Articles Of The Week October 13, 2019


We know that certain things like lifestyle, genes, diet, and habits contribute to the chances of having dementia later in life. However, there is growing evidence that chronic use of certain over the counter medications and prescription drugs are linked to the development and exacerbation of dementia and it’s symptoms.

“Study: Common Types of Medications Linked to Increased Dementia Risk” – The Hearty Soul

As soon as I saw this, I knew I had to share it! Ontario is working a trial where drones deliver an AED to cardiac arrest patients, and they’re arriving on average seven minutes before EMS crews. Imagine the difference this could make if one of your patients was suffering a cardiac condition in your clinic.

“Drones Arrive 7 Minutes Before EMS Crews In Policy-Changing Trial” – EMS 1

Sometimes (well…most of the time), we have to educate the public that there is more to what we do than just simply “massaging” people. In order to change this we not only need to educate the public, but also other health care professionals, providing advocacy, and educating other therapists.

“Physical Therapy, More Than Just Stretches” – Jennifer Stone

I don’t know about you, but for me massage therapy college was stressful, it felt like I was drinking from a firehose with the amount of information being thrown at me. I wish I had this advice with tips on studying while in massage therapy college.

“Tips For Studying In Massage Therapy School” – National Holistic Institute

I’m a TERRIBLE procastinator, so if you’re anything like me, you’ll find value in this article. Even if you’re not, I’m sure we’d all like to find ways to be more productive, so here’s some help with that.

“A Simple Trick For Getting More Done” – Carmen Ohling


Manual Technique Courses Don’t Matter As Much As You Think


Let’s say you need to hire a carpenter. As you shop around online and browse the different potential hires, you see one who advertises his set of 20 different drills and power saws he likes to use to get the job done.

Is this the feature that gives you confidence in hiring him to build your deck, though?

Likely not.

Then why, as therapists, do we so often assume we will become better practitioners simply by taking countless continuing education courses on manual techniques and adding additional treatment tools to our practice?

I see many fellow professionals jumping on the con-ed train straight out of the gates, often as soon as they are immediately out of school. IASTM, ART, IMS; everyone wants to add to their toolkit. With so many options on how to treat a client’s pain, we would undoubtedly be able to reap the rewards of client and financial success, right?

Here is the deep, dark, reality of it, however. 

At the end of the day, these courses just teach you multiple different ways on how to touch people. My explanation when clients ask me about the benefits of different types of treatment techniques is this:

“They are simply different methods of achieving the exact same goal”.

Essentially, having three different techniques under your belt is like having a hammer, a mallet, and a nail gun to join the same planks together to build a fence. It makes little to no difference in the finished product.

When I entered the work field, my first initiative was to simply get my hands-on clients and work on refining my foundations. Regardless of how many different methods I had to “release” a client’s quadriceps muscle, none of them will help me one bit if I don’t know when and why to do so and have a long-term plan to follow up with it. Whether I use the ART technique that I pay annually to display on my cards or the traditional massage strokes that I learned in my undergrad, I am going to achieve the same outcome.

What will be the difference-maker in your practice, then? 

It will be if you can learn to use those techniques mindfully. It’s knowing where in the tissue to address instead of simply chasing pain. It’s creating an exercise plan coupled with proper education to put the onus of control into the client’s hands,

The only con-ed course I have taken to date, in fact, has been a joint-specific one on the TMJ. I didn’t feel the need to learn new techniques. I needed to understand anatomy and physiology better. Courses that help us refine our knowledge of how the body is structured and how it moves will be valuable. Even more valuable will be courses on truly understanding the mechanisms of pain, how to speak to our clients, how to properly educate them, and methods of moving them through stages of change as they recover.

“Soft skills” such as client communication and an ability to build a positive relationship with them are a much more valuable asset to a practitioner than manual techniques. We know from current research that a client’s predicted outcome improves based on how much they like their therapist, how much control they feel over their situation, and their belief in a treatment’s ability to get them better. The tool that you use to get these results isn’t made of metal, it’s made of trust.

