Reflections on Shoulder Pain Rehab – Expert Edition Podcast (#167) with Shoulder Physio Jared Powell

Jared Powell is a busy man – working out of Tweed Heads at Physio Place and the Tweed Health Super Clinic, lecturing in the Physiotherapy program at Bond University and completing his PhD in Frozen shoulder management. From a brief look at his insightful and entertaining Instagram account (@shoulder_physio) you’ll see that this guy knows his stuff when it comes to all things shoulder pain and rehabilitation. 

What started for Jared as a passing interest in the shoulder following graduation from Physio school, has now grown into a full-blown career. Inspired by the work of international Shoulder Physiotherapy expert Jeremy Lewis – Jared works to understand and integrate the best current information on shoulder physiotherapy management, in particular the Frozen Shoulder. 

Jared argued that clinicians (Doctors, Physios, Chiros etc) still tend to view the shoulder from a biomedical lens – explaining shoulder pain/dysfunction from a tissue and joint centric perspective, e.g. “my shoulder hurts because I’ve torn my tendon or inflamed my bursa”. Jared contended that this way of explaining shoulder pain is incomplete and unhelpful for people – disconnecting the person and their pain from significant psychosocial contributing factors. He detailed that assessing and treating psychological and social factors (e.g. beliefs, perceptions, occupation and emotions) in low back pain management has become more common practice – but slightly further up on the body with the shoulder – these things aren’t considered at all, or as much. As shoulder pain is the 3^rd most common musculoskeletal presentation to any primary care practitioner – it’s imperative that we manage it as best as we can.

For the best outcomes with rehabilitating people with shoulder pain – Jared affirmed the need for a wholistic view of the person’s biomedical factors (e.g. torn rotator cuff tendon), social factors (occupation, family, societal beliefs/expectations) and psychological factors (personal beliefs, expectations, personality traits and emotions) for optimal outcome and full return to function.  

Coming back to the biomedical side of shoulder pain – Jared categorised Shoulder Pain into four general groups:

1. Pain related to soft tissue – e.g. muscle, tendon, AC joint, labral pathology etc
2. Pain related to stiff shoulder – e.g. Frozen shoulder, Shoulder Osteoarthritis and Sinister Pathologies (cancer, etc)
3. The Unstable shoulder
4. Referred shoulder pain – pain referred into the shoulder region from the neck and chest

 What is the Rotator Cuff?

Jared states that the rotator cuff is the joint ‘Holy Grail’ of shoulder pain. Around 70-80% of all shoulder pain presentations are primarily related to the Rotator Cuff. The rotator cuff is a small group of four muscles that attach onto the humeral head (top of the arm bone) from the shoulder blade, holding and rotating the arm bone in the shoulder. The rotator cuff is almost always working when we move the shoulder – particularly in the following movements:

• Rotation of the shoulder
• Flexion (lifting the arm forward) – activates the posterior cuff (on the back of the shoulder blade)
• Extension of arm (lifting the arm behind you) – activates the anterior cuff (the subscapularis muscle on the inside front of the shoulder blade)

What can go wrong with the Rotator Cuff?

Jared categorises problems with the rotator cuff into the following:

• Tendinopathy – most common condition
  • Symptoms:
    • Pain around bony area of shoulder and down near the insertion of the deltoid muscle
    • Pain doesn’t go past the elbow
    • Pain in evening – lying on effected side
    • Exertional pain pattern – hurts if you use it, not at rest
      • 90 deg – painful arc
    • Pain with resisted rotation of the arm bone – external or internal
  • Cause:
    • Overload – reactive/degenerative tendinopathy
      • Too much in gym, garden, surfing etc
      • Emotional/psychological stress
      • Reduced sleep (Cortisol/Sympathetic Nervous System/ Amygdala relationship to pain)
    • Tears:

Image: British Medical Journal

• Partial thickness – small tears through the rotator cuff tendons as they insert into one common tendon on the bone.
• Full thickness – full tear through the complete tendon of one of the four rotator cuff muscles as it inserts into

 What does a tear mean?

Jared affirmed that tears in the rotator cuff are not that big a deal. Stats:

• Full Thickness Tear – increases every decade of our life (uncommon in 30s and 40s) more common in60s – 80s, where up to 50% of people can have a FT tear.
• You’re twice as likely to have a FT tear without pain than with pain

“You can exist well with a full thickness tear of the rotator cuff…. IF its managed well, and that’s not necessarily surgical”

Management of rotator cuff tears, as Jared stated, depends largely on the MOI: Mechanism of Injury:

• Traumatic – e.g. fall on to outstretched hand = needs orthopaedic review, does better with surgery statistically
• Atraumatic – e.g. degeneration of tendons over time, no distinct onset of pain = conservative (physio) treatment has better outcomes

‘Shoulder Impingement – a dead, and noceboic term’

Jared then confronted the ‘sacred cow’ of Shoulder Impingement as a diagnosis in shoulder pain management. Ever since Jeremy Lewis started publishing, as Jared said – he has been questioning the validity of the patho-aetiology of impingement. But what is the patho-aetiology of impingement? And what do we mean by Impingement? In 1972 – in what Jared states was a no better-quality paper than an online blog post in today’s scientific standards, a well-known American Orthopaedic Surgeon by the name of Charles Neer published a case series postulating a theory of Shoulder Impingement. The gist of his theory was that whenever you lift your arm the bony part of your shoulder (acromion) rubs against the tendons/tissue of your shoulder leading to mechanical deformation and inflammation. This inflammation/mechanical deformation was apparently more likely if you have a hooked or type 2-3 acromion (see below).

