STA195: 'Shoulder Assessment: Qualitative vs Quantitative' with special guest Professor Ian Horsley

You're listening to the Sports Therapy Association podcast, putting evidence back into soft tissue therapy. Music.

And we're live. Welcome to the Sports Therapy Association podcast, episode 195, entitled Shoulder Assessment, Qualitative vs Quantitative, with my special guest, Professor Ian Horsley.

And he'll be coming up very shortly clinical director at back in action limited.co.uk and plenty more but i'm not going to start that now because it's a huge list we're going to go through it in detail and just to let you know this is part one if you listen to the podcast or whether you've chosen to join us live in the live lounge this is part one of a very special two-part shoulder series with two absolute giants from the industry as i say professor ian horsley will

be joining us for this episode and then in episode 196 which will be recorded live next week treating the shoulder steps to success my guest will be hugely respected shoulder specialist joe gibson also upper limb rehab specialist that we have for performance like i said that's going to be recorded live on april the 30th tuesday at eight o'clock so if you are listening to this podcast and you're thinking actually i quite like to be live so i can ask these people questions directly.

And also gives you a chance to hang out with the other people in the live lounge and that's all you got to do just come along to either youtube or facebook sports therapy association facebook Facebook page and you can be here live. And when you do join us live, I can bring your questions up onto the screen and you can show off your fancy logo or your face. For example, people are coming in the live lounge now. We've got Cecily Hislop

who says, so happy you finally got up to this join. That's true. I've got a little bit of a bias against anything above the waist and I get a bit lost. I've got to watch out for how much I do that. But yes, we're up to the shoulder, Cecily, so I'm glad you're happy about that. If you do find that you've joined us and your message is not coming up on the screen and you're known as a Facebook user, then that's because you haven't clicked the permission link.

But hopefully there will be any of that tonight because I've told you all about that a little bit. Anyway, so for those of you who don't recognise my voice, just to introduce myself, my name's Matt Phillips on the creativerunchatlive.com and like I say, as always, this episode of the Sports Derby Association podcast is being recorded live on a Tuesday at 8 o'clock on the Sports Derby Association YouTube channel and Facebook page.

Before we start this week's episode, I'd like to thank last week's guest in episode 194 let's just bring his face up there for those of you who has joined us live there we go ben wybrow was with us i say every week it was a fantastic episode and you should really go and listen to it it is there on all popular podcast apps and it's on youtube if you want to watch the video it's also on the sports derby association web page which is the sto.uk um fantastic episode for anybody who

works or talks to people in pain which is my kind of sarcastic way of saying it's for all of you. Okay, it's a magnificent, I mean, it's so good. They're all great, these communication experts, because they're, They just help us gently realize that we're not as good at communication as we think. And he made a great point saying that we all feel that simply because we've chosen these careers of looking after people, that obviously the empathy just

oozes from our bodies as soon as people walk into our room. It's what we do for a living. But because of the words we use and the body language we use and how we comment once somebody said something, we're not as empathetic as we would like to think a lot of the time.

The patient just doesn't hear that. that so it's a great episode giving you a few little nuggets on how to actually let the patient realize and the empathy you have got as opposed to just relying on well they know i'm doing the job they must know that i love them so it's it's it's great episode and just he's a great educator we also had as part of the show because it was based on a sit in the mud article that ben did in the msk mag from the physio matters team we did a draw for somebody to win

three months of a free subscription to the MSK mag and we will mention that at the end so let's see if you are the lucky winner of three months subscription to MSK mag but anyway I've left him down in the lobby for long enough I would now like to bring up the guest for the first part of the shoulder two-part series episode 195 shoulder assessment qualitative versus quantitative with special guest professor Professor Ian Horsley.

Music. You're listening to the Sports Therapy Association podcast, putting evidence back in soft tissue therapy. Hi Ian, how are you doing? I'm good, good, thank you, Matt. Thank you for the invitation and thank you for people tuning in live and the ones who download it and listen to it later.

That's very kind of you. Now, it's amazing to have you along. I hope I didn't make your head swell up too much in the various promotions I've done for it because you are I'm sure you will agree to yourself but you are a massive name you've been around for a long time contributing to the shoulder and more so I think maybe to start because I'm hopefully a lot of people haven't heard me that's the whole idea although I was all just sitting in this echo chamber would you be so kind I

know it's tricky because it's quite a long CV but how did you get maybe how did you get to where you are today and and so kind of respected for working with the shoulder and educating people about the shoulder okay uh so a quick potted history i always wanted i always wanted to be a surgeon my sort of my direction of study in my life was to go to university and do medicine and then be a surgeon.

Lost a little bit of focus when I was doing my A-levels. Didn't quite get the grades I needed, but managed to get some grades that got me to Liverpool University to do a combined first year of physiology with the option in the second year, if I did well, to do medicine. And that's where I got to what I now call a lucky break. I broke my back playing rugby at university.

And while I was being managed and treated there I realized that doctors really didn't treat anybody they managed people and out of the continuum that I went through it was a physios who actually sort of treated me did things for me and so I was lucky enough to finish my year at Liverpool and transfer to Manchester to the then what was called Whittington Hospital School of Physiotherapies because in the dark ages okay we weren't at university we had we had schools of physiotherapy,

and then while I was an undergrad there in my second year the local rugby team came and said we'd like a physio to work with our rugby team please preferably somebody who knows something about rugby and I was doing my outpatient placement and they said oh well Ian plays rugby and he's doing all right in his outpatient placement why don't you have him and that's how I ended up getting into rugby and as anybody knows they get a lot

of shoulder injuries in rugby so I had to quickly upskill on managing shoulder injuries in rugby.

