In this episode of PodMD, shoulder and knee Orthopedic Surgeon Austin Vo from Melbourne Shoulder and Knee and Physiotherapist Nathan Rickard from Back In Motion Hawthron, will be discussing the most common shoulder conditions they treat with helpful information specifically on subacromial impingement syndrome and rotator cuff injury, including causes diagnosis management, and when to refer for radiology, physio therapy and surgery.
- Transcript
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*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
We welcome to the Podmd studio Austin Vo, Orthopedic Surgeon and Nathan Rickard, principal physiotherapist who will introduce themselves shortly. Today’s topic for discussion is shoulder pain and in particular rotator cuff tear and sub-acromial impingement syndrome.
We have physiotherapist, Nathan Rickard and spinal surgeon, Yi Yang talking about the full spectrum of neck pain patients and how to best help them
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.Nathan:Shoulder pain is a common and disabling complaint. The reported annual incidence of shoulder pain in primary care is 14.7 per thousand patients per year with a lifetime prevalence of up to 70%. Recovery from shoulder pain can be slow and recurrence rates are high, with 25% of those affected by shoulder pain reporting previous episodes and 40 to 50% reporting persisting pain or recurrence at 12 month followup.
In this podcast, shoulder and knee orthopedic surgeon, Austin Vo from Melbourne shoulder and knee and physiotherapist Nathan Rickard from Back In Motion Hawthron, will be discussing the most common shoulder conditions they treat with helpful information specifically on subacromial impingement syndrome and rotator cuff injury, including causes diagnosis management, and when to refer for radiology, physio therapy and surgery.
Austin, What are the most common causes of shoulder pain that you see?
Austin:Well Nathan, there are lots of causes if you break it down in four categories, there’s the shoulder pain coming from the shoulder or referred pain. So if you exclude, I guess, referred pain and one of the most common is, um, you know, cervical radiculopathy, I guess, the main cause of shoulder pain, number one by far would be impingement syndrome or subacromial bursitis. Um, and that can be related to, or associated with, uh, rotator cuff tears and that can be a whole spectrum of both partial to full thickness tears.
The second cause, and this is a complex sort of problem often to treat for both you and myself is, adhesive capsulitis or frozen shoulder, and then there’s degenerative causes so, osteoarthritis, whether it’s a primary osteoarthritis or what we commonly see and now these days with a long-standing cuff tear is cuff tear arthropathy, which, which essentially is arthritis as a result of long standing cuff pathology, where you have imbalance of the muscles around the shoulder and the humeral head sort of migrates upwards.
So, I guess the top three causes of, of shoulder pain that I see in my practice I guess, um, you want to also consider other pain generators in the shoulder. You know, the shoulder is very complex. You, you know, it’s made of not just a clinic humeral joint, but the acromioclavicular joint sternoclavicular joint and, and you want to factor in scapulothoracic thoracic movement as well and all those can, can trigger pain and it gets commonly associated with, with impingement syndrome, cuff tear is, uh, AC joint arthropathy.
Um, you want, so you want to pick those patients that have that as a, as a concurrent cause of pain. And then last but not least, and this is I guess, the forgotten tendon in the shoulder, are long headed biceps. Um, so I trained through France and, and they’re the ones that taught the world to recognize that the long headed biceps as being a pain generator. Um, so you want to critically assess that and treat that the same time. So hopefully that sort of answers your question there.
Nathan:Yeah, absolutely. And, um, funnily enough, or maybe it’s not funnily enough, but that’s pretty much exactly in line with what I see, uh, in, you know, in my physio clinics, um, it’s those same things. I mean, subacromial impingement syndrome, which I’ve noticed is now, you know, sometimes names change, I’ve seen it more recently referred to as rotator cuff related pain. Um, you know, like you said, it can be, um, subacromial bursitis, uh, rotator cuff tendinopathy. It almost goes in waves or feds or phases in terms of what we actually refer to it as, um, we also see a fair bit of, uh, long head of biceps.
