Changes, challenges and opportunities for the shoulder…

I was recently asked to speak at the Irish Society of Chartered Physiotherapists annual conference at the famous Croke Park Stadium in Dublin. The theme for their conference was on “change, challenge and opportunity” and on this theme I was asked to talk about the challenges faced in our clinical assessment of the shoulder. I was also asked to take part in a panel discussion on the shoulder with Dr Karen McCreesh and Eoin O’Conaire. 

We were each asked to speak for just 8 minutes and then use the rest of the session for open debate and discussion with the delegates. Karen talked about the changes, Eoin on the challenges, and me on the opportunities. It was a great session with great talks by both Karen and Eoin, as well as some good discussion afterwards on various topics, even dry needling believe it or not!

Anyway I thought I would share with you my short 8 minute talk and the slides that I gave on the ‘opportunities’ available in the management of the shoulder, I hope you enjoy it.

Opps 1

So I have been asked to talk to you about the opportunities available to us as physiotherapists in the management of painful shoulders. However, this is a huge topic to cover in a very short space of time so I thought I would narrow it down a little and talk about a subject that is very close to my heart.

I want to just talk about the opportunities that exist in our selection of exercises that we can use when treating weak and painful shoulders in particular those with rotator cuff pathology.

Now, I think you will agree with me that we see a lot of weak and painful rotator cuffs in our clinics, not only due to tendinopathy and tears, but also in nearly every other painful shoulder condition. For example, the cuff is often weak and painful in the arthritic shoulder, the frozen shoulder, and the unstable shoulder.

Opps 2

However, believe it or not, rotator cuff exercises are NOT just this….The good old fashioned, bog standard, dull and boring shoulder external rotation, done in neutral, with a theraband.

Yet I think you will all agree with me again that this exercise is the one that is most routinely used by nearly every physio on the planet, for nearly every shoulder problem under the sun.

This non-individualised, lazy, and boring approach to rotator cuff exercises is, in my opinion, why so many patients fail physiotherapy and end up going for unnecessary imaging, pointless interventions, and of course shoulder surgery.

Now we are often quick to blame our surgical colleagues for the dramatic increase in rates of shoulder surgery, such as the sub acromial decompression procedure. But I’m afraid the uncomfortable truth is, that we as physiotherapists have to accept and shoulder a lot of the blame here as well… if you would excuse the pun

Because the uncomfortable truth is that if we were better at prescribing, progressing, but more importantly, encouraging our patients to do rotator cuff strengthening and loading exercises, then i’m sure we would see much higher success rates with physio, and therefore less people seeking surgery.

Now as I said rotator cuff exercises don’t have to be just external rotation exercises with flipping therabands. There is a whole world of exercise options out there that can strengthen rotator cuffs, just as well, if not more effectively, that don’t use therabands, that don’t have to be done in a neutral position, and in fact, don’t even have to use shoulder rotation at all.

Opps 3

Thanks to the EMG research from Professor Ginn and her team over in the University of Sydney we now have a much better understanding of how the rotator cuff works during movement. We now know that the rotator cuff does not co-contract equally on all movements, but rather has a direction specific action during flexion and extension movements.

For example we can see that during shoulder flexion the external rotators of the cuff, that’s both your supra and infraspinatus by the way, are highly active, where as your internal rotators the subscapularis are pretty much inactive. However on extension movements its the exact opposite, the internal rotators are highly active, and the external rotators quiet. Its only really during abduction movements do we see roughly equal cuff co contraction.

This demonstrates how the rotator cuff actually acts like its in a tug of war with the humeral head trying to dynamically maintain it on the centre of glenoid against the opposing forces of the deltoid and the other shoulder muscles that are trying to dislodge it, the cuff doesn’t actually act like a physical barrier to the humeral head like many think.

This knowledge of how the cuff is direction specific, now opens up a whole new world of exercises that we can clinically reason to target specific parts of the rotator cuff.

Opps 4

For example I can now confidently choose flexion exercises such as these knowing that they are increasing the activity in the external rotators as well, and what’s more beneficial with these exercises over traditional external rotation ones, is that they actually move the whole shoulder girdle and so challenge not only the muscles of the cuff, but also the muscles of the scapula, trunk, and arm, and they do it through greater ranges of movement.

Now strengthening the shoulder through greater ranges of movement is something many physios also tend to over look, or perhaps fearful of doing. Most rotator cuffs we see are not just weak below shoulder height, often they are even weaker above head height, so strengthening and loading in these ranges is vital.