In a professional climate where both clinicians and clients can find ourselves hung up on the latest, trending techniques to address pain, we often see a drop in quality of care because the clinician has forgotten to use those foundations. These types of practices, unfortunately, run the risk of poor client outcomes and treatment-reliance. While it’s ok to add a tool to our kit here and there, where appropriate, we owe it to our clients to constantly return to our basics (whether or not you want to incorporate con-ed techniques) and educate them on the real things that will help them find relief.

I don’t care how many different types of power saws the carpenter has. I care about if he knows how to properly measure and place the cut.


Articles Of The Week October 6, 2019

We know how important movement is for people dealing with chronic pain. There is even research showing if someone with chronic pain gets involved in an activity they enjoy, it can cause pain reduction. Some are now using pole dancing as an activity to do just that, and having some great results.

“How Pole Dancing Is Helping These Women In Their Chronic Pain” – Stephanie Schroeder

As someone who works in sport, I’ve always struggled with the term “sport massage”. Other than doing a stimulatory warm up session before competition, what we do isn’t all that different than what we do in a clinical setting. So, when we look at this article, there are many similarities between what we do in sport, and in our clinic, our intent may just be a bit different.

“Sports Massage For Non Athletes” – Nick Ng

A couple weeks ago we shared an article showing new research on the use of NSAIDs and their relation to heart attacks and strokes. Well, now there’s research showing how damaging NSAIDs can be to endurance athletes.

“Ironman Should Rethink It’s Partnership” – Jason Koop

Exercise is great for our hearts, and can actually remodel it for better strength and efficiency. However, you can have diffferent results for different sports. While there can be variations, the most important message is that exercise is good for our hearts.

“The Heart Of A Swimmer vs. The Heart Of A Runner” – Gretchen Reynolds

While this study was done on mice, it’s interesting to see that scientists have discovered lungs actually assist in making blood. It will be interesting to see if these studies could be done on humans one day to see if there is a similar result.

“An Unexpected New Lung Function Has Been Found – They Make Blood” – Science Alert

Learn How Education And Movement Can Help Frozen Shoulder

If I’ve heard it once, I’ve heard it 1000 times in my career (okay this is an exaggeration, it’s probably only a few dozen times), “I think my frozen shoulder is acting up!”

Meanwhile, the patient is moving their arm all over and wincing with a bit of pain.

The very name is enough to strike long term fear into a patient.

“Frozen Shoulder” it just sounds like something utterly debilitating, no wonder patients catastrophize over the diagnosis.

Part of the problem with this diagnosis is that all too often as soon as someone has an issue with their shoulder, it gets labeled, labeled with a damning diagnosis, and usually an improper one.

So, how do we convince someone their shoulder is probably okay and just needs to be de-sensitized, or actually realize frozen shoulder is the issue? Well, there are several ways, and while we can’t “diagnose” there are certainly some signs and symptoms we can look at which will help us recognize the difference and refer out when necessary.

Getting To Know Frozen Shoulder

Most of the time a detailed intake form, case history, and clinical examination should be enough to manage those who are coming in with shoulder pain, however, there are things we need to look for during this to determine the severity of a shoulder issue.

Frozen shoulder’s clinical name is “adhesive capsulitis” and is characterized by patients experiencing pain along with limited range of motion and disability of the glenohumeral joint which lasts anywhere from 1-24 months. There are two types of adhesive capsulitis:

  1. Idiopathic (primary): occurs spontaneously from a chronic inflammatory response (possibly an abnormal immune system response).
  2. Secondary adhesive capsulitis: happens after a shoulder injury or surgery and can be associated with conditions like diabetes, rotator cuff injury, cerebrovascular accident, or cardiovascular disease.

It seems those with diabetes (10-36% of diabetic patients) are quite prone to dealing with frozen shoulder as both types I and type II diabetics are susceptible and have worse outcomes compared to non-diabetics. They also experience more severe symptoms and are more resistant to treatment. Those who have had a stroke are also quite susceptible as it happens to 25% of stroke patients within 6 months, which is likely due to some muscle spasticity on the affected side. Some studies have also shown an association with Dupuytren’s disease, hypothyroidism, and Parkinson’s disease (however these last few are much rarer).

