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 UPMC 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.