Jared Powell:
Okay, here we are with Filip Struyf or should I say Dr. Filip Struyf, you do have a PhD after all. I dunno where you stand on that. Thank you very much for joining me. You're someone who I've followed in academically for a number of years now. You're quite a prolific researcher when it comes to the shoulder. So I wanted to get you on to have a chat generally, but actually to focus in on the scapular, the contentious scapular as I'm sure we're gonna talk about, so please, if you don't, don't mind, just give us a bit of an introduction about you, your history, and actually how you a evolved over the last, say 10 years in terms of your research.
Filip Struyf:
Yeah. well, thanks jazz for, for inviting me for this this chat in it's it's early in the morning here, but no problem. we'll like we can have a chat about, about the scapula because yeah, scapula is, is a bit my my thing, I started with my doing my PhD in, I think 2003, something like that, or 2002, I started with my PhD until 2008. And well, the, the topic of of this PhD was measuring from a clinical perspective, measuring the scapula. And because at that time 2003, actually this scapula was big, was well, still a big thing, but it was that taste was really a big thing. And we were quite sure that that was the thing we needed to address. So the, the next step was to, to measure it.
Filip Struyf:
I can remember when I, when I started my PhD, I had to choose, I, I had the option of choosing two topics of doing my PhD. I could do a study about scapula, or I could, could do a study about chronic fatigue syndrome. Cause my, my supervisor, he was Joe Nijs. He's a specialist in chronic, in chronic pain. And in, in that time, he was on, on chronic fatigue syndrome and fibromyalgia, but he was also starting something with the scapula so I could choose. And that 2003, I was thinking, oh, I'm not going to do anything on chronic fatigue syndrome because I imagine they will discuss their, your, the relevance of your topic in 10 years. And I, I was doubting that fatigue syndrome and now 20 they're doubting the relevance of dyskinesis. So
Jared Powell:
Things have changed
Filip Struyf:
Exactly. But anyway, I, I don't have regrets on, on choosing topic. And but after doing this these things, this PhD actually more at the end, we were doing some trials, some randomized trials, and we wanted to address the problem and and then measure what we, what we did. That's where we actually first encountered some well, not so much difficulties, but, but a lot of questions because we, we, we focused for instance, in an, in randomized trial on, on, on the scapula. And we wanted to, to, to do scapula stability training training in, in subacromial shoulder pain patients. And then at the end, they, they, they, they did well, they did better than the control group, but when we started doing our, my, my measurements, which I didn't do during my PhD, we actually didn't find any difference between the different measurements.
Filip Struyf:
So we were like, okay, what, what, what, what did we do? And that was the first time that we actually started questioning the relevance ourselves. And that was the moment after the PhD. I evolved to doing a lot of other shoulder related studies going more to but all related to the let's say the, the, the pain pain and, and shoulder problem. So to controller rotated cuff tendinopathy, cuff related, shoulder pain and also the chronic pain story. And then actually, we, we didn't focus on the Scapula as itself, but we always took scapula thing into the studies, some sort of secondary parameter which we wanted to to still follow. Also when doing some studies in, in athletes and in, in swimmers, we wanted to follow the the capital and still look at that picture, but not as, as one goal on itself anymore. Cause we know maybe that's not the case anymore. So, and then over the years, a lot of colleagues also studied and now I think we've, we've come to a point that we we've evolved a lot and we, we had some more clearer logic sense idea of it. Yeah,
Jared Powell:
Yeah, yeah. Well, we get into the, yeah, that's, that's a, that's a very interesting story, actually. So the it's funny how you mentioned 2003, starting your PhD, the scapular. I mean, it probably wasn't even controversial that the scapular obviously led to pain and pathology, right. It probably was barely questioned. And now here we are 17 years later where you can have a conversation about the shoulder without actually men mentioning the controversial capital. Is that right?
