161. Overcoming persistent shoulder pain in tennis players with Jo Gibson

You're listening to the PhysioEdge podcast episode 161 with David Poe. Hey and welcome to the PhysioEdge podcast on your host David Poe in Australian sports and musculoskeletal physio. And on this PhysioEdge short or success podcast, Joe Gibson, who's an upper limb rehabilitation specialist physio based in Liverpool in the UK, takes you through how to assess and treat your shoulder pain patients and how to get really great results. And in this podcast, Joe takes you through the case studies of two tennis players that had persistent shoulder pain and great rehab, but they just hadn't been able to manage to overcome their shoulder pain and get back to tennis fully. So in this podcast, Joe takes you through how to assess these patients, how to understand some of the factors that might be involved in your patients' persistent shoulder pain, particularly if they're sports people or they're involved in overhead activities and sports, then how to go about treating them, how to go about addressing their psychosocial factors, their fears and their beliefs that might be holding them back or might be involved in their persistent shoulder pain. We've got a couple of great resources to go along with the podcast as well. And the first ones are webinar with Joe on the Rotator cuff rehab and reasoning to help you assess and treat the rotator cuff in your shoulder pain patients. You can get your access to that one over at clinicaledge.co/shoulder. And if you want to improve the assessment and treatment of all the other areas of the body, then go and grab your access to a free clinical edge trial membership. That'll take you through all the other areas of the body, give you the practical tools, insights, and knowledge and skills so that you know how to assess patients, you're confident and you know exactly what to do when your patients come in. And that's over at clinicaledge.co/freetrial. And now it's time for this podcast with Joe Gibson. Hi, my name's Joe Gibson and I'm an upper limb rehabilitation specialist. I've been incredibly fortunate in my career to spend a lot of time helping people with shoulder pain and instability. A spoken a couple of conferences round have been asked to talk about the kinetic chain on quite a few occasions. And it's particularly topical because I had a couple of patients in, both of whom had what sounded like really good physiotherapy, very thorough, every shoulder exercise you could think of, and yet they still couldn't get back to doing the things that they wanted to do. Now, it's a real privilege to be asked to problem solve people, but again, it's very important to hear the whole story and understand all the things that could potentially contribute. But the story is very much the same in both of them. They were both keen tennis players, both had anterior shoulder pain, both had an 18-month history, and essentially hadn't got better. They get to the point where they could play some ground strokes, but service was still an issue, and despite endless shoulder exercises and messing around with technique and various other things, they just hadn't got back to doing what they wanted to do. Now, as I said, I was really fortunate. I was involved in a consensus document, a Delphi study that's been published by Lutgera's 2023. So it's really interesting. It was a group of clinicians about 40% of them were from the states where, if we're honest, a lot of the research has come from in terms of the kinetic chain. And it was really interesting to see people's biases and when they thought it might be important. When we looked at definitions of what we mean by the kinetic chain, essentially there was a general consensus that we were just referring to that coordinated sequencing of activation, mobilization, and stabilization of all the different body segments to produce power or complete a dynamic activity. There was a kind of alternative definition, which was very much around the complex interaction and coordination of body segments, which is very much task-specific. But also importantly, when we talk about treatment options, also relates to the generation of force and the transfer of that force efficiently through the system. Now, when you consider that anywhere between 15% and 80% of the power of some throwing actions comes from the lower quadrant and the trunk. It's probably not surprising when I have two athletes like this that are doing their tennis serve and obviously using their shoulders of funnel of force and very dependent on that generation from force from the rest of the body, particularly in their service action, that actually, if I only look at the shoulder, potentially, I'm only looking at kind of 20 to 50% of the problem. Now, in this consensus document, when we were trying to consider, when would you want to consider the kinetic chain, there were four key things that basically the kind of experts dealing with sports people particularly thought were relevant. The first was that the patient had a history of previous lower quadrant or spinal pain and that's well supported in the literature. As we have numerous studies now showing, if we look at athletes who've had a knee or ankle injury, if you follow them up over