What happens if I dislocate my shoulder?

If you’re unfortunate enough to experience a shoulder dislocation, these are the main points to consider:

• Many spontaneously relocated themselves within a few minutes.
• If you can travel please make your way directly to the nearest A&E
• If the shoulder remains dislocated and you are in too much pain to move you may have to to call 999
• Once in A&E your shoulder will be put back into joint by the attending medical staff usually under some sedation but sometimes a general anaesthetic

Many shoulders only become partially dislocated and due to the remaining pole of tendons may relocate themselves spontaneously. Having said that there is often significant ligamentous damage and it is always worth being assessed by a specialist at some point. Often dislocations “lock out” due to the ball catching on the side of the socket and hence the need to attend A&E.

Most the shoulder is dislocated out of the front of the socket due to a inherent weakness in the joint capsule. They do occasionally go out the back of the shoulder but they do not often lockout and this is relatively less painful at the time, although subsequently can cause prolonged discomfort and dysfunction.

After the shoulder has been put back in joint the arm will be placed in a sling for support. Modern day thinking is now of the mind-set that joints are best off being mobilised immediately after an injury to help the ligaments and tendons heal and to prevent stiffness of the joint as well as preventing the muscles around the joint from wasting. You may well be referred to your local physiotherapy service.

Am I at risk of further dislocations if I have dislocated once already?

If you’ve already dislocated your shoulder, the main points to be aware of are:

• You are more likely to have a further dislocation after initial instability episode
• The younger you are the more likely you are to develop recurrent instability
• Activity level is probably one of the most important factors in determining future stability of the shoulder after a dislocation
• Overhead and contact sports are high risk for further dislocations
• If you dislocate the shoulder in your early teenage years you have more than 80% chance of developing recurrent instability

There are not many factors that determine the stability of your shoulder. Some people have naturally loose shoulders which does make them easier to dislocate. Research suggest the main factor is the type of sports you partake in and at what level you play. As you would expect, at higher competitive levels, there is more extreme movement involved and therefore high chance of the shoulder coming out of joint. As you grow older your activity levels tend to decrease and the ligaments become stiffer, both of which have a protective effect on the shoulder in terms of stability.

What structures were damaged when I dislocated my shoulder?

Typically the ligaments within the joint capsule is damaged along with a rim of tissue around the socket called the labrum which gets pulled off. Sometimes bone is chipped off the side of the socket (the glenoid) but you can end up with a dent in the side of the ball (the humeral head) where it comes to rest on the side of the socket. After about the age of 40 dislocations can be associated with tendon injuries which may require surgery.

Does my shoulder need surgery after a dislocation?

A first-time dislocation will not usually need an operation. Surgery is mostly reserved for those people who have developed recurrent instability (i.e. dislocated many times and a minimal force). If you are under 20 and/or partake in high level sports your specialist may advise a stabilisation procedure after your first dislocation.

Although shoulder dislocations are common only a minority go on to have surgery. Probably one of the main reasons for this is, although the surgery is relatively straightforward, it is a relatively long recovery, with the arm and shoulder immobilised and defunctioned during the acute post-operative period (4 to 6 weeks).

What does shoulder stabilisation surgery involve?

Typically this is done as a day-case keyhole procedure with 2 or 3 small holes around the shoulder. The rim of tissue around the socket (the labrum) is reattached along with the associated torn ligaments. If there are associated injuries such as a tendon tear as these may be addressed during the same procedure

This is one of the most common shoulder procedures done in the UK. The repair of the ligaments is achieved by using little plastic pellets called anchors which are drilled into the rim of the socket. The anchors have suture attached them which is then used to tie the ligaments back into their anatomical position. If the shoulder has dislocated many times and there is extensive damage you may have to have a more complex procedure which may involve using bone graft to rebuild parts of the joint.

How long does it take to recover from shoulder stabilisation surgery?

After surgery the shoulder is placed in a brace or sling for between 4 and 6 weeks, and the wounds tend to heal within 5 to 7 days. You may recall require painkillers for up to 10 days but most people stop taking them after a few days.

You can commence rehabbing with a physiotherapist immediately after surgery, and this is something we strongly recommend. After 6 weeks you should have good basic function of your shoulder, and after 3 months you will be able to return to non-contact and non- overhead sports. Contact sports are allowed usually after 6 months but this is usually after a discussion with your specialist.

If you have any concerns about shoulder injuries don’t hesitate to get in touch with OneWelbeck Orthopaedics – you can either call us on 020 3653 2002, or email us at bookings.orthopaedics@onewelbeck.com.