Mostly this affects people in their 50’s with the peak age being 56, but rarely happening to people under 40, and more commonly affects women than men (sorry ladies). However, some research suggests a high prevalence of shoulder issues among the elderly, who aren’t seeking medical attention for the issue.

One study tried to develop a new clinical sign to help diagnose a frozen shoulder with something called the “Coracoid Pain Test”. This is essentially putting digital pressure on the coracoid process, which creates more intense pain compared to the unaffected shoulder. In the study, 96.4% of patients with this condition complained of pain when the test was done, which they argue shows a high specificity rating, but I don’t know if this is widely accepted yet.

If we have a patient come in who is experiencing shoulder pain, trying to get a differential diagnosis is important (even though we can’t diagnose), but if we look at the above instances, these are all things which could be on our intake form that could help us narrow down and understand that maybe our patient is dealing with frozen shoulder as opposed to just some simple shoulder pain. One other thing that stands out as being consistent with a frozen shoulder is the complete loss of external rotation.

Once we understand this, it is also important to understand the “phases” this condition goes through.

There are 3 phases with varying degrees of length:

  1. The painful phase:
    • Pain with AROM & PROM.
    • Reduced flexion, abduction, and rotation.
    • Pain worse at night.
    • Duration lasting 10-36 weeks.
  2. Adhesive “frozen” phase:
    • Pain starts to subside (still bad at full range) but still stiff.
    • Almost no external rotation.
    • Rigid “end feel”.
    • Duration 9-15 months.
  3. Resolution “thawing” phase:
    • Spontaneous improvement in ROM.
    • Minimal pain.
    • Happens during 15-24 months since issues started.

While it is quite common for the symptoms to resolve themselves, it does take a considerable amount of time for that to happen and of course, this depends on whether things like diabetes are influencing the healing process. There are studies showing that 39% of people had a full recovery, the remaining 61% had some issues with pain and or range of motion.

However, there are things we can do to help move this along and education with movement looks like the primary treatment.

Of course, the treatment we are giving must be tailored not only to the patient but also the phase of the condition.

During the painful phase, the main thing we are looking for is pain relief and movement within pain-free tolerances and using graded exposure to get to the edges of painful movement. We did an article a couple of weeks ago where you can see how to do this by clicking HERE. While much of the literature points to the use of NSAIDs, there isn’t a lot to confirm its effectiveness for frozen shoulder.

One study on Idiopathic Adhesive Capsulitis showed good success with an exercise program that involved a four-direction shoulder stretching program that included passive forward flexion, passive external rotation, passive horizontal adduction, and passive internal rotation. With this program they had 64% of patients report a satisfactory outcome, 7% not satisfied, and 5% who went for surgery.

Treatments during the adhesive phase should be more aggressive toward longer stretches and a low load to push toward an increase in range of motion.

When these exercise interventions don’t work, the patient is often referred for surgery or for manipulation under anesthesia and have relatively good outcomes. There is also well-documented use of injected steroids, which when combined with manual therapy have some good outcomes as well. Although, in reading over Paul Ingraham’s post on frozen shoulder, there is also a risk of causing shoulder issues with various types of injections, so this should be considered as well.

Much of this is going to be left up to your clinical decision making, but having a good understanding of the timelines and what is happening, along with feedback from your patient should give you a good idea of how to manage this, should someone come in for treatment.


As mentioned in this post, education is a major part of helping someone with this condition. 

Unfortunately, this probably isn’t done as much as it should be. While most patients are probably looking for a “quick fix”, the reality is, this is just going to take some time and effort on their part and yours. 

There is a normal course the condition takes and at the 12-24 month period it falls into a resolution phase and there is a greater improvement in range of motion. While any patient would look for complete resolution one study showed at the 5-10 year follow up of 41 patients: 

  • 39% had full recovery.
  • 54% had some limitation without functional disability.
  • 7% had functional limitations. 

And still another study showed 50% of their patients had some degree of pain and stiffness seven years after the condition started. 

