Keep on going

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I spoke to a physio colleague the other day about a patient who hadn’t made much progress recently.

This patient hadn’t been very compliant with their physio exercises and was becoming frustrated that they were not feeling better. We discussed that it might be enough for this patient to first continue the exercises they had at the same level rather than looking for progress st every appointment.

I’ve had physio recently and this made me consider my own situation. One of the most frustrating aspects of rehab is doing the exercises. People look for excuses not to do them (I’m just as guilty):

💭 “I’m busy with work”

💭 “I’m too tired”

💭 “I can’t be bothered – it probably won’t work anyway”

💭 “I’ll do them at the weekend”

If you don’t do the work, you won’t get the results.

As healthcare professionals part of our job is coaching people through the plateaus they might hit and helping them to see the progress that lies on the other side.

Flight risk?

With the Easter weekend coming up, I’ve had a few post-op patients asking if it’s safe for them to fly, and what precautions they should take.

Generally, flying post-op is safe if patients are aware of the risks and manage them. For my patients I normally advise at least a week after an operation to allow any side effects of general anaesthetic (if they have had this – many operations are now “awake” and don’t need a general anaesthetic) to wear off, for them to be comfortable in a sling and for pain to be at a manageable level.

There is a heightened risk of deep-vein thrombosis (DVT) after surgery which vary from patient to patient and should be discussed in with the patient’s operating surgeon or GP. Measures to help mitigate this risk include staying well hydrated on the day of and day after each flight, moving around the plane and performing small elbow, wrist and hand movements as shown by the post-op physical therapist and taking an Aspirin if recommended according to the patient’s medical history.

Generally the risk of DVT after shoulder and upper limb surgery is low (less than 1%*) but it’s important patients are aware of it.

In addition to this the general post-op precautions still apply – many patients forget that they are still recovering from an operation when they are in sunnier climes!

Wishing anyone travelling this weekend while recovering from an operation safe and happy holidays!

*Thromboembolic Phenomena After Arthroscopic Shoulder Surgery, Kuremsky et al. 2011

Venous thromboembolism incidence in upper limb orthopedic surgery: do these procedures increase venous thromboembolism risk?, Hastie et al. 2014

woman walking on pathway while strolling luggage
Photo by Oleksandr Pidvalnyi on

Keep it moving!

This picture shows skin changes in the hand post a rotator cuff repair. Although the hand is not directly affected the process of putting the arm in a sling and restrictions of movement post-operatively can have an effect on the whole affected arm. 

In this case, the patient was me (after my shoulder op)!

While understanding the theory behind why we keep the affected arm moving post-operatively I was surprised at how changes in the nervous system manifested in swelling and dryness of the hands, leading to this blistering and skin peeling. It resolved in a couple of weeks, once range of movement improved.

This is a great example of why we give active range of movement exercises from the day of the operation for the elbow, wrist and hand and why it’s important to work with a physical therapist post-op. Physical therapy:

  • reduces swelling by increasing venous return
  • keeps the shoulder from stiffening up
  • keeps the tendons healthy and the muscles active – tendons need gentle loading to maintain their health, and
  • By doing these small exercises it also helps the pain to settle

If you are seeing changes in your hand or the affected arm feels different it’s always worth having it checked by your surgeon.

Do you even lift, Bro?


It’s not just bro’s that lift – I met a fascinating lady yesterday who lifts more than I could in just her warm up. She was suffering from ACJ osteolysis. She told me she had been told that she would “never get over the erosion of the ACJ” and was given the impression she would not be able to lift heavy or competitively. It was disappointing for me to hear that people are still wing given the impression that they should not be pushing weights or pursuing strength training.

Osteolysis means “the pathological destruction or disappearance of bone tissue”. This happens in the AC joint when the end of the clavicle rubs against the ACJ while loaded with heavy forces such as weightlifting, thereby giving it the name “weightlifter’s shoulder”.

Patients will usually be under the age of 40 and present with:

  • Pain over the AC Joint
  • Osteolysis on x-ray and
  • Positive scarf test

Treatment does not always have to involve surgery. The first course should include rest, NSAIDs, possibly an injection and physiotherapy. In this case and is most other cases where an injection is given this would be to allow something else to work – whether that something else is rest, activity modification or physical therapy (in my practice I would always counsel for physical therapy as patients who present with this are usually motivated to get back to the gym and need support to achieve this).

If surgery is indicated then the aim is to remove the eroded bone, and to provide a wide enough healthy space so that the clavicle and acromion don’t irritate each other, followed by good physical therapy.

My advice to my patient yesterday included an explanation that the shoulder joint is not like the knee, where treatment protocols are usually more straightforward. Of all the joints shoulders are pretty complex and I work closely with my physical therapy colleagues to help my patients make a full, and guided recovery.

With thanks for the 📷 to @katiepistello

The SLAP 👋 Tear

This video demonstrates what a SLAP tear looks like anatomically.

I find it’s helpful to visualise this and also to bear in mind that the shoulder is a ball and socket joint but a relatively unstable one (golf ball-golf tee rather than a true ball and socket). The tendons, ligaments and muscles around the shoulder help to keep the joint in place.

