Core Memories: The Physio Matters Podcast Session 3 - The Rugby Shoulder with Ian Horsley, 2014
MSKMag OutLoudShow Notes
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In 2014, Dr Ian Horsley joined Jack Chew on the Physio Matters Podcast to discuss the ‘rugby shoulder’, challenging prevailing orthopaedic thinking and advocating for a more functional, systems-based approach to shoulder rehabilitation. His perspectives, shaped by elite sport and emerging research, questioned diagnostic certainty, emphasised movement quality, and highlighted the role of proprioception, load, and the wider kinetic chain. Over a decade later, the shoulder literature has evolved significantly. Concepts such as regional interdependence, load management, and uncertainty in structural diagnosis are now more prominent within contemporary musculoskeletal and sports rehabilitation literature, although debate remains around their interpretation and application. In this month’s Core Memories feature, we revisit Ian’s key themes and explore how they align with current evidence and contemporary rehabilitation frameworks in 2026 [10,11,12]. Diagnosis, Uncertainty, and the Limits of Orthopaedic Testing 2014 Ian was openly critical of orthopaedic shoulder testing, noting the sheer number of available tests (over 100) and their limited diagnostic utility. He argued that: * Test accuracy is heavily clinician-dependent * Diagnostic accuracy is generally low to moderate and highly variable across tests and pathologies * Most athletes present with multiple coexisting pathologies, reducing test validity * Clinicians should move away from rigid diagnostic labels toward clinical reasoning and response to treatment 2026 This position is broadly supported - and expanded - by contemporary research. Systematic reviews continue to demonstrate limited standalone diagnostic accuracy for most orthopaedic shoulder tests, particularly for labral pathology and instability [1,2]. Clusters of tests may improve diagnostic confidence, but overall certainty remains limited. Importantly, inter-rater reliability remains inconsistent, reinforcing Ian’s point that test performance is clinician-dependent [1]. More broadly, some contemporary shoulder rehabilitation frameworks emphasise clinical reasoning, symptom behaviour, irritability, and functional limitation alongside structural considerations, particularly in non-traumatic shoulder pain [10,11,12]. Contemporary clinical frameworks increasingly prioritise: * Symptom behaviour * Load tolerance * Movement quality * Functional limitation rather than strict structural identification. In elite sport, however, tension remains. As Ian described, coaches and stakeholders still seek clear timelines and labels, especially in high-performance environments. While shared decision-making models have improved communication, the demand for certainty has not disappeared. Current nuance
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It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com