Uh, pain would probably most often call it, uh, a tendinopathy or like compression of the, um, tendon over the anterior humeral head with poor body mechanics and portion and weakness. Uh, and we also see a fair dose of frozen shoulders and shoulder as well. Um, so I guess we do see the same patients are just on, at different points on the continuum. Um, yeah. Um, in terms of, uh, managing these patients, uh, when do you, when do you refer for radiology or when, or when do you think talking more specifically now about subacromial impingement syndrome slash rotator cuff injury? Uh, what are your views on referring for radiology?
Austin:Yeah, I think radiology plays an important role, uh, but it’s definitely not the first step. So nothing sort of is more important than a good sort of clinical history examinations, um, which then you can sort of narrow down your, your focus and have a differential and hopefully the imaging sort of just confirms what you’ve thought all along. Um, I think that the take home message is always start with an x-ray. Um, you know, you can see a lot of things on the x-ray even though just looks at, uh, the bone and joint, but you can look at, um, the clinic human joint and see how, how balanced it is, whether the human can seeing high or not. As I mentioned before, and you see the humeral head sitting high, that’s already an indication that this patient’s cuff is in trouble without getting, uh, uh, more advanced imaging such as MRI ultrasound scan.
Nathan:.Sorry Austin I’ll just interrupt there, um, seeing that’s a bit subjective and I’m sure lucky have a very good read on that. Are you able to give any kind of measurement on that in terms of millimeters space or space relative to other parts of the shoulder?
Austin:Yeah, there’s a sort of classification system. Um, you can, um, look up and it looks at the acromiohumeral distance, but the easiest thing, and rather than look at sort of what grade is, if you just draw a line, uh, we call it like the Shenton’s line, which we copy from the hip surgeons, but if you draw a line on, so the medial calcar the humoral, uh, neck, and you draw that, that should, um, sort of be in line with the inferior aspect of the glenoid. And so if you see that line being broken, that means the humeral head is sitting high.
That indicates that, um, that this patient has a, you know, some sort of cuff pathology. Cause as you know, the cuff, not as actively moves into the shoulder in different directions, but it keeps a human head centered. So, um, and most commonly involved superspinatus, which is the superior attendant. Um, so, um, when you lose that, the humeral head migrates upwards, and you see that clinically in patients with the, you know, when the hitch their shoulder. So that’s a good sign when you look at that break in the Shannon’s line with the sort along the medial Calcutta or medial, so neck of the humerus, um,
Nathan:And when someone’s displaying that How long do you reckon that’s an existence for before it can start causing osteoarthritis like you referenced before?
Austin:So arthritis is a sort of, um, yeah, so the end product of, of longstanding de-compensated, uh, cuff pathology, um, and when shoulder surgeons talk about a rocking horse movement. So every time they try to elevate their arm to the shoulder moves up and down sort of rocking horse movement and that sort of cyclical movement over, I guess, you know, thousand repetitions will cause, um, uh, glenoid wear and osteoarthritis.
Nathan:Yeah, sure, sure. For sure. I’m so sorry. I interrupted you when you’re talking about that. It mate carry on.
Austin:So we talked about imaging, so definitely start with an x-ray. Um, and as I mentioned, you can see all those things and then other things you can see on the x-ray is the AC joint. Um, so, um, and bear in mind, you got to take the, a lot of people who have AC joint arthritis and x-ray, but, um, you need to marry that up with the clinical science. So for me, if they’ve got no tenderness over the AC joint, no matter how arthritic the AC joint looks, that’s not pathologic, it’s just, it’s just part of the, you know, the, um, the process they’ve gone through in terms of wear and tear. So you leave that alone. Um, so apart from the AC joint, you can see calcium deposits.
So another condition within speak about, I guess, less common, but I’m sure you’ve seen this nathan and another one of the most painful conditions we see is calcific tendinopathy, where patients get this buildup of this dense calcium in their superspinatus tendon. And just that pressure within a tenant causes quite significant pain, sometimes even mimics like a septic shoulder that’s how sore their shoulder. So, um, so that you can definitely see it on the x-ray. Uh, I guess that’s the limit of the x-ray, uh, if you’re talking about rotator cuff, we really need advanced imaging for me. And MRI is probably the most useful and that’s probably superseded even ultrasound. You know, I’ve got no problems with pasting an ultrasound, it’s really available.
