There has recently been a high amount of attention drawn to the efficacy of common treatments for shoulder pain within the media, health care professionals and the scientific literature. In this month’s newsletter, Musculoskeletal Physiotherapist Mike Callan will dive into sub-acromial decompression (SAD) surgery and cortisone injections, summarising the latest evidence. He will also look at evidence basedconservative management for shoulder pain.
Shoulder pain is common and can be very complex. There are many structures around the shoulder that can be sources of pain, and many of these blendtogether. For our purposes, we will be talking about sub-acromial pain. Sub-acromial pain originates from any of the tissues that are inside the shoulder, such as the tendons of the rotator cuff and biceps muscle, shoulder joint, or the various ligaments and bursae.
In the 1970s, the common thought for why shoulder pain developed was ‘impingement’. The idea was that repeated ‘pinching’ of the rotator cuff tendons and bursa against the roof of the shoulder (acromion) when the arm was lifted overhead caused shoulder pain, injury to the tendons of the rotator cuff, and bursitis. If continued, this would lead to bone spurs, which in turn would rub against the rotator cuff and cause tears. This was also thought to be associated with the shape of the acromion, as a more hooked shape acromion would cause more of this pinching.
As a result, acromioplasty, also known as subacromial decompression surgery was developed. The idea was to surgically remove the proposed source of irritation by shaving away bone spurs. This would create more space and decrease pinching in the shoulder, leading to both short-term and long-term pain relief, including riskof rotator cuff tearing. This has led to an incredible increase in SAD surgeries.
Numerous studies and reviews of the evidence have shown this to be highly questionable. Many symptoms of shoulder pain are associated with overload or underload of rotator cuff tendons and failure of these tendons, combined with lifestyle, genetics, hormones and age1,2. Also, a majority of tears in the rotator cuff happen on the underside, not the top where supposed bone spurs would affect the tendon. Additionally, the incidence of rotator cuff tears in people without shoulder pain is relatively common, with one study showing 52%4and another showing 50% in those over 704.
Despite the high cost of SAD surgeries, studies have shown that there is no difference in outcome between surgery and a graduated exercise program both one and two years after surgery1,2. Eighty percent of those on waiting lists for surgery who underwent a 12-week rehabilitation program improved and chose not to undergo surgery1. The results of the recent Can Shoulder Arthroscopy Work trial showed that SAD surgery was not more effective than sham surgery (placebo), which puts strong doubt on the efficacy of this surgery2. This trend also carries over to those with rotator cuff tears. A study has shown no difference between physiotherapy exercise program, physiotherapy and SAD surgery, or physiotherapy and SAD and rotator cuff repair at a one yearfollow-up for those with non-traumatic partial rotator cuff tears1,2. For those with full thicknessrotator cuff tears, non-operative management consisting of graduatedexercise was effective at 2-year follow-up, reducing the need for surgery by 75%3. It has been proposed that the prolonged rest following surgery, followed by the gradual strengthening and increased loading around the shoulder is what is responsible for increased function, not the actual surgery itself1,2.
Another highly used intervention for shoulder pain is corticosteroid injections. The commonly held idea is that repeated impingement in the shoulder causes inflammation in the subacromial bursa, which leads to pain. Although this is common practice, there is a lack of evidence for the efficacy of steroid injections for shoulder pain1. Additionally, there is evidence to suggest that steroids can have a negative effect on rotator cuff tendons long term1.
So if you have shoulder pain, but the evidence for high costinterventions are lacking, what should you do? Currently, the evidence suggests gradual conditioning and loading of the muscles around the shoulder, mainly the rotator cuff and scapular muscles, as well as increased general physical activity1,2. Managing overall workloads, particularly avoiding prolonged inactivity followed by periods of high demand, commonly called booming and busting, and adopting a pattern of regular use of the shoulder with gradualincrease in load or difficulty is recommended. Also, addressing any big picture lifestyle factors that might increase pain sensitivity in the body, like lack of sleep, high stress, or high fear of re-injury are also recommended. As each person is different, individualised care is indicated. An experienced Physiotherapist can, after thoroughly assessing you and your problem, highlight which of these factors are driving your shoulder pain and come up with a management plan to help you get on top of it.
