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So just to introduce myself, my name is Mark Jackson. I work as a Consultant Orthopaedic Surgeon and am now predominantly a knee specialist.

I get referrals from across the country, predominantly through general practitioners, physiotherapists, A&E departments and other surgeons. This can involve treating and assessing patients of all age’s right from the age of 12 up to no limit upper limit really, I often see patients well into their 80’s and 90’s. Children who are under the age of 12 tend to be looked after more through the pediatric system.

I am based predominantly here in the UPMC Sports Surgery Clinic. I also work a little bit in the Blackrock Clinic, but my practice is then split pretty much down the middle between looking after patients with sports-related injuries and issues, sometimes we call these soft tissue injuries and those that are more degenerative in nature which for the main means problems with arthritis.

So just to go through a few aims of today’s talk, clearly, we would all like to look like the runner on the right here but I just want to give you some basic anatomy so that we can understand the common conditions that we deal with, go through some of the more frequent conditions that I tend to see in the running population, explain often what a role of a knee surgeon can be and give you then a walkthrough and a talk of some examples of patients I have seen in the last few weeks, then just finding a few general tips and advice for people out there who are currently running or perhaps wondering about their injury.

Anatomy is key to any surgeons life and we need to know this in a lot of detail, but just basically if we look at the picture on the left hand side here this is a picture of a knee from the front with obviously all the skin and fat removed and we can see a few things that we may just touch upon today.

The top is the muscle the quad muscle, quad meaning four so there are four bellies of muscle if you like that blend together to form a quadriceps tendon that is seen in this area here blending onto the top of your kneecap and then below the kneecap is the patellar tendon attaching onto the top of your shin bone here in the tibia.

This whole area is called the extensor mechanism – a very common source of pain in runners. The iliotibial band we hear an awful lot about and that’s this structure here but it extends a lot higher than this right all the way up towards the pelvis and if we look at the structures then on the right with a lot of muscular and soft tissues now removed we are going to be seeing the bones which as we mentioned the tibia being the shin bone, the femur which is your thigh bone, the kneecap here is the patella is reflected out of the way just for the picture.

We can see the joint surfaces which are usually very smooth and have low friction. We see ligaments in the middle so we hear a lot about the ACL the anterior cruciate ligament and then in between the bones there are these things called the meniscal cartilages and you have got one on each side of the joint. We will touch upon a few of these issues as we go along.

If we look at these pictures, the picture now on the left-hand side of the screen is the dissected cadaveric specimen with the knee opened up. Again we see the joint surface here this lovely, smooth, glistening surface. This area here under the LFC is the lateral side if they need the later thermal condyle, this is how it should look.

On the inside of the knee on the medial femoral condyle, there is a patch here somewhere developing, not too bad but it is certainly happening in this specimen and the ligaments in the middle. If we were to put a camera in the joint down here and have a look, this is what the viewers get in our keyhole surgery procedures, this is called an arthroscopy. The camera there shows us the meniscus here sitting wedged in between the surfaces and again in this example here this is completely normal with lovely white smooth articular joint surfaces

The last picture on the right-hand side again shows how these meniscal cartilages one here, one here, wedged in and interposed between the weight-bearing portions of the joint.

It’s important just to understand the differences when we talk about the term cartilage. The meniscal cartilage is often referred to as torn cartilage. So if someone says they have torn cartilage, they’re referring to these things here meniscal cartilages.

The joint surface cartilage we often refer to as chondral, or articular cartilage, and that’s these white smooth surfaces.

Half of my work I mentioned is on sports-related issues and soft tissue injuries. Just to give you a few pictures here the top three pictures of keyhole surgery is looking after meniscal cartilage damage, so here is the tear and this is when we removed it. Here we’re doing some stitching and repair of cartilage and things can get quite complicated. We tend to sometimes offer this in very specific indications in sports injuries only.

The bottom three pictures are maybe more the ligamentous type work we might have to deal with, with the middle picture at the bottom being a very typical torn ACL, or anterior cruciate ligament. Once we’ve cleaned it out, we put in a new one in for patients who are desiring a return to their sports, in particular, it would look like this and this would be a before picture, and after picture when we reconstructed and made a new ligament.

Then finally this last picture on the left is when we have to open surgery for complex injuries when somebody has essentially dislocated their knee and tore apart lots of these structures, we’re talking about.

Then the other half of the work will be the more degenerative and arthritic problems. Just a few examples here, what we might end up having to do for people, top left are the two components of what we call a partial or half knee replacement. This is a full total knee replacement. This would be somebody who’s having to undergo another knee replacement so this is a revision total knee replacement, and this is a procedure called an osteotomy.

This is a younger person with arthritis that we’re trying to delay this individual getting a knee replacement, but don’t assume all these people are old – plenty of these patients we see are in their 40s and 50s. It is not infrequent that we’re doing new replacements on people at that age. Most however are going to be into their 60s and 70s.

How common is a runner’s knee injury? The answer is extremely. You go to any race, you are going to see if people are like in these pictures all taped up wearing straps and bandages. This article here is from the American Journal of Sports Medicine, which is probably our most respected journal within orthopaedic surgery and sports sciences.

It looked at a two-year study on 300 runners who were initially uninjured and followed them up respectively over two years. They’re aged between 18 and 60 and running for at least 10 months per week, and at least one overuse injury was sustained in two-thirds of these individuals over that two year period, with at least half of those individuals getting more than one injury.

If you have picked up an injury and you have a problem, what tends to happen next? People will discuss usually with friends, their family, maybe some fellow runners and people who have had similar experiences and what did they do.

The next step might now be for people to pick up their mobile phone and type things into Dr Google and see what their advice is there online. Maybe they decide to take a break from running for a bit and see what happens, see a physiotherapist, maybe some treatment has begun. If things go well and things settle down, fine, but if not, maybe then is taken further. Maybe a sports doctor gets involved, maybe patients go straight to their GP. Then obviously orthopaedic surgeons can become involved too. I would see patients sometimes referred directly to myself, straight from a physiotherapist or even self-referrals, or sometimes we are the very last people to be involved, because everything else has already been tried, tested, and maybe it is found.

When I do see patients nearly everybody I see is going to have had an MRI scan, and that certainly helps me to give the individual the best diagnosis I can possibly give them and give them a guide to what the best treatment options going forward are likely to be.

So one of the common conditions, we won’t go into this in too much detail, these issues here are very, very common. The tendon type pains, quadriceps tendon. The patellar tendon, hamstrings, and these are the issues also commonly seen.

They can be however divided up a bit more simply into two groups. We have the overloading and overuse type injuries, and we have the degenerative type problems and injuries.

The overload injuries are a bit different, they tend to be fine, they tend to resolve – as long as appropriate treatments are initiated, which are generally non-surgical, and these then can be reversed with most individuals attaining a good outcome. They are also in the main preventable. This picture here just shows a schematic picture of a patellar tendon being inflamed, tendonitis being a very common condition.

The degenerative issues however are a bit different – these are irreversible and need a little bit more careful management and advice. Surgery can occasionally play a role. Is degenerative change inevitable? Yes and no – some people are lucky they escape and they don’t seem to get too many problems, but everyone gets older, everybody’s going to get grey hair and wrinkles. I’m afraid people’s joins do start to show you the strains of the ageing process and some just get it earlier in life more obviously than others.

So what is overload and overuse? Well, it can begin really with some risk factors, those are going to be usually patients have some inadequate strength or strength imbalances, maybe they have quite poor running biomechanics and some inappropriate training regimes. Then there becomes this imbalance and it’s the imbalance between what the body can cope with and respond to what it can heal, and against the load that’s being delivered. If there is too much load and the body can’t respond to it, and heal and become accustomed to that new pressures and loads, then there is this imbalance and overload problems can begin

The majority, as we’ve said, are manageable without surgery. Most of them will have no long term consequences with regards to the development of osteoarthritis, but it is important to have somebody guiding individuals, taking on board advice from experienced therapists, and the sports medicine doctor or GP can sometimes help out. Sometimes investigations are necessary, and injections are necessary, maybe we need to rule out other pathology is there an issue with the spine, is there an issue with the hip, are there rheumatological conditions? So there are sometimes further investigations that are warranted but for most that isn’t going to be necessary.

So what is my role as a surgeon? Well, I can be a good cop or I can be a bad cop. We need to obviously assess the condition, we need to usually take a good history, we’ll examine the knee, and see what we find, help them come to a diagnosis. Interpretation of the imaging and giving this context. The radiological reports vary in quality from around the country and from radiologist to radiologist.

It is really just detailing what is seen on the scan and as we say we don’t necessarily treat the scan we treat the man, so we have to put it in context for individuals and explaining what is relevant and what isn’t relevant. Hopefully, though we are able to then guide people and get them back and keep them running, and if we do that generally then that’s the good cop side of things.

However, we also sometimes have to advise unrealistic expectations, bring people back down to earth a little bit, and also counsel on potential long term issues. In some of my role as well as being a surgeon, which is obviously what we’re trained to do, we enjoy a lot of it can sometimes be a bit of counselling and advising that it is time to perhaps stop running.

The challenge that we face sometimes in a runner’s knee is that both of us see it differently, but we have very similar goals – we both want people to be active. We want people to stay involved in the things that they enjoy doing, but we also don’t want to do this at the behest of having long-term problems.

The runner I see is often very anxious about having some time out, wants to obviously improve symptoms and pain, and some patients are often incredibly surprised that they have picked up an injury. There is often an expectation that we’re going to be able to fix everything and have a very quick fix for it, but you may be saying I have a race coming up in four weeks, I’ve committed to doing a triathlon in Barcelona in two months-time.

We also get a lot of individuals in the current day and age stating that they want to be able to keep running because it’s so important for their mental health. From a surgeon’s perspective, I need to make a diagnosis, I need to know what I can offer somebody, and clearly want to give that person the best route possible to their highest possible function, but we do have that responsibility too that we don’t want people to damage themselves irreversibly and warn of potential implications that can occur down the line.

I don’t want to offend anybody here obviously but there are some challenging runners out there. The retired sportsman or woman who is a keen runner can be a difficulty, they may have picked up quite a few issues in the past, they may have had cruciate ligament injuries or reconstructions, they could have cartilage surgery from their teens and in their 20s, and this is now catching up. That can be sometimes difficult to take.

The runner who is constantly injured, going from one injury to another, from the groin injury to the heel injury, to their knee injury – again these are difficult and challenging people often don’t have quick fixes and aren’t necessarily sometimes taking on board some of the perhaps preventative measures that can be instigated.

The weight runner, again, a bit of a challenge, putting a lot of pressure and force on joints and running in my experience for people who are overweight isn’t necessarily the best way to control weight, certainly not in the long term, there’s usually a lot of other things that should take priority, with regards to diet and lifestyle over just being out running.

Running as a physical job can be a challenge, somebody who’s on a construction site all day or someone who’s farming, who is very heavy on their knees, and that expects to be able to run that evening and over the weekend during long distances that can be quite a difficult need to manage.

The inexperienced and new runner, often in their middle ages. They can be difficult because they’re coming into things maybe with a very poor baseline of fitness and they are enjoying their new running, and they’re feeling the benefits of being able to bounce and being healthy and active, and then gets somewhat surprised when they run into difficulty and have complaints and issues that can’t easily be fixed.

Then there is the perpetual knee abuser – somebody who isn’t listening to the advice, is getting sore swollen knees and keeping on going, has an operation keeps on going, has another operation keeps on going. But eventually usually the penny does drop and people come to terms with their challenges.

As a surgeon, one of my roles is clearly who needs surgery? Actually, for runners, it’s relatively few, but there are some specific indications that we can sometimes help with, as we’ve said the majority of injuries in runners can be resolved with a good diagnosis and expertise from a rehabilitation program.

We do need to have some realistic expectations though, and patience is very important as the change in strength, the changing of biomechanics takes time. This is not necessarily just measured with a few physio sessions over a week or two – this can take months and months and it does often require motivation and dedication.

So just to go through a few surgical examples of patients I’ve recently looked after. This is a very elite level runner in fact hoping to make qualifying times from 1500 meters for this year’s Olympics for Ireland and was referred with symptoms of mechanical nature, symptoms of locking and jamming, and overall it’s fairly unusual to see elite-level runners with knee problems.

It’s a somewhat unusual referral, but he had a very clear problem, he had a condition with osteochondritis desiccants, and what we can see here in the keyhole surgery is me retrieving a loose body that’s floating around in the joint, and this has been generated off the joint surface here. When it moves around in joint like this it can get pinched and caught, but as soon as it’s removed the symptoms resolve and he made a very quick rapid recovery and was back running within about three or four weeks, and is now back up to speed and back on track again hopefully for his goals going forward.

This again is a common presentation – a 41-year-old recreational runner, as a physical job. There was no injury, came on gradually and steadily, but he’s now got to the point where he’s had to stop running, pain is interfering with life, maybe sleep, maybe he’s waking at night and he is limping.

When we put the camera in the knee, this is the problem, this is a tear here in the meniscus in between the joint surfaces. However, the rest of his knee is perfect. This is the other half of his knee, with a normal meniscus and normal joint surfaces. These surfaces are normal, so when we take out the tear which is what this picture is here, so this is the before picture and this is the after picture because the rest of his knee is normal, he can have a very good outcome and indeed he did go back into things and settled very quickly.

This is a similar type of issue and there is a meniscal cartilage tear. It is a bit different, it’s more degenerative and again we can clean this up. So this is taken to this, but the difference, in this case, is that there is some joint surface damage starting. We have to take this a little bit more cautiously because there is the propensity for this to still cause a few issues and pains, and if this progresses over the next few years then it could be more challenging for that individual to stay involved in these kinds of impact and running type activities, and as is often the way there are similar symptoms also developing on his other knee.