However, the above studies did show that the longer the person was in the stiffness stage, the longer the recovery stage, there was a direct correlation. So, perhaps proper education and movement in the painful phase could, in turn, shorten the stiffness and recovery stage?

Interestingly one of the previously mentioned studies showed that prior “physical therapy treatment and a workman’s compensation claim or pending litigation were the only variables that were associated with the eventual need for manipulation or capsular release”.

This is a fact I find really interesting. While some argue that the biopsychosocial approach to pain isn’t in our scope, how can we look at that study and say these other factors are not a contributing factor to a persons pain and disability? In my old job I was told by a compensation representative that their studies had shown if someone was off work for 18 months on an injury claim, chances are they were never going back to that job. And here we have studies showing us that a compensation claim is one of the contributing factors to needing more aggressive treatment for this condition. While we cannot counsel a patient on this, it is something we should be cognizant of when treating them (if a compensation claim is part of their issue).

While we would never want to tell a patient there is only a 50% chance that after seven years they would be pain-free, we do want to try to educate, encourage, and build resilience with them through each phase of this condition, giving them hope for the most positive outcome possible. Reassuring them that there is a bit of a longer recovery process compared to other shoulder issues, but that full recovery is possible will probably bring a better chance of shortening the stiffness, and recovery stages.

Articles Of The Week September 29, 2019

Some great info about Achilles tendon loading progressions, complete with content and images with instructions.

“Achilles Tendon Loading Progression” – The Physio Network

This one is important for those of us who work in sport and also act as First Responders for our athletes. There have been changes made to how we apply stimulation, as well as how the patient responds, and how we interpret the findings.

“The Glascow Coma Scale Turns 40 And Gets A Facelift” – Micheal Fraley

We know that mindfulness and meditation are important, but it turns out this can actually make a massive difference in brain function. Studies show this can increase gray matter in several areas of the brain that contribute to decision making, memory, as well as the auditory and sensory cortex.

“Neuroscience Shows That 50-Year-Olds Can Have The Brains Of 25-Year-Olds If They Sit Quietly And Do Nothing For 15 Minutes A Day”Melanie Curtin

Understanding pain is important for us to help our patients, so is understanding pain behaviours. If we change how we react to pain we could also change pain behavours. 

“My Story: Eeeeek… Pain Behaviours!” –  Tom Bowen

Genes, lifestyle, and relationships can all influence your health, but it turns out, so can your thoughts. What we tell ourselves about who we are and why things happen, influence our stress levels, health, and happiness. 

“Are Your Thoughts Aging You?” – B Grace Bullock PhD

Many Orthopedic Surgeries Don’t Work Better Than Placebo

Unlike drugs, orthopedic surgeries can be sold to the public before they undergo rigorous testing to ensure they are safe and effective. Thus, millions of surgeries for knee, shoulder, and back pain have been done without studies to confirm they actually work. Recently, research has found that many popular surgeries (but not all) work no better than a placebo. And yet these surgeries are still done at the rate of hundreds of thousands per year. This is something you should know if you are considering surgery, or in the business of treating chronic pain.

Knee Surgery

Osteoarthritis of the knee is common but does not necessarily result in pain — many people have arthritis and no pain at all. But surgery to correct arthritis is popular, numbering as many as a half-million per year in the U.S. alone. (1)

About 15 years ago, two of the most common procedures were debridement (removal of damaged cartilage or bone) or lavage (irrigation with saline solution). The goal of either surgery was removal of rough fragments of cartilage that may be irritating the joint. The surgery’s benefits were known to be not so impressive, so people started to wonder whether they were caused by placebo, or could be achieved with less invasive treatment.

To answer these questions, a study was done using a “sham” surgery: one group of patients received real knee surgery, and the other a fake, which involved just an incision on the skin. At several times over the course of a couple of years, the two groups reported their levels of knee pain and function. The result? The sham group did just as well as the surgical group at all points in time. (2) This strongly suggests the surgery worked by changing psychology, not structure.