Toby Baring has extensive experience in shoulder replacements, sports injuries, rotator cuff problems and shoulder and elbow fractures; performing 300-400 procedures per year. He practices the most modern techniques, and constantly looks to improve and innovate treatment to enhance his patients’ recover and outcomes.

Introducing the ‘one-stop’ MRI scan for a groin injury

OneWelbeck has brought together a team of groin injury experts consisting of Sports Doctors, orthopaedic surgeons, hernia surgeons, gynaecologists and radiologists. An important part of this service is the introduction of a one-stop scan for groin pain. Previously, we would perform a combination of scans such as X-ray, ultrasound and MRI. This combination takes time and is expensive. Now, experts at Onewelbeck have devised  a one-stop MRI scan that obtains all this information in just one sitting.  Included in this scan are novel ‘moving’ images to detect small hernias. Rather than having different scans often over a few days, this novel one-stop MRI scan reduces time and cost for patients. In essence, it’s a true ‘one-stop’ scan for the sporty groin pain.

Let’s see an example of ‘one-stop’ groin MRI in action for a groin injury  

This fit 50 year old male triathlete presented with right groin pain after sport. His pain failed to settle with rest and rehab. A clinical assessment by one of our Onewelbeck experts suggested more than one cause – pubic overload or hernia. The pictured MRI scan shows the important tendons, joints and ligaments of the groin. In addition, the moving MRI pictures are taken while the patient is straining. These pictures help to pick up small hernias that cause groin pain.

In summary, a groin injury can be complex and needs a thorough assessment combined with a one-stop MRI to pick up all possible causes.

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What was Madonna most likely to have been suffering from?

The hip showed signs of osteoarthritis. Whilst regenerative treatments such as platelet-rich plasma (PRP) or stem cell injections have shown some promise in managing early wear and tear of hip joints, if it does not provide long lasting relief then further treatment options need to be considered, including joint replacement.

What is osteoarthritis?

Commonly referred to as “wear and tear” arthritis, it is the most common form of arthritis. This happens when the smooth articular cartilage that covers the end of joints, which allows the bones to glide against each other when a joint is bent and straightened, starts to roughen as it wears away. This damaged joint becomes painful as the joint is moved.

It can be associated with previous childhood hip problems or injury to the hip joint. Another important cause is femoroacetabular impingement (FAI). This is a common cause of hip or groin pain in younger patients which is often misdiagnosed and under treated. Earlier diagnosis and treatment may help to prevent the development of osteoarthritis of the hip in the future.

If you have unexplained hip and groin pain or previous hip problems then it is worth having this reviewed. Book a consultation with one of our specialist team of hip surgeons.

Could Madonna have had a hip replacement?

The x-rays Madonna posted did show quite a worn out hip joint and if this continued to be very painful despite the injections then the next step would be to consider a hip replacement.

She has a scar over the front of her hip joint which might indicate an Anterior Approach Hip replacement. This is a less common technique that avoids damage to major muscles as the surgeon works between them rather than cutting them. This leads to less pain which allows faster recovery and less risk of dislocation.

If you think you may have hip arthritis and wish to discuss treatment options including anterior approach hip replacement then contact OneWelbeck Orthopaedics today.

Pramod Achan is a Consultant Orthopaedic and Trauma Surgeon at OneWelbeck Orthopaedics. He focuses on lower limb joint preservation surgery, arthroscopic intervention, primary, complex primary and revision joint surgery.

Joshua Lee is a Consultant Orthopaedic Surgeon at OneWelbeck Orthopaedics, and he provides comprehensive treatment of hip and knee conditions, from sports injuries to joint replacement.

What is a cuneiform fracture?

The cuneiforms make up three bones in the midfoot. These bones interlock with each other and are the bridge between the navicular and the metatarsals. The importance of these bones lies in their solid structure and the fact that they create a very stable medial column of the foot. This stability is extremely important in walking and running, as it allows muscles around the ankle and foot strength to propel the body forward.

Cuneiform fractures are very rare in isolation and are most often seen in the context of Lisfranc injuries of the foot. These are commonly-missed ligamentous injury that can also occur with fractures. As in Mr Biden’s case, it is important to look carefully for them with detailed cross-sectional imaging of the foot (CT or MRI scanning) since if missed, they can lead to mal-alignment of the midfoot bones and subsequent disabling arthritis.

