Shoulder Instability: An Introduction

I love the shoulder joint, its a marvel of evolution, a unique structure within the human body, it is the most mobile joint we have, no other joint can match it in the degrees of freedom it has. But, this mobility comes at a price, a reduction in its stability. The shoulder joint has to constantly maintain a balancing act between the two and sometimes this balancing act can go wrong, in both directions, with shoulders either losing their mobility and becoming too stiff and restricted, but what we are going to look at now is when they go the other way and lose their stability.

Before I begin, lets talk about the terminology and classifications used when describing shoulder instability. When a shoulder is unstable it can dislocate, this is the complete separation of the ball of the shoulder, called the head of the Humerus (HoH) from the socket, called the Glenoid. An unstable shoulder can also sublux, this is slightly different from a dislocation in that its a partial and temporary slip of the ball off the socket. Finally an unstable shoulder can give sensations of instability without any physcial seperation of the joint this is termed apprehension.

Within the orthopaedic world the terms TUBS and AMBRIs have been widely used, and still are in some circles, when diagnosing unstable shoulders and you may have come across them despite the evidence now highlighting that these classifications are no longer useful.

TUBS stands for

• Traumatic
• Unilateral (one shoulder)
• Bankart and Hill-Sachs Lesions (bony injuries that I will discuss later)
• Surgery

AMBRI stands for

• Atraumatic (no trauma)
• Multidirectional (loose in various planes)
• Bilateral (both shoulder affected)
• Rehabilitation
• Inferior capsular shift (if rehab fails)

These terms are way too simple for the complex area of shoulder instability and they don't account for all types of instability. When these classifications are followed it has, and does, often lead to failures in surgery and management and can actually make matters worse for some unstable shoulders.

So I, and all those who I work with use the Stanmore Triangle Classification System when describing shoulder instability, and I highly recommend you do too, this is an excellent way of diagnosing unstable shoulders and planning their management. It was designed by Mr Ian Bayley FRCS and my mentor in all things shoulders Mr Simon Lambert FRCS, two of the countries top specialist shoulder surgeons at the Royal National Orthopaedic Hospital Stanmore, Herts.

Stanmore Classification of Shoulder Instability

The Stanmore triangle uses three classes of shoulder instability, based around if a shoulder has structural or non structural issues that are contributing to the instability, with a third classification for adverse muscle patterning, they are as follows

TYPE I Traumatic structural • significant trauma • often a Bankart’s defect • usually unilateral • no abnormal muscle patterning, (ie: your classic sporting injury)

TYPE II Atraumatic structural • no trauma • structural damage to the articular surfaces • capsular dysfunction • no abnormal muscle patterning • not uncommonly bilateral, (ie the classic recurrent dislocators when doing normal or sporting activities)

TYPE III Habitual non-structural (muscle patterning) • no trauma • no structural damage to the articular surfaces • capsular dysfunction • abnormal muscle patterning • often bilateral, (ie the rarer more complex shoulder with multiple factors)

Now depending on where within the triangle a shoulder lies in this classification system the management can be planned, there is also scope and flexibility for merging of the classifications for those shoulders that don't neatly fit into one of these boxes, which most humans don't, for example it can incorporate shoulders that have had a trauma (ie Type I) but who had a pre deposition to instabilty due to the structure of their shoulder (ie Type II) so this can be called a Type I/II shoulder. Or perhaps a Type III/II shoulder which are those with muscle patterning issues, but have had multiple episodes of dislocations leading to structural changes over time. For more information on the Stanmore Classification of shoulder instability please read this paper.

Now as shoulder instability is a massive area for one article so I am breaking it down into more manageable pieces, this is just a brief introduction into the anatomy of the shoulder with some truths that aren't found in the anatomy textbooks. Each follow up post (there will be three) will look at each 'Polar Type' on the Stanmore classification system in further detail and its subsequent management.

As I mentioned at the beginning the structure of the shoulder has a balancing act to maintain between the roles of mobility and stability, first lets talk about the bony shapes and alignment of the shoulder joint and how these help or don't in shoulder stability.

The ball of the shoulder (HoH) is massive when compared to the shoulder socket (Glenoid), with only about 30% of the HoH in contact with the Glenoid at any one time, for a visual representation think of a golf ball on its tee, and then imagine the golf ball needing to stay on that tee when held horizontal!

To increase the size and depth of the glenoid and help hold the HoH better onto it there is a ring of cartilage called the Labrum that encircles joint. This is triangular in cross session and can increase the HoH contact area by an extra 20%.

There is however vast anatomical difference in individuals shape size and positions of both the gleniod, the humeral head and the labrum. The gleniod can be a variety of shapes and sizes and can be angled in varying tilts, read here for more info. The HoH can also be varied in shape and angled differently from person to person read here for more info, and finally the labrum can be thicker or thinner in various areas read this if you really want to bore yourself silly. These variations all make some shoulders more akin to patholgy and also instability than others read this for more info.

Variations in Gleniod shapes

Next is the joint capsule, the fibrous tissue 'bag' that surrounds the whole joint, its primary role is to contain the synovial fluid which nourishes the joint surfaces, but it also helps a bit with the joints stability as it produces a negative pressure within the joint, which through hydrostatic pressure helps suck the joint surfaces together, think of when you try and get a glass slide off a wet table. Yet again the capsule has vast anatomical differences with some capsules being much more baggy or capacious than others. Are you beginning to see a pattern yet? The text books don't tell you this do they, we aren't all built the same, in fact no two or us are, variation in anatomy is just human!

Blended within the capsule are a group of thickened sections which are classed as the glenohumeral ligaments, these are called anteriorly (on the front) the superior, middle and inferior glenohumeral ligaments and posteriorly (on the back) the inferior glenohumeral ligament, but yet again there is vast anatomical differences with the ligaments with some having larger and thicker ones than others, some even have ligaments completely absent, again read this if you want more detailed info.

Finally we have the muscles of shoulder, first the rotator cuff group of muscles made up of the supraspinatus superiorly, the subscapularis anteriorly and the infraspinatus and teres minor posteriorly, these are responsible for holding the HoH snug against the Glenoid when at rest, this is termed passive stability and helps contribute with all the other above mentioned passive structures ie the labrum, capsule and ligaments. When the other muscles of shoulder ie the Deltoid, Pecs and Latissmus Dorsi etc move the arm around, the rotator cuff work to hold the HoH centred on the Glenoid, this is termed dynamic stability, again some vast variations can be found in the rotator cuffs strength, timing and synchronicity leading to shoulder instability issues for some, and even adverse muscle patterning with any of the other muscles that act on the shoulder also creating shoulder instability, but more on this in later posts.

