Hi, my name is Jo Gibson and I'm a consultant shoulder rehabilitation specialist working at Rehab for Performance in Liverpool in the UK.
Tonight what I've popped on to talk about is a simple clinical reasoning structure that
we can use to underpin our clinical diagnosis, identify patients where there may be some specific treatment options, where injection or certain medications might be indicated, potentially giving us a basis for exercise prescription. But also importantly to inform how we set expectations for our patients and potential timescales for recovery.
Subjective clues that guide diagnosis
Now I think it's really important to say that from the outset, 80% of our clinical diagnosis is based in that subjective domain.
In terms of trying to make a clinical diagnosis when we can and importantly where it might influence our treatment choices, how we approach it in terms of our exercise prescription or the best advice we can give to our patients and whether perhaps an injection is indicated, there are some key things that we need to consider.
Now when we look at our subjective as well as obviously within that psychosocial domain, the beliefs, expectations and concerns and those lifestyle factors, there's some very simple things that can inform our clinical reasoning. Somebody's age, the mechanism of onset, where their pain is, what makes their pain worse, what makes their pain better, and how it affects their sleep, again in association with any potential risk factors for certain conditions, and I'll describe those a little bit more in just a moment.
Now if you believe the literature, 70% of what we see relates to non traumatic shoulder pain, certainly in primary care, and an important message is 80 to 90 percent of that cohort are successfully managed in primary care. Now, as ever we argue about to what to call it, rotator cuff related shoulder pain has become a very popular term, but essentially that was very much a move away from terms like impingement that we know can have a negative context from patients.
What to call shoulder pain? RCRSP or SAP?
People have criticised the term rotator cuff related shoulder pain, but I think we need to remember that it was a real push to have a positive context for patients that really put rehab or movement or conservative management really at the front line. Now, a recent paper by Witten et al 2023 suggests perhaps we need to revisit this and reflect the uncertainty about pain generators and all those multifactorial things that contribute to somebody's pain experience.
And go back to terms like subacromial pain or subacromial pain syndrome.
So subacromial pain, because that's where the pain is and syndrome to reflect the uncertainty in the current evidence about what's likely to be contributing. Now, a recent consensus in 2022 by Requejo-Salinas, and I'm really sorry if I've murdered that name, was an international consensus with some real big movers and groovers within shoulder world.
Now, within that expert consensus, they said for somebody to fit under this subacromial pain syndrome umbrella or rotator cuff related shoulder pain as they called it in this particular study, then expert consensus agreed that these patients would present potentially with a change in load or activity but may not recall a mechanism with pain on active movement,
commonly, flexion or abduction. Pain on resisted external rotation and or abduction. They might have limited internal rotation, but not always. And importantly, they have full range of passive external rotation. So that seems quite straightforward, doesn't it?
4 key questions to ask
But what about other presentations of shoulder pain or instability?
What about that clinical reasoning framework that we talked about?
Well, the first question, there's four key questions we need to ask ourselves. Firstly, not a shoulder. Secondly, is it torn and does it matter? Thirdly, is it stiff and do I need to do anything about it and will that influence my treatment choices?
And fourthly, is it irritable? So let's have a look at those each in turn.
Cervical spine driven shoulder pain
Now the first question, not a shoulder, the most obvious thing to think about here is that somebody may have a cervical spine driven problem with their shoulder. Now that expert consensus talked about the importance that if somebody had full range of cervical spine movement without any stiffness, no palpation findings, and importantly, no pain or limited movement in combined extension rotation, then you could confidently rule in rotator cuff related shoulder pain, subacromial pain syndrome and rule out the contribution of the cervical spine. But again, our age, mechanism, location of pain, aggravating, easing factors, and how it affects somebody's sleep obviously are a big part of making those objective findings relevant. So essentially, our older populations are more likely to have degenerative change.
People who work at a desk are more likely to develop neck stiffness. We have good studies looking at longitudinal studies and showing that link. But essentially, again, mechanism of onset may relate to static postures. Commonly, people with neck driven shoulder problems will not like being static. They'll be much happier moving.
If somebody tells you they relieve their pain by putting their arm on the top of their head or onto the opposite arm, then that's usually a good indication their neck is part of the problem because that takes load off the mid and lower cervical nerve roots. Similarly, if somebody says their sleep is worse lying on their opposite shoulder and is related to their neck position, then again that might make you more suspicious about the neck.
