0:04

Getting in the gym

0:06

with the players and doing high

0:08

load, short duration perturbation

0:10

exercises from a clinical perspective,

0:13

I saw that their confidence would increase

0:16

and it really helped with reducing and

0:18

eliminating instability episodes.

0:23

Welcome to today's episode. We're

0:25

excited to bring you an engaging excerpt

0:28

from a recent Q&A session with Hamish

0:30

McCauley. Hamish is currently

0:32

the lead physiotherapist for the Irish men's

0:34

rugby team. And in this session, Hamish

0:37

explores the management of shoulder instability

0:39

in contact sports, which ties

0:41

in with his practical series he filmed for

0:43

Physio Network on the same topic. Practical

0:46

subscribers enjoy exclusive live access

0:48

to these Q&As where they can ask

0:50

experts like Hamish their burning

0:52

questions. Tune in now to

0:55

catch some of the key insights.

0:59

Music

1:02

Today's Q&A is with Hamish

1:04

McCauley who ran the fantastic

1:06

practical on the management of the shoulder

1:08

instability in contact sports

1:11

for Physio Network. Today we have

1:13

a list of questions for Hamish to go through.

1:15

Hamish, thank you again for joining

1:17

us. If you just quickly reintroduce yourself

1:19

again and then we can get straight into the questions.

1:22

Yep, no worries. Yeah, my name is Hamish McCauley. I'm

1:24

a sports and musculoskeletal physio.

1:26

I have a background in contact

1:28

sport. So I worked in

1:30

Super Rugby with the Brumbies, with the national

1:32

team of the Wallabies, done some consulting to

1:35

the AIS and over in

1:37

Japan to a team, the Black

1:39

Rams and also worked in AFL with

1:41

the Geelong Cats and a co-owner

1:44

of a practice for the last 10 years, which I've

1:46

just moved on from. So that's one of my backgrounds

1:49

over the last 20

1:50

years. Fantastic. Nice and brief. We'll

1:52

move into the questions. Number one, what

1:54

are your three to five main assessments to

1:56

decide return to play for a contact

1:59

sport athlete after dislocation,

2:01

subluxation injury? We want to kick off

2:03

with it because I guess it just talks to the battery of testing

2:06

that you want to have a look at with any of these types of

2:08

athletes. So after an acute

2:10

dislocation or post-operative

2:12

stabilisation, your main areas which I

2:15

would have gone through in the assessment practical are

2:17

Regaining your range of motion. So you

2:19

want that within obviously a good functional range

2:22

within 90%. Normalizing your strength.

2:24

So there's a number of areas that you want to look at

2:26

there. So your relative strength. So if you

2:28

know your athletes from pre-season, you've

2:31

got baseline testing, you want them to

2:33

return to that. Otherwise, you can use the contralateral

2:35

limb as a reference point. I want

2:37

to say relative strength, I'm talking about getting

2:39

back into their normal gym type strength. So

2:41

left equals right and obviously the dominant

2:43

hand is generally about 5% to 10%

2:45

stronger than the non-dominant hand. Your rotator

2:48

cuff testing, if you look at Ann Kool's work, you

2:50

want it to be in this 90 degree

2:52

position, 20% of body weight and

2:54

a ratio of 1 to 1, internal versus external.

2:57

And your more recent testing with your ASH testing,

3:00

your outer range I's, Y's and T's.

3:03

Ben's published

3:05

another article a few years ago

3:07

through Valve called something like more

3:09

juice can be squeezed from the ash test. And there's

3:11

a nice little table in that which summarizes

3:14

relative to body weight. Little caveat

3:16

is that that was taken from professional

3:18

rugby union players. So clinically,

3:21

I generally don't see them getting as strong

3:23

as that in general population, but in your

3:25

professional sport, they do. And you're looking at a sort

3:27

of a minimum of in that eye position, 16

3:30

to 20% of body weight for your net

3:32

peak force. And then it comes down to about 85

3:35

and 75% of that value as you

3:37

go through your Y and your T. But that's

3:39

outlined in Ben's initial paper and that Maybe

3:41

if you want to have a look a little bit further at that detail.

3:44

And obviously with that, the advantage of

3:46

that test is you're also looking at rate of force development.

3:49

And he's more recently been talking about you're

3:51

looking at a minimum of getting them over

3:54

500 newton seconds at

3:56

a time point of 100 milliseconds. So quite

3:58

quick for getting back into

4:00

return to contact type situations. Again,

4:02

I don't see in general population

4:05

people getting as high as that. I am looking at left versus

4:07

right differences because there's no whole heap of normative

4:09

data. So that, I guess, incorporates

4:12

your rotator cuff strength, your outer

4:14

range strength, and some rate of force development or

4:16

power testing. Some of Adele Fanning's

4:18

work is starting to look at some

4:21

plyometric push-ups, so similar to your counter-movement

4:23

jump for your lower limb. She's doing counter-movement

4:25

jumps, drop jumps and press jumps with

4:27

your upper limbs. Again, she's got a little bit of normative

4:30

data in her paper that you can look at.