It can tell, um, whether they’ve got any sort of biceps fluid or bursitis or even rotator cuff tear, but when you want to quickly analyze that rotator cuff in terms of how, how, um, how big the tear is, um, how far its attracted to how far the tendons has migrated from that tuberosity, where it’s torn and probably the most important thing, Nathan is, uh, the quality of the tendon and muscle. Um, because, um, if you’ve had chronic kind of cuff pathology for a long time, that tendon and muscle undergoes a irreversible process called fatty atrophy, where the muscle actually gets replaced by fat and that’s a bad prognostic sign. So when you see a lot of fat compared to muscle, sometimes you have to tell a patient, no matter how good the surgeon or the surgery is, you can’t fix that. So that’s something you want to know before you take the patient to the operating room.
Nathan:Yeah, I would say from definitely from my perspective as a physio to touch on one of the first points you raised, it was, you know, well, for example, we talked about the AC joint just because it shows degenerative change. You can’t just assume that it’s producing pain. And when I, with MRIs as a few studies, that show, when you look at MRI’s in people, i think baseball players was one where they looked at their throwing shoulder, which was symptomatic and then non-throwing shoulder, which was asymptomatic, they both had an equal number of, uh, real, uh, prevalence of tendinopathy, partial tendon tears, even, even labrum tears. And just as it was just as common in the non-painful non throwing shoulder as their painful throwing shoulder. So, you know, the, what we see, um, has to correlate with the clinical findings in that patient’s, uh, presentation, uh, put that like a fatty infiltration you’re talking about will outside the realm of those though, but
Austin:I guess you raise a very important point because, um, and this is why you shouldn’t just order an MRI or straight off the bat for every patient, because MRI is so sensitive, Nathan, it picks up so much. And I guess if you scan it, everyone who who’s over the age of 40 or 50 that crosses the road, half of them will probably have a cuff tear and don’t even know about it. And so, um,
Nathan:But then what happens is when I find out about it, they get nervous. They use their shoulder last. I had like a negative pain construct in their mind about their short of effort, like weaker, weaker, stiffer and can actually give themselves a shoulder problem because of a scary MRI that’s actually showing, you know, relatively age related changes.
Austin:Correct. Absolutely. So you need to put that all into context, I guess that’s important role of both physios and surgeons just to put that perspective for the patient.
Nathan: Hmm, definitely. Definitely. Um, so when it comes to rotator cuff repairs, um, specifically, um, and you’ve mentioned, um, the narrowing of the subacromial space, are there any other tell tale signs, uh, when it comes to radiology or pain or function that to you is a red blinking light saying, yeah, this person does need surgery.
Austin:Um, no, look, the impingement is, is, um, it’s never an emergency, I guess, or, or, or, uh, no one I’d say definitely in surgery. So, um, just, just because it’s so common as well. So I guess the telltale signs where, I guess if they’ve failed conservative treatments, if they’ve tried physio and we’ll talk about the role of physio in a moment, um, if they’d have, um, pain classically, you know, as you know, with painful arch and examination wise, they’ve got a positive opinion of sign or, or Hawken sign.
Um, and then, um, I guess the other thing we have, which we’ll touch upon as well, as well as the role of injections, because for me impringement syndrome, or even chronic cuff tears, you know, part of the first-line treatment apart from physiotherapy is a, is a steroid injection, not just for its therapeutic benefit. Cause we know the coritsone generally lasts only two, three months. Um, but it’s also diagnostic value, safe, injected a shoulder, and they’ve had good belief for the symptoms at least gives you a bit more confidence in, in, in sort of, uh, diagnosing that as their primary source of pain. Um, and that’s, I guess, um, then leads to a step surgery if they’ve tried all those things. Um, but generally surgery is the last resort
Nathan:Sure thing, sure thing. Uh, and that’s pretty much in line with what we, uh, do as physios. I mean, there’s a, um, a broad range of conservative treatment options that we do do. And sometimes we do get GPs asking us, you know, because they might get a patient go to a physio who does massage, or they might go to someone and get exercise, or they might get go to someone and get a stretching routine. So sometimes there can be a bit of confusion around what actually works for subacromial impingement syndrome before they’re at that point of needing surgery. And I guess the answer is it kind of just depends on the client. It depends on the patient. Um, so for us, it’s just crucial to really understand why they keep on impinging. Um, because you know, like, as you said, like injections really, uh, they’re not a really good standalone treatment option without, um, other management, because if they keep on impinging, once the steroid wears off, you know, the problem is still there.