So you weren't tempted because we've had a lot of guests who have become great educators and therapists and because they were injured and sometimes because they noticed that the care they received wasn't as good as they'd wanted it's like well I'm going to do something about this but for you you said it was your back which you had a problem with for a stage where you're like right I'm going to help everybody's backs and you just realise there's more shoulders to work with or

how did that come about? Do you know what, I was a. I was a typical rubbish patient. So my treatment was I was put in a full body plaster cast. So all around my thorax, up to my hips and around my shoulders from there. And every week, every second week, I had another one applied over the top. But I played tennis for the university in a cast. I even tried to play a game of sevens. So I got sent off when the referee realised I had a plaster cast on under my shirt.

It was just i don't know never really thought about it and and just enjoyed just enjoyed getting into physio really i wanted when i started and i had i really thought when i started physio actually i thought i might i want to be a pediatric physio for some reason i don't know what it was but then just things things changed based off the what i did with the rugby club my father's from wigan and he'd be so proud listen to you now because he's always having a laugh at kind of rugby union

players men with handbags down south and saying the league is where the men are so you'd be so proud to go there see there's there's an example there you go that's what you get when you cross the border so um yeah excellent playing tennis in a cast so yeah we you already mentioned i think 14 years was it physio for england rugby union yes yeah six years for the elite playing squad which always sounds amazing yeah so yeah so that time we we we

have big squad so we had the first team the second team so it was that's the first team and what was called the a team. From there, trained together during Six Nations and they'd select the team to play on a Saturday, team to play on a Friday, which was the A team. So I worked a lot on there. I was lucky that during that time, it was 2003, so we won a World Cup then. So I was part of that wider group looking after that squad.

Yeah, so good times. And that change from working through from amateur to professional was really, really nice from the huge change that the way we were looked after as players and support staff was fantastic. Amazing. Yeah, we've had some interesting, I mean, rugby does come up with its fair share of injuries, doesn't it? We have some fascinating conversations, even recently on concussions and the theories and changes and misconceptions about that.

But tonight is all about shoulders. So like you say, yeah, a lot of shoulders injuries in rugby. We were chatting a little bit off air and the feedback we get, and I've suffered it myself. I mean, I look after runners. So like I said in the intro, anything waist up, I'll get it.

Because if you don't work in something then you just don't feel that confident about it but the shoulder joint in particular i know the way it's presented when we learn the anatomy physiology but it's kind of a little bit of a fear joint is that right do you think fair to say yeah i think you're right and you know i i do i do a lot of post post-grad teaching on it and and i ask people you know what is it that that scares them about it you know it's it it in essence the glenohumeral

joint is is two bones which is one bone.

Less than the knee and people seem a lot happier around around around the knee and i i suppose there's there's a lot more instability around the joint itself but when you think of that the the glenoid is part of their scapula that which sits on another mobile platform which is the thoracic spine which sits on something else so there's a lot more connections if you like that then can influence sort of locally as well as globally willy the shoulder i think that's

it i think you just nailed it as well because we are taught it's the most unstable joint of the body so that's that that makes us fearful in treating so imagine how it sounds to patients when we go we do realize the shoulders those unstable joint body but then why are we going to fix you but it's yeah it's interesting it's i think it's because it's got that massive range of motion and and so many so many tests which i'm sure we'll talk about later on but if you know but if

you're looking at in sport you know looking in gymnastics you know it It doesn't look unstable when you see what they do on the rings in there. You know, it lacks osseous bony stability like the hip where you've got a deep socket for that. But it's got fantastic neuromuscular control. That's what you're looking for around the shoulder. And hence the title of the talk tonight, really.

For me you know there's some clever things going on around that around the shoulder that maybe numbers numbers don't capture brilliant great segue good segue into the title yeah so yeah as we said in the introduction tonight part one shoulder assessment qualitative versus quantitative i guess we should start off really not only they're two words which are quite difficult to say if you've had a couple of drinks but yeah could we go into

maybe defining them and then and distinguishing them so our listeners kind of realize what we're talking about here Okay. So my current part of my job is I'm the upper limb lead physio for the UK Sports Institute, which used to be called the English Institute of Sport. And I work in high level Olympic and Paralympic sports and education. There's a massive focus on numbers, okay, strength, power, range of motion, rate of force, force development, lots and lots of numbers that are measured.

And I am not a great fan of that because, so that would be your quantitative stuff. So force production, how much weight you can, sets, reps, newtons, kilograms, whatever from there, you know, degrees of range of motion. Whereas for me, and this is sort of nicking a phrase of John Elphiston and Andre Vleeman, what I look for around the shoulder, as with anywhere else in the body, I want to see beautiful, effortless movement. And that is a sign of a good neuromuscular system.

So this is qualitative. There aren't any numbers for it from there. And so it's based on something that's experienced or observed, really. So that's what's difficult, because I can, you know, having to describe what I can see that that looks effortless or effortful. It is an objective opinion, but it's an experienced, objective opinion that I can tell somebody's movement quality is getting better or getting worse.

Worse and that's my i look at how well they move and obviously the feedback from their patient of whether or not they're getting pain or they're getting their their symptoms because you can measure strength and you can measure range of motion and force production and things and you can still have poor ugly effortful movement and that and your subject your patient can still can still be having symptoms so so i do sit in a as a square peg in a round hole in in the institute.

It's really interesting because it's like and i'm thinking of previous episodes i've been sitting here i'm nodding as you're saying it but then i'm thinking of talking to particularly strength conditioning coaches they're saying that we should all be using dynamometers more because then we've got a tangible way of measuring improvement and we can be working with a team we can show like the coaches or the bosses the managers

look this guy's getting better he's getting closer or and and how important it is to have something quantitative but now you're, sitting on the other side saying hold on we're going over the top with quantitative now where it's not actually quantitative is all very good but it doesn't necessarily correlate with full recovery as well as we might think yeah so you know the quantitative stuff is good for performance okay i agree when we'll you know when we're looking from a performance like

that from a from from a rehab and from a motor control aspect, it's other things. Because if we take. If we take what we said earlier about the shoulder joint having little bony stability. Okay, but it's a neuromuscular control around there, what we've got to make sure that that joint stays stable is that sort of feed forward mechanism, that little bit of pre-activation of a low level of the rotator cuff to prepare that joint for some activity that they can do some wondrous things in gymnastics.