4:32

I generally just look at left versus right differences

4:35

and looking at confidence for a plyometric

4:37

type push-up, but you can look at some of

4:39

the normative data from Adele's paper

4:42

from memory. Her peak push-off was

4:44

six newtons per kilogram and landing

4:46

force was about 13 kilograms, newtons

4:48

per kilogram. And that was in a wide variety of contact

4:51

sports done over in Ireland. So they're

4:53

the main outcome measures that I've been looking at

4:55

in conjunction with some physical performance

4:57

tests. The ones that I use are the closed

5:00

kinetic chain upper extremity stability test.

5:02

So there's a bit of data that says if you score

5:05

below a cutoff of 22

5:07

in that 15 second time period,

5:09

then there's a higher chance of having shoulder pain. That was

5:12

in a low cohort of collegiate athletes,

5:14

collegiate football athletes. But It

5:16

does correlate with your isometric

5:19

rotator cuff strength, but why I like it is

5:21

it's a dynamic test rather than isometric

5:23

test. Test plus it's incorporating

5:25

a core. So that's one that I use. The

5:27

other one that I use is the upper limb white balance

5:30

because those two tests don't correlate

5:33

and the upper limb white balance doesn't correlate

5:35

with your isometric strength as well. They're sort of

5:37

the reasons why I use those ones. If you don't have force

5:39

plates, such as like looking at your

5:41

plyometric power push-ups and those sorts of things,

5:43

your seated med ball test is another really good one, which is one

5:46

I used to use before we had force plates.

5:48

And there's normative data on that for

5:50

double arm and single arm med ball throws

5:53

for that one. So I guess that's most

5:55

of the feasible testing. I then want to be progressing

5:58

them through a return to contact protocol. So

6:00

I've got a four-stage return to contact protocol,

6:02

which outlines... some ideas on where

6:05

i want those strength measures before they start each

6:07

stage and how they're progressing through different

6:09

contact situations i'm just looking

6:11

at contact technique progressing through intensity

6:14

and then back into training so that's a big

6:16

one for me because that's really your

6:18

bread and butter they've got to get back into good

6:20

technique because you'll see people can tick all these other

6:22

boxes but they're still not confident in using

6:24

their shoulder and they can get back to return to play but

6:27

they're not making tackles or they're not getting

6:29

their body in a good position, which then

6:31

further puts them in a compromising position

6:34

for their shoulder. So you want them to be confident.

6:36

So progressing them through a really good contact protocol

6:39

back through normal stages of training as well. And

6:41

then you want them to have a period of full training. So

6:43

this was all, I've talked through this all from

6:45

a dislocation perspective. Subluxation

6:48

injuries, obviously you can go a lot quicker with, but

6:50

yeah, you want to be ticking all those boxes. And then

6:52

last but not least, you want to be looking at their

6:55

psychological performance. parameters as well. So

6:57

looking at a SIRSI is the questionnaire that I

6:59

use. The cutoff is quite low. It's like

7:01

60%. I look at more of a cutoff

7:04

of about 90%. And start

7:06

that questionnaire earlier in their rehab because

7:08

you can see that their confidence improves

7:10

as they start going through the process and getting

7:13

back to full training. So I like them to be somewhere

7:15

around that 80 to 90% before they're back to return

7:17

to play. So probably a little bit more than

7:19

a three to five assessments,

7:21

but I guess if we go back and just quickly

7:23

summarise, you're looking at range of motion, you're looking at

7:25

those strength parameters, you're looking at some

7:28

physical performance tests, you're looking

7:30

at the kinetic chain, you're looking at psychological

7:32

readiness.

7:33

Music

7:34

I'll

7:37

see you next

7:46

time.

8:04

So

8:10

I suppose moving forward and thinking

8:12

about the different pathologies that might be at

8:15

play under the umbrella of shoulder instability,

8:17

could you please share your thoughts on

8:20

the rehab differences for different

8:22

reconstructive techniques, i.e.

