Watch this video of Ms Ruth Delaney, Consultant Orthopaedic Surgeon specialising in shoulder injuries at Sports Surgery Clinic.
This video was recorded as part of SSC’s Online Evening for Tennis in April.
Good evening everybody, and welcome to our 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 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 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.
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.
|The other things that can help in terms of shoulder is that we need to remember not to let the shoulder always be taking the brunt of what we’re doing on the tennis court because the shoulder’s part of what we call the ‘kinetic chain’, which includes your legs, your hips, your trunk and then your shoulder, your elbow, your wrist and your hand and that goes for every shot that we play.|
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.
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.
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 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 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.
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.
The Republic of Ireland Reimbursement Scheme, formerly known as the EU Cross Border Directive, facilitates people living in Northern Ireland and on waiting lists for orthopaedic surgery to travel to Dublin for this surgery.
This webinar was filmed in 2020 pre Brexit and answers many of the questions you may have concerning what is now called the Republic of Ireland Reimbursement Scheme.
|To learn more about the Republic of Ireland Reimbursement Scheme and how you can have surgery in SSC please call Fiona Roche on +353 1 5262168 or Glenda Thorne on +353 1 5262071 or email email@example.com|
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 firstname.lastname@example.org 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.
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.
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.
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.
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.
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.
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.
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 http://live.sportssurgeryclinic.com/Cross_Border_EEA_Application_Form_Directive_Route_06022017-1.pdf
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.
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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.
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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.
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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 firstname.lastname@example.org 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.
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Watch this video of Dr Neil Welch, Head of SSC Lab Services discussing the causes of low back pain and how it can affect Tennis.
This video was recorded as part of SSC’s Online Evening for Tennis.
Dr Neil Welch is Head of Lab Services and Senior Strength & Conditioning Coach at Sports Surgery Clinic in Santry, Dublin.
Hi everyone, my name is Neil Welch. I’m head of SSC’s Lab services at 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.
|Today, I’m going to focus a little bit on back pain, because it is the most common musculoskeletal condition that we deal with.|
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.
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.
|We are looking to try and increase the strength of our glute max and this is probably one of the most important exercises that we use regularly here at the Sports Surgery Clinic for hamstring issues, hip issues, back issues, and it’s very common to have some weakness in our glute max.|
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.
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.
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.
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 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.
Questions and Answers from our Evening for Tennis and Badminton online conference with Ms Ruth Delaney and Dr Neil Welch.
Watch this video of the Q&A session at Sports Surgery Clinic’s Evening for Tennis / Badminton.
At this event, Ms Ruth Delaney (RD), Consultant Orthopaedic Surgeon presented on shoulder injuries in racket sports and how they can be prevented and Neil Welch (NW) Head of rehabilitation at SSC Sports Medicine presented and demonstrated exercises for managing low back pain.
This video is suitable for anyone interested in keeping strong, flexible and active as they get older and for anyone with shoulder or back pain.
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
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.
Watch this video of Joe Collins, Strength & Conditioning Coach at Sports Surgery Clinic demonstrating warm-up exercises for Tennis players.
Hello my name is Joe Collins, and I am one of the strength and conditioning coaches at Sports Surgery Clinic. Today I will be taking you through a quick warm-up for tennis, using bands and five simple exercises that you can do anywhere and when, to make sure you are ready to play.
Exercise one, we have banded squats. For this exercise, you need a Theraband. All you are going to do is place the band just above or below your knee, and from there all we are going to do is have our feet shoulder width apart, and have constant tension on the band. All I am going to do is have my hands crossed across my chest, I am going to sit down keeping tension on the band, and come up nice and controlled, sit down, come back up. From the side, again squatting down and keeping tension on the band, coming back up.
This exercise will be working your quads, hamstrings, glutes and as well as the muscles around the side of your hip. You should feel that in the side pocket, back pocket, and the front and back of your leg.
Exercise number two, we will be doing Monster Walks. Again we need a Theraband, only this time have it just above our ankles. For this one I recommend wearing socks, otherwise you might be in a spot of bother. All I am going to do for this exercise is squat down slightly keeping tension on the band, I am going to take little steps, from side to side. Make sure you go both ways keeping constant tension on the band.
