Physio Network

[Case Studies] A real case of shoulder instability: lessons from the clinic with Ellie Richardson

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In this episode with Ellie Richardson, we explore a case study on a real patient of hers who presented to the clinic with shoulder instability. We discuss: 

  • The importance of the patient’s subjective history
  • Evidence-based outcome measures used in shoulder instability
  • Gaps in current practice in treatment of shoulder instability
  • Strength and conditioning terminology and it’s use in shoulder instability

This episode is closely tied to Ellie’s case study she did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Ellie’s case study here with our 7-day free trial: https://physio.network/casestudy-erichardson

Ellie is a Clinical Shoulder Specialist with extensive experience across MSK, orthopaedics, and sport, including work in the NHS, private practice, TASS networks, and with national sports bodies. She holds a first-class BSc (Hons) in Physiotherapy, a postgraduate diploma in orthopaedic medicine, and an MSc (Distinction) in Advanced Musculoskeletal Physiotherapy. Ellie is also an active member in the British Elbow & Shoulder Society (BESS). Ellie has published in BMJ Sports and Exercise Medicine and contributed to The Shoulder: Theory and Practice. She is a former elite-level track cyclist who represented Scotland and Great Britain.

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Our host is @sarah.yule from Physio Network

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SPEAKER_02:

Welcome to Case Studies from the Physio Network. Today we're diving deep into the world of shoulder instability and rehab with consultant shoulder physiotherapist Ellie Richardson. Based in Manchester, Ellie brings nearly two decades of experience across the NHS, private practice, elite sport and performance environments, working with everyone from post-op patients to Premier League footballers and GB athletes. With a first-class honours degree in MSc and distinction in advanced MSK physiotherapy and clinical role that spans everything from rehab to return to play testing. Ellie is recognised as a voice in the world of shoulder health. She works closely with leading upper limb surgeons, teaches nationally and internationally and brings a dual perspective as both a former elite athlete and seasoned clinician. This episode follows on from a detailed case study that Ellie has completed with Physio Network and builds on those clinical insights. We explore how the subjective history is key to accurate instability classification, how Patient reported outcome measures can be used to strengthen that therapeutic alliance and some of the most common rehab gaps Ellie sees in managing anterior shoulder instability. So whether you're early on in your career or deep into shoulder specialism, there's a ton to take away from this conversation. I'm James Armstrong and this is Case Studies. Ellie, welcome to the PhysioExplained podcast. It's great to have you on. Thanks, James. Thanks for having me. Really excited by this because you've done a fantastic case study for the physio network, which listeners, you can obviously, as I said in the intro, get hold of by taking the link in the show notes. Today, we're going to take a little bit of a snippet of kind of some of the case study, but also encapsulate that around giving some of our listeners some more gems around shoulder instability in rehab. And I thought we'd kick off with something we talk about a lot on the podcast is the importance of subjective history taking. And for this, we're talking about the accuracy in instability classification. I'd love to know more about this, Ellie. Tell us a bit more about subjective history and the classification of shoulder instability.

SPEAKER_01:

I think like with all MSK conditions, the subjective history is really important. What I see a lot in my instability cohort is sometimes it can be very easy to chalk people up as a different type of classification to what they really are. So what I mean when I say that is the moment we generally use a standpoint classification for instability where we've got your type 1, 2 and 3. So your type 1 being your traumatic structural, type 2 a traumatic structural and type 3 your muscle patterning. But quite often if you've got say a referral from a consultant you might have in the letter they've got type 1 instability because they dissipated during a game of hockey or sport or something like we've got in a case study that we go through in detail. But when you take a early classification. So like in the case study, we talk about this traumatic type one instability, someone presenting as that with failed surgeries actually turned out when we took a deeper dive to be a type three, more of a muscle patterning issue from her origins 10 years before on the background of a little bit of hypermobility. So taking a deep dive and not just assuming if you have a letter, I think we're good at that if we've got someone called off the street and we've got to do that ourselves. But if we've got a bit of a back stories and failed surgeries listed for a letter like this patient was in the case study that go through then I think sometimes we can just take it verbatim I think we really need to still sit down and go look let's start again I'm really sorry that you've probably been asked all these questions but take me back just so I've got a really good understanding especially if you know someone's failed repeated surgeries like they did in the case study we went through for you guys and especially if they're a little bit arms folded maybe they've had physio work work not so well in the past it's obviously really important that we understand their expectations concerns beliefs around it but also the original mechanism and I I see that more and more in a lot of people that I've seen who've had things like bone block surgeries, have seen them completely osteolised and we talk about what's normal and what's not in relation to that in the case study in depth with references to the literature and things. But quite often we'll see some of these surgical procedures failing perhaps due to patient selection. In the same way, it will be the same thing for us in terms of our rehab interventions. We know that patient selection is key for the majority of things and in terms of managing their expectations and working out how well we're going to do with the patient, knowing that backstory is really important but for me in that instability group we've got the luxury of time well we should have the luxury of time as physios anyone listening who's getting their appointment time sort of squeezed you know really try and kick back on that because it is as you can see in the case study from the detail that we had to go into in that patient's backstory to tease out the information we needed to work out how long did we need for prehabilitation did we need to kick that back we did kick that hand back later on down the road because we needed longer with this patient given her backstory given what was revealed during that probably 25 to 30 minute conversation with the patient we've got the luxury of time so use it and don't just assume that what's in front of you is necessarily accurate because it is just somebody else's interpretation as to what's been said so I am someone who's a big advocate on taking time in that initial assessment especially with those more complex well they're all kind of I don't really like to use the word complex but everybody's got their own story and it's important they tell it in that initial encounter so if you've got 45 minutes I'd argue that's not enough up. But if you've got an hour, brilliant, you'll at least be able to hopefully sit and document some of that and maybe chuck in a few objective, physical objective markers along the way. But when you take that subjective history taking, you might also potentially incorporate some of your patient reported outcomes and other forms of objective markers along the way. So it's not like you're just chatting. You know, you will be getting some important information that you can benchmark later on down the line. Definitely.

SPEAKER_02:

And I suppose the key thing there as well is the information you've got from a referral from someone else, you don't know how long they have had that patient they may literally have had a 15 if they're lucky 20 minute appointment so they may not have been prioritizing that back history so much and being they may have been focusing on the now and then

SPEAKER_01:

yeah definitely in relation to if we end up going down the sort of patient reported outcome route i think it's a really good opportunity to strengthen your therapeutic alliance if you deploy certain outcome measures especially in your instability group if you deploy them in the right way in the case study that i did for you guys i take a deep dive into the WOSI, the Western Ontario Stability Index, which I use with the majority of my instability patients as an initial benchmark because it's a pathology specific, valid, reliable measure. You can get it online. You can access it if you just Google WOSI online tool. You can sit them in your chair, go behind them and just watch them drag a bar, an agreement bar for over 21 questions. It takes about four or five minutes and it's got four subsections. And in those, it gives them a score and then a total score. So not only do you get the overall value, but you also potentially get within subsections such as physical activity, work, lifestyle, emotion. You get those subsections in broad categories and you can actually see what maybe the elephant in the room is on that particular day. So you're not just dealing with an O-ball number, writing it down, filing it away, and then going, oh, that's that done, which I think a lot of people, especially early on in their career, but even now, just time press. When you're time pressed, it's like, oh, I've got to do this, whether it's for insurance or whether it's an organizational thing, something that they do where you were so you can use that if you've got a pathology specific validated and reliable measure it can be quite a good way to make them feel heard because obviously quite often questions are designed with that particular pathology in mind so whereas they may have been faced with what's your pain out of 10 or what's this and suddenly they're being asked questions that resonate a little bit more and can set that first encounter off on a good footing yeah I think there's lots of ways around it but I think using that time to get that broader backstory is for me the most important thing because it tells me where I've come from or where there coming from and hopefully where we want to go.

SPEAKER_02:

Definitely and that use of that patient reported outcome measure I suppose it can lead to a further in-depth conversation as well some of those questions can then lead on to oh I see you've done this and you said this and you can then find out more based on that it might be some leading questions there that you can use.

SPEAKER_01:

Definitely and in that one you know if you can objectify the fact that they've really flagged up the emotional subsection in the case study wall in that initial encounter now that patient I go through with you guys will was somebody who required surgery because of a complicated backstory and issues at an articular level. But on the day we first met, the elephant in the room was her apprehension and her thoughts, feelings, and fears about moving more above her actual instability of which she did have significant instability, but she wasn't even getting to that point in terms of moving because of what was going on up here. So yeah, there's lots of different, you can either use it to explain why you're doing what you're doing, or you can also say to the more goal-oriented patient, we'll probably redo this again in six, eight weeks. because it's really hard to repeat something. You can't remember this and so many questions and the way you're dragging it is quite subtle. Yeah, you can say, we'll repeat this again and we'll see if we've made any kind of meaningful change to you, but also one here that'll help us, especially when you know you've got a long journey ahead in terms of rehab, because they always find somebody that you're saying, look, this is really like an ACL, whichever we go down in terms of timescales. Unless you're a first time traumatic anterior dislocator, if he wants to go back to sort of normal level activities, nothing particularly high contact or collision, then the journey is likely to be longer than a three-month one. So you're probably looking at more six to nine and maybe even 12 and beyond, depending on their goals. So to ask someone to invest in rehab and to stay on an exercise or a rehab wagon for that length of time is a big ask for anybody. They're going to want to see the incremental changes. And I think I'm quite passionate about using our time together, the appointments that we have to make sure that we are sort of showing people progress at appropriate intervals. because quite often you'll see small goals being achieved before they physically notice it themselves. And it's a bit like, even if you keep it, you know, really simple to goniometry measurement in an elderly population with a cuff arthropathy or something, you know, you might get 10 degrees, 15 degrees on that before they notice anything because they can't get to the neck. You know, so it's the same sort of thing, but obviously tailored to the population.

SPEAKER_00:

Ever wished you could see how experts treat real patients of theirs? With Case Studies by Physio Network, now you can. Watch presentations where top clinicians break down real-life patient cases, step by step, showing how they assess and treat even the trickiest conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click the link in the show notes to start your free trial today.

SPEAKER_02:

Definitely, and it drives that motivation, doesn't it? Just those small changes that patients don't always necessarily necessarily see, leading to the ones that are more meaningful to them that they're aiming for, that they want to see. Are there any other outcome measures at all that you'd recommend, Ellie, that you've used that you think also support that therapeutic

SPEAKER_01:

alliance? Again, I go through a few in the case study. If you're interested in what the literature says, there was a systematic review in 2020, which is a study which gives you an overview of ones that they recommend using for research purposes, specifically for instability. The ROSE is high up there. I think the ROSE score is high up there. If I'm honest, I tend to use the WOSI score. I will always use the sponsor score, which is the stammer percentage of normal shoulder assessment, which is basically just saying today, if you were to rate your shoulder out of a hundred where zero is, or say a hundred is full range, strong, stable, there's everything you want and need pain-free and zero is useless, painful, chop it off, whatever you want to say. You know, depending on who's in front of you and made, you know, those are that's when I'm pretty. Then you can get someone to give you a percentage of score and you just write that percentage down. That's been researched by Andrew Jaggi's group at RNOH. We as an organization use the PSFS as well, which is sort of like a quality of blind, where they just list their three or four activities that would be meaningful to them if they could return to. And then they rank them out of 10, where 10 is I can do it and zero is I can't. But there are tons of others. And I think you're not going to go far wrong if you use one or two, but you don't want to use all of your time necessarily doing it. Some people will do some of them beforehand, like the PSFS and things. There's lots of different things out there. Read the review and see what works for you. But I would strongly recommend the Wosu just because of its ease of use and repeatability.

SPEAKER_02:

Brilliant, brilliant, great stuff. So the other one was some of the rehab gaps that you have seen when managing anterior shoulder instability, some of the things that maybe aren't done or aren't done as well, I suppose, or certainly the gaps that you sometimes see.

SPEAKER_01:

I think that's really interesting because it's been over 18 years now since I've been qualified and you probably know yourself, you know, as a profession, we generally pendulum to what's vogue and what's not. Probably 10 years ago, I was maybe only just seeing one swing from we go local we go isolated we go general kinetic chain we go now we're swinging very heavily towards strength and conditioning and none of those things are inherently wrong but I think as always it's the place for all of those in someone's rehab journey so at the moment and I probably would have said differently 10 years ago but at the moment what I'm seeing is a lot of people are working harder patients from a strength and conditioning perspective they're doing a lot of single planer more simple movements which is great you know you're quite often getting people who are coming with a fairly strong system but the gaps I'm seeing and I see people from whether it's consults for Premier League football clubs down to Joe Bloggs who's fallen off their bike or dislocated or weekend warriors or whatever the things I'm seeing is generally they're doing quite a good amount of work in the gym but the stability is not what it could be so specific things I will see is if you have an anterior dislocation in terms of basic quick range assessments most people will be jumping their arm up behind their back to get that internal rotation and they can get there, but it looks a bit funny. So you tend to see that the anterior shoulder musculature, specifically cuff and subscap, don't work that well as both a stabilizer and mover. You generally see peak force come back quite quickly in neutral, but end range external and internal peak force will be lagging for probably quite a long time. And that's something that I will see, but not just that, the neuromuscular control. So if I was to say two or three key things that often patients will almost immediately benefit for from these anterior instability group who've come to see me after doing some and rehab. I would say things like supported through range internal rotation with a band, because if you do it right and cure it right, you will see that one side is way shakier than the other, and it will always growl at the side that they can't jump their arm up. So people might be standing and doing all this, which is great, but we're not working the calf as a mover. We're working it in a different way, and we're biasing some of the other, what I call Usain Bolt muscles. Everything is, of course, active during all things. I think sometimes people say, well, this isn't an exercise for this. And I agree with that. But if you have a look at the quality of movement, and you're lucky enough to have a good side, and you've applied your functional anatomy, and you know your studies and your biomechanicals, the MG stuff, whether that's relevant or not, you will see something that needs working on. And if there's a big gap, then you want to plug it if it fits the clinical picture. So end range peak torque, internal external rotation, and telegraph is a mover and a stabilizer. And quite often people are not moving quickly early enough. I think that reactivity in terms of their movement, you know, people often leave that to the back end of rehab, whereas I quite like to get people moving quickly sooner because i think a lot of the measures that we take we're not getting especially if we've not got someone that's got a hugely complex story but a lot of these measures we're getting are not necessarily measures of the genuine true capacity of the muscle system you know in terms of if we're getting peak force are we really assessing peak force in them buses are we assessing pain free peak force or apprehension people so on the day confidence peak force you know it's a marker and it's great but to infer that we're necessarily looking at genuine strength, I think is a bit misguided in the pathological population, but it's still a very useful measure regardless. If you've got baseline and it's an elite sports person and you've got all these pre-injury in-season data, out-of-season data, that's different than you actually can say, no, you're X percentage off that. But a lot of our interventions, I think we've swung as a profession very heavily towards strength and conditioning. And now don't get me wrong, as a former elite athlete, I love jumping bits and metal around more than any And I advocate that strongly. I think there's no better way you could invest in your future self than to get and remain strong. But in these painful or unstable populations, there's often other stuff going on as well. So we don't necessarily need to get too bogged down with the, are my reps and sets representing hypertrophy or power or whatever. But we do need to look at the constructs of function that they need and make sure our rehab reflects that. And at some point you might get there. But for me, I like to move quickly early on because you'll often see in people who are apprehensive and painful, that electromechanical delay, that switch on time goes away because, or also increases because they, you know, from injury or apprehension or whatever. So you're trying to kind of get the brain into gear and get that reactivity back, which in turn will shift that force plan curve to the left, you know, which is what we want to do with that RFD type training and things. So in these clinical populations, I think we've got to be, yeah, just be mindful that we're not just measuring for measuring sake and we're putting it into context because at the moment, the way the pendulum's I've seen some of the best physios, rehab professionals that I know feel suddenly intimidated and lacking in confidence because they don't understand all this terminology around explosive strength deficits, EMGs, peak force, RFD, all of that. I see that and it makes me sad because I actually think, okay, yeah, it's great to know and if you're interested in it and you're working in these very top performance environments and even then you've got S&C coaches and tactical and fitness are going to do it better than you, you're still dealing with this. generally speaking, with a pathological cohort. And so you're looking at something a bit different. So an awareness is good, but for goodness sake, don't be bogged down by the fact that maybe you don't understand the ins and outs of it because we're still looking at something a little bit different. That's my take. It's not super vogue and I'm not dissing any of that stuff in any way, but I just think it's like anything, isn't it? Things swing in and out of fashion. There is no one thing that's the be all and end all. It's everything in context.

SPEAKER_02:

Definitely. I think that's a really good point to finish on actually, Ellie, as well, is it? Something that again comes up a lot on the podcast in terms of that pendulum you talk about there and it's really important to be aware that that's what happens and that sometimes that pendulum as it moves away from something we don't want to leave it behind too much because it might be really important for that patient at that particular time. And also reassuring for some of the listeners that maybe do feel like they're a bit bogged down in some of the S&C terminology that actually think about the population you're dealing with that particular time and other people who have those specialisms that can work with those in the elite fields as well so brilliant ellie thank you so much for your time i think listeners will definitely want to have a check out your case study that you've done with physio network again you can see that and find a link in the show notes below but for now ellie thank you so much and i'm sure we'll speak to you again in the near future

SPEAKER_01:

thank you james great to catch up