EU Cross Border Directive and Sports Surgery Clinic

SSC hosted an online information session to assist anyone who would like to learn more about the EU Cross Border Directive and orthopaedic care in Dublin. 

The meeting consisted of two short presentations, followed by a live Q&A session with Mr Dan Withers Consultant Orthopaedic Surgeon. Our team are here to help answer any questions you may have regarding finance, surgical procedures and the EU Cross Border Directive process. Please email or call our team on 00 353 1 5262300 for more details.

Sports Surgery Clinic is a dedicated centre of Orthopaedic Excellence and we have been working with the NHS over the last 13 years, and with Musgrave Park and Craigavon Hospital and the cross border over the last 5 years.

SSC has in excess of 40 consultants in orthopaedic surgery and allied specialities supported by a team of highly specialised nurses, physiotherapists and other healthcare professionals.

Where are we located?

We are located approximately ten minutes from Dublin Airport on the Northside of Dublin City just off the M1 and M50, this means you have easy access from Northern Ireland and won’t have to go near the City and SSC has underground parking.

For further information on EU Cross Border Directive or for any assistance with the process involved please contact Fiona Roche by email or by phone +353 1 5262168

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.


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.

You can download the application form here

Once completed you will have to send this form to the address on the form – The National Contact Centre.

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.

For individual pricing requests please email Glenda Thorne on

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.


For any further questions on EU Cross border Directive please email 

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.

If you have any other queries on the payment, you can contact

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 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 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.

For any further information on this presentation please do not hesitate to contact

Click here to download EU Cross Border Directive Application form

Common Knee Problems and how they are treated with Mr Dan Withers

Watch this video of Mr Dan Withers, Consultant Orthopaedic Surgeon, specialising in knee pain, discussing common knee problems and how they are treated.

This recording is from Sports Surgery Clinic’s first Online Public Information Meeting, intended for anybody interested in learning more about surgical and conservative measures for treating joint pain.

In this video, Mr Withers discusses the common causes of knee pain. He outlines how knee injuries are treated using surgery such as Total Knee Replacement for severe knee osteoarthritis or by adopting conservative methods of treatment such as exercise and physiotherapy for less serious knee pain.

Read Mr Withers’ presentation on common causes of knee pain here.

My name is Dan Withers, I am one of the Consultant Orthopaedic Knee Surgeons at the Sports Surgery Clinic in Dublin.

The talk I am going to give is on common knee problems, the common knee conditions that I would deal with here at SSC.  As most of you probably already know, Sports Surgery Clinic is an Orthopaedic Hospital which opened in 2007 covering all aspects of orthopaedic surgery. It has got five theatres and is in the process of building two more and it has a full suite of  Radiology Services, a Sports Medicine Department, a Physiotherapy Department and Strength and Conditioning.

In terms of joint replacements and the types of surgery that we do, last year, SSC did approximately eighteen hundred total hip replacements and total knee replacements and roundabout a thousand ACL ligament reconstructions.

In terms of the bulk of the stuff that I would see would be a lot of sporting injuries, a lot of ligament injuries. When you are looking at the knee, there are four main ligaments that stabilize the knee.

There are the two cruciate ligaments which are inside the knee, which is the posterior cruciate ligament and the anterior cruciate ligament. Then towards the inner aspect of the knee, there is the medial collateral ligament and towards the outside of the knee is the lateral collateral ligament. Those four ligaments provide the knee stability that these are dealing with their commonly injured when playing sports.

In terms of the medial collateral ligament, it is normally an injury which happens whenever a valgus force is produced on the knee. A valgus force happens normally when you take a hit towards the outer aspect of the knee or if your foot possibly gets caught in the ground and causes a valgus force on the knee itself.

It is quite a common injury in terms of its treatment, generally speaking, it rarely ends up needing any form of surgery if it is an isolated MCL injury that has happened and a lot of times we can just rehab these injuries, possibly with a small brace for a period between two to four weeks and maybe taking some painkillers but it rarely causes enough instability to require a reconstruction. The only time that we would really need to do a reconstruction of this is if it is injured in combination with another ligament.

The other ligament on the outside of the knee is the lateral collateral ligament and its more likely that this gets injured in sport whenever you get a knock to the inside of the knee and this is called a varus producing force.

An isolated injury of the lateral collateral ligament is fairly rare on its own, it normally happens in combination with other ligaments possibly with the ACL or PCL and as a ligament itself in terms of the surgery, the level of stability in the ligament decides whether or not surgery is required.

With conservative management, its is normally a brace for a period of weeks but if it needs reconstruction, sometimes we take ligaments elsewhere around the knee and do a reconstruction of that ligament that is normally in the setting of a multi-ligament injury.

The Posterior Cruciate Ligament, normally it takes quite a high energy impact to cause a posterior cruciate ligament injury sometimes people used to call this a dashboard-type injury whereby in a car crash, people’s knee used to hit off the dashboard and force the tibia backwards, which causes the posterior cruciate ligament to rupture.

In terms of the treatments of posterior cruciate ligaments it depends on how high-grade injury it is and on the whole, again, they can be managed conservatively but if they are very unstable or are very high grade we may need to do constructions of these ligaments as well.