Gymnastics or some incredible throwing judo without somebody's arm coming out there and and you know we're talking about you know this pre-activation about 60 to 120 milliseconds before before the move which is you know which is imperceptible really if you think about it but if you look at some of the research that's been done in sports say if you look at cricket or look at tennis that if you're stood 22 yards away on a cricket pitch there's somebody bowling a ball like 90 miles

an hour for you you haven't got time to see that ball hit the deck and decide what shot you're going to play what happens is because our our brains are very very clever and spot movement patterns that we don't even appreciate you you the best batters can see how the ball is as as a The bowler comes in as he sets, they know roughly where it's going to be and they can pre-empt that.

Similarly, in tennis, when the ball coming at 150 mile an hour, you can't react to a ball coming at 150 mile an hour. But our brains are very, very clever at doing things that we don't know they're doing. So are you suggesting then that because the shoulder is dependent, the way it functions, yes, it's got this instability, but it's got so much of neuro ability as well.

That that's why in their particular case the shoulder joint the pendulum does swing more towards we should be doing qualitative as opposed to quantitative and a joint where maybe there is kind of just kind of flexion extension i mean i mean the same you know we know the same it is to all the joints to stop an ankle sprain or you know with the uh to get damage at your knee or if you get an acl it's the same but they've got a little bit

you know if you look around the the the knee you've got a round bit on a flat bit which is not a great bit of stability but a little bit more stability from both of the cartilages which are in there but massive muscle at the front massive muscles at the back that gives it stability ankle we've got a nice little mortise for a bone to go in and lots of muscles around there so they've got other bits but the the shoulder it's you know it's a ball and saucer you know that it's flat it's not

even round it's pear-shaped you've got a little thickening around the head which is that the the glenoid labrum, which is about seven millimetres thick. There isn't a lot there to hold it apart from the cleverness of the. The information and the message coming from the brain that controls the cuff. And then once we get that right, we can produce incredible forces.

I mean, we know that, you know, from in baseball, where they're throwing a ball, you know, between 90 and 100 mile an hour, at the point of release, there's about one and three quarter times body weight traction force on the arm. But you've never seen a picture in baseball loses arm.

At all from there you know it's it works really really well to sustain some some high forces but we've got to have that that that platform for everything to to work off and we need a platform of stability of the shoulder blade which then the cuff sits on that then can give stability dynamic stability to the humeral head on that sort of flat pear-shaped surface of the glenoid.

Fantastic just to remind people who are joining us in the live lounge feel free to ask questions if there's anything you need clarification on i've even got a little image of the shoulder joint in case you're getting a bit rusty then just say matt can you flash an image up on the screen then yeah just don't let this all go beyond you if you're not quite sure we can take it whatever you want i'm thinking i'm wondering whether i'm just thinking of people who are rehabbing i mean we're

talking at the moment of people who are in kind of some stage of rehab and they're in pain and is it a case of whether there should be more quantitative base in the beginning of rehab or later on or is it should should the quality be there from the very beginning or especially at the end or what's in your experience so again what one of the things you know i try to explain to patients when i when i'm looking at things it is you you can you can ride

a bike that's got a slightly buckled wheel okay but but it's not a comfortable journey, okay so what i'm looking for i want the good good mechanics and what i don't want a buckle wheel that makes it low effort for you to pedal and it makes it a comfortable comfortable journey so first of all we i need you at low level to be able to move your arm beautifully you know i i see patients in in clinic and these are not these are not elite athletes

if you ask them to take their arms out to the side and they get to about here they look like they've got 20 kilograms in their arms as they fight to get their arms up above their head. If they can't do that without any weight, just imagine when you start to put some weight on there. So I wanted to get somebody moving.

Effortlessly at low load and then we can start to change that we can add load as long as it looks beautiful and relatively effortless and then we can change the speed and it needs to be beautiful beautiful and effortless well because that's the sign for me of of skill of performance so if we take something as a sport that's on telly at the moment snooker if you watch them playing snooker and you'll see somebody down at the bottom end of the table where the pink and the black is with the

white and they'll hit a red and it'll go into straight into the center at the top left hand pocket from there and that's 12 feet away from them and you think that's that's easy go and have a go go and have have a go and that's just to put it not to get the ball to whiz around the table and come back and sit on a sixpence so when you think when you see you know A gymnast doing their stuff.

If you see a tennis player serving, it still looks relatively easy, apart from if you – unless you're watching Rafa Nadal, okay, which I always compare Federer to Nadal. Federer, effortless, beautiful, very few injuries in his career. Yeah. Nadal looks like he's fighting a bull every time he plays. High incidence of history throughout his career. Yeah, interesting distinction. I'm listening to you about the importance of the beauty of the movement and I'm loving that.

And I'm wondering whether it reminds me, this has come a few times now, it's on my mind. At Therapy Expo last year in November, people like, I'm sure you're familiar with people like Angela Jackson.

Yeah, Angela. yeah andrew as well andrew mccauley his name always escapes me both of them and more people had some great talks on particularly as andrew who is who who was drawing attention to the fact that still one of the biggest kind of precursors or something which indicates the chance of injury is have they been injured before which kind of suggests that the rehab we've been doing all of these years for somebody is missing something because if that person has

got a really high chance of coming back with another hamstring strain or shoulder injury then maybe we're missing something from the rehab so they were talking a lot both of them about this idea of chaos of that we are not rehabbing properly in the way that they're going to use in sports i'm thinking of that with the shoulder as well it's very easy to get somebody to we're talking about rehab at the moment we'll do a session for the second but you could put

someone through all of the kind of like you know planar movements but you're not creating the chaos which might happen and not so much as snooker hopefully you know in other sports you know where they are going to have somebody trying to stop them or knock them over or you know and change angles so i guess that ties with what you're saying to prepare for chaos you need to have that quality of movement yeah you know and you you take somebody from you know they they're

telling them what they're going to do knowing what to do then to the unexpected so it's it's not often that a shoulder will dislocate when when you know what's going to happen. It's when, you know, when you're not ready and not necessarily, you know, people just might be in a relaxed position and sneeze and dislocate the shoulder. Whereas, you know, that you can tackle somebody equivalent of a 30 mile an hour crash at rugby and bash into them and get up and run across.

