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[Physio Discussed] Tackling large rotator cuff tears with Dr Jared Powell and Dr Kathryn Fahey

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In this episode, we discuss large rotator cuff tears. We explore: 

  • Traditional tests that are used within shoulder assessment
  • Is Rotator cuff related shoulder pain a diagnosis? 
  • Physiotherapy's role in conservative management of rotator cuff tears
  • Surgical vs non-surgical pathway
  • Load management for patient care
  • Rotator cuff tear progression

Want to learn more about the rotator cuff tears in the shoulder? Jared Powell has done a brilliant Masterclass with us called “Evaluation and Treatment of Shoulder Pain” where he goes into further depth on this topic. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-powell

Dr Jared Powell is a Queensland-based physiotherapist, educator, and researcher with a PhD in shoulder pain. He runs The Complete Shoulder course and hosts the Shoulder Physio Podcast. Jared combines over 15 years of clinical experience with evidence-based education, reaching clinicians in 40+ countries.  He is a visiting lecturer at Bond University and focuses on practical, patient-centred care informed by research and critical thinking. More at shoulderphysio.com.

Kathryn Fahy, PhD MSc, is a Chartered Physiotherapist, Researcher, and Educator from Ireland, currently based at Aspetar’s Orthopaedic and Sports Medicine Rehabilitation Department in Doha. She holds a PhD in Musculoskeletal Physiotherapy focused on rotator cuff pathology and led the development of the CALMeR Cuff Pathway - an evidence-based approach to managing large to massive rotator cuff tears. At Aspetar, she contributes to advancing shoulder rehabilitation through innovative, patient-centred strategies and multidisciplinary collaboration.

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

UNKNOWN:

Thank you.

SPEAKER_02:

Does rotator cuff tear progression matter for the onset of symptoms? And does surgery stop the degenerative process of rotator cuff tears? Today's episode dives deep into these questions and more as we unpack the complex, nuanced world of rotator cuff tear management. Jared Powell is a Queensland-based physiotherapist, educator and researcher with a PhD in shoulder pain. He combines over 15 years of clinical experience with evidence-based education, reaching clinicians globally through the Complete Shoulder Course and the Shoulder Physio podcast. Jared is also a visiting lecturer at Bond University and is known for promoting practical, patient-centred care informed by critical thinking. Catherine Fay is a chartered physiotherapist, educator and researcher based at Asparta in Doha, where she plays a key role in shaping world-class shoulder rehabilitation pathways. With a PhD focused on rotator cuff pathology and a deep commitment to patient-centred care, Catherine developed the Karma Cuff Pathway, an evidence-based framework for managing large, to massive tears. Her career spans elite sport and academic leadership, and she continues to push for collaborative, evidence-informed practice in musculoskeletal rehab. From clinical reasoning and functional assessment to shared decision-making in the therapeutic relationship, in this episode we explore how to elevate care for patients with rotator cuff tears. You're going to love this episode. Let's dive in. I'm Sarah Yule, and this is Physio Discussed. Welcome to you both, Catherine and Jarrod. Thank you so much for joining us today.

SPEAKER_00:

Thanks for having us.

SPEAKER_02:

Let's kick things off by perhaps coming back to where every good rotator cuff story begins and what anchors all good clinical care. Our clinical assessment is hopefully more than just ticking boxes in the management of large to massive rotator cuff tears. Catherine, what are your thoughts on our superpower there? You

SPEAKER_01:

know, it's interesting, probably, Tarot and I are both at the same stage now at this point, just coming out the end of a PhD where you're trying to solve some problems and often as clinicians we like to have a system and a flow and it certainly helps us from our approach from that point of view and essentially that's what I've come up with recently in my latest publication was a clinical algorithm but really in the back of my mind always has been that yes we need a system and a structure but it's really important that we don't forget our superpower and our superpower as clinicians is our ability to reason, is our ability to look at a patient that's in front of us and as much as we would like a blueprint of some sort I think it's really important to not forget that you know every single patient that comes through that door has multiple factors that will influence their decision the decision to go down a conservative route a surgical route or essentially a plan depending on how the patient is progressing so yeah for me I think definitely often I've been the first person that will put up my hand and say you can fall into that trap of forgetting to use that superpower all the time And the more we learn, the more we realize that, you know, it really is our skill that we need to make sure that we keep sharp. So, yeah, that's my take on it anyway.

SPEAKER_02:

And Jared, your thoughts?

