Serena Williams and the curse of tennis shoulder

After being forced to pull out of yet another tournament last month, questions are being raised over the future of tennis star Serena William’s career. By William’s standards, 2016 has been a disappointing year as a persistent shoulder injury affected her performance in the Rio Olympics and the US Open. In fact, her loss in the semi-finals of the latter competition set back her shot at breaking the record of 22 Grand Slam Titles which she currently shares with Steffi Graf.

Tennis shoulder injuryHaving recently turned 35, will her shoulder affect her chances of ever beating this record? As she has recently commented, she is “tired of playing tournaments unhealthy and taking losses I would never lose”. Currently the world number two tennis player in the world, Williams is now following doctor’s orders to rest the shoulder to ensure she can play next year.

Having recently turned 35, will her shoulder affect her chances of ever beating this record? As she has recently commented, she is “tired of playing tournaments unhealthy and taking losses I would never lose”. Currently the world number two tennis player in the world, Williams is now following doctor’s orders to rest the shoulder to ensure she can play next year.

Tennis players are certainly no stranger to shoulder injuries. Commonly dubbed ‘Tennis Shoulder’, injuries are caused by repetitive stress to the shoulder joint.

What is tennis shoulder?

Tennis shoulder is a term relating to a range of shoulder conditions. Strokes like the overhead smash, serve and high forehand can place significant stress on the shoulder joints over time, causing them to become inflamed and unstable.
The most common tennis shoulder injuries include:

Shoulder bursitis/impingement

The most common tennis shoulder injury, shoulder bursitis develops when the small sac of fluid known as the bursa becomes inflamed. Its sole purpose is to reduce friction between the bone and the tissue and, when inflamed, it can cause severe pain. In serious cases, the bursa could become impinged between the bone and the muscle, resulting in pain whenever the arm is lifted.

Shoulder impingement can also be diagnosed when the supraspinatus tendon is aggravated or pinched. There are two main types of shoulder impingement including subacromial and internal impingement.

This type of tennis shoulder tends to be caused by high forehands and excessive serves.

Shoulder instability

Over time, the joint of the shoulder can loosen, leading to instability. There are varying degrees of shoulder instability that can occur, with complete dislocation being the most severe. It can also go on to develop into arthritis if it remains untreated.

In tennis, strokes that cause repetitive shoulder motions can cause the joint capsule to stretch and loosen. This in turn causes the muscles of the shoulder to weaken and the humerus ball will start to slip. This is when pain in the shoulder will develop.

Rotator cuff tear

Tears to the rotator cuff can develop after a single, traumatic injury or gradually develop over time. Excess overhead activity is a leading cause of this type of injury, resulting in the arm becoming weaker and pain developing around the joint. In some cases, surgery will be required to repair the tear, resulting in a significant recovery time.

Older players experience more severe tennis injuries

The most severe tennis shoulder injuries are typically found in older athletes due to a more advanced play level. Younger players will typically develop milder injuries. However, the problem comes when these mild injuries are not treated correctly. If left untreated, the injury will usually worsen and potentially threaten a player’s career.

Though prevention isn’t always possible, there are things you can do to limit your chance of developing tennis shoulder.

Proper technique during training, along with rotator strengthening exercises can help significantly. Stretching prior to a match is also recommended.

Overall, tennis shoulder is a common issue experienced by players at all levels. The key to minimising the amount of downtime required is to ensure you seek treatment as soon as possible.

What is shoulder impingement syndrome?

Shoulder impingement syndrome is a common injury affecting those who play ‘overhead’ sports and there are a wide range of activities that involve a repetitive movement which elevates the arm above the head, including cricket, tennis and swimming.

Known as one of the most common causes of shoulder pain, the twinge you feel when you execute your tennis serve can quickly become persistent and affect your ability to perform even the most mundane, everyday activities.

Understanding shoulder impingement syndrome

Simply put, shoulder impingement syndrome is diagnosed when a tendon of the muscle catches within the shoulder. This in turn leads to weakness in the arm and pain when the arm is lifted above the head.

