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.

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.

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.

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.

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!

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.

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.

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…

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.

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…

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…

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

And when shit is fun, shit gets done…
Thanks for reading
Adam