This study was slow to have an effect on the behavior of surgeons. Years later, hundreds of thousands of these surgeries were still being performed at the cost of $3 billion a year. (3) Subsequent research confirmed they provide no more benefit than common sense interventions like exercise, weight loss, and the occasional use of over-the-counter pain medicine. (4) Debridement and lavage eventually became less common but were soon replaced by arthroscopic partial meniscectomy. But the new surgery proved to be equally weak. Like its predecessors, it worked no better than a sham.

In 2015, researchers summarized the results of nine studies on arthroscopic procedures for the knee and concluded that they showed little if any benefit, and the possibility for serious harm. (5) Further studies in 2017 came to similar conclusions. (5a)

A recent editorial in the British Journal of Medicine offered the scathing opinion that arthroscopic surgery for knee pain is: “a highly questionable practice without supporting evidence of even moderate quality.” (6) A clinical guideline issued in 2017 made a “strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease” and noted that “further research is unlikely to alter this recommendation.” (7) In spite of this advice, arthroscopic knee surgery continues to be the most common orthopedic procedure in the U.S., with close to 700,000 performed each year. (6)

Why the disconnect between research and practice? The simple answer is that many doctors trust their personal experience over-controlled research. They will say they have seen surgery provide benefit after conservative therapies failed. Surely this sometimes occurs, but we should be skeptical that the cause is structural change in the knee. Instead, successful treatment for chronic knee pain, through surgery or otherwise, may be caused by complex changes in psychological or neurological processes.

Back Surgery

As with knees, there is a wealth of evidence that backs can have major structural damage and still not hurt. Further, backs can hurt a lot even when they have no apparent damage. In fact, this is quite common — most chronic low back pain is classified as “non-specific”, meaning it cannot be explained in reference to a mechanical or structural cause. Although there is only a poor correlation between back pain and structural back damage, there are many surgeries to correct any damage that happens to appear on an MRI. Several perform no better than conservative care.

For example, vertebroplasty attempts to treat back pain by injecting bone cement into fractured vertebrae. A study published in 2003 showed it works as well as no treatment at all after six weeks. (8) In 2009, two studies showed it worked no better than a sham procedure for fractures related to osteoporosis. (9)

Low back fusion is a common procedure and is intended to enhance low back stability. In 2013, the Spine Journal published a study comparing spinal fusion to non-operative treatments like cognitive behavioral therapy and exercise. It found no difference in long term outcomes and concluded that “the use of lumbar fusion in chronic low back pain patients should not be favored” over conservative care and exercise. (10)

In 2014, an analysis of multiple studies concluded that:

There is strong evidence that lumbar fusion is not more effective than conservative treatment in reducing perceived disability because of chronic low back pain among patients with degenerative spinal diseases. It is unlikely that further research on the subject would considerably affect this conclusion.(11)

As with knee surgery, the research showing the relative ineffectiveness of surgery has been slow to affect practice. Nikolai Bogduk, an internationally renowned anatomist and back pain expert, explains that:

Surgeons and others believe that surgery is effective for back pain. They base this belief either on their own experience or on observational studies. This belief is, by and large, not vindicated by the outcomes in well-reported clinical trials. Those trials indicate that only a small proportion of patients do well from surgery.(12)

Shoulder Surgery

The research on shoulder surgery is less clear, but recent studies reveal a similar pattern. MRIs consistently show that a great many people without pain have torn rotator cuffs. Despite this fact, the most common diagnoses to explain shoulder pain is “impingement” on the rotator cuff by the acromion process.

Surgeries to correct these conditions include rotator cuff repair, or acromioplasty, where a portion of the acromion is removed. In the United States, there are almost half a million of these surgeries performed each year, most of them on shoulders where the damage is degenerative as opposed to traumatic. (13)

Although we cannot rule out the possibility that surgery will be substantially more effective than exercise for certain patients (14), several studies have found that popular shoulder surgeries, such as acromioplasty, are no better than exercise. (15) Further, it has been shown that surgeries for labral repair and biceps tendinosis cannot outperform sham surgery. (16)