This is the most common injury that I would see and it is the most common one people have heard of, it is the Anterior Cruciate Ligament and commonly it’s a non-contact injury. Around about 70 to 80 per cent of ACL injuries are noncontact, whereby in a match someone goes to change direction and it produces a valgus type injury and twist and the ACL is torn but it can also happen in contact injuries or indirect contact injuries as well.

In terms of the treatment of an ACL, normally, we end up needing to reconstruct an ACL ligament and how we would go about that is by taking ligaments from elsewhere around the knee. For example, the patella tendon where we take the middle third of the patella tendon and we drill tunnel’s within the femur, and one within the shin bone, and then we pass that ligament up through the tunnels and lock them in place with screws.

The picture on the right side of the screen is an arthroscopic picture of an ACL reconstruction. Afterwards, it does take quite a bit of rehab and strength and conditioning, and it takes between nine to twelve months, normally, to get back to return to play after an ACL injury.

Other ligament conditions that I would commonly treat are meniscal tears. There are two types of meniscal tears. There are tears that happen in the younger population and then there is the more commonly degenerative meniscal tear in the older population.

In terms of degenerative tears, the more common degenerative tears, a lot of times these can be treated conservatively but they may end up needing to go on to have an arthroscopy, which is at the bottom of the screen there, whereby you need to go and remove a flap of tissue through two small little nicks in the skin. This is another common condition that I would treat.

Osteoarthritis is basically is a degenerative joint disease. Its wear and tear of the articular cartilage and the issue with this is cartilage doesn’t have any capacity to heal itself. It has got no nerve supply or no blood supply so when you get wear and tear on it, it doesn’t repair itself and then it causes the symptoms such as pain, stiffness and swelling within the affected joint. Osteoarthritis most commonly affects the knee or the hip but it can present all around the body, even the back and neck and joints of the hand.

Often, people talk about the various stages of osteoarthritis, and sometimes you might hear people talking about grade 4 changes as end-stage osteoarthritic change. There are four stages and the picture here represents that. In stage one, which is picture A, normally what happens is that the cartilage starts to become a little bit softer. In stage two you start to get some fibrillation of the cartilage, then in stage three, you start to get partial thickness of the cartilage worn away and in stage four the cartilage is completely worn away basically the bare bone underneath.

There are various risk factors. I suppose age is one thing. The older you get, the more sort of the ‘miles are on the clock’. Approximately 50 per cent of people throughout their lifetime will develop some symptoms of knee osteoarthritis and around about a quarter of the adult population will have at some stage symptoms of hip osteoarthritis. So age just a big factor.

Obesity is a risk factor due to the fact that when there is an extra force going through the joints, obviously, you’re going to have more wear and tear within that joint.

Previous injuries, if you’ve ever had any previous injuries playing sports. You can damage the cartilage and as I mentioned it doesn’t actually repair itself, so the injuries there that can progress to full-blown osteoarthritis down the line.

If you have a family history or a genetic predisposition to developing osteoarthritis, there’s another risk factor.

Overuse and also muscle weakness and muscle imbalance. If you have weakness around the joints, or if muscles around the joint are weaker, you are going to put more force through that joint and therefore you may develop osteoarthritis quicker.

We know that osteoarthritis is very commonly asymptomatic. Normally I describe to people, the more miles on the tyre the lower the thread. So everyone to some degree will have a little bit of wear on their joints. There was a recent paper reported that up to 43 per cent of people over 40 years old have MRI signs of osteoarthritis, but no symptoms at all. That’s a quite interesting thing for me, why those people have no symptoms.

Some other studies suggest reasons for this could be to do with biomechanics and strength. We know that if you have a stiffer walking gait or an altered walking pattern, you tend to have more symptoms.

Also, if you have lower muscle strength, especially in your quadriceps muscles, then you are more prone to being symptomatic and having functional deterioration actually in the osteoarthritis process itself.

So the importance of exercise and being active is very, very important.

Some people get quite down if they are told that they have osteoarthritis of the knee and this is something I would normally tell people as well, is that if someone says you have osteoarthritis, it doesn’t mean that you actually end up needing any form of operation.

There was a paper that came out a little while back and they looked at everyone who was given a diagnosis of osteoarthritis and they went on to look at how many of them ended up needing some form of knee replacement or hip replacement and actually only 30 per cent of the people in that cohort ended up going on to have a knee replacement and 14 per cent ended up going on to have a hip replacement.

Some factors that were associated with a higher risk of going on to need an operation included increased weight that is something that we know is quite a risk factor.

So the actual osteoarthritis itself in the knee what happens is that there is a fissure in the cracks within the cartilage itself. Sometimes you have what’s called osteophytes, which is just basically a reaction of your knee joints trying to repair itself and you get some abnormal growths of little bone, which is an osteophyte and sometimes you can even get a little fluid-filled cyst in the bone underneath the knee joint as well and that is all part and parcel of the process of osteoarthritis.

The most common symptom of knee osteoarthritis is obviously a pain in the knee. Other symptoms include a limited range of motion and stiffness. People may have swelling from time to time. They can have that pain when standing or walking for long periods. And some people even end up getting night pain. I think night pain is probably the one thing that would trigger you to think that you may end up needing to have something like a knee replacement if you are starting to get night pain and you can’t quite control it.

