Managing Running Injury Risk Factors – Colin Griffin

Watch this video of Colin Griffin, Strength and Conditioning Coach specialising in foot and ankle rehabilitation discussing ‘Managing Running Injury Risk Factors’.

This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.

Colin Griffin is a Strength and Conditioning Coach in  the Sports Medicine Department specialising in Foot and Ankle Rehabilitation.

Good evening everybody. Thanks for tuning in. So my presentation is going to be covering how you manage the injury risk factors in runners. So just a little bit about my background before I start, I work as a Strength and Conditioning Coach in the Sports Medicine Department where I am lead clinician for foot and ankle rehabilitation and also lead our Run Lab services.

I’m also undertaking a PhD in Achilles rehab and lower limb biomechanics. I am an accredited Strength and Conditioning Coach with the UK Strength and Conditioning Association and the Sport Ireland Institute and also an Athletic Ireland level 3 Endurance Coach.

I’ve also had a background in athletics for the last two and a half decades. My previous career as a race walker was where I competed internationally at European World and two Olympic Games and retired after the London Olympics in 2013. Since then, I took up running as a means to still enjoy keeping fit and taking part in competitions.

I suppose it still gives me a feel for the sport, and I work with a lot of runners as well, so it’s good to have that little bit of a connection.

In the outline of the webinar, we’ll be looking at the biomechanical demands of running how that might affect injury risk. We’ll discuss some of the common running injuries, now again you would have heard from Dr Carolan and Mr Jackson on some knee pain and knee injuries, and Dr Carolan will cover plantar fascia pain, so I am not going to touch on those too much, but I will discuss some of the other common ones, and we’ll also discuss the role of Strength & Conditioning as a means of managing running injury risk factors.

Most systematic reviews of running injuries and where they occur show that the knee is the most common injury site for running-related injuries.

In the most recent systematic review in 2018, 28% of running injuries occurred at the knee, 26% were in the foot and ankle area.

But the main thing you can take from this is that most running injuries, probably about two-thirds of 70% of running injuries, occur from the knee down.

So there’s probably a message in that in terms of the biomechanical demands of the lower leg and how we might maybe try and condition that in our strength and conditioning program.

With running biomechanics, there are basic physics involved here, so when we run when we strike the ground, it is like a collision with the ground, and the earth gives us a force back that goes through the body. It’s like Newton’s third law, so for a reaction, there’s an equal and opposite reaction.

If you look at the example here, so if you imagine you’re running over a force plate as in this video here, you’ll see that the force increases through the ground.

If I play the video, you will see foot strike if you watch the green line and watch the cursor move up. So the initial peak as the ankle sort of decelerates the initial impact, and there is the second peak as the force peaks, as the foot is under the hip.

So, if I was to stand, or if you were to stand up, your body has to be able to produce force more than your own body weight in order to not fall over. If you want to walk or move forward, that force is going to be one and a half times your body weight, and if you jog, it’s going to be twice the body, and if you’re on a steady speed, it’s going to be three times the body weight, and sprinters that max speed will be hitting maybe five or six times body weight.

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So the faster you go, the more force or ground reaction forces you got to try and corporate, and the more force you got to train your produce to be able to accommodate us and to propel the body upwards and forwards.

So we’ll talk therapy as the external force that goes through the body. Well, as I said, in order to do, there are internal forces that are going on. And there are lever systems at play here as well, because when the Ford schools through the body, our center mass lowers our knee joint, and our ankle joint, bend, as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons or ligaments or cartilage, and so on, while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a tennis meter track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, suppose upwards through the body. And I said, depending on how fast you’re going, that can be two times the body weight, even for jogging that can be four times the body weight, if you’re running at a steady-state speed.

With force going through the Achilles tendon as it stretches. So the calf muscles contract and the Achilles tendon stretches that can be six to eight times the body weight and again depending on the speed but the contact force at the joint level of the ankle joint, that’s 10 to 14 times bodyweight that’s like a suction force, where you’ve got bone on bone contact, and that’s where the cartridge is going to play and try to help shock absorb that.

So, higher joint contact force at the ankle, a little bit less with the neighbours, so the significance of 7 to 11 times the body weight. And at the hip, something similar seven to 11 times bodyweight and again at the hip joints in a ball and socket joint is this like a suction force. It’s important that the muscles of the lower leg, and from the torso down, are conditioned to be able to accommodate that efficiently.

Bone Loading, so, we would traditionally believe that impact causes increase bone loading, and it does a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at more thorough in the picture in that sort of midstance point for his foot soldier his hip, his knee is bent as much as one event is centralised at its lowest point is calf muscle contractions areas greatest gasp point peak or loading occurs particularly in the shin further around the tibia.

It comes much later after the initial impact. It’s not just the impact. It’s, it’s how you can absorb that or dissipate that, as your central mass lowers and as your joints continue to flex and as the force goes through the body.

So I guess we ask the question, why do most running injuries occur from the knee down. Well, we know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds.

We know that even at jogging speeds. Our calf muscles are operating at about 80% of their muscle capacity, of their peak force capacity, where the as quads might be operating more than 60% others, but that capacity is low, it doesn’t take much of that muscle to fatigue area than it should do.

A fatiguing muscle is going to affect how the force is distributed and how it’s absorbed. So that’s going to cause problems locally, so that can put a lot more load to the Achilles tendon and put more loading on the ankle joints. But also, if the ankle area gets tired, those forces tend to shift up towards the knee and around the hip, and that kind of big factor in how the knee is loaded and how the hip is loaded and perhaps increase in injury risk in those particular sites.

So we can safely say that when we jog, our calf muscles are pretty much our jogging muscles and particular storage soleus muscle, that deeper calve muscle, it has quite a high contribution to running.

So I suppose when you think about running and look at SSC programs, it’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and most probably more important, and if we were to prioritise things. But as I said, it is probably the most neglected area.

So we just look briefly at the calf muscles, so again, if you look at this MRI image, so if I was to take a slice of my leg from the knee down and look down at it, that’s what we would see. So looking at the LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscle, so if you’re looking at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles. So that’s your medial and lateral gastrocnemius muscle. So again, big muscles.

Quite a big volume, but if you look at the layer deeper than that, the soleus muscle, It’s quiet. It’s an even bigger muscle. So it has more than twice the volume of the medial gastrocnemius muscle.

But when you take into account its short fibers, so again, if you look in the image during the right, you see those short fibers that kind of run at an angle between the borders of the muscle. And it means that more fibers can be packed into a volume of muscle, and more fibers mean that more force can be produced more efficiently, so it’s got a bigger force. It’s got a bigger force contribution and bigger force potential, and against allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

But the calf muscles are also slow-twitch muscles, predominately slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued, but then say other muscles that are faster, which dominant.

So it’s really important that we train the calf muscles to use those big forces and to be able to recover quickly, and to be able to repeat it over and over again.

I said when we lack muscle capacity of the calf muscles, that’s when we got to be issued and if we see somebody coming in with a lower limb injury. It’s probably one of the most important areas that we assess.

So if you look at some of the common running injuries, you got runner’s knee, which can be an umbrella term for a couple of different knee pathologies, but most commonly patellofemoral pain syndrome.

Achilles tendinopathy, shin splints or any type of bone stress injury of the lower leg, a calf muscle strain but again that can be applicable to hamstring muscle strains are quad muscle strains, plantar fascia pain and proximal hamstring and Achilles tendinopathy, so they’re quite common running injuries.

So if you look a little bit at the runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail. The knee joints, being primarily is not designed for massive amounts of torsional rotation, and an order to control that, so again, what you have is an overload of the patellofemoral joint, and that could be a combination of a number of factors, it could be biomechanics and could be how you recruit your quads, hamstrings, and hip muscles in particular, and also the muscle capacity of the calf muscles below it. So when we look at a knee injury, we always access above and below the areas of the calf muscles below and even around the ankle and above us. We assess the quads, hamstrings, and hip muscles.

So again, they’re quite important, and particularly the lateral hip muscles, the hip abductors, so your glute, medius and part of the glute max has a role to play in terms of controlling hip internal rotation, and hip abduction and also your lateral hamstrings, your voice of Morris has a role to play as well in controlling internal rotation of the femur or the hip.

So they are areas we would access in terms of uncertainty if we see weaknesses or deficits in those areas we chase after them in terms of with a rehab program. In terms of running biomechanics and I’ll show you a video in a few slides time. We’ll also look and see what the knee controllers like when you’re running, so look at some from behind and see if the knee keeps rotating inwards. That might give us clues as to their ability to control those rotations from the hip down or from the ankle up.