Filip Struyf:
Yeah. Yeah. Yeah. Like in 2003 we had three, we had dozens of articles showing that different shoulder populations had also some sort of capital dyskinesia. So that was in that times it was like, okay, that, that that's it, there is a relationship relationship, so there must be yeah. Post consequence or whatever, but it's only since then that there are some longitudinal trials going on, looking at predictive value, et cetera. And then because it's, that's a type of study that's a little bit more difficult to do takes a little bit more time more money. And we see actually that's only after 2008 that the longitudinal trials started that's where, where the good thing happens. Of course the interesting things on, on predictive value, et cetera. So at that time, yeah, it was, it was, it was a certainty. Yeah.
Jared Powell:
Yeah. So we could probably do about 10 different podcast on this topic, but I think what we're gonna hone in on is this what I call the measurement problem. It seems to be inherent within, within scapular assessment. I think there is a fundamental in how we measure visually with our eyes, which is how it's done every single day in clinic, all around the world. We don't have fancy 3d biomechanic imaging. We use our eyes, which are very biased, which we won't get into, but we have, we have this measurement problem. And I think if we start at the, is very beginning, if we are looking at well, is this scapular a factor in contributing to pain and pathology? And do we need to normalize it to improve or does it lead to injury and et cetera, et cetera, we have, we measure it. And I think that's we, so in order to have a conversation about this, I guess we have to define what scapular dyskine is. Do you have a neat definition on how we, how you would describe a scapular DYS?
Filip Struyf:
Yeah, it's a good, good point. Well we, we, we use now as the, the main tool for observ for, for looking at, or diagnosing scap dyskinesis, it's not a, not a pathology, but looking at scapes we had a lot of other measurement techniques in the past to to, to, to measure the position of the scapula, but actually these are our use that more, that, that much anymore. So now you'll, we mainly use scap DYS visual observation. And we look at the moment we look at deviations that are really, really present really obvious. So in, in the past, we, we also used like this subtle things. And then we, we, we got a colleague say, look, look, look at this capital. What, what do you see? And then you, you start discussing what you see, or you put them in another light, you, you do it slow, you do it faster, the movements, you put some weights with it.
Filip Struyf:
You, you did several things. You video CA you made a video it, and then you made slow motion pictures of it, and then try to find something. And I think that's really a thing that we, we should get rid of. That's a, a part that that's really not interesting anymore. We have no evidence at all that obvious scapular dyskinesis is really the predictive value. So if there obvious thing is not really predictive of, we don't know whether it's predictive, then don't bother about the subtle things. I think so. Yeah, the subtle in the obvious thing. Okay. We have, we have, we don't have evidence that it's predictive, but we have some evidence that it can play a role, but then we speak of a clear medial medial border of the Scapa that starts to, to internally rotate, to starts to wing a clear inferior angle that starts to tilt or a, a rhythm that's really out of out of its linear pattern.
Filip Struyf:
But I talking about a clear thing. So actually, I, I, in my courses, or in classes, I, I put a patient or a subject or a student in front of the, the classroom all 20 look at their shoulders and I'm standing on the, on the face side of the student. So I, I cannot see the, the, the Caplan. And actually, I, I tell them, actually, I should see on you guys, whether there's scapular dyskinesis or not, you should really see it and all do like, whoa, this, this is big thing. And not, if they, if they're quiet and they're like, and they're starting discuss, I know, okay. It's not, it's not big deal only when there's really, really something apparent. Then, then maybe we have, we, we can start about discussing some of the relevance. So don't, don't bother of things from our way. I think
Jared Powell:
So, so a dyskinesis in your view would be something that's profound and obvious, and it's, it's almost hitting you in the face. You don't have to use a magnifying glass to actually see it. Right. So it's something that is just doesn't look right. And potentially that when it is relevant, but if we're having to deconstruct my neutral in one degree or two degrees of movement, then it's probably entirely irrelevant degree.
Filip Struyf:
Yeah. Yeah, exactly. I don't think we, we have any evidence of what we're discussing now. It's relevance for the, for the obvious things. So I I'm really clear that the clinical relevant of the, the subtle things, the, maybe the one degree, two degree things, I think it could be a waste of time. Yeah. And we know that there are so many inter-individual variations anyway, there is hand dominance difference. There is difference between children and adults, between adults and elderly there's difference between unilateral sports people and bilaterals. And it's, there's so many usual difference that we, we, we cannot judge or, or do anything with, with these subtle differences.