This would be an overload problem, again recreational runner. We’ve seen quite a lot of that in the last 18 months with people perhaps doing more running, the normal increase in the load, running more days, maybe running frequently, maybe running for longer distances. This is a reaction in the bone, so in this MRI scan this is a view of the knee from the front. This is the femur, thigh bone, tibia here, and in this bit of bone, you can see a white pattern. This is a side view showing the same pattern in the bone. What this represents is bone stress, bone bruising if you like or bone oedema.

This is indicative that this bone isn’t enjoying this new load and is reacting because it isn’t getting a chance to heal. This though is in the background of the knee that otherwise looks good. So again, this is rested and protected, the bone will heal, symptoms will usually subside, but it can take time, and this type of condition can sometimes take at least three months, sometimes longer, before we allow that person to then start to up that load and increase their running again, and in the background need to be seeing a physiotherapist to be working on their strength and seeing if there are some preventative measures that can be put in place before that person returns into their desired activity.

This thing gets a little bit more challenging because this is now significant arthritis in a young age. This individual again has been a regular runner over a good few years, and seems to remember there was an old hurling injury, probably tore his ACL ligament, but didn’t need any surgery at that stage, but he’s now at the point where on the scan that this is a very worn-out joint, and when the camera is put inside the knee, there are areas of bare bone rubbing on bare bone. So this is now 100% game over for this individual. This they have to accept, there is no good fix for this, and running is unrealistic. However, there should be other activities we can get this person into the gym, bike, cross trainers, weight training, and we can then hopefully maintain some good function of years, but we’ll have to accept that there are more major surgeries down the line, and we need to delay these for as long as we can.

Somebody who’s been overweight and running as we’ve mentioned can be a challenge. This individual weighs 120 kilos and is using running as his way to control his weight. However, now he’s getting arthritis in the knee underneath the kneecap here on his scan. He also has a poor program of running, very poor basics and is weak. This is very vulnerable to progress and it won’t be long before other areas of his knee also catch up and start to wear down. This is not again a surgical case, this is just about education, telling people what’s going on, interpreting the scan and giving the expectations going forward. This individual needs to now look at alternative ways to control weight as opposed to the impact of the activities and running.

One final case again premature osteoarthritis again in a very active individual in their 40s who has been heavily involved in doing triathlons and long-distance running over about a 10 year period. This is on the background of having a previous cartilage surgery, about 10 years ago. These are both of the knees, the right knee here is bone on bone with a stress reaction again bone oedema, and the left knee less advanced changes, but this right knee, in particular, is in big trouble, his left knee may settle down. This gentleman has persisted with his running despite being sore, hasn’t really listened to his knees. By the time it comes to get attention and be reviewed, things have really moved on, and again this is an individual who probably will need treatments down the line and it is a matter of not delaying this for as long as we can.

Then we get the serial abusers. This would be somebody who’s very vulnerable to getting problems, a daily runner, someone who every single day goes out running without rest and does nothing else, and has been aware of symptoms over time but is now getting worse, still running though, determined to keep running, not prepared to take time out and rest, and as well as the run will often walk for 10 kilometres a day. So what’s happening now is this person is getting arthritis again similar to the overweight case we just discussed, with the kneecap wearing out in front of the joint, but there’s also a stress reaction and stress fracture here in the inner side of the knee. Although this may settle and improve if he/she doesn’t do this can deteriorate quite quickly into a much more significant arthritic problem. So again, education, not necessarily surgery.

A few hard truths about osteoarthritis, it’s obviously great that our life expectancy and things have improved, but it does bring with it the challenges of osteoarthritis, we as yet don’t have good medical treatments.

This graph at the bottom right-hand side shows how the rates of as we say here the prevalence of arthritis in percentage terms is rising through the age groups, so 40-50, 60-70 and 80. At the age of say 70, 40% of the population have screened for osteoarthritis we’ll find that that’s the case.

Prevalence is different to symptoms. A lot of these people still may be relatively unaware of their symptoms, but if we MRI or X-ray people, there are these findings that are developing, and we can see here the significant increase risk and prevalence in women, as compared to men.

Everybody there has an individualized risk, we are not all the same. There are clear risk factors, first of all, a few here, age, and whether male or female, but the other risk factors here which are independent are obesity, which plays a massive role now in the patients we see that arthritis at a younger age, and also those that have significant prior injuries, and the things we can’t do much about like genetics, you can follow your favourite football team and find that there are players who are just constantly being injured, and some of them seem to go through a massive pretty long career without ever picking up much of an injury.

A lot has to do with genetics, how are your limbs lined up, what are the shape of your bones and joints, how is your collagen made up, what are your ligaments like, are you somebody who’s very naturally loose-jointed which can lead to problems, are you, somebody who’s very tight jointed which can lead to problems, are you a responder to training people respond differently? Some people’s muscle hypertrophy comes very easy, some doesn’t, what are your muscle types? There are lots of genetic factors that will probably play into osteoarthritis in itself, some of which we still don’t really understand. We have to remember the surgical treatments for arthritis are often significant and in general, are not going to be procedures that are going to allow patients to return to their running activity.

So, to get towards the end of the talk, my top 10 tips here for runners would be to stay active, but don’t just do running. To get stronger, get some resistance training going maybe get a good rehab person to evaluate and improve your technique. Please don’t try and use running as your primary weight control measure there are other things you can do, and it is important to recognize that the running may not continue forever or you may pick up an injury, so you do need alternative ways.

Similarly, don’t rely purely on running to manage mental health issues – this is clearly a complicated matter, but if you suddenly find you’re out of running for a period of time that can obviously add into anxiety and mental health concerns.

It’s good to get to know an experienced physiotherapist, usually, unfortunately, there aren’t quick fixes or miracle cures and it is important for individuals to accept sometimes timeout is necessary to try to recover and rehabilitate, and you need to listen to some of the warning signs of irreversible joint damage, so in the main, that’s going to be a lot of swelling after activities, stiffness and pain. If these things are happening, please don’t ignore and get somebody to interpret these symptoms for you.

However, if all feels good, and you are managing your load well in your training, well it’s fine to continue, and people will continue well into their 40s 50s 60s and sometimes beyond, but it’s not for everybody at that age group and we just have to be realistic.

In general, even though I’m a surgeon and it is what we enjoy doing in a way and what we’re trained to do, surgery can often be avoided, and it can be a slippery slope. You don’t want to just be looking for quick surgical fixes and find within a few years things have gotten a lot harder to manage.

In summary, we all have the same goals – we want people to be active, we want them to be healthy and enjoy their sports. Most of these conditions that runners will present us with are not going to necessarily be going into anything surgical, and I do encourage you to listen to your knee symptoms, get them checked out if you’re concerned, commit them to some prevention measures which involve some alterations perhaps in your training, and accept that unfortunately injuries relatively common, and you may need on occasion to have a break and some time out.

Supplements is obviously a fairly big topic – the common ones that people talk about are going to be things like glucosamine, chondroitin, fish oils and then there are things like turmeric which are sort of a popular one which people are purchasing and trying at the moment. From a purely scientific standpoint, the evidence for these supplements is pretty weak. People are welcome if they like to try them, some patients I get seem to report that they get some benefit, but scientifically there is no good evidence to show that it slows up the process of wear and tear, rests the process of arthritis or really gives much symptom relief over placebo.

I always tend to say it is up to the individual – they can try it and by all means, they may get lucky and it helps them but I don’t tend to routinely say you must be on this or that supplement. That is the problem with arthritis generally, we don’t have great medical treatments as of yet.

A lot of people might get a few aches and pains – that isn’t necessarily the problem, it’s the degree of pain and the restrictions it causes maybe afterwards. The warning sign in the knee is the knee that reacts badly to that activity that evening and the next day. People may feel that the knee swells within a few hours, maybe you go to bed that evening and waking up with pain, and then coming down the stairs sideways the next morning limping a little bit and then it eases off and then two days later maybe they feel they can run again.

That is a bit of a vicious circle you are getting into. That is what I mean about sometimes listening to the knee symptoms that is your knee telling you there is a problem. I think those are the times I would encourage people to get looked at and maybe get some imaging particularly if there is a lot of swelling and just to make sure you are not running into trouble with significant chondral damage and arthritic issues, but if it is a little ache that doesn’t seem to hold you back too much or doesn’t seem to have like a hangover effect, you are not having to take loads of painkillers and anti-inflammatories, a lot of those can probably be ignored, but it is obviously going to be different from person to person.

Reading the question it is a bit difficult when it is specific to an individual. It sounds like somebody is returning to running after pregnancy. One of the issues with pregnancy is there is obviously a lot of weight gain which puts a lot of stress on the joints and there is also a lot of hormonal changes. Some of these hormonal changes can lead to ligamentous laxity and joint pain in itself and because sometimes a lot of core weakening may happen so with the pregnancy and the stretching of the abdominal muscles and stress on the back, it takes a long time to restore strength in around the core and the glutes. It is not uncommon then that someone even if they have been a runner in the past can return to activity and they are running into a bit of that overload and overuse issue which we talked about in the talk there.

I would think that the predominant thing is to go back to real basic strength and conditioning exercises, work a lot on core. Wearing knee straps I don’t find particularly useful but I know a lot of patients seem to like wearing them. I find it very difficult often to explain to patients what they are doing, the type of straps underneath the patellar tendon and things – I think you are better off going down a goof rehab route as opposed to trying to rely on a strap.

This is one of the commonest knee symptoms for everybody, not just runners, so this is patellofemoral pain, so in front of the knee bone. It won’t think it has anything to do with bicep femoris, which for people is one of their hamstring tendons and I don’t think it will relate usually to the IT band syndrome issues. It is the loading position of the patellar tendon, so that going downstairs is sometimes worse than going upstairs, any single-leg squat, split squats, Bulgarian squats or those kinds of issues and the lunge.

So my feeling on that briefly on the history there would be much more patellofemoral pain, and that can then be the crunching and noises that people get and would be very common in those positions as well, particularly from the patellar tendon joint so the rehab will be focused there.

Again, these are some of those challenging conditions that we talked about there. I don’t know what age this individual is but obviously having had a significant meniscus resection in the past has led to accelerated wear and has now got to what we call unicompartmental advanced arthritis. It would depend a little bit on the patient’s age. Unicompartmental knee replacement is a good option for day to day life but not for returning to running in my opinion. I do partial knee replacements and unicompartmental knee replacements often, but these implants are not designed for running, they are designed to give people a better quality of life in their day to day routine.

Activity expectations are going to be for walking, hiking, and if they do well then they are into the next level of activity which could be your golf, maybe playing some light doubles tennis and that is as far as I usually recommend people take it. Obviously cycling, gym work there are things that you can do but actually going out on the road and running with a knee replacement is not going to be advisable. If you have a uni you want that to last and no moving part lasts forever. If you are in your 50’s and getting a partial knee replacement that is a stepping stone to a total knee replacement usually and you want to look after that knee. So stay active but don’t go into those surgeries with a goal of returning to a heavy impact activity like running.

This is the degenerative meniscus issue, again often you do find people who have very similar experiences on both their knees. Somebody who has got a meniscal tear on one knee obviously been followed up by a similar problem on the other side. Those issues at 55 are evidence really of a degenerative type process that is going on.

I wouldn’t be necessarily concerned about the meniscal tear itself happening again, you would be more worried about the consequences of the damaging meniscus and the damaging joint, so that would mean getting into problems of arthritis, so in terms of having a meniscal tear happening again I wouldn’t be too worried, it is more the consequences of having the tear in the first place that I would be a little bit more concerned with.

All chondromalacia means is soft cartilage and it means chondro is the surfaces of the joint, so soft surfaces of the joint and the common term you hear is chondromalacia patella which is soft cartilage on the kneecap. It is a very umbrella term. It doesn’t in itself mean very much and chondromalacia patella is often talked and it is not usually very responsive to surgery.

In simple terms no, chondromalacia does not usually lead to surgery. It is a process going on of the surface of the joint starting to get a little bit damaged and if it is on the kneecap in particular most sports surgeons would be nervous to recommend surgery for a bit of damage on the back of the kneecap because often it doesn’t change that much, certainly not as much as the rehab probably would.

There are over 30 consultant orthopaedic surgeons based here in the sports surgery clinic specialising in all aspects of the skeletal body: the knee, hip, shoulder, elbow, wrist, hand, plastic surgery, spine, foot and ankle.

Knee Arthroscopy

Some of the common conditions people would present with would be sporting type injuries, the typical twisting knee that people may experience, we do a lot of arthroscopic surgery. For someone who has a meniscal tear, this involves a keyhole surgery where you have two small little nixes and you go in to remove any loose fragments of the meniscus or cartilage tissue and smooth away the loose fragments and that’s a very common surgery performed here.

ACL tear

Anterior Cruciate Ligament tear also typically a lot of athletes would present with that. It’s normally a twisting injury to the knee as someone’s running at pace and goes to step off the foot and turn and their knee will normally buckle on them and cause an ACL tear. What that normally involves is taking tissue from another part of the knee. It can be one of your hamstring tendons or your patella tendon and drill two little tunnels. One on the shinbone and one on the thigh bone and pass the new graft material up and fix it with various devices. The picture on the right is an arthroscopic picture (16:42) of a new ACL graft in place there.

Osteoarthritis

Another large majority of cases we deal with is people with osteoarthritis. This normally presents with chronic pain, long-standing pain, people normally unable to walk very far without getting pain in the knee. You may get swelling at night, or pain at night sometimes and probably needing medication to deal with the pain.