Achilles tendinopathy is a common one that we see. It’s the main focus of my PhD. So some of the common risk factors for Achilles tendinopathy we can separate into intrinsic or internal risk factors and extrinsic risk factors, internal risk factors being calf strength. So for people who have poor calf strength.

There have been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles, and that can, I suppose, change how the tendon is loaded over time.

So perhaps the previous lower limb injury and we haven’t fully rehabbed it, but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, and people who have diabetes or a risk of diabetes, or poor cardiovascular health, and can be at risk of turning of developing Achilles tendinopathy, Because tendons are there is actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on around the body, as opposed to just running.

So if you look at some of the external risk factors that are associated within with this injury and training load, a big increase in volume or particularly intensity, that’s quite relevant given the last 15 or 16 months with our COVID restrictions on people maybe exercising more than normal because they’re working at home and trying to keep fit, or in the least sport, and particularly collective team training and field sports have been curtailed for several months and in the last two months where they’ve gone back again, and the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

The cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, and that can put people at risk of developing Achilles tendinopathy. In some cases, and also alcohol intake is also associated with the risk of developing Achilles tendinopathy.

So, again without going too deep into anatomy here, I just used this picture here to illustrate the difference between a healthy tendon and one that has tendinopathy. So tendinopathy is pretty much pain and impaired function, and in the tendon, and the Achilles, in this case, and again, what causes pain and impaired function. So, in a healthy tendon, as you see there, you go a nice orderly alignment of collagen fibers, and you got a very small level and each fibers kind of wrapped around by a sheet.

Between those fibers you’ve got other cells called Tina sites, and those cells are sensitive to any changes and load that the tendon undergoes, so when it experiences fatigue or when it experiences big strains or fast movements, those tendons can become more active, and they can react and cause I suppose a cascade of events that can change the structure and the makeup of the tendon.

So, when the load has been too much and the tendon hasn’t had a chance to remodel and adapted to that, you’ve got a change in the composition of the tendon, you’ve got the more type three collagen fiberals as opposed to type one, so type one being good collagen and type three being unhealthy collagen, its collagen that is not able to withstand elastic strains, you got those cells become a lot more disorganised, they lose that sort of elongate shape they come more rounded and you’ve got molecules that attract more water so it gives the tenant, more of a swollen or puffy feeling and then you’ve also got an in growth especially when the tendinopathy has become chronic, so if it goes on for several weeks even months, you’ve got new regrowth of nerve of blood vessels, and that normally don’t reside within the tendon but normally sort of in the space between them, and they tend to migrate inwards and they leave chemicals that cause the nerve endings to become more sensitised, and that can give you your pain feedback. And over time, the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulus, so total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Such tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain, around about 6%.

So again, this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little. So too much, you develop little sorts of micro-tears in the tendon, and the cells become more reactive, and it can become more catabolic so kind of degenerate, it’s weird itself, and it’s not able to adapt to that load If it’s not giving time to do that.

If we rest for too long, and we won’t expose it to not strain or enough loading, and again the tenants, again you get a bit of wastage, and the tendon becomes more catabolic as well, and it becomes less able to handle regular exercise. So it’s important to give it that sort of regular bout of loading, and even when it’s sore, we try to find a level of calf exercise that they can do without being too sore once the pain is okay, so as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

So a little bit more about muscle strain injuries, so you know we think of a calf tear or a calf strain or a hamstring strain. We think about the most simple of it, in fact, usually these cases there, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle departments that goes in the middle of it, So like a feather so see in the example on the left.

Usually, the muscle strain occurs close to where there is tendon tissue, so usually where the muscle fibers in the tendon sort of meets, and muscle tail junction are usually there could be a micro tear within the tendon itself or on the muscle.

That can have an impact on the grading of the injury and the prognosis of the injury, so if you’ve got a tear, say, for example, in the soleus muscle is more so than a central tendency, so again if you look at the illustration B there.

That can take longer to recover, then say it was just a muscle fiber tear. Whereas, if, if, if you had a small muscle tear, and that’s just the muscle fiber, even if it’s close to ten but if it’s only the muscle fiber and there’s no tendon tissue disruption that can recover a lot quicker, and you can have less disruption to your training.

It’s important that we get, we’re clear the diagnosis, we use MRI imaging to know the grading of the injury so whether it is a one, two or three or, even worst-case scenario four, whether it’s just pure muscle facet fiber or muscle tendon in the junction of a rescue or tendon tissue that’s disrupted, and that can impact us again if you look at the calf muscle on the side, you’ll see a cadaver image of the muscles, see the soleus you’ll see the two heads of the gastric muscle lateral immediate head. But if you look at the white tissue there that’s, that’s on the, on the image that is the tendon tissue that is in your muscles, and you’ll see different suppose segments of white tissue around the muscle, and that’s the tendon tissue so again, usually close those sites, is where the injury occurs.

So what about bone stress injuries, essentially what we know from people who have looked at and studied bone loading closely in response to exercise and also have developed either shin splints or stress responses to the bone or a stress fracture.

There’s usually a failed healing response in the bone, so when you run when we do impact type stuff when we run or hop or do something that has high impact. We’re temporarily breaking down bone tissue that gives the bone tissue stimulus to recover and remodel. So we’re constantly exposing it to repetitive stresses and strains and small bits of microdamage that occur, but again in normal situations, we’ve got a good healthy metabolism. If we have a good structure to our training, we’ve got enough time to recover quite quickly to that. But if we’re not able to adapt to it, the bone needs more time to adapt and remodel, and they haven’t got a chance to recover well, then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury so basically you have a suppose failed healing response in the bone.

And if you look at what happens within the bone. So when we stress the bone, we have the formation of osteoclasts and osteoblasts. The osteoblast is where the bone almost eats away at itself, and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the, where the injury is or where the microfracture is to be ready for new bone is far more with us, and then you got osteoblasts formation which is where the or new bone cells start to form, and the bone starts to load up again.

Essentially, when we have failed healing in the bone, we have more eating than, say, replenishing. So similar sort of energy deficit, so it’s important that we look at people with bone stress injuries that they have good nutrition as the bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

So if you look at a few common factors related to running injuries so basically, we have a mismatch between load and capacity, so the load we’re putting in the body is greater than our capacity to handle a lot, and it’s a very simple way of looking at it. I know there’s a lot of it’s very hard to say there’s one thing, but there’s an interaction of a number of factors.

So obviously, we try to locally assess someone we want to identify any potential overload factors and then we also assess their capacity. Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training related so if you have a busy work schedule, busy family life.

All those things can be an extra load on the body.

If you have capacity on the others side of things, and that can be poor muscle capacity and high sensitivity to changes and training loads. Some people are more sensitive than others, and people who are fitter or have a higher capacity than those who are people are less fit or have lower capacity to handle a training load, and fatigue, seven or more fatigue, your capacity is reduced.

If you have had a previous injury in the lower leg, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after injury and training age, probably comes along with fitness as well if you have a higher training age, a running for longer than someone took a running last year, you’re going to have a greater capacity to handle those train loads.

So, just, this is a nice graph, and again I’m not going to go through everything in detail those a few relevant points here so, but it’s what they did was able to quantify the loading have someone who is an elite runner who runs 10km when they’re fresh, on an easy day, then runs 10km when they are very tired, so they’re a little bit slower, so the pace is maybe 25 for 35 seconds for common of slower when they’re really tired, versus doing 10, 1k intervals on the track in spikes — the difference between being fresh doing easy running versus when you’re very tired—your step count increases by up to 13%. See more time your feet more or more steps.

If you look at the accumulated vertical ground reaction forces, that is a 6% increase, so just because you’re going slower for the same distance. The accumulated loading can actually increase, so you have more of a step count, and your accumulated forces have increased and looked at the Achilles tendon further down.

Running slow when you’re fresh but relieved and slower when you’re tired, that kind of 5% increases in indicators and forces. So, the main message I would take from that is that running longer and slower when your body is tired, for some people, can be a risk factor.

So, just important that we maybe want to run on an easy day that we just keep some sort of control on the total volume of running, or the duration of the run, so maybe just better, happier and easier run shorter thinking when you’re tired and if you were, if you’re an injury-prone runner, you know, for people who are well trained to a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has as high risk of injury and just got to be careful those days because that’s when the damage can be done because you’re not giving the body the best chance to recover or adding more load to it.

So some of our common assessments, when people present us with injuries or wanting to try and manage their injuries factors, we assess strengths. We assess their power and parametric ability, and we also look at their biomechanics that running biomechanics that are engaged.

