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STA195: 'Shoulder Assessment: Qualitative vs Quantitative' with special guest Professor Ian Horsley · The STA Clinician Podcast

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You're listening to the Sports Therapy Association podcast, putting evidence
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back into soft tissue therapy.
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Music.
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And we're live. Welcome to the Sports Therapy Association podcast,
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episode 195, entitled Shoulder Assessment, Qualitative vs Quantitative,
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with my special guest, Professor Ian Horsley.
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And he'll be coming up very shortly clinical director
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at back in action limited.co.uk and plenty
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more but i'm not going to start that now because it's a huge list we're going
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to go through it in detail and just to let you know this is part one
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if you listen to the podcast or whether you've chosen to join us live in
0:43
the live lounge this is part one of a very special two-part shoulder series
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with two absolute giants from the industry as i say professor ian horsley will
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be joining us for this episode and then in episode 196 which will be recorded
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live next week treating the shoulder steps to success my guest will be hugely
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respected shoulder specialist joe gibson
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also upper limb rehab specialist that we have for performance like i said that's
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going to be recorded live on april the 30th tuesday at eight o'clock so if you
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are listening to this podcast and you're thinking actually i quite like to be
1:12
live so i can ask these people questions directly.
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And also gives you a chance to hang out with the other people in the live lounge
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and that's all you got to do just come along to either youtube or facebook sports
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therapy association facebook Facebook page and you can be here live.
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And when you do join us live, I can bring your questions up onto the screen
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and you can show off your fancy logo or your face.
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For example, people are coming in the live lounge now. We've got Cecily Hislop
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who says, so happy you finally got up to this join. That's true.
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I've got a little bit of a bias against anything above the waist and I get a bit lost.
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I've got to watch out for how much I do that. But yes, we're up to the shoulder,
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Cecily, so I'm glad you're happy about that.
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If you do find that you've joined us and your message is not coming up on the
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screen and you're known as a Facebook user, then that's because you haven't
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clicked the permission link.
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But hopefully there will be any of that tonight because I've told you all about that a little bit.
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Anyway, so for those of you who don't recognise my voice, just to introduce
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myself, my name's Matt Phillips on the creativerunchatlive.com and like I say,
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as always, this episode of the Sports Derby Association podcast is being recorded
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live on a Tuesday at 8 o'clock on the Sports Derby Association YouTube channel and Facebook page.
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Before we start this week's episode, I'd like to
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thank last week's guest in episode 194
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let's just bring his face up there for
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those of you who has joined us live there we go ben wybrow was with
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us i say every week it was a fantastic episode and
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you should really go and listen to it it is there on all popular podcast apps
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and it's on youtube if you want to watch the video it's also on the sports derby
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association web page which is the sto.uk um fantastic episode for anybody who
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works or talks to people in pain which is my kind of sarcastic way of saying it's for all of you.
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Okay, it's a magnificent, I mean, it's so good. They're all great,
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these communication experts, because they're,
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They just help us gently realize that we're not as good at communication as we think.
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And he made a great point saying that we all feel that simply because we've
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chosen these careers of looking after people, that obviously the empathy just
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oozes from our bodies as soon as people walk into our room. It's what we do for a living.
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But because of the words we use and the body language we use and how we comment
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once somebody said something, we're not as empathetic as we would like to think a lot of the time.
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The patient just doesn't hear that. that so it's a
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great episode giving you a few little nuggets on how to actually
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let the patient realize and the empathy you
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have got as opposed to just relying on well they
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know i'm doing the job they must know that i love them so it's it's it's great
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episode and just he's a great educator we also
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had as part of the show because it was based on
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a sit in the mud article that ben did in
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the msk mag from the physio matters team we did a
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draw for somebody to win
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three months of a free subscription to the MSK mag and
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we will mention that at the end so
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let's see if you are the lucky winner of three months subscription to MSK mag
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but anyway I've left him down in the lobby for long enough I would now like
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to bring up the guest for the first part of the shoulder two-part series episode
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195 shoulder assessment qualitative
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versus quantitative with special guest professor Professor Ian Horsley.
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Music.
4:15
You're listening to the Sports Therapy Association podcast, putting evidence
4:20
back in soft tissue therapy.
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Hi Ian, how are you doing? I'm good, good, thank you, Matt.
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Thank you for the invitation and thank you for people tuning in live and the
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ones who download it and listen to it later.
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That's very kind of you. Now, it's amazing to have you along. I
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hope I didn't make your head swell up too much in the various promotions
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I've done for it because you are I'm sure you will agree
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to yourself but you are a massive name you've been around
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for a long time contributing to the shoulder and
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more so I think maybe to start because I'm
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hopefully a lot of people haven't heard me that's the whole idea although I
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was all just sitting in this echo chamber would you be so kind I
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know it's tricky because it's quite a long CV but how
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did you get maybe how did you get to where you are today and and
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so kind of respected for working with the shoulder
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and educating people about the shoulder okay uh so a quick potted history i
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always wanted i always wanted to be a surgeon my sort of my direction of study
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in my life was to go to university and do medicine and then be a surgeon.
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Lost a little bit of focus when I was doing my A-levels. Didn't quite get the grades I needed,
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but managed to get some grades that got me to Liverpool University to do a combined
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first year of physiology with the option in the second year,
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if I did well, to do medicine.
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And that's where I got to what I now call a lucky break.
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I broke my back playing rugby at university.
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And while I was being managed and
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treated there I realized that doctors
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really didn't treat anybody they managed people and out
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of the continuum that I went through it was a physios who actually
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sort of treated me did things for me and so I was lucky enough to finish my
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year at Liverpool and transfer to Manchester to the then what was called Whittington
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Hospital School of Physiotherapies because in the dark ages okay we weren't
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at university we had we had schools of physiotherapy,
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and then while I was an undergrad there
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in my second year the local rugby team came and
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said we'd like a physio to work with our rugby team please preferably
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somebody who knows something about rugby and I
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was doing my outpatient placement and they said oh well Ian plays rugby and
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he's doing all right in his outpatient placement why don't you have him and
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that's how I ended up getting into rugby and as anybody knows they get a lot
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of shoulder injuries in rugby so I had to quickly upskill on managing shoulder injuries in rugby.
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So you weren't tempted because we've had a lot of guests who have become great educators and
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therapists and because they were injured and sometimes because they noticed
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that the care they received wasn't as good as they'd wanted it's like well I'm
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going to do something about this but for you you said it was your back which
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you had a problem with for a stage where you're like right I'm going to help
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everybody's backs and you just realise there's more shoulders to work with or
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how did that come about? Do you know what, I was a.
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I was a typical rubbish patient. So my treatment was I was put in a full body plaster cast.
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So all around my thorax, up to my hips and around my shoulders from there.
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And every week, every second week, I had another one applied over the top.
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But I played tennis for the university in a cast.
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I even tried to play a game of sevens. So I got sent off when the referee realised
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I had a plaster cast on under my shirt.
