#9 Shoulder Impingement - with Jared Powell

[Music] Welcome to the Shoulder Physiopodcast, a podcast dedicated to exploring meaningful topics in muscular skeletal health care. I'm your host, Garrett Thel. Before we begin, the primary purpose of this podcast is to educate in the form. If you use Express in this podcast by myself, and then you get star information only, do not constitute professional advice and that general in nature. If you act on the basis of any podcast episode, you should obtain specific advice from a qualified health professional before proceeding. Today's guest is me. I was privileged to be interviewed by the brilliant team at E3 rehab on the topic of shoulder impingement. I've been a vocal dissenter of this diagnostic label for a number of years now and I have taught this in my courses and written papers about it. In this episode, I take you on a tour de force of why I don't like the term and discuss alternatives to shoulder impingement that might better fit contemporary evidence. Before we get into the nitty-gritty of the conversation and for your information, for the first time in two years I'm running my one-day shoulder workshop in Sydney and Melbourne in May and June 2022. Tickets are limited to 30 participants. The course offers a complete distillation of the evidence base for shoulder pain management equipping you with up-to-date knowledge, techniques and clinical reasoning skills that are clinically actionable. If this is something that you are interested in, check the show notes for more information. Without any further delay, I bring to you my conversation with E3 rehab about shoulder impingement. All right, do you mind introducing yourself to the listeners? My name is Jared Powell. I am a physiotherapist from Australia. I have a keen interest in shoulders as I hopefully can convey to you today. I love science. I love sport and I dislike deliberate misinformation as again, you might get the gist of today. So that's me. All right, well let's jump into it. So today we're discussing the history and evolution of the diagnosis of shoulder impingement. So let's kind of just start with what is it and when, where, and how did this diagnosis come to be? Who, where, where, what? Yeah, so this is a good question because we need to figure out where we're coming from. I think everything should be looked at in the context of history. So if we go back in time, we go back into the 1900s, a long time ago, now there were some rumblings in sort of the 1940s about this impingement thing, but nobody really ever termed or formalized this label shoulder impingement, not until until the 1970s, when the famous demigod Charles Near, the trailblazing American orthopedic surgeon, popularized and crystallized and formalized this term shoulder impingement. And he did this by publishing a case series basically in the 1970s and and Charles Near, I sort of don't want to diminish the work of of near, I think he did fabulous work and advanced the profession at the time to be honest, and I think it was a really plausible hypothesis 50 years ago, just now with with with all the evidence that we have, unfortunately it hasn't stood up to rigorous investigation, but we won't go down that pathway just yet. So so Charles Near stated in 1972, I believe that 95% of all rotator cuff tears were caused by this mechanical abrasion of the rotator cuff, mostly the supersonic artist against the overlying acromion, and he was really confident in this assertion back in the 1970s. And he thought trauma may be worse in rotator cuff tears, but it didn't cause rotator cuff tears. So the cause was nine out of ten times or even more this mechanical abrasion of structures within the subacromial space against the overlying acromion. So the history is that there was this there were sort of rumblings about impingement in the 1940s, like I suggested, this was crystallized by Charles Near in the 1970s, and it's basically to do with this mechanical abrasion of structures within the subacromial space underneath the overlying acromion of the scapula. That's my interpretation of it. And just to go into a little bit more depth, you know, he came up with this hypothesis or this theory, can you explain the evidence that he was using to explain that? Yeah, it's just observation effectively. So so Near is a surgeon, obviously, and he was opening people up and observing their rotator cuff, also associating that with a with an acromion, which was either type one, type two or type three, and he thought he saw an association between a type three, which is a hooked acromion, which we may which you may have been taught about at university, and he thought that the presence of this hooked acromion was an issue that was causing pathology within the subacromial space. And then coincidentally, he invented a surgical procedure to fix this this this type three, this naughty type three acromion, which was called an acromion plus the procedure, which has become, you know, ubiquitous and instantiated in medicine all around the world. And millions of people have undergo on this procedure. I think it's and it's not unreasonable to say over the past 50 years. Yeah, I'm sure we'll touch on that evidence a little bit more later. And just to clarify, you know, impingement is often categorized as primary impingement, secondary impingement, internal impingement, and I'm sure there's other ones out there. Are we grouping all of these together or is our discussion today only applicable to certain classifications? Yeah, yeah, good question. So I'm referring mainly to this concept of external impingement today, which is issues of the subacromial space. So so primary external impingement is this notion or concept or theory of a naughty acromion that is either type one or type two or type three, like I said a moment ago. And then acromion type two and mostly type three cause issues of the subacromial space because they're hooked and they they are meant to cause mechanical abrasion of the subacromial space. So that's that's the primary external classification of shoulder impingement. And then there's the secondary external subacromial impingement, which is probably more