Introduction: Don't Blame the Scan
​In recent years, a growing number of academic papers and social media narratives have raised concerns about rising imaging rates in musculoskeletal (MSK) care. The argument is familiar: imaging doesn’t help, causes harm, and fuels overmedicalisation by assigning labels that instill fear or lead to unnecessary interventions. (1, 2) 

Adding to the argument are studies showing that “abnormal” imaging findings such as disc degeneration or rotator cuff tears, are frequently present in people without symptoms. These findings are often used to recommend avoiding imaging in symptomatic individuals and to argue that similar findings in those with pain are often incidental or irrelevant.  (3-7) Some also claim that routine imaging fails to improve outcomes like pain, function, or satisfaction.(8) Taken together, these messages have driven a narrative that imaging is overused, harmful, and clinically invalid and should therefore be broadly avoided.(4)

Overdiagnosis and overmedicalisation are legitimate concerns. But these problems reflect how imaging is used and interpreted, not flaws in the tool itself. The greater danger is a drift toward clinical nihilism, one where we underuse valuable diagnostic tools in the name of minimalism, and lose sight of the very thing that should guide our decisions: clinical reasoning. 

While many researchers and guideline authors do call for judicious imaging based on clinical reasoning, that nuance is often lost in translation. (4, 9) The result is a reductionist message that calls for blanket imaging reduction and inappropriately applies group data from asymptomatic populations to clinical decisions in individual, symptomatic patients.

In this blog, I argue that the issue is not too much imaging, but misuse of imaging. I challenge the emerging dogma and make the case that imaging, when applied with skill and judgement, remains a powerful clinical tool in MSK care.

The Problem Isn’t Too Much Imaging - It’s How Imaging Is Used
Current criticisms of imaging often misplace blame, targeting the tool rather than the clinician’s decision-making. It’s like faulting a stethoscope for missing pneumonia. The tool is not the problem, misapplication is.

Real clinical skill lies in using imaging judiciously, as part of a diagnostic reasoning process that begins with a well-formed clinical hypothesis. Imaging should be used to help confirm, exclude, or differentiate specific conditions that require specific management when clinical tests alone are not accurate enough to do so. But without robust clinical reasoning as the foundation, even a “correct” image can mislead.

This approach reflects established cognitive models of diagnosis, such as the diagnostic reasoning cycle (10), which emphasizes hypothesis generation, pattern recognition, and iterative probability revision. As Elstein (2002) explained, diagnostic errors often arise from cognitive bias, shortcuts and failure to apply probabilistic reasoning, particularly when clinicians neglect to revise prior probabilities as new information emerges. (11) Diagnostic error remains a major contributor to patient harm. Given the often-limited accuracy of clinical tests in differentiating specific MSK pathologies, rather than abandoning useful tools like imaging, we should focus on improving how they are used in clinical reasoning. (12)

Physiotherapists "Use Less Imaging"
As physiotherapists take on more responsibility in first-contact, orthopaedic triage and other advanced practice roles, it has become common to hear that “physios use less imaging” compared to GPs or medical specialists. While often used as a political or professional selling point, this narrative is not inherently a badge of honour. If uncritically adopted, it reinforces under-investigation, not clinical excellence. We must be cautious not to equate “less imaging” with better care unless it stems from better diagnostic reasoning, not avoidance. 

Avoiding imaging altogether because it can be misused is a false dichotomy. The question is not whether to image more or less, but how to image smarter, knowing when, why, and how to use it within the context of sound clinical judgement for individual patients.

Clinical Reasoning Requires Nuance, Not Dogma
What’s often missing from the imaging debate is an honest conversation about clinician competence.

Appropriate ordering and interpretation of imaging in MSK practice requires the ability to reach a clinical differential diagnosis based on consideration of population-specific prevalence, and history and physical examination findings. In addition to clinical reasoning, imaging requires competence across multiple domains including professional and ethical practice, and communication. When imaging is applied inappropriately, it reflects not a flaw in the modality, but a gap in the clinician’s knowledge, skill and/or clinical reasoning.