1. Bloodletting for pneumonia, prolonged bed rest for low back pain, is subacromial decompression another clinical issusion? Lewis, J. Br J Sports Med 2015; 49:280-281
2. The End of an Era? Lewis, J. J Orthop Sports Phys Ther 2018; 48(3): 127-129.
3. What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears. Boorman RS et al. J Shoulder Elbow Surg 2018 Mar; 27 (3): 444-448.
4. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. Lewis, J, et al. J Orthop Sports Phys Ther 2015 Nov; 45 (11): 923-936.
Osteoarthritis (OA) is a common condition that affects the joints of the body. It is characterised by changes in the joint structures, for example a reduction in cartilage. These changes occur because of complex mechanisms, including inflammatory processes, biomechanics and even genetics. Knee OA in particular affects many Australians – many of us know of someone who has been diagnosed with the condition. It has a high burden on the health care system and is a major contributor to disability and lost productivity.
Recent studies demonstrate that many people living with knee osteoarthritis are unaware of how best to manage their condition. Many people are referred straight to surgery without trying any form of conservative (non-surgical) management. Knee replacement surgery has been growing at an unsustainable rate over the past few decades – in Victoria there has been a 285% increase since the 1990s. Recent evidence has suggested that 25% of knee replacement surgeries are considered not necessary. Another surgical intervention, arthroscopy, has also been on the rise, despite there being high-level evidence of the procedure unlikely to benefit those diagnosed with knee OA. Joint replacement surgery will be indicated for a sub-group of people with advanced joint degeneration and who have exhausted non-surgical care options. This month’s newsletter will discuss non-surgical care options for those diagnosed with knee or hip OA.
Clinically, people presenting with knee osteoarthritis complain of painful and restricted movement about the affected joint. As a result of pain and restricted mobility, patients often have reduced muscle strength in their affected leg. This presentation is enough to clinically diagnose someone as having osteoarthritis – imaging (for example an x-ray) is not always necessary. Also, there is a poor correlation between structural changes visible on imaging and a patient’s clinical symptoms, and it is common for people with no physical symptoms to have evidence of structural changes on imaging. Imaging should therefore be reserved for special cases, for example if needing to exclude other pathology.
To be able to effectively manage your OA, it is important to be aware of the variety of treatment options available. Best practice strongly suggests conservative management should be trialled for at least three months before any surgical intervention is considered. There is strong evidence demonstrating that increasing muscle strength around the knee results in improvements such as a reduction in pain and increased function. Your physiotherapist will be able to provide you with an exercise program tailored to your current ability. Having an adequate understanding of pain mechanisms is very important, as there are many contributors to pain including changes in joint structure, activity, sleep, diet, thoughts and feelings. Pacing your daily activity (not doing too much on your ‘good’ days or too little on your ‘bad’ days) is often a helpful strategy.
There are other management options that should be also be considered when developing a management plan for your knee OA. Weight loss, if indicated, is important to reduce the amount of load going through the knee joint. The use of basic medication (for example paracetamol and anti-inflammatories) to assist in managing pain can also be useful. Using pain medication should always be in conjunction with other form of management and never the sole treatment option. Osteoarthritis is generally managed best with a combination of these different strategies.
We are all living longer, it’s a myth you should just put up with your pain as you get older. Best practice care for knee or hip OA is provision of appropriate non-surgical care. At Central Bassendean Physiotherapy we ensure our understand OA and the related pain. We will formulate a targeted and individualised strategy based on contemporary best evidence to manage symptoms and improve functioning.
BLOG POST AUTHOR
Curtin University 2013
Jezamine has a keen interest in managing chronic conditions, particularly low back pain, and non-musculoskeletal conditions such as COPD. She also enjoys assisting in rehabilitation of sports people following an injury. In addition to treating at the clinic, Jezamine also runs the Thursday afternoon Hydrotherapy sessions at Bayswater Waves, as well as Clinical Pilates classes twice per week on Monday and Wednesday afternoons.
When not at work, Jezamine likes to keep active by playing netball for North Dianella Netball Club and getting out and about with her fur-baby, Henry.
Low back pain is the leading cause of years lived with disability in the world. While rare below 10 years of age, LBP emerges during adolescence and prevalence rates increase until plateauing in early adulthood.