Now remember, a third of patients will have involvement of their neck and their shoulder. So again, it's just teasing out that history to see how things started. Importantly, people don't have to have neck pain or stiffness for the neck to be contributory, but generally they will have comparable palpation findings as in, more tenderness on the side of their symptomatic shoulder.
And generally combined movements may be an issue. But a couple of other important things to consider. When we talk about location of pain, remember location of pain on its own, not terribly useful. But combined with all those other things we've talked about, that's where we weigh up the evidences to the most likely diagnosis.
Certainly if patients have medial border scapular pain, that's one of the most pathognomonic things in terms of ruling in the cervical spine. So is posterior lateral shoulder pain. But again, you need to look at what those aggravating and easing factors are. It's much easier if people have shooting pain or more neural descriptors of their symptoms, but often patients don't.
The other thing, just a word of caution, was the role of repeated movements. Now some expert consensus will say that if you do repeated movements and they increase or decrease somebody's pain, you can be confident the neck's involved. But we actually have some research from several years ago by David Vanderput that actually shows that in patients with no evidence of any cervical spine involvement, so full range of movement, no palpation findings, no stiffness or symptoms on overpressure, that in those patients, if you did repeated movements with and looked at resisted shoulder testing and some other special tests in the shoulder, that in a third of patients with no evidence of cervical spine involvement, then those repeated cervical spine movements actually modulated their shoulder pain.
So I think we have to be a little bit cautious about using repeated movements, but there's no doubt if somebody has full range of movement with no issues on overpressure, no palpation findings in their cervical spine, and no limited movement in cervical extension rotation, we can be confident in ruling out the cervical spine. Now, that's probably one of the key considerations in "Not a shoulder".
Is it torn and does it matter?
Now on to our next question, is it torn and does it matter? Really in this group what we're talking about is a population that might describe a mechanism of trauma that's consistent with a potential structural lesion and identifying those patients that may benefit from an early surgical opinion.
If somebody comes to you with an acute mechanism of trauma, we might be suspecting a rotator cuff tear, some of the important things to consider are their age, that immediate onset of pain and symptoms rather than it came on a few days later, loss of pain and function persists six weeks after original injury, because in that situation, in a group of patients that are under the age of 55, they're more likely to need surgery.
But a really important point, only about a third of that cohort with those descriptors, so significant mechanism, under 55, immediate onset of pain and loss of function, go on to have surgery. We have another group that might have had a previous history of grumbling shoulder pain that have some minor trauma with immediate onset of pain and loss of function.
In those groups, one of the most important things is to identify whether they have a complete subscap tear because they're likely to benefit from imaging and potentially a surgical opinion.
. But in our other groups with a history of that's consistent with degeneration, the evidence would support a period of conservative management first.
Now, of course, there's more detail about patient factors and decision making, but that kind of summarises the key considerations.
Traumatic dislocations
Now, clearly, within that "Is it torn" group, we might also think about our instability cohort. Somebody who has a traumatic dislocation, who continues to be apprehensive, and certainly if they're under the age of 25 and they want to get back to sport, we know that surgery reduces their risk of redislocation by up to seven times.
But how do we identify those patients where surgery might be an option? And importantly, whether or not the patient wants surgery? This is again where imaging can be very useful. So imaging gets really bad press in our non traumatic populations because it doesn't really change our management options.
And importantly, it can make patients more likely to get persistent pain if we image them too early in their presentation. But in somebody who has a traumatic dislocation who remains apprehensive, who wants to get back to sport, and particularly if it's contact or collision sport, then imaging can be very useful to inform that decision making.
Because there are certain structural features that make them 100% likely to redislocate and others that mean they've got more likely to do well with conservative management. So some important things to aid our decision making and help our patients with shared decision making.
Special tests in the "Is it torn" group
Now when we look at that, is it torn group and look at things like our special tests, particularly when we're trying to identify particularly a rotator cuff tear. Then we know that with tests like our full can test, the bottom line is there's lots of other muscles working. So it's not just about supraspinatus. Equally, it can be difficult to tease out whether we've just got pain inhibition or whether we've got true weakness. Now there's some simple things that we can do in terms of modifying things like our full can test to give the rotator cuff more chance to work, but also important to relatively isolate it compared to some of those other shoulder muscles. From Karen Ginn's lovely research, we know that essentially if we support the weight of the arm, so you imagine if I'm doing the full can, it's weak and painful. If I shorten my lever arm, support the arm, maybe put a hand on the scapula as well so I maximally unload that system.