SPEAKER_00:

Assessment is something I think a lot about, like in physical examination more broadly. Where are we at with that? Because there's been a lot of change. For instance, I run a telehealth business, right? And my physical examination will probably look different to a physio in clinic who's, you know, perhaps doing 100 special tests and prodding and poking. and getting out the magnifying glass to look at scapula, dyskinesis. So for me, my assessment is largely becoming like movement exploration. So getting someone into a gym or some sort of movement, some sort of setting that facilitates movement and just like watching them move and asking them, how does it feel? And then making subtle alterations to the movement and then checking back in, how does that change your symptoms? These kind of like behavioral experiments in the cognitive functional therapy literature, or I call them exercise experiments in a paper that we discussed recently. So then your physical examination for me, like, you know, obviously you check range of motion and a bunch of other things and you make sure the arm's not dislocated, rule out red flags and blah, blah, blah, blah, blah. You got your foundational things that you need to do, but then like very quickly, I'm not really doing any special tests anymore. I'm not really looking at the scapula anymore, apart from just like, I maybe turn the person around once and say, lift your arm overhead. And if that scapula not coming out of the chest wall or the posterior chest wall, then I think it's okay. And then I'm getting them straight out into the gym and we're doing all for me in their room on telehealth, looking at how they're moving and making subtle alterations to the movement, symptom modification to see how that changes their pain experience. And then from there, that sort of sets me straight up into going into my treatment whereby, okay, it hurts when I do an abduction movement. If I change that subtly and I have no pain during escape, movement with a weight, that person's going to do scaption exercises at home with a two, three kilo weight for a week or two. And then we're going to come in, we're going to see how we're going. We might check that lateral raise movement again, and we might start doing a lateral raise with a short lever as opposed to a long lever, see what that does, so on and so forth. So for me, my treatment logically follows my physical examination, which is mainly exercise experiments, as opposed to looking for strength deficits, looking for impairments typically that we were trying It

SPEAKER_02:

sounds like, correct me if I'm wrong, are you largely using that shoulder symptom modification tool? Is that what you mean by exercise experiment?

SPEAKER_00:

That's an option. I know Jeremy has pioneered that. I don't really use, I sort of use elements of it, but I don't go through it in any algorithmic way. So someone tells me a movement hurts and I play around with that. So it's derived precisely by what movement hurts them. And then I tweak a variable, be it weight, be it plane of movement, be it range of motion, be it context, distract the person, see what that does to their pain. So you can tweak any one of these sort of parameters of exercise and see what it does to their pain.

SPEAKER_02:

Yeah, great. And then that then becomes your treatment. Fantastic.

SPEAKER_01:

It's really important, just as Gerard was saying there, that's our superpower. It's taking little bits of things that we know work quite well and putting them together. And often it's, you know, the patient will come in, the patient, yeah, they'll come in and they'll tell you they have pain, but they'll tell you they can't do X, they can't do Y, and And exactly as Jared said there, get them to do the movement. What is the movement that's causing that pain? Get them to do it and figure a way. Use your clinical superpower to take a little bit of Jeremy's work, a little bit of Joe Gibson's work. And how can we figure our way around making sure that that patient can complete their function without pain? And that's your in. That's your first step in. And then how do you build it from there? You know, and I think it's really important. It's making sure that we're taking every bit of a lot of the information we have and applying it in direct proportion to that patient that's in front of you.

SPEAKER_02:

Both fantastic points. I think, as you say, we're often in charge of shining light, perhaps where people's blind spots are clinically.

SPEAKER_00:

I'll just expand on that a little bit for one minute. I think we've got to get away from the fact that we've got like a preconceived notion of what we need to do to somebody when they're in there, you know, and it's like mismatch of power where someone comes in and we're like, all right, I've got to do this to this person. That's going to unearth precisely what's going on with this person's shoulder. But I think we just need to like approach this physical examination or assessment, like an exploration, a journey that you're going on with somebody and you don't know what's going to happen and they don't know what's going to happen. And your job is to support that person in the process of like collaboratively coming up with some sort of plan where you can help them. And I think there's a lot of like joy and satisfaction that you get out of that whole process. It goes away from the rigid reductionist scientific paradigm of do this battery of tests and we're Although it can be really challenging and uncertain, I think it's a lot more fun for the clinician. I don't know how it is for the patient, but they often tend to enjoy it as well.

SPEAKER_02:

Before we talk about intervention, on that, I think a lot of the, I suppose, the lens that we view the traditional tests is with the intention to come out with a diagnosis for the patient. And in moving more towards this play and exploration, where do you land in the way of how you're explaining it to patients from a diagnostic perspective? perspective and is it more functional and context and meaning driven explanation for the patient?

SPEAKER_00:

Look this is a bit of a contentious topic at the moment. Everybody's got an opinion on a diagnostic label for shoulder pain. I like calling something rotator cuff related shoulder pain if they've got a condition that is maybe characterized by shoulder weakness and pain in certain movements, insidious onset, it's not stiff, it's not unstable and we're not worried about red flags. For that presentation I'm pretty happy calling it rotator cuff related shoulder pain. Other people have different opinions and that's fine. And then I just explain to the patient, okay, I think you've got this thing that we call rotator cuff pain. It's not that the tissue is torn, although that may be a factor. It's not that it's tendinopathic, although that may be a factor. It's this cluster of symptoms that we think that's going on. Great news. There's a good prognosis. We know that non-surgical care works really well. Let's go out into the gym and see what you can do and let's crack on with getting you better We know that eight out of 10 people will improve considerably over the next 12 weeks without any surgery or any intervention. So let's get on with it.