Image: Physiopedia

Jared stated that Neer’s theory of impingement survived relatively unchallenged for almost 50 years until two recent studies were published in the last 12 months. The first of these studies is the CSAW trial (Can Shoulder Arthroscopy Work) that was completed in the UK and published in infamous Lancet journal.

The CSAW trial, as Jared stated compared subacromial decompression surgeries vs placebo vs control. The study found that both Surgical and placebo groups got better at the exact same rate for the year. Fake surgery was as good as the full procedure for pain and function.

The second of these studies was the FINPAC study – conducted in Scandinavia – published in British Medical Journal (another prestigious journal where only the best quality scientific research is published). The FINPAC study included an exercise group in addition to the surgical, placebo and control groups. It confirmed the findings of the CSAW trial: There was no difference between surgical and placebo surgical groups followed up for 2 years post op. The exercise group clinically got better at almost the same rate – but statistically didn’t do as well.

The term “Rotator Cuff Related Shoulder Pain”  (RCRSP) – postulated by Jeremy Lewis as a more proper diagnosis.

Management of RCRSP:

• Physiotherapy + Strength & conditioning exercises are the best management for RCRSP
• 3 month time frame – patience and clear expectations are required
• Tissue capacity changes through progressive loading

 Jared stated that in a 5 year follow up study – exercise vs sub-acromial decompression surgery: people get better the same rate. Therefore, exercise is the best treatment option for RCRSP we know – it’s cheap, easy and relatively simple to implement under the guidance of a relevant health professional.

“Be patient – it’s going to take time” – Jared Powell

But what exercises? And how much. Jared answered this by saying that any shoulder resistance exercise will get people better – as long as its something that:

• Someone wants to do
• Knows how to complete confidently
• Is progressively loaded

It doesn’t have to be complicated – Jared states that no exercise is better than another from what we know. It just matters that it is done, and that it is progressed.

What about Injections for Shoulder Pain?

• Corticosteroid injections aren’t very good for subacromial/ rotator cuff related pain
• “one in five injections for people to get better more than a placebo – and that effect is lost entirely for 3 months”
• Corticosteroids can retard the healing process and retard the tendon – from a catabolic process
• If the person is older >45-50 years of age and has low demands on their shoulder it may be useful to relieve pain

Frozen shoulder Management

 “Commonly over diagnosed and misunderstood condition”

Jared states that the easiest diagnosis of Frozen Shoulder is = equal restriction between active (how much you can actively move your shoulder joint) and passive (how much your shoulder joint can move with extra pressure/stretching) movement. He also said that in frozen shoulder there is a classic rotation and abduction (<60 deg) range of motion Other conditions Frozen Shoulder can masquerade as:

• Glenohumeral osteoarthritis – insidious onset, pain is less severe, slightly more movement
• Locked dislocation – needs X-ray to confirm
• Malignancies in the shoulder joint can present like a frozen shoulder

“Everyone with suspected frozen shoulder should get an X-ray” – Jared Powell

Prognosis & Management of Frozen Shoulder

“No evidence that frozen shoulder resolves by itself, organically after 2 years” – Jared Powell

Jared then broke another and more renowned scared cow stating the above quote – that the time frame and stages of frozen shoulder are equally a myth. Frozen shoulder is not something that ever resolves by itself – and if it is left to, it can progress to a persistently painful and disabled shoulder. It does much better if actively treated with the options he stated – listed below:

• Interventions that reduce time course:
  • Intra-articular injections – better than doing nothing
    • Hydro dilatation (high volume 40ml)
      • 1-3x injections – depending on the individual
    • Low volume injection (corticosteroids)
    • Subacromial injections
    • Pain > stiffness = low volume injection
    • Stiffness > pain = high volume injection
  • Get the arm moving – how they can
    • Minimise muscle atrophy and kinesiophobia (Fear of movement)
    • Progressive strengthening/loading as able to
  • Manipulations under anaesthetic and capsular release surgeries don’t work that well and are only last resorts

• Classic Quick Frozen Shoulder Demographic Facts:
  • 40-60 years of age – most commonly affected age group
  • In Japan – it’s called the 50 yr old shoulde
  • Slightly more common in women than men (~55% women)
  • 30% of diabetics will go on to develop a frozen shoulder
  • T1 diabetes – 70% chance of developing frozen shoulder
  • Associated with hypothyroidism and Dupuytren’s contracture
  • 70% we think are idiopathic – no known cause
  • Secondary frozen shoulder types/aetiology
    • Intrinsic: Long-term rotator cuff pain
    • Extrinsic: neck pain, collarbone fracture etc
    • Systemic: Diabetic, hypothyroid, long term hypertension populations

  Finally a last bit of advice from Jared:

If you are experiencing shoulder pain:

“Exercise it – move it. Nothing works as well as Exercise”

Jared states that exercise is not just a physical intervention – we are trying to develop a resilience/capacity of the shoulder to tolerate the load they want through the shoulder. You just can’t rest, inject or rub shoulders better.

Find Jared on Instagram @shoulder_physio – for digestible shoulder knowledge bites & also check out his website and mailing list on www.jaredphysio.com for monthly literature reviews

 

 

Oliver Crossley (APAM) POGO Physiotherapist

Book an appointment with Oliver here

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