduction and external rotation, and atrophy will be visible in both muscles, as seen in our patient.
• If the compression is more distal, at the spinoglenoid notch, only the branches to the infraspinatus muscle are typically affected. This leads to isolated weakness in external rotation and infraspinatus atrophy. This pattern is common in overhead athletes and is often associated with paralabral cysts.

The presentation of our 18-year-old patient, with involvement of both muscles, strongly points to an entrapment at the suprascapular notch. This is the classic presentation we aim to address with our intervention.

The Diagnostic and Therapeutic Intervention: A Guided Injection

Given the strong clinical evidence, we decided to perform a diagnostic and therapeutic injection into the suprascapular notch. The goal is twofold:

1. Diagnostic: If injecting a local anesthetic into the space provides immediate, albeit temporary, pain relief, it helps confirm that the suprascapular nerve is indeed the source of the pain.
2. Therapeutic: Adding a corticosteroid to the injection aims to reduce inflammation and swelling around the nerve, potentially decompressing it and providing longer-term relief.

This procedure requires precision. We are targeting a small, deep structure surrounded by important anatomy. While ultrasound guidance is an excellent option, an experienced clinician can also perform this procedure accurately using anatomical landmarks. Today, I will walk you through the landmark-based technique.

Step 1: Identifying the Anatomical Landmarks

Accurate landmarking is the foundation of a safe, successful injection. I begin by carefully palpating the patient’s shoulder to identify three key bony structures.

• The Coracoid Process: This hook-like bony projection projects from the front of the scapula. I find it by palpating just below the lateral third of the clavicle (collarbone). It feels like a firm, deep nub of bone. I ask the patient, “Does that hurt a little bit? Right there?” Even if it doesn’t hurt, the patient’s feedback confirms I’m on a bony prominence. He affirms, “Yeah, you got it. Felt that.” Once I locate it, I use a surgical marker to place a small dot on the skin directly over it. This will be our anterior reference point.
• The Spine of the Scapula: This is the prominent bony ridge you can easily feel running across the back of the shoulder blade. I trace its entire length.
• The Acromion: This is the bony tip of the shoulder, the outermost point of the scapular spine. It forms the “roof” of the shoulder joint.

With these structures in mind, I mark three specific points along the scapular spine:

1. The Medial Border: The point where the scapular spine begins on the side closest to the vertebral column.
2. The Tip of the Acromion: The most lateral point of the spine.
3. The Midpoint: I then identify the exact midpoint of the line connecting these two points along the spine of the scapula. I make a mark here.

Step 2: Triangulating the Injection Site

Now, we use our landmarks to triangulate the target. The suprascapular notch lies in a predictable location relative to these points.

I draw an imaginary line connecting two of our marks:

• The coracoid process (our anterior point).
• The midpoint of the spine of the scapula (our posterior point).

The target for our injection, which places the needle tip near the suprascapular notch, lies at the midpoint of this new line. I place my final, most important mark here. This location places us directly over the supraspinatus fossa, the depression where the supraspinatus muscle resides, and provides a direct, safe trajectory down toward the notch.

I confirm this with the patient, explaining, “Our injection point is going to be right at the midpoint of that line. So we’re right here over the… supraspinatus fossa. We’re going to put our injection right here, which is very close to the suprascapular notch.”

To finalize the mark without leaving excess ink, I use the retracted tip of a ballpoint pen to make a small, firm indentation in the skin. This subtle mark will remain even after I clean the area.

Step 3: Aseptic Preparation of the Skin

Patient safety is paramount. Any procedure that breaks the skin barrier carries an infection risk. Therefore, a meticulous sterile technique is non-negotiable.

First, I use an alcohol prep pad to clean the entire shoulder area thoroughly. This not only begins the disinfection process but also removes the surgical marker lines, which are no longer needed now that the injection site is indented.

Next, I apply a Betadine solution (povidone-iodine). Betadine is a powerful broad-spectrum antiseptic that effectively kills bacteria, viruses, and fungi on the skin. I apply it in a circular motion, starting at the injection site and moving outward. This ensures I don’t drag contaminants from the periphery toward the clean center. I let it air-dry briefly to work effectively. “This will kill germs,” I explain to the patient, ensuring he understands why I do each step.

