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So, hi everybody, good to be here again. Our subject tonight is very much looking at return to play after shoulder surgery. Now why did we decide to talk about this? Well, basically, because it's something I get asked about an awful lot when I'm teaching the course, but also because I think there's some emerging evidence that really kind of challenges what we've previously understood and gives us best value.

Now you remember that we're bringing these Facebook Lives to you as part of our webinar launches, and the free videos that we released several weeks ago now, way before Christmas, looking at the diagnosis of acute shoulder pain. And if you haven't seen those yet, then do go to www.clinicaledge.co/shoulder where you can still get access to those three free webinars, and as I said, looking at acute shoulder pain.

Now we've published looking at accelerated rehabilitation after shoulder surgery, and I always cringe slightly, because it was really never about getting people back to play quicker. That was almost a side effect. The reality was, when we started looking at this way back in 2005, when we looked at the reported literature in terms of people getting back after shoulder surgery. Then the reported return to play times were around the six to nine-month mark. But the thing that I was really interested in, is when you actually looked at the consequences of people getting back to play. So, it was reported in the literature they were getting back to their sport. What these studies showed, very clearly, is athletes still had significant proprioceptive and strength deficits for up to two years post their surgery. And so, whilst they were getting back to play, actually, a large majority of athletes weren't getting back to performance.

Now clearly, that varied from sport to sport, and there was no doubt that contact athletes and throwing athletes, specifically, seemed to give us some challenges. Now, when we did our accelerated rehab, we did it with professional footballers, because they were a group that had constant physiotherapy input, and it was very easy to control things. Our approach was really to get them mobilising early purely to help address those proprioceptive and strength deficits, so that when they were ready to go back to play, they were also near their previous performance. So, if you like, we were preempting things and trying to massively shorten that phase. Now the knock-on was that we got people back quicker and that obviously was great, but we have to be honest that the relative risk of re-dislocation in something like football is relatively low, unless you're a goalkeeper. But actually, we're seeing similar kind of improvements in the time to return to play in things like rugby, but there's some definite caveats to that.

If we're going to look at return to play, then we can almost look at it within a psychosocial model. In terms of looking at the physical factors, we have to consider the social factors, which may be home, work, where they are on the team, the pressure to get back, those kinds of things, but also the psychological. So, we'll kind of look at what gives us best value in measuring those different domains. For me, the other thing that's important to say is, when we look at the things that impact, if we at shoulder stabilisation particularly, there's no doubt that age is definitely one of our key considerations. If we look at very young athletes, so if we look at patients that are aged 16 and below, their relative risk of re-dislocation, if they're going back to something like rugby is very, very high. And actually, a common theme of this Facebook live tonight is that essentially, if we look at the ACL experience, which is basically now showing that if we try and get people back really quickly, particularly in those young stretchy cohorts, actually things go wrong and their outcomes aren't so good in the longer term.

We see a very similar thing in young athletes who are not skeletally mature, who have a stabilisation, go back to contact sports, certainly from a four-month period, and again we see high rates of failure despite having surgery. When we look at the features that actually influence whether people are likely to fail stabilisation surgery, age is definitely a consideration, that young cohort are a big risk. The type of sport, obviously contact sport is a relative increased risk. Hand dominance, so they dislocated and had their dominant side repaired, that's a bigger risk. And also, associated laxity has been shown to increase the risk by three to four times. So, there are some key things about somebody's history that, in terms of return to play, will dictate that we might want to leave them a little bit longer, even if they pass their return to play tests. However, if we are going to look at what gives us best value, there's no doubt that the first thing we need to consider is their psychological readiness.