The very act of supporting the weight of the arm makes it more about the rotator cuff and less about some of those prime mover muscles. There'll still be a little bit of deltoid involved but it relatively isolates it. So if the patient is stronger and less painful, can I rule out a rotator cuff tear?
Absolutely not, but it potentially identifies somebody who's got better potential to compensate. If you look at some of our well reported special tests in identifying large and massive tears, our rotator cuff lag signs, again, we need to be a little bit cautious in our interpretation. So the drop arm sign, again, if that's positive, the patient can't keep their arm there.
Unfortunately, that doesn't rule in or rule out a rotator cuff tear, but what I would say is if they can hold their arm there, again, perhaps that indicates somebody who's more likely to compensate and do well with rehabilitation. If we look at our hornblowers test, so the ability to maintain external rotation abduction in that abduction position, if it's positive, so they get a significant drop, you can be pretty confident that you have got a posterior superior rotator cuff tear.
If it's not positive, they can hold their arm there, it doesn't rule one out. But again, I go back to what I said with the drop arm sign, potentially they might have more likelihood of compensating. The one test that seems to be really good at ruling in and ruling out a rotator cuff tear is our internal rotation lag sign.
So if somebody puts their hand behind their back, we lift it away from the back, can they hold it? Yes or no. If they can't, you can be confident they've got a subscap tear. If they can, you can be confident they haven't. But before you get too excited, the issue with that test is as soon as it's painful, it confounds the results.
So actually one of the more reliable tests for subscapularis is our bear hug test because it's less likely to provoke pain. But of course, all those things have to be taken in context of that original precipitating history. A great example of our special test being more special is our apprehension test.
If you have somebody who's under the age of 25, has an acute dislocation that requires relocation, and they have positive apprehension in that 90-90 position, then they are 85 - 90% likely to have some form of labral pathology. So the test on its own is pretty rubbish, but if you put it together with that relevant history and those descriptors, then it becomes much more reliable. So again, we just tease out where these things might have a potential role.
Is it stiff?
Now, after asking if is it torn and does it matter and identifying if somebody might benefit from imaging, my next question, is it stiff? And essentially in this group, I'm predominantly looking at patients that might present with restriction of external rotation in neutral.
Now, you'll know that we talked about the key risk factors for developing frozen shoulder. And that's really important because a recent paper by Millar et al 2022 showed very clearly that 80% of patients presenting with primary frozen shoulder have at least one risk factor and 35% present with three or more of those risk factors.
Of course, within this stiffness domain, we're not just looking at capsular reasons for stiffness. We're also potentially looking at bony blocks from osteoarthritis in our older populations. From cuff arthropathy, so patients who've had a grumbly history that's got worse over time, develop pain and weakness and now have stiffness.
Again, there might be joint space narrowing and some secondary bony changes. But remember also that young people who had a dislocation in their twenties, a cuff tear when they were younger can go on to develop early arthritis in their forties. Again, teasing out that history of any relevant trauma, even if it was historical, is really important.
Now, of course, in stiffness, we can also consider muscle stiffness and patients who are scared of moving. But that's why, if we're confident that we have a high chance of looking at those contributory risk factors for frozen shoulder, the things that might lead you to believe in somebody's history, that they've got a background of arthritis or cuff arthropathy, then again we increase our suspicion that this might just be a muscle stiffness driven problem and crucially with our objective assessment we're going to be able to change it.
Is it irritable?
Our fourth question, is it irritable? For me really relates to patients who present with high levels of pain and disability. So why do I delineate this group? Basically because if patients present with a history that is highly correlated with a likelihood of high levels of pain and disability, one that might mean it limits my ability to change things when I first start working them.
It may indicate a role for injection or specific medications to help manage their pain. If rehabilitation can't find a way in, but importantly, if they don't have a history consistent with those things, it can be an early indication of negative psychosocial factors, negative beliefs, pain catastrophising and kinesiophobia, which clearly potentially set my patient up to fail.