Used properly, imaging can support:

• Diagnosis and differential diagnosis
• Red flag identification (e.g., trauma, tumour)
• Surgical planning
• Prognostic guidance
• Monitoring and progression of healing (e.g fractures) or pathology (e.g osteoarthritis)

Its value emerges not in isolation, but when embedded within a robust clinical reasoning process grounded in a working clinical hypothesis. Best-practice diagnostic reasoning frameworks support this approach, where information from the history and examination leads to hypothesis generation, followed by iterative testing (including imaging where appropriate).(10, 11)

When is Imaging Appropriate?
As Lin et al. (2020) and others have outlined, imaging in MSK care is appropriate when:(9)

• Serious pathology is suspected (trauma, tumour, structural injury)
• Symptoms are worsening or unresponsive to conservative care
• Imaging is likely to change clinical management

Requesting appropriate imaging is one issue; interpreting and correlating imaging findings clinically is equally critical. A growing body of research reports the prevalence of imaging abnormalities in asymptomatic populations. This information is used to suggest that the same findings in symptomatic individuals are often clinically irrelevant. However, this misapplies asymptomatic population-level data to symptomatic individuals, overlooking the key principle of population-specific pre-test probability, a cornerstone of evidence-based diagnosis.

Believing that “less imaging is always better” represents its own form of cognitive bias, one that risks harm from delayed or missed diagnoses, particularly in patients with serious or complex presentations.  If clinicians are unsure when to refer or how to interpret findings, the solution is not to abandon imaging, but to improve their clinical reasoning and interpretation skills.  

Imaging without context is noise. But in skilled hands, it helps provide diagnostic clarity and reduces error.

Conclusion: A Tradesman Never Blames His Tools
In an age rightly concerned with overdiagnosis and overtreatment, imaging has become an easy scapegoat. But scans themselves do not cause harm, poor reasoning, poor interpretation and poor communication do. Let’s shift the conversation away from polarisation and blanket calls for the reduction or avoidance of imaging, and dismissal of pathologic findings simply because they have been found in asymptomatic individuals, and back towards smarter use and interpretation of imaging. Let's not throw the proverbial imaging baby out with the bathwater. 

Like any diagnostic tool, imaging is only as effective as the hands and minds that use it. Reducing its use without improving the reasoning behind its application solves nothing. Instead, we should focus on elevating clinical competence, refining our use of imaging, and resisting the pull of oversimplified narratives. Let’s stop blaming the tool and start improving the craft.

The Defence Rests. 

COMING SOON....
Imaging Prevalence in Asymptomatic Populations: Are We Misreading the Data?

• I'll discuss why context matters, and why prevalence ≠ irrelevance.

Scans Don't Cause Fear - Poor Communication Does. 

• I'll take a look at how effective explanation (not avoidance), is the key to better patient outcomes.

Also in the Imaging Blog Series:

• "Is X-ray Needed in the Diagnosis of Frozen Shoulder? READ NOW

MORE LEARNING...

•  Shoulder Imaging (online course) VIEW COURSE

​          A 3-hour, self-paced, online course covering shoulder imaging modalities, how to read shoulder x-rays and                        interpreting findings to assess symptomatic relevance. Ideal for anyone in an advanced practice role. 

🔖 References
1. Zadro JR, O'Keeffe M, Ferreira GE. Is It Time to Reframe How Health Care Professionals Label Musculoskeletal Conditions? Phys Ther. 2024;104(4).
2. Zadro JR, O'Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, et al. Diagnostic Labels for Rotator Cuff Disease Can Increase People's Perceived Need for Shoulder Surgery: An Online Randomized Controlled Trial. J Orthop Sports Phys Ther. 2021;51(8):401-11.
3. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology. 2015;36(4):811-6.
4. Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. BMJ. 2021;372:n291.
5. Ibounig T, Rämö L, Haas R, Jones M, Järvinen TLN, Taimela S, et al. Imaging abnormalities of the acromioclavicular joint and subacromial space are common in asymptomatic shoulders: a systematic review. Journal of Orthopaedic Surgery and Research. 2025;20(1):7.
6. Ibounig T, Sanders S, Haas R, Jones M, Järvinen TL, Taimela S, et al. Systematic Review of Shoulder Imaging Abnormalities in Asymptomatic Adult Shoulders (SCRUTINY): Abnormalities of the glenohumeral joint. Osteoarthritis Cartilage. 2024;32(10):1184-96.
7. Shubin Stein BE, Wiater JM, Pfaff HC, Bigliani LU, Levine WN. Detection of acromioclavicular joint pathology in asymptomatic shoulders with magnetic resonance imaging. Journal of Shoulder and Elbow Surgery. 2001;10(3):204-8.
8. Karel YHJM, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. European Journal of Internal Medicine. 2015;26(8):585-95.
9. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54(2):79-86.
10. Higgs j, Sheehan D, Currens J, Letts W, G J. Realising Exemplary Practice-Based Education. 1 ed. Higgs j, Sheehan D, Currens J, Letts W, G J, editors. Rotterdam: Sense Publishers; 2013 11 Feb 2013. 304 p.
11. Elstein AS, Schwartz A. Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ (Clinical research ed). 2002;324(7339):729-32.
12. Hoffer EP. Diagnostic Error: Have We Made Any Progress? The American Journal of Medicine. 2025;138(9):1177-8.

