[Podcast] Shoulder injuries

Interviewer, Adam Bryne:

Hi everyone and welcome to the Joint Approach Podcast. My name's Adam, a physio working for Bupa in central London. On each episode of this podcast we will be discussing a musculoskeletal condition in relation to physiotherapy. Today's guest is Mike Grimmett, a senior physio working for Bupa and during this episode, we're going to be discussing all things related to shoulder injuries. Mike, how are you?

Speaker, Mike Grimmett:

Yeah, I'm very good, thank you. Thanks for inviting me on.

Interviewer:

Pleasure. Thank you for sparing some time in your very busy diary to help me out. We're going to talk all about shoulder injuries, an area I believe that you like dealing with and like treating. Is that correct?

Speaker:

That's correct. So very, very brief overview of me. I have previously worked in professional sport in both rugby and triathlon, both of which you see quite a few shoulder injuries. And then within Bupa, I've seen a lot of shoulder injuries and worked alongside our MSK physicians and consultants in shoulder injuries. I’ve spent time shadowing some of the top shoulder physios in England. So, Andrew Jaggy in London, and Joe Gibson up in Manchester.

Interviewer:

Yeah, nice. Joe Gibson's very kind of widely known actually for her inputs in shoulders. And if we kind of focus on more of the - obviously pulling bits and pieces from you know everywhere you've worked, but within your group of day-to-day clinic, what is the kind of the day-to-day most likely type of shoulder injury that's going to walk through the door?

Speaker:

Yeah, sure. So sure, we do see a lot of shoulder patients. So, our three most common injuries overall or common areas of the body to be injured is the back and neck then knee and then shoulder. So it's something we do see very, very regularly and probably a little bit surprising almost to a lot of people is that the shoulder injuries we typically see aren't aren't normally in relation to like a big sporting injury or a fall or a broken bone, and quite often aren't actually related to sport at all. So, we will quite often see shoulders that have become painful over a period of time, or there may have been a slight sort of mechanism of injury at the start, something that’s kind of almost like the last or the final straw that kind of broke the camel's back in in developing shoulder pain.

So, we typically see people come in with pain in around the front and outside half of their shoulder quite often. They will be struggling with catching within their movement, or maybe struggling to achieve full range of movement. And the pain will quite often be dependent on what they're doing rather than it being they're constant or all of the time. So, I guess two of the main ones that if you're happy for us to talk about really would be something that classes like an impingement within the shoulder and then maybe almost to do with a bit of an overload. So, kind of an overload of something called our rotator cuff. So specifically, the muscles in your shoulder, does that sound alight with yourself?

Interviewer:

Yeah, that sounds absolutely perfect. If we can, let's touch on impingement because I know there's some kind of interlinking with rotator cuff and things when it comes to impingement. What's kind of the most common cause of this type of impingement for you that you would see clinically?

Speaker:

Generally, it's probably fairly close, but generally we will see quite a lot of shoulder impingement in actually relatively sedentary people. So, for people who aren't going to the gym, lifting heavy weights, playing tennis, or swimming.

And a lot of the time it will be down to desk-based working and in particular over the last year working from home, we tend to have sort of desk or office setups which maybe don't enable us to sit up fully, have our shoulders back with our spine nicely upright and all of that tends to lead to shoulders that are called protracted, so almost pulled forward a little bit and rolled inwards so that our hands can meet on the keyboard or phone and sitting in prolonged postures or prolonged static postures, which is for most people what working from home or working from a desk is.

This can just create almost chronic low-level impingement within the shoulder, and when we say impingement that doesn't mean that something is getting abruptly squashed, it can mean that it's just having a pressure placed on it for a long period of time. So, two quite common structures within the shoulder, is one of the rotator cuff muscles, so one of the small ones which runs almost intrinsically within the shoulder joint, something called your supraspinatus.

But again, it's just a very small but important shoulder muscle. And then also we have something called bursa within our body, which are essentially sort of fluid filled sacs which are present at all of our joints in between muscles, tendons and bones and they allow all of those structures to normally slide and glide past one another as we move. But if we have a static posture for a prolonged period of time, applying a low grade level of force through it and we tend to find that these structures can become irritated and we can develop like a bursitis, an inflammation or an irritation to the bursa or even irritate the tendon itself. And in a nutshell, that is what a what, a shoulder impingement is.