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It was just i don't know never really thought about it
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and and just enjoyed just enjoyed
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getting into physio really i wanted when i started and i
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had i really thought when i started physio actually i thought i might i want
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to be a pediatric physio for some reason i don't know what it was but then just
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things things changed based off the what i did with the rugby club my father's
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from wigan and he'd be so proud listen to you now because he's always having
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a laugh at kind of rugby union
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players men with handbags down south and saying the league is where the
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men are so you'd be so proud to go there see there's there's an example
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there you go that's what you get when you cross the border so um
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yeah excellent playing tennis in a cast so yeah we you already mentioned i think
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14 years was it physio for england rugby union yes yeah six years for the elite
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playing squad which always sounds amazing yeah so yeah so that time we we we
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have big squad so we had the first team the second team so it was that's the
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first team and what was called the a team.
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From there, trained together during Six Nations and they'd select the team to
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play on a Saturday, team to play on a Friday, which was the A team.
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So I worked a lot on there. I was lucky that during that time,
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it was 2003, so we won a World Cup then.
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So I was part of that wider group looking after that squad.
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Yeah, so good times. And that change from working through from amateur to professional
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was really, really nice from the huge change that the way we were looked after
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as players and support staff was fantastic.
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Amazing. Yeah, we've had some interesting, I mean, rugby does come up with its
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fair share of injuries, doesn't it?
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We have some fascinating conversations, even recently on concussions and the
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theories and changes and misconceptions about that.
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But tonight is all about shoulders. So like you say, yeah, a lot of shoulders injuries in rugby.
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We were chatting a little bit off air and the feedback we get,
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and I've suffered it myself.
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I mean, I look after runners. So like I said in the intro, anything waist up, I'll get it.
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Because if you don't work in something then you just don't feel that confident about
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it but the shoulder joint in particular i know the way it's presented when
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we learn the anatomy physiology but it's kind of a little bit of
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a fear joint is that right do you think fair to say yeah i think
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you're right and you know i i do i do a lot
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of post post-grad teaching on it and and i
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ask people you know what is it that that scares them about it you
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know it's it it in essence the glenohumeral
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joint is is two bones which is one bone.
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Less than the knee and people seem a lot happier around around around
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the knee and i i suppose
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there's there's a lot more instability
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around the joint itself but when you think of that
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the the glenoid is part of their scapula that
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which sits on another mobile platform which is the thoracic
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spine which sits on something else so
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there's a lot more connections if you like that
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then can influence sort of locally as
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well as globally willy the shoulder i think that's
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it i think you just nailed it as well because we are taught it's the most unstable joint
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of the body so that's that that makes us fearful in treating so
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imagine how it sounds to patients when we go we do realize the shoulders those unstable
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joint body but then why are we going to fix you but it's yeah it's interesting
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it's i think it's because it's got that massive range of motion and and so many
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so many tests which i'm sure we'll talk about later on but if you know but if
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you're looking at in sport you know looking in gymnastics you know it It doesn't
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look unstable when you see what they do on the rings in there.
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You know, it lacks osseous bony stability like the hip where you've got a deep socket for that.
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But it's got fantastic neuromuscular control.
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That's what you're looking for around the shoulder. And hence the title of the talk tonight, really.
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For me you know there's some clever things going
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on around that around the shoulder that maybe numbers numbers don't
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capture brilliant great segue good segue
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into the title yeah so yeah as we said in the
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introduction tonight part one shoulder assessment qualitative versus quantitative
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i guess we should start off really not only they're two words which are quite
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difficult to say if you've had a couple of drinks but yeah could we go into
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maybe defining them and then and distinguishing them so our listeners kind of
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realize what we're talking about here Okay.
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So my current part of my job is I'm the upper limb lead physio for the UK Sports
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Institute, which used to be called the English Institute of Sport.
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And I work in high level Olympic and Paralympic sports and education.
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There's a massive focus on numbers, okay, strength, power, range of motion,
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rate of force, force development, lots and lots of numbers that are measured.
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And I am not a great fan of that because, so that would be your quantitative stuff.
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So force production, how much weight you can, sets, reps, newtons,
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kilograms, whatever from there, you know, degrees of range of motion.
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Whereas for me, and this is sort of nicking a phrase of John Elphiston and Andre Vleeman,
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what I look for around the shoulder, as with anywhere else in the body,
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I want to see beautiful, effortless movement.
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And that is a sign of a good neuromuscular system.
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So this is qualitative. There aren't any numbers for it from there.
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And so it's based on something that's experienced or observed, really.
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So that's what's difficult, because I can, you know, having to describe what
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I can see that that looks effortless or effortful.
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It is an objective opinion, but it's an experienced, objective opinion that
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I can tell somebody's movement quality is getting better or getting worse.
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Worse and that's my i look at how well they move and
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obviously the feedback from their patient of whether or
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not they're getting pain or they're getting their their symptoms because
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you can measure strength and you can measure range of
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motion and force production and things and you can still have poor ugly effortful
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movement and that and your subject your patient can still can still be having
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symptoms so so i do sit in a as a square peg in a round hole in in the institute.
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It's really interesting because it's like and i'm thinking
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of previous episodes i've been sitting here i'm nodding as
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you're saying it but then i'm thinking of talking to particularly
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strength conditioning coaches they're saying that we should all be using dynamometers
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more because then we've got a tangible way of measuring improvement and we can
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be working with a team we can show like the coaches or the bosses the managers
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look this guy's getting better he's getting closer or and and how important
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it is to have something quantitative but now you're,
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sitting on the other side saying hold on we're going over the top with
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quantitative now where it's not actually quantitative is
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all very good but it doesn't necessarily correlate with full recovery as well
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as we might think yeah so you know the quantitative stuff is good for performance
14:56
okay i agree when we'll you know when we're looking from a performance like
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that from a from from a rehab and from a motor control aspect,
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it's other things. Because if we take.
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If we take what we said earlier about the shoulder joint having little bony stability.
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Okay, but it's a neuromuscular control around there, what we've got to make
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sure that that joint stays stable is that sort of feed forward mechanism,
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that little bit of pre-activation of a low level of the rotator cuff to prepare
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that joint for some activity that they can do some wondrous things in gymnastics.
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Gymnastics or some incredible throwing judo without
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somebody's arm coming out there and and
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you know we're talking about you know this pre-activation about
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60 to 120 milliseconds before before the move which is you know which is imperceptible
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really if you think about it but if you look at some of the research that's
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been done in sports say if you look at cricket or look
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at tennis that if you're stood 22 yards
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away on a cricket pitch there's somebody bowling a ball like 90 miles
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an hour for you you haven't got time to
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see that ball hit the deck and decide what shot you're going to play what happens
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is because our our brains are very very clever and spot movement patterns that
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we don't even appreciate you you the best batters can see how the ball is as
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as a The bowler comes in as he sets,
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they know roughly where it's going to be and they can pre-empt that.
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Similarly, in tennis, when the ball coming at 150 mile an hour,
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you can't react to a ball coming at 150 mile an hour.
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But our brains are very, very clever at doing things that we don't know they're doing.
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So are you suggesting then that because the shoulder is dependent,
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the way it functions, yes, it's got this instability, but it's got so much of neuro ability as well.