Jared Powell:
Yeah, no, you you're. It's so multifactorial. And, and I usually quote, in my courses, there are over 10 factors, which have been proven to lead to a scapular, very of movement from person to person. And you mentioned a few and there's a bunch of other ones as well. So we just can't be sure what is causing it in the first place. And therefore, if we need to address it, cause it could been there for, or 30 years, you know, causal akin actually is. So let's talk about reliability of it. So when, when we're talking about reliability, obviously there's intra reliability or intra person or in, in person reliability. So intra meaning two clinicians the same clinician measuring it twice on two different occasions. And then in meaning two different clinicians measuring it and seeing how how much agreement there is between the two. So do you have anything to speak to in regard to the intra and in person reliability?
Filip Struyf:
Well, yeah, we, we, we did some reliability studies and a lot of colleagues also did some reliability studies on observation. I'm not discussing all the, the measurement types. There are a lot of small measurements with CS and, and, and, and in clean medias, et cetera. And there's sometimes they're proven some, some reliability than, than on the other hand. The validity is mostly the question there. But on visual observation there has been some sort of progress towards the the, the, the, the system of it's actually Philip McClure and Angela Tate. The, the thing is on validity and
Jared Powell:
Reliability, the scapular Diskin test you're referring to.
Filip Struyf:
Yeah. And they show that actually, well, if, if you, if you really address the, the obvious thing and, and, and not so much as subtle, but also the subtle was quite okay there. But if you address the obvious scapular dyskinesis, then, then the reliability is is, is okay in terms of intra reliability and also in terms of injury, reliability. And they also prove some validity measures if, if that's possible. Cause that's, that's also a big question. So, but, but it's again, it's we, we also the same if we looked, it all depends on what you're looking at. And we, we, we, we split it out in all different factors on, on scap dyskinesis for instance, we did, we did the, the, the scap is a bit higher than the other. Then you got the internal, external rotation, the tilting of the, and, and the, you got the upper rotation, the downward rotation, the speed, the, but whether it's going smooth or nons smooth you got the lateral slides positions.
Filip Struyf:
There are several of the things we, we studied. And we, we actually saw that a lot of them are, are not reliable. So for instance, the, the, by the one scap is a little bit higher than the other. It's very difficult. And the reliability of that thing is quite bad actually. And because one, especially the inter rate reliability, cause the, the one, one clinician comes in, he says, your right Scala is, is high. And then the other comes in and says, the left one is low, and then you've got a battery reliability, although they you've set the same maybe, and then you've got the, the, the hand dominance thing. So it's, it's really not so not so interesting. So that's why only the, the winging, the tilting and maybe the, the rhythm is is, is something you can test or see. And which has proven quite good reliability.
Jared Powell:
But, but even, even, but even then, there's still only like a moderate reliability, right? So it's not, it's, it's not approaching excellence or anything like that.
Filip Struyf:
Exactly. It's it, it, then you can discuss about how you report these things in literature, because you can talk about the classic significance levels of your reliability in your interclass levels or your CAPA values, et cetera. It's okay. But then there is also, from which moment you talk about clinical relevance, and, and then actually we see that we, you, you need to achieve quite a high level of agreement in order to make it from a clinical point of view. Interesting. And that's where we, we, we often have like 0.8 reliability 0.7 0.8, sometimes 0.9, but mostly it's it's around that. And we know that from a clinical point of value should view, you should
Jared Powell:
Actually get Tod 0.9 or more. So that's indeed a good question. And if you see something and, and if I see something with a patient and the patient is, is away for a few days and he comes back, then I, you can often see the same thing again, because your, your, your, your brain is, is focused on that. And you you're remember it, of course. But then if you, if, if they're the, you got the inter reliability and someone else is there, then it's really dependent on how you introduce the problem. If, if I have a patient and I see something and I, I get a colleague, I say, come colleague, I have something here for you. Look, look at that. Yeah. Then he, he already knows there's something going on here. I should, I should see something and contextual clue.