Interviewer:

Yeah. And I think it's also maybe at this stage in point to highlight that you know, I see sometimes the misinterpretation of what a bursitis might be and so you know I try and reiterate to everybody that having bursas throughout the body like you've just mentioned is an entirely normal thing.

Um and they perform an incredibly vital role to, you know, to our tendons, to our muscles. It's just like you say when they become potentially compressed or there's a small injury to an area that they can become quite inflamed. And unfortunately, a bursitis can be you know, quite painful, can't it?

Speaker:

Yeah, definitely. And I think one of the main things says almost the positive about the bursitis is, is that it isn't for once, it isn't an injury where something is broken, ripped, or torn. It's where something is really, it's where there's a patch of almost localized irritation potentially even inflammation, but our bursae are designed to be squashed anyway. It's just they're not potentially designed to be irritated or compressed or pressurized for such a prolonged period. And if it becomes almost like if it's at resting level and it becomes more agitated, irritated or inflamed, it just means the level of pressure it takes to cause the pain is so much less and so we see it an awful lot in the shoulder.

We see a lot of bursitis problems in the rest of the body, but they actually tend to be more related to our hips or knees or ankles, our feet and potentially more so in relation to sport or activity. It's just the shoulder and a lot of patients we see happens almost or can happen a lot with inactivity.

Interviewer:

Yeah. And I think going back to sustained posture you know, with the shoulders slightly coming forwards, If, like you mentioned, we're working from home on the keyboard or on our phone or everything we tend to do nowadays is kind of in front of us this and I imagine there's quite a lot of people listening thinking, you know, maybe, I sit like this maybe. Is this something that you know is going to cause me to have issues and we see it everywhere? We see it’s super common now, probably a slight uptake like you've mentioned because of the last year that we've unfortunately had.

But that of course is something that you know which can be managed, which we will of course get to and if we then kind of deviate slightly away from the bursitis side of things and touch on now rotator cuff are you happy to kind of explain what the rotator cuff is and kind of what we see clinically that is related to the cuff.

Speaker:

Yeah, sure. So, the reason why I like seeing shoulder problems is because the shoulder joint is a is a brilliant joint and really complex.

So many other joints in the body have a single line of movement either bending and straightening, obviously shoulder can move everywhere. The hip is also a very mobile joint as well. And everyone knows that the hip is a ball and socket, well most people do.

The main difference between a shoulder and a hip is the hip is a very large socket that perfectly fits the quite large ball. At the end of your thigh bone and you very rarely hear of a hip being dislocated or subluxation and the main difference with the shoulder Is that it is still a ball and socket joint and you have quite a large ball at the end of your arm bone your humerus.

The main difference is the actual socket of the shoulder is quite small and open, and the reason for that is you would not be able to move your hand across your body behind your back, twist it, turn it, raise it up towards the ceiling If you had a large socket.

It's almost a very unstable joint and therefore it's reliant on a few structures holding it in place. So, we do have the capsule and ligaments, but most importantly it is these four muscles which are termed your rotator cuff and they work pretty much all of the time, whether or not you're standing or walking, they're still keeping that shoulder in a nice position and holding and joint.

Or if you're raising your arms up above your head, the rotator cuff muscles, they will do some of that movement for you, but their main job is to hold your shoulder joint in the right position so your bigger muscles can work, and in particular they're used. Then say in sports or at the gym as you really can't use your bigger muscles like your pecks or your lats or your deltoids if you don't have a nice strong set of rotator cuff muscles that hold your shoulder in position.

And importantly, the almost the timing of how all four of those muscles work as well, it's kind of crucial and so we see a number of different rotator cuff injuries. And so, yeah, we've mentioned the small little rotator cuff muscle before and it's one that runs over the top of your shoulder joint.

