Gary Ablett hurt his shoulder last weekend. The same shoulder he had reconstructed a few years ago.
The statement made by Marcus Ashcroft, General Manager of football operations for the Gold Coast Suns is below:
“Gary’s shoulder is not as good as we first thought. Initially we thought it mightn’t have been as bad but scans today confirmed he’ll miss the remainder of the year,” General Manager – Football Operations Marcus Ashcroft said.
Prior to the scan on his shoulder the club seemed to feel more positive about his recovery based on his clinical presentation (his pain and movement), however following the scan the club decided to go to surgical interventions.
Doesn’t the MRI tell us the extent of the damage?
Whilst the common public perception is that the MRI is the gold standard for diagnosis, imaging is just one piece of information that is often far less relevant than the clinical picture.
A study by Girish et al (2011) of ultrasound scans on asymptomatic (that is those with no pain at all) men with average age 40-70, showed the following:
- AC-joint osteo-arthritis in 65%
- Sub-acromial bursal thickening in 78%
- Supraspinatus or subscapularis tendinosis in 64%
- Posterior labral (shoulder cartilage) tears in 14%
- Abnormal findings in 96% of subjects
In another study of elite adolescent tennis players by Johansson et al (2014), MRI findings of the shoulder in asymptomatic players revealed:
- 46% of players had abnormal findings including tendon problems and labral tears (cartilage)
A recent study by Schwartzberg et al (2016) found a high prevalence of labral tears (the cartilage in the shoulder) diagnosis again in those without any shoulder pain:
- Over 50% of the 53 asymptomatic adults (aged 45-60) had labral tears with no history of shoulder pain, injury or surgery
So it appears findings like cartilage tears, tendon problems, bursa thickening appear in a considerable number of people that have absolutely no shoulder pain.
These findings are not unique to the shoulder joint either, with studies showing similar results in other joints like the knee and hip.
A study by Register et al (2012) on asymptomatic men (average age 37) and hip MRI found:
- Labral tears (cartilage socket of the hip) in 69%
- Chondral defects (bone) in 24%
- Rim fractures in 11%
So does this mean there is no value in imaging and that we should not do it??
Not necessarily. But it should strongly suggest that decision making should not be based on abnormal scan findings.
You could argue that some of these studies (not all) involve people older than Gary and his shoulder, but given he has had previous surgery on this same shoulder it would be even more likely he would show some of these findings like cartilage tearing, tendon tearing or thickening amongst things.
These studies of those without pain illustrate that a lot of these changes are normal age related changes, and these findings would certainly be expected to be found at a higher frequency in elite athletes who subject their joints to far more loading than the average person.
Ok so can we do some clinical tests to diagnose which structure is the cause of pain in Gary’s shoulder?
There are many commonly used orthopaedic tests that are thought to stress certain structures in the shoulder, that should help us identify the specific structure that is causing the pain.
A systematic review (a review of all available high quality RCTs or Randomised Controlled Trials considered the gold standard for research) by May et al (2010) looked at physical examination tests used in the shoulder.
The conclusion of this review of 36 RCT’s was that no consistent evidence that any examination for shoulder pain had acceptable levels of reliability or reproducibility.
Many orthopaedic tests commonly used by sports physicians, surgeons and physiotherapists have poor specificity (those that do not have the condition test positive) and poor sensitivity (those that do have the condition test negative).
Indeed, positive tests like the Hawkin’s Kennedy or Open-can Test theorised to implicate a certain structure as the cause of shoulder pain, can be rapidly made negative with repeated movements of the neck or shoulder (Kidd 2013).
So the evidence seems to suggest neither scans nor commonly relied upon Orthopaedic tests can identify the source of shoulder pain with any kind of reliability.
Schellingerhout et al (2008) noted that specific shoulder labels like ‘impingement’, ‘rotator cuff tendinopathy’ have only fair to moderate inter-observer reproducibility. And systematic reviews show none of the trials investigating treatment based on these common used labels thought to identify the structure in the shoulder responsible for pain show any large benefit for treatment.