So, yeah, it is about thinking about, you know, all their different facets and, you know, trying to prepare them for those uncertainties that really...

You know, when we talk about the shoulder, the thing that I don't think gets looked at enough around the shoulder when we're rehabbing is looking at proprioception, awareness of joint position sense. You know, we routinely do it for the ankle. You'll get somebody who tests them. You'll stand them on one leg. Can you balance on one leg? You know, can you do it with your eyes closed now? Can you do it on an unstable surface? And that's for a comparatively relatively stable joint.

But when we do the shoulder, and again, when I'm teaching, I ask people how many people routinely assess joint position sense proprioception as part of their assessment and their rehab. How many people rehabilitate proprioception of the shoulder? Because that is the mechanism that's going to tell the brain what's happening at the shoulder. Because everything that we do anywhere in the body is brain derived.

Revived for you know when we're training and we're trying to get a peripheral movement stimulus to we're trying to change a centrally driven stimulus so when we're giving exercise okay but for every one external peripheral stimulus we give there's 30 stimuli coming from the brain so we need to train the brain okay to to sort our joints out and obviously there we're talking about the shoulder the joints but it's the same for for any any joint around there so

proprioception is massive for the for the shoulder and that will be you know one of the early things to assess and and to work on with it right well i can hear i can hear listeners either live listeners or i'm looking in the future now podcast listeners i've just flipped over their pad now and they've just got their pen from behind their ear because we're looking at something which maybe they should be adding to the to the rehab of

the shoulder they're not so yeah give us an idea of early or late stage you know things you should be incorporating which do test the proprioceptive abilities of the shoulder so we can do a you know simple simple thing you can put them so you can see me from here we so we take away the visual stimulus blindfold on the eye you can put their arm into a three-dimensional position on on in space okay their.

Non-injured shoulder and say can you replicate that with your with your shoulder that you've come to come and come to see me with that that's that's.

That's called contralateral mirroring yeah or you can you can take their joint into a position so say supine take 90 degrees abduction take them into 80 degree or something around about 80 and 70 like say 75 degrees of external rotation leave it there for five seconds while they're blindfolded bring them back to point to the ceiling can you replicate that 75 degrees and then you can measure the error the joint position error from there and whether you

undershoot it or overshoot it will give you some bit more information about where their proprioceptive their joint position sense is in there. You know, a lot of this stuff, if you look in literature, and I think when I've spoken to people when I'm teaching, it uses lots of expensive equipment like isokinetic dynamometers and force detectors.

You can use these really, really simply things to get an indication of how that joint is functioning, because unless you give the brain some information, it can't do anything.

Thing so the the quality of the the afferent information that the information coming from the shoulder joint to the brain decides on how good the the response from the brain is to protect that joint you know and that this i hate this say because it's an american but garbage in garbage out so if you've got inappropriate message coming from here because your proprioception is down then your brain can only act on what what information is given and

it gives you some some faulty movement information or stability information back excellent that's lovely that's a lovely idea of the blindfold and just can you can you again using the asymptomatic arm as a measure of what to try to achieve the symptomatic arm one could say there but though there you because you talked about measuring angles you're using a still using a quantitative approach there to measure yeah for that technical example yeah for some feedback so you know i'm not.

Clearly a lot of the time worried about their the the range so for this we're looking at something that's very uh specific that about proprioception how accurate that has to be so when we start to get to the neuro side of things but then we do need a little bit more so one of the arguments that we read about or which kind of like says oh quantitative is the way forward is it is tangible the problem the danger may be of qualitative depending on what kind of assessment or.

Exercise you're doing is that success is measured by the practitioner or the patient of how they feel or or whether it hurts or if they're tired and it's all kind of difficult to to measure and show progress is that kind of overstated by people who are trying to get you to buy a you know some kind of quantitative equipment or have they got a point yeah i mean you've got that there was a nice little blog came out by claire minchell this week

talking about using handheld dynamometry things and talking about the the things you know you can get you can get variability just you know from how how you encourage your your subject to produce force you know how much you shout and scream scream at them you know that that volitional response with it you know the the the position that you you know so so again if we think about the shoulder from a tested testing strength we We talk a lot about internal and external rotation, strength and ratios.

And we might test them at 90 degrees abduction from here. And it will generally be an isometric force.

Okay. So, again, are those muscles working isometrically in that position in sport, in life?

No, they're not really from there. are you know are they are we're testing them in mid-range yes but you will tend to dislocate more to to outer range okay where we we test concentric concentric most of the time where we know that we need some eccentric some some lengthening from there so again when we when we start to think about the quantitative stuff then we need to look into more detail then and more specifics of what it tells us because you know in in sport in in

in in baseball that that 90 mile an hour throw the arm's going something between about 7 000 degrees a second it's rotating at okay and we know that the force produced is relative to the speed in which you move now we haven't got a bit of equipment that that will measure that you know an isokinetic I think dynamometer goes as fast as about 500 degrees a second, no matter what thing. And so we're taking values and,

For me, I'm thinking, so what is the validity? Yes, it's a value, but how does that rate to 9,000 degrees a second with it?