Again, we were always looking for the magic bullet or the magic panacea in trying to identify those patients at risk of failure, but also when we're trying to look at injury prediction risk. If you look at age and psychological factors, they're probably two of the biggies. So, if somebody has an increase in what we call their daily hassle, so just daily stresses, it could be can't pay mortgage, I crashed the car on the way in, I had an argument with my wife. Those kinds of things can actually be more of a predictor of injury than actually anything physical we can measure in terms of range of movement and strength. Now this is no less important when we're looking at trying to get athletes back to return to play. If we look at things like patients having realistic expectations, high levels of self-efficacy, so their confidence to get back. But also, their fear of reinjury also seems to be very key and low levels of anxiety. Now, this is where us and our therapeutic relationship is so important.

There was a nice study by Tjong in 2015 that basically showed that one of the biggest predictors and whether athletes got back to return to play was the relationship and the trust they had with the physiotherapist they were working with. So, guys, we have a lot of power, but also if we build that relationship, then athletes are likely to be much more honest. If we look at trends in professional sport at the moment, a lot of clubs actually use wellness questionnaires now to recognise those daily hassles and those psychological parameters. So actually, they can preempt potential issues. Never more important in this return to play group. Now if you look at different questionnaires, so how can we actually quantify this? There are several options out there, and I think it's fair to say there's a lack of consensus as to which gives you the best value.

The shoulder returned to sport index. There was a paper by Gerometta et al in 2018 which really adapted from the ACL questionnaire and that looks at three key things in terms of their confidence, their emotions, and wellness factors, in terms of measuring whether they're ready to go back, and they give you cutoff values, and I'll send some links to some of these papers on the Clinical Edge public page. One of the other ones that's been reported and validated is the reinjury anxiety inventory and then the third one, again, is the injury psychological readiness to return sport questionnaire. Now the SIRSI is nice, because it's a shoulder-specific questionnaire and as I say, it does seem to have good validity. But interestingly, when we did our paper and we looked at using questionnaires and correlating it with a very simple question, i.e. saying to the patient, "Do you feel confident to do your sport and all the loads that that's going to involve?" Actually, whether they said yes or no, correlated very highly with more complex and more extensive questionnaires.

However, clearly, depending on what your patient's going back to, and looking at their particular sport, having objective measures that really make that transparent are very important, in terms of protecting yourself but also having a level of confidence for your patients. Now, there is also no doubt that when we're looking at those psychological things, we need to consider the wider team.

So clearly, there are lots of other stakeholders potentially involved with your athlete, depending on whether you're looking at a leisure athlete or recreational athletes, or whether he was somebody who's going back to professional sport. A congruence of message, a congruence of timescales is massively important. Because again, we know that lack of congruence about information, lack of congruence about expectations and milestones can really introduce anxiety, particularly in somebody who has less good self-efficacy. So very simple things can really influence them.

So that's our psychological readiness. As I say, three different questionnaires, have good validity. If you're going to use one, the key thing is that you're using the same thing, so you can get some nice comparisons. Now in terms of physical measures, ideally what we want to be doing is actually mimicking what that athlete wants to go back to.

But if we're brutally honest, and we look at the evidence that's out there, there are lots of papers about individual tests, but very little about combinations of battery of tests that give us best value and specifically relate to different sports. So, let's have a look and see what actually is out there at the moment. Well, particularly in the shoulder, if you look at any papers looking specifically at return to sport, then range of movement is one of the first things that they talk about.

Now of course, we want to get almost full range of movements, and again, depending on what an athlete's baseline range of movement is in their unaffected side, that can dictate what percentage we're likely to accept. For example, if somebody has 90 degrees of external rotation in neutral and abduction and the same with their internal rotation, and they've only lost 5% compared to the other side, then up to 10% would actually be acceptable, based on the current studies.

If, however, they only have a natural range of about 40 degrees on the other side, then that relative loss is, percentage wise, much greater. So, there's a general acceptance that you want to have within 10% of the other side. Now again, this is important in terms of looking what we measure. In elite athletes, it would seem to be that the total range of movement is almost more important than any of those individual ranges.