But the things that we tend to look at, uh, you know, tight necks in a stiff, rounded thoracic spine, cause it just gets the mean to a position that when I do elevate their arm and they just get that jamming in the subacromial space. Um, and similarly, um, poor posture. So if they’re not stiff and taught in a rounded position, if they’ve got poor posture and they sort of slump, when they’re actually doing things overhead, they suffer the same, um, jamming or impingement on, um, uh, in the subacromial space. Um, one that I see a lot of is just, um, I’m not too sure why it is exactly. Maybe it’s the fact that we’ve laid relatively sedentary lives, but we tend to, I’ve seen it in a lot of people, a lack of a lack of upward rotation of their scapula. So everything I was saying is quite good, but when they actually do something overhead, their scapula doesn’t actually rotate upwards and face the glenoid, um, upwards, which means it’s still just jamming underneath this subacromial space.
And I’ve had people come in with, um, you know, pain on elevation. That’s quite severe and they’ve had it for ages. And as soon as I just actually facilitate the shoulder blade, turning up upward and teaching them how to do it, they can lift their arms with almost no pain at all. Uh, in which case with them, you know, there’s a lot of motor control retraining or, you know, uh, coordination training with how they, um, how they do things overhead. Um, strength is really important. Um, again, I think it was because we, a lot of us leave very inactive lives. We just lose general functional strength and due to a lack of strength when people reach overhead, um, they tend to just lack the strength and therefore, to actually control the humeral head, which means it can jam, you know, any number of things within that space.
Um, and so with these patients, we do a lot of strength training and they wouldn’t be too many people we see with the subacromial impingement syndrome that we don’t do strength training if it’s it’s that common and, and that needed, um, and probably the last thing that we always make sure we tick off the list with all of our patients is, you know, education and advice, just because it shows that across a range of musculoskeletal injury, but, you know, studies show that, you know, the better a patient understands their pain the more compliant with their exercises and the better their outcome. So now the positive psychology and, uh, and self efficacy, it’s just really important to keep people going and moving and using their shoulder. Cause the worst thing they can do is just get protective, freeze up, use it less, get stiffer and weaker, and then, you know, it all kind of snowballs downhill. Um, so in a nutshell that’s probably like all the different things that we do do, um, as physios.
Austin:Um, you touched on some very important points there. So you mentioned with poor posture, rounded shoulders, have you noticed, um, with people working from home the last 12 months is that I know a lot of more back problems, but have you noticed that sort of, um, moving on to the shoulder as well? Or
Nathan:Yeah, yeah. We definitely have just due to poor workstation setups. People do sit in poor postures. Um, and I think that thing compounding with going back to the gym after period of inactivity and going back to the gym with a lot of enthusiasm and pent up frustration, maybe from being inside for long periods yeah. Then even more likely to then hurt with an accident at the gym. Um, so it happens in both ways, yeah poor posture and then due to a lack of strength and postural strength and control then putting themselves at the gym. Yeah. Pretty common. Yeah. So you have seen that too, like in your, in your surgery?