So if you imagine the line from your almost the base of your neck to the middle part on the outside top of your shoulder, it covers in that same line. And so it's really important in holding the arm bone within the shoulder joint itself. And also, in helping to say, raise your arm out to the side or stabilize it. As already mentioned, the rotator cuff is a small set of muscles and yet they have to work for prolonged periods of time and they are able to do this because they are designed differently to say a bicep or a calf muscle, bicep or calf muscle has a big chunky bit of muscle with very small tendons on either end of it, whereas a rotator cuff is a little bit more like a hamstring or one of the other muscles in your leg.

It is a small muscle, but it has a long tendon and the tendon structure itself is very, very strong. Which is brilliant in the first instance, as the problems we find with tendons are that they are very, very dependent on sort of a little bit like the old adage of use it or lose it. So they like a little bit of work very regularly to keep them fit and healthy and so that they feel that they can consistently adapt to whatever they're being asked to do.

The problems we tend to see are particularly saying a sporting setting, or if someone takes up a new activity, even, say, painting, we see lots of people get shoulder and elbow problems or gardening or sewing or using a screwdriver. All those kind of things is where we get a spike in activity and it lasts a little period of time and it's far more than that rotator cuff muscle is used to.

We know that in the first instance it can essentially react badly to that and either show signs of inflammation or even almost a bit of a weakening to a tendon that’s actually continued, and sometimes we don't get that pain straight away. So there can be changes that happen to your tendon, and it can be a weakened tendon if we say have a scan of it, but we wouldn't be aware of it before we actually start to use it, or almost overstrain it. So we see an awful lot in the in the supraspinatus muscle just because it is involved a huge amount in above head activities, which is all which tends to be a lot of the things that we do all of a sudden if we do them paint their walls or ceiling or whatever else.

And it's also a muscle that we can pinch a little bit within the shoulder joint. So this poor muscle can become a little bit weakened, a little bit overloaded, and then it doesn't have a huge amount of space in which to function either, and so if it does become irritated, it then means that it's more likely for us to also get an impingement of this rotator cuff muscle, and then that combines into a bit of a spiral where it doesn't start to work as well, which means the whole dynamics of how your shoulder moves. Again, gets affected and it's a bit of a downward spiral between dysfunction and pain and not allowing you to do what you want.

Interviewer:

Yeah, it can kind of then you know, roll on to potentially some irritation or like you said, dysfunction of other kind of surrounding groups of muscles are kind of issues within the shoulder itself due to that kind of one like you said, small muscle becoming slightly irritated and not having that, as much room as potentially it would like for function and for movement and for contraction and to stabilize that shoulder, kind of the head of the arm bone and coming away from supraspinatus, you know, we have three more cuff muscles and. Are you happy t just kind of briefly touch on each and say what kind of function wise they do and then kind of where they potentially can become injured or become kind of an issue that we would see in clinic?

Speaker:

Yeah, sure. Just said sort of is primarily, it was a movement function, is raising your arm above your head. But we do have three others. So we have two which support the back of the shoulder. So you have one called your infraspinatus and they will mostly sort of rotate your arm out to the side and draw it back down to the. midline. But what I would sort of hasten to add really is though, that is their movement is something that they can do a lot of the time - the rotator cuff aren't the muscles which provide that, that singular movement we quite often rely on our bigger muscles.

So that kind of ability to do that movement is normally used to stabilize the shoulder joint. So we do if we have any tendon problems or tendinopathies with the either the infraspinatus or supraspinatus you know, they, quite often do tend to be more in relation to sporting activities.

So where there might be shock and impact going through the shoulder and they're having to work really hard to stabilize the shoulder joint, we can see that they can either get overload, they can get a degeneration of the tendon where it starts to become a bit weakened or frayed and we do pick up tears. Within rotator cuff and not so you can get that in a supraspinatus as well, and I think we'll probably touch on sort of any rotator cuff degeneration or tears in a little bit.