What is Osteoarthritis?

It’s a ‘wear and tear’ process on the knee joint itself, you have this shiny material on the end of the knee joint and it helps a smooth gliding of the hinge joint itself and with osteoarthritis basically you get degeneration of that. The picture on the right (17:48) shows the worn away process. This is what an x-ray typically looks like, you can see the picture on the right is completely worn away whereas the other has a nice gap (18:02).

If you present to your doctor initially you are normally given conservative measures to try and deal with the pain and that sometimes consists of weight loss, exercises to try and strengthen up the muscles around the knee and take the pressure off the knee. Painkiller medication sometimes like paracetamol, anti-inflammatories or other times you may need something Codeine based medications. Another conservative measure may be a steroid injection into the knee and if unsuccessful, the next and final step that you may consider is a knee replacement.

A Knee Replacement is essentially shaving away the ends of the bone on the femur and top of the shinbone and putting a metal replacement on either end of that, then a very strong plastic Polyethylene in between that, and that’s your new knee replacement.

On the right-hand side is a picture of what a typical scar might look like after that operation, and this is what a typical x-ray looks like after the surgery as well.

Another option is a partial knee replacement, this is an alternative where you have a very specific ‘wear and tear’ pattern and it’s only on the inside of the knee you may be suitable for this. The advantages of this are that the recovery time it’s slightly quicker, and some people say it feels more like your own knee than a total knee replacement. This is quite a commonly performed operation here as well and it does get good results.

In terms of the aftercare involved of total knee replacement you’re normally in hospital in total 3 days, crutches for about 6 weeks and then it does take a good 6-12 months before you’re back to feeling some level of normality. The initial weeks can be quite tough, it’s all about pushing through and doing as much physiotherapy as you can afterwards to get the movement and strength back in the knee. So getting some physiotherapy sessions is key.

The Hip

Hip osteoarthritis normally the pain presents in the groin you may not be able to walk a significant distance. You may struggle to put on socks and shoes, you get a lot of stiffness and difficulty sleeping with pain.

How do I know if I need a hip replacement?

In terms of options of treatment available; you should go through the conservative line of management first and if all those measures fail you may be considered for total hip replacement. A total hip replacement involves the ball and socket joint. The hip replacement involves removing the ball part of the joint cutting that away and placing an implant down the shaft of the femur and putting a metal socket in the acetabulum and then that’s essentially the new hip joint formed. This is what an x-ray might look like afterwards and a typical scar (22:10).

How long is recovery from a Total Hip Replacement usually?

In terms of rehab for total hip replacement usually, you would stay in the hospital for 3 days in total and on crutches for about 6 weeks.

Rotator Cuff Repairs

A very common shoulder operation performed here is for rotator cuff repairs. Your rotator cuff is a group of four muscles that for into one tendon at the top of the shoulder and those muscles essentially help you lift your arm up and people who have rotator cuff tears will struggle to lift their arm or reaching for something in the cupboard or putting their arms above their head. An operation that’s quite commonly performed is whereby there are some stitches put into the tendon and then the tendon itself is re-attached to the bone that’s done normally arthroscopically, and one of the most common shoulder operations.

Shoulder Impingement

Another common shoulder operation is shoulder impingement. What happens in shoulder impingement is there’s a little bursa, which is a small fluid-filled sac which sits under the top of your shoulder between the ball part of your shoulder and the acromion where sometimes this can get very inflamed and rather than a loss of power it’s more a pain issue where when you lift your arm you get a large shooting pain or your lying in bed at night you feel pain down the side of the shoulder. And that operation is an arthroscopic procedure whereby we go in and remove the inflamed tissue and sometimes remove part of the bone as well which can be a factor in causing the inflammation in the first place, normally that’s a day case surgery and a very commonly performed procedure.

Shoulder Replacement

For conditions of a shoulder which are due to an osteoarthritic change, you may have a total shoulder replacement or a reverse shoulder replacement if your wear and tear is a result of a long-standing problem with the rotator cuff, where it wasn’t able to be repaired and your general change was a result of that, that’s when a reverse shoulder replacement is considered.

The Spine

One of the most common spinal operations is the spinal decompression for sciatic type pain. Your lumbar or vertebral spine consists of multiple bones on top of each other with a gel-like disc between each one and what commonly happens is some of the disc material bulges out and presses on the nerves either side of your spinal cord causing pain radiating down the leg. The operation involves a small cut in the back, going in and removing that to take the pressure off the nerve.

Foot & Ankle

A very common foot operation would be an osteotomy. It’s essentially breaking the bone and realigning it and then fixing it together with some screws and straightening up the first toe. And the common ankle operation would involve an ankle fusion and sometimes if you’re suitable a total ankle replacement is another common operation.

You must be on the waiting list for surgery within the NHS. When you are applying for your funding you will need a letter to confirm that you are on the waiting list. You can get this letter from your GP or your consultant.

Once you have completed the Republic of Ireland Reimbursement Scheme application form you will have to send this form to the address on the form – The National Contact Centre. http://www.hscboard.hscni.net/travelfortreatment/roi-reimbursement/

They are based in Belfast. It takes about 21 days to get approval and the full amount is paid about three weeks after surgery.

Following your surgery, you then send them a copy of a receipt that you’ve paid and then they will pay you back within roughly three weeks.

The cost of surgery is a significant part of the decision making process for people. All surgeries have different costs involved in them and rather than list pricing we would ask you to contact us directly and we will send you an approximate quote. 

Included in the price that we’re going to give you is your first appointment, your pre-assessment which also would include cardiac echo if you need one, consultation and anaesthetic fees, your surgery, hospital stay. Also now included is your COVID screening and post-op appointments, plus x-ray.

What is not included in the price?

Any additional consultations with other specialists? For example, if you had a heart condition. Or you had a condition with your liver and you even didn’t know about it or it’s a pre-existing condition. So you may need to get clearance before surgery from a specialist. So that’s usually an extra fee of approximately two hundred and fifty euro. You may be able to get your own back in Northern Ireland and get a letter of clearance. Any additional investigations that are not part of the normal pre-assessment screening are not included. We normally do X-rays and ECG, so anything outside of that would not be included.

Appointments and surgery can be completed within about 8 to 12 weeks. Before it would have been 6 to 8 weeks. But with COVID restrictions we have a backlog of work to do since closing. It may vary, but that’s something that is subject to change due to the current situation.

How often will I have to visit the Hospital?
We do try and book all your appointments and pre-assessment on the same day to avoid numerous journeys. If you know for example that you have a pre-existing heart condition, we’ll have to do a heart echo assessment. It would be beneficial to inform the secretary so that we’re including that on the same day to avoid another trip to the hospital.

How long will I need to stay in the hospital after my surgery?
This will vary depending on the procedure you have. At the moment, for joint replacements, the total hospital stay is usually 3 days. More minor surgeries are usually a one night stay or carried out as a day case. Your surgeon will inform you at the initial appointment.

What happens if I need to stay longer?
There will not be an extra charge if you need to extend your stay up to 8 nights. There are local hotels, which are in walking distance from SSC, the Crowne Plaza and the Holiday Inn, SSC have corporate rates with both hotels.

Am I entitled to care following my surgery?
The aftercare we provide will be the same as if you had your surgery in Northern Ireland. You are entitled to physiotherapy in the NHS. It’s very important that you start physio within two weeks of going home so maybe book some private sessions first of all while waiting for your NHS appointment. We can also advise on this if you need the name of a physio.

What information do I need to include on the form?
You are not required to fill out every section of the form, only what is applicable to you. Details that are required; your diagnosis, proof of address, proof of bank details and the letter to prove that you are on the waiting list for surgery. It will ask you lots of questions about prescriptions etc. which may not be applicable to you, or questions relating to being abroad which also may not apply to you.

You are also asked where you are having your surgery and which surgeon?

If you do not yet know this information it is ok to say “undecided at this time or to be confirmed”. Your form will still be processed.
If you have any other queries regarding the form you can contact our team who will assist you with this.

What happens if I need to be readmitted due to a problem with my surgery?
If you are to be readmitted within a month of surgery there is no charge, just call us and let us know there’s a problem and we will arrange for you to come back into the hospital.

Can I book an appointment before I get approval for funding?
Presuming that you are on the waiting list already, from dealing with the Cross Border Directive for the last 3 to 4 years and have never come across anyone that’s on the NHS waiting list who hasn’t received funding. What we are telling patients is to get your application form in, it usually takes three weeks to get approval, and all patients that come down here have their approval before they come down.
If you’re not on an NHS waiting list, you won’t get anything back.

Do you need medical insurance for the journey for treatment?
No, there isn’t any insurance that covers you for that. It is mentioned on the form, but that would be applicable where you have been on holiday when the injury occurred.

What is the typical waiting list time frame for hip surgery?
At the moment, due to the current situation, it would be approximately 8-10 weeks for most types of surgery, which you would have your consultation and pre-assessment all complete before then.

I have Osteoarthritis in both hips and wondering if there is a hip resurfacing procedure?
In terms of hip resurfacing no one at this hospital do hip resurfacing, but it may well be worth seeing a hip surgeon just to go over what the options are, for hip resurfacing it’s normally a very specific indication for that generally the track record of a hip resurfacing isn’t as good as a total hip replacement itself, it may well be worth chatting to one of the surgeons to see what the options are basically. If you’re over 40 you’re probably more likely to benefit from an uncemented hip replacement. The liners that they use nowadays are very good a lot of times they would use ceramic on a poly liner which has a good track record. If you’re hitting over 40, you’re probably more likely to benefit from a total hip replacement rather than resurfacing. We have hip specialists here who do hip arthroscopy as well who are specialised, so if you want to give one of us an email on the GP line, we are happy to direct you to one of those consultants.

What way can payment be made? Is it in Euro or Sterling?
All our accounts are in euro; we can’t accept sterling; we don’t have a sterling account. All our quotes that we give are comprehensive; it’s a package that will include your initial consultation, pre-assessment, your surgeon’s fees, your stay in the clinic, anaesthetists fees, a post-op x-ray, a post-op review, a follow-up review and a COVID screen. That will be paid before or on the morning of admission so what we would say is if you wish to pay that directly to our bank account, please do so about five days beforehand as it usually takes about five days to hit our bank account. And to advise anyone that may be paying by card, I’ve had a few patients that have been charge the surcharge by paying with their card which can sometimes be 2-3% which if you’re paying for a hip or knee can amount to €200-300, so ring your bank beforehand and let them know just to make sure there is no surcharge but anyone paying directly to the bank account seems to be the easiest way. We have an online portal you can go on and put in your card details, and there it will automatically issue a receipt. We do accept Euro cheques; however, we don’t accept personal cheques or cash, for patient’s safety.

Does the price change depending on how long you stay in the hospital?
No, it doesn’t, when we give you the price, we will provide you with an idea of how many days you will likely be in the hospital depending on the procedure. For example, for hips and knees, for a hip replacement, our package would include between 5 and 6 nights, and then we will include night 7 and 8 free of charge. This is really to give patients peace of mind, you don’t want to be in a situation where you have to stay for medical reasons and you’re not covered, so you are covered up to 8 nights and anything over that would be quite unusual, and very rarely go beyond that.

Are ankle fusions performed at the UPMC Sports Surgery Clinic?
Most of our foot and ankle specialists don’t do ankle fusions unless maybe you have a referral specifically for this procedure they could review and decide if you are suitable. If you do have a referral for this procedure, certainly do send it into [email protected] and we can have it reviewed by our foot and ankle specialists, and make a decision.

Will the cross border scheme expire?
The cross border scheme is valid until 31st December 2020 obviously, we have lost 3 months of this year due to the pandemic. We don’t know yet whether they will extend that on to maybe the 31st March 2021 we haven’t been made aware yet. However, once you get your approval it is valid for 9 months.

Are Osteotomies performed here?
We do perform Osteotomies, tibial osteotomies and sometimes femoral osteotomies. Normally it’s either an opening wedge osteotomy of the tibia or closing wedge osteotomy of the femur. But rotational osteotomies, again I don’t think there are any of the consultants here that perform rotational osteotomies, it would be quite specific and probably would need to see the patient to take a look and see exactly what is required. We can take a look at the referral letter and see whether it’s suitable for here or not.

How much is refunded by the NHS?
We have found that it’s about 50-60% that you will be refunded. You are refunded in sterling and the prices that we quote are in euro so just to give you an example so let’s say if you were to come in for a hip replacement, what we would charge for the hip replacement is €12,338 as explained earlier is a comprehensive package, includes everything. What you would get back from the cross border is £6,500 to give an approximate idea of what you would receive back from the cross border.

Would you have to have a Hip replacement before a knee replacement if both are needed?
Not necessarily, it depends which pain is worse. It would be a case of having to review the person to have a chat and assess, but not necessarily no.

How long after a knee replacement would you recommend that someone goes back to work? And what about driving?

It depends on exactly what job you are doing but in general about 4-6 weeks before you can go back, if it’s an office job maybe you’ll get back a bit sooner or if it’s something heavier again it might take a bit longer. For driving it would be a similar time frame as well about 4-6 weeks.

For a rotator cuff, how long will it take to get an appointment?
The current waiting list is about 6 weeks for a consultation and for surgery, roughly about 6-8 weeks.

Click here to download the application form for the  Republic of Ireland Reimbursement Scheme 2021.

RD: There is a spectrum of tendinopathy, and there will always be a normal amount of wear that is seen on an MRI of the shoulder, so it depends how the diagnosis of tendinopathy was made. I would be very slow to make it just based on an MRI image.