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That that's why in their particular case the shoulder joint the pendulum
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does swing more towards we should be doing qualitative as opposed
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to quantitative and a joint where maybe there is kind of just kind of
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flexion extension i mean i mean the same you know we know the same it is to
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all the joints to stop an ankle sprain or you know with the uh to get damage
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at your knee or if you get an acl it's the same but they've got a little bit
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you know if you look around the the the knee you've got a round bit on a flat
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bit which is not a great bit of stability
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but a little bit more stability from both of the cartilages
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which are in there but massive muscle at the front massive muscles
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at the back that gives it stability ankle we've
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got a nice little mortise for a bone to
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go in and lots of muscles around there so they've got other bits but the the
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shoulder it's you know it's a ball and saucer you know that it's flat it's not
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even round it's pear-shaped you've got a little thickening around the head which
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is that the the glenoid labrum, which is about seven millimetres thick.
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There isn't a lot there to hold it apart from the cleverness of the.
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The information and the message coming from the brain that controls the cuff.
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And then once we get that right, we can produce incredible forces.
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I mean, we know that, you know, from in baseball, where they're throwing a ball,
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you know, between 90 and 100 mile an hour, at the point of release,
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there's about one and three quarter times body weight traction force on the arm.
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But you've never seen a picture in baseball loses arm.
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At all from there you know it's it works
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really really well to sustain some some high
18:40
forces but we've got to have that that that platform for everything to to work
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off and we need a platform of stability of the shoulder blade which then the
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cuff sits on that then can give stability dynamic stability to the humeral head
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on that sort of flat pear-shaped surface of the glenoid.
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Fantastic just to remind people who are joining us in the live lounge
19:04
feel free to ask questions if there's anything you need clarification on
19:07
i've even got a little image of the shoulder joint in case you're getting
19:10
a bit rusty then just say matt can you flash an image up on the screen
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then yeah just don't let this all go beyond you if
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you're not quite sure we can take it whatever you want i'm thinking
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i'm wondering whether i'm just thinking of people who are rehabbing i mean we're
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talking at the moment of people who are in kind of some stage of
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rehab and they're in pain and is it a case
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of whether there should be more quantitative base in
19:31
the beginning of rehab or later on or is it should should the
19:33
quality be there from the very beginning or especially at the end or what's
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in your experience so again what one of the things you know i try to explain
19:41
to patients when i when i'm looking at things it is you you can you can ride
19:46
a bike that's got a slightly buckled wheel okay but but it's not a comfortable journey,
19:53
okay so what i'm looking for i want the good
19:56
good mechanics and what i don't want a buckle wheel that makes
19:59
it low effort for you to pedal and it makes it a
20:02
comfortable comfortable journey so first of all
20:05
we i need you at low level to be able to move your arm beautifully you know
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i i see patients in in clinic and these are not these are not elite athletes
20:16
if you ask them to take their arms out to the side and they get to about here
20:19
they look like they've got 20 kilograms in their arms as they fight to get their
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arms up above their head.
20:26
If they can't do that without any weight, just imagine when you start to put
20:30
some weight on there. So I wanted to get somebody moving.
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Effortlessly at low load and then we can start
20:38
to change that we can add load as long as it looks
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beautiful and relatively effortless and
20:44
then we can change the speed and it needs to be beautiful beautiful
20:48
and effortless well because that's the
20:51
sign for me of of skill of performance so
20:55
if we take something as a sport that's
20:58
on telly at the moment snooker if you watch
21:01
them playing snooker and you'll see somebody down at
21:03
the bottom end of the table where the pink and the black is with the
21:06
white and they'll hit a red and it'll go into straight into
21:09
the center at the top left hand pocket from
21:13
there and that's 12 feet away from them and you think that's that's easy go
21:17
and have a go go and have have a go and that's just to put it not to get the
21:22
ball to whiz around the table and come back and sit on a sixpence so when you
21:27
think when you see you know A gymnast doing their stuff.
21:31
If you see a tennis player serving, it still looks relatively easy,
21:38
apart from if you – unless you're watching Rafa Nadal, okay,
21:42
which I always compare Federer to Nadal.
21:47
Federer, effortless, beautiful, very few injuries in his career. Yeah.
21:52
Nadal looks like he's fighting a bull every time he plays.
21:55
High incidence of history throughout his career. Yeah, interesting distinction.
22:02
I'm listening to you about the importance of the beauty of the movement and I'm loving that.
22:07
And I'm wondering whether it reminds me, this has come a few times now, it's on my mind.
22:11
At Therapy Expo last year in November, people like, I'm sure you're familiar
22:16
with people like Angela Jackson.
22:18
Yeah, Angela. yeah andrew as well
22:22
andrew mccauley his name always escapes me both of
22:25
them and more people had some great talks on particularly
22:29
as andrew who is who who was drawing attention to
22:32
the fact that still one of the biggest kind of
22:34
precursors or something which indicates the
22:37
chance of injury is have they been injured before which
22:40
kind of suggests that the rehab we've been
22:43
doing all of these years for somebody is missing something because if that person has
22:46
got a really high chance of coming back with another hamstring strain or shoulder injury
22:49
then maybe we're missing something from the rehab so they were
22:52
talking a lot both of them about this idea of chaos of
22:55
that we are not rehabbing properly in
22:58
the way that they're going to use in sports i'm thinking of that with the
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shoulder as well it's very easy to get somebody to we're
23:04
talking about rehab at the moment we'll do a session for the second but you could put
23:07
someone through all of the kind of like you know planar movements
23:10
but you're not creating the chaos which
23:13
might happen and not so much as snooker hopefully you know in other
23:16
sports you know where they are going to have somebody trying to stop them
23:19
or knock them over or you know and change angles so i guess that
23:22
ties with what you're saying to prepare for chaos you need to have that quality
23:25
of movement yeah you know and you you take somebody from you know they they're
23:30
telling them what they're going to do knowing what to do then to the unexpected
23:33
so it's it's not often that a shoulder will dislocate when when you know what's going to happen.
23:41
It's when, you know, when you're not ready and not necessarily,
23:46
you know, people just might be in a relaxed position and sneeze and dislocate the shoulder.
23:53
Whereas, you know, that you can tackle somebody equivalent of a 30 mile an hour
23:58
crash at rugby and bash into them and get up and run across.
24:03
So, yeah, it is about thinking about, you know, all their different facets and,
24:08
you know, trying to prepare them for those uncertainties that really...
24:14
You know, when we talk about the shoulder, the thing that I don't think gets
24:17
looked at enough around the shoulder when we're rehabbing is looking at proprioception,
24:21
awareness of joint position sense.
24:24
You know, we routinely do it for the ankle. You'll get somebody who tests them.
24:28
You'll stand them on one leg. Can you balance on one leg?
24:30
You know, can you do it with your eyes closed now? Can you do it on an unstable surface?
24:34
And that's for a comparatively relatively stable joint.
24:38
But when we do the shoulder, and again, when I'm teaching, I ask people how
24:42
many people routinely assess joint position sense proprioception as part of
24:49
their assessment and their rehab.
24:50
How many people rehabilitate proprioception of the shoulder?
24:53
Because that is the mechanism that's going to tell the brain what's happening at the shoulder.