It is the rotator cuff tendon that causes the condition; responsible for connecting the shoulder muscles to the very top of the arm, this long, thick tendon is situated within a narrow space, known as the sub acromial space. If it becomes trapped within the space, the tendon begins to rub against the bone, causing pain and sometimes, inflammation.

If inflammation of the tendon does occur, it is referred to as rotator cuff tendonitis. This will develop if shoulder impingement syndrome isn’t treated early enough. There’s also the chance that the tendon could start to wear away and become thinner over time.

What causes shoulder impingement syndrome?

There are actually two different types of causes of shoulder impingement syndrome referred to as primary and secondary.

Primary cause: If you are diagnosed with primary based rotator cuff impingement, it refers to the structural narrowing of the shoulder. It is possible to be born with a naturally narrow subacromial space, significantly increasing your risk of impingement. However, structural narrowing can also develop due to osteoarthritis. The condition can cause bony spurs to develop within the space, further narrowing it.

This type of shoulder impingement syndrome increases the risk of shoulder tendonitis and bursitis.

Secondary cause: This secondary cause of shoulder impingement is referred to as dynamic instability. It occurs when the muscles around the shoulder joint are weak, along with abnormal joint laxity and too much movement in the joints.

It is this type which is most commonly found in athletes, caused by repetitive activity overhead, incorrect posture or injury. The shoulder is required to work much harder if it is unstable, increasing the risk of impingement.

If it is left untreated, secondary rotator cuff impingement will worsen and re-occur.

Identifying the symptoms of shoulder impingement syndrome

There are a number of distinctive symptoms associated with shoulder impingement syndrome including:

  • Weakness in the arms
  • Intense pain when the arm is raised overhead
  • The shoulder is painful to lie on
  • Pain which extends down from the shoulder to the elbow

As the condition worsens, you could also begin to experience pain even when the shoulder is resting. Some patients experience a constant, dull ache, rather than intense pain. The condition will need to be diagnosed, typically with the aid of an ultrasound scan. This is most commonly used to identify dynamic impingement.

Shoulder impingement treatment options

The type of treatment required will depend entirely upon where the injury has occurred. Numerous structures can be affected during shoulder impingement syndrome, so identifying the problem area is key to diagnosing the correct treatment.


London Shoulder Specialists’ consultant surgeon Mr Andy Richards
spoke on shoulder impingement syndrome, particularly in relation to rugby players, at last year’s Fortius International Sports Injury Conference:

shoulder impingement syndrome in rugby“Younger rugby players – by which we mean under age of 35 – often have more functional impingement and an inability to control their humeral head with superior translation. They also have a high percentage of sub-clinical instability and standard treatments of injections and subacromial decompression will fail in this group.

“For younger patients you have to look at the pathology and identify labral or partial cuff tears and whether ACJ inflammation is also contributing to the pain they are experiencing. The MRI Arthrogram is definitely the investigation of choice. If there is no structural abnormality, then this group can be rested and rehabbed, with guided steroid injections to the bursa, but if they have a structural abnormality or fail to rehab, then surgery is the best option.”

Stretching is key to avoiding swimmer’s shoulder

Shoulder injuries are thought to affect between 40% to 91% of professional swimmers. This isn’t a surprising statistic considering that competitive swimmers, training for a number of hours, six or seven days a week, will perform many thousands of shoulder revolutions and this continuous movement places great strain upon the joint.

However, while the risk of developing a shoulder injury due to overuse is high for competitive swimmers, studies show there are ways to minimise the risk. In particular, stretching could be the key to prevention.

What is Swimmers Shoulder?

The term Swimmers Shoulder actually relates to a range of different shoulder injuries. Most commonly caused by overusing the shoulders, the types of injuries that can occur are diverse and vary in severity. Three of the most common injuries you are exposed to as a swimmer include:

1. Rotator cuff impingement/tendonitis

The rotator cuff is responsible for keeping your arm within the socket. Made up of numerous tendons and muscles, the rotator cuff is one of the most commonly injured parts of the shoulder.

