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Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE October 2021 Subacromial Impingement RCT: Are We Being Fooled by the Literature…. Conservative Care Prescribing for SA Impingement Re-examined by Mike Napierala, PT, SCS, CSCS, FAFS Clinical Scenario...What would you do? A 50 yr old male c/o gradual onset R dominant side shoulder pain possibly related to a new fitness routine started 3 months ago with increasingly heavier loads and new exercises along with a weekend of trimming trees and other yardwork. He has (+) impingement test findings, tender at SS and LHB tendons, limited/painful elevation and Horiz Add AROM, and weakness/pain with resisted Abd, Jobe, and Abd’d rotations isometric screening. Plain radiographs show mild Type II acromion, no frank osteophytic or DJD changes. Patient has used NSAIDs, seen massage therapist several times, and tried 4 weeks of BIW Physical Therapy without significant improvement. My clinical thinking is: PT/ treatment failed: Do a dexamethasone subacromial injection and FU in 2-4 weeks to consider Physical Therapy again. PT /treatment failed: Order an MRI to better ascertain involved structures and ensure no labral pathology or cuff tearing that might explain lack of improvement, then determine best care. Keep things simple: Provide the patient your customized shoulder/RC HEP sheet and encourage specific adherence to that progression, place on prescription level NSAIDs and FU in 4-6 weeks. Prior care may be inadequate/limited: Briefly review what was done in PT. If excellent/thorough then consider A, B, or C, otherwise refer to more expert PT/group for more thorough assessment and individualized program involving manual therapy, customized exercise, and modalities if necessary then FU in 4-6 weeks. PT / treatment failed: Schedule MRI and prepare patient for likelihood of Arthroscopy to get a better look at the joint/tissues and address findings since prior care has failed. CURRENT EVIDENCE Clausen MK et al, Effectiveness of Adding a Large Dose of Shoulder Strengthening to Current Nonoperative Care for Subacromial Impingement. Am J Sports Med, 49:11, 2021, 3040 - 3049. https://journals.sagepub.com/doi/full/10.1177/03635465211016008 (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRochester.com or if you have a patient case you'd like to discuss) SUMMARY: Shoulder impingement is a highly prevalent shoulder condition that is seen frequently in office by both primary care and orthopedic specialist physicians. Discerning best practices for prescribing conservative care is key, especially as more recent studies have recommended against subacromial decompression surgery ( BMJ 2019), at least as an early treatment option. But clinicians must be wary of quick scanning the literature to avoid misguided thinking based on inappropriate conclusions offered by study authors. As is said…”The devil is in the details” holds true! Clausen et al examined the addition of (an intended) 12 hrs of rotator cuff strengthening exercises over 16 weeks to increase the time under tension stimulus in an Intervention Group(IG) along with “usual care” compared to the control group receiving only “usual care” that reportedly could include modalities, education, exercise, and manual therapy (but were not standardized). There were no between group differences in SPADI score improvements noted from baseline to 4 months. The Intention to Treat analysis also showed no differences for change in Abd or ER strength, Abd AROM scores nor for Patient Acceptable Scale Score(PASS) or global rating of change. Also, only 48% control and 54% intervention groups reached the PASS. The authors concluded that larger strength doses during Subacromial impingement care do not result in superior results. The initial reaction to their conclusion for some may be that four months of therapy was only effective at a mediocre level and some might even characterize as “chance” since only approximately 50% reached the PASS. Others risk deeming this RCT a bit of a “nail in the coffin” of more extensive or lengthy therapy exercise routines, particularly strengthening. One might even be led to ponder “Maybe simple HEP sheets are adequate vs doing formal PT.” It risks serving as evidence that conservative care is inadequate and possibly become reason to entertain surgical intervention earlier. The authors’ conclusion seems premature and inappropriate once you “look under the hood” of this study though. This study’s failure to show superior results with “more strengthening” exercises alone is not disappointing but rather somewhat predictable, especially considering the design allowed in the “usual care” portion. Their findings would, if true, nevertheless, support our position that each patient’s care must be customized to determine not only which exercises are appropriate and when, but also the loading parameters and progressions, as well as pain or inflammation reducing modality/procedure use (ie Class IV laser, iontophoresis, etc) and manual therapy needs for hastening recovery of kinetic chain function. The patient case study demonstrates a comprehensive functional biomechanics and manual therapy based program using customized exercise progressions to achieve recovery in a patient with impingement/RC pain syndrome that is commonly seen in the clinic. Background: With recent recommendations against subacromial decompression non-operative care options become primary treatment, but some studies suggest current care approaches may lack adequate strengthening effect. Purpose: To determine effectiveness of adding a large dose of “time under tension” inducing strength exercises to “usual care” conservative care alone. Methods: RCT design double blind study allocating 200 consecutive patients diagnosed with subacromial impingement syndrome (SIS) aged 18-65 yrs into a Control Group of “usual care” ranging from BIW to 1/mo Physical Therapy over 16 weeks or an Intervention Group (IG) that had four sessions for added training and follow up with a time under tension optimizing strength exercise HEP added that involved eventually three exercises and progressed from 3x20 QD for the first and eventually became QOD for 2x10 for all three during Phase III portion. Measures included SPADI and secondary strength, ROM, quality of life rating, and Patient Acceptable Symptom State (PASS) score. Findings: Both per-protocol and intention-to-treat analysis showed no between group significant differences for any of the outcome measures. SPADI improved for both groups. At 4 months only 54% of IG and 48% of CG patients reached PASS. Author's Conclusion: The addition of larger doses of strengthening exercises to usual nonoperative care for shoulder impingement treatment did not result in superior outcomes. Only half of patients having conservative care achieved PASS by four months, leaving many with unacceptable symptoms. THE PEAK PERFORMANCE PERSPECTIVE It is subtly