Welcome back to the ThreeSpires Physiotherapy blog. Today I thought we would continue with our new series of blogs looking at interesting physiotherapy topics (as I said last time: interesting to me at least!) and look at some of the evidence around them. In the last blog post we looked at hip replacements and examined when you should consider having your hip replaced versus when you should try physiotherapy. In this article we will have a look at when you should consider having shoulder surgery versus physiotherapy. I have been hesitating doing this particular blog for a while as it is a subject of much debate and ongoing research and I am not really sure I will be able to do all the complexities of this area justice in a short blog nor keep it easily accessible to the lay person. As such I will put in a few links to some studies and other blogs that will allow the interested to keep learning.

Today’s blog was prompted by a chat with a friend of mine who is an active rock climber and  who is currently struggling with a shoulder injury. Whilst we were at the crag we were chatting about his shoulder and we were discussing the best options for him. The difficulties I had in explaining to him what his best options were and whether or not surgery would be a good option made me realise how complicated things are with the shoulder and what a difficult area it is to advise patients on how best to proceed.

I guess before we start looking at the evidence, I think we need to be clear that we are looking at people who have shoulder pain that is not caused by trauma, a break or dislocation or have separated their AC joint (the bump on the top of your shoulder). We are going to have a look at someone who has shoulder pain either with a clear sporting or activity related cause or it has just come on over time. To keep things simple I think it is worth using a case study of someone with shoulder pain where things are not clear cut as to the best decision:

Our patient is a male in his mid to late 30s with ongoing shoulder pain which began with no clear cause about 2 months ago. He is an active sports person, goes to the gym, does a lot of weights and is getting increasing levels of discomfort in the shoulder. He has become concerned that things are not getting better and is worried he may need surgery. On assessment external rotation is weak and painful but he has relatively full range of motion with no other obvious problems. He has several questions: “what have I done to my shoulder?” “Do I need a scan?” “Do I need surgery?” “What is the best (and fastest) thing to do to improve my shoulder and get me back to sport?”

So, lets look at some possible answers to his questions. Beginning with: “What have I done to my shoulder?” Seemingly this should be straightforward, in the past a battery of “special tests” were used to identify the structure that was a problem and give the patient a nice answer. However there is now a significant body of evidence that suggests it is not really possible to identify with any certainty the structure involved. (If you wish to know more have a read of this excellent blog post from another physio on the topic https://thesports.physio/2017/08/26/the-most-special-test/). This doesn’t mean I don’t test shoulder strength and range of motion or use the special tests as a help to guide my assessment, it just means that it is very hard to be certain of exactly what the structure involved is. In this case the patient has a weak and painful shoulder on external rotation and needs a programme of exercises and rehab to try to address this issue. This tends to be very frustrating to patients as in general they would like a concrete answer and sometimes perceive a vague answer from a physiotherapist as evidence of incompetence (sometimes true but often more a reflection of reality). However the evidence seems to be fairly clear that shoulder strength and range of motion testing is unlikely to specifically identify the structure involved. These days I try to explain to patients that although it is hard to be certain of the exact structure involved we can identify the weak areas and possible range of motion problems and work on addressing these which in most cases will help.

Okay, my plan with this blog post had been to answer quickly the question of “when is shoulder surgery best and when is physio best?” However I think we will need to split this into at least 2 and possibly three blog posts to do it justice. Next blog we will look at scans for the shoulder and the difficulties that have been discovered around the use of imaging to identify what is wrong.