The Perth based Raine Cohort Study identified at 14 years, 30% of girls and 26% of boys reported LBP in the past month and 11% reported chronic (>3 months) LBP. At 17 through to 22 years, Raine Study participants reporting LBP over the past month, significantly increased from 32% to 45%. Additionally, for those reporting chronic LBP, comorbid pain problems such as neck pain and headache are frequently reported. At 17 years, 20% of adolescents with chronic LBP report negative impacts such as modifying physical and daily life activities, along with taking time off school or work. The burden of LBP can begin young for some.
Specific Adolescent Lumbar Pathology
While LBP is common in adolescents, serious pathologies such as malignancy, inflammatory disorders and infection are rare (less than 1%) and can be initially screened via thorough questioning. Where LBP is disabling and associated with clear trauma, screening for fracture is warranted. While serious pathology is rare, MRI findings such as disc degeneration is present in 30% of adolescents at 13 years and in the vast majority of cases should be considered normal. Disc herniation with associated leg pain (sciatica) is very rare with rates estimated to be 0.2 to 0.6% of presentations.
Adolescent LBP Without Related Pathology
The majority of adolescents with LBP have no clear pathology explaining their LBP. The absence of clear pathology can lead to adolescent LBP being labelled with what can appear clinically appealing labels such as hypermobility syndromes, postural syndromes or muscle imbalances. In Raine Study participants, generalized joint hypermobility at 14 years was prevalent, particularly in girls irrespective of LBP. Additionally there was no relationship between joint hypermobility and chronic musculoskeletal pain or LBP at 17 years. A recent systematic review concluded there is no evidence for an increased risk of LBP in adolescents with scoliosis. Sitting in a slumped position at 14 years only demonstrated a weak relationship with LBP at 17 years. A standing posture study at 14 years of age found standing with a hyperlordotic posture was related to an increased risk of previous and current LBP and was associated with higher BMI scores. At 14 years back muscle endurance was not related to LBP. However in rowers and those with moderate disabling LBP, lower back muscle endurance was observed. At 14 years there was an association with schoolbag carriage and spinal pain. Perceived load, duration of carriage and mode of transport to school were factors. However, actively getting to school by walking or riding appeared to offset the risk. These factors that historically are thought to be involved in LBP are only weak predictors.
Multidimensional factors related to Adolescent LBP
Current evidence suggests there is a significant role of lifestyle factors in chronic musculoskeletal pain including physical activity levels, dietary factors, smoking and poor sleep. Psychological factors have been associated with LBP. At 14 years of age poorer mental health (anxiety, depression, aggressive behavior) was associated with neck and back pain. Have a primary carer with LBP and environmental stresses, such as significant life stress events, also play a role in the development of LBP.
What to do?
Adolescent LBP is common. Once serious causes of LBP are excluded, LBP treatment requires a flexible and multidimensional approach to assessment and management. When disability is significant early intervention involving a wholistic approach is supported by current evidence. Helpful messages regarding LBP include;
If you have significant LBP, our Physiotherapists have the experience and skills to get you back on track. More information on LBP care can be found here, at Pain Health or by reading the reference for this newsletter .
1.O'Sullivan, P., et al., Understanding Adolescent Low Back Pain From a Multidimensional Perspective: Implications for Management. Journal of Orthopaedic & Sports Physical Therapy, 2017. 47(10): p. 741-751.
We all get it. Most of us have had an injury that has settled at some point, but for some pain hangs around longer than we would expect. Why does this occur? And when it does, what can be done? In this article, Musculoskeletal Physiotherapist Mike Callan will talk about pain; how it works, factors that can affect how much pain we feel, and strategies for those who suffer with persisting pain.
Pain is well, a pain. But what is it exactly? An emotion? Physical damage in the body? In reality it is much more. Pain is a complex psychological experience that is different for each person. The experience of pain occurs when your body’s alarm system alerts the brain to actual or potential tissue damage. There is no such thing as pain nerves in our bodies. We have millions of detectors in our body known as nociceptors, which are located in skin, muscle, bone, joint, ligament, blood vessel, disc, and nerve. When stimulated, these detectors can send signals through our nerves to our spinal cord, then on to the brain. But these are not inherently painful. The messages sent from the receptors and nerves are just a ‘danger’ signals; the brain then decides whether or not we experiencing pain, and how strongly we feel it based on how threatening the signal is.