clear in the background presentation by these authors that the 2019 BMJ recommendation against subacromial decompression surgery was less than appreciated. They state “Such drastic changes to care pathways may leave patients without further treatment options if nonoperative care fails.” Their conclusion added “...leaving many of these patients with unacceptable symptoms. This study showed that adding more exercise is not a viable solution to this problem.” As orthopedic specialists and primary care physicians seeing patients diagnosed with subacromial impingement syndrome making correct decisions about conservative care options is a daily requirement, if not at least weekly. The search for evidence to base those decisions upon could easily land one on articles such as this month’s by Clausen et al in AJSM, considered a highly regarded resource for clinical judgement and introspection. While the data has increasingly supported non-operative measures as a first line of defense for shoulder impingement we do not believe that surgery is unnecessary, unwarranted, or inappropriate depending on the case. Again, the challenge may more so be in how studies are done and data presented. We go back to the concept that each patient is an individual and the patient’s history plus findings along with the professional scientific data can both inform that decision process. Both are necessary. This study does demonstrate, however, that “The devil is in the details” still holds true with scientific studies. In school we’ve all been warned to not simply read the abstract and move on, assuming an author’s conclusions are sincere and thoughtful and reasonable. The risks in Clausen et al’s conclusions here are several fold. One might be led to conclude that conservative care (ie, physical therapy) is generally inadequate and ineffective and thus that surgery may be a necessity earlier in the process of treatment, especially when apparent “failure of care” seems evident. Also, some may believe this data demonstrates that more extensive exercise regimens are unnecessary and ineffective compared to “keeping things simple” with a basic series of HEP from a prepared sheet that could be given out in the office or expected to be the level of “simple care” offered at a PT clinic. Their premise for adding strength exercises is based on evidence of inadequate strength gains from “standard” physical therapy, however, a careful look reveals this came from a design where patients only did strengthening during in-clinic visits and did not have any Home Exercise Program (HEP) responsibilities. That is hardly evidence the “usual” physical therapy is, as a proven standard outcome, falling short in restoring strength. Nevertheless, their contention that therapists oftentimes do underdose strengthening exercises is likely a very valid criticism/concern. Still, before simply throwing more volume of strengthening exercises at patients we must remember that other factors contribute significantly to exercise tolerance and design. ● How inflamed and pain sensitive (and reactive) are the tissues involved? ● Are we seeing true “weakness” having developed or is this potentially pain-induced inhibition that does not necessarily require substantial strengthening dosages/stimuli? ● Are there comorbidities to consider that impact common exercises choices? ● How will pain/discomfort during or after exercises be handled? ○ Attempting generally symptom free strengthening? ○ Allowing limited symptoms during and/or after that must resolve within 2-24 hrs (depending on rationale/philosophy)? ○ Encouraging intensity adequate to produce mild (or greater) symptoms lasting only 2-24 hrs? They also make the mistake of overgeneralizing the concept of “larger doses of strengthening” in the title and article. It more accurately should read “time under tension (including isometric phase) optimized HEP RC strengthening” instead. Clausen et al ignore external validity rules when stating that more “strengthening” exercises are no more effective than usual care. Actually, what is no more effective is utilizing a limited amount of isometric based time-under-tension emphasized home exercise reliance with limited 1/mo average provider training and feedback. A major factor also is the lack of clarity on what sort of strengthening the “usual care” group had already performed. Clausen et al utilized a thoughtful progression regarding QD exercise moving toward QOD, however, it was odd that they added one exercise per month with an eventual program of 2x15- - - > 2x10 QOD for each of the three added strengthening drills, two of which were for ER’s. It was a bit unusual that during the QD phase patients performed 3x20 as their “to failure” target. Normally in strength and conditioning if an athlete were performing a progressive resistive exercise for three sets to fatigue they’d very likely be taking 48 hr recovery between sessions. They utilize very specific slow contractions + isometric “time under tension” model program of only three additional Abd and ER exercises. This hardly qualifies as what many might deem “larger doses” of exercise and, in fact, the eventual compliance finding was that instead of 12 hrs of additional total exercise achieved that the IG only did 2.9 hrs of added exercise (per time under tension) over the course of the study. Despite being a “gold standard” RCT design, the findings here should be taken with caution in leading a clinician to forsake significant strengthening stimuli for impingement cases. It does also call to question the common concept of “protocol” type approaches to care. While the study individualized the loading used based on performance and symptom resolution within 24 hours, it nevertheless used very specific, limited exercises and did not allow for customizing angles, planes, exercise choices and sequencing/progressions or altering exercise parameters. It is not clear that cervicothoracic or scapular issues were adequately addressed as key contributing factors to the condition’s onset or recovery capacity. Decades of experience have shown us that individualized functional biomechanics screening and exercise progressions are very often necessary, instead of more simplistic protocol driven simple progressions. Customizing exercise selection, order, sequencing, and making unique adjustments (such as path of motion plane tweaks to avoid symptoms, hand placement to effect more RC stimulus, the use of or cueing away from allowing kinetic chain synergy among others. Manual therapy to address pec minor restrictions that are facilitating functional impingement along with ensuring thoracic extension and ipsilateral rotation especially ( due to more common same-side reaching with ADL) is crucial. With more advanced demands during goal activity then Type I and II thoracic motion can be considered. Finally, modalities such as the Class IV laser can be very helpful in reducing pain and inflammation to allow earlier