Dr Angela Cadogan - Physiotherapy Specialist

Shoulder Stabilisation: Post-op Rehab

More good discussions with the Shoulder Academy team last Thursday on this topic.
🔹 the patient-surgeon-physiotherapist team
🔹 importance of 'prehab' for significant scapula dyskinesis and motor control
🔹 rehab 'speed limits' - who needs to be pushed, and who needs holding back?
🔹 healing timeframes for different surgical procedures (capsular shift, tendon-bone anchors, subscapularis take-down and repair).
🔹 psychologic screening for return to sport: how honest are young people who 'just want to play'?
+ lots more.

Thanks to those who joined. If you missed it, the recording is now available on your Shoulder Academy dashboard.

👉 Next up: What's new in rehabilitation following rotator cuff repair (1/8/2024).

For information about Shoulder Academy see link in comments.

Physio Academy - Learning

💪 Shoulder Essentials - coming to Southland in Sept 2024.

Looking forward to getting back to this great part of the country on 15th Sept to update on the 'essentials' in diagnosis and management of frozen shoulder, rotator cuff and shoulder instability. It's a hands-on course with lots of rehab gems and an online component (12 months access).

More info: https://learning.physioacademy.courses/bundles/shoulder-essentials

Academy - Learning

eLearning also open in Italian until 29th May. 🇮🇹

🚀 Aprono oggi le iscrizioni ai nostri e-learning, con una novità per il 2024 in esclusiva italiana, e in promozione!

✨ E' un compendio approfondito e chiaro della diagnosi differenziale di tutte le problematiche di spalla, ideato da Dr Angela Cadogan - Physiotherapy Specialist pensando ai fisioterapisti che lavorano in accesso diretto.

🤓 Screening generale e specifico, categorie diagnostiche e algoritmo di ragionamento clinico, criteri di referral, storia naturale, prognosi e trattamento: avrai tutto sotto controllo!

Iscrizioni e info su: https://agenzia-ebp.com/angela-cadogan

Shoulder Diagnosis Course
💥 eLearning Now Open en Français 🇫🇷

What are you treating? What is evidence-based management?

Get confident in:
👉 Screening for serious pathology
👉 Clinical assessment
👉 Shoulder tests
👉 Imaging indications
👉 Evidence-based surgical and non-surgical management
👉 Referral criteria.

⏳ Closes 27th May.

👇Registration link in comments.

Shoulder Essentials - Tauranga Course
Earlybird prices end 12th May.

These really are essential 'not to miss' conditions after shoulder dislocation. Could you identify them? What's your plan? Nerve injury not improving? When should you refer?

Anyone seeing acute shoulder injuries should be able to identify these conditions - skills you will learn on this course.... and more....

More info or register here: https://learning.physioacademy.co.nz/bundles/shoulder-essentials

Physio Academy - Learning

Which rotator cuff tears should you refer for orthopaedic review and when? 🔥 hot topic right now.

Shoulder Essentials online course comprehensively covers this topic, and the practical course with give you the skills to manage load for people with irritable rotator cuff-related pain.

Earlybird prices end 12th May, places still available on the Tauranga course.

More info or register here: https://learning.physioacademy.co.nz/bundles/shoulder-essentials

-Learning

Stiff Shoulder -Q&A
Thanks to the Shoulder Academy team for another great live session last night. Lots covered, especially the role of injections (corticosteroid and hydrodistension) in the management of frozen shoulder. The recording is now available for Shoulder Academy members.

Also check the Shoulder Academy Community post for a downloadable copy of the recent clinical audit discussed by one of the participants in last nights session re: use of hydrodistension for frozen shoulder - looking forward to the discussion. 😉

➡️Next up - Unstable Shoulder Q&A (27th June). Details in the Shoulder Academy Community.

For information about Shoulder Academy see link in comments.

Physio Academy - Learning

Why would you use the Belly Press to test resisted internal rotation instead of the traditional 'forearm forward' position?🤔

Find out in the Shoulder Foundations and Shoulder Essentials Practical Courses in Christchurch on 6th and 7th April.

(Perhaps review the shoulder internal rotators before the course! 😉)

Link in comments.

Thanks to the Christchurch Hospital Emergency Department physios for asking me to talk to them about shoulder conditions they commonly see.