So in conclusion for this brief introduction into shoulder instability we can see that there is wide variation in shoulder structural anatomy and that some shoulders are just more predisposed to instability than others. We can see that using the Stanmore Classification of shoulder instability we can cover all types of shoulder instabilities and it gives us flexibility when co concurrent pathologies and causes of instability exist.

In my next post I will be talking about traumatic shoulder dislocations and the subsequent instability that can occur as well as the treatment and management of them, so please watch this space.

As always thanks for reading

Cheers

Adam

 

What is the best way to treat a painful Sacroiliac Joint?

So in my earlier post here I talked about what is the best way to assess 'IF' the Sacroiliac Joint (SIJ) is a source of pain, which it very rarly is, and that using palpation tests to try and determine that a SIJ is dysfunctional have been clearly shown to be unreliable and of no use. This created a flood, well ok, a little ripple, of comments and discussions with some still claiming that they can feel the SIJ and that palpation gives them some useful information in which to direct their treatment.

So from this article, many, well ok, one or two people have asked how I treat a painful SIJ, so this is the subject of this post. Now again I'm sure this will create some discussion and some controversy, so please feel free to comment and give me your experiences and insights but please keep it personable, for some reason the SIJ seems to get therapists fired up more than any other area, I'm not sure why???

Ok let's go…

The first thing to say again is that the SIJ just doesn't cause pain as often as many think, I can count on the fingers of one hand (maybe both) how many I have 'treated' in my career, I do get lots of patients coming to me saying that they have been told they have an SIJ issue/problem, some have even been told by other therapists that their SIJ is out or alignment or unstable, which is complete rubbish, but when I assess it as described in my earlier post, there is rarely any positive pain responses, its normally something in the lower back generating the pain, and often there is no firm or conclusive structural source of the pain, this is whats call 'non specific low back pain' and it can be frustrating for both the patient wanting a diagnosis to why it hurts, and also for the therapist wanting something meaty to give as a diagnosis and to treat, this is why I think the SIJ gets blamed way too often, as therapists love to give out meaty impressive sounding diagnosis…

A very recent study by Cohen et al 2013 states that the SIJ accounts for between 15-30% of all low back pain! I'd argue this is much less, now this maybe due to my 'normal' clientele being slightly different from the study's. Prevalence studies on SIJ pain seem to show higher levels of SIJ pain are found in less active females and obviously in those during and after pregnancy, as well as those with inflammatory conditions and those with elderly arthritic changes.

Ok! So I've found a rare SIJ that is causing pain, what do I do?

Well simply, I get them all doing exercises, great thanks for reading….

 

 

WHAT… WAIT is that it??? I don't I poke, prod or manipulate them, don't I give an anterior innominate rotation thrust or a posterior torsion mob here and there….

Well very, very rarely and if I do its NOT to change or alter its position and its definatley not to 'loosen' or free it up, let me explain why.

Firstly if we look at the anatomy of the SIJ closely, as in this paper by Vleeming et al 2012 does very well, we can see that the congruity of the bony surfaces combined with the many strong ligaments that cross it make the SIJ a very, very stable joint, it has to be, it transfers lots of load from the legs to the trunk and visa versa, this is termed the SIJs form closure ie its shape and structure.

However, the joint also requires the contraction of muscles around it to help restrict the small amount of movement that is available at the SIJ to ensure that it doesn't move to allow effective transfer of stresses across it, this is what's called force closure, read more in this paper from Wingerden et al 2004. Basically the SIJ wants to be stiff and stable but it also needs to move a little bit occasionally.

Now the main reasons that the SIJ is thought to cause pain is either due to excessive movement causing shearing forces between the joints articular surfaces, I use the word 'excessive' here with care, as although the SIJ is a joint and it does move, it doesn't move much at all, on average about 2 degrees, and about a millimetre or two of movement, but it is still thought to be enough to create irritation and wear and arthritic changes.

The other reason its thought to cause pain is that the SIJ becomes stuck or jammed and the little bit of movement that it is supposed to have isn't available and so creates pain.

But are these theories correct!

Now thanks to Greg Lehman an excellent physio and chiropractor and an ex researcher with Stu McGill (he of the papers that have done so much for our understanding in low back pain and stability exercises) Greg has very kindly shown me that actually we can't say excessive shearing, extra movement or laxity at the SIJ causes pain. (Follow Greg here on twitter, and go visit his excellent site here)

This paper here by Damen et al shows that SIJ laxity which is common during and after pregnancy isn't correlated with SIJ pain, they found pregnant women with moderate or severe pelvic pain had the same laxity in the SIJs as pregnant women with no or mild pain.

Also the forces need to produce force closure on the SIJ are not very much at all and actually most muscles around the trunk when they activate even gently create enough force to close the SIJ as shown by this study here by Richardson et al So to say that an individual is having SIJ pains as they dont have enough strength to stabilise or force close the SIJ can't be correct either, if they didn't have enough strength to close the SIJ they wouldn't have enough strength to stand or sit upright either and wouldn't be in front of you complaining about their pains!

So if not shearing forces or weak muscles causing the SIJ pain, what about it getting stuck or not moving enough?

Well I question if this is even possible, and if it is, how do we know its stuck, and why does it occur? I have already discussed in my other SIJ article that there is no way of palpating or feeling a SIJ move or not move so we can never tell if its stuck. If you haven't realised yet I'm a skeptic and like to keep things sensible and rationale, and a too stiff or stuck SIJ just doesn't make sense to me, the SIJ wants to be stiff and rigid, if its too stiff why would that cause pain? And how on earth does it become jammed, does something gets stuck inbetween the joint, highly unlikely in my opinion.

So if not due to excessive movement and not due to it being stuck then why does then SIJ cause pain? Well simply I think its just due to overload and excessive stress across the joint that it can't handle and so irritation and nocioceptors around it complain, as simple and straight forward as that, no excessive this, no stuck or stiff that.

So how do we treat it?