Hey there matt phillips here sorry to interrupt the podcast just seconds to remind you that if you're looking for beard grooming products there is a sports therapy association discount code that will get you 15 off at the brighton beard company website the brighton beard company.co.uk yes i am biased what with brighton being my hometown but the brighton beard company really do offer an absolutely amazing selection of luxurious beard balms and impeccably scented oils

all handmade in small batches with 100% natural ingredients their current spring collection for example contains bergamot coriander thyme and lavender giving you a fresh and energizing essence with both citrusy and peppery notes making it the perfect gift for you a family member or any friend end with facial hair go to the brightonbeardcompany.co.uk and get 15 off now by entering the discount code sta15 doesn't include already discounted bundles okay what

about assessment then it's is that different someone's someone's coming in yet because a lot of our listeners when they move basically i don't know how much you know about the syllabi for sports therapy but But when they move from level four to level five, and there's a lot of fuss over this, basically they just introduced about 30 different kind of orthopedic tests. There's a lot of them on the shoulders and they have to learn them and reproduce them. And.

And there's a question these days as to the validity of these tests for some of the reasons you've just mentioned now, because it's all very well testing apprehension tests of some form. And I think also we've had papers which have shown that maybe the limitations of, I don't know, tests like raising the elbow from the back, the base of your back and stuff like that.

Do you think that even at the level of just assessing patients who come in, that these tests are a little bit flawed and we should be doing tests which are based more about quality of movement as opposed to measuring them and looking at forced production and stuff? I think, again, that those tests and last time I looked, I think there was about 152 manual orthopedic tests around the shoulder. There's probably been another one developed while we've been talking tonight.

Which, as I say to people, there are that many because the reliability of them is poor with it. So some of those tests may be able to identify injury around there, which is slightly different. So if you've got a tear in the cartilage ring around your joint, around your labrum, well, that's going to affect how the joint works. Because one of the things the labral does, it helps keep that negative pressure in your shoulder joint, which sort of sucks the ball into the socket.

It it's like a gasket and if you tear that then air can get in and you haven't got that negative, force sucking sucking the ball in it's also an attachment at 12 o'clock and at six o'clock at 12 o'clock you've got the long head of biceps that inserts six o'clock you've got long head of triceps.

Steps inserts so if they're loose then that affects how they work so some of those are helpers identify might identify possible pathology and a structural pathology that may, need may need surgery uh from it but but but again you know thinking about some of the tests even if we talk about you know as i mentioned about interlex internal rotation there's a good Good study done at Liverpool looking, you know, so if you test internal rotation of your humerus,

the main force producing sort of up here are going to be pec and lat. Okay, which are big global accelerator muscles. When we test external rotation, it's going to be the cuff. It's going to be a bit of supraspinatus, infraspinatus, teres minor, bit of posterior deltoid.

We've got massive muscles versus little muscles okay and we talk about how that's going to give stability the joints we can't really isolate muscles on their own and what we really want to look at if you're trying to get that balance around the cuff is is the the rotator cuff so posterior cuff infraspinatus teres minor and anterior cuff which is subscap so if you test press subscap with a belly press, you get a significantly more, this was from the study in Liverpool,

significantly more subscap than you do peck and lart. But that's not a particular vulnerable position when you're pressing on your belly from there or a functional position for it. And similarly, if you go around your back, which is Gerber's lift-off, where you lift your hand up and back, again, there's a little bit more, there's more some scat than the others. But again, it's not a position that generally is injurious to your shoulders.

Shoulders so so so we need to have some form of idea of you know what what's going on around around the shoulder and and choose our test judiciously there are some that i use regularly.

But i know that give me any that give me information about things for example yeah which so so i so one of the things that i use quite a lot i do like o'brien's test so so bring your arm into 90 degrees of flexion bring about 20 degrees of horizontal adduction and point your thumb down resist shoulder flexion now this test can give you several different results you can get if it produces pain because the location of the pain can indicate possible structures that are damaged

so if you get pain over the top of your shoulder around your ac joint it could indicate an AC joint problem if you get pain at the front it could indicate a superior labral tear cartilage tear or long head of biceps if you get pain or discomfort at the back it could indicate a posterior instability okay but then if you go into supinate and externally rotate your arm and repeat the the test and these become less negative less negative no sorry less positive that then okay Okay,

that sort of confirms that because you're winding structures up. So I quite like that, but I won't just rely on that. I will do some secondary tests to work out what's going on. That's one. You're going to have to give three on this show. So that's one test you like to use quite regularly. What else? Okay, so apprehension test is quite good. So you bring them into this position and you take them into external rotation.

And the original test is they feel apprehensive that their shoulder's going to come out of joint and if you give them a slight stability with an AP on the front, they feel better. So that's telling you they've got some anterior instability. And then, again, if we class the AC joint as part of their shoulder girdle, so again, love a scarf test, horizontal adduction inflection across the body.

What do you like with, because some of these tests will rely on kind of a numerical values given either from the patient or something noted by the practitioner in terms of stiffness or endpoint. These are all quite qualitative, aren't they? They're quite subjective. It depends on the individual. It's difficult to reproduce depending on who's got great intra or inter reliability.

But the whole question about qualitative versus quantitative, is that something that you could talk about with regards to assessment?

Okay so so again when i'm doing an assessment then what i'm looking for is what a meaningful task so what action does that person do that brings on their symptoms okay so it could be i don't take it taking the coat off it could be throwing throwing a ball it could be doing it doing a press-up and so once we've got their meaningful task or something that appropriates that that meaningful meaningful task then what i tend to use then would be improvement testing so

messing about because we sort of chatted earlier poking or stroking i will do things to try and facilitate some muscle recruitment or inhibit some some muscle recruitment kind of symptom modification sort of stuff also if we think about how the force is produced around the shoulder girdle 50% of the force that's produced around the shoulder girdle comes from the waist down 30% comes from the trunk and 20% comes from the shoulder

girdle so I can influence the activity of that 50% so I might get them to stand on one leg. OK, so just arbitrary. Stand on your left leg. Does that work better or the same? Stand on your right leg. Works better or the same. OK, I'm going to put a band around your ankles. I want you to abduct against resistance your right leg. Works better or the same or your left leg or extend.

And I will look at influencing the chain to see how we influence their meaningful task and the outcome of the meaningful task.