Step 4: Preparing the Medication and Local Anesthesia

For this procedure, I’ve prepared a syringe with a specific combination of medications, drawn into a 1-inch, 25-gauge needle. The small needle gauge helps minimize patient discomfort.

The cocktail consists of:

• 1 mL of 1% Lidocaine with Epinephrine:

• • Lidocaine: This is a local anesthetic. It blocks sodium channels in nerve membranes. Nerve impulses (including pain signals) are transmitted via the rapid influx of sodium ions. By blocking these channels, lidocaine prevents the nerve from depolarizing and sending pain signals to the brain. This provides immediate pain relief, serving our diagnostic purpose.
  • Epinephrine: This is a vasoconstrictor. When included with a local anesthetic, it constricts the small blood vessels in the area. This has two benefits: 1) It slows the absorption of the lidocaine into the bloodstream, prolonging its local effect, and 2) It reduces localized bleeding at the injection site.

• 1 mL of a Corticosteroid Solution:

• • Corticosteroids (like triamcinolone or methylprednisolone) are potent anti-inflammatory agents. They work at a cellular level to inhibit the inflammatory cascade. They suppress the production of inflammatory mediators like prostaglandins and leukotrienes, reduce capillary permeability (decreasing swelling), and stabilize lysosomal membranes. In suprascapular neuropathy, the goal is to reduce inflammation and edema (swelling) in the tissues surrounding the nerve, thereby relieving pressure on it. This is the therapeutic component of the injection.

Before injecting, I want to make the initial needle insertion as painless as possible. I use a Pain-Ease Vapocoolant Spray. This topical skin refrigerant (ethyl chloride) rapidly cools the skin’s surface. “Here’s the freeze spray I was telling you about,” I say. The intense cold temporarily numbs the superficial nerve endings, a technique known as cryoanesthesia. I spray it directly onto the indented mark until the skin turns white, indicating it’s cold enough to numb.

Step 5: The Injection Procedure

With the site prepped and numbed, the moment of injection is swift and precise.

I ask the patient, “Does that hurt at all?” referring to the numbed skin. He confirms, “No.” This gives me the green light to proceed.

“Good,” I reply. “So we come directly down.”

I hold the syringe like a dart and insert the needle perpendicularly to the skin at the marked site. I advance it slowly and steadily downward. The target is not the nerve itself, but the bony floor of the supraspinatus fossa: the scapula. I want to contact the bone gently. This provides a definitive endpoint, ensuring I am at the correct depth and not in a dangerous position.

“Touch the bone,” I narrate softly. Once I feel the gentle tap of the needle tip against the scapula, I know I’m at the right depth.

Then, I “back up about a millimeter.” This small retraction pulls the needle tip just off the periosteum (the sensitive outer lining of the bone), creating a small space within the soft tissue of the supraspinatus fossa for the medication to disperse.

Before injecting the full volume, I perform a critical safety check: aspiration. I gently pull back on the syringe plunger. I look for any blood entering the syringe. This ensures the needle tip is not inside a blood vessel, specifically the suprascapular artery, which runs near the nerve. Injecting the corticosteroid and epinephrine directly into an artery could cause serious complications. “Make sure you’re not in the suprascapular artery,” I note. The aspiration is negative (no blood return). “There we go.”

Satisfied with the needle placement, I slowly and steadily inject the 2 mL solution. The medication bathes the tissues in the supraspinatus fossa, including the suprascapular notch and the nerve passing through it. “That’s injected there.”

I smoothly withdraw the needle and immediately apply a sterile bandage. “We’ll be done.”

I check in with the patient. “Did that hurt?”

“No,” he replies.

“Good. There you go.”

Post-Injection Protocol and the Role of Integrative Chiropractic Care

The procedure is complete, but our work is not. The moments immediately following the injection are crucial for maximizing its benefit and for integrating the intervention with our broader therapeutic strategy.

Manual Dispersion and Mobilization

To ensure the medication doesn’t just sit in a single pocket but spreads throughout the target area, I give the patient a simple instruction: “Now, go ahead and take your other hand and rub this. Rub this in right there; use firm fingertips right there, and firmly rub it in.” This manual massage helps to mechanically disperse the fluid throughout the supraspinatus fossa, increasing the surface area of tissue exposed to the anti-inflammatory medication.