important for physiotherapists, which is more issues of motor control and posture and how these issues can lead to changes in the subacromial space, usually via changes in the scapular position, which is then meant to lead to the onset of of impingement type symptoms. So so so secondary external impingement is like a motor control issue of tight pecs or an overactive deltoid or weak scapular stabilizers or up across syndrome or whatever other invented diagnosis is out there, which leads to issues with the scapular, which leads to a reduction in the subacromial space, which leads to eventually impingement related symptoms. And then internal impingement is a little bit different. Internal impingement deals with the concept or the theory that the superspin artist and the infraspin artist can become impinged or irritated into abduction and external rotation against the posterior superior glenoid rim. So this is common in throwing athletes, we might get back into that abduction external rotation position and they might have pain there, and then we theorize that this might be due to this phenomena of internal impingement, which is different from acromial impingement. Great, I think those are great definitions. So thinking about this and this diagnosis that came about 1972, the surgery that came from it, you know, how did this diagnosis influence our understanding and management of shoulder pain? I guess you could talk about it from a physioperspective and also the surgical perspective, which you've already touched on. Yeah, it's been really influential. So shoulder impingement becoming instantiated in, you know, everyday clinical parlance all over the world has has basically led to this to biomechanical factors, structural factors, etc, etc, occupying this privileged position in the possible causation and then resolution of non-traumatic shoulder pain. So as I suggested a moment ago, we became really obsessed with the acromial shape. So we go out and get imaging to determine what what shape this acromion was. We would microscopically look at look at movement of the shoulder complex. We would get the plumb line out to have a look at thoracic posture. We would measure, take minor length. We would observe what the scapula was doing to see if it was behaving nicely. We invented all of these complex and nuanced interventions to to fix somebody's muscle timing and activity to then fix somebody's shoulder blade position to then fix their impingement symptoms. So that's just from a physiotherapy perspective. We had people sort of laying on their phone rolls for hours a day to try and reverse their thoracic vivosis. We, you know, subacromial corticosterid injections became, God knows how many people have had a subacromial corticosterid injection over the last 50 years, the mind boggles. I'm not against these injections, but I certainly don't think they should occupy a primary position in non-traumatic shoulder pain. And then we've got the surgical techniques that were invented where, as I mentioned a moment ago, there was this huge exponential increase in subacromial decompression or a chromioplasty procedures 20 or so years ago with the advent of arthroscopic surgeries. And I think the statistic that's famously thrown out there is between 2000 and 2010 between the that decade, after scoping sub-accurable decompression surgeries increased by 746% in the UK. And I'm sure there are comparable numbers all around the world. Now the big question comes, are these sub-accurable decompression surgeries still being done at such a significant rate? And sort of the answer is that annoyingly they are, particularly in the US, the rate hasn't changed over the last decade, even in the face of some evidence, which completely challenges the notion of impingement. And the efficacy of the operation, which is shown to be no better than placebo surgery. Fortunately, excuse me, in the UK, these rates have come down a little bit. So maybe they're listening to evidence. But unfortunately, in the US, there's been no change in sub-accurable decompression surgeries over the last five years, despite some really good randomized control trials saying that this surgery is not superior to placebo surgery. So just let that sink in for a moment. This surgery, which millions of people have undergone, is not efficacious. It's not better than a fake surgery. So that's something that we should be embarrassed about, I think, in the medical fraternity. It's pretty well to hear that statistic of that over 700% growth and then hearing that after these trials have come out that in the US, at least, that number hasn't declined. And so it is-- it's 2022. It's 50 years later. And obviously, we're already getting your interpretation here. But yeah, give us your interpretation of the literature and just the usefulness of shoulder subaccuromial and pengement syndrome as a diagnosis. So quite plainly, I think, shoulder and pengement is not useful as a diagnostic label. And it's not valid as a diagnostic label either. So it's flawed from a number of different perspectives. We know that most people around the world will have impingement in their shoulder when they elevate their arm into the-- it's as simple as that. The data that we have is that about 50% of people have a cromial impingement when they lift their arm up into the air. I think the data-- the real statistics are probably more. We just have to take a snapshot of people. We can't go and do a randomized control trial on 7 billion people as far as I'm aware. So most people, we can say, that when they lift their arm into the air, there is possibly some form of impingement in their shoulder. But these people aren't more likely to have symptoms than people who don't impinge their arm into the air. So it's kind of like having an asymptomatic rotator cuff tail or an asymptomatic disc bulge or something like that. It is really quite normal. We also know that the subaccuromial space is not any different between people with shoulder pain and those people without shoulder pain. So if you were to take get an ultrasound and measure the acromiocumal distance, which is a measure of the subaccuromial space between people