And then the final one we have is a tendon that wraps around the front of the shoulder called your subscapularis and. It is actually quite a common one for us to pick up tendon issues in as well. It's a bit of a weird one in that it rotates your arm inwards again, it brings it back your arm back to the midline. We will typically see infraspinatus and super spinus issues more regularly, but subscapularis again, it's linked to certain sporting activities. And also just poor movement patterns. Again, if we're thinking of a shoulder that's pulled forwards that muscle alongside some of your pecs and other muscle groups will be consistently held in quite a shortened position, which means it's quite vulnerable when we go into any large sweeping shoulder movements which are placing it very on a stretch or right to a sort of a limit of its shoulder.

Interviewer:

Yeah, OK. Can you associate these sorts of muscles with like if you're looking at your experience with sport? You mentioned in triathlon you know let's say with the swimming motion. Obviously a lot of end range forced overhead type movement. Is there a specific kind of muscle orinjury that you see morecommon within that kind of within that group of sports people?

Speaker:

Yeah. So, sporting wise you can probably I haven't put huge amounts of points, but you can probably break it down into three main areas. There's kind of an overhead athlete whether or not that's a swimmer or say like bowler or pitcher or similar and then we can break it down into the resistance athletes. This one is doing forceful shoulder movements. So either in the gym or lifting in rugby or similar. And then finally we've got an impact athlete which would be say a boxer. And so within those 3 categories, we can, although there'll be lots of crossover, don't get me wrong, we can kind of start to classify into what we might expect to see.

So, in an overhead athlete where either you're a pitcher or a swimmer we'll be using a huge amount of, well, actually, all of your rotator cuffs, but we do regularly see supraspinatus impingement type issues in the early part of an injury or the in the early part of summer career. And that's definitely true in swimming, if someone had chronic shoulder problems.

Over the course of their career as an athlete, we will quite often find that they may actually get to a point where a number of their rotator cuff tendons are actually degenerated or partially torn or even ruptured in some instances. And yet that shoulder can still function with regards to heavy lifting, if you think of a guy down at the gym, either looking at doing a lot of bench press motions or shoulder press motions. Again, you'll typically see supraspinatus and impingement there.

It is quite a classical one for anything that say pressing motion, because again, it's encouraging either your shoulders to be in a forward position or we're encouraging certain muscle groups to work as they're in their most compressed positions. Then supraspinatus and then that further as well. Finally, boxing is a little bit of a different one, where is actually impact going through the joint because there's definitely force generation as in speed of hand movement. But when that hand or fist rather hits a firm object, there is there's quite a substantial force that goes back through the arm and the upper limb in general doesn't tend to have that much in everyday life.

You know, walking, obviously we've got a little bit of impact we get going through our legs running, we get lots of impact and lots of us will do those kind of activities. But things like boxing or doing hit classes where that's part of it, we do quite often see a lot more of posterior, so the back of the shoulder, rotator cuff problems, and you can still get impingements. But we do tend to then see more problems in the infraspinatus and around the back of the shoulder.

Interviewer:

Yeah. And I think it's, it's interesting that you mentioned the impact and it's something I’ve seen kind of come true now for those who are doing let's say gym classes from home that have kind of fortunately for me if I was going to because I don't like burpees, but a lot of people are taking that impact through their hands repeatedly. That kind of a strong force through the shoulder, which typically they wouldn't normally have and they're seeing some kind of injuries in the shoulder because of that sort of thing as well. And of course like you mentioned there are some different sports, but I'm currently actually treating a tennis player.

He's having a lot of shoulder issues from his serve and I think if anybody listening is unsure of the of the capabilities and a range of movement the shoulder has, I would probably strongly advise you to either look at tooth one of two things, a tennis serve because of the rotation and the force it can generate. Or a baseball pitcher. And when you see a slow motion version of a baseball kind of pitcher, the force and the movement of the shoulders is incredibly impressive, actually. And so when the shoulders are in good condition, they're very robust.

But if you have somebody who comes through to you, your main job is to get them, you know, as robust as possible. And when we're talking about the management of these injuries and what's your first step first step? For me it’s always identifying the primary roots of the issue and trying to kind of formulate a plan prioritizing kind of different things from there. Do you have a different way of approaching these things?

Speaker: No, I'm sure I'm sure our approaches will be will be really similar actually, but one thing I'd say about the shoulder, that you highlighted really well there is that it's capable of a huge amount of movement, but it's always combined movement.

