My shoulder approach – a journey over the years
In my physio-beginnings I’ve learned that in shoulder impingement syndromes there is a mechanical loss of space in between the acromion and the humeral head. Therefore, many forms of treatment have also relied on this paradigm. The focus was on expanding the subacromial space. Active and passive caudalizing. Doctors have sent the patients after operative subacromial decompression.
Long before my physio time, Neer published in 1972 his paper about the anterior acromioplasty for the chronic impingement syndrome in the shoulder. He described the presence of a „proliferative spur and ridge“ on the undersurface of the acromion, which needs to be removed to improve the symptoms. Neer’s „impingement“ hegemony was undisputed for at least 30 – 40 years.
This paradigm is logical and plausible. Mechanically explainable. It’s tight, we have to gather space. Though I had my doubts. Doubts about the fast effects during treatment sessions. Fast changes in between sessions with automobilisation or muscle reactivation. And also a very good outcome rate after conservative treatment of the shoulder region and the surrounding areas. How would it be explainable that immediately or over some weeks there is more space, nothing pressing and tearing into the tendon anymore? Questions about the nociceptive innervation of the tendon suffering by the spur. I was also in doubt that my interventions have been so great that I cured this mechanical problem. AAAAND: It was often not a caudal mobilization that was my approach but other directions and as well often not even mobilization but changes in muscle activation.
I detected, that there are more options to impinge. It is no only the subacromial but also the subcoracoidal or an internal impingement. And what got even more interesting to me was to go on the search why there seems to be a conflict problem in different directions in the shoulder.
In 2018 Beard et al published the outcomes of a multicentre, placebo-controlled randomised surgical trial in The Lancet, in which they concluded that arthroscopic subacromial decompression has little or no benefits over placebo surgery for the treatment of subacromial shoulder pain. Hmm, sounded groundbreaking. Yet, also this investigation has some limitations and on the other side it led to many discussions and a rethinking about an old paradigm.
If I may put my approach
together according my patient treatment and also in discussion in Maitland courses I really need to say that it is so helpful to have an initial hypothesis which should be confirmed latest after the inspection, the analysis of the active movements and special tests. As always isolated test results are not very meaningful and this we really got to know in so much research about shoulder special tests. A hypothesis is only possible by combining several tests, the so called clustering of tests. A very nice read could be the work of Walton and Murrell about clustering tests for working out rotator cuff tears. It may take some time before the results of the active movements, the passive physiological movements and the additional special tests are conclusive. The more we practice, the faster we get in thinking. Findings typically extend over a couple of sessions. Clinical reasoning decides which body region is evaluated in which treatment. Continuous reassessments are my central decision-making parameters.
And often there is the conclusion that it is
a multidemensional syndrome.
The identification of individual drivers as well as underlying pain drivers and contributing factors (Littlewood 2016, Mintken 2016) go hand in hand together. This does more justice to the picture than a purely mechanical point of view.
We have to learn that these structural findings such as tendinopathies, bursitides or osseous deposits are part of the normal course of a joint. In many cases they are not responsible for problems (read further in Barreto et al. 2019, Lee et al. 2020). Even more interesting on my learning process was the outcome of the two swedish investigations about guided and supervised exercises for patients as real alternative to a surgical intervention (Virta 2009, Holmgren 2012).
That doesn’t mean that structures don’t play a role, but we have to think about which structures play a role in which patients. And even better we need to think in movement directions. This is what I’ve always learned. I learned to assess the patients symptoms, behavior of resistance, side comparison and the reaction in different movement directions. I’ve learned to distinguish wether this problem is more stiffness related, pain related, motor control related or a stability problem. And then it doesn’t matter so much if we think we influence more the capsule, a part of a ligament or a muslce. We are more movement specialists rather than anatomy detectives. If we can accept that not only one single muscle with a tendon, a fascia or a part of the joint is involved in a movement direction we can possibly better accept that caring about a movement is the more honest way of treatment. And in this way it matters so much to decide in each individual patient or treatment session in what kind of direction we work, do more muscle activation, strength training, passive or active mobilization techniques and how we will go on as a progression. It always needs the evaluation in every situation. Also the evaluation if the underlying mechanism underlies a peripheral nociceptive problem or if other central facts drive or influence the problem. Dosen’t this make our working day much more colorful and diversified?
