To provide the best care for patients with shoulder conditions - through the application of careful and through clinical assessment, judicious use of diagnostic investigations and the delivery of evidence base non-operative and operative therapeutic interventions.
To assess outcomes and monitor effectiveness of various therapeutic interventions to ensure best practice in the management of shoulder conditions.
To create a trustworthy and reliable option for referral for the management of shoulder injuries.
To engage in a process of education and instruction on the best management options for shoulder conditions and to promote the most appropriate, and evidence based, use of optimally delivered non-operative and operative therapeutic modalities.
The management of shoulder conditions should always move through STAGES of:
Careful Assessment with appropriate investigation
Define specific diagnosis and Identify and refer conditions requiring urgent intervention
Rehabilitation and Physiotherapy management
Operative intervention where benefit is likely
Recognising that the shoulder has important mechanical characteristics of:
Motion - of gleno-humeral, acromio-clavicular, sterno-clavicular and scapula-thoracic,
Stability - through range with interplay of ligament, bony and muscular constraints
Smoothness - of joint and tendon surfaces, including adequate space and clearance
Strength - power plus balance and coordination
To restore rotator cuff strength (principally infraspinatus) to provide the humeral head depressor effect to offset the action of deltoid
To correct posterior capsular tightness which may cause obligate anterior impingent with flexion
To ensure there is good Scapular control to ensure the shoulder is positioned optimally
To address inadequate subacromial space by surgical decompression, debridement or repair of a torn rotator cuff, if correcting the first 3 priorities fails to achieve an adequate resolution of symptoms.
Shoulder pain can be the result of a variety of conditions including:
Referred or related to another cause (e.g. from the cervical, thoracic, abdominal regions, neural and vascular tissues.)
Primarily related to a stiff shoulder (e.g. frozen shoulder, osteoarthritis, locked dislocation, neoplasm-such as osteosarcoma.)
Soft tissues (e.g. rotator cuff, bursa.)
A combinations of the above.
Correct treatment requires careful assessment and diagnosis.
Rotator Cuff Related Shoulder Pain
Rotator cuff related pain such as tendinopahty and impingement or rotator cuff tears are common in General practise.
Once other causes of shoulder pain have been excluded, a well-structured rehab program can produce equivalent overall outcomes when compared to surgery for patients with subacromial impingement syndrome/RC tendinopathy or tears.
That is not to say the surgery is never needed. The reality is that many (probably most) patients will get better with a correct rehab program, and thus avoid the need for surgery. Those that remain symptomatic, will have a stronger and more mobile shoulder that is likely to recover more predictably should they proceed to surgery.
The correct rehab program includes: relative rest, modification of painful activities, an exercise strategy that strengthen the weak rotator muscles but does not exacerbate pain, controlled reloading and gradual progression from simple to complex shoulder movements.
A plain x-ray is the most useful primary investigation for shoulder pain and will provide information on many conditions including arthritis, instability and indicators of the chronicity of the possible cuff tear. Asymptomatic partial and full thickness rotator cuff thickness tears have been reported in 50% of people in their seventh decade and in 80% of people over 80 years of age, so finding a tear of an ultrasound is often of no relevance - and a bit waste of money!
Further, the size or presence of a tear on Ultrasound or MRI correlates poorly with symptoms and prognosis, so rarely is specific treatment solely or substantially determined by the findings on scans.
Education is an essential component of rehabilitation and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcome.
If the patient fails to improve with rehab, surgical referral is appropriate.