That's because often, you know, as we mentioned earlier about these repetitive injuries that people get, it's because it's a defect in the chain. And I do quite a bit of work of seeing some failed surgery. So people have had the reconstructive surgery from there. Generally, there tend to be rugby players that I see because of my background that consultants will send. And when I look, I will find a deficit in the kinetic chain.

You know and just by you know and the simple test that i do with all shoulders is i get them to do a a mini squat on one leg and i look for their alignment of hip knee and ankle as i do about a 30 degree squat do the hip knee and ankle stay over the top of each other or do you get that valgus collapse and the knee moving inside that the foot and that will tell me that we've got some lateral stability issues around the the pelvis which will influence the influence

how the shoulder works very interesting i like that idea that's something that people can pick up on changing or looking for symptom modification by not just the angle of the arm or anything that's quite limited there but yeah what's happening with the rest of the body can you repeat those percentages again you mentioned it's 50 so waist waist down so from sort of hips down 50 percent from waist up so core whatever you want to call it from 30 and then shoulder girdle 20.

That's very interesting you could progress and regress just by sitting down lying down taking that with that in mind that's why you need to know what their meaningful task is so because we do tend to assess people in standing in clinic but their fault might be when they're sitting doing something so we should ought to assess them in in sitting because if their fault is in city we don't really have to worry about that 50 because that's not involved so it's that

that 20 that's right that 30 which is that there's a trunk and core and this is this is something else i was thinking because you mentioned like a lot of the people you see are athletes rugby players but of course the importance of having that reactivity in the shoulder and being assessed and rehab properly is quite significant for other populations as well thinking of the elderly for example. It's really important for them. So when it comes to assessing them.

Probably it's not going to be standing on two feet for a lot of them. It's going to be an issue that is when they are seated or something or in bed or something or getting out of bed.

So it's even more important to make it a meaningful, assessment yeah you know i work with paralympic athletes so i see you know we get a lot of shoulder injuries you know yeah you know so you know working it we are working out from from them you know and how they're positioning the chair how their chairs how their chair set up as well yeah so we need to try and make our assessment as as close to what what they do now it's different you know

if you've got a javelin thrower and he's you know throwing a javelin five meters and his.

Arm's going at 10 10 000 degrees a second you can't really replicate that in your gym so you'll you'll have to look at something that might replicate their symptoms sort of and and most of the time it's if you go into abduction into elevation that will tend to be a provocative thing so we might use that in clinic and as i you know as i say to my patient we might be able to clear that in a clinic but that does not necessarily mean that when

you go back to throwing your javelin and i will say right what i want you to do now is go throw your javelin and get back to me because yes your pain's gone and you can do everything that hurt in here but you didn't come in telling me that was your pain go and throw your javelin and tell me what you like now throwing your javelin or doing your ironing or pegging your washing up or whatever it might be clever very interesting and i guess level of fatigue will come into play as

well because i mean sometimes these people only start having issues when they're halfway through their whatever never meant it is my actual race or yeah that's right so yeah you know if it's a swimmer i know and they get it at the end of a training session i say oh we'll we'll try and schedule your appointment to see me when you finish when you're in in the state so i can see see what's going on because by the time you've come to see me which is maybe two days later and you've not

swum that there's nothing for me to nothing for me to see so yeah don't provoke it and when you provoke vote you know come and come and see me that could be so tricky i mean in an ideal world i mean i. Used to do a lot of gays analysis and the situation was these people coming saying oh it hurts me after about 10 miles i'm like, mate i really need to see you after 10 miles because what i'm seeing now especially with running is going to be totally different than how you're moving and a few

people you know you're just stuffing yourself your business model a little bit in the foot because you had to have some really good therapeutic alliance to get them to go and do 10 miles and then come and see you it's like come on mate sort it out now will you but what we do so i do i clear with those we.

Put them on the treadmill in the gym and i put them on and i'll say there's a bell when when your pain comes on ring me i'm here all day literally when your pain comes on well i'll coming up a look at you yeah yeah it's nice it's it's so true it's great question people you're very quiet in the live lounge what's going on are you scribbling things down i want to hear what goes on in your clinics or when you're doing rehab or assessing or that sort of stuff i wanted

to ask you about different kind of like methods of assessment which by the qualitative or quantitative there's been a lot kind of written about one repetition max kind of thing you know that does that come into play as much with the shoulders that's something which eventually actually you incorporate or is that more for lower limb so you know as we get into the performance and so if you're thinking from a sport point point

of view once i am happy that all they've got beautiful effortless movement at different speeds on different load then they will go and work their essence for that but but what's important for me when i'm assessing force production is how quickly they produce instant force so what what we need as i sort of mentioned earlier we need this 60 to 150 milli milliseconds before they move we need the cuff just to sort of hug

a little bit i what what i'm looking to do is i'm looking how quickly they might react when i participate them give them a nudge that's what i'm looking i'm not looking at their total force force. And if we talk about some of the theory around stability of the joint, so we think about the kinetic controls of Comerford and Mottram. You know, you only need 25% of your maximal voluntary isometric contraction to get stability.

So I'm not, you know, I'm not bothered how strong you are to keep your joint stable. I want you to be able to react quickly to produce that 25% ish from there, because what tends to happen is if we produce force, then the muscles that produce force tend to produce stiffness and rigidity. And that's what changes the movement. You know, we use the bigger muscles rather than the local system from there. So often in sport, the answer to anything is make it stronger.

Now, for performance, that is the case, but not necessarily for injury prevention around the shoulder, because we know that muscles can create instability just as well as they can control it. And the muscles which are strong around your shoulder, so pec and lat and to some degree deltoid, they're too far away from their center of the joint. And they, being dominant, they start to create some instability.

Whereas our cuff, which is right next to the ball, they're the ones that work at a low level consistently to keep that humeral head within two millimeters of the center of the joint.

When it's moving at speed and and and you know 9 000 degrees a second whether you've got one and three quarter terms your body weight on it as well yeah fascinating yeah you come up with those stats it really does kind of show the chaos and stuff that's going on and they have to react so quickly yeah really interesting.