intensive exercise. The case below illustrates a comprehensive approach that worked successfully, rather than a mere “extra-volume” of simple RC strengthening drills. A kinetic chain approach helps ensure that the key or at least some of the likely underlying contributing factors for having developed an overuse problem are addressed. THE PEAK PERFORMANCE EXPERIENCE Michael said: “I feel better than I have in years! Now I can lift weights again and golf without pain!" HX: 57 yr old male reports h/o five years with (B) shoulder pain that developed gradually with increasing fitness exercise and weight lifting as well as ADL use. His CC are frequent L and infrequent but more intense dominant side R shoulder pain with fitness/exercise, ADL lifting and reaching, sleep, and recreation (golf, shooting basketball with son). Subjective: Pt reports 80% function and pain L 2/10 and R 4/10. Quick Dash 11% and Sport module 19%. Objective: (Pt had inconsistent attendance due to job demands. Seen 14x over 4 months) (*=pain) Initial Eval DC Re-Eval Flexion AROM 1500/1500 1630/1520 IR AROM T9 * / T11 T6 / T9-10 Abd IR AROM 250/250 550/470 Pec Minor Tightness Mod/Mod Min+/Mod Isometric Flexion 6.6 kg* / 12.8kg 12.8kg / 14.5kg Abd 8.8kg * / 13.7kg 13.4kg / 13.4kg Overhead Press 1st sx L 3# / R> 45# 25# elliptical 16x/19x Abd ER NT 15# 27x / 30x Push ups ½ depth painful 10” box > 10x no sx Key Findings: Thoracic extension and rotation limited, pec minor very tight (B), posterior RC/capsule limited with Hor Add and Abd IR ROM. Elevation strength and Abd Rot’s all weak and painful. Impingement tests (+) in (B) shoulders. Treatment: Manual therapy targeting thoracic spine and pec minor along with GH joint capsule mobilizations for restoring especially inferior capsule length to allow elevation end ranges along with Horiz Add and Abd IR. Self stretching/mobilization/ROM program for same structures-tissues done. Painfree strengthening progression initiated for promoting better scapular retraction and also improving upward rotation ease (based on pec minor induced chronic protraction with reaching/lifting especially) and also 300 abd’d rotations. Strengthening progressed on to sx-free plane elevation with reduced depth starting motion on incline press to reduce gravity demand at 90 and end ranges of lift. Long lever strengthening began lying with tubing to again reduce demands at key impingement ROM zones will still proprioceptively stimulating independent function into full available elevation without pain. Early on parameters were BID 10- - ->30x and then later once a base established PRE were gradually progressed to 2x15 QD and then finally 3x 10-12 TIW for more intensive loading. Outcome: Pt had difficulty attending regularly due to demands of job. He was only infrequently seen BIW and more often 1/wk and still then bouts of 2-3 weeks without visits. Nevertheless he reached self reported > 90% function on each shoulder and had resumed canoeing, kayaking, shooting baskets with his son, playing golf and sleeping comfortably. You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs. Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester. We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients. No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering. No surprises. No hassles. Confident your patient is in the right place. COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

PHYSICIAN UPDATE August 2021 TITLE: How Early Following Rotator Cuff Repair Should Active Motion Begin? by Andrew Neumeister, PT, DPT, FAFS, Certified Running Gait Analyst Clinical Scenario….What would you do? A 47 yr old male with a history of RC tendonitis symptoms injured his dominant arm throwing a football with friends while tailgating before a Bills game. MRI was (+) for full thickness Supraspinatus and partial thickness Infraspinatus tears. He was able to elevate actively to 1500 within two weeks and ordered a 6 wk trial with PT. Function and sx were not improving adequately so a RC-R was done. Sling immobilization for 6 wks chosen post-op. Which of the the following orders would be given for post-op PT care re ROM… PROM only for 6 weeks, AAROM x 2 weeks, then begin gravity neutral AROM for elevation and rot’s at 8 wks post op Immobilized x 2 weeks then begin 6 wks PROM, AAROM x 2+ wks, then begin gravity neutral AROM for elevation and rot’s at 10 wks post op PROM only x 3 wks, begin AAROM for 1-2 wks, then begin gravity neutral AROM for elevation and rot’s 4-5 wks post op Immobilized x 4 wks, begin PROM at 4 wks, add AAROM at 6 wks and then gravity neutral AROM for elevation and rot’s starting at 10 wks post op CURRENT EVIDENCE Silveira A, Luk J, Tan M, Kang SH, Sheps DM, Bouliane M, Beaupre L. Move It or Lose It? The Effect of Early Active Movement on Clinical Outcomes Following Rotator Cuff Repair: A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther. 2021 Jul;51(7):331-344. doi: 10.2519/jospt.2021.9634. Epub 2021 May 15. PMID: 33998264.. SUMMARY: Shoulder pain is one of the most common pathologies seen in orthopedics with a prevalence ranging from 70 and up to 260 per 1000 individuals in the general population. Physical therapy can be a great tool to reduce pain and improve functional ability, however after confirmation of a tear and failed conservative treatment, surgical intervention may be necessary. Post-op RC-R’s are commonly immobilized in the Rochester area for roughly 6 weeks with only passive shoulder ROM allowed per protocol as previous literature has demonstrated benefits of reducing stiffness while minimizing risk of damage to the repair and potential retearing. Silveira et al. conducted a systematic review using eight RCT’s to compare the effects of allowing early AROM after surgery before 6 weeks vs. delaying AROM regarding any significant benefits or risks on ROM, functional outcomes, strength, atrophy, or integrity of the repair. Silveira et al. showed that the integrity of the repair was maintained as per 12 month US or MRI imaging, not showing significant difference in retears between early AROM groups and PROM only for 6 weeks. Likewise, testing by 6+ months demonstrated both ROM and strength were also not significantly different among groups, despite 6 wk testing showing worse functional questionnaire responses early on with the early AROM group. These results pose the question: What are the benefits to immobilization with PROM only following RC-R vs early AROM before 6 weeks? A key perspective certainly is that while early AROM did not reveal any long term worsening of functional scores or objective findings, it also did not result in improved status either (ie. no clear benefit to offset the potential risks). Early AROM, while seemingly not practiced in the Rochester area as a standard, appears to be statistically safe but the potential benefits are still uncertain. Pairing the right individual with the treatment program may increase functional return at an earlier