Force measuring technology has been around for decades but has only recently become more affordable and accessible to the mass physiotherapy market. The ability to objectively measure force and track changes over time provides the patient with a source of motivation, takes the guess work out of manual strength testing, provides us with deeper insights into force production and provides funders with objective measures of progress.

​With increasing amounts of time and money being spent on equipment and collecting force data, maybe it’s a good time to pause and consider what value we are getting from these devices in our shoulder rehabilitation?

Ahead of a workshop I am involved in with other Specialist Physiotherapists at the upcoming Sport and Exercise Physiotherapy NZ conference I thought I’d take a look at some key questions that we should all consider when using force technology. There are more questions than answers in here I’m afraid but hopefully some good food for thought.

I’ll focus on three main questions:
1. Why are we testing?
2. What is the quality of our data?
3. How are we using the data to inform our rehab?
 
1. Purpose of force testing
Force measures are widely used as proxies for strength and power in physiotherapy. Force measures and derived force data such as force ratios have application in injury prevention, rehabilitation and performance monitoring and optimisation.

In New Zealand, the reporting of force “outcome measures” at standardized time-points has recently become mandatory for clinicians as part of funded clinical pathways for patients following injury or surgery. This provides patients, therapists and funders with objective measures of progress, can improve patient motivation in rehab and creates a large database from which valuable insights may be gained in specific populations.

However, when the selection and timing of the test is not clinician-driven but externally mandated, there’s a risk that clinical reasoning processes are by-passed, and these measures become more about ticking boxes and passing tests than informing clinical decisions.

These tests should not replace our clinical reasoning but should add to it by providing more data from which we can decide the next steps in the rehabilitation priority list. Next time you use your HHD or force plate in clinic stop for a moment to consider: Why am I doing this test, what is it measuring and how will the test data inform my rehabilitation?

2. Data Quality
We’ve all heard the saying “rubbish in- rubbish out”. Force data is no different and our clinical decisions are only as good as the data we collect. Measurement reliability is one of the biggest challenges in hand-held dynamometry. Reliable measurements are essential to ensure that the data reflects a true change in strength or function. Without reliability, you risk either over-treating perceived deficits that aren’t real or missing genuine deficits that need addressing.

Measurement reliability is affected by many factors including:

• Instrument factors: Calibration issues and pre-set test parameters.
• Patient factors: Motivation, posture, kinetic chain involvement (“cheating”), fatigue and recovery status from previous exercise.
• Tester factors: Tester strength, positioning, and instructions.
• Test protocol factors: Make vs. break testing, limb movement, number of repetitions, and rest periods.

 
The distinction between ‘make’ and ‘break’ test protocols is important. ‘Make’ testing involves the patient pushing against a fixed resistance, while ‘break’ testing involves the tester overpowering the patient’s force. In ‘break’ testing the amount of force applied depends on the strength of the tester. Break tests also involve eccentric forces which produce higher peak forces than concentric contractions. Understanding these differences and standardizing your approach is key to improving the consistency of your measures.

How reliable is your data?
Do you know your measurement variability? If you don’t, there is no way for you to know your "minimum detectable change" (MDC). Without knowing your absolute reliability (magnitude of the measurement error), there is no way of knowing whether the change you are seeing is simply due to measurement variation or a true change in force/strength. Research reports of reliable test measures for various tests and protocols don't guarantee your measurement reliability either. You need to test this yourself. 

