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[Expert Physio Q&A] Mastering shoulder instability: insights with Hamish Macauley

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This episode with Hamish Macauley is a snippet taken from our Practicals live Q&A sessions. Held monthly, these sessions give Practicals members the chance to ask their pressing questions and get direct answers from our expert presenters.

Learn more about Physio Network’s Practicals here - https://physio.network/practicals-macauley

Hamish holds bachelor degrees in Human Movement Science and Physiotherapy as well as a Masters of Sports & Musculoskeletal Physiotherapy. Hamish is currently Lead Physiotherapist for the Ireland Men's National Rugby Team and has held positions as Head Physiotherapist with the Wallabies Australian Rugby Union Team as well as various AFL and professional Rugby teams. 

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SPEAKER_03:

Getting in the gym with the players and doing high load, short duration perturbation exercises from a clinical perspective, I saw that their confidence would increase and it really helped with reducing and eliminating instability episodes.

SPEAKER_00:

Welcome to today's episode. We're excited to bring you an engaging excerpt from a recent Q&A session with Hamish McCauley. Hamish is currently the lead physiotherapist for the Irish men's rugby team. And in this session, Hamish explores the management of shoulder instability in contact sports, which ties in with his practical series he filmed for Physio Network on the same topic. Practical subscribers enjoy exclusive live access to these Q&As where they can ask experts like Hamish their burning questions. Tune in now to catch some of the key insights.

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SPEAKER_02:

Today's Q&A is with Hamish McCauley who ran the fantastic practical on the management of the shoulder instability in contact sports for Physio Network. Today we have a list of questions for Hamish to go through. Hamish, thank you again for joining us. If you just quickly reintroduce yourself again and then we can get straight into the questions.

SPEAKER_03:

Yep, no worries. Yeah, my name is Hamish McCauley. I'm a sports and musculoskeletal physio. I have a background in contact sport. So I worked in Super Rugby with the Brumbies, with the national team of the Wallabies, done some consulting to the AIS and over in Japan to a team, the Black Rams and also worked in AFL with the Geelong Cats and a co-owner of a practice for the last 10 years, which I've just moved on from. So that's one of my backgrounds over the last 20

SPEAKER_02:

years. Fantastic. Nice and brief. We'll move into the questions. Number one, what are your three to five main assessments to decide return to play for a contact sport athlete after dislocation,

SPEAKER_03:

subluxation injury? We want to kick off with it because I guess it just talks to the battery of testing that you want to have a look at with any of these types of athletes. So after an acute dislocation or post-operative stabilisation, your main areas which I would have gone through in the assessment practical are Regaining your range of motion. So you want that within obviously a good functional range within 90%. Normalizing your strength. So there's a number of areas that you want to look at there. So your relative strength. So if you know your athletes from pre-season, you've got baseline testing, you want them to return to that. Otherwise, you can use the contralateral limb as a reference point. I want to say relative strength, I'm talking about getting back into their normal gym type strength. So left equals right and obviously the dominant hand is generally about 5% to 10% stronger than the non-dominant hand. Your rotator cuff testing, if you look at Ann Kool's work, you want it to be in this 90 degree position, 20% of body weight and a ratio of 1 to 1, internal versus external. And your more recent testing with your ASH testing, your outer range I's, Y's and T's. Ben's published another article a few years ago through Valve called something like more juice can be squeezed from the ash test. And there's a nice little table in that which summarizes relative to body weight. Little caveat is that that was taken from professional rugby union players. So clinically, I generally don't see them getting as strong as that in general population, but in your professional sport, they do. And you're looking at a sort of a minimum of in that eye position, 16 to 20% of body weight for your net peak force. And then it comes down to about 85 and 75% of that value as you go through your Y and your T. But that's outlined in Ben's initial paper and that Maybe if you want to have a look a little bit further at that detail. And obviously with that, the advantage of that test is you're also looking at rate of force development. And he's more recently been talking about you're looking at a minimum of getting them over 500 newton seconds at a time point of 100 milliseconds. So quite quick for getting back into return to contact type situations. Again, I don't see in general population people getting as high as that. I am looking at left versus right differences because there's no whole heap of normative data. So that, I guess, incorporates your rotator cuff strength, your outer range strength, and some rate of force development or power testing. Some of Adele Fanning's work is starting to look at some plyometric push-ups, so similar to your counter-movement jump for your lower limb. She's doing counter-movement jumps, drop jumps and press jumps with your upper limbs. Again, she's got a little bit of normative data in her paper that you can look at. I generally just look at left versus right differences and looking at confidence for a plyometric type push-up, but you can look at some of the normative data from Adele's paper from memory. Her peak push-off was six newtons per kilogram and landing force was about 13 kilograms, newtons per kilogram. And that was in a wide variety of contact sports done over in Ireland. So they're the main outcome measures that I've been looking at in conjunction with some physical performance tests. The ones that I use are the closed kinetic chain upper extremity stability test. So there's a bit of data that says if you score below a cutoff of 22 in that 15 second time period, then there's a higher chance of having shoulder pain. That was in a low cohort of collegiate athletes, collegiate football athletes. But It does correlate with your isometric rotator cuff strength, but why I like it is it's a dynamic test rather than isometric test. Test plus it's incorporating a core. So that's one that I use. The other one that I use is the upper limb white balance because those two tests don't correlate and the upper limb white balance doesn't correlate with your isometric strength as well. They're sort of the reasons why I use those ones. If you don't have force plates, such as like looking at your plyometric power push-ups and those sorts of things, your seated med ball test is another really good one, which is one I used to use before we had force plates. And there's normative data on that for double arm and single arm med ball throws for that one. So I guess that's most of the feasible testing. I then want to be progressing them through a return to contact protocol. So I've got a four-stage return to contact protocol, which outlines... some ideas on where i want those strength measures before they start each stage and how they're progressing through different contact situations i'm just looking at contact technique progressing through intensity and then back into training so that's a big one for me because that's really your bread and butter they've got to get back into good technique because you'll see people can tick all these other boxes but they're still not confident in using their shoulder and they can get back to return to play but they're not making tackles or they're not getting their body in a good position, which then further puts them in a compromising position for their shoulder. So you want them to be confident. So progressing them through a really good contact protocol back through normal stages of training as well. And then you want them to have a period of full training. So this was all, I've talked through this all from a dislocation perspective. Subluxation injuries, obviously you can go a lot quicker with, but yeah, you want to be ticking all those boxes. And then last but not least, you want to be looking at their psychological performance. parameters as well. So looking at a SIRSI is the questionnaire that I use. The cutoff is quite low. It's like 60%. I look at more of a cutoff of about 90%. And start that questionnaire earlier in their rehab because you can see that their confidence improves as they start going through the process and getting back to full training. So I like them to be somewhere around that 80 to 90% before they're back to return to play. So probably a little bit more than a three to five assessments, but I guess if we go back and just quickly summarise, you're looking at range of motion, you're looking at those strength parameters, you're looking at some physical performance tests, you're looking at the kinetic chain, you're looking at psychological readiness.

