Snugging not Shrugging…

Snugging not shrugging… is a phrase I keep coming across recently since I started my shoulder courses. I keep hearing therapists using this to describe what should be happening to the shoulder during movement. Its the belief that we should not let our patients with painful shoulder issues shrug their shoulders when moving. Rather they should focus on snugging the humeral head onto the centre of the glenoid socket. It’s a nice catchy phrase, and I usually like catchy phrases, however, I think this one, is not a good one…

First, why are so many physios focused on telling patients what they can’t or shouldn’t do, rather than spending time finding out what they can do?

It seems perverse to me that patients usually come to see physios because they cant do something, only to have a physio identifying and telling them further things they shouldn’t do, such as stop shrugging a painful shoulder when they move it.

I dont actually think there’s anything wrong with a shoulder shrugging on movement, especially when someone has shoulder pain. I see it happening a lot. It’s a common compensation many use to avoid pain on elevation, and often it is a really effective one, so why would I or you want to stop it?

In fact shoulder shrugging is one of a group of symptom modification test I use with those with shoulder pain. I actually tell some patients to start shrugging their shoulders to get them moving more and with less pain!

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!

Centred?

What also concerns me about this phrase ‘snugging not shrugging’ is there is a belief by some therapists that the humeral head is and should be maintained on the centre of the glenoid at all times, and that they can assess when this is, or is not happening with clinical testing.

The way that many do this is with the Dynamic Rotatory Stability Test (DRST) and the Dynamic Relocation Test (DRT), first 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, the DRST shows the examiner attempting to palpate the position of the humeral head in various positions to assess for excessive movement of it and that it is centered. In the DRT the examiner is palpating to ascertain if the rotator cuff is co-contracting equally without any ‘over-actvity’ of the superficial muscles of the Lats, Pecs during a distraction and subsquent snugging manoeuvre.

Ham Fisted

Now, I remember being taught these tests as a fresh faced, newly qualified physio many years ago, and I remember having the same incredulous, astonished thoughts and feelings about these tests as I had with the spine and SIJ palpation tests, which I describe in one of my first and most popular blogs here.

I just 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 even 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, and if the Lats and Pecs were contracting too much, what is to much?

However, just as with the SIJ my skeptical feelings quickly turned into despair when I began to see and hear that in fact everyone else seemed to be able to do just that! Here we go again Meakins, I thought, you’re still a ham fisted, sausage fingered numpty. Here’s another bloody physio test you can’t do, you fumbling buffon.

But I persevered and kept trying with these tests for a while longer, but try as best as I could I just could not, and I still can not, feel if the humeral head is moving too excessively, or if its off centre, or if the cuff is not working enough, or the Lats/Pecs too much. In fact I can’t even feel the humeral head at all on a lot of people. Ok on the smaller, thinner people, you can, but most with half decent Deltoid muscle bulk its challegening to say the least.

So I have stopped using these tests, 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.

Flawed

Now as far as I am aware, the DRST and DRT have not had any validity or reliability studies, nor any trials to assess their usefulness in the assessment and management of shoulder issues. And as far as I am aware (happy to be corrected thou) there are no specificity or sensitivity figures in their ability to detect these humeral head centring issues.

However, what I can comment on now I have a better understanding of the shoulder, is the premise of these tests is flawed. Firstly the cuff does NOT co-contract equally, and so trying to palpate this is not going to give any information of clinical relevance.

It is now pretty much widely accepted that the rotator cuff has a direction specific action. This has been shown in these intriguing EMG papers here and here and here. They show that during flexion movements the anterior cuff, eg the Subscapularis is pretty much inactive. Instead its the postero-superior cuff that is highly active as it draws the humeral head back and down against the up and forward forces created on it by the Deltoid muscle.

Secondly, the notion of assessing if the humeral head is centred on the glenoid is also flawed. The humeral head does NOT stay centered on the glenoid in normal pain free movement. There are a number of studies here and here that show the humeral head displaces off the anatomical centre of the glenoid in normal healthy pain free subjects. In fact some of these normal healthy pain free subjects have up to 12mm of humeral head displacement!

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

Improbable

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

All shoulders that I do come across with humeral head ‘centring’ issues, are usually very easy to see and assess without the need of these ‘special’ tests. I do accept that attempting to assess and identify those with more subtle shoulder instability is challenging, but, im afraid tests like these dont help, instead we need to rely more on our subjective history, clinical expertise, experience as well as imaging.

So please can we stop telling patients to stop doing things, especially things that may actually be helping them, and that has no evidence its doing them any harm. Can we stop with these DRST or DRT tests, and with the illusion of being able to palpate subtle humeral head movements, or rotator cuff co-contractions. Lets remember we are in 2015, not 1995, and that we should have learnt by now that tests like these are just palpation pareidolia!

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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