How to treat a cuneiform fracture

The management of the injury is determined by thorough patient examination. Bruising on the sole of the foot (Fig. 1) often indicates internal fractures and ligament injuries and should prompt detailed imaging. X-rays may only reveal subtle signs of the injury such as a small bone fleck (Fig. 2) and most often a CT scan is needed (Figs. 3&4 show CT images with an intermediate cuneiform fracture and a base of 2^nd metatarsal fracture where the stabilizing Lisfranc midfoot ligament is attached). If there are any signs of any mal-alignment or instability in the midfoot joints, surgery is most often performed (Figs. 5&6).

A standing CT scan is available at One Welbeck and can be useful to show both the fracture and whether or not the foot is unstable.

Non-operative treatment is reserved only for stable, perfectly-aligned midfoot joints and in President-Elect Biden’s case, he can expect at least 6 weeks in his walker boot followed by several weeks of physiotherapy.

Mr Lee Parker is a Consultant Foot and Ankle Surgeon at OneWelbeck Orthopaedics. A well-known figure within his specialty, Mr Parker has extensive experience in managing foot and ankle trauma. His NHS base is at The Royal London Hospital, one of Europe’s largest trauma centres. To schedule a consultation with Lee, please call +44 (0)203 653 2002 or email bookings.orthopaedics@OneWelbeck.com.

What are the key factors in hamstring injuries?

The acute muscle injury, a “pulled” hamstring, usually results in a sudden popping or snapping sensation, often associated with an inability to continue playing or running. Readers might recall Derek Redmond at the 1992 Barcelona Olympics, hobbling the final part of his 400m semi-final following a hamstring tear.

Hamstring injury is sometimes associated with bruising and swelling into the back of the thigh and knee, indicating a more serious muscle tear injury. Pain is felt either high up in the buttock at the sitting bone, in the middle of the hamstring muscle, or lower down at the attachment just below the back of the knee.

In teenagers and younger individuals it is also important to consider the possibility that the mature muscle and tendon may have pulled off or ‘avulsed’ a fragment of immature bone at the high hamstring which requires more rapid assessment and early investigation.  Sitting bone pain in a young person following a sudden  hamstring injury therefore warrants an early medical assessment, i.e. within the first few days to a week.

The recovery process

A twinge that results in an ability to continue play, with little discomfort afterwards and relatively normal walking gait, most likely indicates a minimal injury that can be treated very effectively with early rest and crutches as required. Icing can be effective for pain relief in the early stages and pain killers such as paracetamol may be used.

There is ongoing debate about whether to use anti-inflammatory drugs, i.e. ibuprofen in the early stages of a sudden-onset muscle injury. Current consensus would be to avoid for the first 24 to 48 hours and then to use as required.

As pain settles one can cautiously return to activity, starting with low impact exercise such a static bike cycling, deep water walking and swimming. If this is well tolerated then progression to activity via a run-walk program, where the individual walks for a short period and then intermittently adds in a light jog as pain allows. If this is well tolerated then one can progress to increase the running speed and reducing the walking duration over several days/weeks.

At this stage the individual can gradually reintroduce sport-specific activity, i.e. passing drills and adding in higher speed/sprinting as pain allows. Ideally a physiotherapist can help guide return to play and assist with hamstring strengthening to prevent further injury in the future.

If there is significant bruising/swelling, high hamstring pain or sitting pain in an adolescent or if pain persists despite appropriate early rehabilitation advice with a physiotherapist then it would be beneficial to seek the advice of a Sports Doctor (Sport and Exercise Medicine consultant) who can make a full assessment, discuss likely injury severity and the need for early imaging and ongoing management.

Dr James Thing is a Consultant in Sports and Musculoskeletal Medicine at OneWelbeck Orthopaedics. He is an expert in the treatment of upper limb injury – including frozen shoulder, impingement, tennis elbow and osteoarthritis – as well as the treatment of lower limb tendon disorders such as Achilles, Patellar and ankle tendons and plantar fascia. To schedule a consultation with James, please call +44 (0)203 653 2002 or email bookings.orthopaedics@OneWelbeck.com.

FAQs

As more areas of the UK go into varying stages of COVID-19 restrictions we are being asked more and more to see patients remotely (via video feed) rather than face to face. This allows patients to access the medical care they need, but without the need to leave home.

Before 2020 this was a relatively unusual occurrence, used mainly for those travelling abroad, whereas now we are all becoming experts in this new way of working.

In this blog Dr Natasha Beach will answer the questions we commonly get asked on remote consultations.