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SPEAKER_01:

I'll see you next time.

SPEAKER_02:

So I suppose moving forward and thinking about the different pathologies that might be at play under the umbrella of shoulder instability, could you please share your thoughts on the rehab differences for different reconstructive techniques, i.e. the latige versus the normal

SPEAKER_03:

stabilisation? So just to recap, our normal anterior stabilization is like your Bankart repair, where you do a labral repair, plus or minus some sort of capsule repair. And the Latige procedures came about traditionally due to glenoid bone loss. So if you've lost some of that glenoid bone due to repetitive trauma or a big dislocation, the surgery involves taking the coracoid process and the associated muscles making a split in the subscap and then popping that onto the side and the base of the glenoid to increase bone's cross-sectional surface area and increase stability in that area because that's generally with your anterior dislocations, that's exactly where it comes out. So that was traditionally why it was used, but these days it's being used more and more in professional sport because of its lower recurrence rates compared to your traditional bank art surgeries. So you do see them going for a Latige procedure as a first line rather than a second line procedure, which traditionally it was used after anterior stabilizations would fail. So the main point of difference there obviously is they've taken that coracoid and they've transferred it onto the base of the glenoid and they've screwed that in. So you've got to wait for some bony healing there and that will be dependent on your surgeon's guidelines. You've got to know what your surgeon wants. Generally, they'll want an x-ray at six weeks to know that things are healing and a CT either at six weeks, some want it at 10 weeks and they'll want you to not really... heavily load them until they're happy with that bony healing. Because I deal with surgeons that are happy with the x-ray CT at six weeks and then they're like, okay, now we can start loading. That first six weeks is generally no different to your anterior stabilizations in terms of you want to be progressing range through guidelines that the surgeon gives you, which again are fairly similar to your normal anterior stabilization. So wanting to achieve zero degrees of external rotation by that week three to four or four to six, depending on surgery, your surgeon and depending on the tissue integrity as well and then range of motion gradations as well and then once you've got that tick of approval then you can start progressing your normal strength loading but even i guess in between that six to ten week if you are having to wait until you can do proper strength work generally surgeons are fine with you doing all your your band work and getting your calf nice and strong in a neutral position and progressing from your isometrics into some loading work so you can still get all of your foundations set through that period but that's the main difference you've got to make sure you've got good bony healing before you start loading them heavily in the gym and i guess one thing i didn't mention is just early on they generally don't want you forcing that external rotation just because of that they want that bony congruity and that and the subscap as well But I find, yes, they are a bit stiffer, but you still want to look at getting them achieving the same similar types of milestones as your anterior stabilizations. Otherwise, they do, they can become quite stiff into external rotation. So I guess they're the main differences with your ladder shaves. Probably worth just pointing out your posterior stabilization as well. which is probably a little bit more common, I'd say. And posterior instability is a lot more common than what I think the literature traditionally talks about. I mean, traditionally, they talk about electrocution and posterior dislocation that way. But with contact sport and people falling onto hands and elbows a lot, especially with a ball in hand and falling like that and getting those shearing forces, I think that posterior instability is a lot more common than what people think. They often present more just with posterior cuff weakness or a feeling of oh, my shoulder's just a bit weak after just falling on it and then it sort of goes away, but they can be left with a cuff that's inhibited and that's weak. But actually what's happening is they're getting some shearing through that posterior labrum, which is inhibiting that cuff. So your main differences there are from your anterior to your posterior stabilisation, anterior stabilisation, your end goal, obviously is getting the man into that ABER position and getting them strong and powerful and reactive out in that position. Whereas your posterior dislocation is more in that shunting position, so that forward press and especially into that internal rotation because traditionally a lot of this happens, I guess, more in the literature, not just in footy, but people falling off bikes and onto an adducted and flexed arm and then you get that shearing load. So that's more of your end goal with your posterior dislocation. So you're not going to go in and do lots and lots of post-kinetic chain early on that you would do with your anterior dislocation. you could start more out into that scapular plane position so that you're getting the load going straight through the glenoid rather than getting shearing through the back. And this would be more of an end stage. So