The Labrum sits as a circumferential rim around the glenoid. It serves to deepen the socket and therefore to stabilise the shoulder in joint. 

A SLAP (superior labral tear from anterior to posterior) tear occurs when there is damage to the superior (top) area of the labrum. It can be an acute or an overuse injury.

Symptoms include:

  • Deep, throbbing pain
  • Decreased range of motion, especially overhead
  • Instability in the shoulder
  • Loss of shoulder strength

Treatment for SLAP tears will normally start with conservative measures such as anti-inflammatories and physical therapy to balance the muscles in the shoulder and rebuild strength. If this fails, arthroscopic surgery combined with post-op physical therapy usually yields good results.

video: Visible Body

Review of the Shoulder Study Day 2019

This is a guest post by Bradley Scanes who attended the Shoulder Study Day and has very kindly written this review of the day, and the speakers’ presentations.  Thanks Brad!  

If you’re interested in attending a Shoulder Study Day or a future event please make sure you’re subscribed to receive the newsletter!

Shoulder Day-58

The Prof and his team delivered again. Always a great day and always great to see everyone there, and of course talk shoulders. So what were my key take home points

1. Research is not all it seems. Take care.

Shoulder Day-31

I’ll start with this point as once again Chris Blunt completely blew my mind with his talk and brings up many more questions about physiotherapy and medical research than we are perhaps comfortable with. The CSAWtrial and the FIMPACTstudy were in spotlight from both Chris and the Prof with some really interesting points. We physios were rather quick to jump on the bandwagon that these trials were a nail in coffin for subacromial decompressions (SAD), but are they when RCTs are, in the words of Chris Blunt, “a shoddy way to do medical research”.

Some food for thought on the CSAW trial:

  • 3 months of physio and a steroid injection didn’t help the 313 patients admitted to the study
  • Small and large partial thickness tears were ignored in the 313 patients in the study
  • Across 32 hospitals, was advice and post op physio at the same level? Was patients compliance without rehab programme monitored. Was it also enough? 1-4 sessions was reported.
  • CSAW trial power calculations indicated that they needed 100 per group and they ended up with 72, 65 and 64 which may lead us to say it’s an underpowered study and could potentially be ignored.
  • Confidence intervals at 12 months for SAD versus diagnostic arthroscopy were from -1.9 to 5.1, so some were worse, some had significant improvements…conclusions…?

Similarly in the FIMPACT study:

  • They needed 70 in each arm to be 90% confident of effect, and they only had 59. Again an underpowered study and suggestive that the found outcome was probably likely
  • 14 in the physio arm also went on to have SAD further diluting the power

So who has the better RCT, or who has the most data? This study(amongst a few others) found SAD better than physio….The answer, I don’t know, and not being a researcher some of this stuff travels way over my head. From a clinical perspective it is important to take each person coming into your care as exactly that….and individual person, and take a multi-disciplinary approach to help them achieve the very best possible outcomes for them. We know from our own practice that some people do need to be escalated on, and that good surgery with good and appropriate dosing of physiotherapy after works. Let’s not clear out something that may help some people just yet.

baby bathwater

2. Context is key

Shoulder Day-52

We do not know what normal is. Or abnormal for that matter. And things change all the time. Adam Meakins produced a ton of research during his excellent talk, to show how scapulohumeral ratio changes depending on a number of different things: age, gender, what your dominant hand is, what plane of movement you are moving through, whether you are moving both arms or one, what speed you move at, the load you are moving, the sports you have played, whether you are fatigued or fresh and whether you are in pain. All of these change how the scapula moves, and we simply can not say that this is how scapula movement should or should not look like.

We also can’t agree on what increases the sub-acromial space with this study showing that an anterior tilt does, and this study showing that downward rotation neither does nor doesn’t. Contrary to the popular viewpoint that posteriorly tilting and upwardly rotating your scapula helps. Again we don’t know, and again it’s likely that in some people it might matter, but it is probably pretty low down on our list of priorities once we have tackled load management, lifestyle factors, strength.

This theme was also brought up by the once again excellent Jo Gibson talking about shoulder instability and the running late but great Ash James in his talk about communication. Which is key, as there is always a story behind the person, and it’s your job, through our methods of communication, whether that be motivational interviewing or otherwise, is to facilitate that person to tell their story and take control of the narrative.

3. Treat the person not the pathology

But don’t forget structural problems! As Jo took us through a couple of cases where instability patients were considered ‘hypermobile’ but actually had had a traumatic incidence to begin with, so taking a good detailed history is really important.

The person is key however and focussing on the whole system important. Even coming back to the bio side we very often make presumptions that the system is weak, but sometimes it is the muscles working too hard. We need to consider muscle recruitment, stability versus mobility, proprioception and movement error and the scapula. Then moving into the more psychosocial part of our model, a really interesting point Jo brought up was that a lot seems centred in a patients emotive centre rather than via cortico-spinal regulation which is really interesting and could have major implications when planning rehabilitation.

Some key papers that came out of Jo’s talk, the BESS / BOA consensus on atruamtic instability, if you are treating shoulders you should have read this, and for the rehab, Bateman’s Derby shoulder instability programme is really nice.