The diagnosis normally involves an x-ray, sometimes we will have an MRI. This x-ray here shows the knee on the left side of the screen. You can see no gap in the joint itself. On the right-hand side, there’s a fairly evident gap so that knee is very arthritic and we would normally get an X-ray to diagnose that.

In terms of treatment, I always start off treatment with conservative management as much as possible and conservative management normally involves pain medication and you could start off with the simple things like paracetamol or anti-inflammatory tablets.

Normally, I recommend if somebody is finding that they are getting painful during certain activities, then taking the tablets one or two hours just before that activity is something that’s quite beneficial.

I mentioned before weight loss is important. We know that around about seven times your body weight goes through the knee on activities such as walking up and downstairs so even if you lose one kilo, that is around about seven kilos less, that is going through the knee on certain activities. Weight loss is definitely something that would help.

Other conservative methods, which are very important are exercise and specifically physiotherapy. Physiotherapy, normally what that involves is muscle strengthening. If you strengthen up your quadriceps and your gluteal muscle which is your bum muscle and your core muscle, it acts like springs’ on the car suspension. It tightens everything up and puts less force through the knee joint itself and less force through the knee joint means that you are going to have fewer symptoms of the osteoarthritis.

Staying active is very important, I encourage people to stay active and they are the main things for conservative management of knee osteoarthritis.

If you have exhausted all conservative treatments, the next thing that you might think about is an injection. There are different types of injection. The most common one is a steroid injection and this is a very strong anti-inflammatory which you inject into the joints and it reduces the pain and inflammation within the knee joint itself.

For some people, they can get quite long periods of time out of that, in terms of the length of pain relief, other people, not so much. There are other types of injections, such as hyaluronic acid, which sometimes people call a gel injection and also a plate rich plasma (PRP) Injection.

This is basically removing some blood and spinning it in a centrifuge and then siphoning off part of that plasma with the platelets in it. Then as you spin, the platelets, disaggregate and release a lot of natural anti-inflammatory properties and then you inject that back into the knee.

None of the injections do anything structurally to the knee. Their basic function is, as an anti-inflammatory to try and dampen down the symptoms. Sometimes people ask how often can you get injections? I would say to have injections twice a year.  If you are starting to need an injection more than that, then you may need to start upping the treatment ladder.

Another thing is sometimes people ask about supplements. If you look at the evidence for supplements, there is no clear evidence that any of the supplements actually prevent osteoarthritis. It is very difficult to prove with studies. So in the evidence, there is no clear evidence for that. Common ones such as glucosamine and Chondroitin have been shown to have a small role in the relief of the symptoms of osteoarthritis but whether or not they protect against it is difficult to say.

If you have gone through all of those treatment options and then the symptoms are ongoing and severe enough, then the next thing that you might need is a knee replacement.

Total Knee Replacement

A Total Knee Replacement involves basically shaving away the diseased end of the bones and putting on metal replacements with a very strong plastic in between the two metal pieces. That is a typical scar on the right of the screen there that it might have afterwards and that’s what a typical X-ray might look like afterwards.

Knee replacements are a very good operation when they are needed but I normally warn everyone that it can be quite tough for the first six weeks and then it can take a good six months to a year before you feel as if you’re back to any sort of normality. The key to any improvement afterwards is the physiotherapy.

Normally you will be in the hospital for around four or five days and you will have crutches for about six weeks afterwards and physiotherapy is the key to avoiding stiffness afterwards.

Partial Knee Replacement

Another option is a partial knee replacement or unicompartmental knee replacement. If you have a certain type of wear and tear pattern, mainly if the wear and tear is more towards the inner aspect of the knee, you may be suitable for a partial knee replacement.

The advantages of unicompartmental knee surgery versus a total knee are that the recovery is probably slightly quicker and also people would say that down the line this would feel a little bit more like a normal knee compared to the total knee replacement.

So those are some of the advantages but it has to be very specific wear and tear pattern to qualify it to have a partial knee replacement.

If you are someone who is very young and you have a lot of wear and tear in the knee joint and specifically on the inside part of the knee joint an option could be a Tibial Osteotomy and this is an X-ray of somebody that I performed tibial osteotomy on.

Normally you have to be probably 40 years old or less to qualify for this and the idea behind this is if you draw a line from the centre of the hip to the centre of the ankle, the mechanical access of your limb normally runs through your knee, through the middle part of the knee if you are looking from the front but when you get a lot of wear and tear on the inner aspect of the knee, then the mechanical access is shifted more towards the midline.

The idea of this is to have to essentially break the bone and then realign the tibia so that you realign the mechanical access and essentially, you are putting the forces more towards the outside of the knee where you have better cartilage, then this dampens down a lot of the symptoms that you have.

In summary, osteoarthritis is very common. It can be symptomatic or asymptomatic. The keys behind reducing symptoms for it are staying active and staying strong and conservative approaches to treatment is the treatment that I would always go for first.

Thank you.

Common issues involving the Hip with Mr Gavin McHugh

Watch this video of Mr Gavin McHugh Consultant Orthopaedic Surgeon, discussing Common Hip Problems.

This recording is from Sports Surgery Clinic’s first Online Public Information Meeting, intended for anybody interested in learning more about surgical and conservative measures for treating joint pain.

In this video, Mr McHugh discusses the common causes of hip pain. He outlines how hip injuries are treated using surgery such as Total Hip Replacement for severe hip pain or by adopting conservative methods of treatment such as physiotherapy for less serious hip injuries.