So, I would always look at combining both. What's interesting is, if you're looking at testing your athletes out and then seeing whether they actually can cope, it can be very useful to actually look at something like GIRD before and after they've done a session. If there's a reduction in GIRD, so literally just looking at passive internal rotation at 90 degrees, if there's a reduction after they've done that session, then that's been shown to correlate highly with fatigue or loss of eccentric external rotation strength and actually some external rotation deficits. Often just doing some sort of warmup exercise will actually relieve that, but if it doesn't, that would have been indication that you've got fatigue and actually probably your athletes shouldn't continue. But in terms of base range of movement, particularly after surgery, it would seem that we need to be within 10% of the other side.

Now strength is obviously one of our other main measures, and that's where a lot of the evidence has concentrated. The problem is, a lot of the evidence talks about specific ratios and what we're seeing now is actually perhaps those ratios should be very specific to different sports. The lovely Ann Cools has done lots of normative stuff primarily in overhead athletes and essentially show, depending on the position that you measure somebody’s isometric strength will dictate what your ratio should be. So, if you look at your external rotation/internal rotation measures 90 degrees in north degrees of rotation, then your ratio should be between 60 and 85%. If, however, you look at it in the 90/90 position, then it should be nearer to 90 to 100% percent, but remember this was in throwing populations. A very nice easy test to do, which doesn't need a fancy kit, because the subjective reliability seems to be quite good, is just lying your patient in prone with their arm in that horizontal position. So, if I'm side onto you, just dangling straight down, there, my internal/external rotation ratio measured isometrically should ideally be one to one. Now Ann's research would suggest, and this has also been shown in handball players, that in that one to one, if you normalise body weight, if essentially that internal/external rotation isometric strength is less than 20% of their body weight, then that's been indicated to be an injury risk. Now again, we probably need more data to underpin that, but certainly if you look at isokinetic tests and we look at our external rotation to internal rotation ratios, again, most texts would suggest that that should be over 75%. So, it's very dependent on what you've access to, in terms of measurement. If you've got an isokinetic machine, then patients definitely like numbers. If you've got a handheld dynamometer in terms of your isometric strength, that can be useful.

But those are the kinds of reported ratios that we have at the moment. Again, you want a comparison side to side, but again you've got to consider the sport. Because if you have a sport with a significant arm dominance, then obviously, that's going to skew your results and you need to allow a percentage for that. But the good news is, we're starting to get more studies giving us that normative data so that we can have a comparison. At the moment, really, in a lot of sports, the best we have is comparing with that other side, but also ideally, any previous performance characteristics in professional athletes or those that are playing at a high level. Now the other thing I would say that is important when you're looking at strength is to consider the sport that your athlete is doing. There's an increasing interest looking at eccentric external rotation strength and doing that as a ratio with isometric internal rotation. Now again, this is specifically in a throwing population. If you look at eccentric external rotation measured from 90 down to the horizontal position, and compare that with isometric internal rotation, again, Ann Cool's work has suggested that, that should be 100% or a one to one ratio. So again, some nice measures that seem to have some validity. Interestingly, when you look at where people tend to lose their strength, it tends to be in mid-range rather than end range, which is interesting. Again, if I look at some contact athletes, I would say they actually lose it in that inner range posterior cuff, but again, in throwing athletes, it is often the mid-range position that they have weakness. So again, I would argue if you're going to measure strength, don't just look at it in one position, look at it in different positions that replicate what that athlete will be subjected to, but use those normative data that we have, particularly in throwing populations, if that's relevant to your cohort.

Now the other thing that's really interesting about strength, and this is where some of the emerging evidence really challenges us. Ben Ashworth brought out a lovely paper, a brief paper, and also an editorial looking at a new test called the Ash Test, which he's actually looking at in more detail as part of his PhD at the moment. Now what Ben demonstrated absolutely beautifully, with some isometric testing using four platforms, was exactly what we've seen in the ACL literature; is that patients pass some of their functional tests, their strength, their range of movement, but then when you get them to do something like a force production or peak force production, then we actually see some deficits in their rate of force production. So what Ben did is he got patients lying down in prone on the floor. He had them doing the I-test at 180 degrees, Y-test at 135 degrees, and the T-test at 90 degrees of abduction.