So, when we’re assessing strength, we want to get a rough idea of whole-body strength. If someone does a squat, whether it’s a back squat or front squat, we like them to be able to get to a point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps, as a minimum. But again, if someone hasn’t squatted before, we’re not going to strap them on that they need.

They need probably a year or two of just basic conditioning to get up to this. And that’s where they get above those thresholds, that’s probably a good level to be asked and 70 for deadlift, the deadlift will probably target the posterior chain most of the hamstrings, glutes a little bit more than the squat would depend on how on your technique and how you clutch it. And you can always lift a little bit more. So again, we’d be looking at 1.2 times, by the way, for more for three reps.

If you look at calf strength, what we often do is measure them on a force bit fitness stand on one leg, with the bar sort of compress over the shoulders at the base pool if they’re trying to do a calf raise but the heel hasn’t got space to lift, and we would expect them to reproduce for us that’s more than two and a half times body wish. As I said, the calf muscles are our big court QC muscles, and they can produce those forces. They need to cope with those, and more and running.

So, that gives us a measure of total all the capitals, but again we’ve got three calf muscles or immediate gastrocnemius muscle or lateral gastrocnemius muscle and our soleus muscle.

So, because the gastrocnemius muscles cross the knee so when you bend the knee, that’s going to impact how much force they can matrix, so we bend the knee to 90 degrees, and we’re kind of dampening down the force contribution from those gastrocnemius muscles, but because the soleus muscle doesn’t cross the knee joint, it doesn’t matter what a straight or bent it is going to produce the same force anyway so if we want to get a rough idea of the soleus muscle force contribution.

We do a seated calf or asymmetric test for this session on a seat, and we’re only at 90 degrees and their heal slightly dropped with their foot on the block, and we get into a seated knee lift where the knee is compressed time and see how much force they produce, and we like to be seeing people hitting above one and a half times bloody weight, and for elite athletes, we try and get as close to twice by their body weight. If we want to get a good measure of their calf endurance, we have to do single leg calf raises. More than 25 of them in 50 seconds, so one raise every two seconds, with good height and good technique and good control.

And if you look good reactive strengths are their primary capability we might test them during a drop jump for them maybe drop off in 20 to 30-centimetre blocks, and try to rebound in less than a quarter of a second, and try to achieve the height of the box at the drop-off or close to that.

And, well, Michael didn’t have one leg and be able to do ten hops on one leg, while maintaining the time in the ground, perhaps, in less than point two eight of a second, without bending the knee too much so try to use the ankle to hop.

When we look at running biomechanics, we can get a 3d model of someone running so we can put some marker sets on them, and we have cameras that a 3D capture of them, and women that are running them, we can create that sort of stickman image of them we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on. And we can look at some of those rotational movements we are talking about at the knee and the ankle.

So again, a couple of some of the key things we look at here at hip pelvis motion.

So how much hip adduction and internal rotation occurs. Is there a purpose? Do they have a pelvis tilt that increases throughout the stance phase, or does your pelvis drop on one side if you’re looking at them from behind? We also look at high-end Shin rotation. We look at the motion of the heel and some kind of controller pronation fairly well or do they collapse and have short, poor control, which might cause more loading run around the foot and ankle area.

And we’ll also work out their contact time, their flight time, so basically the time the grand preferred strike, and the time in the air, and their ability to handle, and the ability to control how much the central mass drops and the most the knee bends as force close to the body, so it’s a measure of spring stiffness.

So why do we do that so again? Some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at the side view people who tend to lean forward a little bit more precisely, people who present with some common injuries tend to lean forward a little bit more land with the foot a little bit further from the body, so the shin is a bit more of an angle and the knee a little straighter.

So if you look at the illustration, a there on the left, versus those who are not injured, tend to have a bit more upright to the torso, land, more of a bent knee, and the shin and a bit more vertically aligned and a force, closer to where the hips are.

And if you look from behind. I can give an example of hip internal rotation and adduction, as well as the pelvic strap. So if you look at the female at least in the image there, you’ll see a little bit more drop of the pelvis at that horizontal line going from right to left a little more tilt us, and you see the line from the side of their hips today, centred the knee, angles, and that can cause more torsional loads at the knee.

It caused a lot more puts bigger demand on the hip muscles, but it can also have a knock-on effect for the foot and ankle because if, if the knee has to, if there’s if the tie has. Suppose the hip attorney rotates and jerks. And you’ve got that rotation but not the need, and there’s going to be more adjustments of the tibia over the ankle and so on, and all the foot under the foot area as well.

The first is who is able to have a more horizontal pelvis position and less of an angled line from hip to knee.

So, when you prescribe strength training, and some of the most important things you try to cover are some sort of a jumper hop exercise, And depending on the time of year, and where the rasp in terms of training program might be done from the start, and having a double like whole body accent like a squat or deadlift, a singular whole body exercise like a step up or a lunge or some variation of us having a calf exercise in their particular at certain points in the year to improve calf muscle capacity, and some sort of a function for exercise and to try and improve torso control.

So in terms of the qualities one is training to improve power or planet capability at a high intensity will hit the reps short, so we don’t want to be doing these long enough, or they’re going to get tired, and we’re power diminishes the way it’s not trained right things, so reps have about three to six reps, you know, for four sets, taking a longer recovery between sets because when you do something sports have you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve sort of power or reactive strength capacity, who might dial back the intensity but go for more duration, so we can work with up to 20 reps depending on what we’re trying to get out of this ever trying to improve strengths, and we do rep ranges between treated like a tour manager more wrestling sets for four sets again if I find a Bruce maximal or sub max strength.

Suppose we’re trying to grow muscle, so trying to improve hypertrophy, not the most important thing for distance runners because more muscle mass means more energy expended to try and carry around. But when someone comes in with an injury or chronic injury.

We often see that the muscle wastage and most of deconditioning so we see what a Muslim one side, smaller than the Muslim, the other side. So we probably will have to find the Muslim students to grow up back to the level of their side where it should be because the smaller muscle will, on the flip side, mean less, as well as capacity to handle those big forces.

In terms of frequency, and if we’re not rehabbing for just training doing strength training in order to improve performance, and we’re fairly good from an injury point of view, twice a week is probably enough. And if a racing week, you know, during, during the busy competition period for racing quite regularly, once a week there’s probably enough to maintain us. What if we are rehabbing and overcoming an injury, we probably need to have that other third in there for at least four to six weeks to try and front load those adaptations in front of us.

So we’re just going to take you to a couple of examples of common in exercises and how am I progressing, so if someone hasn’t squatted before, we’re not going to put up 80 kilos and the shoulders and the bathroom when it’s falling and make sure their squat technique is good and put a chair on them so they can sit back on their heels, and be able to squat smoothly at full technique, and then we can increase weight. So if we could get them to do like a goblet squat for the whole dumbbell, chest, and the nodes the chair on, and they could sit back from their heels and squat. I suppose, reinforce good patterns first, and then if you’ve got that, then we can take the chair away.

And if they’re well-coordinated. The balance they can sit on the heels, and be able to squat and maintain that sort of parallel torso and Shin angle, then we can move to a bar, so we often like, or we can you know for trying to introduce deadlifts, sometimes a hex bar can be useful way today that allows you to train a good technique in a safe way so again set in the bar, less for knee bend or trying to keep the knees a bit stiffer, to try and put more attention to the hamstrings are trying to keep the back 30 straight as well.

And then we moved to the bar from the floor, or maybe from an elevated position on the right there, so again trying to not bend the knees too much like squash, trying to target the hamstrings a little bit more. Keep that back fairly straight as we lift, and we shouldn’t feel the hamstrings, and that leads to most of the work. Here are some of our single-leg exercises, so a step up. We are stepping onto a box.

Ideally, if you can stay on, you would like to hold the position for a second to shore that rebalanced back to a nice control.

So really important, it’s one of my kind of staple exercises and covers a lot of boxes.

I’m going to do some server lunch variation or specified variation, so an example on the right of Bulgarian split squats, but a barbell rear foot elevators, dip and down name travel to fat forward. And again, we should feel this towards the area. We shouldn’t feel much pressure on the needy of this and want to find keep her back fairly straight as well.

So calf strengths I mentioned, bend the knee to break 90 degrees, and have the footstep the elevators, we can put a big load solace muscle on target.

So the seated calf raises.

And also standing calf raises, so again I like to go ahead and the cafe smith machine or leg presses and ideally with regards to starting the like pretty straight, pushing up onto the big toe. Pause at the top for a second to a background slowly and then plyometric exercise some poker hops on the spot, trying to be smooth on the ground spend a bit more time in the year, progress in dropping jump.