with impingement, it would be diagnosed with impingement and people who are asymptomatic. There's no difference. We would be unable to determine based simply on that measure if somebody has pain or not. So that's challenging to this notion of subaccuromial impingement. And then we know that subaccuromial space distance or a human distance doesn't need to increase or change for somebody who has shoulder impingement to get better in terms of pain or function. So that subaccuromial space can remain exactly the same. And yet their shoulder pain and function can improve. So maybe the subaccuromial space is not a mediating variable for somebody getting better, who presents to us with non-traumatic shoulder pain. In fact, there was a study. I'm just reminded of it right now, which came out just last year in 2021, which showed that people with shoulder impingement have bigger subaccuromial spaces relative to people with relative to people without shoulder pain. So I mean, if you ever needed evidence to falsify a theory, that's it. We'd probably should end the podcast here. But I'll keep going because I love talking about this stuff. What else is there? So in terms of the acromion type, that's another conjecture as well. I think the acromion is still relevant. And I actually do admit that those with a type three acromion might be at more risk of developing a rotator cuff tear. But we know that developing a rotator cuff tear is multi-dimensional and multifactorial, is to do a number of different factors. And most of them are non-modifiable, such as age, such as gender or sex, such as occupations, such as genetics, all of these type of things. So there's probably an infinite amount of factors that can lead to the onset of a rotator cuff tear. Yet we choose to spend all our energy, or we have chosen to spend all our energy on one dimension of that, which doesn't make any sense to me. So what else? Where am I? So shoulder impingement, the subacromial space is similar in people with and without pain. The subacromial space doesn't really change over time. Proceed both surgery is just as effective as real surgery, developing a rotator cuff tear is multifactorial and multi-dimensional. So these are just some of the things that we're aware of now in 2022, which I reckon challenge this concept of shoulder impingement to a point where we have to stop using this term almost immediately because it is untenable. This one of those things, though, that you think it's going to take another 50 years before the physio-profession de-adops it. Like is it too ingrained or these large social media followings or the people with large social media following still pushing it so hard that it's just yeah, hard to de-adopped that? Yeah, that's-- I mean, what's that number throwing around? 17 years for research to be adopted into clinical practice. Totally aware that that's what we're dealing with here. And then-- but all-- I'm also aware that we're dealing-- we're in a time now where information is so readily available and so and can be so readily adopted. That I think that that number might be different in this information age where we all have access to PubMed at the click of a button or where we have access to evidence-informed social media accounts. You know, I know that there are bad social media accounts out there as well. But there's more and more and more evidence-based social media accounts that are propping up all over the place that are challenging some of these larger accounts that tend to spread misinformation. So I'm always optimistic when it comes to this sort of stuff. However, you know, I'm not-- I don't have my head in the sand. I know that there are some barriers to this being implemented. You know, just going back to shoulder impingement and this and the validity of the label. We also have to think about the qualitative research that we have coming out and how people who are diagnosed with shoulder impingement actually perceive what is going on. So they perceive the causal explanation for their pain to be due to their chromine ripping in to the tendons of their subacromial space. And it sounds horrifying when you think about it. Why on earth would this person want to elevate their arm in the air when they perceive or think that this acromion, this demon structure, is hooking in to the rotator cuff tendons? And obviously it's going to promote fear in some and perhaps some anxiety and some apprehension of movement and some kinesiophobia. And again, we've got a recent randomized controlled trial by Zadro Atel, which shows that those people who are given a diagnosis of shoulder impingement or a rotator cuff tear have a higher perceived need for more medical management. So those people think that they need more medical imaging and they think that they often need surgery more than other people who are given other diagnostic labels. So when you think about the qualitative research and asked us physiotherapists or physical therapists or whatever, osteopath carapactors, and we know how prognostic or how important patient expectations are to recovery and that if a patient actually thinks that their chromine is digging into their shoulder, that physio can't fix because no amount of physio can fix a bone spur and these are quotes that have actually been given to us in the literature. It's a mechanical issue that requires a mechanical fix. Then what hope does physiotherapy have of helping somebody if that is their expectations going into physiotherapy? So I believe we're shooting ourselves in the foot by using this label. Not only is it valid, perhaps it's harmful, and it's certainly not going to help physiotherapeutic management of this condition as well. Yeah, it's a bit odd from the physioprofession in terms of that contradiction. In the sense that we're saying you have this mechanical problem, but we're going to try to do some exercises for it rather than you have this mechanical problem, just go get surgery and get it fixed. So yeah, what do you think we should call this non-traumatic shoulder pain instead? And I mean, you've already discussed why it matters, maybe why we should move away from using that terminology. So this