A great opportunity for me to reflect on the atraumatic conditions that cause "sudden onset, severe shoulder pain" (SOS) and often drive people to seek care at the emergency department and look to at these through a different lens. What are the key differential diagnoses, how do you do this in limited time with limited resources and what are the 'discharge' clinical pathways? Priviliged to be part of the journey helping to improve patient journeys and outcomes.

What I enjoyed even more was hearing about the great work the ED physios are doing in evolving relationships and systems to assess and manage patients who present to ED with MSK conditions. It really highlighted the skills that these physiotherapists have and what a difference getting the right intervention at the right time can make to patient outcomes. Kudos to you guys for the great work you are doing. 👏

What if.... you didn't have to do loads of 'special tests' for the shoulder? 🤩

A few ROM and resisted tests are all you need. If you are a new graduate have new graduate staff, or just want to update on the basics of shoulder assessment and treatment, the Shoulder Foundations course may be a good option.

The Shoulder Foundations course is all about making the shoulder simple. That includes assessment, simplifying imaging indications, and giving you a structured way of treating shoulders that can be applied to any condition.

Shoulder Foundations is only being run once in 2024 on 6th April (6 weeks away) in Christchurch, places are filling so reserve your place soon (⏳earlybird pricing ends this weekend too).

More info or to register: https://learning.physioacademy.co.nz/bundles/shoulder-foundations

☢️ Ordering Imaging - What are our responsibilities?
Great discussion last night: Scope of practice, indications, safety and we went through basic shoulder x-ray views with clinical examples of what can be seen. The recording is now available for Shoulder Academy members through your dashboard.

Looking forward to the next one: Stiff Shoulder on 18th April.
www.shoulderacademy.co.nz

Physio Academy - Learning

ACJ - The forgotten joint? 🤔 Looking forward to talking about the ACJ in the Upper Limb Masterclass (online event) 29th Feb (1st March, 7am NZDT). I'll use a series of case studies to highlight some of the atraumatic causes of AC joint pain covering clinical diagnosis, imaging and treatment/rehab. 💪

For more info or to register scan the QR code in the image below or go to link in comments.

Physio Matters Physio Academy - Learning

Another 'ah-ha' moment last week. 💡 After first establishing baseline symptoms (resting ache in the R) suprascapular region), correcting the scapula position manually, confirming this did improve symptoms, I then asked the patient to hold the corrected position where both scapulae looked fairly symmetrical. He says "but that doesn't feel right". To him, the corrected position felt 'overcorrected' and he felt as if his whole trunk was leaning too far to the left.

We can correct things all day long, but if the patients' sensory perception (including body schema & proprioception) have been altered by long standing pain (and a whole range of other things), they won't be able to maintain and/or consistently reproduce it.

Homework for this patient? Go home, correct the position and look in the mirror to 're-calibrate' until what you see = what you feel.

Sensorimotor deficits are common reasons why people don't improve as expected with rehabilitation. If you want to find out how to assess and rehabilitate sensory impairments, and improve motor control so that you can make more progress with strength-based training, join Dr Jacqui Clark and myself in Tauranga in 4 weeks for "Rehabilitation of the Complex Shoulder". More info in the comments below...👇

Pains and Brains Physio Academy - Learning

How to Read a Shoulder X-Ray.

Looking forward to meeting up with the Shoulder Academy team at the Shoulder Screening Q&A on 22nd Feb 7.30pm to talk about this topic.

Tune in with a cuppa and we'll cover off:
- practice guidelines
- shoulder x-ray views
- what can be seen
- the clinical relevance
- issues around safety, scope of practice and professional and ethical considerations.

See Events in your Shoulder Academy online community for details. Look forward to seeing you then. 😊

Angela.

Scapula Dyskinesis - Strengthening not working?

In my practice, this is by far the most common thing I see. Clear scapula dyskinesis, ongoing symptoms (pain, clicking, instability) and not responding to typical 'strength-based' rehab. Why? I had to go on a long and rewarding learning journey to find out which led me to team up with Dr Jacqui Clark and combine our MSK/pain/neuro expertise.

You can listen to this Free webinar where Jacqui and I discuss the reasons why some people don't improve with strengthening: https://learning.physioacademy.co.nz/courses/the-tricky-scapula

If you want to develop your own assessment and rehab skills for these patients, see the link in the comments.