Filip Struyf:
Then again, it's, it's really bad for the patient. Sometimes if I get a colleague in there, because then he's thinking, okay, is there, is there something in my back going wrong? Now, there are two colleagues watching at my back, so there must be some problem. And then, yeah, you can, you can get a cascade of, of things going on, which, which doesn't help. That's .
Jared Powell:
Yeah. So, so the intra rate reliability may be moderate in agreement. I think that's mostly what I've seen sort of about maybe up to 7.8 at it's best. But when I, when I had a quick little look at the literature before I came on, and the reliability can be really poor, even, even when experts, even like scapular experts who were actually doing it. And I saw a funny one by Ben Kibbler, who was obviously one of the scapular and he, he had a study in 2012 with Ellen Becker, and the in rate reliability, there was 0.6 to 0.26, just in a simple, like two part classification. So is there scapular dyskinesis yes or no? So that interrelated, Interra reliability was, was really poor. So that, that is influencing. That's so many issues
Filip Struyf:
In there. Yeah, that's true. But it, it's definitely dependent on what, how you classify your scap dyskinesis because if I say to you, okay, let's only classify scap dyskinesis as the presence of scap wing, that's all, for instance, then there's a good chance that reliability will, will get a lot better. But if we say, okay, it's capital it's winging, or the presence of some tilting, or you get a nons smooth, and that's a big problem, a nons smooth, upward. Yeah. What, what's a nons smooth, upward rotation. There's so much skin and fat and muscles on there. So what's the nons smooth movement. And that's where all the discussions come in and there, you got a bad reliability, but if I say it's, it's really only the winging that it then you'll get good reliability, but then you're only addressing one, one thing. Of course. Yeah. So when,
Jared Powell:
When we're talking about, if it's depends on how we measure it, so that's why the scapular dyskinesis test does quite well, because it, it really just looks at profound winging. So that's why those, those measures tend to do quite well in terms of reliability. Yeah. That's so, so if, if anybody's listening and they still wanna keep measuring the scapula, I think the best way to do it would be the scapula DYS test in terms of visual observation. And I think you can read CLU 2009. I, I think it is his paper anyway. So I'll link to that and you guys, and go and read about it. So, so that's for reliability. We'll, we'll, we'll cut it off. Cause again, I think we keep all day. What about actual diagnostic accuracy? So does measuring or assessing actually lead us into thinking, okay, that means there must be a shoulder pathologist in, in that shoulder or on that side is, is, does assessing the scapula actually lead to an accurate diagnosis?
Filip Struyf:
That's the, the big question, of course. So well the, the scapulars can use on itself. First thing, maybe it's, it's not, that's not a diagnosis, it's not a pathology. It's, it's a, it's a, some it's at, at most, it's a variation on, on what what's happening in the normal situation. But then of course, if the big question is if you see scap dyskinesis and imagine you've you've did a, done a reliable assessment with the scap dyskinesis test, then you have two options or you have a patient with shoulder pain, or you have a, an athlete or, or whoever who doesn't have shoulder pain. And then the question is, okay, what do we do with when the case, the patient has shoulder pain and what do we do in case the patient doesn't have shoulder pain? And if you address the one with with, without shoulder pain first well you have the only literature on that is on athletes is on swimmers.
Filip Struyf:
It's on handball players is on tennis players rugby, et cetera. And they they're actually quite a lot on that. So I think about there're about six now, six strong longitudinal trials in these groups. And why do they use these groups? Of course, because that's the, the group in which, you know, that within a year or two year, there will be a lot of shoulder pain patients. So then you can say something for predictive, from predictive value. So and all these studies actually accept one, one or two maybe said, well, there is no predictive value of scap dyskinesis towards developing shoulder pain, and then only one in handball players, but they addressed only it was study of bang Larson. They said, okay in, in the hundred percent male handball players, we have some development of shoulder pain and some S ratios that are actually showing that there is a predictive value.