Simple, as I said earlier, exercises, to build up the joints resitance to take an increased load by increasing the muscles endurance capacity in and around the SIJ and those that act and influence on it. Which muscles you choose to do will be based on individual assessemnts but in a nut shell I dont think it matters too much, as we know from earlier that all the trunk muscles have a role in producing SIJ force closure, but the muscles of the posterior oblique sling are probably the ones to focus on more, namely the Latissmus Dorsi, Hamstrings, Glutes and of course the large powerful Erector Spinae muscles all of which act on the thoracolumbar fascia.

Image courtesy of saveyourself.ca

How you go about this is up to you, it is obviously guided by the levels of pain the patient is in, if really sore, then non weight bearing strengthening of these muscles can be used to start with until the irritation settles combined with other pain relieving modalities (which I will come onto in a second). If they're not too painful then progress them into weight bearing exercises, progressing them until you can get them exercising these muscles under extra load, in different planes and speeds dependant on what that patients goals and tasks are, and I won't be giving away all the exercises possible or we will be here all day!

But what about manual treatment?

Well I'm going to throw in a controversial bomb here and say that although you can apply manual therapy treatments, of which I do occasionally, it really doesn't matter in my opinion WHAT manual treatment you do for a painful SIJ!!! (I await the backlash)

Yes you can apply an anterior or posterior innominate rotational mobilisation or a scaral thrust or two, even give some ASIS distractions or compressions etc, etc, as there is in my opinion, NO physical way you are really going to make any structural difference to this emmensly strong and stable joint with your hands, steam roller yes, hands no! Even if you do affect the SIJ a tiny bit, as soon as the patient moves to get up off the treatment couch and stand up it will go back to where it wants to and started off in the first place, so what's the point???

Well there is some point, I'm not implying manual treatment of the SIJ is a waste of time, far from it, it does reduce the level of pain for grumbling SIJs, it seems to when I do a bit of pushing and pulling there, but what I do argue with is that it doesn't make any difference what or which way you do bounce, rub or push on it, as its not the physical effects to the joint that matter, its more the descending neural pain inhibition effects that do. As Steve a fellow physio in Sheffield said recently, it doesn't matter what you rub or prod people with it will help, he uses organic cucumbers apparently!!!

But surely there is some role for the direction of pushing or poking or even the exercises we give depending on what you feel and observe the persons posture or degree of pelvic tilt/rotation to be?

Well again I'm going to throw in another controversial bomb in here (two in one post) and I say NO, it doesn't matter if someone stands with an anterior rotated pelvis compared to a posterior rotated one, or even if one side is higher than the other!!! (I await an even bigger backlash on this one!!!) and possibly just possibly I might releant on on the 'one side being higher than the other one' if due to a leg length difference, but it has to be a significant one eg 15-20mm different before I'll consider it. This paper by Preece et al 2008 on pelvic morphology just sticks in my mind when assessing the pelvis that bony landmarks are so unreliable.

Anyway, so I do push, pull and poke painful SIJs but with no real clear idea or direction in mind, I do it on trial and error basis. I push a bit this way, get them up and moving a bit, ask if it feels any better, no, ok get them back down, push the other way etc etc.

Now some may say that this is due to my lack of skill or experience or that I haven't got expert super duper 'feely' hands or some extra perspetory skills that some other therapists have! I say nope that's aload of crap, it's just me being realistic in realising no-one can clearly say they can tell which way a SIJ needs to go or which way is going to help, so why limit yourself and possibly miss helping someone out of pain just because of some rubbish tests and personal pride, push that bugger in all directions until something feels better for the patient, simple!!!

But is there such a thing as a bad pelvic, lumbar posture?

This really is a discussion for another post but after years of assessing postures and telling people to stand or sit this way or that, or that they are in pain due to this part of them being over here instead of over there, I have realised that it probably doesn't matter that much.

After looking at 1000's of bodies in my career one thing I can say is that the human body is so varied and never symmetrical especially the pelvis. I see as many people with anteriorly rotated hyper lordotic postures as those with posteriorly rotated hypo lordotic postures, all get as much or as little problems. So is there such a thing as an ideal normal posture, I'd argue NO, this is paper by Lederman 2010 that I urge you all to read talks about the downfall of the postural structural biomedical assessment model that us therapists use and how it actually doesn't seem to fit in with our understanding of the body and research anymore, and raises some interesting points and questions about what we thought we knew.

So is it time for a change in the way we look at movement, the human body, musculoskeletal pains and therapy, I do think so!

So in summary I'd argue the only way to treat a true and rare painful SIJ is with exercises for the muscles in and around the the trunk to increase the resiliance of the SIJ to withstand load and stress across the joint. The exercises you choose I don't believe make much difference but should be chosen depending on the level of your patients pain, irritability and skill. They want to be progressed into loaded, multi directional and varying speeds, dependant on your patients goals, tasks and activity. Manual therapy can be used to relive a painful SIJ but not on the pretence that you are affecting the physical properties of the SIJ or that you can only try it in one direction after an assessment as you can sense or feel the dysfunction, and finally that most of the pain reliving effects from said manual treatment are via descending neural pathways.

Finally does assessing the posture of the SIJ pelvis and lumbar spine of an individual really help us, or does it just place confusion and doubt into the patients mind for no reason when there is scarce evidence to say that any type of posture is of greater risk or worse than any other?

Food for thought I hope???

Once again thanks for reading

Happy exercising

Adam

 

 

Rotator cuff tears: cables and crescents?

So a tear of the rotator cuff is pretty disastrous, right? It means surgery, right? Well NO it doesn’t! As our understanding and knowledge of the shoulder joint improves so does our ability to recognise those cuff tears that are going to do ok without the need for surgery, let me explain more.

It has been well known in the medical world for quite sometime that there are a lot of people out there with tears in their rotator cuff tendons functioning normally with no pain and not even aware of them. Templhof et al back in 1999 published a study that checked the shoulders of people with no pains or reported problems, and 23% of them had cuff tears! Thats nearly 1 in 4!!! However, this study was done on the ‘older’ generation ie 50 years old and onwards, and they also found the older you are the more likely you are to have a tear, no real surprise here I guess, but what is surprising is the numbers, over half of all the 80 year olds they looked at had tears but no problems!

So its fair to say the older you get the more chance you have of cuff tears, but there is also a high chance you maybe blissfully unaware of this, great!