For information on the cost of Total Hip Replacement (THR) Surgery at Sports Surgery Clinic, please contact

Read Mr Gavin McHugh’s presentation on Common causes of Hip pain here.

Good afternoon, ladies and gentlemen, I am very excited to be part of this Sports Surgery Clinic webinar. My name is Gavin McHugh. I’m here to talk to you about some common issues involving the hip joint.

First of all, I’m going to try and talk about four aspects of not just the joint in that I want to take it away from the joint a little bit. Number one, the muscle, number two, the joint itself, number three, the tendons around the area and number four, the bone itself and hopefully try and make a little take-home point about all these issues.

The first element I’d like to mention is a thing called sarcopenia, which is a term that most people wouldn’t have heard of and essentially, sarcopenia, unfortunately, is the age-related loss of muscle mass and function that occurs as we get older. Essentially from around the age of about 30 or 40, around eight per cent of your muscle mass is lost and every ten years or so, and after about the age of 70, that accelerates quite a bit to the extent that after by the age of 80, you’re talking about 30, 40 per cent of your muscle mass that is normally present.

This slide demonstrates it quite well. A cross-sectional scan of over a thigh of someone who’s 25 years of age and you can see the difference highlighted in an older individual where there’s been a progressive loss of muscle mass and replacement with fatty tissue.

What is the significance of this? Well, the significance of this is that as you lose muscle mass, you lose strength and as you lose strength, you potentially lose a lot of your independence.

The strength of your quads muscles or your quadriceps muscles are really the important anti-gravity muscle that allows individuals to stand up from us from a seated position. That is what determines how independent you are, essentially and we know from multiple studies, which is quite remarkable, that the strength in your quads determines really how long you stay independent.

It is more important than associated issues such as mental health issues and the deterioration with Alzheimer’s disease, with other comorbidities, such as lung problems and cardiovascular problems, it really boils down to how much muscle you have in the bank, essentially for the future.

We know that if you’re sick and you lose about 10 days in bed, you can lose potentially 50 per cent off that muscle strength. Then that impacts further in the recovery process.

So that the first take-home message is with regards to the muscle is that it’s never too late. There have been some remarkable studies performed in and we are taking cohorts of patients over the age of 90 and put them through an exercise program of six-eight weeks duration and the increase in strength you get when you perform quite simple supervised exercises can be 150/160 per cent increase in strength at six-eight weeks, which is really, really quite dramatic. If bodybuilders could achieve these types of gains, they would be absolutely delighted. But it just highlights the fact that it’s never too late to start that process.

As I said, whilst people are potentially cocooned at home and throughout this current pandemic, very simple little exercises can be performed to, number one, to maintain your strength. and number two, to actually improve it.

And these are simple little exercises that you can get a lot more information on from here in the Sports Surgery Clinic or indeed, just even touching base with your own local physiotherapist getting a video conference or organise and getting the simple little program.

It really should only take five to 10 minutes in the day. Simple exercises such as even standing up from a sitting position in a chair, performing exercises such as walls slides and bridges. These literally only take a couple of minutes to perform and can really have dramatic improvements and I touch base on how this interrelates to really everything I’m going to talk about regarding the hip.

The next step point is moving on into the joint and it is plain old simple osteoarthritis and really, regarding the hip, this is by far the most common issue that I see on a day to day basis.

What is hip osteoarthritis? Well, essentially, as you get older, wear and tear, as people often call it, you get that sort of pearly cartilage, the pretty white tissue is progressively lost off the surface of the joint.

How does it present? It normally presents with increasing pain, most commonly in the groin area but it can be around the buttock or even over the side of the hip and often that will radiate down to the knee area itself and in fact, quite often people present with just pain in the knee predominately but in fact, that the pain is coming from the hip.

What other impairments do patients note? Things like difficulty with putting on and taking off the shoes and socks, cutting their toenails and difficulty getting in and out of a car and night pain would be particularly common. In fact, night pain would be one of the main determinants that would really pushes us towards considering something like a hip replacement, which I will mention shortly.

Difficulty walking – often times people will notice that, the distance progressively has dropped down from five miles to three to two to one and so on, so forth, to the extent that their normal day to day activities are being significantly impaired.

What tends to be the treatment for a hip replacement? Assuming that and non-operative measures such a simple analgesia, some exercises that I’ve talked about and potentially an injection into the joint to feel that aren’t working well, then the solution is, a hip replacement.

What I often say to people is, that you can pick a lot of worse things to get than a worn hip. Why? Because hip replacement is really the best operation that we do as orthopaedic surgeons. The overall survival of a hip replacement is around 96 per cent to 10 years, which is pretty, pretty impressive and that is increasing all the time so our results are getting better and better.

Essentially what it involves is removing the worn head and the worn socket and replacing both with an implant or a device similar to the one that you see in the picture.

Hip replacements can be either cemented in place or they can be cement-less, which is where the implant has a rough coating that allows the bone to grow onto the surface and that’s how the fixation is gained.

There are pros and cons to both of these that I won’t go into too much detail but either way, both can perform really, really well and essentially from one to two days following the surgery and can lead to really significant improvements in pain to the extent that the majority of people are more or less symptom-free six weeks following their surgery.