Filip Struyf:
And I remember Ben saying, well, I, I don't feel really good as being the only one who's showing some predictive failure. Let's do it again, or, or at some women in the group. And, and then the study of Larson was the, the, the, the whole group of men was added with some group of women in the hand players. And it's the study of Anderson Anderson. That was I think, 2018, or I'm not sure something like that. It's actually the same population of, of Larson, but just with with all the women in, and now actually the this, the predictive value was, was gone. There was no predictive value anymore, so, okay. You could say it's due to the men or, or due to the women. But actually they had a bigger group.
Filip Struyf:
There was a better sample. They also got a better power analysis afterwards. So then there was no predictive value. So actually in, in, in a, when you look at scap dyskinesis on itself, and that's the important thing, I think when on, on itself, we don't have big evidence that it will develop to to show the pain. Mm. But now there are more and more studies that use it, not on a factor on itself, but as an, a factor combined with other factors. For instance, there's one we we're going to, to publish soon. I hope in, in a month or month, month or two in swimmers. And also we have one from Maha Miller in in, I think it's also handball players young handball players, which they show that if an athlete has an increase in load, then they can have higher chance of developing shoulder pain.
Filip Struyf:
If they have scap dyskinesis well, they don't have a predictive, don't really have a predictive value for their developing shoulder pain. But if you add those two, so going too fast in your load increments together with the presence of scap dyskinesis, then the arts rose rose, no increased, increased a lot. Yeah. Increased a lot a lot more for developing shoulder pain. So that was actually when we started to think, okay, maybe this whole capital of dyskinesis on itself is, is, is maybe not the big issue, but in relation to other factors might start to play a role. And then the low thing came in and, and hypothesis of, of, well, capital dyskinesis being a first small predictive factor, but something like I dunno whether you use the, the, the saying the Canary in, in a mine, which drops that when there is some, some gases, well, now some say, okay, maybe this capital is easy. Some, some sort of first sign like watch out it's not developing to shoulder pain unless the load is increased too much. And maybe that's what a sort of sign for developing shoulder pain, but that's a hypothesis. We Don big evidence on
Jared Powell:
That, just on, on that study, 17, 18, I think they also found it was the external rotation strength that led to that as well, in addition to the increase in load. So if you had reduced external rotation kin and then increased your load by think more than that's when it became predictive, but just those two things in isolation had no predictive value. So that's when we start to look at the multifactorial nature of injury, right? So maybe the loading, which brings out all these potential areas of vulnerability that we have. Yeah,
Filip Struyf:
Yeah, exactly. And that's where we where we start to think of more and more about it's, it's important relation being the cuff the, the rotated cuff and we, we start more and more to think, well, maybe maybe the, the, the Scapa is, is we've been blaming the Scapa for decades. as being the, the reason why we have shoulder pay, but maybe actually I'm, I'm really starting to think now that the scap might be the big savior in the, in the problem. Maybe, maybe it's the VI, it's the scap that's trying to fix problems that are, are related to the cuff. And the cuff is, is not, not, not getting it all done. It's there is a recruitment problem. There, there is an EBIT tendinopathy, I don't know. And the scap tries to fix the problem tries to to make sure that the cover is in the best length, tension relationship to, to develop some, some control. And it's not the reason for the, for the shoulder pain. It's rather sort of, yeah. Maybe a consequence and well, I'm, I'm like in 2003, I was more like, it's, it's, it's the reason for shoulder pain and I'm almost the other way of the sling saying, and I almost think it's, it's almost every time the consequence of the, of the problem, and it's trying to fix, it's trying to fix it, but it, yeah, it cannot fix it on its own.
Jared Powell:
I totally agree. I think the scapular here is I think it's adaptive. I think it's adaptive to the organism and to the demand of the system as a whole, and it's doing its best to actually allow that human being, to do the task that that person wants to do. So I think if we think about it from a macro level, we sort of zoom out a little bit and stop being so microscopic in our analysis, a lot of these things start to become a little bit more obvious and that's, that's something that I'm really trying sort of demand of my students and, and people is that zoom out and think about what the person is actually trying to do instead of saying, well, that scapula is not moving in this textbook manner. Therefore that must be leading to pain and pathology. It's far more complicated than that.