Austin:Well I consciously have to try getting better posture as well, working in there on the desk, but, um, yeah, I think that’s important. Um, you mentioned strengthening, uh, as well, and this is, this is what amazes me. Sometimes you see this, you get these patients, I’m sure you’ve seen as well. And they’ve got these massive rotator cuff tears and, and they can still function pretty well. Um, cause it’s been chronic, the tenant’s torn over a period of time and so being able to compensate for it and I guess that’s a very important role of the physio, um, to strengthen the muscles around the shoulder, not just the cuff, but I guess the parascapular muscles, um, can actually elevate the arm with with pretty much no superstars left. Um, have you seen that as well? Yeah,
Nathan:I haven’t seen that. I’ve seen the extreme versions where I’ve had, you know, patients that haven’t had a complete rupture and you can still lift their arm overhead and not just shoulder hitch, like lots can only shoulder hitch and, that’s it. But I have seen those that have just essentially kept on going and sulfury, hadn’t figured it out. Um, and even probably on a lower level, we’ve got some, um, like some, uh, push pull and force plate, uh, dynamometry strength systems at X clinic where we can measure individual rotator cuff and get very precise strength readings on them. And we’ve seen some people that have quite severe and longstanding degenerative tears to have quite a weak superspinatus, um, in comparison to their other shoulder, but their functional strength is just as good. And they might be stronger in a few other muscles when you test them in an isolated fashion, but some total when they actually can change how they use their shoulder slightly. They’re still very effective and have functional strength and low pain in many cases.
Austin:Correct. And then that’s why, you know, a lot of these patients it’s, it’s, it’s it’s my surgeries is a, I guess, a last resort, um, because, um, you can, it’s some remarkable how the body can compensate and sort of, um, uh, you know, um, compensate for that lack of function. I guess on the flipside though Nathan, chronic cuff, tears is one side, but acute rotator cuff is a completely different entity and, and they’re not as common. Um, but you don’t wanna miss those patients cause they’re the ones that did the surgery. They’ve had an acute rupture, their tendon. And unless you fix that tendon back, um, they’ve, haven’t, haven’t had the chance to be able to compensate for. So they’re going to have sort of ongoing weakness and dysfunction. Um, I guess one of the typical scenarios that I often see, um, that actually gets often picked up, you know, um, physios on the ball like yourself is in the patient in the middle aged forties and fifties.
I don’t know I’m in my forties. Um, and then, um, they, they trip over at home or something. They do something in the garden and I dislocated their shoulder and they go to loocal department and, they get their shoulder popped back in, x-ray all looks normal. Um, and then everyone just relaxes and then go, just go see a physio and rehab your shoulder for those patients studies have show that that, you know, over 50% of people would just dislocate the shoulder in the middle-age, we’ll have a rotator cuff tear. So they’re the ones. If we talk about imaging, you have a low threshold for getting MRI scan because those patients have acute, probably large or massive cuff tear.
Nathan:And if that’s, if that’s missed Austin for a while, what is your window of opportunity for operating successfully on them? Uh, look like how long is too long to leave it before the end of the tendon. You know, I started dying off and retract and can’t be successfully stitch back together, period
Austin:Over a period of months, three to six months. Uh, I wouldn’t say it gets harder because what happens is not any retracts, um, because it said it only goes out that atrophy. And so it’s harder to even after you do your releases in surgery, to be able to pull it back because ultimately what you want is to repair a tendon without tension. Um, because know part of the rehab is you want to start moving that shoulder at some stage and you don’t want to have that tendon sort of pull away as soon as you start moving it. So it has to be reasonably tension free. So you want to get it while it’s still, um, pretty early on. Um, that’s definitely one not to be missed acute cuff tears.
Austin:So, um, Nathan. And, um, we talked a lot about, um, shoulder pain and different conditions, but in terms of what you seen, what, what do you think is one of the things that predict ongoing shoulder pain? Um, despite what you’ve done?
Nathan:Yeah, it’s interesting. There’s a couple of key things that some research has shown, um, which is, um, like lower education level, um, poor sleep, um, and lack of activity. Um, they seem to be three key things. It wouldn’t necessarily jump straight to mind when it comes to predicting someone who’s going to have ongoing shoulder pain. Um, but I think some of the outcomes of those things, um, people that fear pain and think the best way, well they fear pain, they think more pain equals more damage.