The next thing to mention then would be again, something that I see quite commonly and this is moving away from the joint and onto the tendon. It is an issue called Trochanteric bursitis.

I use the term bursitis. What is a bursa? Bursa is a little bag that you can see in the picture that essentially acts to reduce friction around the area of either a joint or bony prominence.

Essentially it is two surfaces that are separated by a tiny drop of fluid to allow very low friction movement and the greater trochanter is the bony prominence that you see on the slide and the trochanter bursa overlies it.

Anything with an ‘itis’ at the end of it essentially means inflammation. So if you have tonsillitis is inflammation in your tonsils and bursitis is the same. It’s inflammation of the bursa.

But to be honest, the vast majority of the times there’s not even a bursitis present. Most of the time, patients have small, little micro-tears in some of the abductor muscles, which are the gluteal muscles that you can see again in the picture and the gluteus minimus and medius that insert onto that bony prominence and essentially perform a very important function in balancing the whole rest of your pelvis as you walk.

How do people present with this bursitis? They tend to get the pain out over the side of their hip and this is something that is really, really common, we see several times a week in the clinic. Quite often people describe that they have pain in bed at night time when they lie on the affected side. In fact, it often stops them from lying on that side.

Sometimes it moves right on the outside of the thigh, towards the knee or just below the knee but it is not usually associated with any numbness. Numbness would be more likely to suggest a spinal cause for this and that a sciatica type pain was the cause.

When I mentioned problems with the back, however, it is worth noting that this is something that does seem to be and exacerbated when patients have a lot of trouble with their lower back as well and I think really one feeds off the other and can make the other worse.

The vast majority of times the bursitis usually responds to a course of physiotherapy. In fact, some of the exercises that I’ve mentioned, along with an exercise called the hip hitch can really often help to try and the cause so that the microscopic tears to heal up themselves.

Quite frequently I will augment that with a steroid injection into the area, in fact, sometimes it might take two if not three injections to the area to fully settle it down.

Rarely does it require a surgical fixation if there’s a significant tear in the muscles and it is really not settling with injections then occasionally it will require surgery and that is ninety-five/Ninety-seven per cent of people will get away without any surgery.

The next thing I’m moving away then from the tendons onto the bone, then just to mention a hip fracture and again, you can see here on the on the X-ray, this is the right side as we are looking at the pelvis from the front, there’s a fracture here, which will be an inter-trochanteric fracture of the right hip.

This is as we get older, it’s often associated with a very, very simple fall, just from standing height. And the key is, is that almost certainly synonymous with osteoporosis.

What is osteoporosis? Osteoporosis is weak bones, essentially and it is the loss of your bone mineral density, so the calcium essentially gets sucked right out of the bones, meaning it loses the strength and its bony architecture and that makes people more and more prone to developing fractures.

It is a little bit like that as we get older that we lose the muscle mass, we also lose bone mineral density and you can see there the striking figure for the mortality rate after a hip fracture. This is something that over the last 30 years hasn’t particularly improved even though the surgery in terms of fixing these fractures has significantly improved. We are still looking at approximately one in four people not being alive one year after their hip fracture, which is really quite striking and up there with the vast majority of cancers and essentially this is to highlight the importance of prevention.

So how do we prevent and hip fractures? Well, we deal with the osteoporosis and one very, very simple way of dealing with the osteoporosis, aside from pharmacological means is weight-bearing exercise.

So again, this all ties into not only do we protect our muscles, not only do we protect our tendons and joints, we protect our bones themselves by performing a weight-bearing exercise.

And again, that can be something simple as getting up, getting out and walking and performing simple little squatting exercises all help to load the bone and increases bone mineral density and bone like the muscle, does remodel and rebuild itself.

You can’t be sure that you’re going to avoid problems such as a fracture or arthritis of the joint or bursitis in the future. But you can be sure that it will stand by you if you have to have any procedure. So, for example, the recovery following a hip replacement and is undoubtedly quicker and people who are fitter from the outset.

Common Shoulder Problems with Mr Hannan Mullett

Watch this video of Mr Hannan Mullett, Consultant Orthopaedic Surgeon, discussing Common Shoulder Problems.

This recording is from Sports Surgery Clinic’s first Online Public Information Meeting, intended for anybody interested in learning more about surgical and conservative measures for treating joint pain.

In this video, Mr Mullett discusses common causes of age-related shoulder pain. He outlines how shoulder pain is relieved and treated using shoulder surgery for serious shoulder pain or adopting conservative methods of treatment such as physiotherapy for less serious shoulder injuries.

For further information on shoulder pain or for advice on making an appointment with an orthopaedic consultant,  please contact

Read Mr Mullett’s presentation on common shoulder problems here.

I am Hannan Mullett, I’m one of the shoulder surgeons here at the Sports Surgery Clinic and I’d like to talk to you today about some of the common shoulder problems.

Shoulder problems are very common and it ranks second only to back pain is the most common reason why people might lose work due to musculoskeletal problems, it can be due to someone’s occupation because they are involved in heavy lifting or more commonly nowadays, is that static posture or working at desks or in a fixed position for a long time.

When you look at your shoulder problem on the Internet, you get bamboozled with all this information about different types of tests and different types of treatment, some of them are reliable types of treatments and some of them are not.

