#SPECIALTESTFRIDAY- Roos Test Friday 8 th May Roos Test Friday 15 th May Adsons Test Friday 22 nd May

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1 #PODCASTTUESDAY W/C AM Problem Solving Shoulders part 3 Anju Jaggi and Prof Ginn #AHPSPodcasts W/C AM Problem Solving Biomechanics and pain: The ongoing dilemma with Greg Lehman Shoulders Part 3 with Anju Jaggi and Professor Ginn #SSORT Shoulder Surgery or Rehabilitation Trial #SSORT Clinical evidence, high quality, level 2 for effectiveness of surgery for musculoskeletal problems is sparse. Only one trial comparing surgery to placebo surgery (knee) We need to know more about whether surgery is effective- is the whole process, going to hospital, having time off work etc lead to a greater placebo effect RCT: Trial to look at whether surgical procedure for repair of capsule and labrum are effective in those with an atraumatic instability One group surgery procedure plus therapy and the other surgery no procedure plus therapy o Same therapy at sites Need to recruit patients o Need up to 140 patients Stanmore and Wrightington Criteria o Over 18 o Feeling of apprehension- doesn t have to be dislocating o Can provoke that apprehension o No rotator cuff issues, tears or nerve injury o No significant trauma Patient will need to go under general anaesthetic 2 incisions front and back If suitable they will be repaired or not repaired- only surgeon will know Immobilised in sling for 4-6 weeks Gentle physio Attend for physio after General patients not needing to attend for treatment at 6 months Stay in contact at 1 year and 2 years over phone 6 month assessment questionnaires #SPECIALTESTFRIDAY- Roos Test Friday 8 th May Roos Test Friday 15 th May Adsons Test Friday 22 nd May Roos Test for Thoracic Outlet Syndrome Sensitivity: 84% Specificity: 30% +ve LR: 1.2 -ve LR: 0.53 (Gillard et al 2001) Usefulness: Not in isolation. Aggravating and easing factors, and distributing factors may reveal more. Postural factors also important / cause many Thoracic outlet syndromes.

2 #PATHOLOGYOFTHEWEEK- Thoracic Outlet Syndrome A symptom complex characterised by pain, parathesia, weakness and discomfort in the upper limb which is aggravated by elevation of the arms or by exaggerated movements of the head and neck (Lindgren and Oksala 1995) Pain and discomfort of TOS is generally attributed to the compression of the subclavian vein, subclavian artery and the lower trunk of the brachial plexus as they pass through the thoracic outlet. 3 possible sites of compression o Brachial plexus can get compressed as exits thoracic cavity, passes up and over first rib and through anterior and middles scalene. The upper roots of the brachial plexus can be compressed in sclenes- these exit the cervical spine should be cervical outlet synfrome o Beneath the clavicle in the costoclavicular space o Sub-coracoid tunnel (beneath tendon of pec minor) where plexus may be stretched by abduction. Split into neurological TOS (98%) or vascular TOS (2%) Can be caused by irritation, compression or traction of the brachial plexus Incidence approx. 8% Woman more than men, particularly young woman Postural or occupational stressors with repetitive overuse and associated soft tissue adaptations. E.g. lower anterior chest wall with drooping shoulders and holding head in a forward position Subjective o History of aggravation if symptoms in the arm in an elevated position o History of parathesia C8/T1 distribution o Pain on suspensory holding o Lying on arm o Carrying backpack o Carrying bag by sides o Prolonged postures o Can be linked to trauma of cervical spine, glenohumeral, acromioclavicular, steernoclavicular joints Objective o Posture- long neck, sloping shoulders. Scapula malposition- test at rest and on motion. Symptom modification of scapula useful. o Palpation- Upper limb pain or symptom reproduction on palpation of supra and infraclavicular fossa are useful signs. Morley test or brachial plexus compression test Is positive if compression of brachial plexus in supraclavicular region reproduces symptoms, not just tender. o Active and passive movement- restricted shoulder range of movement can be found and has often been linked to increased anterior tilt of scapula o Assess rotator cuff, glenohumeral joint instability and cervical spine- scalene muscle tightness commonly associated with TOS o Neurological examination- can present with weakness in C5,6 (upper plexus) or C8,T1 (lower plexus) o Carpal tunnel tests- typical differential diagnosis o Provocation testing