24:59
Because everything that we do anywhere in the body is brain derived.
25:05
Revived for you know when we're training and
25:08
we're trying to get a peripheral movement stimulus to we're
25:12
trying to change a centrally driven stimulus so when
25:15
we're giving exercise okay but for
25:18
every one external peripheral stimulus
25:22
we give there's 30 stimuli coming
25:25
from the brain so we need to train the
25:28
brain okay to to sort our
25:31
joints out and obviously there we're talking about the shoulder the joints but it's
25:33
the same for for any any joint around there so
25:36
proprioception is massive for the for the
25:39
shoulder and that will be you know one of the early things
25:43
to assess and and to work on with it
25:46
right well i can hear i can hear listeners
25:49
either live listeners or i'm looking in the future
25:51
now podcast listeners i've just flipped over their pad now and they've
25:54
just got their pen from behind their ear because we're looking at something which
25:57
maybe they should be adding to the to the rehab of
26:00
the shoulder they're not so yeah give us an idea of early or late stage
26:02
you know things you should be incorporating which do test
26:05
the proprioceptive abilities of the shoulder so we can do
26:08
a you know simple simple thing you can
26:11
put them so you can see me from here we
26:14
so we take away the visual stimulus blindfold on
26:18
the eye you can put their arm into a three-dimensional position
26:21
on on in space okay their.
26:24
Non-injured shoulder and say can you replicate that
26:27
with your with your shoulder that you've come
26:30
to come and come to see me with that that's that's.
26:33
That's called contralateral mirroring yeah or
26:36
you can you can take their joint into a position so
26:40
say supine take 90 degrees abduction take
26:43
them into 80 degree or something around about 80
26:46
and 70 like say 75 degrees of external rotation
26:49
leave it there for five seconds while they're blindfolded bring
26:53
them back to point to the ceiling can you replicate that 75 degrees and then
26:58
you can measure the error the joint position error from there and whether you
27:03
undershoot it or overshoot it will give you some bit more information about
27:08
where their proprioceptive their joint position sense is in there.
27:13
You know, a lot of this stuff, if you look in literature, and I think when I've
27:16
spoken to people when I'm teaching, it uses lots of expensive equipment like
27:21
isokinetic dynamometers and force detectors.
27:25
You can use these really, really simply things to get an indication of how that
27:31
joint is functioning, because unless you give the brain some information, it can't do anything.
27:37
Thing so the the quality of the the afferent
27:40
information that the information coming from the shoulder
27:43
joint to the brain decides on how good the
27:46
the response from the brain is to protect that joint you
27:49
know and that this i hate this say because it's an american but garbage
27:52
in garbage out so if you've got inappropriate message
27:56
coming from here because your proprioception is down then
27:59
your brain can only act on what what information is given and
28:02
it gives you some some faulty movement information or
28:05
stability information back excellent that's
28:08
lovely that's a lovely idea of the blindfold and just can you can you
28:11
again using the asymptomatic arm as a measure of what to try to achieve the
28:16
symptomatic arm one could say there but though there you because you talked
28:20
about measuring angles you're using a still using a quantitative approach there
28:23
to measure yeah for that technical example yeah for some feedback so you know i'm not.
28:30
Clearly a lot of the time worried about their the the
28:34
range so for this we're looking at something
28:36
that's very uh specific that about proprioception
28:40
how accurate that has to be so when we start to get to the neuro side of things
28:44
but then we do need a little bit more so one of the arguments that we read about
28:48
or which kind of like says oh quantitative is the way forward is it is tangible
28:52
the problem the danger may be of qualitative depending on what kind of assessment or.
28:57
Exercise you're doing is that success is measured
29:00
by the practitioner or the patient of how they feel or or
29:03
whether it hurts or if they're tired and
29:06
it's all kind of difficult to to measure and show progress
29:09
is that kind of overstated by people who
29:12
are trying to get you to buy a you know some kind of quantitative equipment or
29:15
have they got a point yeah i mean you've got that there was
29:18
a nice little blog came out by claire minchell this week
29:21
talking about using handheld dynamometry things and talking
29:24
about the the things you know you can get you can
29:27
get variability just you know from how how
29:31
you encourage your your subject to produce
29:35
force you know how much you shout and scream scream at
29:38
them you know that that volitional response with it you know the the the position
29:44
that you you know so so again if we think about the shoulder from a tested testing
29:50
strength we We talk a lot about internal and external rotation, strength and ratios.
29:56
And we might test them at 90 degrees abduction from here.
30:01
And it will generally be an isometric force.
30:08
Okay. So, again, are those muscles working isometrically in that position in sport, in life?
30:16
No, they're not really from there. are you
30:19
know are they are we're testing them in mid-range yes
30:23
but you will tend to dislocate more to
30:25
to outer range okay where we
30:28
we test concentric concentric most of
30:31
the time where we know that we need some eccentric some
30:34
some lengthening from there so again
30:37
when we when we start to think about the quantitative stuff
30:40
then we need to look into more detail
30:44
then and more specifics of what it tells
30:47
us because you know in in sport in in
30:50
in in baseball that that 90 mile
30:53
an hour throw the arm's going something between about 7
30:57
000 degrees a second it's rotating at okay and we know that the force produced
31:03
is relative to the speed in which you move now we haven't got a bit of equipment
31:08
that that will measure that you know an isokinetic I think dynamometer goes
31:11
as fast as about 500 degrees a second,
31:15
no matter what thing. And so we're taking values and,
31:19
For me, I'm thinking, so what is the validity? Yes, it's a value,
31:22
but how does that rate to 9,000 degrees a second with it?
31:29
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include already discounted bundles okay what
32:35
about assessment then it's is that different someone's someone's coming in yet
32:40
because a lot of our listeners when they move basically i don't know how much
32:44
you know about the syllabi for sports therapy but But when they move from level
32:49
four to level five, and there's a lot of fuss over this,
32:51
basically they just introduced about 30 different kind of orthopedic tests.
32:54
There's a lot of them on the shoulders and they have to learn them and reproduce them. And.
32:58
And there's a question these days as to the validity of these tests for some
33:01
of the reasons you've just mentioned now, because it's all very well testing
33:04
apprehension tests of some form.
33:06
And I think also we've had papers which have shown that maybe the limitations
33:09
of, I don't know, tests like raising the elbow from the back,
33:13
the base of your back and stuff like that.
33:14
Do you think that even at the level of just assessing patients who come in,
33:19
that these tests are a little bit flawed and we should be doing tests which
33:22
are based more about quality of movement as opposed to measuring them and looking
33:26
at forced production and stuff?
33:29
I think, again, that those tests and last time I looked, I think there was about
33:34
152 manual orthopedic tests around the shoulder.
33:38
There's probably been another one developed while we've been talking tonight.
33:42
Which, as I say to people, there are that many because the reliability of them is poor with it.
33:52
So some of those tests may be able to identify injury around there,
33:58
which is slightly different.
33:59
So if you've got a tear in the cartilage ring around your joint,
34:04
around your labrum, well, that's going to affect how the joint works.