So I’m going to talk a little bit about the most common type of problems we see. For the non-injury type of shoulder problems, wear and tear type problems, the most common problems I see are problems with the rotator cuff. And this can go from somebody where the tendon is intact but rubbing against the overlying bone to people who have torn the rotator cuff. Another common problem is a frozen shoulder, which is common particularly in middle-aged women. Arthritis, probably not as common in the shoulder as is in the hip and knee, but it is a common cause of shoulder pain. I’m not going to really talk today much about sports injuries. It’s more about the wear and tear type of problems we see in the general population.

There are two main parts to the shoulder, the scapula or the shoulder blade and then the humorous, which is the arm bone and at the top of your shoulder you have the collarbones.

The collarbone acts as a type of strut to hold the shoulder blade in position and then allow the ball and socket joint to move so that you can place your arm overhead.

If we go to the next layer, if you like, in terms of the anatomy, we can see that the various muscles around the shoulder and the ones that cause us the most concern, really, are the rotator cuff muscles, which are a group of tendons around the ball and socket joint, the power of the shoulder and particularly the one at the top, the supraspinatus can impinge against the bone and cause pain.

In terms of the rotator cuff, the one that’s most commonly injured is the one at the top called the supraspinatus, which brings the arm out from the side and then the less commonly the infraspinatus, which brings the arm out from the body. These are commonly a source of inflammation and also, they can tear and need attention.

In terms of the rotator cuff, it can go all the way from tendinitis or inflammation of the tendon all the way to a rotator cuff tear and then some patients who have rotator cuff tear, can then develop arthritis due to that tear. About 10 per cent of people with a major rotator cuff tear can get arthritis due to that tear.

As to why some people just get tendonitis and some people it develops into a full tear, this can due to their age and more likely as you get older or if they’ve had an episode of trauma or maybe their occupation. But there is a strong genetic element as in a lot of things in life you can blame your parents!

When we look at the type of treatments, it really depends on how bad the condition is, we can start off with things like physiotherapy or injections are often very helpful, particularly if we want to avoid surgery in the earlier stages of treatment.

Some rotator cuff problems are amenable to keyhole surgery. This can involve either taking away spurs of bone or in fact repairing the tendon.

Some types of rotator cuff tears require open surgery, though this is becoming less common nowadays and then the ultimately small number of the overall patients who develop rotator cuff problems require shoulder replacement surgery.

One of the most common shoulder conditions is impingement. In this image, you can see this long bay structure is the humorous of the arm bone then they have the tendons or the rotator cuff. There is a fluid-filled sac called the bursa and as the patient raises their arm, they can get impingement or pressure on the rotator cuff on the Bursa as it rubs against the bone spur above it.

And in fact, you can get this vicious cycle so that a patient gets a little bit of inflammation in the tendon, the tendon then becomes thicker and inflamed and then more likely to impinge and cause pain.

This is what’s happening in this animation as the patient raises their arms. You can see the tendon impinges against the bone and the ligaments and this is what we see if we end up putting a camera into the shoulder. This is rotator cuff tendonitis. In fact, there’s a lot of terminologies that crosses over so if you get an MRI report showing rotator cuff tendinitis, that’s the same as impingement, which is generally the same as a partial thickness tear.

When you examine the patient, they as they raise their arm up in the air, they may be comfortable when they have their arm down one side and then when they raise their arm up in the air pinches and they get a positive impingement.

When patients have a lot of shoulder pain and are sent by their General Practitioner or by the physio for an MRI scan they are often a little bit disappointed when the result comes back and shows in fact the rotator cuff is intact. Because when the MRI scan is done, you’re lying in this tube in the hospital with your arms down by your side, which is the most undemanding position for the rotator cuffs and it’s not very sensitive for looking at rotator cuff tendinitis.

It is useful in that it can distinguish from other shoulder problems like a full-thickness tear, rotator cuff or arthritis of the ball and socket joint but it doesn’t make the diagnosis you have to examine the patient and take the history of the story that they’re telling into the context as well as to what you’re going to do.

So in terms of treatment, when somebody has a rotator cuff tendinitis, you tend to avoid aggravating factors, if you are a plasterer and you do a lot of overhead activity to try and minimize this there are some occupations particularly plasterers or hairdressers or people where you’re using your arm in a position that aggregates your rotator cuff.

It is reasonable to start off with anti-inflammatory medication for a few weeks. Physiotherapy is also very useful and I certainly would try physiotherapy, anti-inflammatories and simple things before moving on some more complicated things.

If patients have had it generally for more than six weeks or sometimes if it’s very severe, one would think about a steroid injection but we don’t really like to inject the body unless you’ve tried everything else.

Generally, I avoid steroid injections and they’re very useful, but I try not to do it on patients unless they have had it for more than six week period.

Exercises are useful, simple stretches such as standing and raising your shoulders, holding for five, seven seconds and then back down again, squeezing your shoulder blades together and holding five seconds, or putting your shoulder blades down and holding for five seconds is useful. These type of stretches, particularly if you have some stiffness when you’re lacking a little range of motion when you test it out doing simple exercises like this or stretches with your arm across your chest or event this one which you can do against a door frame – these are all useful rotator cuff stretching exercises, which you should do before seeking any medical attention.