date; however, risks may also rise as loaded lifting rather than AROM reaching alone becomes more likely with earlier ADL use. RC-R post op planning considers case by case variables while working closely with a skilled therapist and surgeon to determine the best course of action. At minimum, this study lends some support to common patient requests for light reaching, movements, and possibly things like limited keyboarding or video games etc that may otherwise be prohibited during the immobilization + PROM only phase. (We’d love to hear your professional insights on this topic. Let me know your thoughts after reading this summary at PT@PeakPTRoc.com or if you have a patient case you'd like to discuss.) Background: Immobilization s/p rotator cuff repair with restricted PROM is thought as a measure to protect the joint and reduce stiffness in the first 6 weeks after surgery, however it has not been concluded what benefits or harm can come from allowing early AROM before 6 weeks. Method: A systematic review with meta-analysis was conducted with studies included from 1990 to present reported as RCTs. Metrics were compared between a control group of patients with sling immobilization and PROM only until 6 weeks post-op against early AROM before 6 weeks or “self weaning from sling.” 8 studies were included with 756 participants. Outcomes of interest reported at different times post-op included ROM, strength, repair integrity, return to work ability, and self-reported quality of life. Results: Patients who commenced early AROM vs delayed had greater ROM for flexion and abduction at 6 weeks, and for ABD/ER at 90 deg. at the 6 week, 3 month and 6 month marks with a high certainty of evidence favoring this early active motion post surgery. However, this same group rated themselves worse on the Western Ontario Rotator Cuff Index (WORC) at 6 weeks. There were no differences in repair integrity between groups however the individual studies were underpowered for this measure. There were no group differences for ROM or strength measures at long term follow ups. Author’s Conclusion: Patients who started with early AROM had increased ROM at 6 weeks for elevation and up to 6 months for ER but had worse shoulder specific quality of life ratings by 6 wks compared to those of delayed AROM. Outcomes were similar by 6-12 months between groups in all ROM, strength, functional scales, and repair integrity measures. There was no benefit but also no compromise in the selected measures to early AROM following RC-R. THE PEAK PERFORMANCE PERSPECTIVE Rotator cuff repairs can be necessary treatment for those with full or partial tears and certainly for those who have failed conservative rehabilitation and are still experiencing pain and functional deficits. Orthopedists have varying protocols dependent on which tendon(s) was/were repaired in order to promote healing and avoid overstressing the repair as biological healing ensues. Despite subtle differences, a general theme in the Rochester area is to delay AROM until 6 weeks or longer for many surgeons post-op , moving sequentially to AAROM before actual AROM and continuing to utilize maximum ROM limits until 3+ months post op. Silveira et al. sought to determine if there were any benefits to initiating early AROM defined as before 6 weeks and/or “self weaning from sling” for individuals with a full-thickness tear. A successful rotator cuff repair relies on a strong team of surgeons and rehabilitation specialists to direct the patient in maximizing return to function in an appropriate time frame. There is no denying that protection of the repair is a high priority early after surgery and throughout different stages as ROM allowance and strength initiation is permitted per doctor and tendon specific protocols. A question that appears to remain is whether early AROM before 6 weeks is more of a risk vs the potential benefits of reducing stiffness and atrophy. Silveira et al’s systematic review may guide clinicians into best practice during shoulder rehabilitation. The results demonstrate that early AROM does improve shoulder ROM at 6 weeks for elevation and up to 6 months for ER, however those individuals rated themselves less functional according to the WORC at 6 weeks. Of course, the question remains - what is the value of substantially improved AROM at 6 wks for a RC-R that will likely not be allowed resisted work of any loads until oftentimes 8-12wks post op? The risk of improved AROM early on is limiting concurrent ADL in the presence of this improved AROM. Limitations to this review must always be considered and include that the 8 studies did not all report on the same desired/preferred outcome measures so interpretation of these results is graded on different levels of certainty of evidence and differences from how each study was conducted. Studies often lacked specific protocols for how AROM and sling use were instructed. Also, another limitation was assuming that the surgeons, therapists, and compliance of the patients were comparable across all studies - these variables are impossible to standardize. Nevertheless, it is important to note that by 6 and 12 months there were no statistical differences between delayed vs. early active ROM including cuff integrity, strength, ROM, and functional ratings. So why does this matter at all? If the current practice of delayed AROM until 6 weeks post-op leads to comparable 12 month results, then why bother to initiate early AROM? We cannot forget there are independent variables that cannot be controlled, such as clinical judgement, surgical technique and experience, exercise techniques and progressions, differing between the skilled surgeons and the physical therapists in charge of protecting the repair and guiding the patient on a successful path to functional return. Clinical judgement can be a huge factor especially when a patient is progressing “faster” or “slower” than preferred. If ROM is lagging compared to desired ranges, then the patient may risk increased stiffness and discomfort with loss of functional ability at certain stages of recovery. The opposite is also a common concern regarding trying to avoid straining the repair and compromising tissue integrity. The study reported that with moderate to high certainty, early AROM can be beneficial for increasing ROM at 6+ week mark without increasing risk for re-tear long term. This data does not reflect on ROM limits set forth in protocols nor whether repetitive early AROM was done as an exercise in regimented fashion, and if so, in gravity neutral or gravity resisted positions vs simply via limited ADL reaching etc. It was noted in the referenced studies that subjects in early AROM were cued to allow pain-free AROM. While a good concept and clinically sound, it remains a very subjective and difficult to control variable. Patient education on restrictions and appropriate functional use/ability and home exercises must be made clear to the individual