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Dr Jeremy Lewis PhD is a New Zealand born, Australian trained physiotherapist who currently works as a Consultant Physiotherapist at St Georges Hospital, London, and, as the Research Lead for the Therapy Department at Chelsea and Westminster Hospital, London, and as a Visiting Reader at St George’s University of London. He is also a Visiting Professor at the University of Haifa. Jeremy has been involved in clinical, biomechanical and cadaver research investigations of the shoulder. He also has a Master of Science in Musculoskeletal Physiotherapy, and Postgraduate Diplomas in Sports Physiotherapy and in Biomechanics and has completed MSc modules in (i) injection therapy for joints and soft tissue pathology and (ii) ultrasound imaging. Jeremy has presented lectures at numerous international conferences as an invited and keynote speaker. He has lectured and taught on many international continuing professional development courses and workshops in Australia, Cayman Islands, USA, Israel, Switzerland, Holland, Ireland, South Africa, Poland, India as well as in the UK. His main area of clinical and research interest is the rotator cuff and shoulder pain. Jeremy is currently involved in a number of research studies and is supervising Masters and PhD students. He is also an associate editor for the journal; Shoulder and Elbow. |
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Workshop 3
Session 3B/4B
14.30-18.00
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Rotator cuff tendinopathy / subacromial impingement: The dilemma of diagnosis and a new method of assesment
Introduction
Musculoskeletal disorders of the shoulder are extremely common, with 1 in 3 people experiencing shoulder pain at some stage of their lives. In addition to the high incidence, shoulder dysfunction is often persistent and recurrent, and associated with substantial morbidity, with 54% of sufferers reporting on-going symptoms after 3 years. The most common diagnosis made by GP’s and other healthcare professionals is that of rotator cuff tendinitis. There is considerable uncertainty if this is a valid diagnosis. Furthermore there is some uncertainty whether the tests recommended to diagnose rotator cuff disease have acceptable accuracy. The aim of this presentation is to review literature on clinical testing and diagnostic imaging relating to rotator cuff disease in order to make recommendations to inform clinical practice.
Methods
A systematic review of the literature was conducted to investigate the diagnostic accuracy of the tests and investigations recommended to diagnose rotator cuff disease. These included; clinical investigations and diagnostic imaging. Literature was identified through the Medline, PubMED, CINAHL and Cochrane databases. Search terms included; shoulder, glenohumeral, subacromial, rotator cuff, tendinitis, tendinosis, tendinopathy, bursa, bursitis, palpation, injection, assessment, tests, imaging, ultrasound, radiograph, magnetic resonance imaging, arthroscope, outcome measures.
Conclusions
Within the spectrum of musculoskeletal disorders of the shoulder, pathology involving the rotator cuff and subacromial bursa are the most common. A myriad of clinical tests have been proposed to selectively compress, stretch, contract or relax the tissues of the rotator cuff and subacromial bursa, which aim at differentiating the involved structure(s). The findings of this review suggest that there are an insufficient number of studies that have evaluated the spectrum of clinical tests in the same manner, using the same reference tests to draw definitive conclusions to guide practice regarding the clinical assessment of the rotator cuff and subacromial bursa. Clinical tests require a reference test to be compared against to determine the diagnostic accuracy of the test. No reference test has emerged that may be considered as ‘the’ gold standard. This is because the reference tests identify structural pathology and there is no evidence for the correlation of structural pathology and symptoms. Our understanding of factors leading to rotator cuff disease and the disease process itself are limited and based more upon clinical theory than conclusive evidence. Assessment procedures used to investigate rotator cuff disease lack sufficient sensitivity and specificity to confirm the absence or presence of the condition. Further research is required in order to identify more accurate tests. A new method for shoulder assessment is presented.
Main references
Lewis JS and Tennent TD (2007) How effective are our diagnostic tests for rotator cuff pathology? Evidence Based Sports Medicine (2nd edition). MacAuley D and Best T (Eds). BMJ Books. Blackwell Publishing.
Lewis JS (2009) Rotator cuff tendinopathy/ subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine. 43 (4): 259-264.
Lewis JS (2009) Rotator cuff tendinopathy. British Journal of Sports Medicine. 43 (4): 236-241.
Lewis JS and Valentine RE (2007) The pectoralis minor length test: a study of the intra-rater reliability and diagnostic accuracy in subjects with and without shoulder symptoms. BMC Musculoskeletal Disorders. July 9; 8(1):64.
Lewis JS (2009) Rotator cuff tendinopathy: A model for the continuum of pathology and related management. British Journal of Sports Medicine. Epub online first 12.4.2009.
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