Rotator cuff impingement occurs when the acromion part of the shoulder rubs against the muscle, causing pain and irritation. It occurs when the arm is lifted to shoulder height. Rotator cuff tendonitis is diagnosed when the tendons are damaged or irritated.

2. Scapular Dyskinesia

This condition occurs when the muscles of the upper back are overstretched and loose. Responsible for keeping the bones of the shoulder in position, the upper back muscles can be affected when the shoulder blade is repetitively rotated. To compensate, the muscles of the upper chest tighten and cause intense pain around the collarbone area.

3. Shoulder instability

In severe Swimmers Shoulder injuries, the joint may become loose or disconnect from the socket completely. This is referred to as shoulder instability.

When you consider that 90% of the force required to push the body through the water is provided by the upper body, you soon realise how vulnerable the shoulders are. There are several muscles and tendons within the shoulder joint and any of them can suffer damage from excessive or incorrect use.

Why stretching is key to preventing shoulder injuries

One of the main reasons swimmers develop shoulder injuries is because of improper training. Due to how much pressure the shoulders are put under in the water, it’s vital they are as strong and healthy as possible. Stretching the muscles prior to getting in the pool is an important key factor in ensuring they stay strong and resistant to injury.

In particular, the posterior shoulder capsule needs to be stretched, along with the scapula stabiliser and rotator cuff muscles. This helps to prevent muscle imbalance, as highlighted by a study published by the American Academy of Orthopaedic Surgeons.

A stretching and strengthening routine will significantly reduce the risk of injury, though it is impossible to fully eliminate the risk entirely. If any pain is noticed in the shoulder area, it should be assessed thoroughly as quickly as possible to prevent it from becoming more severe.

Overall, it is estimated that around one-third of top-level, competitive swimmers suffer with a shoulder injury which prevents them from training. If you want to avoid swimmers shoulder, then stretching and proper training technique is vital.

‘Swimmers Shoulder’, lecture by Mr Ali Narvani of the London Shoulder Specialists at Fortius Clinic

As the season kicks off, we focus on a common shoulder rugby injury

As the new rugby season gets underway, specialists across the country brace themselves for an increase in shoulder-related injuries, including AC joint shoulder injuries.

Rugby is a notoriously tough, physical contact sport which puts the body through a significant amount of trauma. A study published last year in the Journal for Orthopaedic Sports Medicine, Arthroscopy and Knee Arthroplasty, evaluated injury risk in International Rugby Union, focusing on the Welsh National Team. The shoulder was found to have the highest injury incidence and suffered one-third of recurrent injuries. Shoulder dislocations were also found to result in the most days lost per injury.

The shoulder is a complex joint, composed of a number of different joints, bone groups, muscles, ligaments and tendons. It has the the greatest range of motion in the body and is susceptible to a number of different injuries and conditions. One of the most common injuries suffered by rugby players is injury to the acromioclavicular or AC joint.

What are AC joint shoulder injuries?

The AC joint is situated at the top of the shoulder, being the junction between the shoulder blade (acromion) and collar bone (clavicle). Due to its location, the joint is particularly susceptible to trauma during rugby, with separation and dislocation being the most common problem experienced. A direct hit to the joint can cause it to become separated, along with a fall onto an outstretched hand.

Understanding the different types of AC joint separation

Like many shoulder injuries, there are different classifications of separation that can occur in AC joint shoulder injuries. They are measured using the Rockwood scale:

Grade 1 – pain is experienced around the AC joint, but the bones remain in position.

Grade 2 – as well as pain around the joint, there is some damage to the capsule, as well as a partial tear in the superior ligament. A lump may also be visible through the skin.

Grade 3 – the coracoclarvicular and the AC ligaments are both ruptured, causing a large lump to be visible under the skin. A true separation occurs and the trapezius and deltoid will have been detached.

Grade 4 – the trapezius is ruptured due to the clavicle moving behind the joint. As with grade 3, the trapezius and deltoid are detached.