The authors of this study recommend getting rid of these labels and that future research should be done to identify common characteristics for subgroups of shoulder problems (rather than a specific structure based diagnosis) that are easily and validly reproduced.
So what should Gary do about his shoulder??
The evidence is clearly stacked against making a decision based on imaging, or even indeed orthopaedic tests meant to identify a specific structure. This is why the statement from Marcus Ashcroft about his management is so disappointing and yet far too common in the sporting world with elite high paid athletes, where people want definitive diagnoses and timelines for return to the field immediately.
Given these difficulties evidence is emerging for identifying specific subgroups of shoulder pain based on their clinical signs rather than the disastrous MRI report that dooms them to season ending surgery!
The Mechanical Diagnosis and Therapy (MDT, also known as the McKenzie Method) is one such classification system emerging with high reliability in the extremity joints and the shoulder in particular (May and Ross, 2009; Abady and Rosedale 2014).
The MDT system would use a comprehensive assessment of Gary’s shoulder and has been shown to identify which specific shoulder subgroup Gary belongs to, which is based on clinical signs and symptoms and not on imaging findings or orthopaedic tests.
- About 1/3 of people with shoulder pain have a relevant neck component to their problem (Abady and Rosedale, 2016)
- 42% of shoulder problems will rapidly improve if repeated moved in a particular direction (May and Rosedale, 2012) called their direction preference
- 11% have tendon problems that need remodelling exercises to stimulate repair
Even better accurate identification of which subgroup he belongs on based on this assessment lends to a specific treatment, which then assists with likely prognosis and timeline for recovery.
If Gary were to fall in the subgroup with direction preferences exercises rapidly reversing his condition (42%) then days to weeks would likely be required to resolve his problem.
Is surgery the best option for Gary?
As highlighted already clinical decision making should be based around the patient’s clinical signs and not by imaging findings. And as illustrated there are research based forms of assessment like the MDT system that can help identify effective conservative solutions is many people with shoulder pain.
Let’s look then at surgical outcomes versus conservative care for shoulder problem’s as Gary is reported to be undergoing surgery looking to “fix” his shoulder problem.
Now I admit I do not know the exact details of Gary’s scan findings or type of surgery planned as these details have not been released to the public at this stage. However, this scenario does not just apply to Gary Ablett and his shoulder, but all athletes and recreational weekend Warriors. People injure their shoulder every day and face similar confusion about the best option to resolve their problem.
A recent systematic review of 7 RCTs of shoulder surgery for impingement (Saltychev et al 2014) found:
- Moderate evidence that surgical treatment is not more effective than active exercises
- Because of surgery’s higher cost and susceptibility for complications, conservative treatment can be recommended as a first choice for shoulder impingement
A study by Padua et al (2007) concluded:
“There is some evidence to support primary surgery in young active patients with an acute first traumatic shoulder dislocation, in order to reduce the risk of recurrence, but there is no evidence for the best surgical technique or best conservative approach, nor is there information regarding the best treatment in other categories of patients”.
Further searching of the best available evidence reveals a clear lack of studies to compare whether those that have surgery for a number of shoulder conditions do better or get better faster.
And yet in our elite athletes where cost is no barrier it appears surgery is all too common.
And whilst surgery may help some and provide good outcomes, there is clearly a lack of evidence advocating surgery as the best option, at least not before a trial of conservative treatment.
It is time for a smarter approach to managing our injured athletes
Elite sport is a high pressure situation.
Injuries to key players affect a team’s chances to win games, especially when they are star players like Gary Ablett.
It appears there is high pressure from the media, supporters and clubs to rapidly make decisions about injured players. When cost is no barrier invasive imaging and surgery seem to become mainstream even though the evidence is clearly lacking to support their use.
Gary Ablett was injured less than a week ago! His season has been written off and surgery deemed the option of choice immediately, which means not only has the imaging clearly dictated decision making but no period of conservative treatment has been tried yet.