Jared Powell:
So that's, so that's what we, so that's looking at the predictive value and there's another, there's a study by I think it's, Wasinger Oringer, if it, I think it's a German name 2015, which looked at the diagnostic act physiotherapist, actually determining whether somebody had shoulder pain or not based on their, their assessment of their scapula. And I think it, it came out at, at 50%, which is a coin flip, basically saying whether that person had had shoulder pain or not based on the assessment of their, so, so how accurate are we really, or how much information does assessing the scapula actually give us in a physical examination? Does it give us anything more than just looking at range emotion or looking at strength? Is it a waste of time? What do you think?
Filip Struyf:
Yeah. well it's it, if, if, if the patient has has a, a for instance, cuff related problem then I think it, it, it's not too much a visual observation, I I'm thinking about now, but more about symptom modification procedures, then these, these tools in, in are actually often reducing the pain in, in patients. But they're, I'm, I'm using this comparison to the, to, to get to your point. If you address symptom modification tools, like, like scap assistant tests or scap retraction tests, et cetera, and you get pain reduction this was often explained like, okay, so, so there's and it's related to your pain, so we need to address the scap. But if we look at the other point of view now, which we discussed earlier, like, well, maybe it's more a consequence and you look at the scap assistant test as being an, a way you, you, you assist the cuff you unload the cuff and the pain has less the patient has less pain.
Filip Struyf:
So actually it's more like a, like the agnostic tool for, for cuff problems rather than a than ACAP of problem. And that's where actually a few years ago or not so long ago, I think, yeah, two also 18 or 19, there was this paper on I think it was Turkish or I'm, I'm not sure showing that you, UK used scapular assistant as, as a tool for cuff tears to diagnose cuff tears. And that's where it, it all the, the bulb starts rolling in, in, in, in, in direction where, where the cuff appeared to be the, the big thing all, all the time and, and the scap was not so much, not so much the really to blame. And and, but, but you can, by, by addressing it with symptom modification test, you can maybe use it as some sort of diagnostic tool for the cuff problem, not for the scap problem.
Filip Struyf:
It's not a diagnostic tool. It's more like raising this, the, the amount of suspicion it's, it's never yes or no. And, and we, we, we don't have any strong evidence that it's like the new the new impingement tests using using the Scapa. So that's not the case. But it's about raising suspicion towards a cuff problem. And I think if, if I use this modification tests, I raise suspicion in towards the cuff now more than than a scap problem using scap dyskinesis test or visual observation as any diagnostic test for rotated cuff problems. I, I don't use it as a diagnostic test actually, but it can, if, if scap dyskinesis present there, the chances of positive symptom modification test rise. So that's, these things are a bit together. So if, if I see a positive scap dyskinesis test in visual observation, I know that my scap DYS, my modification tests will probably be positive, or the chances are higher, that they will be positive.
Filip Struyf:
So in that way they may, they might focus on, on cuff issue. So that's maybe a yeah, bit, bit the way I follow in my clinical reasoning to, to go towards the cuff coughing. I often, I often compare that to if you, well, I'm not sure whether it's, it's gonna gonna be, do we, do we have image also in the picture also in, in the, okay, so if you have a cup and and it's full of full of coffee or, or, or water, and I often compare the, the, the scap as being your, your hand below catching, catching the drops. And, and if you start walking, that's when you start moving the cuff, and it's the scap that also always tries to catch the, all the drops, but if you start moving fast, so if you're going low to cuff heart, yeah.
Filip Struyf:
Then there is a big chance that it will, then it will spill, and then your scap, your, your an will need to catch more and more of the drops. And eventually you will spill and you get, get maybe a shoulder problem. And then you also have the, the amount of water in it. Of course, if you, if you are an athlete and you is already full, and you're, you're training at your, at, at the, at your risk zone, well, and then start moving fast. Yeah. Then you have the biggest problem with your scap, then maybe scap dyskinesis psoriasis, your, your scap cannot fix it while on the other hand, if you have a guy who is in his thirties, not doing any sports his cup is half, and he's like standing still, he's not doing, he's doing having a desk job.
