Shoulder Injuries in Sport – Expert Q&A Injury Rehab Network Event

Over 130 people joined live for the online event where the expert panel discussed shoulder injuries in sport including injury management, treatment, rehabilitation and return to play.

Shoulder injury

The March event of the Injury Rehab Network with The Shoulder Doc, Professor Len Funk was so successful that Len could not answer all the questions about shoulder injuries in the time available. Sterosport and BASRaT were delighted to work with Len Funk to create a unique opportunity for those working in sports rehabilitation to delve further into shoulder injuries in sport.

Professor Funk was part of a panel of shoulder injury experts from the North West including Doug Jones (Altius Healthcare Director) and Ethan Stamp (Sale Sharks GSR) for the latest free Injury Rehab Network online event on Wednesday 26^th May 2021 at 7.30 pm.

The panel tackled several questions which were received both prior to and live during the event.

The recording of the event is available here

Introducing the Panel of Shoulder Injury Experts

Doug Jones

Doug is Director at Altius Healthcare and has worked full-time in professional sport for over ten years both in Premiership and international Rugby Union. Doug is a physiotherapist with more than 17 years working for Sale Sharks, London Wasps, England rugby and in private practice. Doug established Altius in 2016. The inspiration behind Altius came when Doug was diagnosed with a brain tumour and the experience and support that he received on his road to recovery following surgery.

Ethan Stamp

Ethan is a Sport Rehabilitator at Sale Sharks. After spending time leading the academy program, he is now part of the performance team for the senior squad. Academically Ethan has achieved a BSc (Hons) in Sport Rehabilitation, during which he studied in Minnesota, USA working with top-level college athletes. Following this he completed his MSc in Strength & Conditioning at the University of Edinburgh, graduating in 2015. Since then Ethan has developed a range of skills and expertise alongside international and world cup winning athletes at Sale, implementing his rehab methods to help injured players return to the elite level.

Professor Len Funk (The Shoulder Doc)

Len Funk is a Consultant Orthopaedic Surgeon working as part of the large upper limb unit at Wrightington Hospital and has a private practice in Manchester with The Arm Clinic.

Len established and runs Shoulderdoc.co.uk and is passionate about patient information and education, as well as providing the best quality of care through a multidisciplinary team. He routinely treats elite and professional athletes.

His practice has evolved to specialise completely on sports and soft tissue injuries of the shoulder. Providing second opinions, treating complex cases, and performing revision surgery makes up a large proportion of his work. He practices closely with similar colleagues who specialise in complex trauma and shoulder replacement surgeries, as well as therapists dedicated to complex shoulder rehabilitation.

Academically, he has written numerous books and contributed to the work of others on shoulder surgery and rehabilitation and is actively involved in research, with over 100 research publications. He teaches both undergraduate and postgraduate medical, sports therapy and sports medicine students.

Shoulder

Shoulder Injury Hot Topics

Everyone attending the Shoulder Injuries in Sport Expert Panel event was invited to submit questions to the panel in advance. The following hot topics were suggested by attendees and gave the panel plenty to discuss:

Shoulder impingement
Posture imbalance
Long Head of Biceps (LHB)
Return to play

Panel Discussion

Shoulder Impingement

Doug Jones – Physiotherapist, Doug Jones started the discussion about shoulder impingement and how impingement can be managed. Doug described how impingement is a movement disorder causing mechanical pain, often related to pressure in the shoulder. Physiotherapists can help patients suffering from impingement by offering reassurance and showing how pain can be controlled through good movement. Patients can be coached through dysfunctional movement and educated using video and feedback from the physio.

Len Funk – Professor Funk described how impingement is a symptom and sign and that professionals need to work with patients to identify and treat and cause. Impingement is often linked to muscular and postural issues where dynamic movements may cause pain. Impingement can be managed through activity modifications and education. Prescribed exercised should not be painful and if pain persists, other causes such as tendinitis and arthritis should be investigated to define a structural cause. Investigations may include a range of subjective measures and imaging where x-ray, ultrasound and MRI can all have a place but equally have pros and cons. Len’s advice is to ‘treat the pain’.

Ethan Stamp – Ethan discussed shoulder impingement and how it is managed in a professional environment with Rugby Union players at Sale Sharks. Ethan described how impingement is multi-factorial and the aim for rehabilitation is to promote pain-free movement for players. This can be achieved through improving strength and working on quality of movement. Return to play for athletes involved in overhead spots is more challenging. Ethan explained how strength tests can provide a useful comparison and how it may be wise to assess rotator cuff strength. In building strength, players need to create a strong foundation to control and repeat movements.