is a contentious point. So this is a diagnostic labeling is really a hot topic at the moment in muscular skeletal medicine. I think we should call it something. I don't think shoulder pain is sufficient. So I don't think it's Voldemort that he who should not be named or she who should not be named. I think we do need to affix a label to this clinical presentation for medical legal purposes, for insurance purposes, for professional collaboration between clinicians, for social validation purposes, from a patient's perspective, for research purposes, how are we going to research a condition that we can't name? So I think a diagnostic label is really important. So then where do we go? So how I see it, and I'm actually, we're actually writing a paper on this at the moment, is there's two sides of the debate. There is the abandoned diagnostic label, and that's one side, and they're very passionate about that. And there's been some evidence come out recently to sort of summarise that position. I think it's an interesting position. And then on the other side of the debate is the conservation to let these rotator cuff tear terms remain, to let shoulder abysmal term remains. Who cares what label it is they can more about the academic? explanation blah blah blah blah. So how I see to this two sides of the debate get rid of these labels or retain these labels and I think there's a middle ground, which is great. So as you guys might know, my friend of mine and co-conspirator of mine is Jeremy Lewis and he has advocated for the term rotated calf related shoulder pain, which is, which is a contentious diagnostic label. People think it's the devil's work and don't like it whereas other people sort of look at it as the savior. I think it's a decent term and I think it warrants discussion and I tend to use that in my clinical practice. I know that Jeremy actually proposed this term to serve as a middle ground term between these two sides of the debate. And so it's a static alpha related shoulder pain does not mention pathology at all it mentions a structure, which some people don't like and that structure is the rotate of and so that's that's a fair criticism but it doesn't mention a tear it doesn't mention an impingement process it doesn't mention a syndrome which suboccurring your pain syndrome does which might have negative connotations as well. And the basic alpha related shoulder pain is whilst it references a structure, it's stopped short of a fixing a front of mind biomedical pathology which might result in fear or anxiety or apprehension or catastrophizing on behalf of the patient. But what it offers is is a diagnostic label that that patient can perhaps go home and talk to their partner about talk to their doctor about. And they can conceptualize what's happening with their shoulder pain rather than just saying it's non specific shoulder pain or something like that. And so what you do when you ask people will have you heard of a rotate a couple of later shoulder pain. And I haven't but I've heard of rotate a couple of you say great what is the rotate a couple of say a maybe a muscle or a tendon in my shoulder they might say rotary rotary cup which is which is common but it's rotate a cup and they say great well what is what a muscles and tendons do and they say they move they they might respond to exercise so so what where I think the power in this term comes from is that it might make our job easier to sell exercise. As a primary intervention rather than having them fixate on mechanical issues that needs surgical correction or an injection or something like that. Another term that I don't mind is subacromial shoulder pain. But if you type in subacromial into Google straight away this is conflated with subacromial impingement. So so that's an issue as well. So where I stand right now I think rotate a couple of later shoulder pain is the best label to a fix to this clinical presentation of non traumatic shoulder pain, where there's no instability or stiffness. But I'm open to having my mind changed in the future with better evidence. So that's how I see it right now. So if you prefer moving away from impingement and tear because those terms do maybe give the impression that surgery is required and we're using this rotator cuff related shoulder pain to describe this non traumatic shoulder pain and now we as fit physios are trying to describe what we're doing two patients or four patients or you know among one another. So we're doing to help the shoulder pain like what are our interventions doing? How are we treating it? Yeah. This is this is the million dollar question. This is a whole reason for my existence actually this is what my PhD is actually on so we're talking about mechanisms. So let's stick mainly to exercise because I'm not an expert on manual therapy mechanisms. I think you should go and read the work of Joel Bealoski if you want to if you want to understand more about mechanisms and manual therapy. So so let's say someone presents to us they have non traumatic shoulder pain. It's the insidious onset. There's no stiffness. There's no red flags and there's no instability. So let's say we give somebody we give this person an exercise program and they get better or they improve after 12 weeks. What's happening? What's the mechanisms that underpin that if we're not changing impingement or the subochromial space or anything like that which I've just spent 10 minutes or so trying to refute. So mechanisms are really really really really hot topic at the moment in popular topic within popular topic within musculoskeletal medicine. So mechanisms speak to how and why an intervention is working. So there with shoulder pain or within rotator carful later shoulder pain there are over 30 mechanisms which are theorized to explain the effectiveness of an exercise program. So so so we have no firm evidence to actually say whether any of these mechanisms are actually valid but I can hypothesize. So some of these mechanisms which are thrown out there are is a simply just increasing strength is it increasing the strength of the rotator car for deltoid or the entire shoulder complex and that that's a reasonable