So can bouncing up a box as a 30-centimetre box trying to get off the ground in less than a quarter for the second and rebound is almost as high as the box jumps off, and then they’ll be doing single caps on the spot and the singular cups going forward as you see there. And on the far right.

So in terms of how this all fits in meetings but this seems like a running program into four phases or whatever way you want to do it. So general credit phase, we’re trying to prepare the body for the bigger running sets that are going to come.

So it finally approved tissue capacity and muscle capacity to diffuse after per week working on good movement patterns first. Maybe if we have certain weak spots that we’ve had a previous car for Achilles injury or an ankle injury, we’ll do a lot of calf work. If they’re a previous knee or injury, microdata quad and hamstring and hip work or for the previous hamstring injury or recent hamstring injury. We do a lot of hamstring and glute work as well, so again that’s the time to train owner those things so that you get good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards the specific preparation phase where you’re running starts to become more of a priority, and you’re increasing your distances bringing in those key sessions twice a week should be enough. We’re not going to spend as much time in the gym or doing those exercises. So quality is important, so maybe a couple of exercises done really well that’s a good intensity. So we’ll go heavy if it has enough training behind them. And we’ll also bring in Supplementary exercises.

And as we get closer to competition, we want to try and keep that sharp instead because traditionally, that’s for distance runners tend to sort of shove the residency program because there are training for that marathon in six weeks’ time. We’re going to be tired from all the runs, what, when they need to sit in that is probably the time when they need to be at our strongest. So if we don’t train something for a period of six to eight weeks, we can start to lose those qualities, so it’s really important that we keep somebody’s strength training there, in its several ways that doesn’t, that doesn’t that keeps supposedly nice and balanced, so we still try and keep in two sessions a week.

Keep it short and intensive to keep that sort of stimulus and edge they’re a bit more folks the plyometric keeping in touch with your heavy lifts, and they were in season and competing with try to maintain it once on one or two sessions a week if we’re racing in any given week one is probably not during the week—the shorter than normal. And we’re not racing on a given week. We’re probably the second tough session.

So in conclusion, more discerning injuries occur from the knee down, or cut forces, in particular, are probably the one muscle group that works sources towards full capacity even a slower running speeds, compared to quads and hip muscles, so it’s really important that we punish them for that. And, high-intensity strength training so talked about but in reverse also associate improving economy and performance.

And everyone is definitely so, you know, try not to. It’s very hard to give a one size fits all answer to when someone has a question about a particular injury or a hospital assigned training that they should do. It’s important that they come in, whoever if they have an SSC coach close to that’s reputable and experienced and get a proper assessment and have their training, sec program prescribed to meet their individual needs.

Sprinters at max speed will be hitting maybe five or six times body weight. So the faster you go, the more ground reaction forces you’ve got to try and cope with and the more force you’ve got to try and produce to be able to accommodate that and to propel the body upwards and forwards.

I talked there about the external force that goes through the body. As I said, in order to cope with that, there are internal forces that are going on, and there are lever systems at play here as well because when the force goes through the body, our centre mass lowers, our knee joint and our ankle joint bend as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons, our ligaments, our cartilage and so on while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a 10,000-metre track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, so it goes upwards through the body, and as I said, depending on how fast you’re going that can be two times bodyweight for jogging that can be four times bodyweight if you’re running at a steady-state speed.

The force is going through the Achilles tendon as it stretches, so the calf muscles contract and the Achilles tendon stretches, which can be six to eight times body weight again depending on the speed. The contact force is at the joint level, so the ankle joint that’s 10 to 14 times body weight, that’s like a suction force where you’ve got bone and bone contact, and that’s where the cartilage comes into play to try and help to shock absorb that.

Higher joint contact force at the ankle, a little bit less so with the knee but still significant so 7 to 11 times bodyweight, and at the hip something similar 7 to 11 times bodyweight, and again at the hip joint being a ball and socket joint, it’s like a suction force. It’s important that the muscles of the lower leg from the torso down are conditioned to be able to accommodate that efficiently.

So what about bone loading? We would traditionally believe that impact causes increased bone loading, and it does to a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at Mo Farah, there is that sort of mid-stance point where his foot’s under his hip, his knee is bent as much as it is going to bend, his central mass is at its lowest point, his calf muscle contractions are at its greatest – that’s when peak bone loading occurs, particularly in the shin, so they’re in the tibia, so it comes much later than after initial impact.

It’s not just the impact. It’s how you can absorb that or dissipate that as your centre mass lowers and as your joints continue to flex and as the force goes through the body.

I guess if you ask the question, why do most running injuries occur from the knee down. We know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds, we know that even at jogging speeds, our calf muscles are operating at about 80 % of their muscle capacity/peak force capacity, whereas the quads might be operating more around 60 % of it. If that capacity is low, it doesn’t take much for that muscle to fatigue earlier than it should do, and a fatiguing muscle is going to affect how the force is distributed and how it’s absorbed.

That’s going to cause problems locally so that can put a lot more load through the Achilles tendon, it can cause a lot more loading around the ankle joint, but also if the lower limb gets tired, if the ankle area gets tired those forces tend to shift up towards the knee and around the hip and that can have a big factor in how the knee is loaded and how the hip is loaded and perhaps increasing the injury risk in those particular sites.

We can safely say that when we jog, our calf muscles are pretty much our jogging muscles and, in particular, our soleus muscle. That deeper calf muscle has quite a high contribution to running.

I suppose when you think about training, and we look at SSC programs, there’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and more important if we’re to prioritise things, but as I said it’s probably the most neglected area.

So if we just look briefly at the calf muscles, so again if you look at an MRI image, so if I was to take a slice of my leg from the knee down and look downwards at it, that’s what I would see.

The LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscles, so if you look at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles as I said this remedial and natural gastrocnemius muscles. Again big muscles, quite a big volume, but if you look at the layer deeper than that, the soleus muscle it’s an even bigger muscle, so it is more than twice the volume of the lateral of the medial gastric muscle, but when you take into account it’s short fibres, so again if you look at the image on the right you’ll see those short fibres that kind of run at an angle between the borders of the muscle – it means that more fibres can be packed into a volume of muscle and more fibres mean that more force can be produced more efficiently, so it’s got a bigger force contribution and bigger force potential and again it allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

The calf muscles are also slow-twitch muscles, predominantly slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued than other muscles that are more fast and dominant.

It’s really important that we train the calf muscles to produce those big forces and to be able to recover quickly, and to be able to repeat it over and over again. I said when we lack muscle capacity in the calf muscles, that’s when we got issues, and then if we see someone coming in with the lower leg injury, it’s probably one of the most important areas that we assess.

If you look at some of the common running injuries, we’ve got runner’s knee which can be an umbrella term for a couple of different knee pathologies but most commonly patellar thermal pain syndrome, Achilles tendinopathy, shin splints or any type of bone stress injuries at the lower leg, a calf muscle strain but again that could be applicable to hamstring muscle strains or quad muscle strains, plantar fascia pain and proximal hamstring and gluteal tendinopathy, so they’re quite common running injuries.

If you look a little bit at runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail, but the knee joint primarily is just not designed for massive amounts of torsional rotation and in order to control that, what you have is an overload to the patellofemoral joint, and that could be a combination of a number of factors: it could be biomechanics, it could be how you recruit your quad, hamstring and hip muscles in particular and also the muscle capacity of the calf muscles below it.

When we look at a knee injury, we always assess above and below the area, so the calf muscles below and even around the ankle and above it we assess the quads, the hamstrings and the hip muscles so again they’re quite important, and particularly the quads, particularly the lateral hip muscles, so your hip abductors, your glute medius and part of your glute max has a role to play in terms of controlling hip internal rotation and hip adduction and also your lateral hamstrings your bicep femoris has a role to play as well in controlling internal rotation of the femur or the hip and adduction and controlling that sort of rotation around the knee joint.

They are areas that we would assess, and certainly, if we see weaknesses or deficits in those areas, we chase after them in terms with our rehab program, but in terms of running biomechanics and I’ll show you a video in a few slides time, we’ll also look and see what the knee control is like when you’re running, so look at someone from behind and see does the knee keep rotating inwards, and that might give us clues as to their ability to control those rotations from the hip down and from the ankle up.

Achilles tendinopathy is a common one that we’ve seen, again. As said at the start, it’s the main focus of my PHD, so some of the common risk factors for Achilles tendinopathy is we can separate them into intrinsic or internal risk factors and extrinsic risk factors.

Internal risk factors being calf strength, so for people who have poor calf strength, there’s been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain, it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles and that can I suppose change how the tendon is loaded over time, so if we have a previous lower injury and we haven’t fully rehabbed it but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, people who have diabetes or are at risk of diabetes or have poor cardiovascular health can be at risk of developing Achilles tendinopathy because tendons are actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on in the body as opposed to just running.