So if you had you’ve tried the injection or you’ve tried the anti-inflammatories, you’ve tried the physiotherapy, it’s you’re still in trouble, you are getting night pain and pain at night then it is reasonable to try a steroid injection. This can be done fairly readily. It can either done by the radiologist or in fact, it’s a fairly large target that you’re injecting into this large bursa, so it’s very convenient for the patients to be injected in my office, which saves them coming back another time.

This is said generally takes a couple of minutes to do. It is safe. There’s about a one in 10 chance that it’s a bit more painful for a day or two and about one in a thousand people, unfortunately, can get an infection from any injection. This is more common perhaps that they’re diabetics or other risk factors.

So in patients, the small number of patients require surgery. Here we are looking at the right shoulder from behind, the metallic instrument here is a shaver and I am using that to take away the thickened bursa and also in this part of the operation to take away spurs of bone that are impinging against the tendon.

This can be performed as a day case surgery, it’s done through three very small 3mm incisions. The patient wears a sling for a number of days and generally, they can get back to normal activities, such as driving within that four or five days.

Patients also have a small joint to the top of the shoulder between the collarbone and the other edge of the shoulder. This is not an important joint, but in everybody, 100 per cent of people, it gets worn as we age. So if you’re over 40, you get an MRI scan of your shoulder it’s definitely going to show the general change of the AC joint (acromioclavicular joint).

In most patients, this is not a source of pain, but it can be.  If you have pain when you cross your chest and at the very extremes of movement, this is more in keeping with it AC joint type pain and this can also be injected and ultimately if it is giving enough trouble this can also be addressed through keyhole surgery.

If you’re over 40 and you get your MRI scan results, it will always show degenerative changes of the AC joint and you may be told by somebody that you have arthritis in your shoulder. Well, the arthritis is in a very small part of the shoulder and it may be that the rest of the shoulder, in fact, is completely normal.

So what about when we move on then, we’ve spoken about it a little bit about the impingement and rotator cuff tendonitis and we’ve spoken about the general change of the AC joint. What about tears?

There is an old adage that grey hair equals old tear, and certainly, as you get older, there’s a greater likelihood that you’re going to have a rotator cuff tear.

By the time you reach 80 years of age, 80% of people will have a rotator cuff tear, which doesn’t mean that we need to do anything with it unless it’s causing some symptoms. And generally, it’s important you can separate rotator cuff tears as to whether they’re an acute tear, i.e. due to, you lift something heavy or you fall or you trip over the dog and you have your normal shoulder and then you tear the rotator cuff as opposed to the kind of wear and tear type of rotator cuff problem, a degenerative rotator cuff tear.

Generally, if somebody is fit and healthy and otherwise in good shape, if they tear the rotator cuff due to an injury, we tend to repair it. If they have a wear and tear type of rotator cuff problem, we try to treat it with tried physiotherapy and perhaps one or two injections. Rotator cuff tear are generally rare under the age of 40 but as we age, they become more prevalent and most patients over 70 will have some degenerative changes in their rotator cuff.

When you put a camera in the shoulder this is what it looks like, this is the edge of the bone here with a tendon should be attached and the rotator cuff has kind of pulled off the bone with a significant tear. This is a patient here so he raises the left arm without any difficulty and is having great difficulty raising his right arm and when he tries to bring his arm out from his side, even when we try and help him to bring it from his side it just flops back. This is a sign of a pretty severe rotator cuff tear.

As to whether you repair it or not, we generally say with a wear and tear type of tear, we try and treat it with physiotherapy injections, first of all. But if somebody has a fall or an injury, we tend to try and repair it. And in fact, if you have a traumatic tear, i.e., due to an injury, you’re better off having it fixed sooner rather than later because the tissue tends to lose its elasticity and becomes more difficult to repair.

In most patients who come for intervention for their rotator cuff tears, the most common symptom is that they get pain at night. So they have difficulty lying on this side and it disturbs their sleep. To a lesser extent, they come with a weakness, for example, difficulty carrying a pot of tea or something with our arm outstretched or less commonly that the shoulder is unstable or pumping in and out, which is what happens really only with more extreme levels of rotator cuff tear.

It is important that the doctor or the physiotherapist usually starts by taking a history and an examination and then move on to the MRI scan rather than working from the MRI back because as I said if you’re 70 plus your MRI, is unlikely it’s going to show an intact rotator cuff. So we don’t treat the MRI we treat the patient initially.

And this is what it looks like, this is when I put a camera into somebody’s shoulder. This is a right shoulder and we are looking at it from behind. I am using an instrument to assess the white structure here is the rotator cuff. This was somebody who had fallen and I am just checking to see if we can repair the rotator cuff which thankfully we were able to do on this occasion.

Traditionally this was done openly and still, some people do it through an open technique. There’s nothing wrong with that except that it tends to be a little bit more painful that you need a more prolonged inpatient stay and the mobilisation is longer and you tend to get scarring between the various layers between the outer muscle and the rotator cuff and approximately 20 per cent of people with an open repair, will develop stiffness.

As part of the repair, we take away the outer surface of the bone and clear out any scar tissue and then use special instruments to pass stitches or sutures through the rotator cuff, and then we tie these together, then put them into what we call an anchor, which attaches the rotator cuff to the bone.