and a potential risk in allowing early AROM without use of sling during ADLs and at rest, may have patients unwillingly reach for or grab object causing increased strain which may explain why the functional scores reported by the subjects were worse in the early AROM group. The risks of early AROM may not be as detrimental as perceived; however, a skilled therapist needs to direct safe return to function with continuous monitoring of progress. Simple AROM alone, out of the sling, does not afford substantial increases in ADL because most would involve holding or lifting or bracing with objects, adding weight (ie. resistance) that is not allowed yet...although some protocols do happen to specify approval for ADL < 5# despite not having yet approved any resistive training. High communications between the therapist and surgeon certainly are necessary. This serves to inform and collaborate with the surgeon when things are moving slower than ideal or when the patient is taking too many liberties and may risk injuring the tissue. Factors such as number of tendons, surgical technique, or number of sutures all may impact post op planning. Biomechanical considerations must be taken into account that are not often addressed or overlooked in traditional therapy for someone just following a protocol. For individuals who end up with a tendon repair due to years of tissue degeneration which may have once been “impingement syndrome,” underlying causes or what we refer to as “probable suspects” need to be addressed after surgery to ensure these factors will not slow or limit functional capacity. Thoracic mobility in both the transverse and sagittal plane will influence the strain on a cuff by restricting the scapula’s ability to move and clear the acromion with overhead reaching. Limited trunk rotation can also cause the individual to compensate through greater horizontal ADD and ABD reaching in elevated positions causing approximation of the cuff against bony anatomy. Specific manual therapy and exercise techniques, with a goal of restoring normal biomechanics, must be utilized following RC-R, despite oftentimes not being addressed specifically on RC-R “protocols” as part of thorough care planning and case management. Thoracic spine, cervical spine, scapular and hip regions especially must all be examined and attended to in order to both minimize undue stress on the healing repair but also to optimize function long term. In light of the lack of clear benefits associated with early AROM we would generally contend that delaying early AROM is still a “best practice” on the basis of avoiding potential risks with individual patients who would then be more likely to overuse the involved arm during ADL. While that likelihood existed for the study participants and did not ultimately result in clear (-) outcomes this study at least provides some reassurance regarding the safety of those who may be non-compliant from avoiding early AROM or in whom a surgeon and therapist determine can begin early light AROM for dressing, showering/bathing, keyboarding while still avoiding resistive/loaded ADL. The case presented below reports on a successful case of delayed AROM until after 6 weeks with good compliance and addressment of biomechanical nuances to maximize a successful return to function. THE PEAK PERFORMANCE EXPERIENCE Cliff said: “...after 20+ years of shoulder issues, I'm feeling completely better and looking forward to returning to hockey and other activities which have limited me for so many years.” History: The patient is a 54 year old male s/p L shoulder RC-R with pre-op diagnosis of a full thickness supraspinatus tear. Subjective: Max Sx 5/10 with any movements. Self-reported function at 0% as pt immobilized until initiating PT. QD questionnaire rated 75% limited. Objective: See table below. (Minimal PROM testing on Evaluation and 1st Re-evaluation secondary to protocol restrictions) MEASURE ( *=pain) Evaluation 1st Re-evaluation (7 weeks) PROM nER (deg.) -19* 34 PROM Flexion (deg.) 41* 125 PROM Ext (deg.) NT 22* AROM nER (deg.) NT 34 AROM flexion (deg.) NT 95 > stopped at first Sx MEASURE *=pain 1st Re-evaluation (7 weeks) ROM testing at 3.5 months PROM nER (deg.) 34 61/60(101%) PROM 90ER (deg) NT 80/80(100%) PROM 90IR (deg) NT 56/60(93%) PROM Flexion (deg.) 125 174/180(97%) AROM Flexion (deg) 95 > stopped at first Sx 174*/180(97%) AROM ABD (deg) NT 170*/175(97%) AROM Ext (deg.) NT 48/55(87%) AROM nER (deg.) NT 63/65(97%) AROM nIR (deg.) NT T9/T8(100+%) Isometric testing at 3.5 months DC Testing at 5.5 months Iso 90 deg. Flexion (kg) 5.8/12.9(45%) 11.5/15.9(72%) Iso 90 deg.ABD (kg) 6.0/13.9(43%) 11.0/13.2(83%) Iso nER (kg) 7.9/13.5(59%) 10.4/16.5(63%) Iso nIR (kg) 15.3/22.6(68%) 21.6/22.7(95%) Iso 90ER (kg) NT 11.6/16.9(69%) Iso 90IR (kg) NT 14.8/19.2(77%) FNXL OH Press 25# scaption to 83” sup wrist NT 16x/18x(89%) Deceleration tube nRow gray band with controlled pause at max tension (45 sec) NT 56x/54x (103%) Treatment: ADL education for early donn/doff sling and strict review of surgeon specific protocol restrictions Progressive self PROM with opp UE A...AAROM….AROM as able per protocol nER and flexion early...then nIR, ABD, and rotations at 90 deg ABD thoracic mobility addressed with rotation and extension self mobilizations to aid on scapulohumeral rhythm Manual mobilizations with focus on increasing pec minor mobility and posterior capsule pt presented with anterior scapular tilt predisposing them to reduced scapulohumeral rhythm secondary to pec minor tightness anterior GH translation noted through observation from likely posterior capsular tension Progressive RC strengthening with early isometrics before loading the shoulder with external loads short lever positions utilized early before long lever torque demands patient cued to remain symptom free; specifically with over head positions where the SS may become compromised through approximation serratus anterior loading focused though maintaining stability on the thorax without “winging” while undergoing NWB and WB loads at progressive angles from scaption > anterior force to increase demands on scapular stabilizers functional OH press and lifting a various angles of ABD/ER with emphasis on thoracic rotation/extension to reduce strain to cuff at various stages of healing to prep for 3D demands Speed and Impact - Sports retraining speed work completed though band and DB work focusing on the deceleration of tissue to prep for hockey and other patient specific goals impact training staged with bilateral landing prior to single arm strains when scapula demonstrated good control without increased winging Discharge Testing: Reported self fxn at testing visit to be 100%. Patient reported no sx or limitations in ADLs and was able to kayak. Did not attempt hockey yet while waiting for MD clearance due to under 6 months post op, however since discharge has returned to sport. 0/10 pain and 0% limited per Quick Dash functional questionnaire.

Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE July 2020 Rethinking Best Practices on Rotator Cuff-Related Shoulder Pain Special Testing... How strong is the evidence really? In this update we’re departing from the typical research article review to examine a “viewpoint” article recently appearing in the Journal of Orthopedic and Sports Physical Therapy that reviews the evidence base for the “old dog” of rotator cuff-related shoulder pain (RCRSP) special tests often used by physicians, surgeons, and therapists during clinical exams. When you see suspected RCRSP... What special tests do you presently use in clinical exams for RCRSP? What weight do you give them in making a diagnosis? Do special tests for RCRSP help identify specific structures generating pain? Do imaging findings consistently and accurately identify and explain symptom causes? When patients undergo acromioplasty, biceps tenodesis, type II SLAP repairs, atraumatic RC tendon tear related surgery can they be certain the tissue causing symptoms was addressed? Salamh P, Lewis J. (Viewpoint) It is Time to Put Special Tests for Rotator Cuff-Related Shoulder Pain out to Pasture. JOSPT. 2020. 50(11); 222-225. by Mike Napierala, PT, SCS, CSCS, FAFS The full text review is available via the Read More link below. We've begun using this summary of our article overview as a quick read version In an effort to honor your time demands. SUMMARY: As musculoskeletal providers we’re always called to reassess our clinical practices based on new evidence. The concept of test validity requires so called “gold standards” for comparison. The challenge with most existing reference standards used for validating our existing list of RCRSP tests is that asymptomatic shoulders, whether in healthy control groups and even as the contralateral healthy control shoulder in symptomatic individuals, often have comparable abnormalities present on imaging, despite the lack of symptoms. These facts challenge our reliance on the pathoanatomic model as the predominant basis for clinical exam diagnostic testing. The underlying assumption that abnormal morphology on imaging is increasingly being called into question, and at least is controversial or debatable. Since RCRSP special tests are intended to identify specific structures, to the mutual exclusion of other adjacent or nearby tissues, as the pain generator the inability to have clarity on what the “gold standard” really is leaves the use of special tests for RCRSP increasingly difficult to defend. The authors contend that their best and more appropriate use may be as a symptom reproduction test rather than being used to name specific structures that are injured/damaged and thus a basis for non-surgical and surgical treatment decision making. We find that high quality MSK care requires not only, or even most often or primarily always, the clear and undoubted pain generating tissue diagnosis but in the majority of cases, being atraumatic, a careful analysis of the "underlying shortcomings" or biomechanics causes for the tissue overload is really the major key that directs non-operative care and decision making. There is little difference in care of inflamed or damaged tissues...Class IV laser if you have it, iontophoresis, ultrasound, electric stimulation, traction, taping - there are only so many modalities that can be used to promote healing. Too often traditional physical therapy uses a microscopic approach addressing the pain generating tissue and neglects to discover the telescopic view of the kinetic chain that created the overload to begin with. Patients inevitably return with the same condition or others due to the need to compensate once again for the underperforming body parts. Background: Rotator cuff-related shoulder pain (RCRSP) is an umbrella term that includes common diagnoses such as impingement syndrome, RC tendinopathy, bursa pathology, and atraumatic rotator cuff tears – any of which typically lead to a painful shoulder that demonstrates weakness in abduction and/or ER. There are over 70 “special tests” developed for identifying shoulder conditions, many of which are intended for RCRSP. (Others are for labral pathology, scapular dyskinesis, instability, etc...which are not the focus of this article.) Keypoints: Validity of RCRSP tests are typically established by comparison to a “gold standard” such as radiographs, MRI, diagnostic ultrasound, or visualization at the time of arthroscopy/surgery. Thus, if deemed a valid test, the (+) test would correspond to the reference or gold standard test showing pathology, and conversely (-) when the reference shows no pathology. The challenge arises when so many commonly termed gold standard or reference tests detect abnormal findings on the asymptomatic side as well. Barretto et al in J Shoulder and Elbow Surgery in 2019 demonstrated that the asymptomatic shoulder of 123 patients with unilateral pain had as many abnormalities as the symptomatic side with the exception of full-thickness supraspinatus tears. Also, GH osteoarthritis had a 10% higher incidence in symptomatic shoulders. Isolating structures via special testing is also a necessary assumption if special tests are to have merit. Yet, anatomic and histologic studies have shown how interwoven the relationship is between the cuff tendons and the capsule, ligaments and bursa tissues. Discerning between these would be necessary for the various special tests to be accurate at distinguishing one tissue from an adjacent or connected tissue. For example, Boettcher et al in testing the Empty Can test, typically viewed as a supraspinatus test, showed that 9 shoulder muscles were active...and 8 active during the full can test. Findings like these challenge the clinical reasoning that exact symptom sources can be determined by special testing during clinical exams. Musculoskeletal providers have been trained to associate, and therefore seek out in testing and for the sake of treatment, specific structural abnormality to attribute pain generation to. Very complex anatomy, biomechanics, and physiology are often distilled down to simple special tests. Yet, a systematic review by Hegedus et al in British Journal of Sports Medicine was unable to recommend a single test. And Lin et al in the BJSM did not include special testing in their list of 11 best practices for musculoskeletal pain based on their systematic review. Other challenges to rethinking the value of RCRSP special testing also include the time it can take for quality research to be incorporated into practice for experienced clinicians. Conversely, many or most newer clinicians are taught in undergraduate or postgraduate training about special tests and may rationalize their application out of necessity early on. Conclusion: The case is made that relying on special tests or imaging to inform patients on the exact source of their pain or for decision making on invasive procedures of non-traumatic RCRSP is “arguably unacceptable practice.” RCRSP special testing may be appropriate as a specific example of reproducing shoulder symptoms but without reference to specific anatomic structures involved (ie. pain provocation tests). Peak Performance Perspective: The pathoanatomic model has been a foundation for physicians, surgeons, physical therapists and athletic trainers for as long as most of us can remember. From academic foundations to internships/externships/fellowships the reliance on and trust that abnormal findings on imaging explains the cause of symptoms is taken with little debate or confusion. And for larger acute traumas, such as lacerations or fractures and ruptured tendons there’s certainly no debate. The morphology changes are clear and the “leap of faith” needed to claim certainty regarding the “cause” or the involved tissue isn’t really even a leap of faith at all. But then comes along chronic musculoskeletal conditions. Overuse. Microtrauma. Degenerative changes. And now research is showing us increasingly that for a host of the most common conditions we all see clinically that so many are equally present on the contralateral side that is without symptoms in the very same person and in completely asymptomatic people as well. Disc bulges and even herniations. Degenerative RC changes. Tendinopathy. Degenerative