If you look at some of the external risk factors that are associated with this injury, training loads, so a big increase in volume or particularly intensity and that’s quite relevant given the last 15 or 16 months with our Covid restrictions and people may be exercising more than normal because they’re working at home and trying to keep fit or an elite sport where particularly in collective team training in field sports has been curtailed for several months and in the last two months they’ve got back again where the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

Cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, that could put people at risk of developing Achilles tendinopathy in some cases and also alcohol intake is also associated with a risk of developing Achilles tendinopathy.

Without going too deep into anatomy here, just use this picture just to illustrate the difference between a healthy tendon and one that has tendinopathy. Tendinopathy is pretty much pain, and impaired function in the tendon and the Achilles head in this case. What causes pain and impaired function? In a healthy tendon, as you see there, you’ve got a nice orderly alignment of collagen fibres, you got a very small level, and each fibre is kind of wrapped around by sheets and between those fibres you’ve got little cells called tenocytes, and those cells are sensitive to any changes in the load that the tendon undergoes so when it experiences fatigue or when it experiences big strains or fast movements those tendons become more active, and they can react and cause a cascade of events that can change the structure and the makeup of the tendon.

When the load has been too much, and the tendon hasn’t had a chance to remodel and adapt to that, you’ve got a change in the composition of the tendons, you’ve got more type three collagen fibrils as opposed to type one, so type one being good collagen, type three being collagen that’s not able to withstand sort of elastic strains.

Those cells become a lot more disorganised. They lose that sort of elongated shape. They come more around it, and you’ve got molecules that attract more water, so it gives a tendon a more of a swollen or puffy feeling, and then you’ve also got an in growth, especially when the tendinopathy has become chronic so if it’s been gone for several weeks if not months, you’ve got an ingrowth of nerve of blood vessels that normally don’t reside within the tendon. They normally sort of in the space between them, and they tend to migrate inwards, and they leave chemicals that can cause the neural veins to become more sensitised, and that can give you your pain feedback. Over time the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulant – total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain around about six per cent, so again this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little.

Too much and you develop little sort of micro-tears in the tendon, and the cells become more or more reactive, and it can become more catabolic, so it kind of degenerates, eats away at itself, and it’s not able to adapt to that load if it’s not given time to do that. If we rest for too long and we don’t expose it to enough strain or enough loading, you get a bit of wastage in the tendon, so it becomes more catabolic as well, and it becomes less able to handle regular exercise. It’s important to give it a regular bout of loading, and even when it is sore, we try to find a level of calf exercises that they can do without being too sore. A small amount of pain is okay and as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

A little bit about muscle strain injuries – we think of a calf tear or calf strain or hamstring strain, and we think about the muscle, but in fact, usually, in these cases, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle compartments that goes down the middle of it, so like a feather, so you see the example there on the left, and usually, the muscle strain occurs close to where the tendon tissue is.

Usually, where the muscle fibres in the tendon sort of meets and at the muscle-tendon junction or usually there can be a micro tear within the tendon itself around the muscle, and that can have an impact on the grading of the injury and the prognosis of the injury so if you’ve got a tear to say for example in the soleus muscle in the central tendon so again if you look at the illustration B there, that can take longer to recover than say it was just a muscle fibre tear, whereas if you had a small muscle tear that’s just the muscle fibre, even if it’s close to the tendon but if it’s only the muscle fibre and there’s no tendon tissue disruption, that can recover a lot quicker, and you could have less disruption to your training.

It’s important that we’re clearing the diagnosis – we use MRI imaging to know the grading of the injury where there is a one, two, three or worst case scenario four and whether it’s just pure muscle fibre or whether its muscle-tendon injunction or whether it’s pure tendon tissue that’s disrupted and that can impact on us. Again if you look at the calf muscle right inside, you’ll see a cadaver image of the muscle – see the soleus there being stripped off, and you’ll see the two heads of the gastrocnemius, the lateral immediate head, but if you look at the white tissue there that’s on the image, that is the tendon tissue the aponeurosis.

You’ll see different segments of white tissue around the muscle, and that’s the tendon tissue, so again usually close to those sites is where the injury occurs.

What are bone stress injuries? Essentially what we know from people who have looked at and who have studied bone loading closely in response to exercise and those who have developed either shin splints or stress responses to the bone, or a stress fracture – there’s usually a failed healing response in the bone. When we run or when we do impact type stuff, when you run or hop or do something that has high impact, we’re temporarily breaking down bone tissue, and that gives the bone tissue a stimulus to recover and remodel.

We’re constantly exposing it to repetitive stresses and strains. Small little bits of microdamage that occur, but again in a normal situation if you’ve got a good healthy metabolism, if we have a good structure to our training we’ve got enough time to recover quite quickly to that, but if we’re not able to adapt to it and the bone needs more time to adapt and remodel, and we haven’t got a chance to recover – then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury, so basically you have failed healing response in the bone.

If you look at what happens within the bone when we stress the bone, we have the formation of osteoclasts and osteoblasts – osteoclasts are where the bone sort of eats away itself and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the injury is or where the microfracture is to be ready for a new bone to form over that, and then you’ve got osteoblast formation which is essential when we have a failed healing in the bone, we have more eating than say replenishing, and so it’s in that sort of energy deficit.

It’s important that we look at people’s bones for injuries that we have good nutrition intake. Bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

If we look at a few common factors related to running injuries, basically, we have a mismatch between load and capacity – the load we are putting on the body is greater than our capacity to handle that load. It’s a very simple way of looking at it. I know it’s very hard to say there’s one thing, but there’s an interaction of a number of factors so. Obviously, we try to look when we assess someone we want to identify any potential overload factors and then we also assess their capacity.

Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training stresses either, so if you have a busy work schedule, busy family life, all those things can be an extra load in the body or a poor night’s sleep. If you look at capacity on the other side of things, that can be poor muscle capacity, high sensitivity to changes in training loads, some people are more sensitive than others, and people who are fitter have a higher capacity, people who are less fit have lower capacity to handle training load, and fatigue is similar, so if you’re more fatigued your capacity is reduced, if you have a previous lower leg injury, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after that injury.

Training age probably comes along to fitness as well – if you have a higher training age, i.e. running for longer than someone who took up running last year, you’re going to have a greater capacity to handle those training loads.

This is a nice little graph, and I’m not going to go through every little thing in detail, but there are a few of the relevant points here, so basically, what they did was they’re able to quantify the loading of an elite runner who runs a 10k when they’re fresh on an easy day, runs a 10k when they’re tired so they’re a little bit slower, so the pace is about maybe 25 or 35 seconds per kilometre slower when they’re really tired, versus doing ten 1k intervals on the track and spikes.

The main things here and the difference between doing an easy run when you’re fresh versus when you’re tired, your step count can increase by up to 13 %, so you have more time on your feet, more steps. If you look at the accumulated vertical ground reaction forces – that is a 6 % increase, so just because you’re going slower for the same distance, the accumulated loading can actually increase you’ve more of a step count, and your accumulated forces have increased and look at the Achilles tendon further down, again running slow when you’re fresh but running even slower when you’re tired that kind of a 5 % increase in Achilles tendon forces.

The main message I would take from that is that running longer and slower when your body’s tired of some people can be a risk factor. It is just important that when we’re on an easy day that we just keep some sort of control on the total volume of running or the duration of your run, so maybe it might just be better to have your easy run shorter. Picture when you’re tired and if you’re an injury, prone runner.

For people who are well trained, people who trained at a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has a high risk of injury, just got to be careful on those days because that’s when the damage can be done because we’re not giving the body the best chance to recover because we’re adding more load to it.

Some of our common assessments when people present us with injuries or want to try and manage their injuries we assess strength, we assess their power and play metric ability, and we also look at their running biomechanics, their running gate.

When we’re assessing strength, we want to get a rough idea of whole-body strength, so if someone does a squat, whether it’s a back squat or front squat, we’d like them to be able to get to the point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps as a minimum but again if someone hasn’t squatted before we’re not going to start them on that – they need probably a year or two of just basic conditioning to get up to that. When they get above those thresholds, that’s probably a good level to be at.

Similarly, the deadlift will probably target the posterior chain muscles, the hamstrings glutes a little bit more than the squat would depend on your technique and how you coach it, and you can always lift a little bit more, so again we’d be looking at 1.2 times body weight or more for three reps and if you look at calf strength what we often do is measure them on a force bit, so get them to stand on one leg with the bar sort of compressed over the shoulders and basically, they try to do a calf raise, but the heel hasn’t got space to lift, and we would expect them to be able to use force that’s more than two and a half times body-weight as I said the calf muscles are big force-producing muscles, they can produce those forces, they need to cope with those and a lot more in the running.