34:08
Because one of the things the labral does, it helps keep that negative pressure
34:13
in your shoulder joint, which sort of sucks the ball into the socket.
34:16
It it's like a gasket and if you tear that then air can get in and you haven't got that negative,
34:22
force sucking sucking the ball in it's also an attachment at 12 o'clock and
34:27
at six o'clock at 12 o'clock you've got the long head of biceps that inserts
34:31
six o'clock you've got long head of triceps.
34:34
Steps inserts so if they're loose then that affects how they work so some of
34:40
those are helpers identify might identify possible pathology and a structural pathology that may,
34:48
need may need surgery uh from it but but but again you know thinking about some
34:55
of the tests even if we talk about you know as i mentioned about interlex internal
34:59
rotation there's a good Good study done at Liverpool looking,
35:02
you know, so if you test internal rotation of your humerus,
35:08
the main force producing sort of up here are going to be pec and lat.
35:15
Okay, which are big global accelerator muscles.
35:19
When we test external rotation, it's going to be the cuff.
35:22
It's going to be a bit of supraspinatus, infraspinatus, teres minor,
35:26
bit of posterior deltoid.
35:28
We've got massive muscles versus little
35:31
muscles okay and we talk about how that's going to give
35:34
stability the joints we can't really isolate muscles
35:37
on their own and what we really want to look at if you're trying to get that
35:40
balance around the cuff is is the the rotator cuff so posterior cuff infraspinatus
35:47
teres minor and anterior cuff which is subscap so if you test press subscap with a belly press,
35:54
you get a significantly more, this was from the study in Liverpool,
35:59
significantly more subscap than you do peck and lart.
36:04
But that's not a particular vulnerable position when you're pressing on your
36:09
belly from there or a functional position for it.
36:12
And similarly, if you go around your back, which is Gerber's lift-off,
36:15
where you lift your hand up and back, again, there's a little bit more,
36:19
there's more some scat than the others.
36:21
But again, it's not a position that generally is injurious to your shoulders.
36:26
Shoulders so so so we need to have some form of idea of you know what what's
36:34
going on around around the shoulder and and choose our test judiciously there
36:38
are some that i use regularly.
36:41
But i know that give me any that give me information about things
36:44
for example yeah which so so
36:47
i so one of the things that i use quite a
36:50
lot i do like o'brien's test so so
36:53
bring your arm into 90 degrees of flexion bring about
36:56
20 degrees of horizontal adduction and point
37:00
your thumb down resist shoulder flexion now
37:03
this test can give you several different results you
37:07
can get if it produces pain because the location of
37:10
the pain can indicate possible structures that are damaged
37:13
so if you get pain over the top of your shoulder around your
37:16
ac joint it could indicate an AC joint
37:19
problem if you get pain at the
37:22
front it could indicate a superior labral
37:25
tear cartilage tear or long head of biceps if you
37:28
get pain or discomfort at the back it could indicate a posterior instability
37:33
okay but then if you go into supinate and externally rotate your arm and repeat
37:39
the the test and these become less negative less negative no sorry less positive that then okay Okay,
37:46
that sort of confirms that because you're winding structures up.
37:50
So I quite like that, but I won't just rely on that. I will do some secondary
37:54
tests to work out what's going on.
37:58
That's one. You're going to have to give three on this show.
38:00
So that's one test you like to use quite regularly. What else?
38:03
Okay, so apprehension test is quite good.
38:08
So you bring them into this position and you take them into external rotation.
38:12
And the original test is they feel apprehensive that their shoulder's going
38:18
to come out of joint and if you give them a slight stability with an AP on the
38:23
front, they feel better.
38:24
So that's telling you they've got some anterior instability.
38:30
And then, again, if we class the AC joint as part of their shoulder girdle,
38:35
so again, love a scarf test, horizontal adduction inflection across the body.
38:42
What do you like with, because some of these tests will rely on kind of a numerical
38:47
values given either from the patient or something noted by the practitioner
38:52
in terms of stiffness or endpoint.
38:54
These are all quite qualitative, aren't they? They're quite subjective.
38:59
It depends on the individual. It's difficult to reproduce depending on who's
39:02
got great intra or inter reliability.
39:04
But the whole question about qualitative versus quantitative,
39:08
is that something that you could talk about with regards to assessment?
39:12
Okay so so again when i'm
39:15
doing an assessment then what i'm looking for
39:18
is what a meaningful task so
39:22
what action does that person do
39:25
that brings on their symptoms okay so
39:28
it could be i don't take it
39:31
taking the coat off it could be throwing throwing
39:34
a ball it could be doing it doing a press-up and so
39:38
once we've got their meaningful task
39:41
or something that appropriates that that meaningful
39:44
meaningful task then what i
39:47
tend to use then would be improvement testing so
39:51
messing about because we sort of chatted earlier
39:53
poking or stroking i will do things to try and facilitate
39:57
some muscle recruitment or inhibit some some
40:00
muscle recruitment kind of symptom modification sort
40:03
of stuff also if we think
40:06
about how the force is produced around the
40:09
shoulder girdle 50% of the force that's produced around the shoulder girdle
40:13
comes from the waist down 30% comes from the trunk and 20% comes from the shoulder
40:19
girdle so I can influence the activity of that 50% so I might get them to stand on one leg.
40:29
OK, so just arbitrary. Stand on your left leg. Does that work better or the
40:34
same? Stand on your right leg.
40:36
Works better or the same. OK, I'm going to put a band around your ankles.
40:41
I want you to abduct against resistance your right leg.
40:44
Works better or the same or your left leg or extend.
40:47
And I will look at influencing the chain to see how we influence their meaningful
40:52
task and the outcome of the meaningful task.
40:55
That's because often, you know, as we mentioned earlier about these repetitive
40:59
injuries that people get, it's because it's a defect in the chain.
41:04
And I do quite a bit of work of seeing some failed surgery.
41:09
So people have had the reconstructive surgery from there. Generally,
41:13
there tend to be rugby players that I see because of my background that consultants will send.
41:17
And when I look, I will find a deficit in the kinetic chain.
41:21
You know and just by you know and the simple
41:24
test that i do with all shoulders is i
41:27
get them to do a a mini squat on one leg and
41:30
i look for their alignment of hip knee and
41:33
ankle as i do about a 30 degree squat do the
41:36
hip knee and ankle stay over the top of each
41:39
other or do you get that valgus collapse and the knee moving
41:42
inside that the foot and that will tell me
41:45
that we've got some lateral stability issues around
41:48
the the pelvis which will influence the influence
41:51
how the shoulder works very interesting i like
41:54
that idea that's something that people can pick up on changing or
41:58
looking for symptom modification by not just the angle of the arm or anything
42:01
that's quite limited there but yeah what's happening with the rest of the body
42:04
can you repeat those percentages again you mentioned it's 50 so waist waist
42:08
down so from sort of hips down 50 percent from waist up so core whatever you
42:14
want to call it from 30 and then shoulder girdle 20.