Happy New Year! If you're wanting to add more 'tools to the kit' for managing complex shoulders this year, join Dr Jacqui Clark and myself in sunny Tauranga, 9th and 10th March 2024 and fill up your toolbox! ⏳ Earlybird pricing ends in 2 weeks.

Sometimes what seems complex can have a simple solution, you just have to know what you're looking for, and develop some tools to manage it. We'll give you a new set of assessment and rehab skills to do this that you can apply to any MSK condition.

More course info here: https://events.physioacademy.co.nz/events/shoulder/shoulder-rehabilitation-course-trg-rcs-24

Physio Academy - Learning Pains and Brains

Evaluating the Benefits of the MOVE Mentoring Programme to Mentors and Early-Career Physiotherapists.

Last year I had the pleasure of teaming up with my friend and colleague Dr Margaret Potter to run a pilot study on the benefits of a structured mentoring programme for new graduate physiotherapists and our results have just been published.

Some really interesting insights here from new graduate physiotherapists at a time when mentoring is becoming an important part of practice. One of the issues we found was the lack of understanding of ‘mentoring’ and how it differs from supervision. A critical issue when it comes to the mentoring experience.

Thanks to all the awesome new graduates who participated and the fantastic team of mentors who volunteered their time. Hopefully this provides some useful insights for those wanting to become involved in mentoring, or for practices where staff are already engaged in mentoring roles.

👉 Check out our publication in the New Zealand Journal of Physiotherapy, 2023 Issue https://nzjp.org.nz/nzjp/issue/current

Academy - Learning have some mentoring upskilling opportunities coming up in 2024. More on this soon.

TELL Centre Physio Academy - Learning

Rehabilitation of the Complex Shoulder - last practical course for 2023 done! Always fun learning and teaching with DrJacqui Clark. Thanks to the 19 fantastic physios who joined us from all over NZ (and from Denmark! 😀) and to Physio Academy - Learning for hosting the course.

Always fun playing detective and figuring out where in the sensorimotor system the problems lie and so rewarding when you can get quick results with the right rehabilitation.

We're also grateful to have an increasing list of physios around the country we can refer people to who have 'tricky shoulder' problems.

Join us next year in Tauranga or Christchurch if you're interested in growing your toolkit for complex shoulders. https://learning.physioacademy.co.nz/bundles/rehabilitation-of-the-complex-shoulder

AC Joint Q&A: Another good session last week with the Shoulder Academy crew. The main topic discussed was AC joint dislocations (Grade 3 and 5). Surgery vs non-surgical management, predictors of response to non-surgical treatment, how soon is too soon to return to sport and what are the considerations?

Thanks to those who attended for their great questions and discussion. The recording is now available for Shoulder Academy members.

Physio Academy - Learning

Reflections on Specialist Physiotherapy referral - patient seen yesterday.

A 51 year old female was referred for persistent L) shoulder pain following high force axial load injury through a straight arm >1 year ago.

Treatment included physiotherapy, NSAIDs, chiropractor, Sports Physician (referred for subacromial bursal corticosteroid injection - 0% relief). Now considering referral for chronic pain assessment/management due to ongoing symptoms.

Symptoms: Dominant superior shoulder pain, 6/10 at worst, limiting ADLs and recreational activities. No widespread pain or other nociplastic features.

X-ray report: "no bone or joint abnormality'.
Ultrasound report: Rotator cuff intact. SAB thickened.

On examination:
- Full passive ROM (excludes frozen shoulder/GHJ arthropathy)
- Minimal pain/strong rotator cuff tests (excludes sig. RC condition)
- End range pain flexion, HBB, adduction (positions of max AC joint stress)
- Marked tenderness ACJ palpation
- +ve Scarf, cross-body adduction, AC resisted extension, O'Briens test (collectively high specificity for AC joint pain).
- Cervical spine exam: full ROM, no reproduction of symptoms.

Clinical diagnosis: AC joint pain.

On viewing the x-ray myself, this is what was seen (see image)- subchondral cystic changes in distal clavicle.

Interpretation: possible symptomatic AC joint arthropathy and/or post-traumatic osteolytic changes. Both amount to symtomatic AC joint pathology with implications for treatment pathways and prognosis.

After explanation of all the options, the patient elected to 'do nothing' at this point (let natural history takes it's course).