There is also evidence suggesting that when surgery is effective at relieving pain, it is not because of structural repair. (17) MRIs of repaired rotator cuffs taken within a year after surgery often show that the cuff has fallen apart again, even though the patient has recovered. According to Dr. Lawrence Gullotta, “When your rotator cuff is torn, you attribute all your pain and dysfunction to your torn rotator cuff, then you have it fixed and you feel better, but sometimes when you take an ultrasound or an MRI, the rotator cuff looks exactly like it did before you had the surgery.” (18)

A 2017 study compared two kinds of shoulder arthroscopic surgery (with and without decompression), and found that neither provided a clinically significant benefit over no treatment at all. (19) An editorial said these findings “send a strong message that the burden of proof now rests on those who wish to defend the standpoint that shoulder arthroscopy is more effective than non-surgical interventions.” (20)

A blog post in the British Journal of Sports Medicine summed up the situation as follows: “in the light of the current evidence base, the benefits of surgical intervention for the treatment of [shoulder pain] seem glorified and overrated.” (21)


Let me make something clear: None of the above means we should not trust orthopedic surgeons, or that surgery should never be used to treat chronic pain. Many surgeries have been proven to work and are definitely a good idea under certain circumstances. I personally know many people who have received excellent and ethical advice from their surgeons, and dramatic benefits from surgery. By contrast, I also know people who got a surgery that had been proven to be ineffective, were never advised of the relevant research, and ultimately did not get a good result.

I think the lesson here is that the medical establishment has some biases in the way it treats chronic pain. It favors treatments based on simple structural explanations for pain and tends to ignore complex neurophysiological processes that may be more important. We need to be aware of these biases and learn as much as possible about the complexity of pain so that treatment can be improved. And chronic pain clients need to ask their surgeons some good questions before going under the knife.


The above article is an adapted excerpt from my new book, Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance


1. Heidari, Behzad. 2011. “Knee Osteoarthritis Prevalence, Risk Factors, Pathogenesis and Features: Part I.” Caspian Journal of Internal Medicine 2 (2): 205–12.2.

2. Lubowitz, James H. 2002. “A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” Arthroscopy 18 (8): 950–51.

3. Why ‘Useless’ Surgery Is Still Popular.

4. Kirkely, Birmingham, et al. 2008. “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” New England Journal. Vol. 359, 1097.

5. Thorlund, J. B., C. B. Juhl, E. M. Roos, and L. S. Lohmander. 2015. “Arthroscopic Surgery for Degenerative Knee: Systematic Review and Meta-Analysis of Benefits and Harms.” Bmj 350 (jun16 3): h2747–h2747. doi:10.1136/bmj.h2747.

5a. “Brignardello-Petersen et al. (2017). Knee Arthroscopy Versus Conservative Management in Patients with Degenerative Knee Disease: A Systematic Review. BMJ Open 7(5), e016114; Sihvonen et al. (2017). Arthroscopic Partial Meniscectomy Versus Placebo Surgery for a Degenerative Meniscus Tear: A 2-Year Follow-Up of the Randomised Controlled Trial. Annals of the Rheumatic Diseases. 77(2), 188–195.”

6. Järvinen, Teppo L N, and Gordon H Guyatt. 2016. “Arthroscopic Surgery for Knee Pain.” BMJ (Clinical Research Ed.) 354 (July). British Medical Journal Publishing Group: i3934. doi:10.1136/BMJ.I3934.

7. Siemieniuk, Reed A C, Ian A Harris, Thomas Agoritsas, Rudolf W Poolman, Romina Brignardello-Petersen, Stijn Van de Velde, Rachelle Buchbinder, et al. 2017. “Arthroscopic Surgery for Degenerative Knee Arthritis and Meniscal Tears: A Clinical Practice Guideline.” Bmj, j1982. doi:10.1136/bmj.j1982.

8. Diamond, Terrence H, Bernard Champion, and William A Clark. 2003. “Management of Acute Osteoporotic Vertebral Fractures: A Nonrandomized Trial Comparing Percutaneous Vertebroplasty with Conservative Therapy.” The American Journal of Medicine 114 (4): 257–65. doi:10.1016/S0002–9343(02)01524–3.