So you can't raise your arm up above your head fully up above your head and reach it a little bit further back without there being some form of rotation in there as well. So unlike, say again, the knee or another or another joint, there will only be bending and straightening. There won't be those other forces that have to happen. So if you swing your arm around in a circle, you have to be able to rotate, otherwise your otherwise your arm would eventually come up.

I know you mentioned the baseball pitchers that yeah, if you, if you look at the videos of that, they will normally achieve about 330° of rotation, which is huge and astonishing. But if you’re not these pitchers in baseball, I probably would even get to 270° because it's not something I do regularly and within that our shoulder joint is a bit of a weird one because I've said it's a ball and socket.

Yeah, growing and really focused in only on that part, but obviously the socket part of your shoulder is attached to your shoulder blade. And again unlike say a hip, your hip joint is bolted onto your spine. So your pelvis can't really, it's got bits and bobs of movement around, but it doesn't really have a huge amount of movement. It is attached to your spine and then. Your pelvis moves around in your hip joint.

Essentially your shoulder is quite different. Pure movement at the ball of your arm bone - we have a good amount of movement, but we might actually only achieve 120° of like raising arms up into the air in order to get 180 degrees or even a little bit further. Your shoulder blade has to move around on your rib cage. And that then means that if it's going to move around on your rib cage, it's really dependent on the position that your ribs are in. Then the position that your ribs are in is dependent on the position that your spine is in. So, in an elite athlete, we will quite often see that and what you'll notice with, let's say, a runner, let alone like a shoulder athlete is that posture is almost always looks brilliant compared to if you've got a video of you or I running around a track.

Or, you know, trying to play tennis and I think one of the biggest problems we have in good level or even just starting our amateur level, say tennis players or swimmers is that they might have a shoulder that has the right amount of shoulder movement and it might even have not too bad rotator cuff strength and lapse pecks and deltoid strength.

The problem might actually be is that if you're sat at a desk for 8, 9 or 10 hours of a day. And then for about half an hour or one hour, you are fully using your shoulder and expecting your spine to be a perfect upright upright position, and your rib cage nicely flared to allow your shoulder blade to move around your body. It just it really, it's unlikely to happen. So I tend to find your shoulders that particularly when you first get very rarely do I see a shoulder that isn't quite grumbly by the time someone's turned up.

I very rarely get someone unable to have a shower. I certainly sort get a one or two out of 10. Quite often it tends to be bothering them more than that, so I try and use that that first couple of weeks to really sell the value of actually just resting your shoulder.

But we also know that shoulders have a real tendency to become a chronic problem, much like people get a chronic lower back problem. Lots of other parts in the body of a good tendency to recover. And yet the shoulder, if it's not managed well has a tendency to actually become more of a persistent problem for a patient, so I will use that initial part to really obviously try and work out what's going on in the shoulder.

And like you said, work out the root cause and it may well be, say, a tennis serve. The root cause might really be that that person, if they're right-hander, they're not fully leaning back on to their left leg. So, sort of loading up through their left thigh and they're glued the fact they might not be getting a good amount of thoracic extension, or almost reaching upwards, or rotation in the opposite direction, because that without that extension or extension the shoulder is going to really struggle to serve well, repeatedly without being without becoming injured.

So I guess my initial take home, if you do have a shoulder problem to really start considering what your posture is like, just basics at work when walking around. If you're carrying a rucksack, how much movement do you feel that you have at your neck because all those muscles are attached your shoulder legs. Catch up to your head. How much movement do you feel that you have in your thoracic spine.

Google like a beginners yoga or Pilates session. Can you get close to doing any of their movement like any of the movements on that? And if you can't, if you know that you tend to be stiff in your in your back, that would be a part I'd really want to start to tackle before I even before I start to push the shoulder on a little bit.

And if that’s something you try and in that phase, let's say it's like grumbly or quite irritable, do you take that opportunity when you're resting the shoulder to then address some of the other bits that hopefully will then, you know, play into a more optimal shoulder kind of further down the line.

