Snugging not Shrugging…

Many therapists, including myself, have been taught to look for patients shoulders shrugging on elevation of the arm and to consider this ‘abnormal’. We are then told to correct or prevent this from happening. The belief is that shrugging of the shoulder is an incorrect, bad, or even a harmful movement pattern and can be a sign that the humeral head is not being held onto the glenoid well due to rotator cuff issues.

The term ‘snugging not shrugging’ is often used by some shoulder gurus to remind us physios that we should focus our attention on reducing this abhorrent movement in our patients, and that the rotator cuff needs attention to snug the humeral head on the glenoid and stop the shrugging to occur. Now, this is a nice catchy phrase and I usually like catchy phrases, however, I think this one, is not a good one…

I actually don’t think there’s anything wrong with a shoulder shrugging on arm movement, especially when someone has shoulder pain and I see it happening a lot. The common assumption is that shrugging occurs due to over-active upper trapezius and weak lower trapezius. This may be possible, however, I think shrugging simply occurs due to global weakness of the whole shoulder girdle in general, or its a strategy to reduce pain on arm elevation.

I often find that when you ask someone with shoulder pain who is shrugging to stop they often feel more pain, so how is this helpful? In fact, when I don’t see a painful shoulder shrugging on elevation I may ask them to try it to try to see if it reduces their pain. If it does then I see nothing wrong with a shoulder shrugging to allow them to move it with less pain for a while..

Centred

What also concerns me about this ‘snugging not shrugging’ phrase is that it implies that the humeral head should always be ‘snugged’ and maintained on the centre of the glenoid and that we can assess when this is not happening.

Some physios think they can assess humeral head centring on the glenoid with some archaic clinical tests called the Dynamic Rotatory Stability Test (DRST) and the Dynamic Relocation Test (DRT) as described by Mary Margarey in her 2003 paper here. The tests are described and shown in the photos below from the same paper.

As you can see, during the DRST the examiner attempts to palpate the position of the humeral head in various arm positions to assess for excessive superior, anterior, or posterior movement of it. In the DRT the examiner is palpating to ascertain if the rotator cuff is co-contracting equally without any ‘over-activity’ of the superficial muscles during a humeral distraction and subsequent snugging manoeuvre.

I remember being taught these tests years ago as a keen and eager, but sceptical newly qualified physio, and I remember having the same frustrated and incredulous thoughts and feelings about these tests as I had with all the other motion palpation tests of the spine and SIJ, which I describe in one of my most popular blogs here.

I simply could NOT believe that anyone could actually feel anything close to what was expected. I couldn’t believe anyone could feel the humeral head moving an extra few millimetres under all the soft tissues of the shoulder, or more unbelievably if it was centred on the glenoid or not. Nor did I believe that anyone could feel if the rotator cuff was contracting equally, quickly, or strongly enough.

I persevered with these tests for a while, but like most other joint motion palpation tests elsewhere in the body, I stopped using them years ago, and if I’m being honest I forgot all about them, until recently when this ‘snugging not shrugging’ phrase kept popping up on my courses, with some delegates telling me they are being taught them despite no research on their efficacy, but more importantly their validity or reliability.

Flawed

However, even without this research the premise of these tests to assess if the humeral head is staying centred on the glenoid during movement is flawed, as the humeral head actually moves around on the glenoid a lot during pain-free, normal movement. There are a number of studies here and here that show the humeral head moves off the anatomical centre of the glenoid usually in a superior-posterior direction in pain-free healthy individuals. In fact, some of these studies show some individuals have up to 12mm of humeral head displacement, which is nearly 25% of the total height of the glenoid.

And this review here on the biomechanics of the glenohumeral joint describes that the rotator cuff and other subacromial structures regularly come into contact with the acromial arch as the humeral head migrates superiorly during normal, healthy, pain-free movement.

So I hope you can see that trying to assess if the humeral head is perfectly centred on the glenoid, is a waste of time, improbable, and unlikely to be happening anyway, even in those without shoulder pain.

The shoulders that I do think have humeral head ‘centring’ issues are usually easy to identify without the need of ‘special’ tests as they often tell you they feel the shoulder is loose or unstable. I do accept that attempting to assess and identify those with more subtle shoulder instability, if this exists can be challenging, but I don’t think tests like these help.

If anything tests like these often make matters worse, confusing therapists and often over diagnosing and worrying patients unnecessarily. As with anything else, the best way to diagnose patients is with a good detailed history, a simple yet thorough examination, and if indicated appropriate imaging.

So, in summary, can we please stop worrying about and demonising the shoulder shrugging on elevation so much. Can we please recognise a shoulder shrug can be a positive adaption to help reduce pain and allow some to move their arm more comfortably, and there is no evidence that this is going to do them any harm. Finally, can we please abandon these ridiculous DRST and DRT motion and muscle palpation tests, as we are now in 2015, not 1995.

