Mr Ali Narvani on irreparable rotator cuff tears

London Shoulder Specialist Mr Ali Narvani’s article on irreparable rotator cuff tears

An article on Superior Capsule Reconstruction was recently published in The Archives of Bone and Joint Surgery by London Shoulder Specialist Mr Ali Narvani. Alongside colleagues based at Rowley Bristow Unit, Ashford and St Peter’s NHS Trust, Chertsey, Mr Narvani’s article focused on the management of irreparable rotator cuff tears, a shoulder condition that remains challenging.

Superior Capsule Reconstruction (SCR) was first introduced in 2012 by Dr Teruhisa Mihata, a Japanese orthopaedic surgeon, and since then has grown in popularity as an option to treat severe irreparable rotator cuff tears.

Mr Narvani and colleagues reviewed the available literature on the procedure and their conclusion was that short-term clinical results show it is a promising treatment option but further long-term trials, which compare SCR to other treatment options are required. Clarification on the importance of the choice of graft type and thickness is also needed.

pinched nerve in the shoulder

Can a pinched nerve in the shoulder go away by itself?

A pinched nerve in the shoulder, also known as a compressed or entrapped nerve, can be incredibly painful and debilitating. The good news is that most cases of pinched nerves will resolve itself with rest or over-the-counter anti-inflammatory medications, but there is a point when you should seek medical intervention for a pinched nerve in the shoulder.

The suprascapular nerve can become compressed or restricted, either due to direct trauma or due to overuse injury. Shoulder dislocations, labral tears or cysts can all press on the nerve. Repeated overhead movements can result in a pinched nerve in the shoulder so this can be a common problem for athletes such as swimmers or tennis players, or those who work in certain jobs.

What are the symptoms of a pinched nerve in the shoulder?

A pinched or compressed nerve will cause pain and numbness in the shoulder region. You may also experience muscle weakness that extends down the arm to the hand and neck pain when you turn your head. As well as numbness, you may find you have tingling in the hand and fingers.

Your shoulder specialist will take account of your symptoms when diagnosing the cause of the pinched nerve and determine the amount of pain you’re experiencing and how your range of movement is affected. An X-ray or CT scan be used to identify any bones that may be pressing on the nerve and an MRI will assess the soft tissue and nerves.

How is a pinched nerve in the shoulder treated?

Depending on the cause of the pinched nerve, how severe the pain you’re experiencing is and how it’s impacting on your ability to perform daily activities, your shoulder specialist will typically advise a non-surgical approach first.

Non-surgical treatments for a pinched nerve include non-steroidal anti-inflammatory drugs, and oral and injectable corticosteroids to target inflammation and swelling. Physical therapy and lifestyle changes are also advised, but if a non-surgical approach fails to produce a decrease in pain and increase in function, surgery may be recommended.

Arthroscopic decompression of the suprascapular nerve is done through small keyholes, cutting the ligament above the nerve to allow more space. This procedure should result in full movement and reduction of symptoms.

If you’re worried you’re suffering from a pinched nerve in the shoulder, call 0203 195 2442 to arrange a consultation with the London Shoulder Specialists.

Physical Therapy May Reduce Need for Rotator Cuff Surgery

surgery for rotator cuff tearsResults from a new study presented at the annual meeting for American Shoulder and Elbow Surgeons, have revealed physical therapy may reduce the need for surgery for rotator cuff tears. After following participants for five years, the researchers discovered patient expectation was the main predictor of surgery.

Surgery for rotator cuff tears is renowned for its long and often painful recovery process. So, could these latest results change how rotator cuff tears are treated? Here, we’ll look at the study and its findings, and whether physical therapy could prove more effective than surgery.

The findings of the study

 The study led by John. E. Kuhn followed a total of 433 patients for five years, who had been diagnosed with an atraumatic full-thickness rotator cuff tear. Data was provided via questionnaires on factors such as willingness to undergo surgery, symptom characteristics, comorbidities, patient-related outcome and demographics.

The researchers also created a physical therapy routine that the participants followed, and they were assessed at 6 and 12 weeks. During the final evaluation, the patients were asked to choose between three different options. These included, cured with no follow up required, improved followed by continued therapy and an assessment in 6 weeks, and no better with the option of surgery.

Out of all of the participants, just 24% had opted to have rotator cuff surgery, with 75% choosing not to undergo surgery. Those who did undergo surgery, largely did so within the initial 12 weeks of therapy. Activity scale, smoking and patient expectations were the three driving factors behind the 2-year results. After five years, the size of the tear and workers compensation both had a major influence on surgery decisions.