Next, we need to move the joint. This is where my chiropractic and rehabilitation background is essential. Static medication is less effective than medication that is delivered to tissues as they move through their natural range of motion.

“Okay, now while you’re sitting right here, you can stop rubbing. Let’s go ahead and bring your arm up like that, and down,” I instruct, guiding him through abduction. “Okay, up again, and down. Okay, do that a couple of times, and do it a little faster.”

This movement serves several purposes:

1. Spreading the Medication: As the supraspinatus muscle contracts and relaxes during abduction, it acts like a pump, further distributing the injected solution around the muscle belly and toward the suprascapular notch.
2. Immediate Functional Assessment: The lidocaine should be taking effect. By having him perform the previously weak and painful motion, we can immediately assess the injection’s diagnostic accuracy. If he can abduct more easily or with less pain, it strongly indicates we’ve targeted the correct structure.
3. Neuromuscular Re-education: Pain often leads to compensatory movement patterns. The brain learns to avoid certain motions. By performing the motion pain-free, we begin to break that cycle and retrain the brain-muscle connection.

I explain the rationale: “So we’re basically moving the arm through abduction, there to spread it out here in the area. That’s the supraspinatus muscle that’s responsible for that, for the most part.” I also make a clinical observation about his movement pattern: “Although you can see he’s got quite a bit of deltoid that kicks in here.” This is a classic compensatory strategy. When the supraspinatus is weak, the larger, more powerful deltoid tries to take over abduction. This is an inefficient and biomechanically stressful pattern that we will need to address in his rehabilitation.

Next, we address the other affected muscle. “And now let’s do external rotation, rotate it out like that, back and forth a few times, doing that.” This movement specifically engages the infraspinatus muscle. Just as with abduction, this mobilizes the medication toward the nerve’s path and provides another immediate functional check. “Very good,” I encourage, observing his improved motion.

The Broader Integrative Treatment Plan

This injection is not a cure-all; it is a single, powerful step in a comprehensive recovery plan. Our clinic’s true strength lies in what happens next. My collaboration with Dr. Cardenas and our rehabilitation team allows us to build a multi-pronged strategy.

1. Chiropractic Adjustments and Manual Therapy:

From my perspective as a Doctor of Chiropractic, nerve entrapment is often linked to biomechanical dysfunction. While the primary entrapment is at the suprascapular notch, the entire kinetic chain matters.

• Cervical and Thoracic Spine Adjustments: The suprascapular nerve originates from the C5/C6 nerve roots. Any dysfunction, subluxation, or restricted mobility in the cervical or upper thoracic spine can contribute to proximal nerve irritation. With specific chiropractic adjustments, we can restore proper motion to these spinal segments, reduce nerve tension, and optimize the neurological signals traveling from the spine to the shoulder.
• Scapulothoracic Mobilization: The scapula must glide smoothly over the rib cage for proper shoulder function. In athletes, particularly weightlifters, the surrounding muscles (trapezius, rhomboids, serratus anterior) can become imbalanced, leading to poor scapular tracking, or scapular dyskinesis. This abnormal movement can create dynamic tension on the suprascapular nerve. I would employ manual therapy techniques to release tight muscles and mobilize the scapula, restoring its proper rhythm.
• Soft Tissue Techniques: Techniques like Active Release Technique (ART) or Graston Technique can be used on the supraspinatus, infraspinatus, and surrounding muscles to break up adhesions, improve blood flow, and reduce muscle hypertonicity that may be contributing to the problem.

2. Functional Medicine and Nutritional Support:

Inflammation is a systemic process. Dr. Cardenas and I, with our functional medicine certifications, would look beyond the localized inflammation in the shoulder.

• Anti-Inflammatory Diet: We would counsel the patient on adopting a diet rich in anti-inflammatory foods (e.g., omega-3 fatty acids from fish, antioxidants from colorful fruits and vegetables) and low in pro-inflammatory foods (e.g., processed sugars, refined carbohydrates, unhealthy fats).
• Targeted Supplementation: Based on an assessment of his needs, we might recommend supplements like curcumin, boswellia, or fish oil to help manage systemic inflammation and support tissue healing. Nerve tissue, in particular, benefits from nutrients like B vitamins (especially B6 and B12), alpha-lipoic acid, and magnesium, which can support nerve regeneration and reduce neuropathic symptoms.