meniscal tears. “Impingement” syndrome. And within that the more encompassing label of Rotator Cuff -Related Shoulder Pain (RCRSP). As clinicians called to discern and rely upon “best practices” we accept that sometimes the research is lagging but clinical thinking must still arrive at answers. But, when good new research mounts we are called to reassess our clinical practices and grow. Whether new findings reinforce our prior rationale or demands we modify clinical practices to incorporate new “truths” this constant clinical process must happen. Undoubtedly we must also guard against knee jerk reactionary swings of the pendulum based on singular studies. Conversely, sometimes our assessment comes after recognition that the evidence was maybe really never there to begin with. The classic RICE and PRICE acronyms may be our most common proof of that. Dr. Mirkin, who coined the term “R-I-C-E” in 1978, has since indicated that common practice and theory was behind this recommendation, rather than sound research evidence. RICE has reached the level of powerful orthopedic dogma that all of us as musculoskeletal providers have surely used in the past...and for many, still use now. Yet it lacks solid evidence. It’s orthopedic “comfort food”...but is it true? Is it based on sound scientific findings? No. In the case of ice use for more extended times following injury or surgery there is now plenty of indication that pain control and temporary delay of swelling are benefits but that earlier or better recovery and consistent reduction of swelling are, in fact, NOT benefits that should be expected with ice. And our walls crumble. Ice, RICE, PRICE...these were maybe the most engrained and universal musculoskeletal recommendations for the last 40 years. Yet, an evidence base was lacking. We know better now. But change can come slowly. It’s a difficult process for professionals to alter their habitual thinking, decision making, educational talks and treatment recommendations. And the strength and seeming common sense of the concept that ice would be helpful contributes to the self-fulfilling prophecy of internal bias we all have that makes us even uncomfortable and hesitant to accept that so many research papers do fail to support the repeated use of ice for musculoskeltal injury. Salamh and Lewis contend that we really are in the same place with RCRSP special testing. A place where we must reconsider, reassess, our continued use of a comfortable and common practice that really lacks good evidence at this time. The lack of acceptable gold standards to even compare these tests to is a hard point to argue against. Too many studies to mention have repeatedly shown us that a myriad of non-traumatic orthopedic related pains/conditions do not demonstrate, in fact, imaging abnormalities exclusive to the symptomatic side. A clear thorn in the side of pathoanatomic based decision making...or maybe more than a thorn. While we cannot “throw the baby out with the bathwater” on this topic – because so many conditions are very well identified by abnormal morphology on imaging, it may be that we merely need to step back and accept that many of the “special tests” that we’d come to rely upon for atraumatic differential diagnostics during physical exams must instead be considered a group of likely potential tissues involved during a provocative postion/test that can be used later to affirm progress rather than believing we have the ability to discern an exact tissue as the sole pain generator. So then what? The good news from a treatment perspective is that from a functional biomechanics Physical Therapy perspective we’d propose that symptom reproduction, functional biomechanics analysis, and patient specific responses to exercise all have a much greater implication on treatment decision making than a predetermined anatomic tissue (word). Consider examples such as biceps tendinitis. Impingement syndrome. Supraspinatus tendinitis. Any one of these diagnoses could present in a live patient somewhat differently. And, could also easily be misdiagnosed or appear to be one of the others. And as a clinical instructor reminded me three decades ago - “What makes you think that each patient is allowed to have only ONE problem?” So often we strive to find THE diagnosis that we risk neglecting the fact that numerous tissues were experiencing whatever overuse or biomechanical compensation loading that occurred...not just one singular tissue alone. From a biomechanical analysis perspective we’d also submit that determining underlying shortcomings that resulted in microtrauma over time is the real key. Too often physical therapy, or orthopedic care in general, fails because the focus is on the THE TISSUE generating pain rather than caring more about WHY it got that way. Any of those diagnoses above may have a host of adjacent or even distant biomechanical shortcomings that preceded the eventual inflammatory reaction and subsequent pain that led the patient to stop playing, stop working, alter life...and come to see you for help. We rarely find that simple progressive exercise loading to the local tissues from a generic sense is the answer. For so many of the “failed PT” cases we see it ultimately comes down to discovering the underlying shortcomings...or as we say to patients, the “probable suspects” that led to the overuse, the asymmetric loading, the prolonged or early or excessively fast loading that caused the tissue to hurt. For shoulders our keys are the thoracic cage, hip function, and scapular function. Lacking thoracic extension and rotation, type I and II coupled motion issues related to specific sport or ADL/work biomechanics needs, serratus weakness (NOT as a protractor in the “plus” actions typically used in rehab) , hip extension and rotation lackings especially... these all are common issues behind shoulder overuse and eventual pain. Yes – our class IV laser, iontophoresis, ultrasound, therapeutic taping, instrument assisted soft tissue release...there are many treatments that can be helpful at promoting healing and resolving pain of local tissues. But the real key to treatment is ultimately identifying underlying causes. And for that reason, it’s really all the “other” findings on patient physical exams that drive our treatment decision making - and not, our historic reliance on special testing to identify the exact tissue involved. Peak Patient Experience Daphne said,” I’m painfree now. I wasn’t sure my shoulder would ever be normal again. I can do push ups and overhead pressing and pullups again now!” History: 50 yo female with dominant R shoulder impingement diagnosis. MRI showed supraspinatus tendinopathy and ACJ DJD. Pt is a personal trainer who also regularly works out; exacerbated R shoulder pain during vacation despite no specific trauma or overuse. Subjective: R shoulder pain reaching 3/10 with overhead pressing, bench press, push ups, pull ups and turning car wheel. Self-reported function at 30% and QuickDash Sport 69% disability. Objective: (Pt was seen 10x and then released to independent HEP - returned for final testing 3.5 mo after beginning PT) *=pain Test Initial Evaluation Discharge Evaluation Pec Minor R>L mod loss WNL Thoracic Rotation 300/270 WNL AROM Abd IR 270 * WNL Hor Add 380* WNL Isometric Jobe 50% * 84% Abd IR 33% * 96% Abd 50% * >100% Serratus Ant Wall Test 4+ 5/5 Overhead Press 8# <46% * 15# 100% Abd ER NT 10# 85% Treatment: Manual Therapy: Thoracic cage ext and rotation mobilization. Pec Minor soft tissue mobilization. Glenohumeral mobilization. Exercise: Stretching/PROM-AROM, scapular stability Serratus Anterior work as “de-winger” action (NOT as scapular “plus” protraction) both nwb and wb, low load endurance based - - -> strengthening for RC and scapular muscles using modified gravity and lever arm changes to customize sx-free ranges and loads. Transitioning toward functional strengthening for prepration to resume full personal training duties and fitness/wt lifting. Therapeutic Taping: Rocktape used for scapular awareness and RC unloading. Discharge Evaluation: Painfree. Reported function at 95%. Resumed personal training duties and fitness wt lifting progression toward pre-injury/symptom level loads. Quick Dash Sport reduced to 6%.