The most significant finding was that patients who believed the physical therapy would work, did find it to be effective. So, patient expectations certainly play a role in the effectiveness of physical therapy.

Should surgery be used as a last resort for rotator cuff tears?

These new findings certainly aren’t surprising. Shoulder specialists have been using physical therapy as a first response treatment for years now. Due to how complex rotator cuff surgery can be and the long recovery time, it is typically used as a last resort treatment. However, what the research could aid with, is convincing patients that physical therapy can work. As there is a direct link between patient expectations and therapy outcomes, ensuring they understand the benefits of physical therapy is crucial.

It is also important to recognise when surgery would be most effective. This can typically be determined fairly early on if the pain isn’t subsiding. However, numerous factors will be assessed before deciding whether or not surgery is the best course of treatment moving forward.

This new research highlights the importance and effectiveness of physical therapy as a first treatment option for rotator cuff injuries. It also provides hope for patients, showing surgery may not necessarily be required. Those who do suspect they are suffering from a rotator cuff injury should seek treatment as soon as possible. The earlier it is diagnosed, the more effective physical therapy is likely to be.

Shoulder dislocation vs shoulder subluxation

As the shoulder is the largest and one of the most used joints in the body, it is prone to a wide range of injuries. Two common injuries which can arise are shoulder dislocation and shoulder subluxation. So, what is the difference between the two and what treatment options are available?

Shoulder dislocation

A shoulder dislocation occurs when the ball of the joint completely separates away from the socket. It’s a fairly common injury due to how shallow the socket is. It doesn’t take much force for the ball to be knocked out of the socket and most patients tend to suffer from an anterior dislocation. This is where the ball comes out of the socket and is pushed towards the front.

Shoulder dislocations tend to occur due to a fall as the basic instinct is to put your arm out to stop yourself as you hit the ground. The force of the fall can then dislocate the shoulder.

Shoulder subluxation

A shoulder subluxation is actually a kind of dislocation, only the ball and socket don’t fully separate. Instead, they remain connected but severely out of alignment.

This type of injury usually occurs if there has been some form of damage to the tendons or muscles surrounding the ball and socket. An injury, such as a torn rotator cuff, can lead to the weakening of the ball and socket, allowing them to slip out of alignment. As the ball and socket aren’t completely separated, there is the possibility they could pop back into place by themselves.

As shoulder subluxation and shoulder dislocation can cause very similar symptoms, it can be difficult to know which one a patient is suffering with. Therefore, a proper diagnosis by a shoulder specialist is crucial to determine which type of treatment is required.

How are shoulder dislocation and subluxations treated?

If your shoulder is dislocated, it is really important not to try and pop it back into place yourself. There have been many instances on television, where you see people popping their own shoulders back into place. However, if done incorrectly, it could actually damage the muscles and ligaments of the shoulder joint. So, it is much safer to pop the arm into a sling until you can get to the doctor or shoulder specialist.

You will be given an assessment and potentially an x-ray to determine whether you are suffering from a dislocation or subluxation. From there, your shoulder specialist will be able to see the true extent of the injury and they will be able to assist in popping the shoulder back into place before a treatment plan is created.

Depending upon the extent of the dislocation, the specialist may decide to pop it back into place while the patient is under general anaesthetic. Once it is in place, a sling will usually need to be worn for a few weeks while it heals and sets back into place.

Overall, shoulder dislocations and subluxations are similar injuries, but subluxations are typically less severe. If you’re worried you may be suffering from a dislocation, it’s extremely important to visit a shoulder specialist before attempting to treat it.

Yoga and Pilates for Shoulder Injury Prevention

British competitive swimmer Ben Proud who is a World and European Champion in freestyle and butterfly races recently spoke about how he does yoga and Pilates to prevent shoulder injuries derailing his medal-winning hopes. Over half of his workout routine is dedicated to shoulder rehab and he finds these types of exercise are best for shoulder injury prevention.



Even if you’re not a competitive swimmer, you can be prone to shoulder injury; the shoulder is one of the most used joints in the body, making it susceptible to a wide range of injuries. While treatments have come a long way in the past decade, shoulder injury recovery can still prove to be a long and potentially painful process. Therefore, those who are at risk of developing shoulder issues, such as professional swimmers and young athletes, ideally need to focus on preventative measures.

One of the best ways to prevent injury is to build up the muscles and strength within the shoulder. While there are lots of ways to do this, yoga and Pilates are known to be especially effective. Here, we’ll look at how these two forms of exercise can aid in shoulder injury prevention.