42:18
That's very interesting you could progress and regress just by sitting down
42:21
lying down taking that with that in
42:24
mind that's why you need to know what their meaningful
42:27
task is so because we do tend to assess people in
42:29
standing in clinic but their
42:32
fault might be when they're sitting doing something
42:36
so we should ought to assess them in in sitting
42:39
because if their fault is in city we don't really have to worry about that
42:42
50 because that's not involved so it's that
42:45
that 20 that's right that 30 which is
42:48
that there's a trunk and core and this is this is something else i was thinking
42:52
because you mentioned like a lot of the people you see are athletes rugby players
42:55
but of course the importance of having that reactivity in the shoulder and being
43:00
assessed and rehab properly is quite significant for other populations as well
43:04
thinking of the elderly for example.
43:05
It's really important for them. So when it comes to assessing them.
43:10
Probably it's not going to be standing on two feet for a lot of them.
43:13
It's going to be an issue that is when they are seated or something or in bed
43:16
or something or getting out of bed.
43:17
So it's even more important to make it a meaningful,
43:21
assessment yeah you know i work with paralympic athletes so
43:23
i see you know we get a lot of shoulder injuries you know yeah
43:26
you know so you know working it
43:29
we are working out from from them you know and how they're positioning the chair
43:33
how their chairs how their chair set up as well yeah so we need to try and make
43:38
our assessment as as close to what what they do now it's different you know
43:42
if you've got a javelin thrower and he's you know throwing a javelin five meters and his.
43:47
Arm's going at 10 10 000 degrees a second
43:50
you can't really replicate that in your gym so you'll you'll
43:53
have to look at something that might
43:56
replicate their symptoms sort of and and most
43:59
of the time it's if you go into abduction into
44:04
elevation that will tend to be a provocative thing so
44:07
we might use that in clinic and as i you know
44:10
as i say to my patient we might be able to clear that in
44:13
a clinic but that does not necessarily mean that when
44:15
you go back to throwing your javelin and i will say right what i want you
44:18
to do now is go throw your javelin and get back to me
44:21
because yes your pain's gone and you can do everything that hurt in
44:23
here but you didn't come in telling me that was your pain
44:26
go and throw your javelin and tell me what you
44:29
like now throwing your javelin or doing your ironing or
44:32
pegging your washing up or whatever it might be clever very
44:35
interesting and i guess level of fatigue will come into play as
44:38
well because i mean sometimes these people only start having issues when
44:42
they're halfway through their whatever never meant it is my actual race or yeah
44:46
that's right so yeah you know if it's a swimmer i know
44:49
and they get it at the end of a training session i say oh we'll
44:51
we'll try and schedule your appointment to see me when you
44:55
finish when you're in in the state so i can see see what's going on because
44:59
by the time you've come to see me which is maybe two days later and you've not
45:03
swum that there's nothing for me to nothing for me to see so yeah don't provoke
45:07
it and when you provoke vote you know come and come and see me that could be
45:12
so tricky i mean in an ideal world i mean i.
45:14
Used to do a lot of gays analysis and the situation was these people coming
45:17
saying oh it hurts me after about 10 miles i'm like,
45:20
mate i really need to see you after 10 miles because what i'm seeing now especially
45:24
with running is going to be totally different than how you're moving and a few
45:26
people you know you're just stuffing yourself your business model a little bit
45:29
in the foot because you had to have some really good therapeutic alliance to
45:33
get them to go and do 10 miles and then come and see you it's like come on mate
45:36
sort it out now will you but what we do so i do i clear with those we.
45:39
Put them on the treadmill in the gym and i put them on and i'll say
45:42
there's a bell when when your pain comes
45:45
on ring me i'm here all day literally when your
45:48
pain comes on well i'll coming up a look at you yeah yeah it's
45:52
nice it's it's so true it's great question people
45:56
you're very quiet in the live lounge what's going on are you scribbling things down i
45:59
want to hear what goes on in your clinics or when you're
46:01
doing rehab or assessing or that sort of stuff i wanted
46:04
to ask you about different kind of like methods of assessment which by
46:08
the qualitative or quantitative there's been a lot kind of written about
46:11
one repetition max kind of thing you know that
46:13
does that come into play as much with the shoulders that's
46:16
something which eventually actually you incorporate or is that more
46:19
for lower limb so you know as we get into
46:22
the performance and so if you're thinking from a sport point point
46:25
of view once i am happy that all they've got beautiful effortless movement
46:29
at different speeds on different load then they
46:32
will go and work their essence for that but
46:35
but what's important for me when i'm assessing force production
46:39
is how quickly they
46:42
produce instant force so what
46:47
what we need as i sort of mentioned earlier we need this 60 to
46:50
150 milli milliseconds before they move we need the cuff just to sort of hug
46:56
a little bit i what what i'm looking to do is i'm looking how quickly they might
47:01
react when i participate them give them a nudge that's what i'm looking i'm
47:05
not looking at their total force force.
47:07
And if we talk about some of the theory around stability of the joint,
47:13
so we think about the kinetic controls of Comerford and Mottram.
47:17
You know, you only need 25% of your maximal voluntary isometric contraction to get stability.
47:25
So I'm not, you know, I'm not bothered how strong you are to keep your joint stable.
47:30
I want you to be able to react quickly to produce that 25% ish from there,
47:37
because what tends to happen is if we produce force,
47:42
then the muscles that produce force tend to produce stiffness and rigidity.
47:47
And that's what changes the movement.
47:50
You know, we use the bigger muscles rather than the local system from there.
47:54
So often in sport, the answer to anything is make it stronger.
48:02
Now, for performance, that is the case,
48:06
but not necessarily for injury prevention around the shoulder,
48:10
because we know that muscles can create instability just as well as they can control it.
48:17
And the muscles which are strong around your shoulder, so pec and lat and to
48:22
some degree deltoid, they're too far away from their center of the joint.
48:26
And they, being dominant, they start to create some instability.
48:30
Whereas our cuff, which is right next to the ball, they're the ones that work
48:35
at a low level consistently to keep that humeral head within two millimeters
48:40
of the center of the joint.
48:42
When it's moving at speed and and and you
48:45
know 9 000 degrees a second whether you've
48:48
got one and three quarter terms your body weight on it as well
48:51
yeah fascinating yeah you come up
48:54
with those stats it really does kind of show the chaos and stuff that's going
48:57
on and they have to react so quickly yeah really interesting.
49:00
And what you've been around a long time so you've seen lots of
49:03
kind of things come and go and names used and
49:06
different programs but kind of functional testing has
49:09
has being praised and then demonized and but when
49:13
you talk about quality then i'm kind of thinking when you're looking
49:15
for more of a global can they perform this movement beautifully like you
49:18
say that kind of makes me think well basically we're talking more about functional testing
49:21
and seeing how they can move collectively but that
49:24
sometimes gets criticized a little bit as not being as
49:27
accurate because you can't distinguish what individual muscles but are
49:30
you suggesting that sometimes we have to forget about the individual muscles and
49:33
just look how they are performing globally yeah you
49:35
know your your your your brain doesn't really register muscles
49:39
it registers movement you know and and you know
49:42
over the last two years a lot of my reading
49:45
and study has gone more into some of the new stuff around brain training and
49:50
how it's all about accessing accessing your your brain by doing weird things
49:56
and one of my courses we we do we can i can change the range of motion in somebody's
50:02
arm by getting them to smell something. Hmm.