Assessing your own absolute reliability (vs relative reliability using ICC values) can reveal the level of variability inherent in your measurements and help you identify your MDC and interpret your results more accurately. Many devices will do this for you. If not, there are several ways of doing this. One simple way is to calculate the mean difference between your measures, and the 95% standard deviation of the mean difference. Any force measures taken must lie outside this value to be (95%) sure the difference is real and not just related to measurement variability.

3. Clinical Decision-Making
The value of force testing depends not only on the quality of the data, but also many other clinical decisions:

• Safety:  is it safe to perform this test? (e.g post-op rotator cuff repair surgery).
• Test selection: what is my variable of interest? (peak force, force fatigue, RFD).
• Test position: where in the ROM am I interested in testing and can I get reliable measures in this position? (e.g end range abduction-external rotation (90/90) for anterior shoulder instability).
• Test quality: is the patient ‘cheating’ by using other agonist muscles (e.g deltoid, pectorals) or the kinetic chain to compensate during the test.
• Interpreting deficits:

          - What is clinically relevant? 15% might be relevant for an athlete but not for a sedentary individual.
          - What is the cause of this deficit? Can you unpack and ‘reverse engineer’ the test to identify where the system is ‘weak’? (e.g in the ASh test or a countermovement/plyometric push up – what is the cause of reduced force or RFD?)

• Informing rehabilitation: how will I target specific tissues in the rehabilitation programme to improve tissue adaptation or performance based on these results?

I’m going to expand on the last two points.

Reverse engineering the observed deficits:
When deficits are present, we need to be able to reverse-engineer or unpack the deficits to assess specific impairments that may be contributing to the observed deficit. Has the patient ticked the necessary ‘clinical test’ boxes around the glenohumeral joint and scapula to be able to safely and effectively perform a countermovement or plyometric push-up?

• No symptoms
• Full ROM
• Adequate motor control
• Adequate strength in key muscle groups
• Adequate power (rate of force development) in key muscle groups.

 
Failing to detect underlying clinical impairments risks returning someone to higher level participation with functional strength, but with underlying untreated deficits that may put them at risk for re-injury.

Informing rehabilitation:
Understanding how your data informs your rehabilitation requires a fundamental knowledge of the physics of force production and tissue mechanics (contractile and non-contractile components) during various contraction types (concentric, eccentric and isometric).

For example: Rate of force development (RFD) is often used as a proxy for power. Power = Force x Velocity. If you want to increase power, you either increase the force (using heavy slow training) or the velocity (light, high velocity training). Which one do you choose and how do you programme that? Does the patient have sufficient tissue capacity to do that safely? How do you target specific bone, muscle, tendon and other connective tissues specifically in your rehabilitation to optimize adaptation or performance? Some questions to ponder.

Summary
Force technology has been a game-changer for physiotherapists supporting our clinical reasoning and providing objective markers of progress for patients and funders.  However, their value depends on the knowledge and skill of the tester in selecting the appropriate test, the quality of the data and what we do with the results.

​Here is a checklist of questions to ask yourself when using force technology to help you get the best value for your testing buck:

• Why am I measuring this and how will I use this information?
• What is the quality of my data?
• What is a clinically relevant deficit?
• Can I reverse engineer this movement to assess its components and identify and rehabilitate contributing impairments?
• Do I understand the tissue mechanics and mechanics of force production in this test?

 
A lot of questions that I hope will point you in the direction of some answers, or some targeted CPD. If nothing else, hopefully some food for thought.

May the force be with you. 

RESOURCES
Cadogan A, Laslett M, Hing W, McNair P, Williams M. Reliability of a new hand-held dynamometer in measuring shoulder range of motion and strength. Man Ther. 2011;16(1):97-101.​ (Article link)

Force Plate Fundamentals for Physiotherapists (Free Webinar).

​Enhancing Muscular Performance (Online Learning). 

​

"Orthopaedic triage" is becoming a common term in the world of physiotherapy and musculoskeletal care. As healthcare systems evolve to meet the rising demand for elective musculoskeletal and orthopaedic services, orthopaedic triage has found itself in the spotlight.