SPEAKER_01:

Yeah. And the biggest thing we'd see now with patients, you know, often as Jared just said there, they leave and automatically they're a bit more confident. And I think that's the biggest thing. It's probably a little bit easier, you know, Jared and I sitting here having immersed our lives in it for different topics, but for the last, you know, four to five years and with that comes confidence and, you know, your ability to know that you don't need this special test and you don't really need this MRI and you know you can shift through exactly as we've talked about there from a point of view of your clinical assessment and understanding their pain and finding your way in and what's their functional capacity. I think the key thing then is explaining it to the patient because at the end of the day often the fear is the unknown rather than actually you know the structure and once you explain it you know this might be causing or driving or influencing your pain, your movement. For me I actually sometimes just draw it out or I get one of the models and I show the patient the This is where, you know, the muscle comes around. Your joint looks really good. This is really important, especially, you know, we have this fear around driving a lot of our way and all this. And it's explanation, you know, and often we would say with a lot of our stuff is clarity imparts confidence. And I think that's really important.

SPEAKER_02:

I think that's a brilliant point. And as you say, it's our superpower. And Jared, it also sounds like the adherence to, we know in treatment, the adherence to treatment is so much stronger if we can actually demonstrate to the patient that there's a cause and effect for their pain as well. So if you can find that and use it as treatment, that's so powerful. I

SPEAKER_00:

absolutely agree. I think if something makes sense to the patient, then they're going to do it and they're going to understand it and they're going to be invested in the process and that's half the battle. So yeah, that's a good place to start.

SPEAKER_02:

You mentioned conservative and surgery. I'm curious, both of your thoughts on are patients failing conservative management or are we as physios failing at conservative management for rotator cuff tissue? is. Catherine, your thoughts? Unfortunately,

SPEAKER_01:

without a doubt, I think we as physios have failed with our conservative management approach and often that's just down to, again, as we just said, a lack of confidence. It's a little bit harder now. I think if I think of me, the physio 10 years ago, was I the same physio I am now? Absolutely not. So as a physio, when we grow in that confidence and we understand the literature and obviously as the literature has moved now and I think the biggest thing for us as physiotherapy is hearing the surgeon saying, we need to push these to physio. Surgery is not working. So I think we've done a big flip on that. And that's been really poignant for us as physios. But in my systematic review, I quickly looked at, we just did a cert, you know, consensus of exercise template and just pull the information from the research. And I could not tell you that essentially less than 50% of any of our interventions are actually explained well enough for us to use them as physios. So if we're not providing some bit of information how are people on the ground that are not immersed in research going to know you know what might be the best step here and the biggest thing then as well is four weeks five weeks into the treatment and the patient's not getting any better all of a sudden you know physio is failing and we've gotten better at understanding timelines and knowing that we need a little bit longer but again the biggest thing and this was two years ago like the biggest thing from our clinicians again in Ireland was like confidence you know not being confident that knowing that you know they're getting better because often the symptoms don't reduce as quickly and it's the same thing it's like going back to what Jared is saying like you still have undergraduates coming out with their list of tests and they're going through their tests and not really sure what the tests are telling them but they're getting a positive or a negative and then they're left with you know a lot of information and how do you quantify that as a young inexperienced or gaining experience physio so really for me the key thing with that is again the confidence comes but I feel I have a little bit of a job here now to try and start to impart some confidence or a help educate some of the clinicians to be able to be, you know, a little bit more confident in their decision making, understanding timelines and knowing we need a minimum. You look at that three to six month mark, depending on what's in front of you. But yeah, the key thing for me is, is definitely, I think we need to do better. I think we're trying and I'm not sure what it's going to look like, but we are definitely trying to, you know, essentially come up with patterns or ways or educating young physios. No different to this podcast, eh? On being a little bit more confident in their approach and finding their superpower not looking for that checklist that at the end of it, we don't really know what we're using it for.

SPEAKER_02:

Those are great points. I think we care about what we measure, but are we actually measuring what we care about? Jared, your thoughts?

SPEAKER_00:

Yeah, it's a big question. Whose fault is it? I think it's a multi-dimensional answer, as many of these things tend to be. Like, let's not forget that pain is a mysterious beast. Shoulder pain is no different. So we're very early in our, the science is still very and trying to understand pain and figure it out, especially musculoskeletal pain. And then by virtue of that, our treatments for helping musculoskeletal pain is in its infancy as well. So we've got a lot of work to do. The traditional model of how physios have trained or have been trained to treat shoulder pain has been pretty poor for 50 years, I'd say, based on this impairment model that we had to find and fix issues with mental therapy or with modalities or with exercise. And that really hasn't borne out in the research over the last decade or more. So now we're in this spot of trying to transition to a biopsychosocial model of care that we keep hearing about. And are we actually doing that? I would probably argue no, especially in a 20 minute consultation in a private practice on your 20th patient of the day. I don't know how much psychosocial care is going on there and it's not the physio's fault. It's a system issue that I don't know if the governments are going to change. So I guess I don't want to appoint blame on anyone in particular. It's a system issue and it's It's a real challenge. I guess I'm trying to tend to my area of the garden and try and educate clinicians on where the evidence is and how we can improve our little bit of contribution to society with getting away from certain diagnoses and explanations of pain and getting away from certain treatments that have no evidence for them and going down this sort of really pragmatic pathway of advice, education, embracing timeframes, embracing natural history, embracing movement and exercise, getting away from nocebic terms, getting away from highly invasive procedures that have no evidence of benefit above and beyond non-surgical care. So I think that's where we need to focus a lot of our attention and hoping the politicians do their bit in helping the system.