With this exercise, we are working on the side of your hip, so your glute max and glute med. Again you should feel it in your side and back pocket.
Exercise number three will be banded chest flies and reverse flies. For this you need a length of exercise band tied around either a bike or the fence of the tennis court. All that you are going to do is make sure you are kneeling down with your chest nice and upright, and I’ll be working my outside arm, pulling my arm back across my chest, this is working my rear delt and the muscles across the back of my shoulder. From here all I am going to do is turn around and bring the band across my body, working my anterior delt and my pec minor and major. This one should I should feel on the front of my body. Make sure you work both arms.
Exercise number four will be a banded shoulder raise. Again we need the same length of band we used before, this time tied in a loop. Make sure the knot is tight so it doesn’t come undone. Have the band on your hands resting just above your thumb, and from here all I am going to do is keep tension on the band, raise the band above my head keeping constant tension and make sure my chest stays nice and square. This exercise is for the anterior delt also the muscles around your rotator cuff in your shoulder just fills this the whole way round. It is important to keep tension the whole time and keep your chest square.
For our fifth and final exercise, we are going to use our same length of band. For this one we are going to put together the first four exercises. I have the band in my left hand, I am going to tread on it with my right foot. This one we will call the tennis serve exercise – all I am going to do is rotate my body to the left and bring my arm up and then back down to my right foot, rotate up and out, and back to my right foot. Again we should feel this in our hip and our shoulder make sure we work both sides.
There we have it – a quick and easy tennis warm-up. You can do this anywhere or when, before you play or just before you train, with only two pieces of equipment. Make sure you go for 10 reps on each and every exercise or if the exercise involves separate arms you can do 10 reps on each arm. Go for three or four rounds and make sure you’re warm and ready to play.
Hope this helps.
Watch this video of Ms Ruth Delaney, Consultant Orthopaedic Surgeon specialising in shoulder injuries at Sports Surgery Clinic.
This video was recorded as part of SSC’s Public information meeting focusing on Orthopaedics.
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 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.
|Four of the most common diagnoses that we see with shoulders are rotator cuff problems, frozen shoulder, shoulder arthritis, and shoulder instability.|
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 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.
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.
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.
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.
|For further information on this topic or to make an appointment with an Orthopaedic Surgeon please email firstname.lastname@example.org|
Fiona Roche (FR) Business Development Manager at SSC put some of the audience’s questions to Ruth Delaney (RD).
FR: Ruth thanks for a really interesting talk – we have a lot of questions coming through for you this evening. The first one is from Michelle: She has had a recent MRI diagnosed full-thickness tear, use of the supraspinous ligament. Is surgery the only option for her, and if so how long after surgery would she expect the full movement of her shoulder?
|RD: 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.
FR: Question from Sue: she has also torn her supraspinatus and calcification of the biceps which ruptured a full 8 months ago. She says is it too late for surgery as she continues to have discomfort and occasional pain in her upper arm, with limited movement but full function?
RD: 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.
FR: Sylvia had an MRI on her shoulder which shows nothing. Would you recommend having an ultrasound? It is very painful, feels like bones are rubbing and very hard to raise her arm.
RD: 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.
FR: I am asking a question here from Liam: he says he has an implanted defibrillator – can he get an MRI or other insights for shoulder pain?
RD: 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.
FR: Getting a COVID injection in an already painful shoulder, is that ok?
RD: 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.
FR: Tom is a 60-year-old male living with rheumatoid arthritis. After doing some painting, or working with the shovel while gardening etc. he developed severe shoulder pain within two days to the point where it is impossible to lift his hand up to his face and after 6 days though on steroids it seems to be sorted?
RD: Well the fact that it responds very quickly to steroids would suggest an inflammatory cause of his pain. With rheumatoid arthritis, that could be the rheumatoid arthritis affecting the shoulder or it could also be something else in the shoulder causing inflammation like a rotator cuff problem.