If there’s pain associated with it and inflammation around it, it can take time to settle down of the order of months, and it kind of depends whether you’re actively treating it in terms of things like injections or physiotherapy, but that should hopefully shorten it, but I’d say typically two to three months.

NW: I included one in the presentation towards the end, the one where they are sat down using the dumbbell.

Just a couple of points with the exercise, you’re looking to try and make sure you take the muscle to fatigue, because usually when you have pain in a part of the body, you lose strength around that body part, so you’re trying to restore the strength in the muscle.

The other thing you’re looking to try and avoid is pain within the tendon itself. So none of the exercises should increase your tendon pain, and that’s a really important part of the rehab.

RD: We don’t use them that much, the times that we use them are typically for the opposite of restricted movement when somebody has sort of too much movement and instability of the shoulder, we might use a brace for that. If you have something minor that’s kind of restricting movement – often, it probably won’t feel much better with a brace and a brace will just restrict movement even more, so I think it’s the case of trying to settle down the minor injury, but if it feels better with the brace on it is not going to do any harm.

NW: Great to hear they have come out the other side – frozen shoulder can be a bit of a journey to get through.

The main bits, assuming it’s fully recovered and you got full range of motion back is just trying to restore any strength you’ve lost in the shoulder. A general upper body programme, including a couple of shoulder exercises that were included in the presentation, but general push/pull exercises such as working towards full press-ups, any pull exercises or role type exercises is going to be a benefit to the shoulder as well.

RD: Wrist is not my sub-specialist area but in terms of ganglions and cysts in general, if it’s minimally symptomatic it’s okay to leave it alone.

RD: Biceps tendonitis usually up around the shoulder – there are two biceps tendons heading up towards the shoulder. The longer one goes through the shoulder joint and actually doesn’t really do very much of the work the shorter which is outside the joint tends to do most of the work, the longer one that turns a corner and goes up through the shoulder joint is the one that usually gets inflamed when you have bicep tendonitis, up at the top end of the biceps.
Neil can probably speak to this in terms of exercises, often we find that what we call eccentrically loading the tendon, so loading it as it’s getting longer so as we’re straightening the elbow can help. So it’s something we do use physiotherapy for.

For the shockwave therapy question: The thing that I would usually use that for is calcific tendinitis in the rotator cuff – which would be the main indication around the shoulder. Not sure that would make a big difference to bicep tendinitis but you could talk to your therapist.

Neil I don’t know if you have something about exercises for biceps tendonitis that you would have.

NW: You will quite often find people will go to stretching as the main exercise to try and assist with any tendon issue really, that’s one thing that a tendon doesn’t like, you are going to aggravate it even more.

You try and stick to strengthening exercise, if it’s the biceps tendon, making sure everything is strong around the shoulder, but you can do local exercises such as bicep curls to assist with that. As Ruth was saying eccentrically loading it.

If you imagine a bicep curl, being you are bending the arm up and then slowly lowering it will be the eccentric portion of that movement. If you can control that motion, you’ll load the muscle. As it is a tendinopathy, you are trying to avoid pain in and around the tendon site itself – you are loading the muscle rather than trying to target the pain site.

RD: It can vary from consultant to consultant, but in general you don’t necessarily have to have a referral from your GP to come to see me. You don’t need to have a referral letter.

It is helpful if you have your entire medical history and the full list of any medications that you take, but your GP can refer you, your physio can refer you, or you can also self-refer through our website, but your GP will always be informed about your visit, so we will always send a letter back to your GP then after you are done.

FR: I think that’s the same for most consultants, but especially the spinal consultants will always want a referral from a GP or a physio as well, and Neil for sports medicine, you don’t always have to have a referral from a GP either do you?

NW: No, we’re open house so no referral if fine as well.

RD: I suppose it depends whether the pain on the top of the shoulder is coming from the AC joint at the end of the collarbone and the point of the shoulder which would be right there, or it could be a trigger point in your upper trapezius muscle, so it’s hard to tell without someone actually examining which it is.

If it’s a trigger point, then it can respond to manual therapy and sometimes trigger points are injected, if it’s the AC joint that can be injected with steroid and occasionally keyhole surgery, just to excise the little joint. It sort of depends on exactly where the pain is coming from.

FR: Neil any specific exercises on that one, or do you need a diagnosis?

NW: A diagnosis first on that one. Just pop down to a local physio and they should be able to help guide you in a certain direction.

RD: There are a couple of ways that can happen it is common enough. One is that if you have one shoulder that is sore then you’re tending to probably use that shoulder less and you are going to use your other shoulder more.

A bit of overuse of the non-injured shoulder can lead to some inflammation flaring up in the non-injured shoulder. The other way it can happen is just having a sore shoulder on one side can lead to tightness in the upper trapezius on both sides and the shoulder blades can be sitting a little bit differently so you may have pain in the upper trapezius muscle on the opposite side to your originally injured shoulder

RD: It depends on the diagnosis. There is definitely a sort of a feeling out there that injections sort of mask things and aren’t good. That’s the case if there’s a structural problem that maybe needs to be fixed or addressed differently with physiotherapy.

If there’s an inflammatory problem, then an injection of a big-time anti-inflammatory or corticosteroid or cortisone makes sense because we treat the inflammation. So I think that the answer to the question really depends on the diagnosis, and it’s never an injection by itself. An injection may be part of an overall solution.

NW: I think you’re referring to the deadlift exercise in the presentation. It’s quite challenging to load that exercise heavy without dumbbells, but there are loads and loads of alternatives.

Lots of single-leg exercises possible to take at home that are quite challenging just using your bodyweight.

Again there are lots of other options for fitting out home gym & home workouts, stuff like resistance bands can be a very useful tool to do that.

NW: Well, depends on what you’re trying to achieve. If the foam roller makes you feel good, before and after playing tennis, then it’s beneficial. It’s not necessarily going to make any muscles longer or stronger.

Pilates, again it is a personal preference as an exercise form. It’s one of those exercise modalities, it’s quite good for training the abdominals, but in terms of increasing your strength per se, my opinion would be that you would need something a little more challenging. Resistance training would be the best way to deliver that.

RD: Yes it can be. Ice, cryotherapy, there are lots of fancier ways of doing it than bags of frozen peas and they’re probably not different. We use it post-surgery and sometimes for swelling. It can help when there is something acutely inflammatory.

Often we will tell people who have really inflamed shoulders like for example frozen shoulders to use heat in the morning or before they are going to stretch to loosen out the muscles and ice afterwards to cool it down.

So generally I suppose we think of heat as being useful for muscle pain and tightness and ice as being useful for acutely inflammatory pains, so depending on what is going on it can help if you find it helpful it is certainly something we do use.

Yes, there’s a couple of exercises within the presentation, the deadlift, the hip thrust, and the clam exercise – they’d all be great for conditioning the hip.

Just for a labral tear, in some instances they can require surgical opinion, many of them are asymptomatic though and do well with rehab. Just to bear in mind that at some point down the line you might need a little bit more guidance than just the exercises from the presentation.

NW: Yes they can be. Again, probably not to start off with, we use what we call isometric exercises where essentially there is no movement to it essentially you are loading a muscle without moving. The evidence around that is that it has an analgesic effect so it can help calm the pain down.

Eccentric, obviously it depends from case to case – if you go straight into eccentric exercises it can be a little bit too much load for the tendon you can aggravate it more than help it initially. So isometric first and then you generally move on to eccentric.

RD: Usually hypermobile shoulders are more of a problem when you’re younger. As you get older your ligaments naturally tend to stiffen up a bit. As we get older you lose some of that flexibility.

For a lot of people, that’s not good – if you start it out hypermobile that is helpful, because as time goes on you lose a bit of that hypermobility. If you’re still truly hypermobile in the shoulder then the best way that you are going to protect it is by strengthening everything around it.

The hypermobility is going to be the capsule or the ligament layer that’s the deepest layer around the shoulder joint, then you have all the rotator cuff muscles just above that, and then the bigger deltoid and pec muscles around particularly around the rotator cuff muscles and smaller muscles, they are dynamic stabilisers of the shoulder so if you can strengthen those that would compensate for your hypermobility and would protect your shoulder.

NW: With many of the questions we are getting, there are many factors that can contribute towards that. In general, maintaining healthy upper body strength through pushing and pulling exercises isn’t really going to have any negative effect.

It tends to be one of the areas that people don’t do too much of, even if they are training at home and don’t have access to a gym. Training the upper body is actually a really important part of a well-rounded strength-training plan, especially for a sport like tennis where the upper limb is so involved.

Basic pushing and pulling exercises using a resistance band or a cable machine for the pulling. Being able to press up I think is a really important strength skill.

The majority of patients who we would see who are not completing regular upper body training won’t be able to complete a single press up. So there’s a decent starting point to work towards

RD:

Basically what a Hill Sachs Lesion is the shoulder dislocates, so basically if my fist is the ball and my other hand is the socket, the back of the ball hits the front of the socket when the shoulders out and then the shoulders put back in but often a divot has been left in the back of the ball.

This can predispose to future dislocations because now if there is a divot in the back of the ball, it’s easier for it to jump out over the front of the socket, and wouldn’t necessarily restrict the range of motion, but it might inhibit stability.

It depends on what age, the person is. You’ll see a Hill Sachs Lesion after a lot of dislocations if it’s small and shallow, and if the patient is over 25 when they’ve had a first-time dislocation, often they’ll get away without surgery.

If you’re under 25 when you dislocate for the first time there’s a high chance it’s going to happen again and so surgery might be considered. It sort of depends on the exact individual situation, but a Hill Sachs Lesion is probably worth coming and having a chat with a shoulder surgeon.

Good evening everybody, and welcome to our UPMC Sports Surgery Clinic webinar and evening for tennis players.

I know that everybody has been off-court for a long time, with the lockdown and restrictions and this week everybody is getting excited to get back on court, so it is probably a good time to talk about some tennis-related things.

My name is Ruth Delaney, and I am a shoulder surgeon here at UPMC Sports Surgery Clinic. We are going to talk a bit about some things that pertain to tennis and shoulder injuries. My colleague Neil Welch, who is a strength and conditioning coach, is going to speak to you about also some low back issues.

Everybody has been off court for quite a long time with lockdown and restrictions and only this week getting excited to get back on court. One of the most important things is going to be warming up and stretching properly and Neil is going to take you through some exercises that are going to help with all of that.

I am going to talk about a few other things to do with Tennis, and then we will get into some shoulder things.

So let’s talk about Tennis and where better to talk about Tennis than from Wimbledon, although I wish I was actually there – who knows if anybody will get to be there this year.

Tennis has been part of my life for a long time – my parents took us to Garryduff, which was up the road from where we grew up and put us on the tennis courts there. We were really lucky to get this background in Tennis, lucky that there was a young coach there named Declan Gray, who was willing to teach some kids how to play Tennis. It was for quite a number of years a big part of life, and it is really a great sport, so I am glad that we can do this evening, and talk about Tennis and the shoulder.

I did most of my shoulder training in Boston, having graduated from UCC and got to train at Massachusetts General Hospital on the Harvard Orthopaedic training programme. Then as a shoulder fellow in my last year of training doing just shoulder surgery, I spent time in France in Annecy and Lyon before coming back to Dublin in 2014.

Shoulder Pain

Shoulder pain is really common – up to 70% of us are going to experience shoulder pain at some point in our lives, and about a quarter of people who have shoulder pain, it is not their first time having it. It can have a significant effect on people’s lives in terms of sleep disturbance and work absences, and so it is something that is a really important part of musculoskeletal medicine.

Tennis Equipment

One of the things if you are dealing with a shoulder or arm injury and playing tennis or if you are trying to prevent running into trouble with your shoulder is to have your equipment optimised as best as you can and so talking to your tennis coach or club pro about that is really helpful as well. So with tennis rackets – everyone has their own preference. I have had these tennis rackets for a long time, and they suit me really well.

The grip size is really important, and that is something that is worth taking a bit of time to talk to whoever you are buying a tennis racket from, talk to your coach and have a look – because if you have a grip size that is too small, then you are going to be gripping your racket really tightly because you have to in order to hold on to it. That is going to lead to strain coming up here, which is where we get problems with tennis elbow and can lead to problems with your shoulder.

If you have a grip that is too big, you are not going to be able to get your hand all the way around it, and you may run into trouble with your wrist. Having the right grip size is a really important place to start to prevent injuries and not to aggravate any underlying issues that you might have.

One of the simplest ways that I was taught when I was growing up playing tennis to figure out what grip size I should have, was just to have my hand on the racket in my regular forehand grip or semi-western grip or whatever you like and then see when I fit my thumb in between my fingers and sort of the heel of my hand here what we call the thenar eminence, put my thumb right here. If that fits nicely there and there isn’t a huge overlap or big gap, then I have got about the right size grip for me because all of us obviously have slightly different sized hands, so finding the right grip size for your tennis racket is going to make your arm, your elbow your shoulder much more comfortable when you are playing.

The other thing with your racket is obviously your strings – I am guilty of this, I have not restrung this racket in ages, and that is because we have not been playing a lot in a long time, and I think most of you out there are probably the same. So before getting back on court, it is good to check-in and get your racket restrung.

Your club coach will be able to advise you on whether there is someone in your club who can restring your racket for you and get advice about the type of string and the tension that you want to put in it, depending on whether you are somebody who needs help generating more power, so you might want to go down on the tension a little bit, so that you are not trying to use your shoulder and elbow to generate all of the power, or if you are going to go higher on your tension that is going to give you a bit more control and there are lots of other things about the type of string and all sorts of variations.