SPEAKER_02:

I'm glad you outlined that. So from your pro sports experience, Hamish, have you seen any– you've touched on it briefly tonight, but have you seen any risk factors in athletes that increase the chance of dislocation during a season?

SPEAKER_03:

Yeah. Yeah. One of those tricky ones because I guess we categorize injuries into two main categories, your preventables and your non-preventables. So, your preventables traditionally being your soft tissue injuries, your overuse, your bone stress and your tendon issues and then your non-preventables being your contact injuries and your sprains. If you look at the literature on these factors for recurrence, the big risk factors there are being male because a lot of the research was traditionally done in male because they were the ones playing the sport but I extrapolate that to females, absolutely. Age less than 25 and playing contact sport with a traumatic mechanism of injury. So that's your recurrent risk factors. So if they've got those three risk factors after a dislocation, they've got a very high chance of having another dislocation up to 90% of the literature or over 90% of the literature. But your other risk factors there are increased laxity. So always making sure that you do just a simple bait on your athletes so they know are they a bit of a floppy. Dominant side involved as well. So if it's their dominant shoulder from a statistical standpoint, standpoint, they've got an increased chance and your psychological factors. So one of your best prognostic, well, in terms of where prognosis really lays in shoulder pain is with psychological factors. So things like unrealistic expectations or self-efficacy, fear of re-injury, high anxiety and stress. So if you've got a player that's not in the literature, but from a clinical perspective, someone that's from my experience, I'd be wary if they were hypermobile, were having some instability, not but having some instability episodes and they had some psychological risk factors, either those alone or especially coupled together would be heightening my, I'd be on alert, I should say. Because what often happens once you're starting to get those instability factors, then the system starts to work differently. If you look at some of your functional MRI studies, we know that people that don't have shoulder pain or shoulder instability, when they do a motor test, their motor cortex lights up. But people that have had ongoing pain or just instability feelings or episodes from six months or more, and they get a whole bunch of areas in their brain lighting up when they do a shoulder task. So we know that we get central changes like processing changes. And that's where I guess we want to be in our rehab, really looking at addressing kinetic chain factors involving the kinetic chain because the brain processes movements rather than muscles. and really thinking of it from a central perspective, not just from a peripheral perspective. Just to

SPEAKER_02:

build on the psychological side of your rehabilitation, just being one of those risk factors, is there anything different you'd do apart from perhaps take a bit more time exposing them to movements that might be a little bit more apprehensive with? Yep.

SPEAKER_03:

I guess, yeah, I learnt when I was... working in footy, getting in the gym with the players and doing high load, short duration perturbation exercises. From a clinical perspective, I saw that their confidence would increase and it really helped with reducing and eliminating instability episodes. So I'm talking about getting them doing all your perturbation work up into three and four point and into overhead positions. So often in, say in AFL, going to marking positions, getting hit in the back and those sorts of things. So getting them into their park or their handstand positions and doing perturbation work with them, doing perturbation work on the rings. So what you're trying to train here is the system to react unanticipated forces. So that's the sort of avenue that I go down with these players to one, put them in positions to make the system work under load, especially high load and unanticipated situations. And that's a lot of the end stage work that I do with any of these athletes. Fantastic. Thank you

SPEAKER_02:

again, Hamish. It's been great to chat to you and you've been very thorough and insightful with your responses tonight. We might start wrapping up here, Hamish, and the meeting for everyone. Thanks again. Thank you very much. Cheers.

SPEAKER_00:

That's it for this Q&A episode. We hope you enjoyed Hamish McCauley's valuable insights. Remember, this was just a short segment from an in-depth 45-minute Q&A. As a practical subscriber, Thanks for tuning in and we'll catch you next time.