hypothesis. Some people believe that I've published some work that may be challenges that a little bit and you don't have to get tangibly stronger in your shoulder in order to improve your pain and function but I think doing strengthening exercise is bloody important for this condition and it is my it is my number one bias but you just don't have to get strong. But that's cool. So so that's that's one area that's that's one mechanism that's been proposed another mechanism that's been proposed is it's correcting scapular dyskinesis for example, but we know the evidence doesn't really support that are we changing muscle timing and activity or motor control. That's another mechanism and we have evidence that kind of refute start as well are we changing psychological variable so we're changing how somebody perceives that shoulder pain maybe we haven't really investigated that in shoulder pain we've investigated that in non specific low back pain we know that fear avoidance pain catastrophizing and kinesiophobia mediating factors of recovery. So perhaps that applies to shoulder pain as well are we changing and this is an important point are we changing the biochemical milieu or environment of the shoulder are we flushing out substance piece somehow from the bursar or from the from the super spin artist tended are we changing in flammate cellular biocellulone flammatory markers within the rotator cuff tendon tissue and we have some evidence to support that as well are we changing emotional factors are we simply marking time on nature. It takes us course are we providing a distraction you know are we just entertaining the patient while regression to the mean and natural history just do their thing there's there's so many mechanisms that have been proposed are we increasing the stiffness of the rotator cuff tendons or improving the capacity and robustness and resilience of the shoulder and of the person are we promoting healing this was a popular mechanism that we used to think occurred quite a while ago with patellar turned it up at the inner kill is sending up if you that. East centric loading et cetera et cetera was promoting a healing response within the tendon and that's been challenged more recently so in answer to your question guys I can't give you an answer i've got a lot of hypotheticals that we're hoping to test but we really have no one mechanism or even a handful of mechanisms that we can say are leading to the resolution of shoulder pain and improvement in function and people who present to us or maybe maybe it's just so complex that it is that it is a combination of all the mechanisms that I proposed. And they all interact together and they sort of emerge into this. Emerge into this this higher order thing that that that pain reduces and function improves maybe that's the case or maybe it's just different in every single individual and it's a waste of time most of time trying to figure it out I don't know so I hope I didn't create more confusion there but I definitely I definitely can say based on the literature at the time of recording in February 2022 that impingement or changing impingement is probably the least valid hypothesis that we have right now so given that you're outlining the distinct flaws in his previous approach on the mechanistic theory on shoulder impingement the flow of the diagnosis all these things and we're going to outline that we do see that exercise is beneficial is it specific exercise other categories of movements that we should be focusing on are there certain theories along those guidelines of possible benefits of the mechanisms that then guide choice choosing exercises and interventions and so specific exercise so let's break this down a little bit so exercise type let's start there so resistance exercise versus stretching exercise versus motor control exercise versus proprioceptive versus plyometric versus mobility whatever the fuck you want to call it all of these exercise modalities or types are non superior to each other. This is a frustration for me because my bias is resistance exercise and I don't despise motor control exercise but it annoys me how complex it is and how the barriers to giving it prescribing it and also trying to explain it to a patient and what they think you're trying to do so but we have we have evidence such as suggest that a simple resistance exercise like a non specific resistance exercise regimen like doing external rotation exercise and a scaption or lateral raise exercise is just as effective as a convoluted complex motor control exercise regimen so so so within that when when we have a situation that arises where there is no one best treatment or no what not one best exercise this is why we invented or came up with this thing called patient centered care and shared decision making when everything is kind of a quivicle and equal in terms of its effectiveness then you got to ask the patient what they would prefer to do because you have no evidence to suggest that this intervention is better than the other so this is where shared decision making becomes really really important so basically in answer to your question there is no one best exercise there is not one best exercise type. Maybe progressive exercise is better than non-progressive exercise, which kind of makes sense. So progressively increasing reps or time under tension or whatever, whatever dosage variables you want to count, changing that seems to be more beneficial than not. And again, that is my bias. There was a great systematic review published in 2015 by Chris Littlewood, which kind of mapped out the exercise parameters. And it said, it said, it said things like three sets were better than two sets, apparently. It said that resistance exercise might be a little bit better than non-resistance exercise, but we don't know whether this reaches clinical significance. What else is there exercising into pain? Might not be any different than avoiding pain. So on and so forth. So it's a little bit, the literature is a little bit disheartening at this point of time. If you're a therapist that says, okay, I want an algorithm to tell me how to fix this patient in front of