An increasing number of physiotherapists are working in “orthopaedic triage” roles in elective (non-acute) settings in both the private and public sector. Elective services include anything that is not urgent or emergent. In New Zealand, examples of elective orthopaedic services include community-based ACC funded ICP/ECP pathways, referrals to private orthopaedic services and referrals by GPs to elective orthopaedic services in the public hospital.

​But here’s the issue – the term “orthopaedic triage” doesn’t mean the same thing to everyone. Depending on where you work or who you talk to, "orthopaedic triage" can take on different meanings, leading to confusion and inconsistent practices. A shared understanding of what “orthopaedic triage” is in the elective setting is needed to help us prepare for these roles as they emerge.

In this post, we’ll take a look at what orthopaedic triage is (and isn’t), we’ll explore definitions and why these matter, and review the purpose of triage and some of the factors that shape it. 

​What is Orthopaedic Triage?

Definitions
“Orthopaedic triage” has become one of those buzzwords that everyone is using right now. So, what is “orthopaedic triage”? Here are some definitions from the Merriam-Webster dictionary:

Orthopaedic (ˌɔːθəˈpiːdɪk): “a branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the skeleton and associated structures (such as tendons and ligaments)”

Triage (trē-ˈäzh)-ˌ 1. the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximise the number of survivors. 2. the sorting of patients (as in an emergency room) according to the urgency of their need for care.

Interestingly, there is no universal definition of the combined term “orthopaedic triage” in the elective setting. “Orthopaedic triage” means something different depending on who you ask. And that’s where the confusion sets in. Let’s get some clarity on this.

Orthopaedic Triage
“Triage” is currently being inconsistently described as both the triage of patients, and the triage of referrals. So, which is it?

Triage of patients:
In acute health services, e.g emergency departments, the “sorting and allocation of treatment according to urgency” (see previous definition) is based on an initial brief assessment of the patient by gathering information on symptoms and measuring vital signs on entry to the department.

Triage of referrals:
This differs in elective (non-acute) musculoskeletal and orthopaedic services where ‘optimising survivorship’ is not the issue as the conditions being referred are not life-threatening. In elective orthopaedic settings the “sorting and allocation of treatment according to urgency” is based on information provided in a written referral without any contact with the patient. In this context, the triaging clinician uses the information provided on the referral along with any other available information (e.g patient health records and imaging investigations) to decide on the appropriate clinical pathway and level of urgency.

Referral triage in the elective setting is thus a non-contact procedure that is often used as a pre-cursor a more detailed clinic-based assessment through appropriate clinical pathways that usually occurs days, weeks or months later.

Triage vs Clinical Assessment
Triage of elective orthopaedic referrals does not involve patient contact. This is a distinct and separate role from the clinic-based assessment and treatment planning role that occurs within specific clinical pathways which involves direct contact with the patient.

For example, physiotherapists working in a community clinic might use the term ‘orthopaedic triage’ to describe the process by which decisions are made about whether a patient with a confirmed diagnosis of knee osteoarthritis should be on a non-surgical pathway or needs surgical review based on clinical assessment of the patient. While this is an important clinical decision, this isn’t the same as “triage” (referral management).

In contrast, physiotherapists working in referral management roles within orthopaedic sub-specialty services in secondary care (e.g., Spine, Shoulder, Elbow, and Hand services) are often working with limited or variable information in the referrals, leading to diagnostic uncertainty. These referrals frequently involve complex cases and a high prevalence of serious pathologies, many of which fall outside the physiotherapy scope of practice. These two roles require different levels of clinician competency and involve the knowledge and utilisation of distinct clinical pathways.

The triage clinician in the elective setting is required to make a ‘best-guess’ at possible diagnoses from the (variable) information provided in the referral and allocate the patient to the appropriate clinical assessment service for further differential diagnosis and/or treatment.

Why Clear Definitions Matter
Without clear definitions, it’s easy for confusion to arise – not just among clinicians, but also among patients, employers, funders, and regulators about the role, its’ purpose, practitioner capability and resource requirements.

Clear definitions are important to employers to ensure appropriately skilled clinicians are recruited for specific roles. They are important to physiotherapists to understand the scope, skill and CPD requirements for the role. They are important for regulators to understand scope of practice and to benchmark standards and monitor adverse events. They are important to funders to prioritise funding for greatest value. They are important for politicians to ensure government healthcare priorities are achieved.