Grade 5 – similar to grade 3 injuries, though the separation is more severe. The clavicle punctures the above muscle and, as with grades 3 and 4, the trapezius and deltoid are detached.

Grade 6 – the least common injury, grade 6 sees the clavicle become hooked underneath the coracoid process after being pushed downwards. It ends up behind the coracobrachialis and biceps.

AC joint injuries: symptoms and prevention

Pain is the most notable symptom of AC joint shoulder injuries. This will be experienced towards the outer end of the collarbone. It will also likely feel tender to touch and be inflamed too. Once the injury has settled, the pain will be very localised and won’t radiate towards other parts of the body. You’ll likely notice the pain becomes worse with certain activities, such as lifting your arm above your head.

The symptoms are similar to a variety of collarbone and shoulder injuries. Therefore, a specialist diagnosis is required to ensure you receive the appropriate treatment.

If the ACJ is injured, then the lesser grade injuries can generally be treated without surgery, however, higher grade injuries may need an intervention. Recently, Mr Steve Corbett of the London Shoulder Specialists has presented both nationally and internationally on the decision making involved.

It’s very difficult to prevent AC joint shoulder injuries in rugby, as it is a contact sport with a high likelihood of knocks to the collarbone. Learning how you can stabilise the shoulder and also building up the muscles can help somewhat.

If you’re concerned that you may have an AC joint injury, book a consultation with London Shoulder Specialists at Fortius Clinic today. There are a number of treatment options available and our specialists are highly experienced in treating rugby injuries at every level of the sport.

Understanding SLAP tears

After appearing in just two games for Sussex, Bangladesh fast bowler Mustafizur Rahman’s England cricket season came to a premature end in July with a shoulder injury that saw him undergoing surgery last month with Mr Andrew Wallace of the London Shoulder Specialists at Fortius Clinic to treat a SLAP tear.

SLAP tears are diagnosed when the top part of the labrum becomes torn due to injury. Responsible for stabilising the shoulder, the labrum is made up of strong tissue which runs in a ring around the shoulder’s socket. SLAP is an abbreviation for Superior Labrum, Anterior to Posterior, and refers to the area of the shoulder that’s been injured.

There are actually various types of SLAP tears a patient can experience, all relating to the severity of the tear. It’s most common in those who play contact or overhead sports and is therefore a common injury suffered by fast bowlers like Rahman.

Understanding the different types of SLAP tears

When a SLAP tear is diagnosed, it is classified as a specific type:

Type 1: A partial tear, including degeneration of the superior labrum. The edges of the free margin are frayed and rough, but the actual labrum itself is still attached. Treatment typically includes cleaning the edges, a process known as ‘debride’.

Type 2: Diagnosed when the labrum has totally come away from the glenoid, this is the most common type of SLAP tear. It tends to occur after an injury such as dislocation and a gap is left between the labral attachment and articular cartilage.

These types of tears are also commonly broken down into sub-categories such as posterior, anterior and a combined posterior/anterior tear. To treat it, the labrum will need to be reattached via keyhole surgery. The slap repair is carried out arthroscopically with suture anchors.

Type 3: In some cases, the tear in the labrum causes it to hang down into the joint, causing it to frequently pop and lock. Treatment is similar to a type 2 tear, using the same keyhole surgery technique. The only difference is the hanging section of the labrum, commonly referred to as a bucket-handle tear, is eliminated before the remaining labrum is repaired.

Type 4: A severe tear which extends within the long head of the biceps tendon. SLAP repair surgery will need to be carried out to reattach the labrum, as well as potentially repair the tear in the biceps.

How do I know I have a SLAP tear?

The first sign of a SLAP tear is pain, ranging in severity, throughout the top section of the shoulder. This will largely present itself when you’re performing overhead activities. Mustafizur Rahman noticed his SLAP tear after his second game of the season, experiencing significant pain when bowling.

The pain experienced is sometimes assumed to be associated with AC joint issues. A good way to establish whether you’re experiencing a SLAP tear or AC joint issue is to do a bench press. If you experience a lot of pain while going down into the press, it’s a SLAP tear. AC joint issues commonly cause more pain as you press out of the bench press.