So again, get advice from the professionals who can help you with that, and that will not only help your tennis but help keep you out of trouble with injury as well. Some players used to like shock absorbers on their strings – that is a personal preference, a lot of us find they just damp the feeling, and it is sort of a different sensation when you are playing. They have kind of gone out of vogue a little bit, but some people still like them if they have trouble with tendonitis issues in the wrist & elbow, and the vibrations coming through the racket. Your strings are important as well, and your grip size and getting good advice on all of that before you get back out on court can really help.

So this week, everybody is looking forward to getting back on court. Some people have maybe already gotten back on court since Monday. I think there are lots of different aspects to that.

Adult players and seniors who like to play doubles all the time are maybe feeling a bit upset that doubles is only possible with people in your own household, and maybe not so comfortable playing singles. But if you’re smart about it, everybody can play singles. Maybe you just play in half the court and use the tramlines. Maybe you realize that for the sake of your shoulder or the rest of your body that you’re not going to serve overarm all the time because remember when you’re playing singles, you’re going to hit double the number of serves, but everybody can get back out and play singles in a way that works for them.

I think a lot of the juniors have been very frustrated with all the time away from courts or maybe trying to find some ways to hit on court somewhere, but it is okay if you went a few months without hitting – it will all come back, it will all catch up. For the juniors, too, being smart in terms of warming up properly and being patient to get back into your rhythm, and everything will start to happen again.

One of the other things about gear that we sometimes forget about is the tennis balls that we’re using, and especially in our Irish weather, it doesn’t take long for the tennis balls to get damp and wet, particularly if there’s a bit of rain out there, so depending on your tennis balls, this one’s been used a bit it’s kind of starting to fade it’s still perfectly fine to play with, but after a while, tennis balls may start to get wet, and there’s absolutely nothing wrong with opening new tennis balls halfway through your session.

It is not just the pros who get to say new balls please every seven games – okay, it adds expense, but if you’re somebody who has trouble with your shoulder or elbow playing tennis, then it’s something to be conscious of if it’s a wet evening and you are playing tennis. It might be an idea to bring an extra set of balls and halfway through just to open a new set of balls so you have a nice, light, dry set of tennis balls, particularly to be serving with so you’re not putting extra stress down through your shoulder when you’re hitting.

Tennis & The Shoulder

The serve is probably the best example of the complex biomechanics involved in tennis and how when they don’t happen the way they should, and the shoulder can get in trouble. This is from a recent article published by Alan Curtis and his team from the New England Baptist Hospital in Boston. This diagram shows us the phases of the serve and starts to get us thinking about what we call the kinetic chain.

There are a couple of things about your technique when you play tennis that can help save your shoulder as well. I’m no tennis coach. When I did my level one coaching qualification as it was called back then (it was quite a while ago, so I’m pretty sure it’s out of date) – your tennis coach in your club and your own tennis coach can work a lot with you on things that can help if you have an injury or if you’re trying to prevent an injury.

There are a few basic things that we’ll mention tonight just to have you think about as you get back on court – one of them is footwork.

It’s easy to get lazy about footwork and not get your feet in the right position so that if the ball is out there, we’re doing something like this instead of actually getting our feet there, and that’s going to help you in terms of saving your shoulder and your arm so getting yourself in the right position early whether it’s singles or doubles that you’re playing, that’s going to be important.

So if you’re hitting a forehand, that will often start from the ground up, whether it’s an open stance or more closed stance, you’re still going to get yourself ready and have that body rotation and lead with your hip rotation so that it’s not all coming from the shoulder and so that if you do have any issues in your shoulder, you are protecting your shoulder by actually using the rest of your body. The same applies to your backhand; whether it’s a one or two-handed backhand, or whether you’re hitting a serve, it is going to come from the ground up, legs, hip rotation, trunk and only then your shoulder and arm and so that is something to work on with your tennis coach at your club.

So thinking about all of that, then it is the legs from the ground up, the trunk, the shoulder girdle and then the upper extremity or the arm. We run into trouble if it is all coming from the shoulder. The legs and core should provide a stable base. The shoulder blade is key – it is a stable platform for the shoulder to function in general, not just in tennis. It protects the rotator cuff if the shoulder blade is working properly, and something that we call scapular dyskinesis, or basically the shoulder blade not moving the way that it is supposed to, gives a really high increased risk of shoulder pain in overhead athletes, including tennis players.

There are these key points during a serve action, for example, that are referred to as nodes when we are talking about Biomechanics. If any one of those isn’t happening correctly, then it can lead to another downstream effect that can result in injury and overuse and again, this is from Curtis’ paper. I think it is interesting to just think about this – that your foot position can affect what is happening with your hip and your trunk, same with your knee motion as you go into a knee bend and then extension through contact with the ball and all the way up.

The scapula and the shoulder are almost like a funnel directing all that force from the ground up towards the arm and then finally into the racket and into your serve. All of these things are important in protecting the shoulder when you play tennis, and that is why the tennis coaches spend so much time getting all of these things right for their tennis players.

Shoulder Symptoms

In terms of shoulder symptoms that we see – a lot of times, it is shoulder pain as the main reason why people come to see us. It can also be stiffness or weakness. Sometimes it can be an issue with shoulder instability.

It’s also possible that some symptoms that you feel around your shoulder can be coming from a problem with the neck, and there can be overlap between a shoulder problem causing neck pain or a neck problem causing shoulder pain. Sometimes we end up looking at both.

When we assess shoulder problems, we take a history, try to figure out the pattern of what’s happening, and then examining the shoulder gives us a lot of really useful information. Usually, we will want some imaging – sometimes X rays are more useful, sometimes an MRI is helpful. It depends on what’s going on with the shoulder, and sometimes we use other things like CT scans.

Four of the main things that we see with shoulder problems are the rotator cuff that you’ve probably heard of, frozen shoulder, which is quite common, arthritis of the shoulder and often in younger, overhead athletes, there can be issues with instability or tears of the labrum, which is the cartilage bumper around the socket of the shoulder.

In Tennis players, there can be very particular patterns of those labral issues in younger tennis players – often those are things that we do not treat with surgery.

When there are problems that we consider shoulder surgery for, I think it’s important to get advice from a shoulder specialist, there are a lot of things on the internet out there, and you have to be careful where you get your information.

A shoulder specialist will walk you through the risk/benefit balance of considering surgery or non-operative management for a problem.

What’s really important for active people like tennis players is, of course, the recovery time, the rehabilitation involved, how long you’re going to be out of action and preparation for the surgery is important as well.

Knowing some of the background of what’s involved in your surgery is the job of the shoulder specialist to show you and teach you.

At our practice, we like to be really meticulous about following up the outcomes of our shoulder surgeries as well, based on the principles of Ernest Amory Codman, who was a shoulder surgeon from over 100 years ago at Mass General who actually got thrown out of Mass General for having the ‘cheek’ to suggest that surgeons should be held accountable for their outcomes. Now over 100 years later, that’s something that I think the whole world of surgery embraces.

So if we do a shoulder surgery, the patient fills out surveys at various points after surgery, and that shows us if that patient is on track compared to our averages and the averages of a whole load of other practices all over the world – so that keeps our standards on a par with everywhere else.

Rotator Cuff

To go back to these specific problems that we see in the shoulder, if we talk about the rotator cuff. A lot of people hear about the rotator cuff, and a lot of times, any kind of shoulder pain is called a rotator cuff problem, which may or may not be the case, but the rotator cuff are these four muscles that are deep inside the shoulder. This shows the front and back view of those four muscles. Their job is to help compress the shoulder in its socket and to help raise the arm as well as obviously perform rotation, so the rotator cuff does a lot of work when we’re playing tennis.

These tendons haven’t got a great blood supply, and they do tend to wear over time. There’s a certain element of normal wear in the rotator cuff, so if you get an MRI scan of any shoulder over the age of about 40, you’ll see some normal wear and maybe even partial tears; those are often not things that we have to fix surgically, but they may cause pain or inflammation. Full-thickness tearing where the tendon tears away from the bone is something that we sometimes consider surgery for.

Things that cause inflammation and pain will often be treated with physiotherapy. An injection may have a role in it – things like steroid injection or cortisone, or sometimes some other types of injections, and those may help settle things down, so you can then work on your physiotherapy, retrain the muscles around the shoulder blade to get back to that shoulder blade control and again enable you to get back on the tennis court, without necessarily having surgery.

If there’s a full-thickness tear it might be something that we recommend repair for, depending on the size of it, and that’s usually a keyhole surgery to reattach the tendon but the recovery takes time afterwards – you are probably looking at about five or six months before you get back on the tennis court after a rotator cuff repair. That’s something that we try to take time to explain beforehand, so we set everybody’s expectations appropriately for afterwards.

Frozen Shoulder

Frozen shoulder is something that is really common. It’s often poorly understood, but the main problem with frozen shoulder it’s where the capsule or the soft tissue lining around the ball and socket of the shoulder joint becomes inflamed. It’s also called adhesive capsulitis.

It happens often for no good reason, but it is more common in certain groups. These groups can include people who play Tennis.

It’s more common in women typically in their 40’s or 50’s. It’s associated with hormonal things like diabetes, thyroid or around the time of the menopause, but we do see it in people who don’t fall into any of those categories.

Certainly, if you’re developing a frozen shoulder, it will become really difficult to continue playing tennis. Most cases will resolve without surgery – the inflammation of the capsule is the main problem, and that’s what gives the pain, to begin with. Then as the capsule becomes more inflamed, it gets thickened and tight, and shoulder gets really stiff, so we use anti-inflammatory strategies to try to hurry up the natural process of this settling down.

Sometimes oral tablets just aren’t enough because the pain can be quite severe, so we often inject the joint with cortisone – it’s important where that injection goes, so again a shoulder specialist will inject right into the main joint where that capsule is all inflamed. Sometimes we might even use a short course of oral steroid tablets.

We use really gentle stretching – the instinct sometimes when a shoulder is stiff is to push it and try to stretch really hard. But with frozen shoulder, the more you are aggressive with it in these painful stages, often the more that can aggravate it and actually end up as a vicious cycle of just inflammation and pain.

We just use a gentle stretching program and usually avoid formal physiotherapy.

Often when the swimming pools are open, we use swimming pool based stretches as well to help get the range of motion back in the shoulder.

So these are some of the stretches and this is Orla the physiotherapist who works at my practice and who helps patients navigate this.

In a very small number of cases, we consider surgery for frozen shoulder if the symptoms are not resolving, and that’s a keyhole surgery where we release that thick and inflamed capsule.

The old way to do it was to manipulate the shoulder under anaesthesia, but it’s much safer and more controlled now to do it as a keyhole surgery.

You will often use a nerve block as well as the general anaesthetic to allow for immediate stretching afterwards. Once we have released the shoulder, it’s different then – we will be aggressive with physiotherapy because we don’t want that capsule to scar back in.

It’ll take a few weeks for that to settle and to allow somebody start to get back to high-intensity activities like tennis, and obviously, after any intervention on the shoulder, if you’re getting back to tennis, you go back gradually and take it one step at a time, small steps.

This is what the inside of the shoulder looks like if there’s frozen shoulder, the cartilage is on the left. On the left-hand picture, you can see the cartilage of the humeral head and then a really angry red nasty capsule that we’re dividing with a radiofrequency device.

The other diagnosis that we come across in the shoulder quite a bit is arthritis, and this can affect our tennis playing population, particularly in later years, but actually, you can see arthritis, even in slightly younger patients too. That can be a challenge to manage for younger patients.

Shoulder Arthritis

Shoulder arthritis for us means cartilage wear of the main shoulder joint, which is the ball and socket joint. On almost every MRI scan of the shoulder, there would be some arthritis or wear of the AC joint or the acromioclavicular joint, which is the joint between the end of the collarbone and the point of the shoulder, and often that’s not actually causing any symptoms. So if you have an MRI scan and you have shoulder pain, and it says arthritis of the AC joint, there’s a good chance that’s not actually what’s causing your pain, unless the pain is right at the top of the shoulder if somebody presses on the AC joint.

That’s not what we’re talking about when we’re talking about shoulder arthritis, we’re talking about the main joints and sort of like the hip, the ball and socket part, and that can become arthritic when the cartilage wears.

You see an irregular shape and loss of joint space that can lead to stiffness and difficulty moving, which is a different stiffness than what somebody with frozen shoulder has and unfortunately, with arthritis, there’s not really any way to undo the arthritis; there’s not really any way to put back the cartilage that has been worn away, so we use strategies to try and work around it, and the strategies centre around pain relief. Sometimes with physiotherapy again being gentle with the range of motion – if it seems to be aggravating the shoulder, we will back off on it. Various injections can help with shoulder arthritis, based on steroid injections, or there are what we call viscosupplementation injections.

Those are sort of a gel type injection that mimic the joint fluid and can help lubricate the joint, and some patients get relief from those. We can use something called platelet-rich plasma, which is where your own blood sample is taken and spun down and then the platelet-rich fraction of that is injected into the joint, sometimes in earlier arthritis, that can help.

Then in some cases, a keyhole surgery might be appropriate in shoulder arthritis; again, it depends on the stage of the arthritis, sometimes the arthritis is too advanced to consider that, and we actually think about shoulder replacement, which is something that people hear about less commonly than hip replacement, but it is something that’s really successful for shoulder arthritis – it is the most definitive way to treat the arthritis because it’s the only way we can actually get rid of it.

How long the shoulder replacement lasts can be affected by how you use the shoulder – in terms of how much you do with it and how high impact the activities are that you do, but a lot of sporting and recreational activities are possible with a shoulder replacement including tennis.