Reflections:
1. AC joint pathology is often under-reported on x-ray. Important to always look at the x-ray yourself and to upskill in reading basic x-rays if you are ordering them.
2. Clinical correlation of imaging is also important. Subacromial bursal pathology is VERY common on imaging and not always symptomatic.
3. "Exclusion of other conditions" is part of the criteria for diagnosis of persistent pain conditions, including nociplastic pain. "Other conditions" hadn't been excluded in this case.

Looking forward to talking more to the Shoulder Academy crew on 8th November about AC joint conditions.

📄 Shoulder Physios - posting on behalf of an orthopaedic group conducting a Delphi study to develop post-op outcome measures for ACJ and clavicle fractures. If you're interested in participating there is more info below and please share. Contact details in post below....

"Developing a consensus on the outcomes measured in the effectiveness of surgical management of acute acromioclavicular joint injuries and lateral clavicle fractures – A Delphi Study"

Expression of interest

We are inviting expressions of interest to take part in Delphi consensus to determine the core outcomes that should be measured in surgical effectiveness trials of acromioclavicular joint injuries and lateral clavicle fractures.

To help patients, allied health professionals and medical professionals make decisions about treatments, we need evidence about what treatment works best. To do this, researchers need to look at the effects those treatments are having on patients. Researchers do this by measuring an ‘outcome’.

When researchers design studies to investigate treatments for health conditions they need to measure outcomes that are important and relevant to those affected by the condition. To decide which outcomes are important, researchers need to seek wider views and try to reach agreement, or ‘consensus’, on the most important outcomes.

The study is in the group forming stage in which we are inviting surgeons, allied health professionals and patients from around the world who have experience in treating or have had a collar bone injury to express an interest in taking part. If you decide to take part the Delphi consensus process is completed through three rounds of online questionnaires where you will be asked to rate the importance of outcomes that are commonly measured in surgical trials. In each round, you will be asked to reflect on your own ratings as well as the ratings of the rest of the group. For further information please see attached information leaflet [link].

For those participants completing all three rounds you will be eligible to enter a prize draw to win either $200, $100 or $50.

To register your interest in taking part the study please click on the following link or copy and paste into your browser https://redcap.link/CollarBoneDelphi.

It may take a few minutes to load the survey, please be patient.

Yours faithfully

Professor Amar Rangan
Investigator - UK
University of York, South Tees NHS Foundation Trust

Helen Ingoe
Investigator – New Zealand
University of Otago
on behalf of the Steering Group

If at any time you need further information, please contact: [email protected]

Last minute touches to presentation for Sports Medicine NZ - Wellington Branch tonight. What tools have we got for those patients when "strengthening" doesn't work? We know there are structural & functional changes at sensorimotor cortex level but how can we assess these impairments & what does targeted rehabilitation look like? Looking forward to this discussion. Thanks for the invite! 👍 Now 🤞 the forecast gale force southerly is running late! ✈️💨

Last courses for 2023 are coming up. Still some places available. Big focus on clinical reasoning in these courses - no recipes here! 😊 More course info in post.

Physio Academy - Learning

More from Orthopaedic Triage Shoulder Clinic:

Patient referred from GP with painful clicking around the scapula. X-Rays showed multiple exostosis in the proximal humerus, with scapula and rib abnormalites.

Hereditary Multiple Exostosis:

🔹 Genetic conditions passed on to child from a parent and can also be a genetic mutation, affecting approx. 2 per 100,000 population.

🔹 Characterised by multiple osteochondromas mostly affecting the growing ends of long bones of the arms and legs, also the scapula, ribs and iliac crests.

🔹 Associated with short stature, pectoral and pelvic girdle asymmetry, limb deformity, knee valgus and radius, carpal and phalanges deformities.

🔹 Usually presents in early childhood, the exostoses become more prominent as the child grows and usually stop developing at skeletal maturity.

🔹 Most are painless but they can cause pain when present under tendons or superficial locations and may also cause limb deformity, pressure on nerves/vessels, and approx. 5% may become malignant.

🔹 Diagnosis is by X-Ray. CT can be used for further characterisation of bony features. MRI and arteriography sometimes used evaluate other specific and vascular complications.

🔹 Treatment is surgical removal of symptomatic growths.

Triage decision: Surgical FSA (Orthopaedic review).