These are all lying on the floor with a four-centimeter block underneath the head, and then a force platform. The patient is instructed to push down as hard and fast as they can for three seconds. Now obviously, that gives you a graph, and what you're hoping to see is that immediate force production and maintained for the three seconds.

But interestingly, what Ben's work picked up was, in some athletes who'd pass their other tests, on this, you'd find often, particularly in their risk position, so initially this was rugby players, particularly in that horizontal tackle position, that there would be a delay in that kind of buildup of force. As well as measuring that rate of force production sense and an average of output over three different repetitions in those each position, he also looked at the highest peak they were able to actually exert. Now they did a warmup set of two submaximal contractions in each of those positions, but they also excluded test results if they saw a significant anterior tilt of the scapula, if they tried to cheat by bending their elbow rather than keeping the arm straight, if there was any movement in the lower quadrant.

But this is a really nice test that's getting an awful lot of interest at the moment, because it does seem to actually help identify deficits that haven't been picked up with some of those other tests. They're also now, some of the football clubs I've worked with, were playing around with the position that we assess people in to make it very specific, actually, to what that athlete is doing. But remember, important to look for those compensations and obviously somewhat dependent on you having a force platform. But again, a nice piece of kit if you're in a position to get one, because it's a definite feature of a lot of the emerging research. The other thing that's important is to assess the impact of fatigue on any of these measures. So, if you do a drill, or you do a training session and come back and measure those things and see how much tail off you've got.

Generally, across studies looking at it, you expect a 10 to 20% tail off. But actually, some of these strength studies would suggest that the injured players that perhaps haven't really had far enough are getting much greater drop off than that when they repeat the tests. So, another little thing to consider. Now in terms of strength, we can also look at scapular push and pull ratios, and again, there's normative data reported for that with a three to two ratio. Again, most of it using handheld dynamometers. We're lucky in that we have a Baltimore work simulator, which is a kind of cable system. So, it's a very nice way of replicating some of the speeds that patients actually have to use in their sport, but not something that's been well validated. So, what are the validated tests? We've talked about the ASH test, which is definitely an exciting test that's really kind of challenging, just using strength range of movement and grocer tests. However, in terms of anything that has any reliability or validity and has any science behind it, the closed kinetic chain upper extremity stability test is a well validated test. I think the problem is, with a couple of tests I'm going to tell you about, we're not entirely sure what they're telling us. And actually, most of their validity has been established as an injury prediction, rather than actually a return to play measure. Now the close kinetic chain upper extremity test is done, essentially, in a plank position with your hands about 91 centimeters apart. Why 91 centimeters? Because originally it was done in an empirical measure and essentially you have two white tapes and the patient sees how many touches they can do hand to hand, in a 15 second period. You can do a modified test on the knees for ladies, which what they did in the original study.

Now they suggested cuts. They looked at high school athletes and found a cutoff of 21. So, if people scored less than 21, their chances of getting a shoulder injury in the subsequent season was much higher. Now, I have to say, when I've looked at our elite footballers, going back to sport, the average of those passing all their other return to play tests has actually been near a 30 in that 15 second period. There isn't any qualitative measure in terms of failing them, if they lose scapular congruence, or they're kind of compensating through their kinetic chain. But for me, qualitative, those are things that I would look at. So that's one test. We're not entirely sure what it measures, but it does seem to have some validity in those kinds of studies. Certainly, in throwing athletes. The other test, you all I'm sure be familiar with the Y balance test, which is actually a lower quadrant test, in terms of sliding towards those different directions, medial, lateral, et cetera, and that's been done in the upper limb as well. So, if you have your testing arm as the one that's in weightbearing and then you basically slide to each of those different, you will use a plastic cone.