a three-year period and compare them to an age-match control group doing the same sport, then they're risk of having a shoulder injury is two to three times greater. Now, of course, we're not saying the lower limb injury caused the problem and the factors, if they've had one injury, they're more likely to get another one anyway. So we have to be sensible. However, if they've had a previous injury and depending on how it's rehab, that's definitely one thing that I need to consider. The other thing that was pretty well agreed was that essentially if you have an athlete who's got repeated shoulder issues where the story is, they do very well with their rehab, they go back to do their sport, they might be able to do it for a little bit longer before their shoulder becomes a problem, but there's still this consistent message that when they start loading it, if they have any increase in load or change in activity, then the shoulder starts to complain again. The other two things were a loss of performance and as we know, a loss of performance often precedes patients presenting with symptoms that get related to slap lesions. And then generally, the consensus group thought that just being involved in overhead sport generally was a good indication that you might need to consider the rest of the kinetic chain. Now, in terms of what to assess, no great surprise, you need to see them doing their sporting activity and seeing if there's anything obvious subjectively. Of course, we have to do the basics in terms of making sure they've got good cuff strength, making sure in terms of ratios of external rotation to internal rotation, we can't ignore the basics, but what was really interesting in this consensus, particularly given what bad press the scapula gets at the moment, was not looking at the scapula in open change, just kind of active range of movement, but actually looking at congruency during loading activities. Now, again, we could have a big discussion as to how relevant that is and we don't have a lot of evidence to support it at the moment, but it was an interesting observation. And then the final thing, no great surprise was to consider doing some lower quadrant performance tests, purely again to see if there were any deficits and you can imagine if an athlete's had a previous injury, then that would make a whole lot of sense. Now, for me, if I've got these two athletes here, one of them did have a previous history of repeated ankle sprains on their contralateral limb as opposed to their service arm. The other guy had just got his symptoms after increasing what he was doing strength and conditioning wise. And for whatever reason, just hadn't been able to get back to his previous level without exacerbating his pain. So two slightly different scenarios. And I'll talk a little bit more about those in just a moment. For quick screening test, because obviously in the clinic, I want to think how far I'm going to look into this. I've looked at active movement, I've made sure they're not stiff. I've looked at their rotator cuff function isolation. I might get them to demonstrate their sporting activity, but how do I have a quick screen to see whether I think that lower quadrant might be relevant? The first thing is just looking at one leg balance and a one leg squat, Ben Kibler did some really nice normative data around this in different age match populations. And essentially, what you're looking at is do they fix through the affected arm when they're standing on one leg or doing a squat? Is there an obvious kind of protection of the shoulder when they're doing that? Now, of course, it's a tiny little window that might mean it's worth me looking at that lower quadrant further. But another really nice quick screening performance test is just doing a single leg heel raise. Now, again, we have lots of normative data in different sporting populations, but on average, you'd expect somebody to be able to do 30, 35 if they're doing sports regularly or at any level. So that's a really nice way for me to do a comparison side to side and see if there's any deficits. Now, in my guy who'd had a previous lower quadrant injury repeated ankle sprain when he stood on that leg and did a small one leg squat, he really fixed through his shoulder as he was squatting down. So I'm thinking, OK, let's look at your heel raise, we look at the heel raise. And actually, he could do 35 on his unaffected side no problem at all, but fatigued after 12 on the ankle weighed had repeated sprains. And non surprisingly, his balance wasn't too hot on that side either. Now, I always think we have to be a little bit cautious when we look at balancing people with shoulder pain, because essentially whilst we have studies showing very clearly that with balance measures and also things like the lower limb star excursion test, there are definitely abnormalities or porous scoring in people with shoulder pain compared to age much controls. But the problem is if you have shoulder pain, you're not going to use your balance mechanisms, your writing mechanisms in the same way, because potentially pain will inhibit that. So as ever, we have to be a little bit cautious in terms of interpretation. Now, when I look at these two guys, what are the other things we know