Clear definitions thus help ensure that everyone – from clinicians to regulators – understands what orthopaedic triage entails in elective orthopaedic settings. As these roles emerge at the very least, we need context-specific operational definitions for “orthopaedic triage” in elective orthopaedic settings to guide this process.

Now let’s review the purpose of orthopaedic triage and some of the factors that shape it.

The Purpose of Triage
In broad terms the goal of triage is to get the right patient to the right place at the right time by allocating patients to appropriate services for further assessment, diagnosis, and treatment. In doing so, orthopaedic triage services help by:

Managing Wait Lists:
By prioritising patients based on the severity of their condition, clinics can ensure that those in most urgent need receive care as quickly as possible.

Screening and Streamlining Care:
By allocating patients to an appropriate surgical, non-surgical or alternative clinical pathway for further assessment, diagnostic workup, and specific treatment planning. Where a trial of non-surgical management has failed, patients can then be ‘re-triaged’ for surgical assessment. This helps make best use of surgeon clinic time by prioritising patients with the greatest surgical need.

Accessing Treatment:
​In some cases, patients are referred through orthopaedic pathways simply to access treatment services not available to them in the community. Such is the situation in New Zealand at present with a general lack of primary care funding for the non-surgical management of non-accident-related musculoskeletal conditions including physiotherapy treatment and injections.

Effective triage can help reduce unnecessary healthcare costs by avoiding inappropriate investigations and treatment. Effective triage also optimises patient outcomes by minimising downstream negative impacts on health and quality of life that result from delayed access to appropriate treatment.

Key Variables in Orthopaedic Triage
While there are many variables involved in elective orthopaedic triage, here are some of the key variables that influence and shape who, how and where ‘triage’ occurs.

Where Referrals Come From
The source of referrals to elective services influences the information available at the point of orthopaedic triage. Common referral sources include:
- General Practitioners (GPs)
- Other Orthopaedic Specialists
- Physiotherapists
- Nurse Practitioners and other Allied Health Professionals
- Community Cultural Health Centres

The amount and quality of information in the referral can vary depending on the professional background of the referrer, the location and setting in which they work and the diagnostic investigations available to them. This influences the extent to which the triaging clinician can determine a differential diagnosis and therefore allocate an appropriate clinical assessment and treatment pathway. Sometimes the triaging clinician needs to request or obtain more information such as additional imaging to make this decision.

Reason for Referral
The reason for referral plays a big part in determining the knowledge and skill requirements of the triaging clinician. Common reasons for referral include:

Diagnosis and Treatment Planning:
In most cases, patients are referred to orthopaedic services for a musculoskeletal condition either because the diagnosis is unclear, or because the patient is not making adequate progress with non-surgical treatment. The goals are to ensure diagnostic clarity and to access and provide appropriate treatment or onward referral.

Additional Investigations:
Sometimes radiologists make recommendations for further high-tech imaging to characterise lesions seen on routine imaging to exclude serious pathologies such as metastases or other concerning bone lesions. Primary care clinicians often cannot access these investigations and send a referral to orthopaedic services for that purpose. After triaging the referral, the recommended investigation is requested, and results followed up to allocate the patient to the appropriate pathway.

Inter-Orthopaedic Surgical Requests:
Other orthopaedic surgeons in the private or public sector who have already seen and assessed a patient and determined a need for surgery may refer patients to elective services if the planned surgery can’t be performed in the private setting e.g ACC declined funding, or if the surgery can’t be performed within a specific clinical subspecialty or geographic area.