me. Unfortunately, there's not going to be that recommendation out there. I think we need to take the entirety of the literature into account. And then we need to ask the patient what they've done in the past or what they would like to do. And then collaboratively between the clinician and the patient, you can devise an exercise program that they're likely to adhere to. And I think that results in the best outcomes for the patient. Let's assume that we have two groups of listeners right now. One who's been trying to integrate some of this, you know, research into their practice and moving away from some of these flawed mechanisms and descriptions. And then maybe another group who's hearing this for the first time, do you have recommendations on how both or either group can start implementing this into their practice, whether it's what their descriptions, what their exercise prescription, etc. Yeah, so I think the first thing is the label that we turn this condition. And I think that that's a really good place to start. So the causal explanation towards causing somebody's pain is where we need to start because how we speak about a health condition, I think really sets up how we manage a health condition and also how a patient perceives their health condition as well. And health professionals have immense power when it comes to the beliefs that patients end up developing. Most beliefs from patients actually come from their health care professionals. So I think it starts there and that's why a rail really quite hard against terms which may actually worsen outcomes such as rotated cuff tearing such as shoulder impingement. And then I think it comes down to just being informed on how exercise might work and how and how our management might work and just be and just appreciate the complexity of a patient and clinician interaction. And the many different ways that a clinician can help a patient without actually giving them this convoluted specific biometically oriented advice which has not been shown to be right. So straight away just listening to the patient, listening to their story, listening to their narrative, trying to understand where their shoulder pain fits into this person's life. Like how are they perceiving their shoulder pain? Have they been told in the past that yes, it's an acromion digging into their rotated cuff tear? Have they been told that lifting their arm makes their rotated cuff tear worse? Have they been told that exercising makes their rotated cuff tear worse? Have they been told that they have a person that's getting pinched and punched up when they abduct their arm? Have they been told that they need injections every year for the rest of their life? Have they been told that they have arthritis in their ac joint or going to human joint? So straight away asking that person, well hey, how do you perceive your pain? What have you been told in the past and what's your interpretation or evaluation or analysis of what's going on? And then you can chime in in a non patronizing way and say and give your piece of expertise, which is so your place as a clinician is an expert, a content expert in all the research evidence that's out there. So I kind of don't have any time for clinicians, just I don't have time to read to read evidence because that's such a cop out. You are, you are a physiotherapist or a physical therapist that is an applied science degree. So you need to stay true to that and you need to read not all of you need to read some form of literature and then follow other people who read more literature and then listen to podcasts and read books and watch YouTube videos in this information age. There is no excuse for not having come across literature that's been published in the past decade. So that's so that's the first thing there. So you really need to be aware in in part or in brief of what's going out there in the latest evidence, you don't need to go into the to the complexity of the statistics and the confidence interval and all this sorts of stuff. Let the other experts deal with all that stuff and you can read their conclusions. So that's why your guys company is great and there's some really other good companies out there as well, which kind of distilled and synthesized the evidence. So well done, shout out, shout out to E3. And so where was I with this question? So how can clinicians up? So so the first thing is changing the label. The second thing is reading a bit of evidence every now and then the third thing is being aware of the complexity, a complexity associated with a patient clinician interaction reassuring somebody can be really helpful. All right, just saying that you don't have a sinister pathology within your shoulder and you're not going to wear your rotator cuff out when you lifted can be really helpful for somebody who was trying to overcome their fear and apprehension of or valuating the shoulder into the air. So so these are some some common places to start. Then you go into exercise and you and you can actually quote some evidence and even say that exercises just as effective as surgery exercises just as effective as injection therapy. Exercise has none of or one million of the possible toxic side effects of surgery and an injection and it also helps your general health that might might help your health related quality of life. It might help you psychologically. It might help your musculoskeletal cardiometabolic system. Do I need to keep going there? So all of these secondary or even primary effects of exercise kind of sell themselves when it comes to managing somebody with with non-traumatic shoulder path. So so I think there's a number of things that clinicians can do to move away from this kind of old school dogmatic way and biometically oriented way of managing somebody with a quote unquote shoulder impingement and more towards this holistic humanistic 21st century way of managing somebody with non-traumatic shoulder path. Are there any other myths or misconceptions related to the shoulder that you want to address? Yeah so there's my look. The shoulder is plagued by misinformation for some reason. So I reckon the shoulder now is like 20 years behind low back pain