“Treating the person not the pathology” was a key theme throughout the rest of the talks as well.  Ash brought it back to self-determination theory and how we need to structure around autonomy, competence and relatedness but remembering that we need to act as a communication bridge and not to follow our traditional rooted righting-reflex.

We might know what the patient needs to do, but they need to be the ones to get there, and a nice way to facilitate that is via our motivational interviewing / talking skills, of which I write about here. Ash used the nice example of myth busting early on can lose a patient straight away, and I know we have all been guilty of that….so validation not invalidation….”Physios should be more Alfred and less Batman”

Once we are on our way, the focus can then switch to building resilience, and the things we can effect is nicely demonstrated in the slide below.

slide 1

This was further validated by Doug Tannahill’s holistic outlook and some key pillars to consider; Activity, recovery, mindset, nutrition and bringing it all together but in a sensible way. Again we might know what a person needs to do….yes they need to exercise more, yes they need to drink less and eat better, yes they need to sleep more, but what small things can we facilitate the patient to change to get small wins each time. Leo Babauta suggests that when trying to instil habits, if you go for three daily habits a person is only 10% likely to do them, if you go for one, 85% likely.

4. We need to take our patients or athletes far enough 

This has always been a hot topic for me. I never feel that with many physios prescribing stretches, and banded exercises that we sometimes fail to get a patient back to an appropriate level. And that doesn’t just mean out of pain but strong enough to complete everything they want to do again without any worry. And that starts with Nick Grantham’s very first point of the day about knowing your athlete and the constraints of the sport you are working in, or simply the activity or work task they need to do. Ben Ashworth followed this up with a great line also; Prepare your athlete or patient for the chaos of their sport or life. I have also heard “prepare for the worst case scenario” before as well, and this means that we need to plan back from what an individual wants to do and build a rehab programme specific to them based on that. For example a football goalkeeper close to returning following a shoulder dislocation needs to be doing controlled landing on that shoulder before introducing external factors to reduce that control (This is a good read).

So how might this look in clinic. It starts with the objective assessment and ensuring we take someone far enough in that or as Ben put it, get as close to function as possible when testing. It is definitely not enough just to test isometric strength in the mid range, and some of the excellent work Ben is producing now is giving us ideas of how we can improve our assessment and put some values on it. He discussed using isometric hold tests or repetition max tests as good clinic assessment tools.

Then comes the rehab, which needs to be well planned with an end outcome in sight. If you can, a nice tip from Nick is to try to connect this outcome to the rehab or exercises you prescribe. Provide pictures or videos of the athlete or the movement occurring in the sport or activity.

Rehab in fatigue has been a hot topic before as well and Ben in closing the day off with the excellent data he is producing, showed us some really nice stuff that the medical team at Saracens have produced showing reduced strength in the ASH test (not named after him :)) post rugby smash. Some of the other data also suggests that rate of force production maybe an important issue, beyond when an individuals strength has fully returned, therefore we also need to be mindful of retraining speed, power and reactive stiffness too.

There is certainly the scope for being better though, and the CSAW trial highlights our deficits as well as surgeries, in that 313 patients failed physio. This brings me to my final point and a quote from this paperbrought to us by Nick; “Unimodal rehab interventions and generic prescriptions based solely on evidence based medicine are unlikely to be optimal in rehab” which sums up that not one side fits all.

5. It takes time!

This was another theme throughout the day reiterated by just about everyone. It brought about a nice discussion between speakers and delegates and a loose consensus was drawn out that. 12-16 weeks and a patient should be improving but it can take longer. It is important to recognise those that are not progressing and stop flogging a dead horse as it were. So if symptoms are not improving or they deteriorate then escalate and have those conversations involving the patient, the physio and the surgeon. If they are not progressing at all in the first 4-6 weeks then this is a good time to escalate as well.

Discuss this with the patient from the first session. A lot of what we do is centred on expectations, and we should be making these plans with the patient from day 1…and plans can change, treatment is ongoing and is not a one time consideration; those that may be appropriate for physio or surgery one time may not be at another.

And on that note I have already gone well over what I was aiming for. Hopefully I got all the key points from everyone, once again thank you to Tony, Ashu and the great team they have for organising such a good event once again, a cracking line up which will be one to top next year. I’ll leave you with one of Alfred from Batman Forever, “broken wings mend in time” ….but I wonder if they get strong again!


Hi!  Thanks for visiting this site.

I’ve been lucky to work with great colleagues and over the years, I’ve learnt a great deal from them.  If there is one thing that I want this site to be, it would be a resource or space for everyone (colleagues, patients, therapists, coaches) to gain information and advice so that they either don’t get injured, or recover as quickly and effectively as possible.

I’ll be posting regularly on a variety of subjects in a variety of formats.

There may be important research articles that have made me take note and amend my practice.  I’ll also be posting videos of interesting cases or quick videos with tips and advice for patients (eg. how to wear a sling and immediate post-op care).

I’d love to hear from you if there is anything you would like me to cover, or if you’re interested in posting a guest article.