That gives a measure of the total of all the calf muscles, but again we’ve got three calf muscles: our medial gastrocnemius muscle, our lateral gastrocnemius muscle and our soleus muscle, so because the gastrocnemius muscles across the knee, when you bend the knee that’s going to impact how much force they can produce so when we bend the knee to 90 degrees, we’re kind of dumping down the force contribution from those gastrocnemius muscles but because the soleus muscle doesn’t cross the knee joint it doesn’t matter what a straighter bend does, it’s going to produce the same force anyway.

If you want to get a rough idea of the soleus muscle force contribution, we’ll do a seated calf isometric test where they sit on a seat with their knee at 90 degrees and their heels slightly dropped with the top of their foot on a block, and we get them to do a seated heel lift where the knees compress down and see how much force they can produce, and we like to be seeing people hitting above one and a half times body-weight, and for elite athletes, we try to get them up close to twice body weight.

If you want to get a good measure of their calf endurance, being able to do single-leg calf raises – more than 25 of them in 50 seconds, so one raised every two seconds with good height and good technique and good control. If you look for good reactive strength, their plyometric ability, we might test them doing a drop jump where they maybe drop off a 20 to 30-centimetre box height and try to rebound in less than a quarter of a second and try to achieve the height of the box that they drop off or close to that.

We might get them to hop on one leg and see if they are able to do ten hops on one leg while maintaining the time on the ground per hop in less than 0.28 of a second without bending the knee too much, so try to use your ankle to hop.

When we look at running biomechanics, we can get a 3D model of someone running, so we can put some marker sets on them, and we have got cameras that give a sort of a 3D capture of them, and when they’re running then we can create that sort of stick man image of them – we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on, and we can look at some of those rotation movements I’ve talked about at the knee and the ankle, so again a couple of some of the key things to look at here is hip and pelvis motion, so how much hip abduction and internal rotation occurs, do they have a forward pelvis tilt that increases throughout the strength phase or does their pelvis drop on one side if you’re looking at them from behind.

We also look at high-end shin rotation, we look at the motion of the heel, so can they control the pro-nation fairly well or do they collapse and show poorer control which might cause more loading around the foot and ankle area and we’ll also work out their contact time and their flight time, so basically the time on the ground per foot strike and the time in the air and their ability to control how much the centre mass drops and how much the knee bends as force goes through the body, so it’s a measure of spring stiffness.

Why do we do that? So again some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at in the side view people who present with some common injuries tend to lean forward a little bit more, land with the foot a little bit further in front of the body so the shin at a bit more of an angle and the knee a little bit straighter, so if you look at the illustration A here on the left versus those who are not injured tend to be a bit more upright through the torso, land with more of a bent knee and the shin a bit more vertically aligned and the foot closer to where the hips are and if you look from behind again give an example there of hip and turn rotation and abduction as well as pelvic stroke, so if you look on at the athlete the female in the image A there, you’ll see a little bit more drop of the pelvis – you see the horizontal line going from right to left a little more tilted and you see the line from the side of their hips to the centre of the knee a little bit more angled and that can cause more torsional loads at the knee, it puts a bigger demand on the hip muscles but it can also have a knock-on effect around the foot and ankle too because if the hip internally rotates and adducts, and you’ve got that rotation going on the knee then there’s going to be more adjustments of the tibia over the ankle and so on and around the foot area as well. For example, B who’s able to have a more horizontal pelvis position and less of an angled line from hip to knee.

When we prescribe strength training, some of the most important things we try to cover are some sort of a jumper hop exercise depending on the time of year and where they’re at in terms of the training program, it might not be done from the start. Having a double leg whole body exercise like a squat or deadlift, a single leg whole body exercise like a step up or lunge or some variation of it, having a calf exercise in there particularly at certain points of the year to try and improve calf muscle capacity and some sort of trunk control exercise to try and improve torso control.

So in terms of the qualities we want to try and train, if we’re trying to improve power or plyometric ability at a high intensity, we’ll keep the reps short, so we don’t want to be doing these long enough where they’re going to get tired, and our power diminishes otherwise we are not training the right things so reps of about three to six reps you know for four sets, taking a longer recovery between sets because when you do something explosive you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve power or reactive sprint capacity, we might dial back the intensity a little bit and go for more duration so we can work up to 20 reps depending on what we’re trying to get out of it. If we’re trying to improve strength, we’ll do rep ranges between three to eight with a two minute or more rest between sets for four sets, again if we’re trying to produce maximal or submaxim strength.

If we’re trying to grow muscle so try to improve hypertrophy is not the most important thing for distant runners because more muscle mass means more energy expended to try and carry it around, but when someone comes in with a chronic injury, we often see a lot of muscle wastage and muscle deconditioning so we see a muscle on one side, smaller than the muscle on the other side so we probably will have to try and give that muscle a stimulus to grow it back to the level of the other side where it should be because a smaller muscle will on the flip side mean less capacity to handle those big forces.

Now in terms of frequency, if we’re not rehabbing, if we’re just doing strength training in order to improve performance, and we’re fairly good from an injury point of view – twice a week is probably enough. During the busy competition period for racing, if we are racing quite regularly once a week is probably enough to maintain it, but if we are rehabbing an overcoming injury, we probably need to have a third in there for at least four to six weeks to try and front load those adaptations we are trying to get.

I am just going to take you through a couple of examples of common exercises and how we progress them so if someone hasn’t squatted before, we’re not going to put up 80 kilos in the shoulders and hope for the best we’re going to try and make sure their squat technique is good, put a chair under them so they can sit back on their heels and be able to squat smoothly, have good technique and then we can increase the weight so if we could get them to do like a goblet squat while holding a dumbbell or kettlebell held into their chest and they know the chair under them they can sit back on their heels and squat.

If we got that, then we can take the chair away, and if they’re well-coordinated and balanced, they can sit on their heels and be able to squat and maintain that sort of parallel torso and shin angle.

Then we can move to a bar, so if we’re trying to introduce a deadlift, sometimes a hex bar can be a useful way to do that, it allows you to train a good technique in a safe way so again standing in the bar, less of a knee bend as we’re trying to keep the knees a bit stiffer to try and put more tension in the hamstrings and we’re trying to keep the back fairly straight as well.

Then we move to the bar from the floor or maybe from an elevated position on the right there so again trying to not bend the knees too much like a squat trying to target the hamstrings a little bit more, keeping that back fairly straight as you lift and we should feel the hamstrings and the glutes doing most of the work here. I think it’s over to the single-leg exercises, so a step up so stepping onto a box ideally if you can stay on one leg hold that position for a second or two to show that we’re balanced and back down nice and controlled.

It is one of my staple exercises, covers a lot of boxes and we can do some sort of lunge variation or split squat variation, so an example here on the right of a Bulgarian split squat with a barbell, rear foot elevated, dipping down, not letting the knee travel too far forward and again we should feel this closer to the hip area, we shouldn’t feel much pressure on the knee doing this, and we are going to try and keep our back fairly straight as well.

Calf strength as mentioned, if we bend the knee to about 90 degrees and have the foot slightly elevated, we can put a big load through the soleus muscle, and target that was so doing seated calf raises and also standing calf raises, so again I’d like to go ahead in the calf raises so split machine or leg press is an ideal way to do that, just standing with the leg fairly straight pushing up onto the big toe, pause at the top for a second too and back down slowly.

Then plyometric exercises and pogo hops on the spot, trying to be smooth in the ground spend a bit more time in the air progress do a drop jump so again bouncing off a box that’s a 30-centimetre box trying to get off the ground in less than a quarter of a second rebound is almost as high as the box he jumped off and then maybe doing single-legged hops on the spot or single-legged hops going forward as you see there and then on the far right.

In terms of how this all fits in, we can split this season like a running program into like into four phases or whatever way you want to do it, so in the general prep phase, we’re trying to prepare the body for the bigger running sessions that are going to come so we’re trying to improve tissue capacity muscle capacity two to three sessions per week working on good moving patterns first maybe if we have a certain weak spot if we’ve had a previous calf or Achilles injury or an ankle injury we’ll do a lot of calf work if we had a previous knee injury we might do a lot of quad and hamstring and hip work or if we had a previous hamstring injury or recent hamstring injury we’ll do a lot of hamstring and glute work as well.