This anomaly of tears in the rotator cuff with no symptoms isnt just seen in the older generations either, it is also seen in younger and more sportier people too, Conner et al showed 40% of elite over head athletes have rotator cuff tears with no reported problems, even better!

So why is this? Why are there so many people out there with tears in the rotator cuff functioning normally, and what can we learn from those that have tears with no pain or loss of function.

Well first we need to look at the location of the tears in the cuff, although the cuff works synergistically together and needs balance in all areas, some parts of the cuff can be classed as more important than other parts in terms of structure and function.

To help with working out which parts of the cuff these are we have to think of the superior rotator cuff as a suspension bridge! Confused? Let me explain more…

Burkhart et al, first used this description when he described a thickend section (nearly 3 x as thick as the rest of the cuff) in the supraspinatus and infraspinatus tendons, which he called the cable, in front of this was a thinner poorly vascularised section of the cuff, which he called the crescent. He explained how the cable can ‘bypass’ the crescent and tranfer load between the anterior and posterior portions of the cuff and so ‘shield’ the crescent in front of it. Just like a suspension bridge cable carries the load from one pillar to the other across a span. See the images below

B= crescent C= cable S=supraspinatus I= infraspinatus BT= biceps tendon

So a tear in the ‘crescent’ area of the cuff can be thought as not too much of an issue functionally for the shoulder, as the cable behind it can continue to take and distrubute the load and tension between the anterior and posterior rotator cuff. These means the superior cuff can continue to dynamically stabilise the humeral head and prevent superior humeral head translation on arm movement. However, if the tear goes through or is behind the ‘cable’ of the cuff this means the superior cuff cannot comminicate effectivly with the anterior and posterior sections and so as the superior cuff weakens it cannot balance the forces on the humeral head and so it can translate superiorly and compresses under the subacromial arch causing pain, irritation and even stopping the arm from lifting completely, called pseudo paralysis.

Now the crescent area of the cuff is thought to be where most cuff degeneration starts due to its poor vascularity and also due to the high demands placed on it in depressing the humeral head against the opposing force of the deltoid as the arm raises. This means there is a good chance that most superior degenerative cuff tears start here in the crescent. However, if the tear settles and stabilises and doesn’t progress through the cable then the shoulder can happly function as normal. It is these cuff tears that the above studies see in people living normally with no pain or loss of function. However if the tear progresses and or is large enough to go through the cable, these tears cannot function well and suffer limitations in activity.

So how do we know if the tear is in the crescent or the cable?

Surely the amount of pain in the shoulder gives us a clue if its small or large cuff tear? Well actually NO I’m afraid not, pain is bad indicator of the amount of cuff damage, in fact it has been found that smaller partial cuff tears can be MORE painful than bigger tears? Gotoh et al found that when the cuff tendon is only partially torn it releases more pain chemicals that when fully torn, also Carr et al found that its more likely the bursa above the cuff that generates the pain than the cuff tear itself due to its rich innervation further confusing the picture. Anecdotally I have seen small tiny cuff tears make fully grown hard men cry like babies, and conversely seen massive huge cuff tears produce very little discomfort, so as a rule, pain just cannot be an indicator of damage or a prognosis of outcome.

So if we can’t use pain what about function, well yes this does help inform us if there is a crescent or cable tear. Pseudo paralysis or what’s called a drop or lag sign where you can’t hold your arm in certain positions does tell us that the cuff is badly torn with cable involvement. BUT don’t jump the gun, I have seen pseudo paralysis in shoulders in the first acute stages of small partial crescent tears that can resolve spontaneously within a few weeks just due to the pain levels.

So really the only true way of knowing if a cuff tear is affecting the crescent or cable, or both, is through imaging or directly looking at it via arthroscopic (keyhole) surgery. MRI is usually the best way of visualising the exact location of cuff tears, as well as the quality of the muscle behind the tear, important in deciding what type of surgery will or won’t help. Ultrasound scanning is also useful for looking at the rotator cuff, its quicker and cheaper to use, but it can be tricker to interpret and you cant always see all the bits you want to. I have been using ultrasound scanning in my clinics for over three years now and I’m still learning and still often send for an MRI to confirm what I think I may have seen. Although a lovely little paper by Morag et al that I found this week shows that with care and skill using an ultrasound scanner the rotator cuff cable and crescents can be seen.

So in summary, if you perosnally have, or see a patient with shoulder pain and think it maybe a rotator cuff tear, don’t jump the gun and don’t think it automatically needs surgery, it needs investigation to determine if its in the crescent or cable combined with other factors before a prognosis can be made. Also remember a lot of rotator cuff tears can settle and manage very well with very little intervention. And finally remember that pain levels and cuff tears are completely unrelated.

As always thanks for reading

Happy exercising

Adam

This is article is intended for information purposes only, if in doubt please consult your doctor or physiotherapist for further advice.

What is the best way to reliably assess the Sacroiliac Joint?

Within the therapy world the assessment of the Sacroiliac Joint or 'SIJ' as its commonly known, is a fiercely debated area which can cause heated discussions between therapists, as I recently found out when I posted a comment on Twitter a week or so ago stating that I was surprised by some therapists still using palpation and what I assume to be outdated tests for assessing its movement and position, and then using this information as a way of diagnosing dysfunction and pain. After some heated, RSI inducing tweeting, which ended up with one tweeter calling me a 'critical arse' forcing me to write another post on critical thinking (see here), I decided to do this post on what the evidence, as well as my own clinical experience, is telling us about the assessment of the SIJ.

Now maybe I am a bit biased against the SIJ as for me it has always been one of those areas I never did like, right from when I was a fresh faced student physio many years ago. I can recall being in classes having tutors tell me to press here and here on one of my buddies backsides and then saying 'can you feel that counter nutation of the sacrum', or, 'do you feel that blocked left sided innominate'… 'errr yeah sure' i'd reply sheepishly with a bemused look on my face, but to be honest all I felt was skin and some bony bits and not much moving anywhere at any time! But everyone else around me seemed to be getting it, so I kept quiet and prodded a few more times and dared not question anyone (oh how things have changed).

I persevered with this SIJ assessment stuff and thought that I just needed to get my 'eye in' which would happen once I get my hands on some more SIJ's… I didn't. So a few years after graduation I went on a very well known SIJ post graduate course hoping this would make me an SIJ assessing machine… it didn't.