8:24

the latige versus the normal

8:27

stabilisation? So just

8:30

to recap, our normal anterior stabilization

8:32

is like your Bankart repair, where you do a

8:34

labral repair, plus or minus some

8:37

sort of capsule repair. And the Latige

8:39

procedures came about traditionally

8:41

due to glenoid bone loss. So

8:44

if you've lost some of that glenoid bone

8:46

due to repetitive trauma or a big dislocation,

8:49

the surgery involves taking the coracoid

8:52

process and the associated muscles making

8:54

a split in the subscap and then popping that

8:57

onto the side and the base of

8:59

the glenoid to increase bone's

9:02

cross-sectional surface area and increase stability in that

9:04

area because that's generally with your anterior dislocations,

9:07

that's exactly where it comes out. So

9:09

that was traditionally why it was used, but these

9:11

days it's being used more and more in professional

9:13

sport because of its lower recurrence rates

9:15

compared to your traditional bank art surgeries. So

9:18

you do see them going for a Latige

9:20

procedure as a first line rather than a second

9:22

line procedure, which traditionally it was used

9:24

after anterior stabilizations would

9:27

fail. So the main point of difference

9:29

there obviously is they've taken that

9:31

coracoid and they've transferred it onto

9:33

the base of the glenoid and

9:35

they've screwed that in. So you've got to wait for

9:38

some bony healing there and that will be dependent

9:41

on your surgeon's guidelines. You've got

9:43

to know what your surgeon wants. Generally, they'll want

9:45

an x-ray at six weeks to know that things are healing

9:47

and a CT either at six weeks, some

9:49

want it at 10 weeks and they'll

9:51

want you to not really... heavily

9:54

load them until they're happy with that bony

9:56

healing. Because I deal with surgeons that

9:58

are happy with the x-ray CT

10:00

at six weeks and then they're like, okay,

10:02

now we can start loading. That first six

10:05

weeks is generally no different to your

10:07

anterior stabilizations in terms of you

10:09

want to be progressing range through guidelines

10:11

that the surgeon gives you, which again are fairly

10:14

similar to your normal anterior stabilization. So

10:16

wanting to achieve zero degrees of external rotation

10:19

by that week three to four or four

10:21

to six, depending on surgery, your

10:23

surgeon and depending on the tissue integrity

10:25

as well and then range

10:27

of motion gradations as well and

10:29

then once you've got that tick of approval then you can

10:31

start progressing your normal strength loading

10:34

but even i guess in between that six

10:36

to ten week if you are having to wait

10:39

until you can do proper strength work generally surgeons

10:41

are fine with you doing all your your band work

10:43

and getting your calf nice and strong in a neutral position

10:46

and progressing from your isometrics into

10:48

some loading work so you can still get all of your foundations

10:50

set through that period but that's the

10:53

main difference you've got to make sure you've got good bony healing

10:55

before you start loading them heavily in the gym

10:57

and i guess one thing i didn't mention is just early on

11:00

they generally don't want you forcing that external rotation

11:02

just because of that they want that bony congruity

11:04

and that and the subscap as well But I find,

11:07

yes, they are a bit stiffer, but you

11:09

still want to look at getting them achieving

11:11

the same similar types of milestones

11:14

as your anterior stabilizations. Otherwise, they do,

11:16

they can become quite stiff into external

11:18

rotation. So I guess they're the main differences with

11:20

your ladder shaves. Probably worth just pointing out

11:22

your posterior stabilization as well.

11:25

which is probably a little bit more common, I'd say.

11:27

And posterior instability is a lot more common

11:30

than what I think the literature traditionally talks

11:32

about. I mean, traditionally, they talk about electrocution

11:34

and posterior dislocation that way. But with

11:37

contact sport and people falling onto hands

11:39

and elbows a lot, especially with a ball in hand and falling

11:41

like that and getting those shearing forces, I

11:43

think that posterior instability is a lot more common

11:46

than what people think. They often present

11:48

more just with posterior cuff weakness

11:51

or a feeling of oh, my shoulder's

11:54

just a bit weak after just falling on it and then it

11:56

sort of goes away, but they can be left

11:58

with a cuff that's inhibited

12:01

and that's weak. But actually what's happening

12:03

is they're getting some shearing through that posterior

12:05

labrum, which is inhibiting that cuff. So

12:08

your main differences there are from

12:11

your anterior to your posterior stabilisation,

12:13

anterior stabilisation, your end goal, obviously

12:15

is getting the man into that ABER position and

12:17

getting them strong and powerful

12:20

and reactive out in that position. Whereas your posterior

12:23

dislocation is more in that shunting

12:25

position, so that forward press and especially into

12:27

that internal rotation because traditionally a

12:29

lot of this happens, I guess, more in the literature,

12:31

not just in footy, but people falling off

12:33

bikes and onto an adducted and

12:36

flexed arm and then you get that shearing load. So

12:38

that's more of your end goal with your posterior

12:40

dislocation. So you're not going to go in and do lots

12:43

and lots of post-kinetic chain early

12:45

on that you would do with your anterior dislocation.

12:48

you could start more out into that scapular

12:50

plane position so that you're getting the

12:53

load going straight through the glenoid rather than getting

12:55

shearing through the back. And this would be more of

12:57

an end stage. So

12:58

I'm glad you outlined that. So from your

13:01

pro sports experience, Hamish, have you

13:03

seen any – you've touched on it briefly

13:05

tonight, but have you seen any risk factors

13:07

in athletes that increase the chance of dislocation

13:10

during a season?