Interviewer:

Yeah. And normally in a clinic, say I can, I can normally give a good demonstration just with the patients good shoulder and really simple things like if I get even if you were to if you're listening to this now if you were to sit and generally slump. So kind of have a rounded back and potentially how you might be at 6 o'clock, 7:00 at night, you're still trying to hit a deadline.

If you maintain that posture and try and raise both your arms up as high above your head as you possibly can, and you won't get much movement at your shoulder at all. Like you might raise it to 100 and 5000 and 60° if you allow yourself to fully sit up, right? Imagine you're trying to be as tall as you possibly can do.

You'll be able to reach your hands easily straight up towards the ceiling. And I'm not saying that. That's not like a perfect physio test, but it's a good way of reiterating how important actually spinal and particularly thoracic movement is for your shoulder blade to be able to move, so yes, absolutely. If I've got a sporting patient, even if nonsporting really, but if I've got a sporting patient who wants to return to practicing their tennis whilst the shoulder is quite unhappy and we can't do too much with it because we actually do need to let it settle down, otherwise we'll just continue to prolong the problem.

I'll really, really push kind of my frantic spying work that either I do hands on or that they're obviously going away and doing a bit of a home exercise program as well.

Speaker:

Yeah. Great. That sounds, yeah, I think it's incredibly important and it's actually something I demonstrate sometimes. Like you've mentioned that kind of slumped trying to elevate the arm in comparison, just as you mentioned to that nice upright position. If you know so you're a few weeks down the line, the shoulder is now like you mentioned a 1 or a 2 out of 10. Pretty manageable. And it's now time to start treating directly into the shoulder.

Let's say you know, for arguments sake you then go to then kind of loading the shoulder, strengthening it in those sports’ specific positions. Uh. Or do you have kind of a different sort of route or I guess system for managing these uh issues and conditions?

Interviewer:

Yeah. I think that’s a really good question. I think the main the main thing you really want to hopefully do first of all is kind of clear the shoulder being able to achieve a good functional amount of movement within the shoulder, relatively pain free. It doesn't mean you can't start load, you can't start to strengthen or load it until that point.

But having a good functional amount of movement, I’d say still really important and if that isn't possible because it's still too painful or unhappy. It's a tricky one because I see it from both sides of being an athlete and then being a physio, although not much of an athlete anymore.

But when I was it is it's incredibly hard t hold back another week or 10 days, but at the same time if you start trying to strengthen or load the shoulder or any part of the body, really too quickly you will really just be adding weeks or months. On to how long it's going to take to recover in the long run, so one of the hardest parts of being a physio is knowing how long to rest a certain area before you start doing something. But yeah, certainly I you're what people think even in the general sort of public or news or in relation to sort of sports, people are hearing more of now is the term loading or load management.

I saw it recently in regards to a football player previously they would still struggling with injury. Now we're saying their injuries recovered but they haven't. They haven't fully built up their load management yet and essentially what does load management mean?

Speaker:

I think it's a good way of describing it better than just saying strengthening as you can say load in relation to a shoulder. There is still some load going for your shoulder, although it's very minimal. Just in standing. I mean you're technically your rotator cuff and the other few intrinsic muscles are having to hold your arm, your shoulder within its socket essentially.

I know not much, but that term loading we can then look at loading in a neutral position. With your arm bone down by your side. So, whether or not we can start doing some kind of movement where you don't move the arm but you resist against it.

So what's called like an isometric kind of exercise if you're from an easy one to visualize is kind of obviously your squat, so you can either squat down and come back up again. You could add weight to that, you could jump anything else, but isometric squat would be that you just bend your knees and hold that position, or that you do a squat. Against the wall. So you'll work. You can work very, very hard, but you're not actually moving lots. And that tends to help at the start, particularly with shoulders, because again, it's very easy to overstep the mark with a with a shoulder.

So, if you've just got back to stage, you can start to strengthen it’s quite good being able to push into your hand almost in different positions and then you resist that with your shoulder and hold that sustained contraction. And that's quite a nice way of waking up your rotator cuff, potentially getting a tiny bit of strengthening and kind of getting them ready, then for starting to before you can start to move on to normal strengthening or sport specific strengthening.