And what you've been around a long time so you've seen lots of kind of things come and go and names used and different programs but kind of functional testing has has being praised and then demonized and but when you talk about quality then i'm kind of thinking when you're looking for more of a global can they perform this movement beautifully like you say that kind of makes me think well basically we're talking more about functional testing and seeing how they can move collectively but that

sometimes gets criticized a little bit as not being as accurate because you can't distinguish what individual muscles but are you suggesting that sometimes we have to forget about the individual muscles and just look how they are performing globally yeah you know your your your your brain doesn't really register muscles it registers movement you know and and you know over the last two years a lot of my reading and study has gone more into some of the new stuff around brain training and

how it's all about accessing accessing your your brain by doing weird things and one of my courses we we do we can i can change the range of motion in somebody's arm by getting them to smell something. Hmm. I can change the range of motion by getting them to put their eyes in a certain position or put their tongue in a certain position because these affect your cranial nerves.

So if we think about, if we coach movements rather than the muscles, I think we'll be better because if we think about one of the muscles that gets trained a lot around the shoulder is serratus anterior.

Okay massive muscle of the of the shoulder blade it does everything that we want the shoulder blade to do it upwardly rotates it posterior tilts it externally rotates and it also protracts it if you do a google search now exercises for serratus anterior out of the top 10 probably eight or nine of them will be protraction exercises now i have i can't ever remember having to coach protraction for the scapula what i have to coach a lot of is upward rotation.

Okay so if i want serratus to work as a better upward rotator i have to make serratus work as an upward rotator not as a protractor with it so we if we think about the movement that we want around the around any joint but around the the shoulder girdle we that will help us help us better knowing what muscles do that is okay but we think right what what movements that do they produce what what are we lacking you know so it generally is humeral external rotation as

we go into elevation and then upward rotation or posterior tilt or external rotation of the scapula so looking at those and i'll coach those movements you know don't don't have to have emg on to see is it is it serratus that's doing that or or is it middle trap that's doing that i'm i'm watching okay is the scapula doing what i want to do and training that movement regardless of what the muscle is very interesting and yes it's great to hear professionals like yourself who

are on top of the research and everything talking about we've had a few professionals who went the vestibular training and things and how that's now being looked at a lot paul coco you've already come across in your travels he's very much into that at the moment and this course is talking about it again andrew jackson's very much talking about it as well and it's a lot of stuff's been done on it and it's um.

Yeah, it's interesting that, because once we go through so many stages, once you've kind of like reached a few decades in the industry, things just get blown out of proportion now. But I'm wondering how long it is before we go over the top with vestibular training, because it's pretty, like you say, sometimes just smelling something or, you know, just doing a movement with your eyes beforehand. It's opening up a whole, I can just see the DVDs being made as we speak.

But it is something pretty exciting and novel that seems to be filling a gap, you know, and it should be. I think in therapy, we've got a problem that we like to be on the next bandwagon, you know, and very often we get on that bandwagon and we jettison all other things because this is the new kid on the block. Now, different things work for different people. Every person you see is an N equals one. OK, and so there aren't really recipes.

You need to know what works for that patient doing that movement at that point in time. Time and and though it's a little bit more challenging i think if people certainly around.

The shoulder we discussed how people tend not to like the shoulder be a bit wary of it i think they they try and fit recipes and formulas to it but if you you know what i'm you know what i'm teaching i'd say what we're going to do we're going to some play okay we're going to try things and look at improving symptoms we're going to look at improved quality movement improved feedback back less pain better range for the patient what do we do okay what do i have to do i poke this and,

stroke that and touch this and tell you to you know change your posture things you know and work out right what do we need to do to change that and then come up with a strategy.

Great stuff brian huxley here is just i think sorry i'm looking at your comments people whether, brian says vestibular rehab very important and underused in my opinion yeah definitely i wonder know how many have been kind of using it without even realizing we're using it because when you do invent and look for symptom modification and what makes this better what makes it sometimes i think we've been kind of dipping into it already without even

realizing it but yeah definitely something people should be looking into it's one of the kind of the when people say what cvd should i doing should i be doing more of this i'm like have you thought about maybe some of that because it's probably something you haven't considered so yeah very interesting and also made me think of again game with rugby players concussion because that's obviously potentially a big area where it's been inhibited or because of

concussion and may not be involved in rehab as much as should be so yeah good point brian i like it right it's somehow it's already 8 57 nearly nine o'clock so you need my wife to come and pull the fuse i love that i love that she must know you so well yeah but uh yeah great well no what i'm conscious of is i don't want to keep you from the nine o'clock.

What there's a couple of things well i'm going to give you a little bit of a challenge which i should probably have mentioned before you came on the show but i like to try and remember at the end of the kind of 57 minutes of loads of information and tips one kind of theory into practice so thinking about our audience who are long the sports therapist they're probably seeing a lot of athletes and not athlete populations who've got shoulder issues what's

kind of one little thing that you think some people could take away from this which they could put into practice on tomorrow or whenever next week which maybe they might not be doing in the moment with regards to quality versus quantitative assessments of the shoulder so okay you don't have to answer yet but okay all right have a little think i'm gonna just refer to something i mentioned earlier on but yeah one theory into practice which they can take away i mean

some might not need it but some of them might be a great tip but whilst ian is in horses having a think about that i just got a message i was going to tell you who's won three weeks free subscription to msk mag but But actually, I've just received notes saying that we have no time to collate people together to get a draw. So what we're going to do is we're going to roll it on for another week and then we'll pull everybody together.

So obviously, people who have already done a post, what you had to do, basically, and we said it in the last week's podcast, was if you do fancy three weeks, three weeks, three months subscription, free subscription for MSK Mag, which has got, like I say, it's got some fantastic articles.