As well as pain, clicking is another common symptom, along with weakness in the shoulder. You may also feel like the shoulder is going to pop out of place and there could be a deceased range of motion.

Depending on the type of tear and how it is affecting you – whether that’s your performance as a top-flight cricketer or your ability to discharge day-to-day activities – the London Shoulder Specialists can offer a range of non-surgical and surgical treatments.

Could an electric shock zap shoulder arthritis pain?

An innovative approach to pain relief could provide hope for sufferers of rheumatoid arthritis.

In a limited trial at the University of Amsterdam, 17 rheumatoid arthritis sufferers were fitted with an electronic implant in the vagus nerve that controls many of the important functions of the body, including inhibiting inflammation which is the underlying cause of rheumatoid arthritis.

In this degenerative condition, the body’s immune system mistakenly attacks the joints causing swelling, stiffness and pain. The implant works by releasing an electric pulse that stimulates the vagus nerve, reducing the levels of immune cells that cause the damage.

All patients enrolled on the trial had previously failed to respond to medication and all reported a marked reduction in stiffness and discomfort. Rheumatoid arthritis is just one of many different types of arthritis that can affect any joint of the body, including the shoulder. The most common type of shoulder arthritis is osteoarthritis, which is often associated with ageing.

Understanding shoulder arthritis

Arthritis means inflammation of a joint in the body. As the shoulder is a very mobile joint it can develop wear and tear over a lifetime. The cartilage which lies on the bones of the shoulder joint becomes thinner and ultimately can be destroyed. As a result, one bone then rubs on the other causing pain, stiffness and loss of functional abilities. One option is to then consider a shoulder replacement. Whilst this type of surgery is not as common as hip or knee replacements, on average, approximately 4,500 shoulder replacement surgeries are carried out each year in the UK.

Unsurprisingly, the National Joint Registry found that osteoarthritis was indicated in 58% of shoulder replacements, but there are other types of arthritis or conditions that can affect the shoulder requiring replacement surgery. These include

Rheumatoid arthritis

Affecting the joint lining of the shoulder, rheumatoid arthritis is one of the more common types experienced by patients. The autoimmune condition can present itself in one or both shoulders, causing stiffness and pain. Over time, it can lead to deformity of the shoulder joints, as well as an erosion of the shoulder bones.

Post-traumatic arthritis

Shoulder injuries are common, particularly in young athletes. When an injury occurs, it can trigger post-traumatic arthritis. Patients who have experienced shoulder dislocation or fractures are particularly at risk of developing the condition. In this type of arthritis, fluid can build up within the joint, causing pain and swelling.

Rotator cuff tear arthropathy

Rotator cuff injuries are fairly common and they can lead to a type of arthritis known as rotator cuff tear arthropathy. It is most commonly caused by a longstanding tear of the rotator cuff tendons, which results in muscle weakness and loss of support for the shoulder. As a result, a painful arthritis then develops.

Avascular Necrosis

Avascular necrosis is a condition whereby the blood supply to the humeral head (ball) is disrupted. This then causes bone cells to die. The body attempts to regenerate itself but the process is flawed and the ball can become very irregular. Conditions that can cause avascular necrosis include sickle cell disease, high dose steroids, excessive alcohol consumption, previous fractures and radiotherapy.

What are the treatment options for shoulder arthritis?

As consultant shoulder surgeon Mr Andy Richards of the London Shoulder Specialists commented in a recent lecture on shoulder arthritis: “There is no cure for arthritis so all the surgeon can do is reduce the symptoms and pain. Range of movement and function may be increased through reducing pain.”

This new electric shock implant may prove beneficial for patients suffering with rheumatoid arthritis. It is worth noting, though, that the trial was very limited so although results are promising, more in-depth studies are required. Also other types of arthritis will require a different approach and these include a range of non-surgical and surgical options. At London Shoulder Specialists, we will first assess the type of shoulder arthritis prior to offering expert, impartial advice on the most appropriate treatment.