Obviously going on oral steroids over and over again isn’t a long term solution so I think just getting an assessment of the shoulder, starting off with an X-Ray, seeing if it is arthritic, getting an examination, seeing if the rotator cuff is weak – sometimes we can inject the steroid around the shoulder and it will calm it down, but if it is a reoccurring problem then we might need to look at doing something more definitive. So I think just starting with an assessment of the shoulder overall in the context of the background of the rheumatoid and see where it’s at.
FR: There is a question here from Cliona: experience of adhesions under the shoulder blade in the region of the mid-thoracic area on the back where the blade sits on the rib cage on the back.
RD: 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.
|To make an appointment with Ms Ruth Delaney please contact email@example.com or call 01 5262335.|
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Professor Joe Queally is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic in Santry Dublin who specialises in the hip and knee.
Good evening, everyone. Joe Queally here, one of the Orthopaedic Consultants at the Sports Surgery Clinic. I’m also an associate professor at Trinity College Dublin.
My talk this evening is five common questions that patients ask me about hip replacements. The idea is that I will try and give you answers based on the most recent evidence and scientific literature that’s available.
Asking questions about hip replacements, in general – it’s important to ask your surgeon whoever he or she may be as to how successful it is. And these are questions that would include how long would it last? What type of hip replacement is being used? Questions that are particularly relevant to your personal situation – what do you want to be able to do after the hip replacement? Also, to take into account what medical problems you might have, such as having diabetes or being overweight, how this might affect your hip replacement, and what you can do to help optimize and make sure that you have the best outcome possible.
It is good to have answers that are based on the most up to date, available evidence as possible, because in medicine facts and evidence, change all the time and it’s important to have the most accurate and up to date information when you’re when you’re making a decision about going ahead with a total hip replacement.
Before we get into these questions I’m just going to, in a very simple way, discuss how we measure success after a total hip replacement.
There are two basic ways that we measure success: the first we look at is implant survivorship – by that I mean is, how long does the joint replacement last. That’s really important because you want your hip replacement to last for as long as possible.
The second question that we look at is how well does your hip replacement work. So we want it to last really long, and we want it to work really well. In terms of how well it works, we’re interested in, particularly how quickly patients can get back to function – to walking into doing things that they would like to do.
We’re also interested in seeing how long this good function lasts. We would hope that your input, along with lasting a long time, would also work very well for a long time. When we’re deciding what type of hip replacement to use and how to put it in. These are the two basic questions that we look at.
How do we gather evidence on hip replacements?
There are a few basic ways that we can gather evidence. The first is that surgeons record how well their patients did. They publish their work in an academic paper and a simple example of this is a surgeon might say I did 50 hip replacements – I asked him questions about how well they’re recovered and I found that they could all walk without crutches, by eight weeks after their surgery.
This generally limits the amount of patients to relatively smaller numbers.
The second way that we can try and figure out which is the best type of hip replacement, or the best type of technique is we can compare two different treatments.
So, a surgeon can set up a study where he does, or she does 25 replacements using one technique, and then does 25 hip replacements, compared to a different technique, and they can say that the ‘x’ technique resulted in a better hip replacement, because it lasted for 10 years longer than the ‘y’ hip replacement.
The third way we have of looking at how well joint replacements do in general and this is becoming more common, is that in most countries all surgeons have to report on how well their patients did to a national body, so you have to submit data, saying what type of hip replacement that you have done, and the data is subsequently gathered on how long your hip replacements last, and how well they work.
This is a really powerful tool, because it gathers information on hundreds of thousands of hip replacements, over prolonged periods of time and it gives really good evidence on which replacements work best and as care and techniques evolve, which techniques are better than others.
So that’s just a backdrop for how we figure out how joint replacements work well.
When I’m answering the five most common questions, this is the type of evidence studies that I will be discussing.
So the first question and the most obvious question is what is a hip replacement?
A hip replacement is where somebody’s hip joint, which is this circle here, is removed in its entirety, due to a problem with it. and an implant which we can see here on the right is put in its place.
The implant mimics your natural hip and that it’s a ball and socket type of implant. So the socket part here goes into the pelvis and into the thigh bone here, there is a stem with a bald part attached. The actual joint then is this ball and socket baring here, which the idea is that it mimics your own native hip joint.