SPEAKER_02:

There's a few questions in my mind that fall out of what you've both said, but Catherine, going back, you mentioned the sort of three to six month mark in terms of conservative management. How often do you both think conservative care is prematurely abandoned or perhaps delivered without the right load specificity that the tears often made?

SPEAKER_01:

I think unfortunately, too often. And again, sometimes we look for the one answer, we look for the reason why. And as Jared has just mentioned, it's multifactorial. You know, a couple of the factors we've looked at, you know, obviously, as you said, the clinician's confidence, you know, their education. And we have students coming out after three, four years and we take students here and we know everything. I'm like, who's feeding them this? No, you don't. You know how to learn and now you need to learn. You know, you've figured out how to learn. From a point of view of timelines, again, there's a bit of fear around that because you're often, you know, afraid to give yourself sometimes that they're not going to buy in because it's too much time. But again, if you educate them exactly why and get them to understand and in that longer timeline, set smaller goals within that timeline. Too often, we've heard four or six weeks, I think is probably a really key time point that I've come across a lot that you know they feel like they should be already you know improving and I think that's the other side of it they probably are but are you you know picking the correct prognostic indicator to show actually you are improving and that comes back to those skills isn't it you know it's like a social element of understanding and again that understanding pain but you know finding factors that and that's the biggest thing I would often say they're like it's not getting any better and I just spend five minutes rewind this is actually where you were you know and just remind them and now this is where they are because they're living with it every day so very very hard for them to see that there's been an improvement because an improvement look we know it can be quite minuscule and it could be quite small but I think grasping onto things like functional patterns that they weren't able to achieve and finding your in quickly finding your buy-in as we've mentioned already but now and again I think two years ago it was you know a lot worse and I do think now it's getting better but for me I would say prematurely to too many times and whether that's just that they end up going on a, you know, a wait list for a consultation with the surgeon at that point, you know, don't get me wrong. I think a plan B is really, really important, but it's how quickly you're pressing that evacuation shift. And I think too quickly.

SPEAKER_02:

All great points. Jared, your thoughts?

SPEAKER_00:

Yeah, I agree with Catherine entirely. Like I push very hard to have someone dedicate 12 weeks of proper evidence-based rehab for a non-traumatic shoulder pain presentation before I consider anything else, because I know that the evidence is fully supportive of that. So I'm happy to go all in on it as an evidence-based practitioner. Look, ultimately it's the patient's decision. I'll take the information to them. I'll be persuasive in my manner to try and help them understand that this is probably the best path to go down. It's obviously up to them at the end of the day, but yeah, at least 12 weeks. And we see that in all the randomized control trials that come out. There's a pretty strong improvement in the first three months and then it tends to tail off after that with non-surgical care. So yeah, I push for that. We've got some really good evidence as well that says that there's a trial by Sederquist in 2021 that it got a bunch of people with non-traumatic rotator cuff and lateral shoulder pain. It was like 400 or 500 people, which is a really big study, and then gave them like three months of non-surgical care. And at the end of the three months or the 12 weeks, those who still had pain were then randomized to either surgery or non-surgical care at the end of that three-month period. And even those who failed an initial three-month period of non-surgical care continued to improve after that three months again and were statistically equal to those who had surgery like six months down the line. So there's important caveats to that. If you had a full thickness rotator cuff tear, you did better with surgery if you did fail that initial three months of non-surgical care. But overall, people with very, very variable types of rotator cuff pathology, there was no differences between non-surgical and surgical care, which is interesting. So if somebody comes in, they've got a partial thickness rotator cuff tear or rotator cuff tendinopathy, they've tried three months of non-surgical care. The evidence still supports another three months of non-surgical care on top of that. So that's six months down the line before you're really going to start to consider going down a surgical pathway. It's a little bit different if they have evidence of a full thickness rotator cuff tear, especially if they're younger, in their 40s or 50s, you might want to tend towards having surgery if you've tried three months of conservative care. So the evidence is quite supportive of that. Try three months, see how you go. And even after then, you might want to continue with non-surgical care depending on the person. I'll just add one more point to that. A paper has just come out by Harris and Hansford, which explored the smallest worthwhile effect that a patient would need to consider surgery compared to non-surgical care. And patients would only consider surgery if it was going to be 40% better than non-surgical care. And we're not seeing that in any clinical trial. It's never 40% better. Sometimes there is a statistically significant difference between surgery and non-surgical care, but it's minute. It's rarely clinically important. So I think that's an important thing to consider. Don't just talk to your patient about, does surgery work? Ask them, how much better does surgery need to be for you to consider it over just keep doing these lovely little exercises a couple of times a week. So like considering the costs and the risks associated with surgery. So I think that's an important conversation to have.

SPEAKER_02:

Those are some powerful articles there. We've spoken about high quality evidence-based conservative care. What constitutes high quality evidence-based care in this space?

