Shoulder Lab

Focused clinical approch to shoulder health

Our ambition at the Sports Surgery Clinic is to help reduce the risk of shoulder re-injury in sport. Our shoulder review service provides you and your physiotherapist with a measurement of your progress to date, information on how your injured shoulder compares to the uninjured shoulder and highlights areas that you may need to continue to work on. A team of highly experienced and motivated biomechanists, physiotherapists and strength and conditioning coaches deliver our service. We have a brand new 14,000 sq ft state of the art facility that is equipped with gold standard testing equipment to give you a detailed picture of your shoulder health and help guide you back towards a safe return to play. To fulfill our ambition and to further strengthen our learning about risk factors of re-injury we must continue to carry out robust and large-scale research. We therefore have a team of researchers who work in house and help analyse and interpret your data. Most importantly this allows us to improve the advice and feedback you are given. We also collaborate and share our findings with the world through peer reviewed publication and presentations all over the globe.

Why use our shoulder review service?

At the Sports Surgery Clinic we see nearly 400 patients a year who have undergone shoulder reconstruction. This has allowed us to develop a good understanding of common issues that arise on an athlete’s journey back to sport. Unfortunately due to the construction of the joint and the demands placed on the shoulder in sport, shoulder re-injuries and re-dislocations can occur. Also if a player has sustained an injury in one shoulder they are at higher risk of sustaining an injury on the opposite side. The benefit of having regular testing and feedback throughout your rehabilitation is that any problems can be identified early on. Both you and your physiotherapist can then work together on any issues identified to help ensure your safe and successful return to sport.

What is our shoulder review service?

Our review service consists of 6 areas:

1. You will meet a physiotherapist on the morning of your surgery. You will be asked some questions about your injury and it is also an opportunity for you to ask any questions you may have about your rehabilitation post-surgery.

2. Post-surgery inpatient physiotherapy will start you on the road to recovery. It will equip you with the skills to negotiate the very early stages of your rehab prior to seeing your own physiotherapist.

3. You will undergo your first series of testing at around 14 weeks post-surgery. We will assess the strength of your shoulder muscles using isokinetic dynamometry and assess your ability to produce power on dual force plates. We will also use 3D biomechanics to assess your sense of joint position in space. You will then be provided with a report that highlights any limb asymmetry present and identifies areas that you may benefit from working on.

4. At 6-months you will likely be getting ready to return to sport or may have already returned to sport. At this stage you will repeat the tests to assess for limb symmetry and ensure that previous deficits identified have been addressed. Any areas that you and your physiotherapist need to continue working on as you return to sport will be highlighted.

5. The 12-month test is your final, and the most important time to test. By this stage, you will be back at sport. However, we know shoulder re-dislocations most commonly occur in the first 2 years. Often this is the period of time when athletes cease to do their shoulder recruitment and strengthening exercises because their shoulders feel ‘normal’. It is imperative that you maintain control and strength of your shoulder to prevent re-injury and testing at 12 months will help to ensure that you are track.

6. The 2-year follow up questionnaires help us to understand how successful your surgery and rehabilitation has been. It allows us to learn and refine the service to further reduce the risk of those that follow from suffering a re-injury

SSC Shoulder lab Tests

Isokinetic dynamometer:
The rotator cuff is the common name for the group of 4 muscles and their tendons that provide strength and stability during motion of the shoulder. Studies have demonstrated that a lack of adequate muscle strength of the rotator cuff can predispose an athlete to injury. In particular, shoulder injuries have been associated with muscle imbalances between the external rotators (muscles that help rotate the shoulder outwards) and internal rotators of the shoulder (muscles that help rotate the shoulder inwards). Isokinetic dynamometry is the most reliable way to test the strength of these muscles. Strength testing will highlight any strength difference between shoulders and identify the ratio between your external and internal rotator muscles.

Upper body power testing on dual force plates:
In sport, successful outcomes largely depend on the muscle’s ability to exert maximal force in a minimal amount of time. To allow us to assess these qualities you will be asked to perform a countermovement push up, a press jump and a box drop landing on our force plates and with the aid of inertial sensors we will record your power qualities and track your movements.

Shoulder Joint Position Sense:
Research has shown that joint position sense is altered in people with shoulder pathology. If your joint position sense is impaired, it may not be possible for you to engage all the appropriate muscles that stabilise the shoulder during your sporting activities and this may potentially leave your shoulder more susceptible to injury. We will test your shoulder joint position sense using 3D motion analysis. The tester will take your shoulder joint to a predetermined position and then back to the start position. You will then be then asked to replicate the movement to the predetermined position, in the absence of visual feedback to become: while blindfolded. We will compare your results between affected and unaffected side.

What to expect on the day of testing

Isokinetic dynamometer:
• Your range of motion will first be measured using a digital gonimeter.
• You will be asked to lie flat on the chair with shoulder in line with the dynamometer.
• The first set is a warm up and familiarisation trial. You will be asked to rotate your unaffected arm forward and back against the arm lever at 80-95% of max effort (increasing strength intensity each time by giving feedback from the screen).
• You will then have a rest period and repeat the test. The next set is 5 maximal rotations forward and back, pushing and pulling as hard and fast as you can against the arm lever.
• You will then rest and repeat the test one more time.
• The procedure will then be repeated on affected arm.