Now there are a group of exercises that physios do give to patients, that do ask patients to lift their arms above their head, but unfortunately these only tend to be used when a physio believes there is a dysfunction with the scapula, which is another massive contentious area worthy of debate as is scapula dysfunction a cause or effect of rotator cuff issues? But thats for another time!

Opps 5

However, what we need to consider with these Scapula rehab exercises today is that ALL these exercises have been shown in EMG studies to produce high levels of activity in the rotator cuff as well as the scapula muscles. In my opinion these exercises help people with shoulder pain not by improving scapula biomechanics or stability, but more by loading their rotator cuffs through greater ranges of movement.

So from now on, I actually want you all to start considering scapula rehab exercises as actually rotator cuff rehab in disguise.

Opps 6

Now I don’t want you to think I am saying that you can never use any isolated external rotation movements to strengthen and load the external rotators, of course you can, its just that don’t have to always use them in a neutral or unsupported positions. In fact thanks to yet more EMG research from Professor Ginn’s team we now know that the rotator cuffs activity actually INCREASES when the arm is more supported in abducted positions.

Opps 7

So exercises like this one here that support the upper arm on the knee may actually be better at strengthening the rotator cuff, and maybe better to use as early isolation exercises when compared to the traditional unsupported external rotation exercises done in neutral.

Now this exercise here is actually one of my favorite early isolated rotator cuff exercises, and it has rather amusingly been given the nickname…. the PORNSTAR thanks to Anju Jaggi, a shoulder physio who I think many of you will know…

Opps 8

Anju seems to think this exercise makes her look like a pornstar when she demonstrates it… however, I’m not entirely sure what sort of porn films Anju’s been watching, as all the ones I’ve seen, the porn stars never have as many clothes on… similar shoes thou!!!

Anyway moving on, the last point I want to make about the opportunities for the management of the painful and weak rotator cuff is this.

Opps 9

We don’t always have to ask our patients to do 3 sets of 10 reps.

But yet again I think you will agree with me, this prescription is the most commonly used one by physiotherapists when asking ANY patient to do ANY exercise. And yet again this lazy and non individualised exercise prescription isn’t suitable for everybody, often leads to poor results and needs to stop.

In my opinion it is far simpler, and much more effective if we start prescribing exercise parameters with the only limitations being, do as much you can… either guided buy pain, fatigue, or fear! And lets not stop at 3 sets, lets think of 4, 5, 6…

Opps 10

Because despite lots and lots of confusing and conflicting research out there, the simple truth is that we just have NOT found, nor do I think we are we likely too find, an optimal number of sets and reps to give everyone with a weak painful rotator cuff, or any other musculoskeletal injury or issue.

The only consistent finding that does show results in the research is when exercises are done towards the individuals tolerance, when they are challenging, variable and progressive, when they are not to painful, but not completely pain free either, but most importantly when they are done frequently and consistently.

So I will leave you with these final thoughts around the opportunities available to us when choosing exercises for the rotator cuff…

Opps 11

Lets step away from the bloody therabands, lets think beyond external rotation exercises, and lets stop with the 3 sets of 10 reps.

Lets start choosing exercises that not only challenge and stimulate the rotator cuff, but also challenge and stimulate our patients.

Lets choose exercises that confronts patients with their own strengths, and gives them the confidence they are not broken.

But most importantly lets choose exercises that patients actually want to do, that are fun and engaging…because remember, the best exercise for ANY problem… is the one that’s being done regularly

Opps 12

And when shit is fun, shit gets done…

Thanks for reading

Adam

 

 

 

27 thoughts on “Changes, challenges and opportunities for the shoulder…

  1. So you’re saying that all the exercises for example from “kinetic control”-concept is bulls***? (As those exercises try to manage control dysfunctions..)

    (Btw. this blog has been very interesting this far! Thank you for writing!)

    • First things first… Stay confused, its good to be confused, keep you searching for more info!

      Simple answer is yes and no… There has been an increase in the trend of ‘motor control’ exercises recently, they were all the rage back in the early 2000’s, then it died down and now I see making a come back.

      Also it does depend on what people mean by ‘motor control exercises’ as it means different things to different people, as I mentioned in another blog not so long ago

      If you mean to ask some one to move in a way YOU want them to move based on flawed ideas of what is normal or abnormal, then no thats BS. If you mean to use non loaded movements with focus to reduce high error of variability, fear etc that is causing pain on movement then yes that is a good exercise.

      I also want to state there are no bad exercises or movements, just bad explanations and better options.

      Motion is lotion

      Cheers

      Adam

  2. This is a great entry, Adam. I coach my patients that quality > quantity and the ‘as many as you can’ provide you maintain the right form, speed, breathing, etc. No garbage reps to pad the stats.