SPEAKER_01:

Yeah. Feeding into what Jared was saying there as well. We talk about high quality care and we can talk about the numbers. You can talk about your 12 weeks. Essentially for me, progressing it obviously is reducing pain. Your symptoms modification, it's having your functional, I often say your entry point is really important. I think we get that wrong. I think one of the biggest things, unfortunately, is we get that wrong and always have to be giving them something. I think it's important to see step one sometimes is actually taking something away and seen it too many times where patients have come in often for a second opinion because they've got the shoulder pain that is, you know, not getting any better. And I love that sentence because I think it's so important to Del into what does that mean to them because Is it night pain? Is it function? Is it I can't do my sport? Because it's very different. And I think this is what makes it so difficult from a point of view of somebody who comes in and they want to be able to hang out the washing. We do that in Ireland a lot, actually, but I don't realize people do it around the world a lot. It's such a big thing. And then, you know, too, I want to be able to play, you know, tennis three days a week. So like your approach to those patients are so different. And we look at the evidence. It's the expectations of the patient is the first thing that has to undermine the rest of your research, your evidence-based informed decisions from that point on. I don't even think of it anymore, really, to be honest with you, is a program. Yeah, I think the exercise is really important. Jared has explained that so many times or love getting to that point where you can get them to the gym. But for me, first thing is what's the patient's expectations? Because we know that's what's going to influence how long that they're going to be staying put with us. And it's really important that we try and educate, maybe persuade sometimes because we know the evidence, but ultimately it's what our patient's going to want. Second thing for me is, yeah, settle them. You know, if somebody is really, really hurt I spend a lot of time asking them, what's night time look like? You know, what are the functions throughout the day? What do I need to do to their normal daily life first to try and make sure that we have got a shoulder that is going to be happy to be able to tolerate load? And then we can move on to the stuff that, you know, I started out with, that that was my caveat, you know, the exercise intervention. I love that. I love being able to, you know, tweak the pattern of movement, you know, then they can do it and then we can start to really build a robust shoulder. Look, I think we've done well with that from a point of view of understanding our concepts of load and Adele and I would always talk about this from, you know, load or gravity assisted. And often, you know, you come in with your one kilo weight and you can see they're like, well, I can lift heavier than that. You just make sure that they know that that cuff is really, really important. I think the last thing for me from a point of view as we progress through, I often say this is a change in lifestyle now. This is not rehab for three months. This is not rehab for six months. It's great, but you will have a plan that keeps you healthy for as long as you want to be active. And I often think we forget to see that sometimes because you've seen those patients who've done really well, three, four or five months, they go back into triathlon or swimming or whatever. And, you know, the last thing I want to do is see them back in four or five months time because they've stopped doing their exercises because they didn't have pain. So I think educating them on, for me, when they come in and once we get settled and they're happy and they're progressing, I think the key thing is getting them to understand this is like brushing their teeth now this is a way of life if you want to do that you need to make sure that we you know we maintain our strength through the cuff but even you know making sure that we're strong enough especially with our overhead movements so yeah for me it's sometimes take away before we add and I don't think we do that enough settle it down and then follow our three months progressive from our gravity assisted active assisted into our you know supine into our standing to be honest with you I'd and get as functional as quickly as I can? What are the patterns of movement that cause them pain? And how do we figure our way around that? And I often say, and I say to the patients, I think if I wasn't a physio, I think I'd rather be a detective. But for me, I think they're the same skills. And that's what I love about the job. Every shoe that comes in the door is different. Every approach is slightly different. And look, I think that's what makes it so hard for people.

SPEAKER_02:

Some great points in there. The more that I'm a physio, the more I realize there's more is not always more. And there is an art to subtracting the right amount so that you've actually got the right recipe there. Jared, your thoughts?

SPEAKER_00:

Yeah, I don't know if I have too much to add to Catherine's high quality care for me. The first thing is establishing a therapeutic relationship. And so nothing happens until that is established, in my opinion. We know that that's probably the biggest predictor of outcomes along with expectations and pain self-efficacy of the patient. If that patient doesn't like you for whatever reason, because you're an asshole or you haven't remembered their name or you kept them waiting for half an hour on the first appointment in the waiting room, which happens, you know, that can really derail a rapport. You've got some work to do. Then even if you craft the best exercise plan or are the best physio out there, perhaps there's going to be a barrier to recovery. So for me, a foundational skill of a therapist is to develop a strong therapeutic relationship. And I can take a couple of sessions to get that before I give anybody an exercise. And like Catherine was saying, load management is a I think it's maybe taking an activity away, developing a therapeutic relationship, providing an explanation about their pain. That can take a couple of hours sometimes to really get through all of that. And so I don't feel the pressure to go, all right, we've done 30 minutes of this. I've got to give two exercises to give this person something to go home with. I don't feel that pressure anymore. I know it might be different for a new grad and somebody who has a boss leering over them saying, what are you going to give this person? And I'm very sympathetic to that person. But yeah, I've gone through that and I'm sort of coming out the other side 15 years later knowing that the benefit of seeing a physio or a clinician is not just in what you give them, it's how you treat them and how you relate to them. And if they trust you and if they believe what you're saying, then the whole process is going to be a lot smoother.