So when do we do it?
The most common reason for doing hip replacement is for arthritis of the hip.
What is arthritis?
So a normal hip joint, as we can see here on the left, the ball and socket part of the joint is lined with cartilage which is a very smooth structure that allows your joints to move like a bearing and it allows it to move in a smooth and friction-free way.
What happens with arthritis is that this cartilage lining gets worn out, or gets destroyed for a variety of different reasons.
Because of that, your hip joint is no longer able to move in a smooth and pain-free way.
What happens after a while is that bone starts to grind on bone. This causes severe hip pain and consequent reduced ability to walk or to do things like, play golf, gardening, or hiking.
So really osteoarthritis is damaged cartilage around the lining of both the ball and the socket part of the hip joint.
This is an example here on an X-ray of a normal hip, over here on the left side. We can see space between the ball and socket part of the hip joint.
This is where the cartilage sits, which I’ve just mentioned earlier. When we look at the right here there’s no space between the bones. This is because the cartilage has been damaged or worn away. What’s happening here on the right side is that bone is grinding on bone.
It’s a bit like a rusty hinge – it doesn’t move in a smooth manner, it causes pain, because of that patients can’t walk properly, and they can’t do activities, such as, as I said, such as such as playing golf or even dressing themselves, or even getting in and out of a car can be difficult.
This is a patient who has had arthritis in both hips. He’s had both hips replaced as we can see here.
So the second question that I get asked quite commonly is how long would my hip replacement last?
Again this is a really important question because we want hip replacements to last for as long as possible. Because sometimes we need to do hip replacements a second time around, and that’s called a revision hip replacement.
Revision hip replacements are a harder operation both for patients to recover from and also for the surgeon to carry out. They are best avoided for as long as possible.
That’s why we tend to avoid doing hip replacements in younger patients because we want to avoid having to do a second hip replacement, and some patients they need three and four and in very rare cases even up to five hip replacements over a prolonged period.
How long can we say that hip replacements last in general?
This is a paper published in 2019 in The Lancet, which is one of the leading medical journals – the author’s looked at a huge number of hip replacements that were reported in the scientific literature – so they looked at all surgeons who reported how other hip replacements were doing, and they also looked at joint registries in countries such as the UK, New Zealand, Australia and the Scandinavian countries, who have been recording all hip replacements that are done in their countries and how long they last.
They added all the hips together to try and come up with a figure of how long does the average hip replacement last for.
The number of hips that they included in the study was 228,888 hips, which is a huge number. This is really good because the more numbers in a study, the more accurate the data is.
So what did they find?
|They found that 85% of patients can expect for hip replacements last 15 years, 75% of patients can expect for hip replacements last 20 years, and 58% of patients can expect her hip replacements to last 25 years.|
So roughly over half of patients who have a hip replacement can expect it to last 25 years which is a good outcome – this says these figures have slowly improved over the past 30 to 40 years.
Obviously the other side to this is 40% of patients, their hip replacement won’t last 25 years, and these patients often need to have their hip replacement done a second time, which is called a revision hip replacement.
The average age at which patients in the study have a hip replacement is 67. The majority were women at 55%, and the vast majority of hip replacements were carried out for osteoarthritis.
Other causes for hip replacements apart from arthritis, will be for patients who have damaged their hip really badly after an accident who have a really bad hip fracture, patients who have had infections in their hip which is unusual but sometimes happens, or patients who have had childhood hip disease – who have had an issue with their hips since birth, where their hips haven’t quite formed properly.
Another question I get asked all the time in my clinic is which surgical approach is best?
By which surgical approach I mean is – what is the best way to put in a hip replacement, and the best way to get in and around the muscles to put the replacement in?
There is three basic ways to do this:
One is the anterior approach – this is where the hip replacement is put in from the front of your hip. There is what’s called the anterolateral approach, where the hip replacement is put in from the side. And then there is the posterior approach, where the hip replacement is put in from the back of your hip, and they are the three main ways that we put hip replacements in at the minute. Patients often ask which is which of these three is the best way to do it?