Instead I now had to deal with a 'Mr Sacrum' (yep I still got the laminated card) with 6 planes of movement including rotational and twisting movements that I was supposed to be able to detect. I had days of pretending I was a sacrum with my arms up out to the side twisting this way and that, as well as pressing lots more backsides (some nicer than others) and people asking me again if I could feel this and that, but yet again all I got was skin and bony bits and a sinking despondent feeling as everyone else around me seemed to be feeling things I just couldn't, with shouts of joy ringing out when they felt an anteriorly rotated innominate or even an upslip here and there.

What was going on!!! Was I just a ham fisted numpty that couldnt feel anything???

Well, no actually I dont think I was, rather just perhaps more realistic and cynical in what I can feel with my hands and maybe not succumbing to the tutor lead palpatory pareidolia, I always was, and still am hard to convince (some call it stubborn).

But, I'm not alone in this, there is evidence that palpation of the SIJ has been found to be very unreliable and shows poor inter-tester reliability. Holmgren and Waling showed that four common static tests used to detect asymmetry is of “doubtful utility“, and a very interesting study by McGrath questions the ability to detect the commonly used bony landmarks stating “the continued use of manual diagnostic palpation as a basis for manipulative intervention is questionable” . Finally a study by Preece et al highlights the vast anatomical differences there are in the human pelvis and that variations in pelvic morphology “may significantly influence measures of pelvic tilt and innominate asymmetry“

So it seems that by just feeling for the SIJs bony bits you are not going to gain any useful information, just as I've always found. But what about those claiming they can feel it move or not move!!! Well again I couldn't and still can't, and I do (quite often) question those that say they can, hence my tweet last week getting myself called a “critical arse”.

We know that although the SIJ is a joint and it moves, it doesnt move much, in fact it moves just a few degrees, equalling just a few millimeters of actual movement. Goode et al shows at max its about 8mm of movement, realistically its less than this with average movements being quoted as around 2-3mm.

Three good papers look at the commonly used movement assessment tests used in 'feeling' SIJ movement ie the Stork, Gillet's etc, two from Freburger and Riddle here and here both showing poor inter tester reliability, low sensitivity and poor specificity, and another by Robinson et al confirming the other two studies, so basically confirming you just cant reliably feel the SIJ move or not move… phew I'm not a ham fisted numpty after all, well perhaps for this.

So combine poor palpation reliability and very small movements and I hope you can see that assessing the SIJ's movement with touch is in my opinion, as well as that of the research, implausible and delusional, and yet the techniques are still popular and many claim they can. I do find this a lot in this industry, therapists desperate to hang onto something they feel works for them even in the face of over whelming evidence and sometimes just plain old common sense.

So where does this leave us therapists, and you patients who may also be reading this as well, in trying to assess possible SIJ problems? How do we know if an SIJ is causing pain if we can't palpate it, feel it move or not?

Well there are tests we can do, in fact its more a group of tests and it doesn't involve trying to palpate microscopic movements here and there. These tests in conjuction have been found to be so much more reliable and sensitive in determining IF an SIJ is causing pain rather than trying to determine if its moving too much or too little, or its twisted this way or that, which doesn't really matter if its not causing any pain.

First is just using the location of your pain, Van der Wurf et al showed that you can possibly predict an SIJ issue if the pain is located in whats called the 'Fortin' area but NOT in the 'Tuber' area see below image

However you can't just use the location of the pain alone, we need other tests to confirm the SIJ is an issue. Laslett et al seminal paper along with another by Van der Wurf et al shows that there isnt one stand alone test but rather a combination of 5 tests and if you have a positive sign on 3 or more then there is a 85% sensitivity and 79% specificity for saying the SIJ is the issue.

These tests are

1. Gaenslen torque test
2. FABER's (Patricks Test)
3. Femoral shear test
4. ASIS distraction test
5. Sacral thrust test

For video demonstrations of these tests check out the this Youtube site with them all on.

I would also add to this list the Active Straight Leg Raise or ASLR test as it has also been found to be validated to highlight pain from the posterior pelvic area here

So in summary I hope you can see that by trying to assess an SIJ by its position and movement or lack there of, or even just its resting location using palpation tests you are barking up the wrong tree and will not gain any useful or relevant information, in fact it can lead you down the wrong road of treatment completely. Just because a SIJ is slightly this way or that compared to a so called 'normal' SIJ, whatever that is, doesn't mean its a source of dysfunction or pain, and that goes for any joint/posture!!!

I would ask that if you are a therapist that still uses palpation test to assess the SIJ to strongly question your reasons for doing this and look at what the evidence is telling us, and STOP. If you are a patient with a suspected SIJ issue and you have a therapist palpate your SIJ claiming they can feel it move or not I would question them why they are doing it or just walk away.

I'm sure this will create some mixed feelings as it did last time I mentioned it, please feel free to comment and discuss the issues I have raised but remember be polite, curtious and respectful, after all I have reflected and feel that actually im not a critical arse… most of the time

Once again thanks for reading

Happy exercising

Adam

 

Critical thinker or just an arse?

Critical thinking is not just being critical, and just being critical is not critical thinking.

I have decided to write this short piece on this subject mainly so I can reflect on what critical thinking is, and to ensure that I am doing this and not just being a 'critical arse' which I have recently been accused off when commenting about some rather dubious treatments used in the therapy world!

Critical thinking is something we should all be doing daily, hourly, especially in this line of work when there is very little good quality evidence that allow us to make firm decisions on the best treatment options for our patients. We should not just accept that something works or accept that we understand the mechanisms behind it due to others saying so, or even because there are some fancy research papers on Google Scholar or PubMed that say so, research can be of extreme variability in quality, and results manipulated to suit a cause. Finally im afraid we cant say something works based on your own observations and results in clinic as this is highly bias and without knowing it can and does lead clinicians astray, blinded by their own beliefs.

Critical thinking can be defined in many ways, I like this one…

“The intellectually disciplined process of actively and skillfully conceptualising, applying, analysing, synthesising or evaluating information from, or generated by, research, observation, experience, reflection, reasoning, or communication as a guide to a belief and action”

Being critical on the other hand is defined as…

“Being inclined to judge severely and find fault”

Thats just being an arse… The key to separating the two is the combination and use of good quality evidence from multiple sources as well as observations and experiences to inform a decision or action, a critic wont have these!