There's a very expensive piece of kit that you can get, but we just use tape, and a Y, and a plastic cone. And again, I'll just post some links to the actual tests, themselves. You then add up each of the three directions and you measure the length of the arm and then essentially normalise that and get a percentage and compare side to side. Now again, do we know what that measures? This has been shown to have no correlation whatsoever with upper limb strength, which is interesting. Again, we don't know what it tests but it doesn't correlate massively with the closed kinetic chain upper extremity tests in groups such as Ann Cool's. And what they would suggest, and a lot of the return to play experts would suggest, is if you have two tests that you do as a functional test but they don't correlate highly, that's a good reason to do both, because they're telling me different things.

Which sounds a bit wooly, but again, we have cutoff. So, with the upper extremity Y balance test, you want to have a side to side difference of no more than 5%. Some studies say as low as 90%, but certainly, again, with our elite population of footballers, they all got within 5% of the other side as part of their return to play measure. Now there's another test called the posterior shoulder endurance test, which is done in prone and coming up into abduction. You give them a weight that is 2% of body weight and you have a metronome timing them at 30 beats a minute. So, they all must lift, have a brief stop, and come back down again. They have to keep in time to be able to do the test, and you're looking at a side to side comparison.

We lack masses of normative data, so again, a side to side comparison seems to be the best that we've got. Now, some other really lovely emerging evidence done by the lovely Adele Fanning, who is based in Ireland at the fantastic sports clinic there, is looking at different types of pushup. Now there's been a lot of interest in plyo push-up, and that's certainly one of the things that we use. We use a counter movement jump and we use variations of plyo pushes on a force mat, or jump mat, which again gives us some nice data. Depending on which clubs I'm working for will depend whether we've got easy access to force platforms, and again, we can do the same thing which gives you that rate, rather than just that total output, if you like. Now, Adele's research has basically looked at some of the lessons that we've learned from the ACL literature in terms of an athlete's timing of force and also their ability to take force, or their willingness to take force if you like.

And she's looked at things like a counter movement jump, a press jump, and also a drop jump, where you start on two steps and then drop down and done some fantastic movement measures with movement sensors, that give you some lovely outputs and show you some real discrepancies side to side. What's really interesting, in terms of comparing isokinetic strength and vertical ground reaction force, each of those three measures seem to measure very different things. And so, we're not just looking at rate of force absorption, rate of force production confidence, willingness to take the weight. And as I say, those three different things seem to measure different aspects of upper limb function. So, you kind of see the complexities. The great thing is, by doing a plyo push and doing those variations that Adele suggested, but also another validated test is the one-line hops. So, seeing how quickly somebody in high kneel on their knees, almost like a press, can do hops over a middle central line, and how quickly they can do five.

Then again, there's usually about a 5% difference, side to side, between dominant and non-dominant. And that's a test that, again, is becoming more of a feature of some of the suggested batteries. So, we've got lots of different options here. Again, we want to be looking at drop off after fatigue, but we've said psychological readiness, definitely. Range of movement, no brainer. We need range for our muscle system to do its job. Strength, lots of different strength options. Most of the validated data is done in throwing sports, but we have some limited data for contact sport.

In terms of functional tests that have some normative data, good validity, and reliability. The closed kinetic chain upper extremity stability test, our upper extremity Y balance test, and our posterior shoulder endurance tests, again, these have been tested mainly in overhead throwing populations.

Now Ben's work with the ASH test, the I's, Y's, and T's, and Adele's work with the counter movement jump, the press jump, and the dropdown jump have all been done in contact with athletes. So, rugby players. And so that's really nice that we have some really good objective tests that we can use in those populations.

Now one of the things we haven't talked about is frank measures of proprioception. We can do joint matching, but interestingly, that's obviously an important measure and we can do open chain and again, we can measure it with lasers and joint reproduction sense. But one of the other proprioceptive measures that we seem to lose is, again, our sense of force production sense. So, one of the things that we do is, with a pressure by feedback, is get them to do an 80% push, we have the number, obviously this is done with eyes closed, and then they have to replicate on the other side, and we'll do that in their risk position. So, for an instability patient after stabilisation surgery, they'll obviously do it in that 90/90 position. Again, a nice little test.