Frozen shoulder: the symptoms and solutions

It is estimated that one in 20 adults in the UK will suffer a painful shoulder condition at some point in their lifetime. One problem that people can develop is frozen shoulder, which is medically known as adhesive capsulitis. The condition can be confused with arthritis or other shoulder problems such as bursitis. Below, you’ll discover how to spot the signs of frozen shoulder and what solutions are available.

What is frozen shoulder?

Frozen shoulder occurs when the articular shoulder capsule – the lining that surrounds the shoulder joint – shrinks and stiffens. It’s a very painful condition that can affect sleep, reduces mobility and makes everyday tasks extremely difficult such as reaching for something or even just getting dressed. It usually affects just one shoulder at a time, but in some cases, both shoulder joints can be affected. If one shoulder does develop the problem, then there is a 20% chance that at some time point the other shoulder will develop the same problem.

The good news is that for most patients the condition is self-limiting and it will get better. The bad news is that it can take 18 to 24 months to completely resolve, and, in some cases, it can persist for even longer.

The exact nature of the problem is till under investigation.

Who is at risk of developing frozen shoulder?

Frozen shoulder most commonly affects those between the ages of 40 and 60 and women are more likely to suffer than men. Whilst in many cases there is no obvious cause,  some people are more susceptible to the condition, such as those with diabetes, Dupytrens disease, Parkinson’s or possibly thyroid problems. Additionally, patients who have had a stroke or immobility caused by an injury or previous surgery can be at increased risk.

Studies suggest frozen shoulder in diabetics is brought on by collagen glycosylation in the shoulder joint caused by high blood sugar. Those who are insulin dependent have also shown to be six times more likely to develop shoulder issues than others.

What are the signs of frozen shoulder?

Most cases of frozen shoulder follow a pattern, with symptoms worsening and then resolving within an 18 to 24 month period. Typically, the stages of frozen shoulder are classified as freezing, frozen and thawing.

Stage 1: Freezing

This is the painful stage and the sufferer starts to notice discomfort and the shoulder gradually tightening, limiting mobility. This can occur over a period of weeks but the pain is such that there will be significant night pain causing sleep disturbance. Discomfort and pain may also be experienced simply at rest. When the limits of movement are reached, again the shoulder is very painful. This period can last for six months or more.

Stage 2: Frozen

In this stage, whilst there is still some pain, this generally improves. However, the shoulder remains very stiff. making it difficult to carry out everyday tasks. Again this period can last for over six months.

Stage 3: Thawing

In this final stage, the movement in the shoulder gradually returns and any residual pain dissipates. It is unusual but not impossible to develop the same problem again in the same shoulder.

How is frozen shoulder diagnosed?

London Shoulder Specialists diagnose frozen shoulder by assessing the level of pain experienced and the range of motion present within the joint. An X-ray is likely to be requested to check whether there are any other issues in the shoulder which could be causing the pain and stiffness. Occasionally we may carry out an MRI to establish the full extent of the damage caused to the soft tissue surrounding the joint. An alternative might be to perform an Ultrasound scan.

What are the treatment options for frozen shoulder?

Once diagnosed with frozen shoulder, there are numerous treatment options available aimed at relieving pain and increasing or preserving mobility and flexibility in the shoulder. A recent web survey carried out in the Netherlands and Belgium, revealed shoulder specialists most commonly opt for non-steroid anti-inflammatory drugs along with intra-articular corticosteroid injections to treat the first stage of the condition. This can be very helpful in reducing the significantly debilitating pain symptoms, particularly those experienced at night. Usually, injections are limited to 1 – 2 episodes and sometimes the cortisone is combined with water (saline) to try to expand the capsule (hydrodilatation).

If the pain persists or if stiffness remains significant following injection, then an arthroscopy (keyhole surgery) can be considered, whereby a camera is put into the shoulder and the tight, thickened capsule is released. This technique has largely superseded manipulation of the shoulder under a general anaesthetic.