How do yoga and Pilates help with shoulder injury prevention?

Yoga and Pilates work in several ways to prevent shoulder injuries. Firstly, the poses can really help to build up the muscles surrounding the shoulder and rib cage. The stronger these muscles become, the more resistant to injury they are going to be.

Another way these exercises help is by teaching you how to use the muscles of the shoulder blades and rotator cuff more effectively. This, in turn, allows you to reduce the strain placed upon the muscles due to incorrect posture and movement.

Finally, both yoga and Pilates are designed to strengthen the core. Focusing largely upon the deeper, smaller muscles located in the stomach and back, the poses help to build up strength, allowing the core to better control the spinal position during dynamic movements. Building up a strong core can really help to prevent against numerous types of injury, including shoulder injuries.

Which poses should you focus on?

While a lot of yoga and Pilates exercises can really help to build up strength and stability in the shoulder, some are considered better than others and you should always moderate if you feel you are putting pressure on the shoulder joint. For example, the plank pose is known to be one of the most effective core-building exercises. However, it can place a significant amount of pressure onto the shoulders; especially if you’re a beginner to this type of exercise, so it is best to moderate the action by starting off with the Wall Plank Pose.

Whether you wish to prevent a shoulder injury occurring or looking for a workout routine post-shoulder surgery to help you return to full function, yoga and Pilates could be the solution.

Rotator cuff injury: when post-exercise shoulder stiffness is a sign of something more serious

shoulder stiffnessWhen you exercise, especially after a break, it’s common to feel sore and stiff the morning after. However, did you know that post-exercise stiffness could point to a more serious issue?

Stiffness and soreness presented in the shoulder, for example, could be a sign of overuse. Many injuries present themselves in ways we don’t necessarily understand. For example, a rotator cuff injury could start by presenting as stiffness in the joint, causing you to start moving slightly differently the next time you exercise. This, in turn, can lead to a worsening of the injury.

Why ignoring shoulder stiffness can prove problematic

Dismissing post-workout stiffness as a natural occurrence could prove disastrous for the joints. If the stiffness is down to an underlying injury, it’s only going to worsen over time. The more serious the injury becomes, the longer it’s going to take to recover after seeking treatment.

The trouble is, when stiffness starts to occur, you automatically start to move slightly differently. For example, if your shoulder starts to stiffen, you’re going to start lifting weights differently and carrying out exercises in a different, unnatural posture. It is this which really poses a problem and the potential for injury.

The majority of overuse injuries will not go away by themselves. So, even if you were to rest once you notice the stiffness, as soon as you return to exercise, it is going to continue to worsen.

What you need to remember is that stiffness after exercise which relates to an injury, often means damage has been done to the tissue. Therefore, even without pain, the damage could already be done, making it important to get any long-lasting stiffness checked out by a doctor or specialist. If you are suffering from an underlying rotator cuff issue, immediate treatment is paramount.

What is a rotator cuff injury?

The rotator cuff is made up of tendons and muscles, helping to keep the head of the upper arm in the shoulder socket. If an injury occurs, it commonly causes a dull aching within the shoulder which can get worse when you lie on the affected side during the night. Those who carry out a lot of overhead movements such as athletes, painters and carpenters, are most at risk of developing a rotator cuff injury. It is also known that age is a factor in the risk of injury.

Can you prevent a rotator cuff injury?

It is possible to potentially prevent a rotator cuff injury, largely by building up the strength and stability of the rotator cuff. Making sure you don’t overuse the shoulder and that exercises are performed with proper posture is also important, but also medical intervention at an early stage can ensure a niggling issue doesn’t become a big problem.

Shouldering the pain: working with shoulder arthritis

working with shoulder arthritisThe Minister for Disabled People, Health and Work, Sarah Newton, recently urged UK employers to make adjustments within the workplace for those suffering from arthritis. Current statistics reveal that around 30 million working days are lost each year due to arthritis and similar health conditions.

Living and working with shoulder arthritis pain can be extremely challenging for patients. While some employers have gone above and beyond to accommodate those with painful arthritis, many others are yet to follow suit. Here, we’ll look at the challenge’s employees with shoulder arthritis experience, the adjustments that can be made and preventative measures that can be taken to stop arthritis developing within the shoulders.

What challenges do those working with shoulder arthritis experience?

