The shoulder

Dr Jeremy Lewis PhD FCSP  Professor of Musculoskeletal Research (University of Limerick, Ireland)  Reader in Physiotherapy (University of Hertfordshire, UK)  Consultant Physiotherapist  Independent Prescriber  Sonographer Central London Community Healthcare NHS Trust (www.clch.nhs.uk), London, UK Centre for Health & Human Performance (www.chhp.com), London, UK www.LondonShoulderClinic.com @JeremyLewisPT Lecture title: The conundrum that is the shoulder: Expanding our ability to manage shoulder pain. IFOMT Conference, Scotland, UK 5th July 2016 (14:30 - 15:30) Content What this lecture will cover: 1. Where are the symptoms coming from? / The dilemma of diagnosis 2. The problem with the shoulder - 3 million years of evolution from the African savanna to the 21st Century 3. Posture / 50 Shades of Grey / We are going to make history! 4. Management & Opportunities for the future Abstract The shoulder, together with the elbow and hand, permits a multitude of complex upper limb functions. These activities range from tasks requiring dexterity and precision typically performed inside our field of vision, such as threading a needle, to high powered explosive activities commonplace in sport, such as the tennis serve or baseball pitch. These activities require a highly responsive vestibular and sensory motor system that is capable of calculating (often in fractions of a second) the distance and direction to a target, which may be moving, and where we may also be moving. As well as being a joint of communication (child’s shoulder shrug) and carriage (carrying a backpack) the shoulder and upper limb is also a weight bearing limb, as evidenced in street dance, gymnastics, yoga, mountain climbing and when lifting ourselves out of a chair. To perform these incredible functional tasks, the shoulder requires combinations of strength, agility, speed, stability and endurance. The ability to perform many upper limb activities (such as a tennis serve) also requires energy transfer from the lower limbs. As such, assessment limited only to the shoulder may provide the clinician with an incomplete understanding of the individual’s functional needs. Deriving a definitive pathognomonic diagnosis is often beyond our current clinical ability. Furthermore, findings from multiple studies have revealed that there is an uncertain relationship between current imaging findings and symptoms for the majority of musculoskeletal conditions involving the shoulder. In addition to this, clinicians need to; exclude serious pathology, consider pain mechanisms, unravel controversies associated with posture, determine the relationship and influence of other co-morbidities, and, discern the contribution from often profound, obscured and interwoven psychosocial factors. The process of diagnosis is complicated, and becomes more so with the emergence of new research information from a multitude of specialities, which is often incomplete, and frequently contradictory. Evolutionary changes and adaptations may be an additional factor influencing modern shoulder function. Although people experiencing musculoskeletal shoulder problems should derive considerable confidence that exercise therapy is associated with successful outcomes that are comparable to surgery, management outcomes may be incomplete and associated with persisting and recurring symptoms. This underpins the need for ongoing research to; better understand aetiology and pathology, improve methods of assessment as well as management. References: Lewis, J, Green A, Yizhat Z, Pennington D (2001) Subacromial impingement syndrome: Has evolution failed us? Physiotherapy. 87: 191-198. Lewis J, Green A, Wright C (2005) Subacromial impingement syndrome: The role of posture and muscle imbalance. Journal of Shoulder and Elbow Surgery. 14(4): 385-392. Lewis JS (2009) Rotator cuff tendinopathy/ subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine. 43 (4): 259-264. Lewis, JS (2011) Subacromial impingement syndrome: A musculoskeletal condition or a clinical illusion? Physical Therapy Reviews. 16(5): 388-398. Lewis JS, Ginn K (2015) Rotator Cuff Tendinopathy & Subacromial Pain Syndrome. Grieve's Modern Musculoskeletal Physiotherapy (4th edition). In Jull G, Moore A, Falla D, Lewis JS, McCarthy C, Sterling M (Eds) Elsevier, London. Lewis J, McCreesh K, Roy J-S, Ginn K (2015) Rotator cuff tendinopathy: Managing the diagnosis-management conundrum. Journal of Orthopaedic and Sports Physical Therapy. 45 (11): 923-937. Lewis J (In Press) Rotator cuff related shoulder pain: Assessment, management and uncertainties. Manual Therapy. Lewis J, Hegedus E, Jones M (In Press) Shoulder pain: To operate or not to operate? In Jones, M & Rivett D (Eds) Clinical Reasoning in Musculoskeletal Practice (2nd edition) Edinburgh: Churchill Livingstone / Elsevier. McCreesh K, Donnelly A, Lewis J (2014) Immediate response of the supraspinatus tendon to loading in rotator cuff tendinopathy. British Journal of Sports Medicine. 48:A42-A43. Ratcliffe E, Pickering S, McLean S, Lewis J (2014) Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine. 48(16):1251-56.