As always thanks for reading

Adam

13 thoughts on “Snugging not Shrugging…

  1. as always such a great blog, and as always I nod as I read it saying yes that’s just what I think, particularly the distress felt as an undergraduate when every other student had ‘felt’ the thing they were supposed to except for me. Do you ever run courses/do presentations?? I would love to hear you present some of this no-nonsense well thought out stuff.

  2. Agreed, it’s nigh on impossible to detect if you are getting millimetres of excessive anterior or posterior translation (or a slider) with your fingers. Or maybe we just have fat fingers with minimal sensory input!
    Good blog

  3. Thank you for posting this. Reminds me of the Displaced Axis of Rotation stuff being taught in the mid 1990’s.
    I had an engineering background prior to being a physio and the force vectors and variables involved at any instant in a shoulder movement are highly complex. Of course, this will not stop people trying to objectivise the unobjectivisable (made up word) in their quest for Treatment A for condition B for Outcome C.
    It is much easier in our profession to look for objectivity (where it is not there) and prescription so we can tread the path of least resistance. I can remember with amusement some courses where everyone said they could pick up the tiniest of movements with relation to a certain dysfunction. We have all read the Emperor’s New Clothes.

    What also comes with this objectivity obsession is the physical examination and working to a pre-meditated outcome. I bet loads of physios fail to write down findings which do not fit with their treasured predictions or beliefs.

    There is still an unwillingness to accept our current knowledge of pain physiology as well. It is either acute adaptive pain or chronic maladaptive for some. Other combinations are also available.
    I can remember being told as a student that the body/brain knows nothing of muscles just movement. Whilst this may be open to debate, we probably need to stop trying to get our patients to activate the upper 23/64 of the upper fibres of a certain muscle in isolation.

    Finally, should we not ban course feedback comments until at least a year after the course to stop sensationalist comments. ‘This course has changed my life forever…..’

  4. I am a final year physio student and I love this blog! I often feel ‘ham fisted’ when I can’t feel things that seem impossible, when others ‘can’, and this gives me hope! I learn so much here, thankyou!!

  5. Hi Adam
    Great post, as always. You’re a clever guy – without a doubt.
    I like your reflections and argumentation. And luckily this Is 2016 – and NOT 1995.

    Though – I’m wondering…?
    In the text you’re criticizing the DRST/DRT (which I s relevant) – due to lack of evidence and trials assessing the sensitivity/specificity of these tests…
    But – you also suggest that “we need to rely more on our subjective history, clinical expertise, experience as well as imaging”…??? What is the evidence for that opinion..? Have you got data to support these reflections?? Or is it your clinical experience and expertise is superior to other therapist’s…? (those who use the DSRT/DRT – AKA what you call the Dinosaurs)…?
    And as far as I remember you have previously posted about imaging (Treat the man, not the scan…) https://www.facebook.com/adam.meakins.5 But we need to rely more on imaging..??

    As I said- I like you reflections and agree with most of your argumentation, but to me it seems like some of your argumentation is a bit contradicted..? Well, just a thought..
    Regard
    Jeppe T. Andersen

    • Hi Jeppe

      Thanks for your comments, I get the feeling your are accusing me of a little hypocrisy and I guess there is a little.

      But to answer your questions, first yes there is lots of evidence on the power of the subjective history in making our diagnosis, for the sake of brevity I shall just give you one of the first papers from 1975 to show how effective the subjective history can be in making diagnosis here http://www.ncbi.nlm.nih.gov/pubmed/1148666

      Next the topic of experience and expertise is a tricky one to interpret. We know that with experience pattern recognition is developed in clinical reasoning and so diagnosis can be made sooner and more reliably, however it can be double edged sword as it can lead to complacency and indeed some research has shown up to half of all experienced clinicians actually perform worse than less experienced colleagues http://www.ncbi.nlm.nih.gov/pubmed/1148666

      Next imaging is not to be solely relied on of course, I am not saying or implying this, rather it can aid to building a clinical picture that can lead to a diagnosis when used wisely and taking into account normal age related changes.

      I hope that answers some of your questions and try’s to show that I am not being as contradictory as you may think.

      Regards

      Adam

  6. Hi Adam
    Thanks for your response/feedback.
    As you – I have a strong natural skeptical side and I do agree that we should always demand evidence (if possible) and think critically.
    You postulate that there is “lots of evidence on the power of the subjective history in making our diagnosis” and then you’re referring to this study from 1975 http://www.ncbi.nlm.nih.gov/pubmed/1148666
    Well – for sure; old studies/data can be important and relevant.
    Though – do you think this “un-controlled”, “un-blinded” and “non-randomized” study, from an outpatient medical clinical, including patients suffering from angina pectoris, hiatus hernie and high blood pressure, is appropriate support for your arguments/opinions in this discussion – that we need to rely on history taking when seeing shoulder patients? Do you consider this study is good quality evidence?? To me it it’s a bit pseudoscience. And I not convinced.