Identifying “Responders”
Like every other physical therapy intervention, manual therapy should be selected based on clinical reasoning throughout the assessment, diagnosis and treatment planning process to identify those people who are most likely to benefit from it.  Deciding whether manual therapy may be an effective treatment tool starts during the assessment.
​
In my experience, the ability to modify a persons’ symptoms during the movement-based assessment suggests the person may benefit from the inclusion of manual therapy as an adjunct to their treatment programme. Indeed, evidence has shown that the ability to change shoulder symptoms and/or range of motion of shoulder elevation with manual facilitation of the scapula was associated with better functional outcomes of treatment for shoulder pain. 1  

There are many forms of manual therapy ‘symptom modification’ techniques described for shoulder girdle pain 2-4  These are applied during the provocative movement (usually flexion or abduction) to the shoulder and surrounding areas (e.g cervicothoracic spine) and change in pain is measured. An improvement in pain with a manual therapy technique suggests a mechanical/nociceptive (vs nociplastic or neuropathic) flavour to the pain phenotype. Based on our understanding of nociplastic and neuropathic pain mechanisms, it is unlikely either of these would exhibit an immediate reduction in pain with a manual therapy intervention.

Mechanisms of symptom improvement
While our early assumptions were grounded in the biomechanical model, we now know that combinations of neurophysiologic changes, endogenous pain control mechanisms, placebo and contextual effects can all interact to result in improvements in pain with manual therapy. While we may never be certain which of the myriad mechanisms is responsible for the improvement for any given person, an improvement suggests the person may ‘respond’ to manual therapy.

Does the mechanism matter? No, but it matters how we explain the improvement to the patient to avoid maladaptive beliefs about the manual therapy “magic trick” that may create unrealistic expectations, lead to unnecessary health-seeking behaviour or foster dependency.

Manual therapy as a treatment for shoulder pain
The addition of manual therapy has been shown to improve treatment outcomes for pain and function for people with subacromial pain 5  and frozen shoulder.6  Scapula, humeral and cervicothoracic manual therapy techniques can be valuable adjuncts to treatment when they reduce pain and facilitate functional movement. Once functional movement is established, load can then be increased to build capacity within a multi-modal, movement and exercise-based programme.

There are other ‘non-specific’ benefits too. The application of manual therapy creates space within the clinical encounter to hear the patients’ story and develop the therapeutic alliance. The enhanced level of trust this affords often leads to the disclosure of other, more personal information, that may also influence treatment outcomes.

The ability to change symptoms gives the person hope that there may be a way to improve their symptoms, the level of trust in the practitioner increases and I find I get instant engagement with the treatment and exercise rehabilitation plan from that point on. The person is more confident to move, is less fearful that ‘something serious is wrong’ and when they can replicate this at home it gives them a self-management strategy for symptom improvement.

Case examples:
Here are two recent examples of patients I have seen who responded well to manual therapy:

1. A 24-year-old professional athlete who had completed 4 months of ‘hands-off’ treatment including exercise and was still unable to perform his overhead sporting activity because of end-range pain in shoulder elevation. After two sessions of acromioclavicular joint mobilisation, he had pain free elevation and returned to sport.
2. A 76-year-old woman with an irreparable cuff tear with significant disability due to pseudoparalysis. Deltoid re-training was difficult due to pain with attempted arm elevation. Posterior humeral glides (WMW) abolished her pain, and she regained full active shoulder elevation after 4 weeks of manual therapy combined with exercise-based rehabilitation.

 
Trick or Effective Treatment?
Manual therapy can be an effective adjunct to treatment for people with shoulder pain when delivered within a multi-modal programme. When applied within a clinical reasoning model and aligned with the persons beliefs and realistic expectations it can be an effective treatment to help reduce symptoms and facilitate improvements in movement and function. Don’t treat manual therapy like a “trick” and you may start to see it as an effective treatment for the right person.

References
1.     Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: A multicentre longitudinal cohort study. British Journal of Sports Medicine. 2016.
2.     Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine. 2009;43(4):259-64.
3.     Satpute K, Reid S, Mitchell T, Mackay G, Hall T. Efficacy of mobilization with movement (MWM) for shoulder conditions: a systematic review and meta-analysis. J Man Manip Ther. 2022;30(1):13-32.
4.     Aytona MC, Dudley K. Rapid resolution of chronic shoulder pain classified as derangement using the McKenzie method: a case series. J Man Manip Ther. 2013;21(4):207-12.
5.     Pieters L, Lewis J, Kuppens K, Jochems J, Bruijstens T, Joossens L, et al. An update of systematic reviews examining the effectiveness of conservative physical therapy interventions for subacromial shoulder pain. J Orthop Sports Phys Ther. 2020;50(3):131-41.
6.     Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2016;97(5):815-25.