Shoulder arthritis can be debilitating, causing a wide range of issues within the workplace. Just some of the challenge’s patients can experience include:

  • Tasks take much longer to complete
  • The inability to perform all of their tasks
  • Becoming fatigued very quickly
  • Stress from the job causes the condition to flare up

Musculoskeletal disorders such as arthritis, are known to be one of the major contributors to short-term employee absence rates. However, the practicality of making adjustments within the workplace for those who do suffer from arthritis can be a major challenge for employers.

The adjustments which can be made

So, what adjustments should employers be making for workers who are suffering from arthritis? According to sufferers of the condition, flexible working hours can be a great start.

As the condition can flare up and worsen at unpredictable times, having a working schedule which allows a little flexibility can prove vital. It would allow working hours to be adjusted to fit around appointments, as well as to work later or earlier in the day to accommodate any flare-ups.

Employers could also consider introducing a physiotherapist into the workplace, or an exercise programme which employees can take part in. One of the key arthritis management tips for patients is to keep moving the affected joints so they don’t stiffen. So, in office environments for example, providing an exercise space or anything which encourages employees to move around, can help to reduce the symptoms and ease shoulder pain.

Standing desks can also be a great investment as these are known to help reduce back, neck and shoulder pain.

Preventative measures

Living with shoulder arthritis is both challenging and painful. Therefore, it is recommended patients with a weak shoulder, undertake preventative measures to avoid developing the condition.

Exercise of the joint is highly recommended to both keep it moving and to build up its strength. A physiotherapist can recommend specific exercises to help build up the muscle and prevent injury. However, it is important to note that shoulder arthritis cannot be fully prevented.

As there are many different causes of shoulder pain, patients are advised to seek a proper diagnosis before seeking treatment. Arthritis of the shoulder is just one condition which could be causing shoulder pain. Book a consultation with a shoulder specialist today to get to the root cause of the problem and identify the best course of treatment.

5 reasons for shoulder pain that have nothing to do with old age

shoulder pain causesThe shoulder is one of the most-used joints within the body, so if something goes wrong, it can severely impact your range of motion, as well as cause significant pain when carrying out daily tasks.

Shoulder pain is often associated as a sign of getting older. However, there could be many potential causes and identifying the cause of shoulder pain is, therefore, key to getting the right treatment. So here, we’ll look at 5 reasons why your shoulder hurts that have nothing to do with the ageing process.

  1. Shoulder Instability

Shoulder instability can occur either through overuse or as the result of an injury. It occurs when the head of the bone of the upper arm is forced out of its socket. This can either cause a full or partial dislocation.

A partial dislocation is known as subluxation, with the bone coming partially out of its socket. A full dislocation occurs when the bone comes fully out of the socket. The muscles, tendons and ligaments surrounding the joint are usually weak, allowing the bone to dislocate out of the socket.

Shoulder instability can cause pain in the shoulder, as well as down the arm and neck. You may also be able to feel the joint coming out of place.

  1. Shoulder Impingement

If you feel pain in the shoulder when raising the arm up, it could be down to shoulder impingement. The condition occurs when the acromion, or top of the shoulder blade, places pressure onto the soft tissues as the arm is lifted. If left untreated, it can lead to tendinitis and bursitis which would limit movement as well as cause pain.

  1. Frozen Shoulder

Otherwise referred to as adhesive capsulitis, a frozen shoulder refers to a stiff, painful shoulder. It occurs when the tissues surrounding the shoulder joint become inflamed. This causes the tissue to start to shrink and become tighter, leading to issues with motion and pain.

There is no sure cause of frozen shoulder, but exercises can help to rebuild the strength in the shoulder and improve the condition over time.

  1. Rotator Cuff Tear

Rotator cuff tears are extremely common, and they can significantly vary in severity. They are caused by either an acute injury or through overuse. The tears can either be full or partial and the severity of the pain can also vary.

Strength and motion loss typically occur with this type of shoulder injury. Patients also often report trouble sleeping because of the pain.

  1. Radiating Pain

Sometimes, the pain in your shoulder could be down to a condition of the neck or spine. This is known as radiating pain and it typically presents as tingling, a burning pain and numbness. It could be there has been an injury to the cervical disc which is causing pain within the shoulder.

These are just some of the reasons why your shoulder could be causing you pain and establishing the cause and severity of the problem is essential to ensure optimal treatment. Book a consultation with the London Shoulder Specialists today to get to the cause of your shoulder pain once and for all.

How long does a fractured shoulder take to heal?

Injury to the shoulder can result in a shoulder fracture of either the humerus (the ball part of the joint), the clavicle or collar bone or the shoulder blade (scapula) and recovery can vary dramatically depending on the location and extent of the injury and whether it requires surgical treatment.

