Shoulders part 2 Anju Jaggi and Prof Ginn #AHPSPodcasts Part 2

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1 #PODCASTTUESDAY W/C AM Problem Solving Shoulders part 2 Anju Jaggi and Prof Ginn #AHPSPodcasts W/C AM Problem Solving Effective ankle taping: Mechanisms, myths and more with Chris McNicholl W/C AM Problem Solving Biomechanics and pain: The ongoing dilemma with Greg Lehman Shoulders part 2 Anju Jaggi and Prof Ginn #AHPSPodcasts Part 2 Humeral Head Centring Everything about the shoulder is about active control GIRD Essentially it is a loss of internal rotation don t get caught up on the term Is it tight or stiff or is it weak or not motor control functioning well enough AJ- doesn t exist as a stiffness problem it s an active control issue Always check if it is passively stuck Some throwing athletes have more twisted humerus therefore look like they have more external rotation range but actually whole range is just tilted backwards (retrotauted humerus) Test passively in supine Frozen Shoulder Assessment is key- are they passively truly stuck Problem comes when it is painful and can t assess properly o Try different positions o Try with patient supporting arm AJ- most see are a weak shoulder or motor deficient shoulder Should X-ray be mandatory? o Paper presented at BESS- increased use of US in shoulders found quite a lot of osteosarcomas were missed o Better to x-ray than not o Red flag question are essential o One of diagnostic criteria is that they don t have OA so need x-ray We have learnt very little about frozen shoulder in 100 years Our treatments don t work- no evidence If this is a stuck capsule then why does it unstick itself in 2.5 years Could it be a muscle response to protect joint like muscle spasm in the back o It is a joint which is so much about muscle control Pain Relieving Injections Can be helpful but must address underlying issue Wouldn t use as first port of call, want to see patient exercise first o Look for permanent solution Does have a damaging effect on tendons Get better assessment and understand what problem is. Lots of thing cause pain, let s understand this better first Steroids are damaging and we shouldn t really be doing it Night Pain More they do throughout day influences this One of last things to go Indication that they are overworking during the day- like a blister o Your moving a joint that rather than moving smoothly is clunking around in there. Then it hurts at night secondary to inflammation from this and that distractions are gone o Must modify what doing during the day Positioning, use of pillows important What can you do to relax you i.e. listening to music etc.

2 #SPECIALTESTFRIDAY- Resisted Hip Flexion Test Friday 24 th April Resisted Hip Flexion Test Friday 1 st May Trendelenburg Resisted Hip Flexion Test Sensitivity:92% Specificity: 84%?? +ve LR: Not reported -ve LR: Not reported Usefulness: It seems hard to see how this painful provocation test can be useful considering other possible sources of pain. Can test this in 45 degrees of hip flexion and 90 degrees of hip flexion, may be useful to also test in Thomas Test position also to cover all angles. Pain would indicate a positive test for the deep hip flexors. #PATHOLOGYOFTHEWEEK- Adductor Tendinopathy Adductor group helps stabilise the pelvis and connect it to the femur Common in activities with high running loads, rapid change of direction and kicking. Can often be multiple clinical entities driving the pain Subjective: o Insidious onset, usually related to increased load o Usually felt in one or both proximal pubic bones and adductors but can be centred on lower abdominal or inguinal regions. o Pain presents following activity and is accompanied by stiffness o Get full training history Objective: o Localised medially in the groin, may radiate down the adductor muscles o Pain on passive stretching o Pain on palpation of adductor tendon insertion o Pain on resisted adduction (squeeze test). Weakness is also common Early signs to look out for: o Tightness / stiffness during or after activity with little relief from stretching o Loss of acceleration o Loss of max sprinting speed o Loss of long distance kick on the run o Vague discomfort with deceleration Treatment o Pain free exercise o Identify and reduce sources of load on the pelvis o Improve lumbopelvic stability o Strengthen local musculature o Progress to return to play level