I developed problems with pain and limited range of motion in my left shoulder that only worsened with exercise and activity. Further evaluation revealed a torn rotator cuff injury that was repaired surgically in August 2018. Mike has guided me through a progressive regimen of stretching and strengthening exercises as my shoulder has healed. I am now well on my way to full recovery, not only from the injury and surgery, but in regaining my ability to engage in the full range of activities I used to do. I am so grateful for Mike’s expertise and persistence in bringing me through to full recovery. ~ William Morehouse

I was referred to your organization, after rotator cuff surgery, by a trainer at Penfield Fitness who knew of your work. I was assigned to Andrew and that turned out to be a really good choice. I’d had this surgery 10 years before, but I must not have coalesced adequately, resulting in a more severe problem. I had neither strength nor range of motion in that shoulder when I met him. Andrew advised me intelligently, humorously, cajoling me to what will be a near-complete recovery. I can now wash my hair with that arm, scratch my back and lift weights overhead that I was unable to lift! During that time I also experienced a knee problem, so we soon transitioned to the other end of my 77-year-old frame. Same outcome…Andrew gave me exercises that have led to pain-free and flexible walking without surgery. I admit, he’s a better therapist than I am a patient, but his encouragement makes following through with his program less of a task and more of a healthy routine. Andrew is results-oriented, clearly knows his “stuff,” and is a true professional. Thank you, man! ~ Arthur North

As the colder temperatures set in, we often see a rise in the number of patients who come to physical therapy for shoulder pain. Despite living in Rochester, the cold weather is not likely to blame for these problems! Overhead sports, all sorts of yard work and things like shoveling can really take a toll on your joints until they start to nag you so much that you change how you move. Eventually you’re forced to change the way you are functioning and...all too often...to STOP enjoying your favorite activities. Many different structures in the shoulder can cause pain. The rotator cuff ("rotor cup" as some would say), part of the biceps muscle, the labrum (shoulder socket cartilage ring), AC joint (small bump on top of shoulder), and multiple bursae (fluid sac friction reducers) can all be culprits that cause pain and limit function. But sometimes people are too quick to assume the cause is where the pain is and are "fooled" into blaming the shoulder when other nearby parts could really be at fault. Did you know that your shoulder pain can come from its nearby neighbors, the neck (cervical) or mid-back (thoracic spine)? Radiating pain from joints and nerves in both the neck and trunk can send symptoms to the shoulder blade and sometimes down the arm...which can be tricky as they pass right through the shoulder area. Pain doesn't have to be the only "feeling" that can raise a flag or concern; weakness or numbness/tingling can also be a sign that something is wrong. For those of you reading this thinking, "I know, stretching and strengthening exercises are the answer"…you might be right. Or you might not be. And do you know which ones are the right ones to do? You see, the real challenge is first doing an evaluation to determine the source of the pain, figuring out which tissue is making that shoulder hurt but then ALSO digging deeper to find any underlying causes for why it happened in the first place! Seeing a skilled, knowledgeable health care professional is that first step. A good history and a thorough physical exam are the key first steps to discovering why your shoulder hurts. Yes, there are times when "films” might be necessary. But be careful of ‘hanging your hat’ on X-ray or MRI findings. Studies remind us that plenty of people with no pain often have similar findings on imaging studies...so they’re sometimes part of discovering what’s going on, but they have to be interpreted alongside an excellent clinical exam. Too many of today’s common treatments focus on simply masking your symptoms. Temporary “feel good” options do work to block your pain or inflammation, but have they really helped handle the actual problem? Can you be confident this isn’t going to come right back again? Keep an eye out in your inbox for our next email and we’ll share a little more about understanding those different causes of shoulder pain better. Hope this helps!Allison Pulvino, PT, MSPT, CMP, CAFS and Andrew Neumeister, PT, DPT, FAFS

As a personal trainer and group exercise instructor (TRX and boot camp), dealing with rotator cuff pain due to impingement was definitely a huge issue. On top of it interfering with my work, it was making my own workouts suffer as well. Working with Mike was an eye-opening experience. Not only did he test my range and strength in my shoulder but he also showed me how my mobility in other areas was contributing to my limitations and pain. He taught me exercises to treat the issues I was having but also taught me new ways to think about my own personal training as well as well as working with my clients. I’m happy to say I’m now working out pain free and stronger than ever! Mike and his team are awesome and I will continue to recommend Peak Performance to my clients and friends. Thanks, Mike! Daphne M. December 14, 2017

My goal was to see how well I could still play volleyball with a rotator cuff operation. While not back 100%, I’m about 90% hitting. My goal was met and I’m very happy with Peak PT-thanks, Karen! Ed C. March 14, 2017

There is no greater gift than having the ability to assist someone in increasing or regaining their quality of life. Mike has done this, for me, three times in the past 6 years. I came to Peak Performance in 2010 for physical therapy after rotator cuff repair. I was referred to Peak Performance PT by my surgeon, after the initial physical therapy services from a different provider resulted in little to no progress in my healing process. I returned to PPPT again in 2011 after rotator cuff repair on my other shoulder, and most recently for physical therapy after a total hip replacement. I returned to Peak Performance time and time again because of my strong belief that I am in the most qualified hands in the Rochester area. This belief is founded in my own successes as a result of the physical therapy I received while in Mike’s care. The individualized treatment plan that was put in place for each of my recoveries was developed with a holistic approach, combining Mike’s expertise on functional movement, biomechanics and physical therapy techniques with my personal hopes and desires in regard to the activities I wanted to return to and participate in. Mike was able to listen, and continued to adjust the plan of care based on the visible and measurable strengths and needs as my rehab progressed, as well as always taking into consideration my continued input and feedback. My ability to regain strength, flexibility, and increased participation in the activities of life and leisure that I value was evident to me early on in the rehab process, and continued to grow throughout. I attribute my success to Mike’s expertise guidance, ability to listen, and genuine care. I know that if I find myself needing physical therapy again, I will request services from Peak Performance PT. I highly recommend Peak Performance to my family and friends, and to anyone else that may need Physical Therapy. Oh, and 9 months post surgery, not only am I greatly enjoying a summer filled with Pro Kadima, long bike rides on the canal and my basic and gentle yoga sessions…I flipped my dog!!! With a heart full of gratitude, Jennifer I.M. July 25, 2016