SPEAKER_02:

Very well said. I think communication is our biggest tool. Okay, moving to cuff tear, Jen. My question is, does rotator cuff tear progression matter for the onset of symptoms? Gerard, I'm keen on your thoughts on this one first.

SPEAKER_00:

Historically, up until about a year ago or two years ago, I thought a progression of rotator cuff tear size was a really big predictor of developing shoulder pain. And so particularly in my younger patients with rotator cuff tears in their 40s and 50s, younger in relative terms, I would err on the side of getting rotator cuff repair surgery early in order to stop that progression and inevitable escalation of symptoms. But some really interesting work by John Kuhn, who's an American orthopedic surgeon, has challenged that. And he's looked at all of the evidence and suggests that a progression of rotator cuff tear size really doesn't move the needle in whether somebody develops pain or develops an escalation in their symptoms. It doesn't really tell us anything. The tears are just as likely to progress and remain asymptomatic as they are to progress and become symptomatic. So it's not really this one-to-one or cause and effect relationship that we used to think. Now, if a tear progresses by like a centimeter, which is a lot in a short amount of time, and it penetrates the rotator cable, that can cause a lot of issues, both in terms of pain and in dysfunction and strength and can lead to what we call pseudoparalysis and a massive loss of strength in their shoulder. That's a different kettle of fish. But we can't just say that if somebody comes in with a rotator cuff tear, we can't just say it's probably gotten bigger in size. We need to get this thing operated on as soon as possible. And that's going to stop it from getting bigger down the line.

SPEAKER_01:

I was in Italy when John Kuhn spoke to us as a physio group and I think poor Professor Karen Gin was caught for words for once eh when I don't think she expected him to say that you know he was pre-empting the information that he knew was coming and I think it's really good for us because I would have been very much the same as Jared you know we're younger patients and look I still think there is a time obviously from that point of view that you know you'll have some of those patients that need to probably go down that route straight away again you're high-functioning and yoga athletes high demand I think demand is a really important word that often we don't really think of from a point of view of especially you know outside a sporting context from a point of view of their work we would have seen that a lot you know we've a lot of farmers we've a lot of older farmers it's always that question we talk about pseudo paralysis you know I've seen plenty of massive cuff tears and they come in and they can function perfectly well so a needs must isn't it the cows need to be milked and I've just got to figure out a way of how I'm going to do that so I think that's also are really nice because it shows us we really do have that ability to be able to compensate and cope and I think Ken that's what makes it so difficult but yeah I think you know John's works has been really really positive it's reassuring I think I think that's important you know it's reassuring to know because there is that time you're like will we won't we will we won't we or you know and the patients like I don't want surgery often and some of them are and then now it's nice to know right if I let's give this a go at worst we know if the tear does increase a small bit like that, we know that we're not going to correlate that often with massive increases in pain, which would have been our thought on that.

SPEAKER_02:

It's always interesting seeing the alignment or the misalignment between what the images show and functionally what the patient can do. And I'm curious, you both obviously use function as we should to drive your intervention, but how often in that are you doing imaging? Jared, you mentioned quantifying one centimetre in terms of a tear, which obviously needs imaging. So what's your clinical decision making with regards to that?

SPEAKER_00:

Very simple for me. If there was a trauma, perhaps go down the path of imaging. If there's unexplained symptoms, if there's severe night pain, unremitting pain, all this kind of stuff, that's basic physio 101. You've got to triage that person and get them out for imaging or refer them on. Somebody that comes in with run and then bill, non-traumatic, rotator cuff related shoulder pain, minimal night pain, minimal disability. Sure, there's pain, but it's predictable. You can bring it on with certain movements and goes away outside of that. I will not image that person unless something drastic happens, like three months or more of care that's not working at all. That person's regressing. Perhaps I'll consider it. Does that person really want to scan? Great. They can go off and get their scan. I'm not going to stand in their way there. So the old maxim is that I'm not going to order imaging unless it's going to change my management. And so I stick to that pretty quickly. And look, nothing that comes up on an MRI is really going to change what I do unless it's a, I don't know, not even a massive rotator cuff tear anymore, thanks to Catherine's work. There's nothing really that's going to be like, this needs urgent surgery, you know, apart from a fracture or something like that. So yeah, that's where I'm at with imaging.

SPEAKER_01:

Yeah. And I'm going to obviously echo those words. And Jared said it there, you know, why are you ordering it? I think that's the first question. And I think unfortunately, and we had a quite a significant issue in Ireland because GPs were going this quick free access to MRIs so a patient presents to a GP first often in Ireland their first point contact care and the GPs don't have a huge amount of MSK knowledge they've got a lot of information that they've got to have stored and unfortunately you know non-specific shoulder pain presentation is not at the top of that list and that was kind of why we designed what we designed definitely and unfortunately I would say I've spent more time undoing the harm and the issues and the stress and the I can't move my arm because I have this tear. And I think, to be honest, I've spent more time negating the effect of an MRI than I have actually using it. I actually am not sure if the last time I've used the results of an MRI to actively change anything in my treatment plans. And I remember Rich Delaney, you know, one of our surgeons in Ireland saying an MRI is for surgical planning. Often if it's not in the instances, as Jared said, in your acute traumatic, you know, where you've got anything there from a red flag, one of you, your triage, your basic information but for me reserve it for if again you know you're three six months down the line and you feel okay you know what let's just check let's just have our plan B or you know I'd often have a conversation with the surgeon if I can first before and often the surgeon will say right let's scan them I'll see them same day or whatever it might be but for me it needs to not be pen and paper first it just has to we have to move away from that and that was a big voice done a lot of work at the GPs in Ireland and that was a big first take home because we are wasting time with patients sitting on waiting lists because they have this tear not even waiting for physio unfortunately and then I would say the issue is doubled by the time they see me because they've probably been four months sitting on a waiting list for a surgeon that was never ever going to go near them.