The 'critical thinking community' is an excellent site for reading more on what critical thinking is or isn't and how it should be used and I recommend everyone stop by and have a read.

Believe it or not I am open minded, or at least I like to think myself as being so. I am willing to adjust and change my practice and treatment, and I have done so many, many times throughout my career. What I do in my treatment sessions today is so different from 10 years ago its almost unrecognisable, and I beleive that what I will do next year will be different from now.

However to change my practice I will not just go on the say so of one or even a few people, in fact I won't change my practice even if the majority says I should. I need two other things 1) evidence, not conclusive nothing ever is, but strong good quality evidence and 2) time to experience and observe it myself, this is not being stubborn or arrogant, just reasoned and cautious, I like this diagram of how research, experience and practice should work together.

Unfortunately though, through this adjustment process it usually involves me discarding treatment techniques rather than adding new ones, for example I no longer apply acupuncture, cervical manipulation, ultrasound, fascial release, ITB stripping etc etc as these I find offer no benefit to my patients in our time together and nor does the research support either the proposed mechanisms or show that they make any significant difference. But occasionally it does mean I incorporate a new method such as enhancing my previous eccentric tendinopathy loading exercises with isometrics and heavy, slow concentric/eccentric work which has been shown to achieve better results, which has been further backed up with observed effects with my patients in clinic, I have also started to use of kinesio tape for reducing pain (I await the backlash on this) I know this may sound contrary as there is no good evidence to show kinesio tape does much, but this is where I am prepared to give a treatment some time to establish an evidence base and prove itself clinically, as long as there are no risks, or detriments to the patients and its not a profit driven modality, or it just doesn't make any common sense, I won't discard it immediately.

We should always be constantly evaluating what a treatment technique is achieving and try to understand its mechanisms, I do this all the time and I will always question techniques and methods, even well established and so called tried and tested methods such as good old basic massage and joint mobilisations or manipulations?

The reason I do this if I'm being 100% truthfully honest here, is I dont think there is much, if any, manual therapy techniques that I do use that I can say that I wholly understand what they are doing at a physical level. This is due to the more I read and discuss these techniques with others the more opinions/views and research/evidence I get from both sides giving me a confusing and muddling mess to pick through. This can be scary and daunting, and somewhat disheartening, as something you believed in so strongly and passionatly and that you can swear on your mothers life has been working, suddenly starts to look not so rosey, believe me I've been there many times and I will be again I'm sure.

I've said this before and I do like this quote…

” the more I learn, the less I understand”

But its ok, this is the nature of working with such a complex and diverse thing as the human body of which we understand very little, and as we learn more so must we adapt, and not hold onto out dated methods or techniques just because they are comfortable.

To change your practice and methods isn't an omission of error or of wrong doing, far from it, its a sign of an excellent clinician with a critical thinking mind. I truly believe that if a therapist hasn't changed or modified at least one or more treatment method/technique or approach each year they are not reading and criticially evaluating themselves enough.

Now all that being said, it may come across that I don't like manual therapy or that I think it doesn't work, of course not. I pull, poke, prod and rub my patients as much as the next therapist in an attempt to reduce their pain, what I have issue with is the crap and gumpf that surrounds most manual treatments and the explanations given as to what, how, why they are working.

To think that this rubbing and poking does some of the things people claim it does is just not critical thinking, I am going to breifly highlight some of the debates I've had recently next, I will not go into too much depth as many much more intelligent people than me have done far better than I could, and I just want this article to highlight the critical thinking process not the actual subjects themselves but to kick off…

Fascial release: If you think you are releasing fascia by rubbing the skin with your hands or other device please have a stop and just think about that, as Paul Ingraham says on his website and via the excellent @painfultweets the stuff is stronger than steel and Kevlar, if it was any thicker us humans would be bullet proof. If you think rubbing your hands over the skin changes this stuff then that's just not critical thinking. I'm not saying it doesn't do something to change the way the person feels or moves, I'm kinda sure it does something when I do some of the techniques, but critically thinking it through this has to be on a neurological level but not on a physical “I've changed some fascia's structure level”, you just can't explain it that way, that's in my opinion critical thinking not being critical. For more on fascia myths this read the excellent @greglehman website here

Sacroiliac Joint palpation: If you think you can palpate 2-3 degrees of movement in an SIJ covered by adipose tissue skin fascia and ligaments then again please just stop and critically think about it, read my post on the SIJ here

Psoas: If you think you can touch, rub and so effect the physical properties of the psoas muscle that lies so deep in our abdomens and under so much tissue and intestines, again please stop and just think about that.

Bony landmarks: If you think that you can always find a C4/5 facet joint or a L3/2 spinous process and can apply a constant uniform pressure to that joint each and every time, again please stop and… Your getting the point now I guess so I'll get down off my soap box then!

So there you go just a small little scratch on the surface of critical thinking, as I've said this is not me saying that all this pushing, poking, rubbing and pulling a patient is worthless, far from it! I will continue to do so until I have 1) realised that it makes no difference, or 2) my hands and body give out, for which I hope that is many, many years away yet for both!

I hope that this has made people think about questioning what you do and to start critical thinking a bit more often and a bit more harshly than we probably would like to do.

I also hope that when I do sound critical via twitter or elsewhere that you perhaps can realise I'm not being an arrogant critical arse rather just thinking out loud, if not then I've realised you can't please all the people all the time, that's just life, and I won't lose any sleep over it!

Finally a great quote that I stick to from another great critical thinking mind @neiloconnell is that

“if you find yourself agreeing with everyone, you're not thinking hard enough”

Once again thanks for reading

Keep thinking, and try not to be an arse!

Cheers

Adam

 

The Upper Trapezius, over looked, over blamed & misunderstood!

All too often with shoulder and neck pains do I hear people blaming it on their tight and taut 'upper traps' with therapists telling patients/clients that their upper traps are so tight, knotted, tense etc etc and that they need to be relaxed or that they are over active!

Well I think this is a load of codswallop, and the poor old upper trapezius muscle has had a rough time of it, and is very poorly understood and unfairly blamed for nearly all pains and problems around the shoulder and neck when really they are usually NOT responsible, let me explain more.

First lets look at the anatomy and function of the trapezius muscle as a whole, its a massive muscle and its commonly described as having three sections the upper, middle and lower portions. Its the most superficial muscle of the upper back, neck and shoulders, it runs from the base of your skull, along to the tip of your shoulder and all the way down the middle of your back, see image below.