From this perspective to my very devote perspective it can also not be accurate to just change a name from impingement to rotator cuff related shoulder pain. This also implicits misunderstandings. If it’s not the rotator cuff but tight parts of the capsule with the inserting rotator cuff, should we then call it posterior shoulder capsule and rotator cuff related movement dysfunction? Or in another patient we could then name the problem scapular dyskinesis related muscular inhibition? Rather not, I guess. We would get in troubles with our interdisciplinary collegues.
In an online trial Zadro et al (2021) investigated whether different labels for rotator cuff disease influence people’s perceived need for surgery or imaging. People labeled with a rotator cuff tear had slightly higher perceived need for surgery and imaging compared to people labeled with bursitis. People labeled with subacromial impingement syndrome had a slightly higher perceived need for imaging compared to people labeled with bursitis. In general after an explanation of the problem not being serious the overall mean perceived need for surgery was low.
The same as we do in other regions like the cervical spine we are well trained not to scream out load and inform the patient about having an instability in the middle cervical spine and this is pinging onto any neural tissue. We learned how to communicate (or at least a professional therapist should) not to harm the patient with our wordings. Isn’t this the same also at the shoulder? Don’t we continuously inform the patient in the management process about the findings, our hypotheses and the consequences? Then the „name“ of a clinical happening is not frightening the patient anymore. Then we still can discuss what our thinking about the underlying mechanism in this impingement problem is. And yes, it could also be rotator cuff related or based.
The journey will go further on.
The journey in reframing the name and the more important journey in training ourselves more in detecting underlying mechanisms which lead to problems in our patients.
The idea of a pincing acromion squeezing a tendon as a pathoanatomic diagnosis should be kicked out of our mind. Let us focus on a functional shoulder assessment as well as a functional treatment based on the individual clinical findings. This means of course the involvement of active and passive treatment options and as an overall goal the promotion of self-management strategies based on the outcome of the assessment and the reaction to the previous treatment.
In the end it does not matter if we call the problem an impingement or a rotator cuff related shoulder pain as long as the movement specialist is analyzing and building up hypothesis about which dysfunction may drive the patients actual problem. By now a changing of a name doesn’t change the patients concerns.
Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. Journal of Shoulder and Elbow Surgery. 2019; 9(28): 1699-1706
Beard DJ, Rees JL, Cook JA et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018; 391: 329-338
Holmgren T, Björnsson Hallgren H, Öberg B, Adolfsson L, Johansson K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. BMJ 2012;344:e787
Lee CS, Goldhaber NH, Davis SM, Dilley ML, Brock A, Wosmek J, Lee EH. Shoulder MRI in asymptomatic elite volleyball athletes shows extensive pathology. Journal of ISAKOS. 2020; 1(5): 10-14
Littlewood C, Bateman M, Brown K. A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study). Clinical Rehabilitation. 2015. ISSN 1477-0873
Mintken PE, Cleland J, Mcdevitt A, Boyles RE. Cervicothoracic Manual Therapy Plus Exercise Therapy Versus Exercise Therapy Alone in the Management of Individuals With Shoulder Pain: A Multicenter Randomized Controlled Trial. Journal of Orthopaedic & Sports Physical Therapy. 2016; 46(8): 617-628
Neer SC 2nd: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. Bone Joint Surg Am. 1972 Jan; 54(1):41-50.
Virta L, Mortensen M, Eriksson R, Möller M. How many patients with subacromial impingement syndromerecover with physiotherapy? A follow-up study of a supervisedexercise programme. Advances in Physiotherapy. 2009; 11: 166173
Walton J, Murrell GAC. Clinical Tests Diagnostic for Rotator Cuff Tear. Techniques in Shoulder & Elbow SurgeryVolume 13, Number 1, March 2012
Zadro JR, O’Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, Maher CG. Diagnostic Labels for Rotator Cuff Disease Can Increase People’s Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial. journal of orthopaedic & sports physical therapy. 2021; 51(8): 401-411
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