Now the other consideration that haven't talked about just yet is the kinetic chain. And those of you that know me know that I talk about this a lot, but again, we do have some measures. The seated medicine ball throw is something that, again, there's a lot of reliability and validity data for. So, somebody literally sits in long sitting and then throws a medicine ball as far as they can, either with both hands, or you can do a side to side comparison. It's been shown to correlate very moderately to highly with shoulder strength and elbow strength. And it's interesting, I don't think we've got a comparison of what happens when you actually add in or take away the kinetic chain, but again, another proposed test.

In terms of the kinetic chain, there is no doubt in throwers, there is evidence to suggest the importance of lateral trunk endurance in your throwers and certainly the side hold rotation. So, you're essentially in a side plank, and then just doing rotations through Margie Olds suggests seeing how many you can do in a minute, and again, comparing it to their non-affected side.

Side plank endurance does have some good validity with a cutoff of about 90 seconds. That's been done in contact athletes, as well as in your overhead athletes. Now for me, what's really important, say I have a goalkeeper who's going back to play. If he's had a previous history of low quadrant injury, then arguably, those lower quadrant performance measures are equally as important. So, I might look at jump height and power measures for the lower quadrant, as well. Why is that? Well, because we do have evidence that if we do a fatiguing drill on the glutes or we do a fatiguing drill on the lower quadrant, certainly in the throwing literature, this has the consequence of increasing load through the shoulder. So, clearly, when they've had their surgery, it's an opportunity to improve all of those lower quadrant performance measures anyway. But also, for me, it's an important consideration when they go back to play.

Now there's been a recent paper published by a lady called Margie Olds, suggesting a battery of return to play tests and she looked at eight specific tests. She looked at ball taps, which was with a 55-centimeter swiss ball, literally in this able position, she looked at drop and catch, again, in this abduction and with 90 degrees at the elbow, and drop and catch in that position.

Now interestingly, the ball taps and the drop and catch had a learning effect. So, they found people got better at doing it, not necessarily because they improve functionally, but just because they learned how to do the test. The other things that she did was she had a medicine ball lifting from the floor, like an overhead snatch.

All these things were done for a minute. She also did one where she started with a three-kilogram medicine ball here, extended, came back up to the ceiling and back. So, a kind of repeated functional test. She did a push up with a clap. She did the one-line hop that we've talked about, a modified closed kinetic chain upper extremity stability test, because she did it for a minute, and she did that side rotation. So, a gambit of eight tests, but she then said six of those, so I exclude the ball taps, exclude the drop and catch, and again I'll send you a link to this paper that these had potential. Now we have to be very honest. Is that a suggested test? It's shown good for liability and she has nice normative data, but we haven't seen its relevance, in terms of how it relates to return to play.

So, she's obviously going to do that as her next test. The bottom line is, if we're looking at return to play, we clearly need a battery of tests that reflect what the athlete is going back to. The top of my list is definitely that psychological readiness. As I said, I've given you a suggestion of three different particular questionnaires. I liked the SIRSI, because it is shoulder specific, and it mimics what's been already validated in the ACL literature, but we need a consensus really, so we can get comparisons between studies. Range of movement and strength, clearly very important. But I think also looking at strength, it's relevant to that patient's sport. In our throwing athletes, eccentric external rotation seems to be very important and remember the ratio, but equally looking at the difference between isometric strength and isokinetic strength, in different positions.

Ben Ashworth's work is lovely. The ASH test gives us some fantastic places to go. In terms of swimmers, again, a lot of these tests that incorporate the kinetic chain, so your closed kinetic chain upper extremity test, your posterior endurance test is a no brainer, but the thing that's important with your swimmers, depending on their pain, is looking at subscapularis. Because they're the one group that we do seem to have some additional evidence that subscap function is particularly important.