I would absolutely let a shoulder replacement patient of mine play tennis. Once they’ve worked through the rehabilitation afterwards, which does take a number of weeks to months, and it’s probably going to be four to six months after a shoulder replacement before we let you back on court, particularly hitting a serve.

When we do a shoulder replacement, we get a CT scan, and we actually plan surgery with 3D software so that we know exactly all of the pitfalls of that individual person’s shoulder before we get in there.

This is a good example of getting back to tennis after a shoulder replacement: Tom Brown was a US professional tennis player. He passed away a few years ago, but he played in the era of Jack Kramer, right before professional tennis came in, and he was a famous doubles partner and also a really accomplished singles player himself, making it to Grand Slam semifinals and finals.

He had a shoulder replacement, and four months afterwards, he was back on court and regained his world rankings in the over 65’s, having had a really successful shoulder replacement with a surgeon named Tom Norris in California. I think most of us would be happy to let a patient with shoulder replacement back on court.

Shoulder Replacement

There are two types of shoulder replacement: the anatomic type, which is we replace the joint as it is with the ball and socket, or a reverse type of shoulder replacement where we actually put the ball and socket the other way around.

The two main reasons that we might do this would be if the rotator cuff tendons are no longer there around the shoulder if they’re torn and not working, the regular anatomic type of shoulder replacement can’t function, so the patient needs a reverse or if the socket of the shoulder is so worn that we can’t fit this white plastic socket in there and it’s not going to be stable, then we also would do our reverse shoulder replacement.

They work in very similar ways, there are some minor differences. The rehabilitation is the same, and again, I think a patient with a reverse shoulder replacement can get back out there and play some tennis as well once they’ve recovered.

What a shoulder replacement involves; the patient is usually about two nights in the hospital and four weeks in a sling afterwards. Often, people feel really good, really quickly after a shoulder replacement, because we’ve taken away that arthritic joint, the pain relief can be quite quick. But it’s a case of being patient in terms of working through the rehab and getting back to things like sports.

This is how we do shoulder replacements, how we plan them, and the future is actually here, in the sense that we have this software which allows us to see in 3D our patients shoulder. We can even get a 3D printed guide to help us place our components really accurately.

Now we can actually use this plan in a mixed reality setting where we wear a headset, and that’s projected right in front of us as we operate.

I’ve been really privileged to be one of the first surgeons to be given that headset, and later on this week, we’re going to do the very first case in Ireland this Friday right here in Dublin, where we use this technology and all the time the field of shoulder replacement is advancing.

It hasn’t been around maybe as long as hip and knee replacement, but huge advances are being made, and so that allows it to be a very successful intervention for our patients.

So coming back to tennis, I think all of us know that it’s a sport for life. Kids can take up tennis pretty young, and I have patients in their 80s and 90s who still play tennis.

The benefits of staying active, both the mental and physical benefits, often outweigh any of the wear and tear that’s sustained along the way.

So I think keeping the simple things in mind to preserve your shoulder longevity while you’re out there will make it so much more enjoyable and hopefully avoid you getting into trouble with the shoulder, so the things that we were thinking about, like the kinetic chain, the whole body working together, footwork to make that happen, and some of the things to be smart about with your gear for tennis, and hopefully that keeps you out of trouble, but if you have shoulder trouble then there are plenty of things that we just discussed that we can do to help you out of it.

Thank you very much.

Hi everyone, my name is Neil Welch. I’m head of SSC’s Lab services at UPMC Sports Surgery Clinic in Santry.

I’d like to take a minute just to say thanks to everyone who’s watching today, for taking time out of your day to listen. Hopefully, you’ll find the talk interesting, and you’ll find it helpful to help you get back into tennis.

Very often it can be very debilitating and stop you from doing many of the activities that you want to do – in this instance, obviously tennis. So we’re going to talk about how we can stop your back from stopping your tennis.

Low Back Pain

If you do experience low back pain, I suspect there’s a good few of you who are tuning in who are dealing with it – I’ve no doubt you have tried lots of things to try and help yourself get better. That’s really common – if we have a problem that we try and solve, we’re feeling uncomfortable or feeling sore – we reach out for some simple methods to try and assist.

We might take action by using something like a back support to try and reduce the load on the back, and that’s a common approach.

It also would be very common to make other lifestyle adjustments. So I’ve had people email me lists of mattresses and for advice on what mattress to pick up and I wouldn’t be the world’s foremost expert on mattresses and neither do I think that’s going to be the way to solve low back pain either.

Similarly, I’ve had lists of chairs sent to me, and anybody who’s managed to swing one of these for the office at home, fair play. But again, I’d be of the mind that some of these external solutions the supports, the mattresses, the chairs might not be the best approach for improving your back.

Similarly, we looked at remedies as well, so when we tried dry needling, acupuncture, or something a little bit more extreme, and the use of cupping seems to be a little bit more common these days.

I guess with all these approaches, they kind of make sense in one way because we’re looking for ways to improve our situation and very often we look for ways that are external to us. We’re looking for the magic pill or the silver bullet to make us better.

Sometimes we go the way exercise. Frequently, when we look at the exercise solutions that are offered up. These images are actually from a research study looking at the impact of exercise and low back pain.

I guess two things kind of stand out. One is the research evidence around this exercise is mixed. When we look at the type of exercises that are being used, I guess you might see a reason why.

I’m a strength and conditioning coach by trade. So when I look at these images, and I look at the exercises and maybe what they’re trying to achieve – the only thing I could sort of see from this intervention is this person, if they do this for a period of time, is going to get better at balancing on a red ball.

So what I want to do today is talk you through maybe some of the factors that might be a little bit more effective for helping you manage your back, and keeping you on the court.

Managing low Back Pain

So when we talk about low back pain, broadly speaking, we’re not talking about the spine itself. I’m sure lots of you have had scans of your back and they’ve shown disc bulges or changes in facet joints, but these are very common elements or findings on an MRI scan that people without low back pain have.

More often than not, what we’re talking about are muscular issues.

So when we finally are a little bit sore on either side of the back, we might be thinking that there’s an issue with our lumbar extensors. These guys are active in lumbar extension, so when you arch your back, those muscles are working.

They also play a role in stabilizing the back, but you can see where the very bottom of the orange and yellow images, your lumbar extensors, they attach to the pelvis. They can be active in trying to control the movements of the pelvis and extend the hip.

Once we start to understand the role of the muscles, we can maybe start to figure out why they might be doing a little bit too much work for us.

Some of us might be finding that when we get a sore back, it’s a little bit more out towards the side – so what we would call our lateral quadrants.

One of the muscles out there that contributes is called a Quadratus Lumborum. This is a lumbar extensor, so again it helps you to arch your back. If you utilize those strategies quite frequently – that might be a reason why those muscles are taking on more work. They’re also responsible for assisting in lumbar lateral flexion, so that’s bending over to the side. What they also do is help control the pelvis – they help provide stability when we’re on one leg.

Broadly speaking, when we’re thinking about low back pain, we’re trying to understand why some of these muscles might be doing a bit more work than we would want them to.

What we also need to do in context as well, is try and understand the role you might be playing, while you’re playing tennis – ultimately that’s what we are discussing today is how to keep you guys on the court without your back from stopping you from doing that.

Now when we consider the musculature in the back, there are a few areas that we’re looking to try and consider. I’m sure people have heard and been told in the past their hip flexors might be a little bit weak or a little bit tight.

This is one of your hip flexors, your psoas muscle – it’s attaching to the front of your spine. I’ve crossed the hip. In this instance, the reason I’m showing this is to give you some idea of what a well-conditioned psoas muscle looks like. The dark grey image there is muscle. Any of the white bits you can see towards the bottom of the green box, a whisper of white marble, and that’s fat.

These are your lumbar extensors. So again, the same sort of thing, give you some idea of what a well-conditioned set of lumbar extensors looks like – a little bit marbling in there indicating some fat infiltration within the muscle but only a small amount. Looking at this on the scan you’re looking at a very well-conditioned set of lumbar extensors and hip flexors.

Just to give you some context what happens when we’re a little bit deconditioned or a lot deconditioned in this instance. So again we think about that psoas muscle, we think about the size and strength of that, so we are likely going to be weak here in our hip flexors, but then we can see the degree of fatty infiltration within the longer extensors.

So a lot more towards the rump steak end of the spectrum, rather than the filet steak. We can start to understand then maybe why some of the muscles in the back might not be coping with some of the work we’re asking it to do, particularly in the condition they are in.

Strengthening Exercise for the back

If we were looking to try and increase the strength of our back there are certain exercises we can do. I’m going to talk you through a deadlift now which would be one of the ones that we would use in order to be able to increase the strength of the muscles of the back of the body as a whole, but we’ve some research published that shows the increase in size and the reduction of fat within the muscles in the back from doing this.

Deadlift

This would be a deadlift movement – we are going to show you it in a rack, so once we’re back in gyms, hopefully, you’ll be able to do this. If you have dumbbells at home, you’ll be able to pick these up off the floor. The most important points here are the top of the lift, where Jack is really working on squeezing his bum. On the way down, most of the movements is from the hips, so he’s working very hard and pushing his bum backwards.

If you’re doing this right, you’ll feel the muscles down the back of the back the legs feeling like there’s a big stretch on them, so Jack will be feeling a stretch down his hamstrings and in his bum here.

Most important really with this is you shouldn’t feel like the back is doing most of the work – we are targeting the hips with this exercise that the back is playing in an assistance role.

If we think about our lumbar extensors, I said before about them being active in lumbar extension. If you arch the back a lot they’re working quite hard, and the key bit as well for me is the last point, hip extension.

If your primary hip extensors aren’t doing the work as well as they might, then you might be recruiting the lumbar extensors a little bit more, so essentially the hips don’t do the work, your back has to do a bit more.

Our primary hip extensors are Glute Max. It’s the biggest & strongest muscle in the body. Again as I said, if we’re underactive here and not very strong, then we’ve got to start considering what other structures are going to take that work on.

Single-Leg Hip Thrust

Single leg hip thrust is a really good option for you. You will see here the setup is to have the back on the bench, and you’ll see Jack here is keeping his eyes pointing straight down the gym – he is not throwing his head back and his ribs up.

The idea there is that all of the portion of movement comes from his bum. So you’ll see again when we go through that he is working very hard with his left glute to push up and squeeze, and to lock the hips out using the bottom, and that’s what you should feel when you are doing this, you should feel like your bum is working really hard.

Progression with that is to start adding weight by putting a dumbbell on top of the thigh, but if you could manage that with your body weight then you’re doing all right as a starting point.

We start thinking about those of us who are dealing with more lateral low back pain – it’s very common when you can kind of tell when somebody starts rubbing their back, they have the chicken wing, the elbow out to the side and then they are rubbing towards the side of their back. This is more the area that we might be thinking about. So, it’s an active lumbar extensor as well, so we can’t discount the two exercises that we’ve just done that should help. They’re also important for helping provide stability around the pelvis.

So we look at what else provides stability around the pelvis again it’s one of our glute muscles – our glute medius.

Banded clam

This is going to be an important one for us to exercise as well. How we might get after this is through relatively basic clam exercises there is a couple of important points here. Keeping the heels together, slowly dragging the knees apart, and just making sure we’re not rolling backwards away from the floor.

If Niall is rolling back and starting to point his hips up towards the ceiling, then his bum isn’t going to do as much work as we’d like it to. He wants to keep his right hip rolling forward and his hand provides stability there, slowly pull the band apart, and if you are doing this right, you will feel a really strong burning sensation going on the side of the bum cheek. That would be our glute medius taking on some work for us.

With all of these exercises, you should feel like you’ve had some improvements immediately after doing them, so the back should feel a little bit lighter and a little bit looser.

Obviously, in tennis, there’s a lot of rotation involved and sometimes we can use our muscles and our back a little bit more when our abdominals aren’t doing enough work.

This is where some of our rotational exercises in order to be able to target some of the muscles around the front of the body and get them doing a little bit more work for us.

Half-kneeling Pallof Press

A Half-Kneeling Pallof Press is a good option. All you need is a band at home. So some tension on the band, we are on one knee and we are slowly pushing the hands out in front of us and we hold.

We are just resisting rotation so that the hands ideally stay in the midline of the chest all the way through. The band doesn’t get an opportunity to pull us closer to the rack. By doing that, what you should feel is the muscles around your stomach, resisting that movement.

Jack here should feel the sides of his stomach working quite hard.

Again, just going to a point where you feel fatigued in the muscles in the stomach and then switching sides should help reduce some of the loading on the back, as well as obviously help our performance when we are playing.

One of the important factors again, when we start more considering overhead work, obviously serving is a large component of what we do when we play tennis, trying to understand the range of motion that we have in the shoulder becomes important.

Shoulder Flexion

One of the tests that we do for this is shoulder flexion. Just lying on your back and seeing whether you can get your thumbs over your head to the ground. On the second part here, I’ve just tried to flatten my back. It’s a little bit harder but I’ve got decent shoulder range of motion, get my thumbs to the floor.

If I arch my back it’s a lot easier. What that is telling me is that I am borrowing a lot more range of movement from my back. It’s not my shoulders necessarily doing the work.

So if I’m a second example in the middle here I’ve got my back flat against the floor. I can’t get my thumbs to the ground, I am lacking a bit of shoulder flexion, which means I’m going to struggle with anything overhead, or I’m going to borrow from my back in order to be able to get my arms overhead. So one of the reasons we get back pain on our overhead movements is because we lack shoulder range motion.

If you try that yourself at home, there are some exercises we can do to help them.