    Remember you once wrote (critical thinker or just an arse; https://thesportsphysio.wordpress.com/2013/04/11/critical-thinker-or-just-an-arse-2/ );
    Being truly certain of anything within the therapy profession is, in my opinion, ridiculous, there is scarce good quality evidence that allows us to make any firm decisions or conclusions. Research and evidence can be of extreme variability in quality and results and conclusions can be manipulated to suit a cause, in both directions, so a critical eye must be used when reading any literature, or on when on any training course or learning any new treatment technique.
    When reading your posts on the blog, it seems to me, that you sometimes are a bit biased in your argumentation and reflections. Generally I’ve noticed that you’re very critical when it comes to manual therapy, motor control exercises, kinesiotape, acupuncture etc etc. That’s fine – I can accept that, but I think you could be more careful you don’t “pick” your evidence or manipulate results / conclusions to suit your case..!
    This is also relevant regarding your thoughts about scapula dyskinesis
    “Now, if shrugging becomes maladaptive once pain has ceased, then yes, that needs to be addressed, but in my experience rarely does this happen, most shrugging shoulders usually return to ‘normal’ once pain has eased, stiffness loosened, or strength has returned without any intervention or fuss”.
    But physios and Scapula’s are a strange mix, I see many over focus, over diagnose, and over treat them. Please can we just let Scapula’s be Scapula’s. Let them wiggle and wonder around a bit occasionally, there is little to no evidence that it causes any issues or does any harm!
    (and that’s your experience/opinion – well then – how important is this really?? As I remember “expert opinions” rank VERY low in the evidence hierarchy. Correct if I’m wrong….??)
    Adam – What is the right thing to do here??
    A few thoughts/questions;

    1) Should we let scapula wiggle and wonder around a bit occasionally – or should we correct maladaptive movement strategies.
    2) When is a scapula movement strategy malapdaptive? And can we really identify a maladaptive scapula movement strategy in a valid and reliable manner?? As I understand your blog – we can’t identify maladaptive glenohumeral joint (or in other of your blog; SI-joint) – but that’s not a problem when it comes to scapula or??
    4) I guess – at least part of your rational for correcting scapula dyskinesis is based on “biomechanical considerations”? That abnormal biomechanics cause’s increased/altered stress/strains on musculoskeletal structures and therefore correcting these movement patterns would be an important part of the intervention strategy?? Or?? That rational would fit well with the “Physical Stress Theory” (Muelle & Maluf, 2002) and one of the old dinosaurs (S. Sahrmann’s) “kinesio-pathological model”…? But why would you try to correct scapula dyskinesis – but not abnormal movement related to other joints??

    As you have stated elsewhere we should avoid letting our own biases and opinions cloud our thinking when something goes against what we think…Are you getting overly attached to your own experiences and hypothesis here – “just because it’s yours”.
    I guess you have no ambition/intention of becoming what you have describe as a ‘guru’ Therapist
    “Eloquent, confident, witty, and usually good looking, the ‘guru’ therapist is able to enthrall and dazzle audiences with their charisma and charm. They show therapists the errors of their ways, how they have been doing it all wrong and how if they do it their way it will be better. The guru therapist has a slick website and marketing image, they develop a loyal following and surround themselves with sycophants who hang off every word they say”.
    Well, it was just af thought…

    Adam – just to clarify.
    I like your blog/posts and think your reflections and arguments are relevant and important and contribute to take our profession forward. Though – at times – I do find your argumentation and rhetoric a bit too confrontational/controversial and maybe a bit biased…
    Keep up the good work / Regards
    Jeppe

    • Hi Jeppe

      Sorry for the delay in replying, busy few weeks and comments on my blog tend to take a back seat.

      You again make some excellent points and I dont really want to get into a too in depth discussion about them here, maybe over a beer if we ever meet face to face.

      However I will say one thing on the subject, that is please remember this is JUST a blog, not a peer reviewed journal. This is my blog for me to put down my thought and ideas. So yes they will be biased, but anyone reading any blog who isnt aware of this is a little naive (im not calling you naive)

      I try to critically review as much research and evidence as I can and use this with my clinical experience to come up with my thoughts and ideas. I am aware I will not be able to read or remember everything and so my views and opinions will be skewed, but whose are not?

      Once again thanks for taking the time to reply, and sorry for not responding fully to all your points, I just dont have the time.

      Regards

      Adam

  7. Hi Adam

    Thanks for your reply.
    Let’s continue this discussion over a beer if we ever get the chance 🙂

    Best wishes,
    Jeppe

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