and so maybe in 20 years time we'll have as much information as we have about low back pain. Not that low back pain is you know there's still a lot of misinformation about low back pain but I think the shoulder is at another level. So other other issues that I have the scapula. The scapula has issues from the ground up. There's issues with the reliability of testing scapula disconesis, visual observation observation of the scapula is almost entirely flawed. The scapula disconesis doesn't need to change for pain and function to improve. That's that's pretty clear so you can stop fixating about the scapula. Stretching stretching is not the worst exercise in the world stretching gets a bad rap relative to other interventions. Other more sexy interventions such as strengthening. But stretching helps people when you actually look at it from an evidence-based perspective and I've had to actually modify my beliefs on that in the last couple of years. We've had some clinical trials come out that show that stretching is an effective intervention for people with subacromial shoulder pain or a chaedica-related shoulder pain. We've got misinformation as it relates to surgery but we've kind of discussed that subacromial injection therapy is basically the statistic is a subacromial corticosterid injection is effective 20% of the time. So that's one in five people who will have some sort of an effect with a subacromial corticosterid injection and we don't really and this might be associated with some toxic or catabolic effects on local soft tissue that we're still investigating. So why on earth will we inject something into somebody's shoulder where we don't really have any idea of what's going on from a biological perspective with that injection that only works one in every five times. Now I get that they have a place if somebody has failed or not sufficiently improved with a with an exercise-based program or something like that. I think they serve as a necessary elevation of care before surgery but certainly they should not be offered in the first six or 12 weeks of somebody developing these symptoms. So injections have a lot of dubious evidence for them. As we said a moment ago there is not one best exercise which means that there is no single exercise that must be in every single exercise program and there is also no universally bad exercise that needs to be avoided. Now I've seen a lot of stuff on social media recently where the empty can exercise or the upright row exercise have been have been demonized as causing impingement and causing pain and I see like these red arrows on videos of people doing red cross-sorry on videos of people doing these exercises and saying this is the worst exercise you can do for shoulder pain with an exclamation mark in capital letters and it's just not true. It's an opinion based on some person's experience and that's fine they're allowed to have an opinion but when they're promoting themselves to be evidence-based and they're actually promoting health-based advice to vulnerable people I really think they need to do better and actually read some damn research and they might find and they might be quite surprised that what they're actually promoting is not only wrong but also harmful and nocebic to the population at large. So there's some of my pet peeves when it comes to the shoulder. There aren't more, but I've just forgotten for the moment. - You know, we made a video on the upright rail a while back and recently I posted about it again and got a lot of pushback and I probably shouldn't have posted it. I was in the middle of moving states and so I wasn't as like a thorough and mindful with my responses, but yeah, those kind of posts are exhausting too. Just going back and forth with people and comments or DMs, even if you are really respectful, you don't always get that back. - No, social media is a wild place and it doesn't really, it doesn't really promote rationalism. It promotes, it's emotionally charged and I understand that. So whenever I get hate or I comment on a big account and I say, "Can you please explain? "This is kind of wrong." I just laugh at some of the responses and I'm not laughing in a patronizing way. I'm just like, "Well, what can you do? "You're not going to change someone's mind "on a social media comment. "I just think it's important sometimes "to chime in every now and then to present "an alternative viewpoint, maybe plan to seed "and then maybe in five years time, "ten years time, that person might remember that one comment "on Instagram and it might change their life." Maybe. - Yeah, in addition to probably linking some other stuff in the show notes, I don't know if you've read this paper. I read it probably half a dozen times early in my career and I just brought it up because everything that you're talking about maybe think of it. So it's becoming a physician, tolerating uncertainty, the next medical revolution by Simkin and Shortsdien. It's literally a two-page perspective, but I'm gonna link that in the show notes because I think what you're providing to the listeners is going to probably create some uncertainty and I think it's okay. And I think it's a two-page paper and I think it's really helpful. - Yeah, well, I think look, I understand the friction between wanting certainty and the evidence base which reveals that everything's kind of uncertain. I understand that friction. I've experienced it myself and that's kind of led me to doing a PhD and starting a social media account and doing all this stuff because I had an existential crisis. Honestly, about eight, nine years ago, when so I graduated about 10 years ago and then I started working and then I started to see evidence coming in that falsified my belief system and also what I was doing in clinical practice wasn't really working sometimes and I had no explanation for why. So it forced me to do a bit of a deep dive into the literature and it was uncomfortable. It was very uncomfortable. And so I understand why people want to avoid that. That's built into us from an evolutionary perspective to avoid uncertainty. We can talk about predictive processing and stuff there where we're kind