Lying Banded Y

So the first part is a relatively basic exercise here. We will be taking a bit of Theraband, keeping some resistance & trying to keep the back flat and just trying to work through a greater range of motion.

One of the reasons we sometimes lack range of motion around the shoulder is just because we don’t train ourselves to get into those positions. So simply by adding some of these exercises to your routine, you will your shoulder range of motion improves.

Pushing out against the band and keeping the thumbs pointing backwards will activate the muscles in your rotator cuff. It will be a good rotator cuff workout as well as improving your shoulder flexion range of motion.

Shoulder Rotation

Now, shoulder rotation is a very important component within tennis as well – testing your range of motion here is something you can do to find out whether it’s an area you need to develop. So just resting your elbow on a cushion, keeping the legs flat, and just seeing whether we can get the hand back towards the ground.

The temptation here is to reach for the fingers rather than trying to give the back of the hand/wrist to the floor. A lot of us will struggle in order to get the hands all the way down to the ground. In which case, again, we’re lacking some rotation range of motion, which very often comes from the muscles controlling the movement, rather than the joint itself, which means that it’s trainable.

So an exercise we can do is something we should be doing if we aren’t playing tennis anyway, providing stability and control around the shoulder is really important and our rotator cuff muscles are really important before this, is some external rotation work.

So again a very simple exercise, small dumbbell at home. Just have the elbow resting on the knee, and it’s the rotation we’re looking for. So the elbow should stay at 90 degrees all the way through, exactly where I’m grabbing my shoulder – that is where you want to be feeling it.

Sometimes it’ll take a bit of work and bit of playing around with the technique to make sure you feeling it at the shoulder blade, rather than say at the front or the top of the shoulder or play around with the exercise as soon as you have it, then a little bit of work taking that muscle to fatigue will start to condition your rotator cuff.

There will be some of us here who will have had to deal with rotator cuff tendinopathy in the past and this type of exercise would be a really important part of your rehab.

So, again by starting to implement some of these exercises into your routine – first of all, should stop you getting injured. If you do have some soreness, it will likely take care of a lot of it.

Okay so hopefully that gives you a little bit of an insight into some methods that you can take on yourselves to help with your back, to help train some of the muscles around your back so that you feel a little bit less discomfort, a little bit less pain, and help you to get back on the court.

The shoulder obviously is a really important component of playing tennis. Test your range of motion out at home. Try those little tests that we put up on the presentation there, and then what you should find gradually if you are consistent with those exercises, is when you go back to retest your shoulders you should notice some improvements.

If you need any more help at all feel free to contact us here in the UPMC Sports Surgery Clinic and we’ll see if we can help. Thanks very much for taking the time out to watch the presentation. We’ll be back shortly with some questions and answers.

Hello and welcome to our evening discussing orthopaedic problems. Thank you for tuning in. My name is Ruth Delaney – I am a shoulder surgeon at UPMC Sports Surgery Clinic and I am going to talk about some common shoulder problems that we see.

My own background is that I’m originally from Cork and I then spent a lot of time in Boston doing most of my orthopaedic training, particularly at Mass General where I also did shoulder fellowship and got to spend time, as well as Boston, in France here in Lyon before coming back to Dublin in 2014, where I practice exclusively in the field of the shoulder.

Shoulder pain is really common – 70% of us are going to have shoulder pain at some time during our lives, and about a quarter of people who have shoulder pain, it’s not their first time having pain around their shoulder. Pain in the shoulder can lead to disturbance of sleep, which obviously has a major effect on the quality of life. It can make it difficult to keep up your normal work or your usual activities. Pain in and of itself around the shoulder is an important symptom. There are other symptoms that often present besides pain, and shoulder weakness, can be a feature of shoulder problems, even to the point of having difficulty raising your arm. Shoulder stiffness can also be a major issue, and unstable shoulders recurrent dislocations are something that we see quite a lot, particularly in the sporting population.

So when we assess shoulder problems. We take a history so we ask you questions that help us to figure out what might be the underlying diagnosis and a lot of times the pattern of your symptoms and certain things that aggravate or help them can give us a good idea as to what’s going on, and in certain cases even your own background medical history. Examining the shoulder is really important, it’s really helpful for us as we get a lot of information from actually examining the shoulder. Imaging sometimes is not even all that important, it may help us to confirm a diagnosis or to rule something in or out.

Depending on what your shoulder problem is – an X-ray might actually help us more than an MRI sometimes, so for things like shoulder arthritis, a certain type of tendinitis where there can be calcium deposits in the rotator cuff so calcific tendinitis and those things are actually seen better on an X-ray. So our AC joint or acromioclavicular joint problems. Sometimes even if you already have had an MRI – we may need to go and get an X-ray.

For some things, MRI can be helpful. Sometimes there are other studies that we’ll get like for example CT scans in certain situations. If there’s shoulder arthritis and we want to plan a replacement or if there’s a fracture.

So some of those problems sometimes lead to consideration of shoulder surgery. But there can be a lot of different rumours out there and a lot of misinformation. So, if a shoulder problem is at the point where shoulder surgery is becoming a consideration – I think it’s really important to get advice from a shoulder specialist.

Because shoulder is a fairly rapidly evolving field, there’s a lot of recent knowledge there and sometimes even with the best will in the world, other people be it laypeople or even healthcare professionals may not have an in-depth understanding of your particular shoulder problem.

When we’re considering surgery for a shoulder problem, we will help you look at the risk/benefit balance in your individual case. Also important to consider the recovery and rehabilitation period involved after a surgery for your own lifestyle, your work, what you need to be able to do, and so you have the right expectations going into a procedure as to how long your rehab afterwards might be. Preparing for shoulder surgery is important too from a practical standpoint, if you’re going to be in a sling for a little while afterwards, that will mean that you can’t drive it will mean that you will need help at home in terms of preparing meals even getting dressed and undressed. So all of that needs some thought beforehand.

Also if your shoulder for example is quite stiff before surgery sometimes we’ll have you do some physiotherapy beforehand in order to make your post-operative recovery a bit easier so there can be quite a lot of thought and preparation that will go in before you even come as far as having surgery for a shoulder problem.

We are always adding to our website and trying to increase the amount of resources that we have available for our patients and their families in order to get more information about what to expect. For any shoulder condition, and for those that require surgery.

We also use something called surgical outcome systems for all our patients who are going to have shoulder surgery and this is based on the idea that all surgeries should have their results measured, so that we can report those results and be very upfront about them, and this comes from one of the first shoulder surgeons over 100 years ago, named Codman.

So everybody who has surgery will have the opportunity to be part of this email based system, and it will send questionnaires to patients at various time points during the recovery, and then we’ll be able to see where that patient is relative to the average both within my practice and also a global average which is very reassuring.

This is the team who work with me; Danielle heads up the administration staff, joined by Barbara and Lorraine. Orla’s our physio and our current fellow right now is from Belgium, Joachim, and later on this year we’ll have a French fellow taking his place.

So to go back to the main diagnoses that we’re going to look at today. Shoulder instability is something that’s a huge topic and probably a whole other talk on its own. So we’re going to focus mainly on rotator cuff, frozen shoulder and arthritis, but if anybody has questions about shoulder instability I’d be more than happy to discuss it during the question and answer phase.

Rotator Cuff

Rotator cuff is something that you hear a lot about in terms of shoulders, and often every shoulder pain is blamed on the rotator cuff, which isn’t always necessarily true. The rotator cuff is a group of four muscles deep inside the shoulder. We can see them here from the front and from the back there’s one big one in the front, one over the top and two in the back.

Their job is generally to help elevate the arm and rotate the shoulder, and also to keep the ball cantered in the socket.
The tendons that attach those muscles to the humerus or the arm bone don’t have a great blood supply and they do undergo normal wear over time. They can also get inflamed which can lead to pain, and sometimes there can be full thickness tearing in the tendon where it detaches from the bone as we see in those pictures there.

The normal wear over time will often be seen on an MRI may not be the cause of the symptoms happening in the shoulder. It doesn’t need any treatments so things that you may see on an MRI described as tendinopathy, tendinosis, partial tearing – those are often normal age related changes and will often look exactly the same on a non-painful shoulder as on a painful shoulder when looked at on an MRI.

If rotator cuff inflammation or tendinitis is the problem we’ll often treat that with physiotherapy as a mainstay – sometimes we’ll use a cortisone injection to damp down that inflammation to allow you to engage with physiotherapy.

If there’s a full-thickness tear or detachment of the tendon – it doesn’t necessarily always have to be fixed it depends on a number of factors including the size of the tear, the age of the patient, the desired activity levels. So sometimes physiotherapy and injection will also be how we will treat some of the smaller full-thickness tears or the more gradual degenerative tears, as opposed to tears that are acute and traumatic – ones that happen suddenly if somebody falls down or something like that.

So in some situations, surgery will be the appropriate consideration for example if a tear is bigger, or in a patient who’s a bit younger.

If we do surgery to repair a rotator cuff, it’s done keyhole or arthroscopic, and we reattach the torn tendon to the bone as you see in those pictures using anchors that go into the bone and those have stitches or heavy stitches going through them which allow us to stitch the tendon back to the bone.

Even though it’s a keyhole surgery, it’s quite a bit of work on the inside and so the recovery process does take a bit of time and that’s an important conversation that we have before embarking on rotator cuff repair surgery.

After rotator cuff surgery, we use a shoulder immobilizer – it’s like a sling with a pillar which gives you a bit more support than a regular sling and takes tension off the repair, typically four weeks is the period of time that you spend in the sling but if the tear is large or the tendon is fragile we might use it for six weeks.

You can’t drive while you are in a sling – with the physiotherapy program is designed to support the repair and get your shoulder moving in the initial phases, and then later move on to strengthening but it’s important to know that it can take about six months to work through all of the rehab from a rotator cuff repair surgery. This is a video recorded a few months ago on what to expect for rotator cuff repair.

One of the most common problems that we see involves the rotator cuff. A lot of people aren’t sure what the rotator cuff is and basically it’s these four small muscles that are deep inside the shoulder, and they’re attached to tendons – tendons attaches the muscle to the bone, the rotator cuff helps keep the ball centered in the socket of the shoulder joint and helps the ability to raise the arm as well as obviously rotate the arm. The rotator cuff tendons don’t have a great blood supply so over time they often have wear and that’s pretty normal it doesn’t necessarily cause symptoms, it’s something that’s often seen on an MRI and may even be described as a partial tear. Sometimes that can lead to inflammation and pain and we can often treat that with injections and physiotherapy. But when the rotator cuff wears to the point where it fully tears off the bone, or if you have a trauma such as a fall and that causes an acute tear of the rotator cuff where the tendon actually detaches from the bone, then often that’s something that we do need to consider surgery for.

The problem is with the poor blood supply the tendons can’t actually heal themselves. So very small tears, don’t necessarily need to be repaired. So if one tendon has a little tear in it often the other tendons can compensate. Sometimes we’ll try physiotherapy to work on those muscles to compensate as well as the big deltoid muscle on the outside of the shoulder. But other times if the tear is a bit bigger, or if the conservative approach isn’t working, then we need to consider actually repairing the tendon back to the bone in order to get it to heal and to allow the shoulder to function better and to decrease pain.

With rotator cuff surgery, there is quite a lot involved and we have information leaflets that we will give to patients in order to help you to take in all of the information. Even though it’s a keyhole surgery, it is quite a bit of work on the inside, and therefore the recovery time is longer than what you might expect from a keyhole surgery.

So what the inside of a rotator cuff repair looks like at the end is pretty much this: this is an example of a reasonably large tear, we use these anchors in the bone that allow us to stitch the tendon back to the bone using these heavy sutures.

This takes a while to heal – that’s why after a rotator cuff repair the patient typically spends four weeks in a shoulder immobiliser – sometimes six weeks if it’s a very large tear or if it’s a tear that isn’t directly repairable and we have to augment it with a graft, but for most rotator cuff repairs, you’re talking about four weeks in a sling, the sling is a shoulder immobiliser with a pillow at the side like this, and that serves to take tension off this repair in the initial phases of healing.

Depending on the quality of the tendon and how large the tear was you might or might not be allowed to do some gentle exercises during that initial four week period. I’ll see you back in about two or three weeks, we’ll check that the sling is fitting you okay that your wounds are healing well, and that you’re ready to go on to the next phase of your rehab.

When you come out of the immobiliser at four weeks – the next stage is that you are allowed to actively move the arm. Up until that point we don’t want the arm moving under its own power because we don’t want to put too much stress on the repair.

Once you’re out of the sling, it’s all about regaining range of motion, up until about 12 weeks after surgery we don’t worry about strengthening. It’s too soon to try and strengthen the shoulder before 12 weeks, the rehab protocol is built around that and all of those instructions will be given to your physiotherapist so that they know how to design your exercise program.

Usually, we’d meet again at about 12 weeks before we start that strengthening phase, so that I can make sure that you’re making good progress with your range of motion and we don’t have any problems with stiffness before we start to move on to the strengthening phase. In terms of what you can and can’t do during the phases of your recovery, a common question is ‘when can I drive again?’ – you can’t drive when you are in a shoulder immobilizer, you’re not insured to do so even if you think you could manage with one arm so you absolutely cannot drive during that first four/six week period.

Most people find it takes them another week or two after they come out of the immobilizer to actually get comfortable to drive – from my point of view it’s okay for you to start to try to drive once you’re out of your shoulder immobilizer so typically four weeks for most tears six weeks for some of the bigger tears.

I always suggest that you try in an empty carpark or maybe your driveway before you go out on the road and drive.