Interviewer:

Yeah, I find that, that's obviously something that I use a lot as well. Those isometrics and even sometimes as they're getting to mid and late stage I I even put those in as potentially a bit of a warmup. But pre doing those more challenging exercises, one of the things I find I where I get resistance is like you've mentioned if they are a sports person, or if they are somebody who's generally pretty active or who goes to the gym and knows that they do all of these other different exercises and I get them pushing the back of their hand against the wall to engage some of their cough.

And they're probably thinking this isn't going to do anything, but sometimes when the shoulder is quite irritable and in pain I will just get them doing some isometrics and then retesting some of those movements and a large portion of the time you see a change almost straight away.

And you know that muscle is now warm, there's an increase in blood flow through it, it's feeling good and it's actually functioning a bit better once you've warmed it up. But when it comes to those higher level. So it's getting them on board with that. So trying to demonstrate those things that you might find is really important and how beneficial they can be.

Speaker:

Yeah. So I tend to find again that transition period is quite a difficult one when you've got a shoulder that isn't really painful to move and you know you can start to load it, but that person wants to be playing tennis it it's so annoying because the jump seems like it could be done very quickly and easily and sometimes it can.

But I would hasten to add that the majority of the time, if you make that jump too quick or too quickly, you will only end up reinjured or back at the start again, which is obviously not good.

The Temptation to make that jump is huge, but so often it's just not worth the hassle of having to restart. And there are lots of good exercises I'd say with that I do with people who are trying to return to a sport is where we would use, say, like one of our resistance bands and I would get them to pull apart or maintain attention so that it is technically isometric, but then you can get them to move in different movements.

So, they're doing movements that the muscles they're using and recruiting and activating are their rotator cuffs. It becomes tough, it's hard enough that people can feel like a strong work within the shoulder, but it's obviously nowhere near the same as giving them a I don't know, 15K dumbbell and telling them starting shoulder presses.

So it's a kind of it's a different way to start that loading, particularly with your shoulders, rotator cuff. But I know you mentioned about when you sort of, you know, building into sort of sports specific positions. I do really. I do completely agree about the one thing I say is if you think you say of like a shoulder, I don't think there's a huge amount of benefit and luckily this is sort of backed up by some very, very good shoulder studies as well.

So it's not it's not per my opinion. And I don't think there's a huge amount of merit in potentially putting your shoulder to end range sort of flexion or too high up and then working a rotator cuff just.

At that point where you're trying to transition from strengthening that rotator cuff in certain positions, and then doing a sport, the likelihood of overloading is actually probably quite high again. So, we would always look to get thrown up into a more sport specific position and we might quite often or so quite often might use sort of 90° whether the arms out to the side and we're doing some sort of rotation. Movements or 90° in front of body in in a sort of similar, but we very rarely start to work the rotator cuff in a in a physio exercise much higher than that it is in really trying to sort of focus in on the strengthening of it.

Interviewer: Yeah, I think it's kind of going back to a point you made just a moment ago in, in terms of when somebody's feeling like the shoulder is ready to do everything that they want to do ad then there's that jump – one way I try and explain it to these people is that it's difficult for us to recreate the reactiveness of the sport. You're going back to and everything we do in clinic. You're aware of what we're doing? Your home exercises are in a controlled manner. You know, you go back to playing tennis and it's completely reactive.

A lot of the time, unless your super high level, and so it's that's kind of where some of the challenges then lies in where you're putting the force or the forces through the shoulder in ways that you've not actually done in, in the rehab. So the essential moments of getting it as strong and as stable and as ready for that as possible is really quite crucial.

Speaker:

Yeah. So and this is where there's potentially a big difference between what you're able to achieve in elite sport and then what we're able to achieve is almost like as a an amateur or good level club, say tennis player as an example. So if you were that elite, uh, if you were that professional rather you would be doing all these strengthening exercises. You're completely right with the speed, the force, the reactiveness that we can mimic in a training session or so a physio session for a shoulder. We can't mimic what you do in in tennis, it's a bit different if you again if we have a hip and near an ankle problem, we can get you, you know, walking, jogging on the spot running, we can get your hopping, bounding, changing direction before you add that that kind of rugby ball football, whatever it might be and it's still obviously the reaction element of it when you're playing against someone. But we can mimic quite a lot of what you'll be doing.