So they use their shoulder less to avoid pain, um, particularly anything overhead. So they get stiffer, tighter, weaker and they impinge more and have more issues. Um, I find that people that are inactive in general just don’t use their shoulder enough to naturally rehab it, you know, go back a hundred years ago. And there weren’t, there were no surgeons and there were no physios, people hurt their shoulder and they had to keep on going so that I did an they kinda didn’t use their shoulder if it was too painful and when they could use it, like they did a sort of self rehab, almost like that patient group.
We talked about who find out a way to keep on using their shoulder effectively, even though one’s quite deficient one rotator, cuff muscles, quite defficient. Um, so conversely people that just aren’t active, they are quite often have more problems than those that are. Um, and people do have sometimes have, um, patients that aren’t very intuitive. They’ll hurt their shoulder or impinge their shoulder lifting something overhead routinely at home or they might be at work, like reaching up onto a high shelf from their desk chair. Um, and for some reason they don’t think to stop doing it. They just keep on doing it. So even they might see a physio, they might get exercises and I’ll check in with them and they’re still doing that same repeated painful action that keeps on injuring it. So without, a bit of education, um, they’ll keep on having, uh, ongoing issues. Um, what about yourself in the, um, patient groups that you see?
Austin:Yeah, so, um, what I sometimes see, uh, I guess, important not to miss is, is make sure you’ve got the right the right diagnosis. And I mentioned from the outset, you know, that the shoulder is so complex, so many pain generators, and, and often I get referred patients, who’ve had great surgery done by other shoulder surgeon. They had a great rotator cuff repair, you know, excellent rehab, but they’re still got shoulder pain, six to 12 months down the track, and then you come closely and the AC joints tender, or the long headed biceps is, is tender. And then probably wasn’t recognized at the time, because I guess the rotator cuff took precedents, which is fair, but yeah. So, uh, whether it’s been sort of a miss sort of, um, diagnosis of other concomitant causes of pain, um, I guess is one thing. Um, and I guess, um, um, yeah, that’s probably the, the main thing that I see.
All right. Uh, so Nathan, um, we’ve discussed a lot of things. Can you just, uh, I guess summarize, um, for the audience out there, what are the main take home messages at this stage?
Nathan:Yeah, for sure. I think one of the key ones is just reassuring the patient that their shoulder can sustain considerable wear and tear and show it on MRI and still get back to being a hundred percent pain-free and fully functioning. And that no matter what their problem is improving their flexibility, how the shoulder moves and strengthening with exercise is key. Um, uh, from what I’ve seen conservatively, pre-surgery when, before someone needs surgery, no matter what other treatment is done, if the patient’s left with a stiffer or weaker shoulder they’ll just keep on stressing and, and reinjuring, um, just being positive and educating the patient about pain mechanisms, pain doesn’t equal more damage. And I give them confidence that if I keep on doing what’s important to them and finding out a way to use their shoulder, they’ll actually self rehab and improve. Anyway. Um, what about yourself Austin, for your, um, take home messages?
Austin:Very similar look, I’d say if you’ve got a patient with impingement syndrome or a rotator cuff, explain to them that it is fairly common, um, and, um, and it is certainly treatable without surgery. So definitely go down that path. Um, so find yourself a great physio, uh, try, try the cortisone injection and if all else fails, then we still have surgeries and option. Um, the other, I guess, message we’ve touched upon is don’t miss the acute rotator cuff tear that’s a separate entity and they’re the ones that probably need to, um, to move on a bit quicker. Uh, we talked about judicious use of MRI scan and sort of the rationale for that. Um, and, um, I guess, uh, the last but not least is, is, um, the shoulder is a very complex joint, you know, this is for, um, you know, for, um, joints there. Um, there’s 30 muscles that, that helped move it. Um, so so many pain generators. So, um, look outside and make sure you’re not missing something else apart from the rotator cuff that you can treat at the same time.
Nathan:Awesome. Thanks Austin. Uh, that was, uh, that was great to speak to. Yeah, it was, I like chewing the fat on different injuries like that. It’s uh, it’s good. Fun. And yeah, you always learn something every time. I think when you speak to, um, someone like yourself, it’s fantastic.
Austin:Great, Nathan, thanks for having me and definitely learn something as well from yourself and greatly will share a common interest in helping patients get better.