The three parts of the traps are usually described as having differing functions on the action of the scapular (the shoulder blade) as well as the spine when the scapulae are fixed. When you read the conventional anatomy textbooks they describe the role of the three sections of the trapezius muscle in isolation on its actions on the scapular as, the lower traps (LT) depress and medially rotate the scapular, the middle traps (MT) retract the scapular and the upper traps (UT) elevate and laterally rotate the scapular.

However, this is a way too simplistic view of the actions of the trapezius especially the UT, and this, I think is why so many myths and misconceptions about the UT emerge.

Firstly, we know muscles don't work in isolation this includes the trapezius, they work, or are supposed to work, in synergy with others muscles not in isolation. Secondly the angle and orientation of the muscle fibres, together with where they attach, the UT have been found long ago by Johnson et al back in 1994 to be not sufficient enough to create any elevation or upward rotation of the scapular alone, nor is the UT in isolation alone, able to rotate the scapular, instead they need the assistance of another much underrated and over looked muscle in shoulder girdle function, the Serratus Anterior (SA). I will cover this in another post.

Yes that's right UT don't and can't elevate the scapular alone!!! Not what you got taught in anatomy I'm guessing, I know I'd didn't?

Its only when the SA starts to pull the scapular laterally around the chest wall does the LT act to resist this, so starting to create an upward rotation action on the scapular, it is only then assisted by the UT.

So the UT only assists upward scapular rotation and elevation once its already been started by LT and SA!

This has massive implications in exercises and actions that are thought to influence and strengthen the UT. For example if we just elevate the scapular with the arms down the sides (ie shrugging), are the UT working? NO they are not, its the Levator Scapulae (LS) doing the scapular elevation combined with downward rotation which is usually the exact movement we are looking to avoid with most shoulder impingement problems but that's another article. The UT muscle fibres are only working once the scapular has started rotating when the arm is abducting (moving away) from our side, not when it's down beside us, which is where most give UT exercises, if they give them at all!

But what about those studies suggesting that we need less UT activation compared to MT or LT such as the work done by Ann Cools et al 2007. Well I think EMG is a useful insight and tool for assessing muscles, but they need to be interpreted with caution and remebered that they dont tell us the full story. For example the point commonly used for surface EMG readings for UT is controversial as it also overlies the Levator Scapulae lying underneath the upper trapezius and so I question how can you distinguish between the two, also I think the EMG readings of UT can be tend to be thought of as high due to the action of the UT actially pulling and rotating the distal clavicle rather than acting directly on the scapular and so can be mis interpreted as over active.

The majority of the UT attach on to the distal third of the clavicle and due to the orientation of the clavicle when these UT fibres contract they rotate the clavicle medially. This can assist in elevating the lateral superior angle of the scapular by rotating the clavicle and drawing the lateral end of the clavicle upwards rather than acting directly on the scapular. This rotation of clavicle rotation also helps compress the sternoclavicular joint, and this is a rather useful, beneficial and often overlooked action of the UT! As the sternoclavicular joint is the only bony attachement our scapular, in fact our whole arm has to the main skeleton, this compression of the sternoclavicular joint by the UT allows a transfer of the load from the arm and shoulder away from the neck and down through the collar bone, into our sternum and rib cage, great one happy offloaded neck, right! So this action of the UT on the clavicle is what gives off a strong EMG reading in all these research studies! Does this mean the UT is 'over active'? In my opinion NO, just misunderstood functionally!

But unfortuanly due to these so called 'over active' findings of UT there is a culture and tendency for therapists to give exercises and do therapies to those with shoulder impingement and neck pains that try to reduce or inhibity UT activity in favour of LT, this I believe is a BIG, HUGE mistake!

I have already shown you how a good strong UT helps direct force away from the neck down the clavicle, so why do we want to stop this happening with someone in neck pain? It just doesn't make sense! If the UT are less involved then that only leaves the Leavtor Scapulae to continue to work unopposed and its THIS muscle that I think is the main culprit of a lot of neck and some shoulder pains not the poor old UT, I think its trying its hardest to oppose the pull of LS during scapular movement.

I also definitely don't agree with those that what to reduce UT activity with those suffering classic sub acromial shoulder impingement, more here on that subject. If the UT become stronger and more resilient then I feel it can be only a good thing for the function of the shoulder in general too assist the upward elevation of the acromion again through rotation of the clavicle and so increase the sub acromial space during arm movement.

I often give out so called 'bad' exercises for 'shoulder impingement' patients with an big emphasis on the UT and only seem to get good results, purely anecdotal I know but it works for me. Some examples of these so called bad exercises I use are over head shrugs see below (I prefer the elbow a little more flexed so the arm isn't too high in elevation as this can be painful sometimes in impingement), I also like cable upright rows with a rope (I await a backlash on this) yes a full up right row can cause potentional impingement etc etc, but only with a bar and only with the shoulder in full internal rotation, if you keep the elbows in a scapular plane avoid internal rotation by holding the ropes with thumbs up and lift hands above the face keeping elbows below wrists I find its a great UT exercise, the same goes for cable rope face pulls. Another exercise I think is great is what I've termed 'Monkey Shrugs' basically hold some weights down sides of your legs then slide them up the legs to about hip height so your elbows are out to side, and then shrug from this position, this gets the UT muscles screaming as the scapular are already in slight rotation due to the arm in abduction and so they are able too function much more effectively. I couldn't find pictures of these two UT exercises as they are my own versions so I will do my own soon!

Over head shrug

Finally, lets look at another common complaint that the UT regularly gets the blame for, thats in causing pain from that old chestnut of 'poor posture' ie slouched sitting or 'rounded shoulders'. I hear a lot of therapists telling patients that they need to sit up straight and pull their shoulders back to stop your upper traps from becoming stretched and strained and so causing pain.

Well I disagree, not with the fact that sitting for long periods with the shoulder girdle protracted (forward and downward) is causing pain, nor that better positioning of the shoulder girdle is beneficial and relieves pain, no, what I disagree with is that its the UT are the source of pain as often as we would like to think, so I question the need for the soft tissue rubs, manual therapy etc given here, although a good neck rub does feel nice.