13:11

Yeah. Yeah. One of those tricky ones because

13:13

I guess we categorize injuries into two

13:15

main categories, your preventables and your non-preventables.

13:18

So, your preventables traditionally being your soft tissue

13:20

injuries, your overuse, your bone stress and your

13:22

tendon issues and then your non-preventables

13:24

being your contact injuries and your sprains.

13:27

If you look at the literature on these

13:29

factors for recurrence, the big

13:31

risk factors there are being male

13:33

because a lot of the research was traditionally done in

13:35

male because they were the ones playing the sport but I extrapolate

13:38

that to females, absolutely. Age less

13:40

than 25 and playing contact

13:42

sport with a traumatic mechanism of injury. So

13:45

that's your recurrent risk factors. So if

13:47

they've got those three risk factors after a dislocation,

13:50

they've got a very high chance of having another dislocation

13:52

up to 90% of the literature or over 90%

13:54

of the literature. But your other

13:57

risk factors there are increased laxity.

13:59

So always making sure that you do

14:02

just a simple bait on your athletes so they

14:04

know are they a bit of a floppy. Dominant side

14:06

involved as well. So if

14:08

it's their dominant shoulder from a statistical

14:11

standpoint, standpoint, they've got an increased chance

14:14

and your psychological factors. So one

14:16

of your best prognostic, well, in

14:18

terms of where prognosis really lays in shoulder

14:20

pain is with psychological factors. So things

14:23

like unrealistic expectations

14:25

or self-efficacy, fear of re-injury, high

14:27

anxiety and stress. So if you've got a player

14:30

that's not in the literature, but from a clinical

14:32

perspective, someone that's from

14:34

my experience, I'd be wary

14:36

if they were hypermobile, were

14:39

having some instability, not but

14:41

having some instability episodes and they

14:43

had some psychological risk factors, either

14:45

those alone or especially coupled

14:48

together would be heightening my, I'd

14:50

be on alert, I should say. Because

14:53

what often happens once you're starting to get those

14:55

instability factors, then

14:57

the system starts to work differently.

15:00

If you look at some of your functional MRI studies,

15:02

we know that people that don't

15:05

have shoulder pain or shoulder instability,

15:07

when they do a motor test, their motor cortex

15:09

lights up. But people that have had ongoing

15:11

pain or just instability feelings

15:14

or episodes from six months or

15:16

more, and they get a whole bunch

15:18

of areas in their brain lighting up when they do a shoulder task.

15:21

So we know that we get central changes like

15:23

processing changes. And that's where

15:26

I guess we want to be in our rehab,

15:28

really looking at addressing kinetic chain factors

15:31

involving the kinetic chain because the

15:33

brain processes movements

15:36

rather than muscles. and really thinking of

15:38

it from a central perspective, not just from a peripheral

15:40

perspective. Just to

15:42

build on the psychological side

15:44

of your rehabilitation, just being

15:46

one of those risk factors, is there anything different

15:49

you'd do apart from perhaps

15:51

take a bit more time exposing them to movements

15:54

that might be a little bit more apprehensive

15:57

with? Yep.

15:58

I guess, yeah, I learnt when I was...

16:00

working in footy, getting in the gym

16:03

with the players and doing high

16:05

load, short duration perturbation

16:07

exercises. From a clinical perspective,

16:10

I saw that their confidence would increase

16:13

and it really helped with reducing and

16:15

eliminating instability episodes. So

16:17

I'm talking about getting them doing all

16:19

your perturbation work up into

16:21

three and four point and into overhead positions. So

16:24

often in, say in AFL, going to

16:26

marking positions, getting hit in the back and those sorts

16:28

of things. So getting them into their park

16:30

or their handstand positions and doing perturbation

16:33

work with them, doing perturbation work on the

16:35

rings. So what you're trying to train here is

16:37

the system to react unanticipated

16:40

forces. So that's the

16:42

sort of avenue that I go down

16:44

with these players to one, put

16:47

them in positions to make the system work under

16:49

load, especially high load and

16:52

unanticipated situations. And

16:54

that's a lot of the end stage work that I do with any

16:57

of these athletes. Fantastic.

16:59

Thank you

16:59

again, Hamish. It's been great to chat to you

17:02

and you've been very thorough and insightful

17:04

with your responses tonight. We might start

17:06

wrapping up here, Hamish, and

17:08

the meeting for everyone. Thanks again. Thank

17:11

you very much. Cheers.

17:14

That's it for this Q&A episode. We

17:17

hope you enjoyed Hamish McCauley's valuable insights.

17:20

Remember, this was just a short segment

17:23

from an in-depth 45-minute Q&A. As

17:26

a practical subscriber, Thanks

17:33

for

17:36

tuning in

17:39

and

17:49

we'll catch you next time.