3 o Return to running criteria: Brisk walk is pain free Resisted hip flexion in Thomas test position in pain free Pain free No cross-over sign Minimal adductor guarding #NEWSOFTHEWEEK Firstly I would like to direct you towards The NAF Physio Podcast, brought to us by Mr Meakins aka The sports physio. Mainly because we are on it! Some kind words from Jack Chews who is being interviewed placing #AHPSPodcasts amongst BJSM and Physioedge as a podcast to listen to which is great so thank you to them both there. Take a listen it s a good entertaining listen and I look forward to the next instalment. Secondly enter another article from the ever excellent Aspetar Jounral. Those of you involved in Sport or management of a team will like this. Cold Water Immersion by Hamish McGorm, Lilian Roberts, Jeff Coombes and Jonathan Peake What the research says Lack of physiological findings, main focus on performance Broatch et al (2014) found that it induces nothing more than a placebo effect Yamane et al (2006) regular cold water immersion attenuated gains in endurance, maximal strength, endurance time, vo2 max and ventilator threshold (handgrip and cycling) Frohlich et al (2014) found increases in maximal strength Halson et al (2014) found no gains in sprint performance of cyclists Current knowledge of possible physiological changes is summarised in the diagram below Application of ice or cold reduces nerve conduction velocity which will increase pain tolerance, which may lead to an increase in performance (Algafly et al 2014) Wilcock et al (2006) followed the route that cold water immersion provided hydrostatic pressure on the body which in turn may limit swelling and inflammation Versey et al (2013) examined cold, neutral and hot water immersion which did show favourable results towards cold water Broatch et al (2014) however found no difference in strength between thermoneutral and cold water- a placebo trial of a recovery oil (bath soap) was just as effective

4 The Study Survey study including 29 responses in elite sport Most commonly used was degrees for 5-10 minutes (fits with Versey et al 2013 study) Large placebo effect belief noted by respondents Summary More research needed! Particularly in physiological response Best way to recovery may be to work with athletes and gauge what is right for them in terms of beliefs Thirdly Matt ed round an article during the week which is an important article for us. Any article published in the press and given such media attention is always going to lead to questions for us a healthcare professionals. Please please do read the article because it is actually a great article and we ll take a closer look in #ARTICLEOFTHEWEEK. It will make you think about your diet, the way you train and incorporate a diet and you ll see how it has also been misrepresented in the media. Even just the from reading the title You can t outrun a bad diet tells us that that is common sense and not a reason to cast exercise away, if you do 30 minutes of exercise 5 times a week but eat a cake 5 times a week then yes you are not going to lose any weight. The two come hand in hand. It also brings to the fore a question I feel is so important particularly in the youth of today and that is their consumption of these sports drinks, which have high sugar content and are a big cause of obesity in the kids of today. Have a read! Make your own mind up, but do not forgot all the other benefits that exercise has! #ARTICLEOFTHEWEEK- Cochrane Review (2015) Exercises for Mechanical Neck Pain 6 computer databases were used and RCTs comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy were included. 27 trials were included Acute Neck Pain Only No evidence was found Chronic Neck Pain Moderate quality evidence supports o Small to large beneficial effects on chronic mechanical neck pain when combining use of cervical, shoulder/scapulothoracic strengthening exercises post treatment and at short term and long term follow up (up to 24 months) o May be a slight benefit from endurance training Low quality evidence suggests general fitness training and cervical spine stretching and range of movement exercises alone may not change pain or function

5 Chronic Cervicogenic Headache Moderate quality evidence supports cervico-scaulothoracic strengthening / endurance exercises immediately post treatment Acute Radiculopathy Low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilisation exercises Summary Overall the study provides no high quality evidence and an uncertainty about the effectiveness of exercise for neck pain. Good high quality meta-analysis however limited by the studies included: small numbers, low quality design, no evidence of optimal dose. And the Cochrane review itself, although does a good job of categorising the exercises, doesn t give us any information on the exact exercises used which would be helpful. What It does show us is that there is moderate level evidence to favour strengthening exercises, particularly cervical, scapulothoracic, shoulders, over stretching and range of movement exercises. There is some evidence to support a combination of them both so the question is, is one type of exercise not enough, do we need to combine it, would adding in some manual therapy improve the effectiveness of the exercises : ).clinical forum.discuss. #EXERCISEOFTHEWEEK- Adductor Lateral Slide Another one of my go to groin exercises along with the adductor squeeze is the adductor lateral slide. Slide one foot out naturally and then pull it back to the starting position. Foot should be pressed against floor with a much force as tolerated. It is also another exercise which makes up the Holmich et al al (1999) protocol. They split the rehabilitation protocol up into 2 phases. Part 1 involves static and dynamic exercises for 2 weeks before moving on Part 2 which is dynamic exercises. Well worth a read and we ll keep going through some good groin exercises. #FROMTHEEDITORS Remember any one has any content they want to share, write ups of articles or courses they have been on please me. Enjoy! #AHPSCLINICALWEEKLY COMINGSOON 1. #PATHOLOGYOFTHEWEEK- Groin injuries 2. #SPECIALTESTFRIDAY- Trendelenburg 3. Summary of Taping pod 4. #EXERCISEOFTHEWEEK- A look at Groin rehab and soleus rehab. 5. #ARTICLEOFTHEWEEK- Physical activity and obesity 6. #NEWSOFTHEWEEK