when people have had pain for a long period of time, one that they can get into the habit of protecting their shoulder. And so get very stuck in those protective strategies. So that could be conscious. I think there's something damaged. So when I go into those risk positions, consciously, I'm tightening everything up to try and protect it. It could also be non conscious. I've just got into the habit of anticipating pain. And that pattern of protection has got really established. You think both these people have had symptoms for 18 months, when we look at the evidence, we see very clearly cortical change, that one that can be very cognitive related in terms of what I just described with fear. But also because of proprioceptive changes and just that abyss of movement, that can get very well established. Now, if we look at how that might manifest, we have some lovely studies, Liam Owens, who's a the emerging researcher at Hope University in Liverpool that I've had the privilege of working with is just finishing his PhD. And he found some really convincing links between a loss of interpersegmental sequencing, some changes in terms of how athletes wind up their rotation through range. And you might be thinking, "Joe, that's all very exciting, but what can I measure?" And actually what we see is a very clear message that reductions in thoracic rotation over a season actually link very highly with some of these changes in segmental rotation. Now guys, we've got to be very careful because while we have evidence that shows us that low-acquodrant injury, poor-lumber pelvic stability, poor low-acquodrant performance tests can make somebody doing overhead sport more likely to get shoulder pain. We need to be cautious claiming that's causation. It's definitely a correlation, but remember when we look at sport injury generally, it's certainly injuries more highly correlated with changing load, changes in sleep, psychosocial stress, previous injury, et cetera. So we do need to be a little bit honest about the potential relevance when we look at these two patients. Now, so if we go back to these two patients, I've got some key things. I've got my screening test that in my ankle instability athlete definitely showed some deficits in low-acquodrant performance. When we then looked at his service action, that was having an impact on how he was generating forces his shoulder. When we looked at some old videos, he was much better, much more knee flexion, a wider stance that essentially was allowing him to build up more momentum and then push that through his shoulder. Because of the ankle sprain, he'd narrowed his base of support, and essentially didn't have as much time to wind up the power, but he could, he was getting tired. So he reported this consistent picture. He could do a few games of tennis, and then it became really sore at the front and he'd had to stop, be horrible the next morning, settle over a couple of days and the same thing would happen again. So what do we do with him? We did some balance work, we did some low-acquodrant capacity work, but then we also exaggerated that and talked to his coach about maybe looking at the things he was doing before his injury and then seeing whether we could make life easier. And essentially from his ankle sprains, his shoulder problem was actually only about a six-month gap. So working on his low-acquodrant capacity, and then liaising with his coach about how we might just give him a bit more time to wind up that power, definitely made a huge difference with this guy. Now the other patient I told you about was really interesting because essentially I did my low-acquodrant performance test. He all raised 35 on each side. Something I'd better look a bit closer. We can look at hip rotation. And again, if we get changes over a season, that can correlate with fatigue in the hip muscles. And again, we know fatigue in the hip muscles puts more load on the shoulder, but again, his range of movement was fine. So then I asked him, I said, what do you think's wrong with your shoulder? And he said, I don't really understand. I've done all this physio, it hasn't got better. And essentially, I'm continuing to have problems. So tell me what else is going on in your life. And this guy had all sorts of stress going on with a relative that was terminally ill. He wasn't entirely sure that tennis was the thing for him 'cause that's, be honest, it's a really demanding sport. It requires travel, lots of money. He was worried about the financial stresses it was putting on his family. So there was a whole backstory in terms of things that were potentially driving other contributors to his problem. Now, as I say, in terms of performance, I couldn't find anything terribly convincing. Other than he was a bit stiff in his thorax, but interestingly, when I then watched him doing his tennis, he adopted this protect strategy and wasn't winding his arm up. He was almost anticipating end range. And so the consequence was he was almost destabilizing his shoulder. So what do we do? We obviously talked about the impact of all those other potential things on his pain and why when there was a change in load or things were more stressful at home, he seemed to have less tolerance to doing those things as part