SPEAKER_02:

Sounds like all roads are leading to the therapeutic relationship and actually treating what we find and what's important to the patient which is great news for us. My next question here is does surgery stop the natural degenerative process of rotator cuff tears?

SPEAKER_00:

Uh No, it doesn't. It might slow it down, but it doesn't stop the natural degenerative process. Look, we know when we look at the data, the evidence that up to 50% of rotator cuff repairs fail in the first year. So they're retorn and that person has a rotator cuff tear. Again, that might be a little bit smaller and it might be a little bit more stable, but it's a rotator cuff tear nonetheless. And those people have identical clinical outcomes to people who have an intact rotator cuff repair surgery. So So maybe there's a difference actually in strength, but that doesn't seem to be borne out in function and pain. So this sort of adds layers to the issue of, there's a conversation, I don't know if you've heard it, about like prophylactic surgery for rotator cuff tears that are asymptomatic to stop them becoming symptomatic down the line. And it's a stupid question if you ask me, because you'd have to operate, I think the number needed to treat is you've got to operate on like 10 people with an asymptomatic rotator cuff tear to stop one tear possibly becoming bigger in size and possibly becoming painful down the line. So it's not borne out when you look at it from a statistical perspective. So rotator cuff repair can help people with pain and with function, arguably no better than non-surgical care in many cases. And we also have to confront the inconvenient truth that a rotator cuff repair will fail up to five out of 10 times for people. And that can be worse with smokers and people with medical anabolic syndrome or diabetes as well. There are lots of baseline factors can lead to that tear not healing after surgery that we need to worry about. But also again, smokers and diabetics, they might tear easier after surgery, but they have good outcomes with surgery again as well. So here's the paradox between structure and pain and function. So there's many little paradoxes within there. So to answer your question very simply, rotator cuff repair doesn't really change the natural history of of a degenerative rotator cuff repair. It might slow it. It doesn't really change it.

SPEAKER_02:

Fantastic answer. Thank you. Catherine, anything to add there?

SPEAKER_01:

Yeah, exactly. And I think always my worry is, you know, that immobilization period, a little bit of a contentious issue depending on where you're operated on and who operates on you, you know. But for me, that's often one of the biggest issues. If you have somebody immobilized for six weeks, you know, whatever, protecting the repair and the surgeon needs to do everything they can to ensure that that repair doesn't fail. But then I think, yeah, we're left to try to really build back up a shoulder that has been immobilized for up to six weeks. So if you think about realistically, you don't start loading it significantly until 12 weeks. And then all of a sudden you're faced with a big hill to climb, I think, to be honest with you. And I think that plays into it a lot. I don't know what Gerard's kind of thoughts are on that, but it's something that I'm often quite worried about.

SPEAKER_00:

Yeah, I agree. And I've had a lot of patients who I've seen after a rotator cuff health repair who become obsessed with the fact that they have they've retorn their tendon can they start moving their shoulder again they're terrified of getting out of the sling because the surgeon has fed it into their brain don't do too much to say we've got to preserve the integrity of this repair that's all i think about and i've had one particular gentleman who had like six mris in the first 12 weeks after surgery because he thought something's going on here i've retorn and it wasn't he was just terrified from the surgeon or anxious from the surgeon that this has got to completely ruined his surgery and, you know, therefore all this time and money that he's invested into it. So I think we need to like chill when it comes to that. There's a study going on now, the RACER trial, which is looking at like a, not even an aggressive rehab, it's just let the patient decide when they want to take the sling off. They can use it if they need it. They can start using it when they need the, they can start using their shoulder when they want to for basic activities of daily living. You They're not saying go out and bench press on day one, but they're saying much like after you sprain your ankle, we don't need to have this like six weeks here and then you start passive movement and then you start active assisted and then active this like regimented approach. This trial is actually looking at just let the patient decide when they want to start moving their arm again. Let's face it, two weeks after a rotator cuff repair surgery, that person ain't going to be out there trying to swim or trying to play tennis with that arm. The body's very good at like protecting itself and they're going to gradually put more load through it. Of course, a physio should oversee it and oversee that entire process. But yeah, it's going to be really interesting to see whether that approach, just like let the patient decide when to take the sling off and when to start using it versus these regimented approaches of don't do anything until six weeks and then it's this and then it's that. See what comes out on top. It's going to be a really fascinating outcome.

SPEAKER_02:

Well, that approach certainly allows a lot more patient autonomy than perhaps we do historically give.