In terms of work, it depends on what your job involves if you have a job that involves any heavy physical activity, then you’re probably going to need to wait until that 12 week mark before you go back to your full duties at work because the shoulder is not going to be anywhere near strong enough to take any stress.

If you have a job that does not involve any heavy lifting if you have for example a desk job, then you can often go back even before you’re out of your immobilizer once your pain is under control.

Rotator cuff repair can be pretty painful in the first couple of weeks but that does tend to dissipate quite quickly. We always make sure that you have a prescription for painkillers and we can adjust that as needed in those initial few weeks.
Typically recovering from rotator cuff repair takes on average about six months to have the shoulder back in good working order. And it’s important to understand that before you start on the process so that you’re aware of what to expect and the fact that sometimes it takes a bit of patience before you get there. We will always follow you closely and communicate closely with your physiotherapist to make sure that we optimize your recovery.

Frozen Shoulder

So moving on to the next category in our common shoulder diagnoses: Frozen Shoulder is something that we see quite commonly. It can be often misunderstood and the term frozen shoulder can often be applied to any shoulder that’s stiff and sore and that’s not necessarily true.

Frozen shoulder is a specific condition where the capsule of the shoulder joint – so the lining that in case of that ball and socket joint of the main shoulder actually gets inflamed so that’s an inflamed capsule or capsulitis. So it’s also called adhesive capsulitis.

It often happens for no good reason that’s the most common scenario, and it’s more common in certain groups, particularly in women in certain age groups and it can be associated with underlying hormonal conditions like diabetes, thyroid issues or around the time of the menopause, but it can affect anyone and particularly with the past year we’re seeing it a lot more commonly in just about anybody.

It can be very painful when it first starts the inflammation in the capsule causes a lot of pain, particularly with any movement of the shoulder. As that inflammation develops the capsule of the shoulder gets thickened and tightened the shoulder starts to get stiff it becomes very difficult to move the shoulder. It can be frustrating because you don’t really see anything on imaging. So again, examining the shoulder is the key to figuring this one out and having the right diagnosis.

An MRI will often just confuse things because you’ll see things that maybe aren’t actually relevant to what’s going on.

The pain is quite intense so arriving at the right diagnosis and starting treatment can be really helpful. If you were to do nothing at all with frozen shoulder, it would theoretically burn itself out, but that can take up to two or even three years. For most people, that’s just too long to wait around because it’s just too painful.

The problem is inflammation, so the strategies we use to hurry up the process of resolution are anti-inflammatory strategies, whether that’s non-steroidal anti-inflammatory medications and things like ibuprofen or some of the prescription things like maybe diaphine.

We also often use steroid, as a big term anti-inflammatories – so cortisone injections. It’s important that the cortisone injection is into the main shoulder joint because that’s where the capsule is.

A lot of times, people who are not shoulder specialists will inject shoulders, but they might not inject the main joint. And so sometimes patients come to see us who’ve already had injections and haven’t gotten any benefit, but they may not have just had the right spot injected yet – in patients who have a lot of pain will often use a short course of steroid tablets for just about a week or 10 days as well.

Sometimes it takes a second set of injections. But most people find that with injections and a gentle course of stretching, that the frozen shoulder does settle down. We don’t tend to use formal physiotherapy because somebody else pushing the shoulder and stretching it can often just aggravate it. So we give you a home stretching programs and videos to follow – what can be really helpful when they’re available obviously we don’t have the option right now is getting into a swimming pool and doing some stretches in the water so not actually swimming but just gently moving the shoulder in the water.

These are some pictures from the videos that we use this is Orla our physio showing you how to do some gentle stretching with the shoulder. This is something that you do yourself at home – only up to about 5 out of 10 discomfort no severe pain, no aggravating shoulder.

And I would say over 90% of frozen shoulder cases get better that way.

In a small number of cases, we might consider surgery, if things are not settling down. We do a keyhole surgery called an arthroscopic capsular release.

So it’s not a case of just blindly manipulating the shoulder the way that used to be done, it’s much safer to release the thickened capsule in a controlled fashion. We do this under general anaesthetic and we usually use a nerve block so local anaesthetic around the nerves that supply the shoulder and arm, and that helps with pain relief and it also helps with immediate physiotherapy afterwards in the hospital, because the arm is numb and so the physios can really stretch it.

The thing we want to avoid is the shoulder stiffening up again. So where we were being really gentle with it, when we’re treating without surgery, if we do end up having to do a release for frozen shoulder, then we need to start immediate physiotherapy straight away to stop them from getting stiff and purely for that reason will usually keep the patient in the hospital for one night so that they get immediate physiotherapy the afternoon that they’ve had their surgery and then again the following morning so we get a head start on range of motion.

This is what it looks like on the inside – a really red angry capsule of the shoulder joint and this radiofrequency device releasing the thick layers of capsule and restoring range of motion in the shoulder.

Shoulder Arthritis

Another reason that a shoulder can be stiff and painful is arthritis. And the way we tell the difference between frozen shoulder and arthritis is principally by an X ray, because they can examine very similar. Usually the history will give us some clues as well.

We talk about arthritis of the shoulder, we’re talking about arthritis of the main joint of the shoulder so the ball and socket joint. There is a small joint above the shoulder called the AC or acromioclavicular joint. This is the joint between the collarbone and the point of the shoulder. Almost everybody gets so-called arthritis and that joint it wears in everybody, but it often doesn’t cause any pain.

So again on an imaging report, particularly MRI, you may see the word arthritis, but if it’s arthritis of the AC or acromioclavicular joint, it’s probably not the issue.

In some cases that can be inflamed and painful just right on the top of the shoulder. But when we talk about shoulder arthritis we’re talking about the deeper joint – the main ball and socket and arthritis is wearing away of the cartilage in that joint, so that the joint surfaces become irregularly shaped and the joint space is lost, and that causes pain and stiffness.

There are many options for treating shoulder arthritis similar to arthritis and other major joints in the body.

The main goal is pain relief whatever way we achieve it.

Some patients find that just taking some simple painkillers can help them enough that they don’t need to consider anything else. With physiotherapy sometimes it’s helpful, sometimes it can aggravate the Arthritis a little bit so we try it and see, and it’s usually a gentle approach with physiotherapy if it’s not helping then we don’t push it.

Injections can be helpful, they’re not going to change the underlying arthritis itself but they may help with the pain that is secondary to the inflammation caused by the Arthritis so again cortisone injections being anti-inflammatory. We also use other types of injections – what we call viscosupplementation, which basically mimics the joint fluid and theoretically acts to lubricate the joint. It works for some patients but not as often as cortisone works in mild cases of arthritis or younger patients something called PRP or platelet rich plasma can be an option as well.

In some cases, a keyhole surgery or arthroscopy can be appropriate again in the earlier stages of arthritis where we clean out the joint, take away some of the inflamed structures. But again, we’re not altering the underlying arthritis.

Shoulder Replacement

The only thing that really takes that away is doing a shoulder replacement, which is an operation quite similar to a hip replacement. It’s the most definitive ways to actually treat shoulder arthritis and get rid of it.

We are a little bit hesitant to do it in younger patients in their 40s or early 50s, because of how long the implants last they last pretty well for 15 or 20 years but it depends what you do with them.

So if there’s heavy use of the shoulders or high impact activities, then you may wear out the shoulder replacement sooner, but a lot of sports and recreation activities are just fine to do with a shoulder replacement.

It’s usually an X ray that we start with when somebody has shoulder arthritis. And then if we are at the point of considering a shoulder replacement we get a CT scan that allows us to see the shape of the bones more precisely in particular the socket of the shoulder, and that allows us to plan each individual surgery using 3d software.

This is a picture of a shoulder replacement. It has a stem, and then a metal ball and a plastic socket. Sometimes we use a slightly different configuration called a reverse shoulder replacement. That’s done in situations where either: there’s a rotator cuff problem in addition to the arthritis or perhaps even a rotator cuff problem on its own where the tendons are gone beyond repair. Or if there’s so much wear of the socket of the shoulder that we can’t fit a regular shoulder socket on there. Then we go to our reverse shoulder replacement,

The rehab and recovery is very similar for both. The surgery is done under a general anaesthetic and most people spend about two nights in the hospital – four weeks in a sling or shoulder immobilizer afterwards again it’s that one with a pillow, and that’s to allow the structures around the shoulder to heal.

In patients who have really bad arthritis pain – they often find that post-surgical pain is almost nothing and that the pain relief is dramatic because their arthritis has gone.
We work on regaining range of motion in the shoulder with physiotherapy after surgery.

In shoulders that have been extremely stiff for a long time we don’t necessarily expect completely normal range of motion, but certainly a much more functional range of motion, than before surgery. The biggest gain that we see early on is the pain relief, it probably takes about six months to get the most out of your shoulder replacements after surgery.

Future of shoulder surgery

The future is already here in terms of shoulder surgery and shoulder replacements. This is the CT planning program that I use on every patient who has a shoulder replacement with me. It allows us to see your shoulder in much more detail and plan things very precisely for your individual operation.

We can even order a 3d printed guide, based on your specific anatomy of the socket of your shoulder and that is something we then take into the operating theatre with us, and it directs a key part of the surgery in terms of placing the component on the socket of your shoulder.

The next step is augmented reality where we are able to project your CT scan on a hologram in front of the surgeon during the surgery and again that allows us to be even more accurate in how we’re putting in the shoulder replacement, which we hope will translate in the future into the shoulder replacements lasted even longer.
So while shoulder replacement is not as well-known as hip and knee replacement it’s something that’s been around for the last couple of decades and it’s something that’s evolving a lot – we have a great amount of success with it and it’s something that if it’s appropriate for your shoulder to shoulder specialist will be able to discuss it with you.

So I hope that’s been helpful. It’s a quick tour of some of the really more common shoulder problems that we see and I’ll be happy and I will be happy to answer any questions you have afterwards.

Well, I suppose before we dive into any of the questions, I will just say that anything that I say here obviously isn’t specific medical advice for any individual patient without knowing the full story and examining someone – I am just giving general thoughts on the questions that are raised.

So in terms of that question, we probably touched a little bit on it with the talks where surgery is not necessarily the only option. It depends on the size of the tear, age and activity level of the patient. Some Rotator Cuff Tears can be managed without surgery – physiotherapy can compensate with the other muscles of the rotator cuff that are left. Sometimes an injection forms part of a pain relief strategy.

Sometimes we will advise surgery for a bigger tear. In terms of post-op rehab, it is slow – I suppose full use and full activities would be 6 months, but it is graded, so by 3 months you would be doing most day to day things, no heavy lifting, and by 6 months you will be back to all of your activities after a rotator cuff repair surgery.

Again, it kind of depends on the tendon tear – sometimes it can be too late for surgery if it is a very large tear and the muscle has started to waste away – too late for repair surgery, but there are other types of surgery that can be done. So it would depend on exactly the size of the tear. I suppose there are often other things we can do, be it grafting the rotator cuff or just cleaning out the shoulder to take care of pain if the shoulder is still functional or in very severe cases even replacement type operations. So it is never too late for us to be able to do something – it is always worth looking at if the shoulder isn’t something you can live with.

Yeah I think the MRI isn’t the be-all and end-all, you can have something causing pain in your shoulder that isn’t obvious on an MRI, and might be more obvious to us when we examine your shoulder. If the MRI hasn’t shown up much, it is very unlikely that an ultrasound will show anything different because an MRI is more detailed than an ultrasound. I would say probably having somebody who specialises in shoulders actually examine your shoulder would probably give you more information than further imaging tests or ultrasounds on that situation.

Good question. It is a pretty common scenario. Sometimes you might not actually even need an MRI. If you do really need an MRI, there are ways to get it, but it depends on the exact defibrillator device you have and on the facility where you are going to have the MRI and it is often the case that they have to do something special to turn off the defibrillator because the MRI is a big magnet.

But if you take a step back and just make sure that you actually really need an MRI, because a lot of shoulders that get sent to MRI didn’t really need them – sometimes X-Ray and a good clinical exam will give all the information we need, other times we can find a way around it if we are looking at the soft tissues an MRI would evaluate – we can look at them with ultrasound, it is not as detailed but we can see them. The other option that we sometimes use is CT scan, this goes for people who are claustrophobic too and would have a really hard time tolerating an MRI. Maybe let a shoulder specialist look at your shoulder first and determine whether you really need the MRI.

It is unlikely to make the shoulder problem worse. There are rare situations with any vaccine where we see something called ‘shoulder related injury related to vaccine administration, and it can happen that it flares up a shoulder. I suppose the most sensible thing to do is to just get it on the other shoulder unless there is a good reason not to have it on the other shoulder.

The injection for the vaccine should just go in the deltoid muscle and in a body of the muscle rather than into any of the structures deep into the shoulder but I think you are going to be sore for a day or two after your Covid injection – I would probably put it in the other shoulder and know it is going to get better in a day or two.

We see that from time to time, what we call ‘scapula thoracic bursitis’ – obviously scapula/shoulder blade and thoracic/rib cage. The shoulder blade is really important in how the shoulder works – it sits on the back and the ribs are underneath the shoulder blade. The shoulder blade has to move around like this to allow the shoulder to actually move. There is a layer of connected tissue/fluid line that helps the shoulder blade to slide around – that can get inflamed sometimes. Sometimes we do an injection underneath there, very occasionally we do surgery underneath there. It is less common than injecting other areas around the shoulder and usually, physiotherapy would have a major role in that help with the control of the shoulder blade. It is a tricky area to inject because the lungs are not too far away – so it is something we weigh up with the patient, but it is something we can treat quite successfully.