Now in terms of common reasons for high levels of pain and disability, that we would expect patients to report that, certainly some of our subgroups with reactive tendinopathy, so a clear loading history that's precipitated their symptoms. Similarly, an acute calcific tendinopathy where generally patients will wake up with an acute onset of horrible anterior lateral shoulder pain, often bad enough that they go to casualty, have an X-ray, we see the calcium.
Frozen shoulder in stage one when they're not yet stiff, again, the pain associated with that is reported as some of the worst in musculoskeletal pain. And another consideration, particularly in these times of COVID, is Parsonage-Turner, where like calcific tendinopathy, about 70% of patients will report waking up with horrible onset of symptoms.
But unlike calcific tendinopathy, it's not limited or local to the shoulder. It can be around the whole upper quadrant and typically is in that supraspinatus fossa, upper fibres of trapezius and the lateral arm. And again, typically patients will start to develop weakness within 48 hours of their symptoms.
But as I say, if it's not any of those things, and there might be some other things that we need to consider, the bottom line is remember, it can be an early indication of negative beliefs, negative expectations, and so we really need to understand that patient understanding. Now within this irritable shoulder group, within our rotator cuff related shoulder pain or subacromial pain groups, the bottom line is when we look at things like Hawkins and Kennedy tests, impingement tests, our Neer impingement tests, the bottom line is these provocation tests don't tell us anything new.
They really tell us what we already know is their shoulder hurts and they're probably not the best use of our time. Consensus will say that resistance tests are helpful in ruling in or ruling out subacromial pain or rotator cuff related shoulder pain. But then I'm left asking, what else can I do in terms of my assessment?
Of course I want to look at active movement and passive movement for all the reasons that we've talked about. But equally, we see this increasing narrative in the literature at the moment that essentially whilst we describe a lot of neuromuscular effects of our exercises, increasingly, when we look at exercise effects and what seems to make a difference to patients is educating and getting them moving in a way that increases their confidence, reduces negative beliefs and gets them back to the things that they want to do.
Can I change it?
So if you like empowering and educating our patients through movement and exercise. Exercise and that changing movement also almost becomes the vehicle to get patients back on track and then build them back to the things they want to do. So having asked myself those four key questions about what the likely cause is of somebody's pain, my next thing is, can I change it and is it strong enough to do the things that they want to do?
Now in terms of can I change it, I just apply some really simple principles in terms of symptom modification. Based on what we understand about the muscle system, but also importantly, acknowledging that it could just be about distraction. It could just be about getting patients to move in a different way.
And that's why whilst I might have an approach that works in my clinic, we always need to reflect on what those mechanisms might be. That's the fun of the evolving evidence. But essentially, if we unload the shoulder, if we manipulate hand grip, if we add some resistance. If we get some tactile input, or even if we just exaggerate the rest of the body, all these things have a proven efficacy in changing how our patients move, and potentially giving us a basis for exercise prescription.
When I've got a patient that's confident to move, I like to look at the cuff in isolation, just if it's ability to support the weight of the arm. Again, it's a way of validating somebody's pain experience, but again, importantly informing a potential exercise that makes sense to the patient. When we look at the things that are consistent and associated with the outcomes, what we see is no specific superiority of one exercise intervention over another. Apart from perhaps that emphasis on getting patients confident to move, reducing that kind of kinesiophobia or protective strategies in the first six weeks, but after that, very little superiority of any specific intervention. However, if I get my patient moving confidently, the important thing then is to do a graded return of loading back to the things that they want to do. And the more it looks like they want to do, as I say, the three key things that seem to be associated with good outcomes are no more than three exercises.
The exercises are meaningful to the patient and they progress over time. Some really simple concepts. Some really simple questions that essentially we can use to underpin our clinical diagnosis, identify patients where there may be some specific treatment options, where injection or certain medications might be indicated, but also importantly to inform how we set expectations for our patients and importantly potential timescales for recovery.
Summary
Essentially what I've done there is reiterated that simple clinical reasoning framework but importantly, the questions to ask yourself in terms of, is it torn? Is it stiff? Is it irritable? Can I change it? Is it strong enough? And importantly, how that will inform your exercise prescription. And if you get stuck and a patient stops progressing, some tips and tricks about that too.
So guys, thanks for listening this evening. Bye for now.