Filip Struyf:
And maybe this thing is really not necessary. It doesn't matter where this is where the scap is. It's you will not spill. So it's, maybe I'm not, I'm sure whether my metaphor coming in, but it's something I use sometimes to explain how the, how the scap works now, maybe you to, to, to get, to get the thing there. And if the, if the load is getting too high or, or there other factors that, that multifactor that are there, then the will be challenged, but it's not the, that's the reason why it's spilling.
Jared Powell:
Yeah, no, exactly. Right. So that's,
Jared Powell:
That's a really, that's a really important point. So I, I do agree when, when, when there's high load or high velocity loads going through the shoulder system, for example, in professional overheads, there may, there is some predictive value in it, but I'm still not certain that you need to normalize the, the mechanics of the movement. And in fact, I dunno if there's any evidence that you can, you still go and strengthen all of the components within the scap thoracic joint in the Glen joint to, to increase the strength of the, of the whole system or the absolute ability of the system. But I still don't think you need to normalize the mechanics of it. Do you agree that?
Filip Struyf:
Yeah, well when I say if you have an athlete it, it can be a professional, but doesn't need to be a professional, but it's an athlete who has some load increments. And , if there is the presence of scap dyskinesis, I think the, the main focus would not be okay. Oh, we should, we should check this scap dyskinesis we should do something about the scap dyskinesis cause it, otherwise they will develop shoulder pain. No, the first reaction should be, we should check the load management, eh, yeah, because that's the, that's the reason why things go wrong. Eh, it's the scap is, is is, is something we don't have high predictive value and it can be in a way to, to stay PainFREE even, eh, that's, that's also a big, good possibility that athletes develop scap DYS, just to stay PainFREE during the high load increments, but it's yeah. It's, it's like fixing, fixing a problem and there is a problem is in the loop management then. So yeah.
Jared Powell:
Yeah. I tell you what, Tim, Tim GATT will be smiling from ear to ear listening to this in regards to all this load management talk in, in the upper limb, which is unusual. So, so there you go, there is some load management rationale in the upper limb as well. Not just lower limb.
Filip Struyf:
I'm certain of that. Yeah.
Jared Powell:
Yeah. That's that's so that, that maybe rounds off the diagnostic accuracy. Well, I'll just finish with, with one statement, which was from a systematic review, I believe by right in 2013, which suggests that asy or motion alterations do not provide any additional clinical examination benefit with regard to diagnosing shoulder pain or pathology. So that's that I think that was published in the BJSM in two 13. So quite a, quite a bold statement there saying that really visual observation of scapula provides not much more information than a typical physical exam shoulder. So, so just, just quickly, I'm just, I'm conscious of your time. I don't wanna keep you for too long. Are you gonna work today? What's going on over in Belgium.
Filip Struyf:
Yeah. It's it's, it's logged down time. So we're all working from home now and we have our meetings through Skype and all these things today. Yeah. That's that's our new way of working, but I, I can imagine it's bit the same
Jared Powell:
For you. Yeah. It's, it's exactly the same here. I've, I've, I've taken two months off to try and ride it out, but we'll see, we'll see how we go. Let's, let's finish up with, with, let's talk about, so a lot of the conversation, these days centers around imaging and the, the amount of, or the prevalent of structural abnormalities that we find on imaging in asymptomatic people, as well as symptomatic. And the same thing probably goes with the scapular. Do we see a high proportion of people who are asymptomatic, so have no pain have this scapular dyskinesis. And, and does that have any bearing on or influence on how we approach people who do, and let's just talk about nonathletic day to day people here.