What is a remote consultation?

This is where the consultation is done via phone/tablet/computer rather than you coming into OneWelbeck to be seen face to face.

How do I book an appointment?

This is done in the usual way – by contacting the secretary of the consultant directly or by contacting OneWelbeck on bookings.orthopaedics@OneWelbeck.com

How does the process work?

Once you have an appointment date and time, you will be sent a link by text message or email. At the time of your appointment click the link and you will be able to see and hear your consultant using your phone, tablet or computer.

It is worth trialling the link in advance of the consultation to check that you don’t need to download any software in order for the call to work.

Are they recognised by insurance companies?

Yes, they should be – all major insurance companies recognise the need for remote consultations at this time however its always worth checking with them that it is covered.

What about self-pay options?

Remote consultations are available to everyone, even those self-funding.

What do I need to wear for the consultation?

This depends on what you are being seen for. If the problem is regarding your knee for example, then shorts will allow us to see your knee and its movements more clearly on the camera.

Where is it best to do a remote consultation?

Try and pick a quiet space to reduce background noise and to give yourself some privacy. Your consultant may ask you to move around so having some room to do so would be helpful.

Is it possible to have a mix of face to face and remote consultations?

Yes absolutely. Face to face consultations are still continuing so remain an option for you at any point.

What happens if the consultant recommends any investigations eg MRI, blood tests etc?

The joy of remote consultations is that we can see patients from anywhere around the UK without the need for travel. Equally we can refer patients to any private hospital (insurance provider permitting) for tests and investigations if needed. Just because your consultant is in central London, doesn’t mean you need to travel there.

Once you have had your tests, the results will be sent to the consultant who can then go through them remotely (or face to face) with you.

Are there any disadvantages to remote consultations?

Remote will never be a like for like substitute to normal consultations as there are limitations to how much of an examination that can be performed. However, all consultants have been doing this for many months now and have developed their own ways to get the most out of the consultation so this should not be a reason to discount remote as an option for you.

Top 5 tips to getting the most out of your consultation

• Test the computer link before hand
• Check your camera is on and that you are not on mute
• Turn the lights on so we can see you more clearly
• Come dressed so we can see the relevant body part without you needing to get changed
• Pick somewhere quiet with space to move around in.

Why does shin pain happen?

Like most things there is rarely one single factor leading to pain developing.

Some of the most common triggers include:

• Increasingly mileage or over training
• Hill running
• Running on a camber or on a hard surface
• Shoes past their use-by date or without the right support for your foot type
• Muscle imbalances/tightness
• Stiff ankle/knee joints
• Hypermobility
• Low bone density

What are ‘shin splints’?

‘Shin splints’ is not a diagnosis – it’s a description commonly used to describe the feeling of pain at the front of the shin. Investigations are needed to work out what the specific cause of the pain is.

MTSS/Bone Bruising/Stress Fractures

MTSS, (or Medial Tibial Stress Syndrome to use its full title) results in the feeling of pain in the lower part of the inside of tibia which is thought to be as a result of overloading this area of the leg.

Further loading (e.g. continuing running) can lead to the development of bone bruising and if this continues a stress fracture can form.

What about radicular and referred pain?

While pain may be felt in the shin, it could be coming from elsewhere. For example, a number of different nerves within the lower back can each cause pain within the shin if they are trapped or restricted (this is known as radicular pain) and this isn’t always associated with back pain.

Equally the way the body is wired can sometimes lead to confusing messages, with pain being felt in the shin which is actually coming from somewhere else such as the knee or the ankle.

How is the diagnosis made?

This depends on the diagnosis and the reasons behind it developing in the first place. Generally, patients are referred for a period of rehab with a physiotherapist or osteopath with an interest in lower leg injuries. A review from a podiatrist may also be recommended and this could result in a change in trainers or the addition of orthotics.

Those with stress fractures will likely be placed in a boot and or crutches to allow the fracture time to heal, and this will be accompanied by additional tests to look at bone density (DEXA scan) and bloods tests too look for contributing factors. Also, for some people, a review by a dietician may be useful to optimise the patients diet for an optimum recovery.

Will pain return?

For the majority of people, the pain should slowly disappear during the rehab process, however some people may notice a reoccurrence in ether leg in the future.  In this instance the patient should be re-reviewed to identify the trigger so that the symptoms can be dealt with quickly.

Find out more

To find out more about shin pain, contact Dr Natasha Beach (Sports Medicine and MSK Consultant) at natasha.beach@onewelbeck.com