That’s the time to try and iron out those things so that you’ve got good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards specific preparation phase where you running starts to become more of a priority and you’re increasing your distance bringing in those key sessions twice a week should be enough we’re not going to spend as much time in the gym or doing those exercises so quality is important so maybe a couple of exercises done really well at a good intensity so we’ll go heavy if the athlete has enough training behind them and we’ll also bring in some plyometric exercises and as we get close to competition we want to try and keep that sharpness there because traditionally that’s where distance runners tend to sort of shelve the rest of the program because they’re training for that marathon and in six weeks’ time they’re going to be tired from all the runs but it’s probably the time when they need to get their strongest so if we don’t train something for a period of six to eight weeks we can start to lose those qualities so it’s really important we keep some of the strength training in there in a clever way and that keeps us nice and balanced so we still try and keep in two sessions a week, keep it short and intensive to keep that sort of stimulus and edge there, a bit more focus on the plyometric, keeping in touch with our heavy lifts and then when we are in season and competing we try to maintain it once one or two sessions a week if we’re racing it in a given week one is probably enough in the week a little bit shorter than normal and if we’re not racing on a given week we can probably do the second top up session.

So, in conclusion, most running injuries occur from the knee down. Our calf muscles are probably one muscle group that works close to its full capacity even at slow running speeds compared to quads and the hip muscles, so it’s really important that we condition them for that.

High-intensity strength training, so I talked a lot about the injury, but it’s also associated with improved running and performance, and every runner has different needs – it’s very hard to give a one-size-fits-all answer to when someone has a question about a particular injury or what sort of strength training they should do, it’s important that if they have an SSC coach that’s reputable and experienced they get a proper assessment and have their training SSC program prescribed to meet their individual needs.

At this event, Colin Griffin (CG), answered questions from our live audience asked by Fiona Roche (FR).

FR: How influential do you think reds have in the occurrence of running injuries? What is the management pathway you follow if you suspect this?

CG: Yeah, a good question actually and quite a common one particularly for probably for younger athletes and so if any parents of an adolescent athlete, doesn’t have to be adolescent actually they can be adults too or coaches, so red are running who doesn’t understand, it is relative energy deficiency syndrome, so quite common in female athletes and obviously mid to late adolescence even into early adulthood, and we would see a lot of them who have like recurrent stress fractures so the metabolism is a big factor and so definitely we would look at energy deficits are they getting enough calorie intake at the right time around training or are they in a constant state of depletion, looking at like hormonal profile have they got a regular menstrual cycle.

Even just looking at psychosocial factors as well and are they more conscious of their body type and body shape – with those types of athletes or runners, we would probably have a bit more of a holistic approach here because young athletes we want to try and involve the parents and the coach to make sure they’re on the same page in terms of how to manage them they may need nutritionist and psychologists intervention as well, but as I said it’s not just limited to female athletes, male athletes can be energy deficient and can have recurrent stress factors as well so we would certainly look for that and if we suspect that that’s a factor we would definitely push the nutrition side of things, careful load management and making sure that they have a good SSC program, a well-balanced running program that suits their needs.

FR: Can stress fractures in shins take a long time to heal? I haven’t run in six weeks. I’ve been told I have a grade three stress fracture. What am I doing wrong? I walk, cycle and swim. Could this be a delay in my recovery?

CG: Yes grade three can take a bit longer to heal like a standard sort of lower grade stress fracture you’re talking six weeks and probably trying to immobilize for a good bit of that as well to allow for early bone healing and remodelling to take place, then once that healing has taken place you want to try and get back into a gradual exercise program, so get back walking first to be fairly pain-free and have no sort of gait abnormality and then get back into some strengthening exercises because there will be some muscle wastage if you’re in a boot for a while and you’re not using those calf muscles and ankle muscles and foot muscles so definitely want to recondition those and then you want the body to be able to tolerate some little bit of low level impact so like doing things like hopping or skipping is a good bone stimulus just short 30 second bouts maybe once or twice a day is a good bone stimulus and to be able to tolerate that and then gradually get back running and then obviously make sure that your energy intake is good, calcium and vitamin d levels are good, and nothing more than a low level of pain or discomfort as you progress through it.

Obviously, if there’s a worsening or there’s a high level of pain that is not getting better, you may want to just get reassessed again and see how is there incomplete healing and does it need maybe a more long-term approach.

FR: Joan is saying she has had Achilles tendinitis for the past four weeks, not getting better is there anything she could do to speed up her recovery?

CG: Obviously, you want to be sure of the diagnosis that it is Achilles tendinopathy and nothing else. I suppose to find what you can do that’s not too sore and maybe what is a sticking point? So there’s a certain level of exercise that you go above where you’re going to be sore, but it’s really important to find some level of exercise that you can tolerate, and that’ll sort of accelerating tendon adaptation to exercise, so finding some sort of calf raise exercise if it’s just a static isometric hold or a half health position putting tension on the calf muscles throughout the tendon being too sore and trying to progress from that.

Again depending on how long it is, some of our sports med doctors might look at an injection that might help to settle the pain a little bit and allow them to exercise a bit more, they might maybe use something shock wave, and from a nutritional point of view we tend to encourage people to supplement with collagen and vitamin C which helps to give the tendon the important nutrients it needs to have to repair itself and remodel, but definitely trying to find a level of exercise that you can tolerate and progress on from there, and sometimes people just can stagnate on the rehab program, they can do things that may be too easy, the body gets too used to that, and there’s no progression or added stimulus there, and momentum can be lost, so again it’s very hard to cover everything there when I don’t know the full picture, but that will be my sort of general advice.

FR: What is the prognosis when diagnosed with possible hag Lund deformities? Struggling with Achilles problems for four years, and there is a bony spur on the right insertion.

CG: That’s a tricky one, the heel is kind of like a sharp enough bony structure as it is, and if you’ve got a hag Lund deformity which is an extra little bit of bone growth, you’ve got that bone kind of digging into the tendon on one side, and if you’re wearing shoes you’ve got the heel cup of your shoe digging in on the other side, and that could just keep annoying the tendon over and over again so if it’s not responding to rehab, it’s worth getting a surgical opinion on that, so I’d be kind of referring someone to a sports med doctor, so maybe to a foot and ankle surgeon just to see is another intervention required, because that might be the nature of it might be just you know constantly irritating it and maybe stagnating progress.

FR: What do you think about the barefoot type of shoes for running or walking in, and generally what type of shoes so? We’ll probably answer a lot of people’s questions there.

CG: Barefoot type of shoes, to be honest with you, it’s more the transition so if you’re used to wearing cushioned shoes and all of a sudden you go barefoot or you go minimalist, and you don’t adjust your training load you’re putting yourself at a huge risk of injury because your lower muscles have to adjust a lot to that, they’re going to get tired quickly because they’re not used to that and if you’re trying to do the same amount of miles or train the same intensity, you’re putting yourself at risk of injury.

If you’re going to do it for whatever reason you’re doing it, there’s no necessarily one sort of clear right or wrong here if you need to do it.

Just allow a gradual adjustment time. I think it’s good to do some exercise in minimalist or even just without shoes just to try and train foot a little bit more, but it was a bit of a swing towards minimalist and barefoot maybe in the last five to ten years it’s kind of going back a bit more if you look at all the new shoe technology in races, they’re going back to more towards cushioned shoes with special sort of spring cushioning in them along with the carbon fibre plate.

I’d try not to break a formula that that’s working for you already unless you’ve got a very good reason to do it, and I don’t know your full history to be able to give you a very precise answer on that.

FR: Lots of calf muscles generally strains at the moment. What’s causing this, and how long to rest for?

CG: Probably the simple answer there, given we’ve seen in the last few months, is you probably have weak calves and trying to ask the calves to do more than they’re able to give you when you’re trying to run a certain level, so trying to increase calf capacity because they’re so important for running we demand a lot of them when they’re running and if the capacity is low it takes a lot less for them to get tired, to get sore, to get spasmed and for an injury to occur, so load up calf strength, find a management level running that you can tolerate and then try to increase gradually from there.

That would be probably right without knowing the full picture. That would be my best advice there.

FR: Allan says he’s got a pain in the space between his Achilles and ankle originally thought to be Achilles tendonitis. If he did not resolve the conservative strength exercises, an MRI of the ankle was unremarkable, an issue now suspected posterior ankle impingement. Is cortisone shot the best option from here?

CG: That is not my decision. I suppose the clinical test you can do that can differentiate between an Achilles tendinopathy and having a posterior ankle impingement, so if you’re quite sore, if you put someone lying on the front, bend their knee, and you try to force them into n range plantar flexion, so you’re trying to kind of squash the ankle bring the heel as close to the top of the ankle as possible and if they’re sore doing that and give the heel a few taps and it’s quite sensitive there’s a good suspicion that it is a posterior ankle impingement, quite common in dancers who spend a lot of time on their toes in those kinds of heel raise positions.