How do I know if I’ve fractured my shoulder?

Types and locations of shoulder fracture often vary by age. If you’re suffering from shoulder pain, swelling, bruising, a lump at the site of the fracture and an inability to move the arm or raise it above the head.

  1. Clavicle Fracture: the most common shoulder fracture, particularly in children, is a clavicle fracture. The clavicle is the long, thin bone that extends from the base of the neck out to the shoulder and it can occur at any age. It is usually the result of fall or contact sports.
  2. Scapula Fracture: fracture of the shoulder blade or scapula is most rare and can be seen after severe trauma such as a car accident.
  3. Humerus Fracture: the humerus is the long bone that runs from the shoulder down to the elbow. A proximal humerus fracture occurs at the top of the bone, either at or just below the humeral head, or ball part of the joint. Fracture of the humerus can happen at any age but is more prevalent in the older population, often presenting as a crack in the bone resulting from wear and tear.

A shoulder fracture is often described as displaced or non-displaced. The majority of this injuries are non-displaced – almost 80% – which means the broken bone fragments remain in their correct anatomical position and typically heal well without surgery. The arm is kept immobilised in a sling while the shoulder fragments heal, which typically takes six weeks depending on the extent of the injury. A severe fracture can take up to three months to fully heal.

However, the remaining 20% of shoulder fractures are categorised as displaced. The bone fragments are separated and require surgery to restore normal anatomy. A high risk of developing arthritis in the future is another reason why surgery might be recommended. Within a week or so of surgery, you will be advised to start your physical rehabilitation programme to recover which again can take between six weeks and three months depending on how severe the initial fracture was.

It is important to note that a fractured shoulder is often accompanied by injury to the tendons or ligaments of the shoulder and if you are not recovering how you expect, there may be another shoulder injury that is impeding your progress.

Shoulder Stability Index developed to help predict treatment outcomes

shoulder instability treatment in athletesA new Shoulder Stability Index has been developed in order to help predict non-surgical shoulder instability treatment outcomes in athletes. The results of the study were presented at the annual meeting of the American Academy of Orthopaedic Surgeons and have proven promising at helping to identify the best possible treatment plan.

Here, we’ll look at what the study revealed and how shoulder stability indexing could help with the treatment of young athletes.

Understanding the shoulder instability study

The recent study carried out by John M. Tokish and his colleagues, analysed 57 adolescent patients who had presented with anterior shoulder instability for the first time. All had received non-operative treatment and were high-school athletes with at least one season remaining.

Their specific risk factors were evaluated individually and those deemed to have a higher predicted risk of failure were put into a 10-point Non-Operative Injury Severity Index (NISIS). The resulting score was then used alongside chi-square analysis and regression analysis to identify the overall predicted failure score of non-operative treatment.

There were six factors in total which were identified as potential risk factors and added into NISIS. These included patients who were aged over 15, the type of sport performed, the type of instability, bone loss, arm dominance and female gender.

Out of the 57 patients, 79% were able to fully return to their chosen sport without surgical intervention. They also didn’t miss any time out because of their shoulder instability. Those who had a preoperative score of >7 had 90% rate return to sport, while those who scored <8 had a 50% return to sport rate. This clearly shows that the higher NISIS risk patients would benefit from a more surgical approach.

Further studies will now need to be carried out to independently validate the stability index. However, it is already showing promise that it could be used by physicians to help decide which form of treatment to use when young athletes seek help for shoulder instability.

What is shoulder instability?

Shoulder instability is a very common shoulder issue, where the ball is unable to stay securely within the socket. This largely occurs when the structures around the joint of the shoulder stop working correctly.

Patients often discover they have shoulder instability when the ball partially slides out of place, causing subluxation. This is basically a partial dislocation. It presents either as a dead arm, or there could be significant pain.

The instability can occur in either the front of the joint (anterior instability), or at the back of the joint (posterior instability). However, the most common is anterior instability, which is what the study above focused on.

Treatment options vary depending upon a number of factors. However, non-surgical methods are almost always chosen as a first course of action. These can include physiotherapy sessions which aim to strengthen the joint and keep it in position. Non-surgical treatments are usually carried out for a few months before it can be determined whether or not they are working.

The new study is an interesting development, showing NISIS shoulder stability indexing could help to determine the best course of treatment for patients presenting with shoulder instability. However, it is uncertain when it could be introduced due to further testing requirements. In the meantime, patients who are concerned they may have shoulder instability should seek treatment as soon as possible to prevent the condition from worsening.