of, we're intrinsically wide to have our predictions come true, which is our beliefs come true and we seek out information to verify our predictions and our beliefs and we avoid information which refutes our beliefs. Anyway, so tolerating uncertainty can be really hard, but there are many, as I said a moment ago, just because our interventions are a little bit uncertain or our understanding of a pathology is a little bit uncertain, doesn't mean you can't help someone. So just zoom out a little bit and understand that there is a person coming to you, they're in pain. How are you going to help this person get back to their life or get back to their meaningful or valued activities? That's really all you need to do. And so you can use a bunch of different interventions within that or communication styles or whatever you want in order to develop a report, to develop a therapeutic alliance, get that person's trust and then help that person to return to their life as best as you can. Now you don't need to do it in a way that a particular social media guru tells you to do it. There are many different ways to go about doing this. All right, so the end result is the main thing, honestly. So as long as you're not selling bullshit and stuff that's deliberately wrong and stuff that can perhaps be harmful, then I'm okay with using a bunch of different techniques. I'm even okay with manual therapy. I don't know if that's controversial these days, but you are allowed to use manual therapy in your clinical practice. If it's wrapped up in the right context and the right messaging, you are allowed to give three sets of 10. That's fine as well. You are allowed to use therapy. You are allowed to give an upright row. You are allowed to give an empty can exercise. You are allowed to just give one or two or three exercises and you don't have to progress them every single week and they don't have to get a gym membership and they don't have to do high-pertrophy type training but you don't have to do power training. So there's just so many avenues within physiotherapy, right, which is a profession, not an intervention to interact with a person with pain and try and help that person as best as you can to try and return that person to their best life. And I know that sounds like a basic kind of 21st century thing to say, but that's the business that we're in. We're in the business of helping people live their best life. There's a little, there's a caption for you. After this episode goes live, I think upright rows with yellow bands is gonna sweep across physiotherapy clinics across the world. Normalize upright rows with yellow bands. Any final tips for clinicians working with individuals with any type of shoulder pain, really? I mean, it could be, you know, the sombrella or other shoulder pain as well. It's hard. Treating people with pain is hard. The shoulder is no different, but the shoulder has a reputation as being the most complicated joint in the body because it's the most mobile, blah, blah, blah, blah, all the surgeons would tell you, it's the most mobile, which means it's the most vulnerable to injury and there is a case for that shoulder pain presentations, are the third most common clinical presentation that we'll see in primary practice. So dealing with people with shoulder pain is hard. Dealing with the complexity of pain is hard and the psychology and the social dimensions of pain is hard. Dealing with the biological and the physical aspects of it is hard as well. So I'm just gonna reiterate what I said a moment ago, just zoom out. If you're struggling with the evidence, take a macroscopic approach to helping somebody with pain. Like the more we analyze, the more we focus in on one or two variables, the harder we make it, in my opinion, or the more we are just looking at the tip of the iceberg when they're all these factors underneath the water that you can't see. So gain the person's trust. Give them some sort of movement-based exercise to do, maybe progressively make it harder over time, try and avoid using no civic language as best you can. Try and promote optimism, try and promote good expectations of recovery, list out all the different ways that exercise therapy or physiotherapy management might be just as beneficial as surgery and as injection therapy. Tell them be accurate about time frames. This is going to take probably three to six months or maybe more. Do not expect miracle queues here. A flare up, three weeks down the line, four weeks down the line, doesn't mean that you're not getting better. We need to zoom out and look at the greater progress that you have made. When I first saw you, you could only abduct your arm, 90 degrees, now you've got 150 degrees, right? When I first saw you, your manual muscle tests were three out of five. Now they're five out of five. Well, our dietary momentary testing was this, now it's this. You could lift five kilos, now you can lift 10. So sort of come back to these objecting measures that a patient can see that they're improving by. So you can keep incentivizing that person to keep going down the pathway of non-sturgical therapy. So sort of harping on a little bit now, but zoom out a little bit. Try and respect the complexity of pain, respect the complexity of shoulder pain, but simplifies best you can by zooming out and understanding that all that complexity, perhaps just the tip of the iceberg, and there's many different ways that you can actually help somebody return to their life. And I think that's the crux of dealing with somebody, not just with shoulder pain, but with any form of pain. Thank you for listening to this episode of the Shoulder Physio Podcast. If you want more information about today's episode, check out our show notes at www.shoulderphisio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice in leave a rating or review. It really helps the show reach more people. Thanks for listening, I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Ugambar people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning and working from every day. I pay my respects to elders past, present, and emerging and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.