The posterior approach, which is the approach that I use, is the most commonly used and this is where the hip replacement is put in via dissection through the muscles of the back of the hip. This is a good approach because it gives you a very good view of the hip joint itself and it allows the hip replacement to be put in a really good position. There’s a theoretical disadvantage that there might be a higher risk of dislocation.
The second approach is anterolateral – this is where the hip is put in from the side. This involves going through muscles at the side of the hip, and the potential disadvantage of this is that there may be a slight risk of limp after this approach, due to disrupting the muscles at the side of your hip
The third approach is the anterior approach which is a newer approach, where the hip replacement is put in from the front of the hip.
Muscle sparing means that instead of cutting through muscles, the hip replacement is put in between muscles.
The assumed advantage of this is that you may get back quicker to doing activities such as walking. The disadvantage of this is that there might be a slight increased risk of problems afterwards, such as fracture when putting the hip replacement in, or injuring nerves at the front of your hip.
Obviously, for surgeons and for patients, we all want to know which of these three approaches is the best and which one should I have for my particular situation.
The answer needs to be found in the evidence and what studies show to be the difference between the three approaches.
I just picked one very recent paper which was published in June last year, which has come from Boston and Copenhagen. These surgeons looked at 93 patients in two different groups.
In one patient they use the anterior approach and in the 2nd 93 patients to use the posterior approach.
What they looked at was how well do the hip replacements function from six weeks, up to to five years. They are wondering which approach – the anterior approach from the front or the posterior approach from the back, results in the best hip function from very early on to, to the five year mark.
They found that both approaches resulted in a significant improvement in function by asking patients questions such as, how far can you walk? What activities of daily living can you do? They found that there was no difference between the two approaches in scores at six weeks, one year or five year.
They found for hip function it doesn’t really matter which approach is used. There is no difference.
The next paper I’m going to look at is, as I mentioned at the beginning, is how long does a hip replacement last when it’s done via the anterior, from the front, from the side or from the back?
This is a study from one of the Scandinavian registries, and they looked at over 20,000 patients that had each of these three approaches either again from the front, from the side, or from the back. They looked at the implant survival as two and five years.
They found no difference between the approaches in terms of survivorship (98% at five years). They concluded that how long a hip replacement lasts is not linked to which approach is used.
So in terms of which approach to recommend to patients: The scientific evidence does not show benefit of one approach over another, in terms of how long the implant lasts, how well it works, or how quick the patients have returned to walking.
So even though I use the posterior approach, because it’s the approach that I have been trained in but I can’t say that that’s any better than the other two approaches, and vice versa.
So, moving on to question number four, this is ‘what about hip resurfacing instead of hip replacement?’
So what is hip resurfacing? It is a form of hip replacement where instead of taking you out to hold the hip joint as we see here on the right -much of the hip joint, particularly the ball part of the hip joint is retained, and the metal cap is put on the top of the ball part.
So what it means is that just less of your hip joint removed and the potential advantages to this are that it kind of preserves more of your natural hip joint. So in theory could result, potentially in better hip movements and better hip function. It’s also less likely to dislocate and this is due to the size of the cap that is put on the top of the ball part.
The big problem with this metal cap was that the baring that was being used was metal on metal and this led to big problems with metal ions.
Most hip replacements have a metal on plastic baring or ceramic on plastic bearing which we’ll see in a minute. But this resurfacing type of hip replacement has to use a metal on metal bearing. As a lot of people are probably aware, this caused major problems with early failure of a lot of patients who had hip resurfacing.
This was due to a problem called metallosis. Here on the left we see what a standard hip replacement bearing is like, whether it’s a metal head and a plastic liner in the socket. With resurfacing, there is a metal cap and a metal liner in the socket.
This resulted in the production of metal debris or wear in the hip joint, and this is demonstrated here in this black material, and it resulted in early failure of hip replacements, but up to 25% of hip replacements failing at the five-year mark, when this should be 6%.
This resulted in a product recall, where all these procedures were stopped, and all the previous resurfacing had to be investigated and some of them had to be replaced and because that hip resurfacing essentially died out and become a procedure that was no longer performed.