3. A Phased Rehabilitation Program:

The injection creates a window of opportunity by reducing pain, allowing for more effective rehabilitation. Our physical therapy team would design a program that progresses through stages:

• Phase 1: Pain and Inflammation Control: The injection initiates this phase. Gentle, pain-free range-of-motion exercises are key.
• Phase 2: Restoring Mobility and Neuromuscular Control: This involves exercises to improve scapular stability (“scapular setting”), correct the compensatory deltoid dominance we observed, and reactivate the atrophied supraspinatus and infraspinatus muscles. This starts with isometric contractions and progresses to light, controlled movements.
• Phase 3: Strength and Endurance: Once proper movement patterns are established, we begin to rebuild the strength and endurance of the rotator cuff and scapular stabilizers. This is critical for an athlete who wants to return to high-level activity.
• Phase 4: Return to Sport: This final phase involves sport-specific drills and a gradual, carefully monitored return to weightlifting. We would analyze his lifting form and correct any biomechanical faults that may have contributed to the injury (e.g., improper bar placement in squats, excessive protraction in bench press).

4. Medical Management and Follow-Up (Under Dr. Cardenas’s Oversight):

Dr. Cardenas’s role as Medical Director is crucial for ongoing management. We will schedule a follow-up appointment in 2-4 weeks to assess the patient’s response to the injection.

• If the relief is significant and sustained, it confirms our diagnosis, and we continue aggressively with the conservative plan.
• If the relief is transient (lasts only as long as the anesthetic), it still confirms the diagnosis but suggests the degree of compression is too severe to be resolved by a single injection. In this scenario, we might consider a repeat injection.
• If there is no relief, we would need to reconsider our diagnosis and perhaps order more advanced imaging, like an MRI or MR arthrogram, to look for other pathologies like a significant labral tear or a large ganglion cyst that might require surgical consultation.
• In rare, refractory cases that do not respond to conservative care, surgical decompression of the nerve may be necessary. This involves surgically cutting the transverse scapular ligament to free the nerve. Our role would be to identify these surgical candidates and refer them to a trusted orthopedic surgeon, while co-managing their pre-operative and post-operative rehabilitation.

Conclusion: The Power of an Integrated, Patient-Centered Approach

The case of this young weightlifter with suprascapular neuropathy is a microcosm of modern healthcare. His condition is not just a “sore shoulder”; it is a complex interplay of anatomy, biomechanics, repetitive stress, and neurological compromise. A simplistic approach would fail him. A pain pill would mask the symptom without addressing the cause. Random exercises could even worsen the compensatory patterns.

Our approach at Injury Medical Clinic, P.A. is built to handle this complexity. By combining my expertise in chiropractic biomechanics and functional nursing with Dr. Maria Cardenas’s diagnostic acumen and medical oversight, we create a synergistic effect. The landmark-guided injection was a precise, evidence-based procedure that served as both a diagnostic tool and a therapeutic intervention. But its true power is realized when embedded in a holistic care framework that includes spinal and extremity adjustments, targeted rehabilitation, nutritional support, and meticulous medical follow-up.

We take the reader—and our patients—on an easy-to-understand journey from symptom to diagnosis, from intervention to recovery. We believe in empowering our patients with knowledge, explaining the “why” behind every step of their treatment. This is the future of healthcare: collaborative, integrative, and relentlessly focused on restoring function and improving lives.

References

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Jezierski, H., Płociński, J., & Sibiński, M. (2017). Suprascapular nerve entrapment: a review of the literature. Ortopedia, Traumatologia, Rehabilitacja, 19(6), 513–521. https://doi.org/10.5604/01.3001.0010.7208

LaFosse, L., Piper, K., & Lanz, U. (2011). Arthroscopic suprascapular nerve release: indications and technique. Journal of Shoulder and Elbow Surgery, 20(2 Suppl), S9–S13. https://doi.org/10.1016/j.jse.2010.12.007

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