The role of physiotherapy in the first stage of the condition is slightly controversial, but there seems to be no question that it is beneficial in the second and third stages of the disease.

Summer of sport: spotlight on shoulder instability and the young athlete

For young athletes, summer is prime time to get out there to train, compete or even just to engage in sport for fun and relaxation with friends. However, increased sporting engagement also means a rise in shoulder instability cases.

It is recognised that a trauma to the shoulder, such as a fall, can cause shoulder instability and many people know someone who has dislocated a shoulder.

However popular summer sports such as swimming, volleyball, tennis and cricket, can lead to shoulder instability, due to repetitive actions involving arm rotation. Shoulder instability can be painful and it can also put you out of action.

What is shoulder instability?

Shoulder instability presents itself in numerous ways including a full dislocation,  a partial dislocation (subluxation) and mild looseness (laxity). It occurs most dramatically when the ball (head) of the upper arm (humerus) is forced out of the socket (glenoid). In doing so, the ball can tear a ring (the labrum) that runs around the socket The problem is that once shoulder instability occurs, it is likely to recur. In repetitive sports, the injury to the labrum can be less acute and develops over a period of time.

There are a number of ways to classify shoulder instability. These include the cause of the instability – trauma, natural laxity, poor muscle patterning – the direction of the instability – anterior, posterior or multidirectional – the degree of the instabilty and the anatomic site of any injury within the shoulder.

The most common problem experienced by young athletes is anterior instability. It occurs largely in men aged between 18 and 25 and accounts for approximately 85% to 95% of shoulder instability cases. The most likely cause is trauma causing a complete dislocation, though subluxations are also common.  If there is a complete dislocation, patients can sometimes relocate the shoulder themselves, however often they need to attend hospital to have it reduced.

In the case of a subluxation, the shoulder only partially comes out and then slides back into joint by itself. This can still be painful and result in ongoing symptoms, such as pain when trying to rotate the shoulder. Very occasionally, the instability can be associated with altered sensation within the arm.

At the London Shoulder Specialists, we first assess the cause of the instability, as to whether it is the result of a trauma, natural joint looseness (hyperlaxity) or due to poor muscle control. It may be possible to utilise physiotherapy to help strengthen and coordinate your shoulder muscles and thereby reduce any instability symptoms, or the risk of a further significant event. We are often asked about the use of braces and, in certain circumstances, these can be helpful.

However, particularly in the younger population, surgery may be the best course of action to reduce the risks of further problems.

Surgery could reduce need for follow-up procedures

Research carried out by the American Orthopaedic Society for Sports Medicine, has shown first time dislocation surgery  significantly lowers the risk of re-injury and reduces the need for follow up procedures.

Within the study, 121 patients, with an average age of 19, were examined on average, 51 months after surgery. The group included 68 patients who had a first-time dislocation and 53 who had experienced several dislocations after initial non-operative treatment. Results showed that just 29% of first-time dislocation patients experienced further shoulder instability issues after arthroscopic surgery, compared to 62% in the patients who hadn’t undergone surgery.

This was a long-term, in-depth study which recorded data from 2003 to 2013. The results clearly highlight the benefits of first-time surgery for shoulder instability cases, providing hope for young athletes. It supports a number of other studies, which have shown similar findings. Indeed many of these have shown even better results for patients undergoing surgery. One area that has improved the results of surgery is better selection of patients and matching patients to the surgical options.

Most patients who suffer from first-time shoulder instability are understandably worried. This new research eases that worry and demonstrates that sometimes surgery can be the best way forward to protect their athletic career.

Mr Ali Narvani publishes article on rotator cuff repair technique

Consultant orthopaedic surgeon Mr Ali Narvani and fellow researchers recently published an article in Arthroscopy Techniques, the companion to Arthroscopy: The Journal of Arthroscopic and Related Surgery, on a rotator cuff repair technique that aims to reduce the significantly high failure rates associated with repair of very large rotator cuff tears.