Until, 2019, when Andy Murray, a tennis player famously had a Birmingham, which is a type of hip resurfacing procedure, carried out.
It has started to reappear in a very small subgroup or selection of patients. There is an argument that there may be a role again now for resurfacing in some patients, there may be better implants where this metal wear is less likely to happen, and it may be better for younger patients who are young and active and want to continue to have a very active sporting life in particular.
So again, the rules are the same, we have to look at what is the evidence say as to whether hip resurfacing is a good idea or not.
In terms of how long they last – they last about 94% for 10 years which is similar to a total hip replacement, and what about how well they work this is a paper published in the BMJ which is another major medical journal.
In 2018, they looked at 60 patients who had hip resurfacing and 62 patients who had a standard total hip replacement. They found no difference in function at any stage, from six weeks to five years.
So where are we with hip resurfacing in 2020?
Is there a role for younger patients who are active, maybe patients who are aged 30 to 50? Is there improved implant technology where this metal wear effect is less?
I would say for most patients, there is no evidence to support this currently.
Hip resurfacing is generally to be avoided due to potential serious complications, as there’s no evidence at this current moment in time that these patients do any better than total hip replacement, in terms of how long it lasts, or how well it works.
So question number five is should I have a hip replacement if I am overweight or what does being overweight mean for me in terms of my hip replacement?
This is a study again another big study published in 2020. It looks at how being overweight affect having your hip replacement.
They divided patients up into three different groups based on their body mass index which is a measure of how overweight or obese you are based on your weight and your height.
For patients with a BMI less than 30 were considered non-obese – greater than 30 they were considered obese and a BMI greater than 40 they were considered morbidly obese.
This study is a great study because it looked at over 2 million patients, and looked at their outcomes after having a total hip replacement.
They found that being overweight and having hip replacement resulted in a slightly increased risk of complications or problems after your hip replacements.
These figures here represent how many times more likely you are to have a problem – so for infection, which can be a big problem in hip replacement surgery or any joint replacement surgery, if you were obese to the point your BMI is over 30 – you’re 2.7 times more likely to have a problem with infection afterwards. If you are morbidly obese, where the BMI is greater than 40 that rises to 3.69 times more likely to have a problem with infection.
In real terms, this changes maybe from about .5% to 1.5 or 2% of patients who have a hip replacement, but it is a significant number, and it is something that patients need to be aware of.
There is also slightly higher increased risk of dislocation and the need for having to have a second hip replacement.
So what does it mean being overweight and being significantly overweight does increase your risk of complication after total hip replacement. I don’t think it means that you can’t have a hip replacement, but it means for patients who are who are significantly overweight should consider a trial of weight loss or weight reduction to try and reduce and minimise the risk of having a problem after your hip replacement prior to having it.
It is important that patients are aware of the risks and that you are given an opportunity and help to lose weight, and to drop your BMI before surgery.
Just to summarize the talk, hip replacement involves replacing your hip joint with an implant to restore pain-free movement back into your hip and with that comes an improvement in your quality of life.
In terms of how long hip replacements last? Over half of patients can expect your hip replacement to last 25 years.
In terms of how hip replacements are put in? there’s no evidence to support one approach over the other at this moment in time.
For hip resurfacing, there is no role or minimal role for hip resurfacing at this current time, and being overweight increases the risk of complications slightly, and it’s best to try and reduce your weight prior to surgery.
Fiona Roche (FR) Business Development Manager at SSC put some of the audience’s questions to Professor Joe Queally (JQ).
FR: The first question is from Teresa and she’s asked: She’s got a hip impingement with severe cartilage damage, mobility is very restricted, high pain intensity – she’s only 56. Is a total hip replacement the best option? She was offered an injection but believes this is for short term pain relief, and she’s confused as to why she was offered an injection.
JQ: Given your age impingement is a common enough problem these days, and it can lead to arthritis or degeneration of your hip cartilage.
Really, many impingement patients or patients who want to live without arthritis do need a hip replacement. When you need a hip replacement really is decided by the severity of your symptoms. So when your symptoms are severe to the point where you have constant pain, where you can’t walk a reasonable distance or do the activities of daily living that you like to do, such as walking for example or playing golf and you are having difficulty sleeping at night – they are the general criteria for proceeding with a hip replacement.