Pre returning and the tennis it's not quite that easy. So again having worked in to a decent level in tennis at least and sort of had access to see what some of the pros would do is that they are not. There, there is no ego in for them returning to when they return to tennis and genuinely just playing either within three quarter court or choosing to use training balls which are they're not the same speed. I don't know. It seems silly to say weigh a tennis ball, but again there is that impact element of when the tennis ball hits your racket and that gets dissipated. For the for the arm. And also they will return to playing where they will only hit within what they know is their, like their happy striking position.

So not fully reaching anything that anything that then goes further when they're when they're practicing of their hitting partner, they'll actually just leave whereas we never really have that as a as an amateur you're either not playing tennis or you're going down to a club night and even if you're just at you know at club night playing with a friend. You can't really sort of change everything just for it to be about yourself and it's quite difficult to do.

Obviously we can do different things to say, swimming or boxing. There's no reason why you can't go back and initially start owning on back stroke or swim on your own and things like that. But things like tennis or sport specific ones for the shoulder, it's quite difficult to make that stepping stone as an amateur.

Interviewer:

Yeah, yeah, that's a good point in it. I think like you mentioned you don't want to make that one session all about you. So you're kind of you're in or out really, but it's just getting them ready for that for that point of being, you know, 100% to return to, to the level that they want to be at. And I think, Mike being honest, we could probably talk about this for a lot longer.

Kind of to wrap up, do you have any kind of take away information or take away kind of pieces of advice that, you know, if somebody's listening to this with shoulder injury or even? You know, they're potentially taking part in some of the sports that we've mentioned and they're and now quite keen to avoid the potential of a shoulder injury. Is there any kind of advice that you would give?

Speaker:

Yeah, particularly if you know for anyone who has previously suffered, give a shoulder problem or you feel that you might just be getting the initial part of the niggle and you know you're planning on doing a charity triathlon or swim event or something that you are committed to achieving. It's so it's so difficult getting that balance between training enough and overtraining or undertraining. I think you can't listen to every tiny little niggle you feel, but at the same time you do need to be honest with yourself and if you feel that you've persistently had a low level ache or pain you do need to ease off one way or the other, and if you realize that you've got that and you know that you tend to be quite stiff or immobile as that, I really recommend looking at your back movement and just seeing if you feel happy twisting and turning both directions and standing and sitting and your neck move as it should do.

And if you notice anywhere it's stiff or tight, really working on your spinal movement I think at that point I would, I would urge you to go and see a physio because it will speed up that process and hopefully expedite any sort of mishaps really.

If you don't have any shoulder problems again, I'll certainly make sure I make sure you're as mobile as possible from a spinal point of view. I would say there's no harm in starting some low level rotator cuff exercise even if you're just a Google or look online or similar, as long as it is low level, as long as you're not pushing yourself to fatigue or anything like that at all, even if your someone goes to the gym regularly and lifts weights, I think the rotator cuff is a particularly.

Underdeveloped or under trained area of the body, and if you know you're going to be doing anything with your shoulder or want to be doing anything your shoulder later on this year and it is well worth starting that training at early just because again tendons and rotator cuffs take quite a while to sort of strengthen up almost.

Interviewer:

Yeah, brilliant. I think that's I think it's really good advice. Just you know obviously like you said, you can't listen to every niggle you have but If you're concerned about something, see somebody, because some of the assessments that somebody can do, you can't do yourself and it may be able to highlight these things a little bit clearer and for sure the stronger your cuff is and kind of if you're priming your cuff for these activities the lower the chance of these injuries. So nice way to finish, I think, Mike, thank you very much for your time. I really do appreciate it.

Speaker:

Perfect. Thank you again for having me on.

Interviewer:

My pleasure. Thanks a lot, Mike.