Filip Struyf:
Yeah, well it's true though. If we just look at if we take a hundred people from, from the street non-athletes from the street there have been some, some systematic previews on that. I think it was from burn burn, I think in 2016, who said, well, about 33% of just regular people from the street will have capital dyskinesis. So it's one one third of of the, the, the people on the street, not, not athletes will have capital dyskinesis. And if you look at athletes, it's, it's almost double, it's like 60, 60, around 60%. I can remember of people with of athletes with scap. Dyskinesis so healthy, non, non impaired patients non impaired people. Yeah. Mm.
Jared Powell:
Yeah. And I've, I've got some, I've got some data here. There's one from you in 2009, which suggest that up to 72% of asymptom asymptomatic people can have a scap dyskinesis and then the plumber 2070 found that 60% of people. And this is just with visual observation of a control group had ACAP disc. So here we're getting into trouble again with, well, how relevant is this finding to this person's pain right here right now, when I could take someone off the street with no pain and they'll have the exact finding. So here in lies of the controversy or the gray area, how, how do we get around this and how does this influence us in our day to day practice?
Filip Struyf:
Yeah, well, it brings us a little back to the, to the, our previous discussion in, in, in that case that we, if we look at athletes, we don't have any predictive value. So imagine you have people who don't challenge their shoulders on a day to day basis, while then you, you can see scap dyskinesis or, or you don't see it, it, it actually doesn't matter a lot. So if, if I have a PA and also with patients with pain, if I, if you have patients in, in clinical practice and they have shoulder pain and they have scap dyskinesis, that's something I will never tell, tell, tell to the patient or rarely tell to the patient. Okay, whoa, I'm, I'm, I'm seeing some winging here and this and that. Because we, we don't have strong evidence on that. I use it in my, a clinical reasoning more to to go through towards the cuff than than focusing on Che.
Filip Struyf:
So it's, it's true where you can see it a lot. It can be a normal vari variation, maybe some compared with the gate. You, you, all people walk differently. So maybe it's it's the same thing with with the, I don't know, it's, it's well possible. We don't have evidence that we need to do anything about it in a, in a healthy population anyway. So whether it's there or not, maybe we shouldn't bother a lot about that. About as the figures at all. Only when the patient develops pain or they challenge their shoulders a lot. That's the groups that we should maybe think about. But in, in the, in the healthy group, we don't have a big evidence. And the big problem here is also that we will not have evidence in a short time because if you wanna know whether the, the non-A population will develop shoulder pain based on their scap dyskinesis, you would need to follow a group of non-athletes and wait until they develop shoulder pain, but that's, that's, that's not possible because then, then you will need to have thousands of people and you will need to follow them for 10 years or longer and wait to see hopefully to see something.
Filip Struyf:
And nobody's gonna fund that, that type of study. So
Jared Powell:
We need billionaire to develop shoulder pain and then start funding of these studies. Right? Exactly.
Filip Struyf:
Yeah, exactly. Yeah. Like this
Jared Powell:
Let's get somebody under that. Yeah, exactly. Well, bill gates is into philanthropy these days, so maybe he can have a look at this problem. I'm sure. I'm sure it, yeah, exactly. Right. With all this I'm sure. Scap at the, of the right. We might. We might, we might wrap it up there. I think, I think we could probably do another conversation at some point over the next month or so, and look at actual treatment and see what, see if there's any evidence behind specific training versus general training, et cetera, et cetera. So thanks so much for, for joining us. You've, you've been a, you've been a wealth of knowledge. Where can, where can people find out more about you fully? What are you, what are your social media handles? Where can people find, find you?
Filip Struyf:
Well, I'm, I'm I'm not on Facebook, but I am on on Instagram and and Twitter. That's that's the easy things I think. So yeah, link easier. Yeah, sure. And, and I have the intention on putting, especially on Instagram, not so much on Twitter, but I've intentional on putting more like videos or things on that to steer rehabilitation of KA issues. That's that's the reason I started with Instagram not so
Jared Powell:
Long ago. Yeah. Cool. All right. Well, we'll we'll hope, hopefully have a chat soon and we can get to the bottom of actually how we intervene and help people with a ULAR dyskinesis potentially. Yeah. Yeah. Thanks. Very.