SPEAKER_00:

For sure. And that's what it's all about, hey? Just trying to empower that patient. That's self-efficacy. Let them figure it out.

SPEAKER_02:

My final question is more just to wrap up what we've already spoken about, but I'm curious on what both of your thoughts are in terms of, do you have any final words of wisdom for the clinician listing managing the full spectrum of rotator cuff tears?

SPEAKER_00:

There's uncertainty. I know we've been speaking about being confident and all this, and I think that's right, but I think we should also convey to the patient that a lot of this stuff is underpinned by uncertainty and we don't know how you're going to respond, that might come across as a little bit of a bad thing to say because patients want certainty and they want definitive answers. But I think we need to be honest and say, hey, like the evidence base is pretty uncertain. We know that surgery is not superior to non-surgical care. We do know that, but we don't know how that applies to you. They, the individual, they're averages that we see out in the literature, but we can use that to guide what we do. So for me, I strongly encourage, and I'm going to, I'm going to repeat things that we've gone over. 12 weeks of non-surgical care. Start exercise and movement as soon as we can. Start any exercise. Now, I'm not a strength absolutist like many out there are. You can do motor control. You can do stretching maybe if you want. I'm not a huge fan of stretching, but you can do it. Just start moving the damn shoulder again in a way that gets that person not developing any kinesiophobia and all these type of things which tend to come on and persist people's pain. Start movement on day one. educate, reassure, give advice about how long this should typically take, answer questions about corticosteroid injections, answer questions about surgery, answer questions about load management, what they should and shouldn't be doing. All these types of things, it sort of governs or underpins everything that we do. And they're basic questions. They're questions that we have answers for. We can't say exactly what day this person is going to get better. We can't say when their pain is going to get down to two out of 10 and when they can start surfing again. We can We can give ballpark figures. We can give sort of frameworks of recovery. But sadly, a lot of it's underpinned by a little bit of uncertainty. And I think we should be honest and authentic in communicating that rather than just being like, I can fix you. It's going to take two weeks. Do these three, you know, the three best exercises to cure your pain. If you look at Instagram and they're going to get better, I think we should get as far away from that as possible. And just be honest in what the evidence says and what we know. We've done PhDs on shoulder pain. I think I know a fair bit. it, but I have no idea how an individual patient is going to respond to a treatment. I have no idea. It's way too complex. I can take like probabilistic guesses, but they're going to be wrong like four out of 10. Maybe I'm right six out of 10 times. Maybe I'm wrong four out of 10 times. So it's a challenge. And so what I'm trying to say is to early career clinicians and you guys, don't be so hard on yourself. This is a real challenge. Read the evidence, listen to these great podcasts, try and get better every day, but also like you can't help everyone all the time sadly.

SPEAKER_01:

Lots of gems there. I'm going to be harsh on Jared and say that you can be certain about being uncertain eh? You can definitely be certain to say that look everybody is different that's what makes it uncertain and I think actually I find it it does calm the patient because I think sometimes they're like there is no clear path nobody seems to be able to be confident in making right it needs to be excellent and I would always say to them we've got this grey area it's not white it's not black we're in the middle and I think it involves the patient a little bit more I think they become a little bit more active in their own care because as we would say you know based then on how the patient presents you know from day to day from week to week from appointment to appointment from month to month and I think it's really important to know that the word month is often used as well but you know when we talked about the patient sometimes they just want to acknowledge that it is pain they need to understand why they have it and then exactly as Jared said there I think there's such a powerful thing about they forget that they can move their hand their arm they can do things with our hand because we know our brain only really cares about our hand because our poor shoulders in the middle they can do it without pain and I think that's really a powerful from a point of view of you know your exercise selection and you know I always say what's your in and that's the biggest thing I would say to young grads is you know just take your time to figure out what's my in here get the easy wins at the start get the patient confident build the rapport build the trust. I think we're probably very lucky often when I see patients they've maybe seen a surgeon at a point and the surgeon will say look we know a really good shoulder physio and those little things are all helpful to get that patient buy-in but I think being confident in knowing that it's chaos a little bit of the time and chaos is okay and been really clear I think the plan B is the other big thing. I would say from the start we will always have a plan B. Give me time and when the time is right when I think or if you're a little on certain we can discuss this you know we can have a chat about this plan b but it's been certain in the uncertainty which is not easy and finding your easy wins find your entry point

SPEAKER_00:

can i just reiterate something that katherine said which i think is super important early wins is like where it's at that's why i'm such a pluralist or a liberalist when it comes to exercise and movement pick something that person can master like if that person's coming in and they're struggling and they're disabled and they tried everything don't give them the most complex exercise you you can do to flex your intellectual superiority. That's silly. Give them something easy that they can do because mastery and early wins underpin self-efficacy. And if that's the biggest predictor of outcomes, then we really need to do that early on. So that's a really good point from Catherine.

SPEAKER_02:

Some wonderful advice from you both. So a great discussion and a very big thank you to you both. Thank you for sharing your expertise and your experience. I think your ability to challenge and clarify and refine our thinking is what helps keep moving our profession forward. So thank you both.

SPEAKER_00:

Thank you. Thanks, Harvey.

SPEAKER_02:

Yeah, thanks.