Often we try and delay a hip replacement for patients who have lesser symptoms and a hip steroid injection is something that can be useful.
The reason for that is the average life span of a hip replacement for about 60% of patients now is about 20 years.
You may need a second hip replacement after that, and a steroid injection is used for patients with lesser symptoms, to try and delay a hip replacement. But there will come a time I’m sure when you may well need a hip replacement, and if the steroid injection doesn’t have much effect or starts to wear off, then that is generally the indicators that it’s time for a hip replacement.
FR: Thanks, Joe. Barry’s another one who says: he was told he needed a hip replacement 10 years ago, but he was too young. Is hip resurfacing or hip replacement with younger patients, and can minimally invasive hip surgery be performed on any patient?
He can function normally day to day and work with paracetamol but he’s edging closer to having surgery.
JQ: Yes again that just kind of feeds on to the previous answer. Really we do try to avoid if possible, hip replacements in younger patients, due to the lifespan of an average hip replacement.
It’s worth again pointing out that a revision hip replacement is a much more complex procedure for both us and for patients, in terms of recovery afterwards. The amount of function you have after revision total hip replacement tends to be less than your original hip replacement.
So I think if you have a reasonable level of function and you’re managing with paracetamol – again, you probably don’t hit those triggers or criteria that we have for proceeding with the hip replacement, and I am sure it will come with time.
Having hip replacements is like a lot of things it’s about getting the timing right. It’s the wrong thing to do to have it too early and it’s also a bad thing to have it too late. From a patient’s perspective, it’s about getting the timing right so that your symptoms haven’t progressed too severe.
You have reasonable hip flexibility so that you can recover after your hip replacement afterwards. But again, as I said, it’s important to avoid having you too early, so that you avoid having to have a revision hip replacement if at all possible.
FR: Thanks. Jeanette asked a very practical question there: could she still go horse riding after a hip replacement?
JQ: Yes, that’s a great question. I guess the best answer to that is maybe. There’s no reason why you can’t go horse riding. It depends on factors such as what your hip flexibility is like after your hip replacement, and that in turn will depend on your hip flexibility before your hip replacement.
So some patients have really stiff, hips before surgery due to arthritis. Whilst a hip replacement will bring back some flexibility in your hip, and may not bring back enough flexibility for horse riding and for getting on a horse and using a saddle.
You can certainly use aids to get onto the horse, like a stamp box. But spreading your knee’s on the saddle is the difficult part, it certainly is possible but you know, it depends on what your flexibility of muscles is like after your hip replacement.
I would say I have a written a recent article that you can access on my website for anybody who’s asked questions about what can you do when after a hip replacement? My website is www.joequealy.com.
On the news section, there is an article that goes through most sports – it’s based on a recent paper published in one of the leading national hip journals, and when it’s safe to go back to activities such as golf, cycling, even tennis, running and horse riding.
For horse riding, it’s generally at the six-month mark, if you have enough flexibility and range of movement after your surgery.
FR: That leads to Vivian’s question which is how soon, could you play golf after hip replacements?
JQ: Yeah again so golf, you can generally get back to Golf a little earlier. So generally I will say at the 12-week mark – some patients can get back a little earlier than that and again, your return to function after hip surgery – many things influence it, like what your flexibility is like after your hip replacement, which as I said, is influenced by your flexibility beforehand, your overall muscle strength and coordination will decide what type of activities you can do afterwards.
Again this feeds into the point I made there about not leaving it too late to get a hip replacement you know, if you wait until symptoms are very severe, which we sometimes see, then it’s hard to get good hip flexibility afterwards even with a hip replacement, that can limit your ability to return to any kind of higher functioning activity such as golf and so on.
FR: Mary asks: Which is the most common anaesthetic for a hip replacement general or epidural, and what are the advantages and disadvantages of both?
JQ: The most common anaesthetic by far is a spinal or epidural anaesthetic, which I would say in my practice is carried out for probably 96% of patients. This is really because it is the safest form of anesthesia for the majority of patients.