So the technology has certainly advanced even over the last five to 10 years, making this a lot easier to do and keyhole surgery, if it works well,  saves the patient a lot in terms of open surgery and here I have passed the sutures through the tendon and am now putting the anchor into the bone so that hopefully the patient will heal the tendon to the bone.

Next, I will talk about a very common problem called frozen shoulder. Generally, it happens between the age of 40 and 60. It is a bit more common in women than in men. People with diabetes and thyroid problems can get a more severe form.

There is generally no particular cause for it but it can happen after a minor injury. So somebody trips over the dog or trips over the curb, and within a few weeks their shoulder becomes painful and they put it down to the injury but it may just be the thing that triggered the frozen shoulder and in fact, you can develop a frozen shoulder after surgery.

This could be shoulder surgery, for example, if you have your bone spurs removed in the first operation, I described a small percentage people can that can trigger a frozen shoulder or it can be triggered by it used to be quite common with open-heart surgery or a breast surgery in women. That can be cause for it. So what happens is there’s a thin membrane or a lining of the joint between the ball and socket joint and this becomes red and angry and thickened.

Patients present really with severe shoulder pain with a frozen shoulder, particularly if they overstretch. The Americans call it ‘jerk pain.’ So if they reach for somebody, they get searing pain. They also have significant night pain and sleep disturbance and then the shoulder becomes restricted and they notice restricted range motion, for example, tying their bra.

Luckily only get it once per side but if you get it on one side, you’ve at least 10 per cent chance of getting the other side. Generally, it takes nine to twelve months to resolve but it can be as long as two years.

There are three stages. The first stage is the most painful stage, usually will last four to six months. The shoulder is painful with restricted movement, pain at night, pain if you’re overstretched. The second stage, the pain gets better, but it still remains restricted and the third stage, it comes back to normal.

In the first stage, I often send patients for physiotherapy. Although physiotherapy for shoulders is generally a very good thing for stage one frozen shoulder, it tends to be too painful and it can actually just aggravate things to some extent. The Physio can help by mobilizing the neck and the shoulder blade but the ball and socket joint is too painful so in the first stage, taking painkillers can be helpful and I find, in fact, injecting the shoulder when somebody has a stage one frozen shoulder really helps the pain.

The second stage physiotherapy is more useful and the second and third stage, generally, the patient is much more comfortable and if they are happy in the knowledge that it’s going to get better over time, a lot of them do not need any further treatment. Probably about maybe 10 per cent of patients where it doesn’t improve within a satisfactory timeframe then we end up doing keyhole surgery.

This is what I do in keyhole surgery. This is the right shoulder. We’re looking from behind the white structure to the right side of the field is the ball and I’m taking away all this very abnormal red, angry, inflamed and thickened tissue, which is the thickened capsule. which is the structure causing the frozen shoulder. This generally can be performed as day-case surgery as its relatively straightforward. The patient just uses a sling for a number of days and does a lot of physio after this to try and keep the movement.

Next, we move on to shoulder arthritis. You have probably had, or maybe your friends have had joints replaced such as hip or knee replacement. Shoulder replacement is not as common an operation, but it is the third most commonly performed surgery.

Shoulder arthritis tends to occur at a slightly older age group, and as we survive longer, more and more shoulder replacements are being performed. In fact, the technology for shoulder replacement surgery has increased fairly dramatically over the last couple of years, so it’s a lot more successful.

This x-ray shows the normal ball and socket joint is very narrowed and there are lots of new bone formations called osteophytes, which is the cause of the problems. If the patient is suitable for it, we can do a lesser procedure where we don’t put long stems down the centre of the bone, we call it a stemless procedure. In fact its the operation I generally perform for this so we would cut the arthritic part of the bone away and then we take away a core of bone and then measure the distance between the cut surface and the outer edge of the bone and then we can put in the components.

The components are made and to accommodate for different sizes so that there’s an array of different supports plates called the trunnion. Then we advance this with what we call it a cage screw. It is a hollow screw that goes into the top part of the arm bone. Here we see the impaction of the metallic humeral head and this allows the preservation of the bone in case they need further surgery. The humeral head articulates with a plastic socket that is cemented into the shoulder blade.

The other type of shoulder arthritis we see which is probably on the increase as people live longer and lead healthier lives is arthritis due to a significant rotator cuff tear. This generally occurs in people over 75 years of age.  This usually presents with an arm that’s painful, but the patient can’t really do their normal activities – even putting a key in the door can be trouble so they can lose their independence.

This is a different type of shoulder replacement where it’s called a reverse geometry shoulder replacement. So in this, you can see on the left side of the image there, we have the normal ball and socket joint and we replace this by putting a ball in the socket, under the socket and the arm bone, so we reverse the geometry of the shoulder replacement and this is done to allow us to take advantage of the fact that the outermost of the deltoid is intact so we restore what is called the fulcrum of the shoulder.

This is what it looks like on an x-ray. It’s a slightly more invasive surgery than the other type of shoulder replacement but, in fact, patients recover generally very reliably afterwards.  They wear a sling for four weeks, and often when they come back for their post-op visit, at four to six weeks, they have better movement, particularly in terms of raising their arms above the horizontal than they did before the operation.

In fact, after they reverse geometry, shoulder replacement, the patients can, in fact, regain a range of motion and have a fairly comfortable shoulder in a very quick time frame.