    • Thanks for the comments Marc.

      Yes good ‘form’ is to be monitored, but there needs to be variability in all movements including rehab exercises, and the odd garbage rep wont hurt anybody, unless of course it does hurt too much when doing it then its not to be done again!

      But I’ve seen many people and have experienced it myself pain and discomfort when trying to do exercises in so called good form, eg squats and deadlifts, when variations in ability and anatomy are not taken into account by therapists and trainers

      Cheers

      Adam

  3. Hi Adam, I’m a physio student and I always enjoying reading your blog. When you say sets of as many as you can, is that limited by difficulty and/or pain? Is there a general level of pain where they should stop or that just down to what the individual is comfortable with?

    I was also wondeeing if you are starting with isometrics to ease pain, is the dosage similar in that they hold for as long as they can? again limited by difficulty and/or pain?

    And lastly, how do you start with isometrics in patients who are scared of tearing their rotator cuff (if that’s what they are diagnosed with?)

    Thanks,
    Brian

    • Hi Brian

      Good questions.

      First the fear of tearing a tendon. I come across this a lot thanks to some other therapist or even surgeon telling a patient they have torn things or worse its hanging on by a thread.

      In these cases I like to explain how our tendons muscles are tough stuff and just because part is damaged the rest can resiliant. I sometimes ask them to think of a raw steak that is partially cut, if you pull on it can you tear it all the way through without a knife, nope!

      Also I like to explain how the movements and loading actually help the body heal and regenerate, resting and avoiding loading actually dont help help. We can’t rest it better!

      Then a graded exposure to resistance is best and as you said isometrics are a good way to start, they are less fearful and patients can self administer how much and how long they feel comfortable and slowly prove to themselves they wont break.

      Isometrics can be done anyway that the patient find helpful and safe, but yes the research shows the longer, the harder the better the effects tend to be.

      Hope that helps

      Adam

      • Hi Adam
        Love reading your blog and just listened to your podcast on PhysioEdge which I thought was fabulous! So question about your exercises (both isometics and isotonics). Im confused about how much pain one should allow when doing these exercises. I always find that patients like a guide (I use a the subjective VAS scale) to guide them into how much pain is acceptable during exercise. I usually use the 2-3/10 count when it comes to pain provocation with exercise. Some amount of pain or stress is acceptable when it comes to loading tissues but not much more as then neural mechanisms may kick in along with fear which may be detrimental to getting the patient to continue to exercise. Im eager to hear your thoughts on how much pain you think is acceptable when prescribing exercise

        • Hi, and thanks for the kind comments

          Using the VAS as you describe is a good way to ‘measure’ pain during rehab exercises.

          I suggest a little higher usually on the VAS, up to 5/10 when doing rehab exercises. Reason I ask this high is although it hurts when doing it the patient soon realises that it is short lived, ie just as they do the exercises, they are in control of this pain and so it can improves their confidence in their robustness

          Of course each individual case needs to be assessed individually, some patients have high fear and anxiety about pain when rehabbing than others, therefore a slower and more gentle approach is needed.

          Its aways good to remember broad simple principles when treating patients but to always apply it individually to the person in front of you.

          Kind regards

          Adam

  4. Would you change any of your recommendations in the sporting shoulder series based on this information? Also, please write a book, pamphlet, or sketch with stick figures, on keeping shoulders healthy for exercising population. There is no good information in the fitness community (besides your excellent blog) to counter the corrective exercise “right way to move crowd.” Thank you sir.

  5. Thanks a lot for the blog Adam. Some very interesting points raised.
    I was just wondering if you have a reference available for the Professor Ginn EMG study by any chance?
    Appreciate your help.

  6. Love it.
    The 5 to as many as possible ticks a lot of boxes for me from strength and conditioning science. To take it a little further I’d minimise rest to 1-2mins between sets to promote an even more anabolic effect for muscle and tendon. The hormonal response to resistance exercise is essential in rehab of soft tissue.
    For load management instead of using 1rm percentages the OMNI resistance scale or perceived rate of exertion scales are really grea, easier for patient to do and allow for daily variables I.e feeling like crap.
    There are other variables we can manipulate to maximise the rehab response and experience such as drop sets, time under load / tension, use of external count downs and vascular occlusion ( not sure how this would be achieved in the shoulder), I suspect hypertrophic type training schemes are what we need to look at for rehab as they provide the optimal balance of hormonal, metabolic and mechanical tension to elicit the response we look for, and with the right loading analgesic response as well ?
    .mery Xmas back to the turkey

    • Hi Dave thanks for the message and I totally agree, I don’t think there is much difference if any from using strengthening programs as they are used in normal populations to be used in rehab settings! There needs to be allowance for pain levels and respect to physiological healing time frames but that’s about it, enjoy the turkey, I’m into the ham !!!