Instead I suggest that the vast majority of these 'postural' upper shoulder neck pains are not caused by the UT muscle which is soft, flexibile and adaptable, but rather from traction to the supra scapular nerve which isn't. This little nerve emerges off the upper posterior branch of brachial plexus and runs through two points of potential 'fixity' first the supra scapular notch and secondly around the spine of the scapular as it inervates the infraspinatis muscle see below.

When the scapular is protracted as when slouched sitting these points of fixity can 'pull' on this nerve at its origin at the brachial plexus. We know that a nerve only needs to be elongated less than 4% of its length before it registers pain, and only 10% before structrual damage starts to occur. As the supra scapular nerve is roughly only about 10cm long (give or take) from its origin off the plexus too its first point of fixity the scapular notch, this means only a pull of less than 0.4cm (give or take) is needed for this nerve to register pain, obviously there is some sliding and gliding of the nerves to accommodate this movement but test this for yourself, drop your shoulder forwards and down when slouching, they move a lot more than 0.4cm don't they, so what's more likely to give that deep dull diffuse upper shoulder and neck pain, the UT muscle or the supra scapular nerve? Just a thought…

So I hope I have given you some food for thought about the upper traps and that you now have a better understanding of its role and actions, and perhaps you might not be as quick to blame this misunderstood muscle quite so often or so quickly with your shoulder and neck pain patients, I also hope that you can see that actually strengthening and improving the function of the upper traps can help a lot of neck and shoulder problems and that you will start to give exercises for them more often

As always thanks for reading

Happy healthy exercising

Adam

 

Should endurance athletes do weights? A guest article by Andrew McDonough

So today I am very pleased to give you a guest blog by Andrew McDonough, an excellent physiotherapist with heaps of qualifications and much more importantly loads of front line experience in professional sports as the Head of Medicine at Widnes Vikings RLC. I'm even more pleased he has agreed to do this guest blog as we didn't quiet 'get off on the right foot' when we first came across each other via twitter due to some strong comments I made, for which I feel a right plum now, but hey ho live and learn and I definitely owe him a pint or two, if and when I met him in the future.

Follow Andy on twitter here @andymcdonough1 Take it away Andy….

A recent debate on twitter led me to revisit some previous work I’d done on performance training in endurance athletes. I like a good debate on twitter and its actually how Adam and I started talking. By talking I mean arguing on twitter and we have never actually spoken or met. I do however agree and like an awful lot of what Adam posts on line in various forms. His no nonsense, practical and common sense approaches to our profession is refreshing. It is said the average research paper is read by one person in its life. If Adams 2,700+ followers on twitter are anything to go by blogs and twitter may be the future of CPD and professional discussion. I’d like to thank him for allowing me to write this blog and hope to do it justice.

Should endurance athletes do weights?

THE CASE AGAINST

We have all heard weights make you slow; weights make you too big; too heavy; inflexible and don’t help runners improve. Runners don’t need to lift weights to run so why bother? Indeed there is evidence to show weight training does not improve endurance performance (Mikkola et al 2007).

Furthermore there are people who say that weight training and endurance training together can be detrimental to performance. As with any subject you can find supporting literature if you look; Hickson 1980; Dudley and Djamilj1985; Hunter et al 1987 and Glowacki et al 2004. These papers are often trotted out in defence of old training regimes with various examples of famous athletes given to back them up.

THE CASE FOR

Numerous papers support weight training, plyometrics and maximal velocity lifting amongst other training techniques (Hamilton et al 2006; Paavolainen et al 1997; Guglielmo et al 2009). All these studies used a variety of the previously mentioned methods with improvements in both anaerobic and aerobic testing measures. Importantly they all found an improvement in their athlete’s race times! If there is one study to try and find and read of those I’ve mentioned I would recommend Paavolainen et al (1997; Journal of Applied Physiology, 86, 1527-1533) for an excellent and comprehensive training program.

SO WHY???

As with many things the answer is not yes or no to weight training (it is yes* really but keep reading). What a cursory review of literature can give you is easily five papers (many more i'm sure) to support the evidence based argument against weight training. These can be spoken of as “research shows weights don’t work” and some clever people can remember authors by heart and sound even more clever when arguing this point. However if you really READ these studies; not just abstracts, there is a common factor…..

When looked at as a percentage of total volume Mikkola et al’s study swapped 19% of endurance training for explosive strength training. They improved the athletes lactate threshold and sprint time but not endurance performance. These other improvements are often left out by those defaming weight training. The type of training is also poorly defined but I’ll try not to bore you with too much research.

In the other studies mentioned stating a detrimental case against weight training there is equal time spent on weights and endurance training, so 50% of training volume. Those studies mentioned in the case for, use a program based around approximately 33% of training being weight training. From these studies plus a little bit of not so common, common sense we find a possible answer…. The AMOUNT of weight training.

Could it be that 19% weight training would not develop enough changes to produce results? After all this is less than one day a week. Also it seems sensible that 50% of time for an endurance athlete spent on weights is too high and would have a detrimental effect due to a lack of time training the aerobic system.

An inclusive training programme incorporating maximal sprints, plyometrics and explosive strength training at 1/3 of training volume sounds sensible and gives improved results. Areas such as running economy, sprint times, lactate threshold and most importantly race times all improved in these runners. Feel free to remember some of the articles above and sound equally clever when replying to those decreeing weight training.

*As with most subjects it is not a yes or no answer.

If done correctly weight training in conjunction with plyometrics, sprint work and good endurance training will improve your runner’s performance. The type of weight training is also probably important. High velocity lifting gives the best results and this requires a fair bit of technique in the gym. Interestingly it is the INTENTION to lift quickly rather than the actual speed of the lift that matters. By trying to lift as quickly as possible you will recruit fast twitch fibres and get the desired neural and muscular responses.

Which exercises to do is far too detailed a subject to cover in a blog. If I had to name three easily achievable exercises for an amateur runner I would suggest a dead lift, squat and single leg box squat but this could be argued all day. For gym novices maybe a leg press, hack squat and smith machine squat?

As a last point lifting weights will obviously make your runner stronger. As one of the greatest predictors of injury is muscle weakness then as well as improving performance weight training will reduce your runner’s injury risk. If there is something so simple that will make you run faster, for longer and stay fit then why not do it?

Andrew McDonough

Head of Sports Medicine

Widnes Vikings Rugby league Club

 

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