50:06
I can change the range of motion by getting them to put their eyes in a certain
50:12
position or put their tongue in a certain position because these affect your cranial nerves.
50:19
So if we think about, if we coach movements rather than the muscles,
50:24
I think we'll be better because if we think about one of the muscles that gets
50:29
trained a lot around the shoulder is serratus anterior.
50:32
Okay massive muscle of the of the
50:35
shoulder blade it does everything that we want
50:38
the shoulder blade to do it upwardly rotates it posterior tilts
50:42
it externally rotates and it also protracts it
50:45
if you do a google search now exercises for serratus anterior out of the top
50:52
10 probably eight or nine of them will be protraction exercises now i have i
50:58
can't ever remember having to coach protraction for the scapula what i have
51:03
to coach a lot of is upward rotation.
51:05
Okay so if i want serratus to
51:08
work as a better upward rotator i have to
51:11
make serratus work as an upward rotator not as
51:14
a protractor with it so we if we think about
51:17
the movement that we want around the around any
51:20
joint but around the the shoulder girdle we that
51:23
will help us help us better knowing what muscles do that is
51:26
okay but we think right what what movements
51:29
that do they produce what what are we lacking you know
51:32
so it generally is humeral external rotation as
51:35
we go into elevation and then upward rotation or posterior tilt or external
51:41
rotation of the scapula so looking at those and i'll coach those movements you
51:45
know don't don't have to have emg on to see is it is it serratus that's doing
51:51
that or or is it middle trap that's doing that i'm i'm watching
51:54
okay is the scapula doing
51:57
what i want to do and training that movement regardless of
52:00
what the muscle is very interesting and
52:03
yes it's great to hear professionals like yourself who
52:06
are on top of the research and everything talking about we've had a few professionals
52:09
who went the vestibular training and things and how that's now being looked
52:13
at a lot paul coco you've already come across in your travels he's very much
52:17
into that at the moment and this course is talking about it again andrew jackson's
52:20
very much talking about it as well and it's a lot of stuff's been done on it and it's um.
52:26
Yeah, it's interesting that, because once we go through so many stages,
52:30
once you've kind of like reached a few decades in the industry,
52:34
things just get blown out of proportion now.
52:36
But I'm wondering how long it is before we go over the top with vestibular training,
52:39
because it's pretty, like you say, sometimes just smelling something or,
52:42
you know, just doing a movement with your eyes beforehand.
52:45
It's opening up a whole, I can just see the DVDs being made as we speak.
52:49
But it is something pretty exciting and novel that seems to be filling a gap,
52:53
you know, and it should be.
52:54
I think in therapy, we've got a problem that we like to be on the next bandwagon,
52:59
you know, and very often we get on that bandwagon and we jettison all other
53:05
things because this is the new kid on the block.
53:09
Now, different things work for different people.
53:12
Every person you see is an N equals one.
53:17
OK, and so there aren't really recipes.
53:21
You need to know what works for that patient doing that movement at that point in time.
53:28
Time and and though it's a little bit more challenging i think if people certainly around.
53:34
The shoulder we discussed how people tend not to like
53:38
the shoulder be a bit wary of it i think they they try and
53:41
fit recipes and formulas to it but if
53:43
you you know what i'm you know what i'm teaching i'd say what we're going to
53:47
do we're going to some play okay we're going to try things and look at improving
53:51
symptoms we're going to look at improved quality movement improved feedback
53:56
back less pain better range for the patient what do we do okay what do i have to do i poke this and,
54:02
stroke that and touch this and tell you to you know change your posture things
54:08
you know and work out right what do we need to do to change that and then come up with a strategy.
54:14
Great stuff brian huxley here is just i think sorry i'm looking at your comments people whether,
54:19
brian says vestibular rehab very important and underused in my opinion yeah
54:24
definitely i wonder know how many have been kind of using it without even realizing
54:26
we're using it because when you do invent and look for symptom modification
54:29
and what makes this better what makes it sometimes i think
54:32
we've been kind of dipping into it already without even
54:35
realizing it but yeah definitely something people should be looking into
54:39
it's one of the kind of the when people say what cvd should i doing should
54:41
i be doing more of this i'm like have you thought about maybe some of that because it's
54:44
probably something you haven't considered so yeah very interesting
54:47
and also made me think of again game with rugby players
54:50
concussion because that's obviously potentially a big
54:53
area where it's been inhibited or because of
54:56
concussion and may not be involved in rehab as much
54:59
as should be so yeah good point brian
55:02
i like it right it's somehow it's already 8 57 nearly nine o'clock so you need
55:09
my wife to come and pull the fuse i love that i love that she must know you
55:13
so well yeah but uh yeah great well no what i'm conscious of is i don't want
55:18
to keep you from the nine o'clock.
55:20
What there's a couple of things well i'm going to give you a little bit of a challenge
55:23
which i should probably have mentioned before you came on the show but i
55:26
like to try and remember at the end of the kind of 57 minutes
55:29
of loads of information and tips one kind of theory into practice so thinking
55:35
about our audience who are long the sports therapist they're probably seeing
55:38
a lot of athletes and not athlete populations who've got shoulder issues what's
55:42
kind of one little thing that you think some people could take away from this
55:45
which they could put into practice
55:46
on tomorrow or whenever next week which maybe they might
55:49
not be doing in the moment with regards to quality versus quantitative assessments
55:53
of the shoulder so okay you don't have to answer yet but
55:56
okay all right have a little think i'm gonna just refer to something i mentioned
56:00
earlier on but yeah one theory into practice which they can take away i mean
56:04
some might not need it but some of them might be a great tip but whilst ian
56:08
is in horses having a think about that i just got a message i was going to tell
56:12
you who's won three weeks free subscription to msk mag but But actually,
56:16
I've just received notes saying that we have no time to collate people together to get a draw.
56:21
So what we're going to do is we're going to roll it on for another week and
56:23
then we'll pull everybody together.
56:25
So obviously, people who have already done a post, what you had to do,
56:28
basically, and we said it in the last week's podcast, was if you do fancy three
56:31
weeks, three weeks, three months subscription, free subscription for MSK Mag,
56:37
which has got, like I say, it's got some fantastic articles.
56:39
Because it's where we found Ben Wyber's article, and it's got some marvellous
56:43
authors in there, which will help your therapy and everything,
56:47
then all you're going to do is basically just do a post on Instagram or Facebook.
56:52
Or Twitter, if you like, and tag in at UK underscore STA.
56:56
It says at UK underscore STA. And just say, I'd love to win three months of
57:00
free subscription to MSK Mag because I make up something which will make me laugh.
57:03
And we will put them all together, and we will get next week's guest.
57:07
I mean, it was always going to be Joe anyway who was going to draw it.