  7. Hi Adam first post for me!

    First things first I wanted to say thanks for all the great information you put out, your Physioedge podcast with David Pope was also brilliant! It’s so much easier for patients to get on board with their exercises when they have a better understanding of their condition and your simplification has helped a great deal with this.
    Unfortunately I find more often than not patients are handed generic exercise crib sheets, unfortunately it’s not explained to patients why they are carrying out these exercises and 9 times out of 10 they are not adhered to because of this.
    Having come from a sports conditioning back ground prior to physiotherapy I see some physiotherapists out there who’s prescription and well as their description of exercises needs to be looked at (some not all).
    All that was a bit of a tedious link, I was wondering if you’ve looked at Reniod et al paper titled, Current concepts in the scientific and clinical rationale behind exercises for glenohumeral and scapulothoracic musculature?
    I know the scapulothoracic region is somewhat of a contentious area and EMG studies often produce varying findings but in a nut shell it backs up your thought process of getting everything stronger and talks about specific exercises for certain conditions around the shoulder.
    Thought it might be of interest if you haven’t already reviewed it.

    • Thanks for your comments Matt

      Ive not read that paper yet so thanks for the tip, I assume you mean Reinold as the author as in Mike Reinold?

      As you say EMG studies have there limitations but they are useful to help us reason in which exercises give us most bang for our buck.

      However there is soooooo much more to choosing an exercise for a patient than EMG studies.

      First we need to find one that the patient will do, there is no point giving an exercise to a patient if its too hard, too easy, too painful or they just don’t enjoy it or see the point of it just because we know its the best for them.

      The best exercises for patients tend to be ones that are challenging, meaningful and most importantly… Fun…

      I have a saying I use a lot…. When shit is fun, shit gets done!

      Cheers

      Adam

      • My bad, yes Mike Reinold is what I meant
        Totally agree with you regarding the exercise prescription and EMG studies. Really interesting stuff regarding Professor Ginns work also.
        Appreciate the quick response and thanks again for all the info

  8. Hi Adam Matt again, having just listened to your critical thinking podcast with chews health I have an area of my critical thinking that I’m currently looking for some advice with! I went through a paper by Kuhn yesterday titled (Exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol). Without going into details they were suggesting that AAROM cane exercises into abduction and flexion/elevation should be used in someone with a “sub-acromial impingement”. Now here is where my critical thinking is confused, if we have someone with an “impingement” and one of the suggested mechanisms for this “impingement” is OH movements then surely doing repetitive OH AAROM cane exercises this would further exacerbate their symptoms? In theory wouldn’t we want to strengthen the dynamic stabilisers to prevent the translation of the humeral head first before doing all these potential aggravating movements? Sorry for the long winded question, any advice would be greatly appreciated.

    Kind Regards
    Matt

    • Hi Matt

      As my thinking stands at the moment I don’t avoid overhead movements in those with sub acromial pain. The reading I’ve done has shown me that mechanical impingement is not certain and actually may not be the issue in impingement shoulder pain. I do load and move overhead. I find it tolerated it helps patients develop resilience and also challenges expectations which can and does create adaptions both physical and psychological

      Hole that helps

      Cheers

      Adam

      • Hi Adam thanks for the response always good to pick your brains as there seems to be a fair amount of conflicting thoughts re OH movements! Thanks again

  9. Hi Adam,

    Thought provoking stuff as always.

    As a recent graduate and band 5 MSK physio, I’ve been getting tonnes of shoulder patients these last 2 weeks and it’s highlighted how much of a weak area it is to me.

    Curious about some of these exercises you’ve mentioned as I think as an inexperienced physio I’m always a bit fearful, especially with shoulders given my lack of knowledge, to really push them. Exercises like the pornstar etc. activate and challenge the cuff more but does that make them more ‘risky’ (for use of a better word) than the normal Theraband exercises? I know you’re a fan of JUST F*CKING LOADING IT haha which I agree with but do you find there are certain patients those exercises are more suitable for and do you use them initially or as more of a progression once pain is better tolerated or do you think patients need to load the cuff as much as possible?

    Much appreciated!

    • I do believe that some exercises are more suitable than others for some due to lots of factors which are too long and indepth to explain here.

      Just fucking load it, does have some caveats!

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