Entitled ‘“Owl” Technique for All-Arthroscopic Augmentation of a Massive or Large Rotator Cuff Tear With Extracellular Matrix Graft’, the article explained that although the techniques and technology utilised in rotator cuff surgery have greatly improved over the years, there is still a high failure rate in repairing massive tears.

Patch augmentation is reducing these failure rates, but arthroscopic patch augmentation is highly challenging for the surgeon, so the article detailed a ‘simple and reproducible technique for all-arthroscopic extracellular matrix graft augmentation’.

Click here to read the article in full.

New painkilling techniques trialled in shoulder surgery

New painkilling techiques are being tested in the hope of reducing the amount of medication prescribed after surgery. Opioids are a common pain relief medication but there are concerns that they are being overprescribed after surgery. They reduce the intensity of pain signals before they reach the brain and affect the areas of the brain that control emotion. They range from hydrocodone, oxycodone, morphine and codeine and differ greatly in strength.

These prescription drugs can be extremely addictive. A 2015 US study published in the Mayo Clinic Proceedings, found one in four people who have been prescribed opioids go on to develop an addition. It is a worrying pandemic that’s particularly affecting young athletes. UK data is less comprehensive than that gathered in America, but a survey released by the charity Action on Addiction last year estimated that nearly one in ten UK adults believe they could be or could have been addicted to opioid painkillers, with a quarter taking opioids for more than five years.

Doctors are hoping the new painkilling techniques being tested may be used in conjunction with or instead of opioid medication to minimise patients’ reliance on this form of pain relief.

Combination of non-addictive treatments is key

Rotator cuff surgery can involve a painful recovery process, hence strong opioid prescriptions are often required in the initial post-operative period. However, the new painkilling techniques being trialled aim to deliver the same relief without the addictive nature of opioids and the dangerous side effects.

While the techniques have been used individually to relieve pain after surgery, it’s the combination of the different methods which is key according to surgeons at NYU Langone Medical Center’s Department of Orthopaedic Surgery in New York who are aiming to greatly minimise the pain experienced after elbow or shoulder surgery and, therefore, the use of opioids. Their techniques include:

  • Non-addictive anaesthetic – including the use of injections around the nerves in the neck and shoulder
  • Catheter implant – delivering anaesthetic over a set period of time
  • Mechanical stimulation and wearable icing devices – helping to reduce swelling and pain throughout physiotherapy
  • Drug regimens – helping patients to move onto non-addictive medication like Tylenol

There are of course some potential drawbacks with these techniques. Patients have to become accustomed to having weak or numb arms for a number of days. Catheter implants can sometimes be difficult to keep in place and they can seem like an ‘intimidating’ option.

Instead, single injections can be used which would effectively block pain signals for up to 24 hours. Opioid medication can still be used for a short amount of time before transitioning patients onto other medication

Many units, including Fortius London Shoulder specialists now employ regional anaesthesia, where injections are placed about the nerves in the brachial plexus to reduce post operative pain requirements. There are some risks that come with these injections such as nerve damage and the potential for the anaesthetic to leak, though these are relatively small.

Understanding rotator cuff surgery

Rotator cuff surgery is carried out in one of two ways. It can be performed via open surgery or arthroscopically. In the open surgery method, an incision is made in the skin and the procedure is performed through a large wound – the torn tendons are reaattched to the bone.

Arthroscopic surgery is performed using an arthroscope, or mini camera, so the surgeon can view the inside of the shoulder on a monitor. Small, specially designed surgical instruments are used so less extensive incisions are required. Arthroscopic surgery typically causes less trauma to the muscles surrounding the shoulder, which in turn reduces the discomfort felt after the surgery.

A study entitled ‘Effectiveness of Open and Arthroscopic Rotator Cuff Surgery’ published in the NIHR Journals Library, provided a better understanding of each method. Interestingly, the post-operative pain management required was similar with the open and arthroscopic method. Two-thirds of participants were still taking painkillers after two weeks and after eight weeks, though painkiller use was decreased from 66% to 55%.

Overall, regardless of the type of technique used, recovery from rotator cuff surgery should not be underestimated.