So the benefits to it are that it’s safer, as it protects your heart and lungs from having a general anaesthetic. It also allows you to recover a bit quicker afterwards.
Most of our hip replacement programs are now enhanced recovery, or fast-tracked hip replacement, where we aim to get people or patients walking, ideally within four to six hours of other hip replacements – so the same day of surgery typically in the afternoon.
We can do this because we use spinal or epidural anaesthesia that wears off. It is designed to wear off quickly. It’s designed to get patients walking and mobilizing as soon as possible which will speed up and enhance your recovery in general.
FR: After full hip replacement can you expect to get back to full rotation of the hip, for example getting the hip up to a 120-degree angle, I’m 60 have a full replacement after a fall seven months ago, and she runs and swims as well.
JQ: Again, this comes down to your range of movement of your hip is a function of two things really – one is your flexibility and the second is your muscle strength around your hip, and how much range of movement you have after your hip replacement is dependent to some degree on how flexible your hip was beforehand, as I’ve mentioned.
So if you’ve had good flexibility before your hip replacement, good muscle strength, and you’re quite active as you seem to be, then I would expect a good range of movement afterwards, whether you get up to 120 degrees of hip flexion, that’s hard to guarantee.
They certainly would expect a good enough range of movement to do you know most things such as cycling and swimming, and even playing tennis is possible, again after about six months after a hip replacement.
FR: Okay, that’s good and I’m just looking there was a question from Roisin White: she did have a hip replacement in 2013, and she’s had pain since then and she’s been told it’s been bursitis. She just wondered would it improve? because she does need the other hip done as well so she’s probably a bit nervous about that.
JQ: Yeah, so pain after a hip replacement does happen sometimes. The satisfaction rate from the scientific literature after a hip replacement is about somewhere between 90 to 95%.
So for most patients – it is probably the most successful operation of all time really, in terms of satisfaction after surgery, but the corollary of that is there is 5% of patients who have problems or difficulties. That is due to a variety of different reasons.
One of the more common causes of pain after hip replacement is bursitis on the outside of your hip, and it often causes pain on the outside of your hip. This is generally treatable with, generally with anti-inflammatories and physiotherapy to stretch the hip abductor muscles in that area in your hip – sometimes for your hip, a steroid injection into the bursa is required.
So in general for most patients, bursitis is generally treatable, but there are some patients who do have ongoing difficulties, I have to say. Does it mean that it would happen if you had another hip replacement? I would say not necessarily, but again, it would be hard to guarantee that it wouldn’t happen. But yes that’s bursitis after hip replacement.
FR: Someone asked: if you delayed a hip replacement will your muscles waste?
JQ: So it’s a good question, and again, it’s, you know, as I said, timing and hip replacement – it’s about getting the timing right really.
Those general triggers that I mentioned about having constant pain, pain at night time, and the inability to walk a reasonable distance. They’re generally the triggers that we use to proceed with the hip replacement.
Some patients may you know, for whatever reason, may have those symptoms for many years. And maybe avoiding surgery or they may not be aware of surgery or they may not be aware of the diagnosis, and often they’ve very stiff hips and recovery afterwards is not as good as if they had more flexible hips, before surgery.
So certainly about getting the timing right – not waiting too long with severe symptoms, to try and optimize and get the best possible outcome after your hip replacement, as I said though, going too early is also a bad idea. It’s about getting the timing right but for most patients that I meet, most patients do generally have a good sense of the right timing for their hip replacement.
FR: When you’re talking about the markers, she has just said: is limited movement, such as being unable to put on your socks and shoes – would that be an indication?
JQ: It would yes. Again it all depends on what your needs are really so and your age and your activities.
So, the classic difficulties that patients have, and again, that’s due to stiffness, is that they can’t walk a reasonable distance. They’ve difficulty putting on socks and shoes because their hips are stiff and they can’t bend or flex it. They have difficulties getting in and out of cars, again, because you can’t bend their hip properly are even using public transport.
When you start to hit those triggers, then it’s generally time to start at least have a discussion with somebody about is it time to go ahead with the hip replacement.