Upper body power testing on dual force plates:
Countermovement press up
• You will start in kneeling pose.
• You will be instructed to assume a push up position with hands under shoulders and feet together.
• You will be instructed to perform a quick dip down and explode away from the plate as quickly as possible.
• You can land however is comfortable.
• Hold the landing for 2 seconds.
• Return to kneeling pose

Press jump
• You will start in kneeling pose.
• You will be instructed to lower down to the bottom of a press up and hold.
• You will be instructed to explode away from the floor as quickly as possible.
• You can land however is comfortable.
• Hold the landing for 2 seconds.
• Return to kneeling pose.

Box drop landing
• Two 20cm steps will be placed on either side of the force plates.
• You will start in kneeling pose.
• You will assume a press up position with hands on either step with hands under shoulder and feet together.
• You will be instructed to drop off step, land and put brakes on, stopping as quickly as possible.
• Try to stick the landing for 2 seconds.
• Return to kneeling pose.

Shoulder joint position sense:
• A laser will be attached to your index finger.
• You will be instructed to move your shoulder into three predefined angles and the corresponding laser dot will be marked, creating three targets.
• You will practice aiming the laser at each of the three targets.
• You will then be instructed to aim the laser at one of the predefined targets and hold for 2 seconds.
• You will then be blindfolded.
• You will be instructed to aim the laser at the target again.
• You will be instructed to hold for 2 seconds and return to start position.
• You will repeat the above procedure for all three predefined targets set at the beginning of the test.

Goals at each testing stage

The ultimate goal is for you to have an efficient and successful return to sport. However, you must remember return to sport depends on many variables. It is both player specific and surgery specific, taking into account the quality and type of surgical fixation achieved. The battery of tests you will perform are designed to reflect different qualities we would expect in a healthy shoulder.

• At 14 weeks, the aim is for you to have full range of motion and a stable and controlled joint. You will have completed a lot of control and strength work and are likely in the gym doing a strength and power program. You may have started some early return to contact drills. ISO Test CMPU Test Press Jump Test Drop Box Test Shoulder Joint Position Sense s01733 SSC_Shoulder A5 brochure.indd 7-8 06/03/2018 14:54 A team of highly experienced and motivated biomechanists, physiotherapists and strength and conditioning coaches deliver our service.

• At 6 months, the aim is for you to have maintained muscle balance and stability and re-introduced return to contact exercise drills into your training program. Indeed, you may already be back at sport. The emphasis in your training program will have often switched with a focus on increasing the power (the ability to generate force quickly) of the shoulder muscles. Testing at this stage is to ensure any previous deficits identified have been addressed.

• At 12 months, you are likely to have returned back to sport. Often this is the period of time when athletes cease to do their shoulder recruitment and strengthening exercises because their shoulders feel ‘normal’. It is imperative that you maintain control and strength of your shoulder to prevent re-injury and testing at 12 months will help to ensure that you are track.

What to expect on the day at SSC Shoulder Lab

First and foremost, we strive to deliver you a world-class service with friendly, professional and experienced staff. You will be given an opportunity to ask any questions that you have about your rehab to date and discuss any concerns you may have about the testing procedure. It is important to remember that none of the tests should cause any discomfort and if you have any concerns you can raise this with your tester on the day or give us a call beforehand. We aim to provide you with an impartial, objective view of your shoulder health. You and your physiotherapist will be provided with a report explaining the results of your tests. This may help guide the return to play decision making between you, your surgeon and those assisting with your rehab. Note, patients who have had their rehabilitation at the Sports Surgery Clinic will not be tested by their own physiotherapist or strength and conditioning coach. This is to remove bias and provide all patients with a true reflection of their progress to date.

Real-time analysis and interpretation of data

How we use the data

Every test completed and every questionnaire filled out is extremely important to us. When re-injury occurs, we look back at the data and compare the differences between re-injured patients and those that don’t re-injure. We then use that knowledge to inform our review service and the feedback we give patients. If we can better understand why re-injury occurs, we should be better able to prevent the injury occurring in the first place. It is
therefore extremely important we capture information on re-injury by gathering data via questionnaires at 2 post- surgery.

The hardest bit of the service

By far the most difficult part, but also the most important for us, is the collection of data at 1 and 2 year follows up. Without this, we can’t learn and improve. The questionnaires take 10 minutes to fill out and, they will help others who go through what you have.

Research and my data

You are playing a huge part in improving outcomes from injury, as many have done before you. As with any scientific research, full ethical approval was given by the Sports Surgery Clinic ethics board. This means the research team considered the risks, implications and validity of the interventions and the data collected. When you enter the service, you will be taken through the testing process and risks and offered the opportunity to ask any questions. You will then be asked whether you consent to your data being included in our research. This means your de-identified questionnaires, your operative notes and your biomechanical data will be used for research to further understand shoulder injuries. Of course, your participation in the study is entirely voluntary. If you do not wish to participate in the study your decision will not in any way affect your medical care and you can still take part in testing. If you do decide to participate in the study your identification will remain completely anonymous and nobody will be able to link the information to you.