Now personally, I do most of my cuff testing in prone. But again, for that swimming population, looking at that one to one ratio here would be very useful, and arguably things like your side plank endurance, again, is important. Looking at that lateral strength, because again, we know with swimmers, often the issues elicited from elsewhere in the kinetic chain, resulting in overload of that shoulder. So, our strength, our range of movement, specific strength tests that are irrelevant to the sport, proprioceptive tests, and remember that it's that force production sense as much as joint reproduction sense.

Looking at the impact of fatigue on any of those measures, but then also not forgetting functional tests. You can use the ones that are validated, but also don't forget to incorporate the kinetic chain. So, lots of tips and tricks. I think we have to be really honest in the shoulder. We do not have a consensus on a battery of tests that is relevant across sports, and what's becoming abundantly clear is the ratios and the strength requirements, we know, are very different to different sports. We need more normative data.

But equally, if we have preexisting data from our patients, then we have a better benchmark of what we're getting them back to. When we did our original paper that we published, essentially, we used the plyo push, we used one hand hops, we used a closed kinetic chain upper extremity test, we used side plank endurance, and a couple of other kinetic chain tests.

The psychological readiness questionnaire, as well as strength in different ranges of movement, tested differently, and to be fair, in terms of our re-dislocation rates, they were very, very low and all of the patients that re-dislocated was a result of a further arguable tour almost. So, they did as well. But I think what's so fantastic about Adele and Ben's work is it's really opening our eyes to the fact that there are still deficits there. Which, particularly if you've got contact athletes or people going to high loaded activities, really give us food for thought in being a little bit more thorough in things that give us best value.

Now guys, quickly before I go, just check that I've answered all the questions. Where do you get your guidelines for dosage and what's your take on manual therapy? So, for me, manual therapy, I think there's evidence that it has a role, but it's only temporary. There's no doubt there's probably a placebo role. We do know that if we touch and mobilise people's thoracic spines, we have an impact on scapular recruitment temporarily. If we mobilise the cervical spine, we modulate shoulder pain, we improve the cuff recruitment temporarily. For me, I'm always going to try and show patients they can achieve it themselves with exercise first, but depending on their expectation, their previous experience, I also know if I put my hands on it can be a tool to change somebody's movement experience.

It's a very small part of what I do and I use it to facilitate change. So, things like mobilisations with movements can be very useful. There is also evidence that manual therapy changes patients' perception of change. So, there's a big anti-manual therapy movement in the UK at the moment. I probably use it less and less, because I get better and better at educating and showing patients that they can achieve the same thing with key exercises. But I would definitely never say never, because that would be dishonest, because it does feature as part of my practice with some patients.

In terms of my dosage, it's very dependent on what I'm trying to achieve and I'm trying to teach more movement, if you like. I don't want to say motor control, because that seems to be a swear word too, but if I'm trying to change somebody's pattern or efficiency of movement, then I'm looking at motor learning reps.

If I'm looking at strength, I'm going to use a strength dosage. So really, I need to be clear what my aim is, and that will dictate what dosage I use. Joe, as I say, I'll give you some quick tips about swimmers, but I'll dig out some stuff and send some links on that on the Facebook page. And guys as ever, I overstepped my half an hour. Here I am, 35 minutes later. I hope I've shared some useful information. I'll send links to Ben's papers, watch this space, because Adele, I believe, is going to be publishing some normative data soon about her research, some really exciting stuff to really improve our return to play approach.

But again, I hope I've given you lots of tips and tricks that you can use, and I hope you find the resources really useful. I'll be back again in a couple of weeks. If people have particular things they'd like me to talk about, do let me know. But as ever, don't forget those free webinars at www.clinicaledge.co/shoulder, there's three free webinars about shoulder diagnosis and acute shoulder pain. But as I say, come back and join us for our next Facebook Live. Thanks to all of you that have commented and joined us tonight, and I'll see you again very soon. Take care.