of his game. We also talked about how we could make life easier for the shoulder in addressing that bigger picture in terms of his sleep, his stress, et cetera, but also importantly, potentially, just make him a little bit more sequencing that force transfer a little bit more efficient. And what's lovely is we now have a couple of papers that show us if we add the kinetic chain to our shoulder exercises, it translates into what they're doing in their sport. So if you like, it makes them more efficient. It reinforces that sequencing. And that's a very long-winded way of saying we just exaggerated thoracic rotation and that lower quadrant combination and probably distracting it a little bit about anticipating that pain at end range. And we translated that into everything he was doing. Now, one of the great ways of doing that initially is to get people integrating lower quadrant knee flexion extension with thoracic rotation, but do it with both hands, so you can do it with pulleys, with cables, with terabans, whatever you want to use. But the advantage of doing that is you have to rotate your thorax. So if you've got somebody out here trying to protect themselves, it's a really good way of getting them out of that habit. But I think really what these two patients taught me and the reason I just wanted to mention the kinetic chain tonight was not to say it's the magic solution. We see this increasing theme at the moment, but when we look at our patients with shoulder pain that don't get better, it highly correlates with sleep, it highly correlates with lifestyle factors, and it highly correlates with psychosocial stress, but also things like your job satisfaction, your locus of control, et cetera. However, we need to be a little bit cautious because certainly when we look at a sporting coer or somebody who regularly overloads above head, there is some emerging evidence increasingly to support the relevance of the rest of the body, as I say. I'm not saying it's causation, but what I am saying is it definitely potentially makes life harder for the shoulder. And again, we have nice papers showing if we fatigue the lower quadrant, essentially the impact is the shoulder has to move through a greater range of movement and almost create more speed at the end of release to make up for the deficits elsewhere in the chain. So again, that potential overload of that anterior system. So if you like my little guide, I'd add the ankle sprain, pretty straightforward. We just made sure we'd got the capacity, made sure we'd got the balance and then built that into his shoulder rehab. My other guide, there was a whole lot of psychosocial stress, a whole lot of fear, and a poor understanding of what was happening with his shoulder. Now I'm not saying the clinicians he'd seen before hadn't given him a good explanation, but for whatever reason it hadn't resonated with him. And certainly when I'm probably solving patients, one of the first questions I ask is, look, you've seen a whole lot of healthcare professionals. They've all given you an explanation of your paid what's your understanding. And when somebody says to me, I don't really understand, that doesn't make me think all the others did a bad job, it just makes me think, for whatever reason it's not resonated with this athlete, so I need to get to the bottom of it. And as you heard, there was a whole lot of stuff going on in this guy's life. And he actually turned around to me after the first session and said, I'd never really considered how all these other things might be influencing my shoulder. But now I think about it, when X, Y and Z have happened, that's actually when I could only do a couple of games before it's problems, when I've had a better week, actually I can usually pay four or five or six, or even a couple of sets. So again, often shining a light onto those things, it might manifest as a protective pattern that's affecting his low transfer, but fundamentally I can give him all the capacity in the world, it just means he'll be able to do it for longer before the system breaks down. So guys, a couple of interesting patients that got me thinking this week, but also allowed me to just highlight that loop goers paper, a nice, simple read. It was a consensus from some really cool people that it was really great to be involved with, but I hope it's given you some food for thoughts. If there's anything you want me to speak about particularly, or something that's causing your headaches, then please just drop us a line on the Facebook page and buy it for now and thanks so much for joining. - Thanks Joe, that was awesome. Hope you enjoyed that podcast. You've got lots of ideas now about how to go about addressing any of your patients that have persistent shoulder pain, particularly if their sports people are overhead athletes, and then how to go about addressing all those factors that might be involved in their pain. Remember, you can grab your access to the free resources, if you've got your webinar with Joe Gibson on Rotated Cuff, Rehab and Reasoning, and then you've got your free trial clinic leadership to improve your assessment and treatment of all the other areas of the body. Thanks again, and I look forward to catching you on the next Physio Edge podcast. See ya.