It can be managed conservatively. We do see a lot of them and that you can improve how you control the ankle, so people who are hypermobile have a lot of space to move, a lot more room for bone on bone contact – that can be managed by being more stable to the ankle, being stronger in the calves in those sort of heel raised positions and if not then yes it’s worth getting a sports med doctor to have a look at it and see if an injection might help to settle things down a little bit.

FR: Ann-Marie said they will running on grass reduce forces on the lower legs, and will this have a notable reduction in the risk of injury?

CG: It goes back to the changing shoes as well; it’s what you’re used to. If you’re used to running a road, and you go on grass, it can be greater stress on the body than doing the opposite. Your software is not always better.

When you run on softer surfaces, your muscles have to contract a lot more if the surface is quite soft, particularly grass in, say winter and springtime, you’re going to be on the ground that little bit longer, so muscles have to work a little bit harder and if you are not used to it they’re going to get tired a lot quicker, whereas on the roads you can use your natural spring system better you can use the tendons a lot more and they could save the muscle work.

There’s pros and cons. Personally, I actually hate running on the grass, but that is my own personal opinion. I wouldn’t force anyone else, but I think it’s a good idea to mix it up, do some runs be off the road or do some runs on the road and even just doing some off-road running can actually help just to improve strength and stability.

The force going through the body is actually the same; it’s just how you coordinate around the joints when the ankle, knee and hip can differ.

FR: What is the right rest period for shin splints from running? I have this from May. I’m nervous to start running again as I don’t want to prolong the injury time frame being any longer.

CG: Shin splints are kind of a pain on the lower inside of your shin, and I suppose it’s on the spectrum of a stress fracture, so it’s like an early stage, so the bone stress response we’re struggling to heal and adapt to what you’re asking to do so there’s no set time frame if it’s shin spins and it’s a low level of discomfort some people can run through it just adjust the training maybe space out the runs a little bit more, but I would definitely be looking at running mechanics.

I would be looking at your running load, make sure there’s no recovery time in there, staying below a threshold of running that you can tolerate that doesn’t cause pain or cause a worsening of it, make sure calf strength is good because again it comes down to those bone-bending forces and if the inside calf muscles and the deep calf muscles aren’t strong enough to cope with that, there is going to be like more fatigue in the muscles and a lot more loading going through the bones so make sure that’s addressed.

Then it’s a question of trying to progress back up again – if someone has a muscle injury or a tendon injury, we can probably let them train with a level of pain that might be like a four or ten on a scale, but for a bony type of injury like shin splints, maybe a little bit less than that maybe like a one or two out of ten that doesn’t worsen and the main thing is you can increase your running and whether it’s volume, whether it’s intensity or frequency without worsening symptoms.

It’s very hard to give a proper time frame and is also important then as I mentioned in one of the other questions is to look at your nutrition and look at energy intake and to make sure there’s good recovery, and you’re in good metabolic health to be able to adapt what you’re asking to do.

FR: Jim said he has an ongoing battle with gluteal tendinitis, he’s done full rehab, had running analyzed, and one issue was that she doesn’t lift her knees enough, which causes her hips to drop when she strikes the ground, is the only way forward to continue to try and change her gait?

CG: It’s one way forward, and it’s important to look at that, so again, as I mentioned there in the presentation, the example of a hip drop that causes a compression of the glute tendon against the bone and so if that’s happening every stride the tendon is going to be constantly annoyed because there’s an extra compression so the base of the tendon’s getting sort of squashed against the bone.

It is definitely important to look at strength around the hip muscles. There’s a few questions there people saying I’ve tried rehab it hasn’t worked, it’s like you know there are different ways of rehabbing, it’s like saying I’ve tried running, but I haven’t got any fitter or haven’t improved my pb so running isn’t for me you know or I need to do something else – just maybe the way you went about it might be the right way for you, and that’s not criticizing anybody else or that, people do things with the best of intentions.

But you may need to try a different approach, and you need to maybe get a proper assessment of your strengths and have numbers there that gives you an objective measure of where you’re at and then try and chase it, do a program and try and make sure that you’re getting changes in those type of measures and if you are looking for engagement, someone telling you you’re not lifting your knees enough, again I don’t think that’s the biggest issue, but the hip drop is one to look at, and you want to make sure you’re doing something to maybe modify that a little bit.

You mightn’t be perfect, but you can maybe reduce that a little bit, and that might take a little bit of load off the tendon, but it’s really important that strong hip muscles and also make sure the level of running you’re trying to do is manageable for you for your individual needs.

For further information or to book an appointment with Colin Griffin please contact sportsmedicine@sportssurgeryclinic.com
Tennis and Shoulder Injuries

Tennis & The Shoulder – Ms Ruth Delaney

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.

 Ms Ruth Delaney is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic in Santry Dublin who specialises in shoulder injuries.

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

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

Tennis Equipment

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

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

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

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

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

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

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

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

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

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

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

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

Tennis & The Shoulder

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

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

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

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

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.

Shoulder Symptoms

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

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

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

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

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

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

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

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

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

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

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

Rotator Cuff

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

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

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

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

Frozen Shoulder

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shoulder Arthritis

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

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

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

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

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

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

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

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

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

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

Shoulder Replacement

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

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

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

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

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

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

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

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

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

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

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

Thank you very much.

To make an appointment with Ms Ruth Delaney please contact info@dublinshoulder.com or call 01 5262335.

Republic of Ireland Reimbursement Scheme: ROI How to apply.

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.

Watch this video to learn how to apply for 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 info@sportssurgeryclinic.com

Sports Surgery Clinic (SSC) is a dedicated centre of Orthopaedic Excellence and has been working closely with the NHS over the last 15 years and with Musgrave Park and Craigavon Hospital and the cross border over the last 7 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.

Knee Arthroscopy

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

ACL tear

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

Osteoarthritis

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

What is Osteoarthritis?

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

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

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

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

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

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

The Hip

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

How do I know if I need a hip replacement?

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

How long is recovery from a Total Hip Replacement usually?

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

Rotator Cuff Repairs

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

Shoulder Impingement

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

Shoulder Replacement

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

The Spine

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

Foot & Ankle

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

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

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

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

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

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

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

What is not included in the price?

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

For individual pricing requests please email Glenda Thorne on glendathorne@sportssurgeryclinic.com

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

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

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

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

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

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

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

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

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

 

For any further questions on EU Cross border Directive please email info@sportssurgeryclinic.com 

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

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

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

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

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

If you have any other queries on the payment, you can contact glendathorne@sportssurgeryclinic.com

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 gp@sportssurgeryclinic.com and we can have it reviewed by our foot and ankle specialists, and make a decision.

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

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

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

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

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

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

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

For any further information on this presentation please do not hesitate to contact info@sportssurgeryclinic.com

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

Tennis Back pain

Low Back Pain – Stopping your Back from stopping your Tennis – Dr Neil Welch

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.

Deadlift

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

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

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

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

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

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

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.

Banded clam

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

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

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

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

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

Half-kneeling Pallof Press

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

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

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

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

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

Shoulder Flexion

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

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

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

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

Lying Banded Y

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

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

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

Shoulder Rotation

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

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

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

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

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

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

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

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

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

If you need any more help at all feel free to contact us here in the 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.

For further information on low back pain or to make an appointment with Neil Welch please call 01 5262030 or email sportsmedicine@sportssurgeryclinic.com
Tennis Injuries

An Evening for Tennis Q&A Session

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RD:

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

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

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

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

For further information or to make an appointment with an SSC Clinician please contact info@sportssurgeryclinic.com 

Warm up exercises for Tennis with Joe Collins

Watch this video of Joe Collins, Strength & Conditioning Coach at Sports Surgery Clinic demonstrating warm-up exercises for Tennis players.

For further information or to make an appointment with a Strength & Conditioning Coach at SSC please contact sportsmedicine@sportssurgeryclinic.com

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.

Common Shoulder Problems – Diagnosis & Treatment with Ms Ruth Delaney

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.

Ms Ruth Delaney is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic in Santry Dublin who specialises in shoulder injuries.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Frozen Shoulder

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shoulder Arthritis

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

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

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

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

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

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

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

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

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

Shoulder Replacement

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

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

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

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

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

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

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

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

Future of shoulder surgery

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

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

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

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

 

For further information on this topic or to make an appointment with an Orthopaedic Surgeon please email gp@sportssurgeryclinic.com

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 info@dublinshoulder.com or call 01 5262335.

A letter of referral may be required.