9. Kallmes, David F., Bryan A. Comstock, Patrick J. Heagerty, Judith A. Turner, David J. Wilson, Terry H. Diamond, Richard Edwards, et al. 2009. “A Randomized Trial of Vertebroplasty for Osteoporotic Spinal Fractures.” New England Journal of Medicine 361 (6): 569–79. doi:10.1056/NEJMoa0900563.

10. Mannion, Anne F., Jens Ivar Brox, and Jeremy C.T. Fairbank. 2013. “Comparison of Spinal Fusion and Nonoperative Treatment in Patients with Chronic Low Back Pain: Long-Term Follow-up of Three Randomized Controlled Trials.” The Spine Journal 13 (11): 1438–48. doi:10.1016/j.spinee.2013.06.101.

11. Saltychev, Mikhail, Merja Eskola, and Katri Laimi. 2014. “Lumbar Fusion Compared with Conservative Treatment in Patients with Chronic Low Back Pain.” International Journal of Rehabilitation Research 37 (1): 2–8. doi:10.1097/MRR.0b013e328363ba4b.

12. Bogduk, Nikolai, and Gunnar Andersson. 2009. “Is Spinal Surgery Effective for Back Pain?” F1000 Medicine Reports 1 (July): 27–29. doi:10.3410/M1–60.

13. Jain, Nitin B, Laurence D Higgins, Elena Losina, Jamie Collins, Philip E Blazar, and Jeffrey N Katz. 2014. “Epidemiology of Musculoskeletal Upper Extremity Ambulatory Surgery in the United States.” BMC Musculoskeletal Disorders 15 (1): 4. doi:10.1186/1471–2474–15–4.

14. Steuri, Ruedi, Martin Sattelmayer, Simone Elsig, Chloé Kolly, Amir Tal, Jan Taeymans, and Roger Hilfiker. 2017. “Effectiveness of Conservative Interventions Including Exercise, Manual Therapy and Medical Management in Adults with Shoulder Impingement: A Systematic Review and Meta-Analysis of RCTs.” British Journal of Sports Medicine, bjsports-2016–096515. doi:10.1136/bjsports-2016–096515.

15. Ketola, S., J. Lehtinen, T. Rousi, M. Nissinen, H. Huhtala, Y. T. Konttinen, and I. Arnala. 2013. “No Evidence of Long-Term Benefits of Arthroscopicacromioplasty in the Treatment of Shoulder Impingement Syndrome: Five-Year Results of a Randomised Controlled Trial.” Bone and Joint Research 2 (7): 132–39. doi:10.1302/2046–3758.27.2000163.

16. Brox, Jens Ivar, Cecilie Piene Schrøder, Øystein Skare, Petter Mowinckel, and Olav Reikerås. 2017. “Author Response — sham Surgery versus Labral Repair or Biceps Tenodesis for Type II SLAP Lesions of the Shoulder: A Three-Armed Randomised Clinical Trial.” British Journal of Sports Medicine, bjsports-2017–098251. doi:10.1136/bjsports-2017–098251.

17. McElvany, Matthew D., Erik McGoldrick, Albert O. Gee, Moni Blazej Neradilek, and Frederick A. Matsen. 2015. “Rotator Cuff Repair.” The American Journal of Sports Medicine 43 (2). SAGE PublicationsSage CA: Los Angeles, CA: 491–500. doi:10.1177/0363546514529644.

18. Large Study of Arthroscopic Rotator Cuff Repair Reveals Some Surprises.

19. Beard et al. (2017). Arthroscopic Subacromial Decompression for Subacromial Shoulder Pain (Csaw): A Multicentre, Pragmatic, Parallel Group, Placebo-Controlled, Three-Group, Randomised Surgical Trial. The Lancet. 391, 329–38.

20. Schreurs et al. (2017). No Benefit of Arthroscopy in Subacromial Shoulder Pain. The Lancet. 6736 (17).21. “Unnecessary Shoulder Surgery on the Rise — BJSM Blog — Social Media’s Leading SEM Voice.”