Research – Len and Doug described how they worked together on an isokinetic study that showed that impingement is linked to anterior and exterior stability. A hand-held dynamometer can be useful to assess strength and stability with for example a 1 rep max test. A dynamometer provides a quick and easy way to identify deficits. The panel members noted that the best indicator to rehabilitation is not equipment but the professional, their support and reassurance.

Imbalance

Definition – “Lack of proportion or relation between corresponding things”

Ethan Stamp – Ethan kicked off the discussion about muscle imbalance stating that in theory, imbalance is part of clinical reasoning for good posture, but that good movement is often more important than good posture. This is particularly true in rugby players where size and shape can vary considerably.

Doug Jones – Doug described how the mechanics for good posture and balance can be developed through therapeutic treatment. Work on the trunk and hip can help to provide a strong foundation for good posture. Doug noted the importance of looking at imbalance elsewhere and to not just focus on the shoulder.

Long Head of Biceps (LHB)

Len Funk – Len Funk described the shoulder pathology and how frozen shoulder and instability can cause pain in the LHB. Len discussed how treatment is through rehab but that the focus needs to be on more than just direct treatment of the biceps. Tests can be used to provide comparisons and ultrasound can help to identify fluid and inflammation. Diagnostic injections can also be helpful.

Ethan Stamp – Ethan explained that LHB pain is often a secondary issue and that although it is important to manage symptoms, there is a need to identify the cause. A dynamometer can be used to assess various movements. Ethan discussed the importance of creating natural movement.

Doug Jones – Doug discussed how the LHB is a mover and stabiliser and how overactivity can cause inflammation and pain. Treatment of the biceps can help to take away anterior pain. Dry needling can be an effective treatment.

Return to Play

Question – Is there a reliable test for return to play for shoulder injuries?

Ethan Stamp – Ethan discussed how in professional sport there may be access to equipment such as force plates which can be used for various tests including a dynamic press up. A dynamometer can also be used to assess strength and force. Ethan described how a dumbbell can be used for a range of tests to assess capacity. Ethan stated that professionals should also consider both output force and acceptance force when considering whether an athlete is ready to return to play. This is particularly important in a sport like rugby where strength and power are important but the ability for a player to tolerate repeated impacts and deceleration forces is equally important. Sports rehabilitators should therefore build capacity and players threshold for both output and acceptance forces. Ethan discussed how rugby players may try to cheat return to playtest and how the use of a metronome can be useful to standardise tests, promote good technique and prevent cheating.

Doug Jones – Doug described how a cable weights machine is good for shoulder injury return to playtests with, for example, 3 rep max tests and through the fatigue tests providing useful insight into a player’s readiness to return. Doug’s work with motorsport athletes has shown that there is an association between the neck, shoulders, and grip strength. As athletes tire, fatigue sets in and can impact grip strength. Weighing scales can be used to test shoulder strength in different ways. Doug described how nerve injuries should be considered and how professionals should assess capacity based on neural fatigue i.e., the tackling technique in rugby.

Frozen Shoulder

Len Funk – Len discussed how frozen shoulder is a common injury. Causes include calcific tendinitis and arthritis, and these conditions can be investigated with an x-ray. Len described how it can take 2-4 years to recover from frozen shoulder and that it is important to help patients to manage through pain. Treatment includes a steroid injection or hydro dilation with steroid. Rehabilitation should not be forceful but should focus on strength and function. Len prescribes physiotherapy and discussed the importance of support for patients to complete exercises and to be educated on their shoulder rehabilitation.

Doug Jones – Doug described how patients with frozen shoulder are often middle-aged with many other lifestyle factors to consider. If the condition cannot initially be managed through physiotherapy, Doug will refer to a doctor for a steroid injection to help the patient to manage their pain and enable rehabilitation. Doug discussed how frozen shoulder is often linked to stress and anxiety and that physios should use good personal skills to offer reassurance, support behaviour change and discuss positive opportunities. Healthy activities that can help the patient to take their mind off pain should be encouraged. Doug described how a stiff shoulder is better than a loose shoulder and how adaptations and modifications can create a solution.

Ethan Stamp – Whilst frozen shoulder is not a common injury in elite sport, Ethan discussed how athletes may suffer from shoulder stiffness post operation and how he would support their rehabilitation. Ethan described the importance of moving as much as possible even in the early stages after an operation. A brace may be worn for up to two weeks post-surgery with initial rehab being very light. The shoulder injury is activated through loading as soon as it is safe to do so.

Learn More

Professor Len Funk’s website includes information and resources about shoulder injuries for both professionals and patients.

Find out more about Altius Healthcare on their website.

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Recording

The recording of the event is available to view here.

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