Maybe it is time for Gary to come and see an MDT trained clinician for a second opinion? He may be in the 42% that rapidly respond to specific direction based exercises. They have been shown to reverse positive orthopaedic test findings, rapidly restore movement and eliminate pain often within days (Aytona and Dudley, 2013; Kidd, 2013, May and Rosedale, 2012).
Or at least he should be given a trial of some kind of evidence-based treatment to see if he can recover without surgery, potentially at a faster rate and possibly with a more effective treatment than surgery.
It’s time we made better decisions for our athletes! They deserve to be given that chance to rapidly respond before going under the knife!
Abady, H. and Rosedale, R. (2016). Application of the MDT system in patients with shoulder pain (In press, presented in 2015 in Copenhagen at McKenzie International Conference).
Abady, A., Rosedale, R., Overend, T., Chesworth, B. and Rotondi, M. (2014). Inter-examiner reliability of diplomats in the mechanical diagnosis and therapy system in assessing patients with shoulder pain. Journal of Manual & Manipulative Therapy, 22(4), pp.199-205.
Aytona, M. and Dudley, K. (2013). Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. Journal of Manual & Manipulative Therapy, 21(4), pp.207-212.
Girish, G., Lobo, L., Jacobson, J., Morag, Y., Miller, B. and Jamadar, D. (2011). Ultrasound of the Shoulder: Asymptomatic Findings in Men. American Journal of Roentgenology, 197(4), pp.W713-W719.
Johansson, F., DeBri, E., Swärdh, L., Cools, A., Adolfsson, A., Jenner, G. and Skillgate, E. (2014). MRI FINDINGS IN THE SHOULDER OF COMPLETELY ASYMPTOMATIC ADOLESCENT ELITE TENNIS PLAYERS. British Journal of Sports Medicine, 48(7), pp.612.2-612.
Kidd, J. (2013). Treatment of shoulder pain utilizing mechanical diagnosis and therapy principles. Journal of Manual & Manipulative Therapy, 21(3), pp.168-173.
May, S. and Rosedale, R. (2012). A Survey of the McKenzie Classification System in the Extremities: Prevalence of Mechanical Syndromes and Preferred Loading Strategies. Physical Therapy, 92(9), pp.1175-1186.
May, S., Chance-Larsen, K., Littlewood, C., Lomas, D. and Saad, M. (2010). Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review. Physiotherapy, 96(3), pp.179-190.
May, S. and Ross, J. (2009). The McKenzie Classification System in the Extremities: A Reliability Study Using Mckenzie Assessment Forms and Experienced Clinicians. Journal of Manipulative and Physiological Therapeutics, 32(7), pp.556-563.
Padua, R., Bondì, R., Bondì, L. and Campi, A. (2007). Surgical versus conservative treatment for acute first-time anterior shoulder dislocation: the evidence. J Orthopaed Traumatol, 8(4), pp.207-213.
Register, B., Pennock, A., Ho, C., Strickland, C., Lawand, A. and Philippon, M. (2012). Prevalence of Abnormal Hip Findings in Asymptomatic Participants: A Prospective, Blinded Study. The American Journal of Sports Medicine, 40(12), pp.2720-2724.
Saltychev, M., Äärimaa, V., Virolainen, P. and Laimi, K. (2014). Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disability and Rehabilitation, 37(1), pp.1-8.
Schellingerhout, J., Verhagen, A., Thomas, S. and Koes, B. (2008). Lack of uniformity in diagnostic labeling of shoulder pain: Time for a different approach. Manual Therapy, 13(6), pp.478-483.
Schwartzberg, R., Reuss, B., Burkhart, B., Butterfield, M., Wu, J. and McLean, K. (2016). High Prevalence of Superior Labral Tears Diagnosed by MRI in Middle-Aged Patients With Asymptomatic Shoulders. Orthopaedic Journal of Sports Medicine, 4(1).