Because it's where we found Ben Wyber's article, and it's got some marvellous authors in there, which will help your therapy and everything, then all you're going to do is basically just do a post on Instagram or Facebook. Or Twitter, if you like, and tag in at UK underscore STA. It says at UK underscore STA. And just say, I'd love to win three months of free subscription to MSK Mag because I make up something which will make me laugh.

And we will put them all together, and we will get next week's guest. I mean, it was always going to be Joe anyway who was going to draw it.

It so we'll get next week's guest joe who's going to draw a name out to anybody who does that post so if you're listening to this podcast you've now got a week if you're listening to it well it depends you've got until the 30th to put a little post out there i'd love to win three weeks three months of free subscription to msk mag because i'll make sure that goes into the show notes for this one to remind you but um it's a great opportunity you might even decide you like it

and then pay what is not a lot of money per month i think it's a 10 a month to get the basic subscription for for msk mag anyway so we're not going to draw that it'll be next time back to professor ian horsley.

Theory into practice over to you okay so as i mentioned earlier i i think about considering the influence of the kinetic chain it's massive so you can see the as i say a simple thing by as i say standing on one leg seeing if that changes or standing on the other leg and see seeing how that changes adding some resistance to right hip abduction or left hip hip abduction or right hip extension or left hip extension and look one at the quality of movement and

the feedback from the from the from the patient it's really informative from that because.

It's hugely important in in how force is generated around the shoulder and movement patterns and if you oh if somebody's got an insidious shoulder injury that's come out of the blue with no known mechanism just to check about whether they've had in the last 12 months if they've had any lower limb injuries because i'm sure joe will talk about it next week they looked at a paper they produced a paper looking at professional footballers who had shoulder injuries and when

they looked through them most of them had had lower limb injuries in their year before or from there and they found a deficit in the kinetic chain that's a great that's a great take that's something people can put into practice if you've got any shoulder injuries in there assessing rehabbing just see what they can do standing on one leg or maybe with a band for some hip adducts or something great play around with it people and then

you can let us know maybe next time or you can always email questions into matt at the sda.co.uk or if you really want to comment or leave a question then the best place to go is to the sports therapy association youtube channel and stick a comment or a question in there it just stays far more alive than facebook Facebook is over once a new post appears. So YouTube stays on Google. So try and use the YouTube comment section on the Sports Therapy Association

channel to put any questions in. And I will make sure it gets answered one way or the other. Fantastic. Well, look, it's 9.02. I just wanted to bring up your website in case people will do a few links in the show notes about how to contact you.

I'm just going to bring this up on the screen. We can still hear you if I put it on full. um so worth going out to check www.backinactionlimited.co.uk so that's all the w's dot back in action limited.co.uk professor ian horsley is clinical director of back in action rehabilitation limited on twitter it's at back underscore in underscore action on instagram it's at back in action physio like i say the links will be in the show notes on facebook look up Back in Action Rehabilitation.

Loads of great information being put out there, obviously for free. So it's worth checking them out and keeping up to date. Not just on the shoulder. Obviously, there's loads of other stuff there as well. But I believe in terms of courses and things, Ian, have you got anything coming up? I do shoulder courses called Sporting Shoulder, and that's for a company called HDPPN. And I believe we are just organising one for the back end of the year.

And next, in June, I'm doing a webinar on return to play considerations for the sporting shoulder.

Older so looking at the tests that are out there and what i what use i think some of them are fantastic people want information on that can they get it from your website from back in action the best of things but i don't know about it probably a younger demographic i'm old and mostly i'm on i'm on twitter still call it twitter not x but if they contacted me through there i i respond a lot from there but but the other whatever facebook or instagram

that'll that'll get to me my secretary uh managers.

Though okay you're not yet on you're saying you're not yet on tiktok no snapchat haven't you know what we have uh our youngest member of the practices has got us a tiktok chat chat from there but i haven't seen it says tells me it is a proper thing and she's not taking the mickey on it so we'll have all right i'm gonna check that no no i'm going next check that out that'd be great fantastic yeah so and we'll put links in the notes to all of that as well in case

you want to keep in contact with professor ian horsley and what's happening there so fantastic right like i say next week is park part two if you are listening to the podcast and you'd like to come along and ask questions directly then just head along to youtube sports therapy association youtube channel or facebook page eight o'clock we can look out out the adverts and set a little reminder i'd recommend youtube normally because it's just easy to get to and and you can leave comments

in there that last for longer but yeah we're going to have episode 196 which is treating the shoulder steps to success with as i say special guest joe gibson who's a fantastic shoulder specialist and educator and it's going to be a great show and it'll be a really we'll obviously touch on some of the things that professor ian horses mentioned tonight she's in liverpool as well you're based in liverpool you both No, that's all right. I'm in Yorkshire.

No, you're in Yorkshire, aren't you? Of course. Where did I get the Liverpool link with you? I do stuff at Liverpool Hope University. There we go. That's great. But yeah, as you will hear from Joe's gracious tones, definitely born, bred and raised in Liverpool. That'll be next week in episode 196. We'd love you to join us live if you can. But if not, you'll find it on all popular podcast apps and also the live recording on YouTube.

Thank you to those of you who joined us in the live lounge tonight. Brian Huxley says, really enjoyed the session, guys. Fabulous seeing and a big thank you. And also Brian Huxley says, a fellow Yorkshireman.

Excellent. excellent let's get a little bit of bonding there and louise acre as well uh says sums it up nicely saying thank you it's been really informative gives a better way to look at the shoulder joint in rehab and thanks guys for joining us live it makes all the difference i do love just makes it a little bit unique i always like to record these things live so i appreciate it and thanks for the feedback from people who do download the podcast if

you have listened to the podcast you've enjoyed it do please take a couple of moments to leave a review and a rating because it just helps the a good word of guests like professor ian horsley get out there more it just it's directly related to what appears in google at the top so do please leave a rating particular podcasts if you'd be so kind right that just leaves me to say thank you again to professor ian horsley for giving up your time thank you very much thank you everybody and have a have

a good evening fantastic thanks guys um hopefully see some of you next week take care of each other bye. Music.