This month’s newsletter will be focusing on lateral hip pain, which is often referred to as trochanteric bursitis. Recent evidence suggests that the primary cause of pain may actually be a result of gluteal tendinopathy, rather than from inflammation of the bursa, which may actually be a secondary finding to tendinopathy*. Tendinopathy involves changes to the structure of the tendon and breakdown of the collagen structure of the tendon, resulting in a tendon that is more like a weak spring as opposed to a healthy tendon that behaves like a stiff spring. Traditionally tendon overload has been considered to be tensile; however compressive load may play a significant role in the development of tendinopathy**. The gluteal muscle group is made up three muscles – gluteus maximus, medius and minimus, all of which are located in your hip region. The smaller two, gluteus medius and gluteus minimus, are the muscles that are commonly involved in gluteal tendinopathy.
Frozen shoulder is a condition involving considerable pain and loss of movement in the shoulder joint. Historically, this has been a difficult condition to treat due to a lack of evidence showing the best course of treatment. Left alone, the natural history of frozen shoulder generally takes 12-42 months with the average being 30 months, although the condition is somewhat self-limiting, it is not uncommon for patients to have ongoing limitation of shoulder movement. The standard approach for managing frozen shoulder has been to let the condition run its course; however it is understandable that many patients would rather have the condition resolve in less than 30 months or know the best options for treatment if they are experiencing strong and bothersome pain.
Rotator Cuff Related Shoulder Pain
Rotator cuff related shoulder pain (RCRSP) assessment and management, a recently published article by Jeremy Lewis, a leading shoulder pain researcher.
RSRSP is related to shoulder pain and dysfunction typically during shoulder elevation and outward rotation. Shoulder pain is common and associated with high levels of morbidity. While there is a range of influences that can create RSRSP, the major influence appears to be excessive and maladaptive load exerted on the shoulder soft-tissues, particularly tendon. Similar to other musculoskeletal conditions, such as low back pain, a definite structural diagnosis for RSRSP may be elusive. There is ongoing debate as to the cause of RSRSP with;
1) The mechanisms of pain uncertain
2) Poor correlation between symptoms and structural failure often observed in rotator cuff tendons, substantial numbers of people without shoulder pain demonstrate structural rotator cuff changes on imaging.
One Leg Physio is challenging you
Balancing is a necessity for our health and fitness of our bodies, it helps our bodies to stay upright and steady. Balancing in particular for people of senior age is very important as one in four people aged 60+ fall. One Leg Physio wants to see the average a person can balance on One Leg (categorised in age brackets).
How to take the One Leg Test
Breathing is one of the most basic and fundamental functions of the human body, yet little attention is often paid to it in a therapeutic sense.
Breathing can be considered dysfunctional when the person can no longer breathe efficiently or if it is ineffective in response to changing environment or does not meet the physiological needs of the person. This can in turn affect their quality of life, challenging homeostasis, resulting in physical symptoms and compromised health.
In practices such as Yoga, stress reduction, pain relief and meditation breathing is a prime area of focus. Research is revealing that the breath is a powerful tool and that regular practice of mindful breathing or meditation can facilitate a better state of health and wellbeing (Chaidlow et al 2002, Van Dixhoorn 220, Kim et al 2012, Telles et al 2008, Joshi & Telles 2009, Telles et al 2012).
Psychological factors play an important role in the development of chronic low back pain (LBP) and associated disability. Factors identified include interpreting pain as a threat, paying too much attention to pain (hypervigilance), increased pain sensitivity, difficulty ignoring pain and poor cognitive coping strategies. A recent article “Easy to harm, hard to heal” explores attitudes, beliefs and perceptions related to LBP (1). Key themes to emerge was the back is vulnerable to injury, there is a need to protect the back by resting, LBP is difficult to understand if you haven’t experienced it and LBP has an uncertain prognosis. Unfortunately these negative beliefs do not accurately represent the back.
However the key themes indicate there is an attentional bias toward information which demonstrates that the spine is vulnerable and some activities are dangerous, as well as toward information indicating that back pain is serious or the pain will persist. Some key positive messages should include LBP has a good prognosis and resuming normal activity as soon as reasonable is advised. Also the back is a strong structure and pain does not equal harm.