3 Adson s test Costoclavicular test Wrights test Roos test Differential diagnosis o Cervical spine pathology o Peripheral nerve compression- ulna and carpal tunnel common o Rotator cuff pathology o Lateral / medial epicondylopathy o Glenihumeral joint instability o CPRS o Dequervains tenosynovitis o Horners syndrome o Raynards disease o Brachial plexus trauma o Systemic disease o Upper extremity DVT Next week: Mangement For further reading on Thoracic Outlet Syndrome I strongly recommend these 2 papers: They are Athens access, if you can t get them let me know and I ll ping them over to you. #NEWSOFTHEWEEK Firstly a couple of pictures I just had to save thank you. Great slides 1 st looking at rotator cuff rehab. Secondly looking at Isometrics think Matt made it to the front to already see this one though : ). Bit hard to see second one. It says ideal position to enhance cuff activation and minimise compression deg scaption, position to reduce deltoid and other muscle activation seated with elbow supported, 30 secs 4-5 reps for 2 mins time under tension, use like paracetamol throughout the day and with as much force as tolerable.

4 Second is an article I saw in the Guardian about Doctors overtreated.could this be true of physios as well..? Be interesting to get thoughts on the forum. I always stick to a 3-4 sessions rule, if they re not getting better by then, then something is failing. Third and I haven t read it yet but very much looking forward to is a thesis by Clarie Hebron, who is a lecturer at University of Brighton. You can catch her Article is here, titled The Biomechanical and Analgesic Effects of Lumbar Mobilisations. Exciting! : ) #TECHNIQUEOFTHEWEEK Ankle Taping A follow on from last week s podcast, I thought I would start with Ankle taping. Lots of different ways this can be done, this is my way but be good to get others thoughts on the clinical forum. I work on a continuum basis to help wean a patient / player off of the tape over a period of time and it usually follows 3 steps for me. 1. Rigid taping using the beige rigid leukotape / sports tape. Order of application below. I wrap in underwrap first. a. 2 x stirrups medial to lateral b. Six c. Half six d. Half 8 e. Lock off strap at top f. (if serious sprain and patient wants more support I will sometimes cover that with EAB and some heel locks but the above is usually enough)

5 2. Somewhere in the middle taping using EAB a. Wrap with figure of 8 pattern and add heel locks 3. Flexible Taping using K-tape Lots of different ways you can do it, no book seems to be the same. I tend to follow a similar patterns to number 1. The rigid taping and use a couple of stirrups with a six and cover that with a wrap around the heel and foot not dissimilar to a heel lock. #EXERCISEOFTHEWEEK- Adductor Lateral Slide One I really like as a rehab exercise for the groin. I will often give with isometric- adductor squeeze as a 2 part rehab programme to start if they can do it. Does get it working hard but have to be careful patient is doing it right and not causing more pain. Make sure they have a slippery surface and are just wearing a sock. Standing with feet parallel, injured leg slides out, with foot pressed to floor with as much force as tolerated and then is brought back in. Ensure using adductor muscles to pull leg back in. Perform continuously for 1 minute. #FROMTHEEDITORS #AHPSCLINICALWEEKLY COMINGSOON 1. #PATHOLOGYOFTHEWEEK- Thoracic outlet syndrome Mx 2. #SPECIALTESTFRIDAY- Adson Test 3. Summary of Biomech and pain pod 4. #Techniqueoftheweek- taping 5. #EXERCISEOFTHEWEEK- A look at Groin rehab and soleus rehab. 6. #NEWSOFTHEWEEK