57:09
It so we'll get next week's
57:09
guest joe who's going to draw a name out to anybody who
57:12
does that post so if you're listening to this podcast you've now got a
57:15
week if you're listening to it well it depends you've got
57:18
until the 30th to put a little post out
57:21
there i'd love to win three weeks three months of free subscription to
57:24
msk mag because i'll make sure that goes into the show notes for this one to
57:28
remind you but um it's a great opportunity you might even decide you like it
57:31
and then pay what is not a lot of money per month i think it's a 10 a month
57:34
to get the basic subscription for for msk mag anyway so we're not going to draw
57:39
that it'll be next time back to professor ian horsley.
57:43
Theory into practice over to
57:46
you okay so as i mentioned earlier i i think about considering
57:50
the influence of the kinetic chain it's massive
57:53
so you can see the as i say a
57:56
simple thing by as i say standing
57:59
on one leg seeing if that changes or standing
58:02
on the other leg and see seeing how that changes adding
58:06
some resistance to right hip abduction or left hip hip abduction or right hip
58:13
extension or left hip extension and look one at the quality of movement and
58:18
the feedback from the from the from the patient it's really informative from that because.
58:24
It's hugely important in in how force is
58:27
generated around the shoulder and movement patterns and
58:30
if you oh if somebody's got an insidious shoulder
58:34
injury that's come out of the blue with no known mechanism just
58:38
to check about whether they've had in the last 12 months
58:41
if they've had any lower limb injuries because
58:45
i'm sure joe will talk about it next week they looked at
58:47
a paper they produced a paper looking at professional footballers
58:51
who had shoulder injuries and when
58:54
they looked through them most of them had had lower limb
58:57
injuries in their year before or from
59:00
there and they found a deficit in the kinetic chain that's
59:04
a great that's a great take that's something people can put into practice if you've
59:06
got any shoulder injuries in there assessing rehabbing just see
59:09
what they can do standing on one leg or maybe with a band for
59:12
some hip adducts or something great play around with it people and then
59:15
you can let us know maybe next time or you can always email questions into matt
59:19
at the sda.co.uk or if you really want to comment or leave a question then the
59:22
best place to go is to the sports therapy association youtube channel and stick
59:26
a comment or a question in there it just stays far more alive than facebook
59:29
Facebook is over once a new post appears. So YouTube stays on Google.
59:34
So try and use the YouTube comment section on the Sports Therapy Association
59:37
channel to put any questions in. And I will make sure it gets answered one way or the other.
59:42
Fantastic. Well, look, it's 9.02. I just wanted to bring up your website in
59:47
case people will do a few links in the show notes about how to contact you.
59:50
I'm just going to bring this up on the screen. We can still hear you if I put it on full. um
59:54
so worth going out to check www.backinactionlimited.co.uk so
1:00:00
that's all the w's dot back in action limited.co.uk
1:00:04
professor ian horsley is clinical director of back in action rehabilitation
1:00:09
limited on twitter it's at back underscore in underscore action on instagram
1:00:16
it's at back in action physio like i say the links will be in the show notes
1:00:21
on facebook look up Back in Action Rehabilitation.
1:00:24
Loads of great information being put out there, obviously for free.
1:00:28
So it's worth checking them out and keeping up to date. Not just on the shoulder.
1:00:32
Obviously, there's loads of other stuff there as well.
1:00:34
But I believe in terms of courses and things, Ian, have you got anything coming up?
1:00:40
I do shoulder courses called Sporting Shoulder, and that's for a company called HDPPN.
1:00:48
And I believe we are just organising one for the back end of the year.
1:00:55
And next, in June, I'm doing a webinar on return to play considerations for the sporting shoulder.
1:01:06
Older so looking at the tests that are out there
1:01:09
and what i what use i
1:01:12
think some of them are fantastic people want
1:01:14
information on that can they get it from your website from
1:01:17
back in action the best of
1:01:21
things but i don't know about it probably a younger demographic i'm old
1:01:24
and mostly i'm on i'm on twitter still call
1:01:27
it twitter not x but if they contacted me through
1:01:29
there i i respond a lot from there but but
1:01:32
the other whatever facebook or instagram
1:01:35
that'll that'll get to me my secretary uh managers.
1:01:39
Though okay you're not yet on you're saying you're not
1:01:42
yet on tiktok no snapchat haven't you know what we have
1:01:45
uh our youngest member of the practices has
1:01:48
got us a tiktok chat chat from there but
1:01:51
i haven't seen it says tells me
1:01:54
it is a proper thing and she's not taking the mickey on
1:01:57
it so we'll have all right i'm gonna check that no no
1:02:00
i'm going next check that out that'd be great fantastic yeah
1:02:03
so and we'll put links in the notes to all of that as well in case
1:02:06
you want to keep in contact with professor ian horsley and what's
1:02:08
happening there so fantastic right like i
1:02:12
say next week is park part two if you
1:02:15
are listening to the podcast and you'd like to come along and ask questions directly then
1:02:18
just head along to youtube sports therapy association youtube channel
1:02:21
or facebook page eight o'clock we
1:02:25
can look out out the adverts and set a little reminder i'd recommend youtube normally because
1:02:28
it's just easy to get to and and you can leave comments
1:02:31
in there that last for longer but yeah we're going to have episode 196
1:02:34
which is treating the shoulder steps to success with as i say special guest
1:02:37
joe gibson who's a fantastic shoulder specialist and educator and it's going
1:02:42
to be a great show and it'll be a really we'll obviously touch on some of the
1:02:45
things that professor ian horses mentioned tonight she's in liverpool as well
1:02:50
you're based in liverpool you both No, that's all right. I'm in Yorkshire.
1:02:53
No, you're in Yorkshire, aren't you? Of course. Where did I get the Liverpool link with you?
1:02:57
I do stuff at Liverpool Hope University. There we go. That's great.
1:03:03
But yeah, as you will hear from Joe's gracious tones, definitely born,
1:03:07
bred and raised in Liverpool. That'll be next week in episode 196.
1:03:11
We'd love you to join us live if you can. But if not, you'll find it on all
1:03:13
popular podcast apps and also the live recording on YouTube.
1:03:17
Thank you to those of you who joined us in the live lounge tonight.
1:03:20
Brian Huxley says, really enjoyed the session, guys. Fabulous seeing and a big thank you.
1:03:24
And also Brian Huxley says, a fellow Yorkshireman.
1:03:27
Excellent. excellent let's get a little bit of bonding there and louise
1:03:30
acre as well uh says sums it up nicely
1:03:33
saying thank you it's been really informative gives a better way to look at the shoulder joint
1:03:36
in rehab and thanks guys for joining us
1:03:39
live it makes all the difference i do love just makes it a little bit unique
1:03:42
i always like to record these things live so i appreciate it and thanks
1:03:45
for the feedback from people who do download the podcast if
1:03:48
you have listened to the podcast you've enjoyed it do please take a couple
1:03:51
of moments to leave a review and a rating because it
1:03:54
just helps the a good word of guests like professor ian horsley get out
1:03:56
there more it just it's directly related to what appears in
1:03:59
google at the top so do please leave a rating particular podcasts if you'd be
1:04:03
so kind right that just leaves me to say thank you again to professor ian horsley
1:04:08
for giving up your time thank you very much thank you everybody and have a have
1:04:12
a good evening fantastic thanks guys um hopefully see some of you next week
1:04:16
take care of each other bye.
1:04:17
Music.