Frozen Shoulder in Athletes

Frozen Shoulder in Athletes

An all-too-common malaise that is faced by many athletes is the pain of a frozen shoulder. This injury is often experienced following excessive use of the arm and shoulder during workouts and/or during competition or may even simply arise suddenly with little indication as to how the injury occurred.

 

What Is Frozen Shoulder?

Frozen shoulder is the gradual development of stiffness and pain in and around the shoulder joint area. This stiffness and pain are caused by the inflammation of the joint capsule of the shoulder. 

Frozen shoulder pain is often felt when rotating the shoulder joint or moving one’s arm away from the body. This pain causes limited reaching of the arms above the head or to the side. 

The initial stiffness and pain of a frozen shoulder often lead to the patient reducing shoulder movement, which in turn causes contraction of the joint capsule and decreased elasticity. As the joint capsule shrinks, it diminishes the protective lubricating fluid (synovial fluid) that is present between the upper arm bone (the humerus) and the joint capsule.

As the condition progresses, this joint capsule thickens, becomes inflamed and eventually inelastic. This results in the formation of thick bands of scar tissue forming between the joint capsule and the head of the humerus. 

These bands of scar tissue are referred to as adhesions and are the reason for the medical term for frozen shoulder – Adhesive Capsulitis (AC). 

 

Who Is at Risk of Developing Frozen Shoulder?

Frozen shoulder is predominantly felt by women (4 times more often) between the ages of 40 – 70. People with vascular diseases, diabetes, cancer, and Parkinson’s Disease are also at higher risk. 

It’s important to note here that people with diabetes are at a significantly higher risk compared to the other diseases. This is thought to be because diabetics have an increased formation of collagen due to having a high blood sugar level. This excess collagen goes on to form more numerous and thicker adhesions that are responsible for frozen shoulder.

Individuals who have bad posture or are immobile for long periods due to fractures, broken bones or other sports-related injuries are also at greater risk of developing frozen shoulder.

However, this does not mean that young people, including male athletes, are not at risk. It has been documented that athletes whose workout regime focuses on excessive pectoral (chest) and deltoid (shoulder) training can sometimes increase the risk of frozen shoulder. It is recommended to include periods of stretching before and after exercising to prevent damage to these muscles and the development of a frozen shoulder.

Athletes who are most at risk of frozen shoulder are those who use these muscles the most. Athletes playing games or participating in activities such as tennis, ping-pong, badminton, squash, rock climbing, golf, baseball, volleyball, and swimming will find themselves at the greatest risk. Essentially, any activity that requires intense use of the upper body.

 

Can You Stop Frozen Shoulder From Progressing?

There are three different phases of frozen shoulder; the freezing phase, frozen phase, and thawing phase. It is possible to accelerate the transition from each phase, shorten the time spent in each, and even stop frozen shoulder from progressing if treated quickly and adequately.

 

The Freezing Phase (Stage One)

This is the primary stage whereby the shoulder begins to stiffen up or freeze, and pain is experienced upon movement of the arms and shoulder. Pain will continue to worsen during this phase as the shoulder gets more and more stiff. This phase can last anywhere between 2 to 9 months on average.

 

The Frozen Phase (Stage Two)

This is the intermediate stage when pain begins to teeter off, but stiffness continues to increase, and those suffering will find their range of movement reduced tremendously. This phase can last anywhere between 4 to 12 months on average.

 

The Thawing Phase (Stage Three)

This is the final stage and is the beginning of the healing process. Range of movement will improve, and there will be almost no pain at all. This phase can last anywhere between 12 to 42 months on average. 

A small percentage of people may not fully regain the complete range of movement of their shoulder even at the end of this phase.

 

What Treatments Are There for Frozen Shoulder?

There are various forms of treatments available to help stop frozen shoulder from progressing or relieve it more quickly. These treatments are in the form of oral medication, injections, home remedies and physiotherapy.

Doctors will typically prescribe anti-inflammatories, muscle relaxants, and pain killers in the form of tablets to be taken orally to help alleviate symptoms in an attempt to move through the freezing and frozen phases more quickly. 

Besides oral medication, one increasingly popular treatment is cortisone injections. Cortisone is an anti-inflammatory medication that reduces swelling and scarring. It has been found that this form of treatment is best administered during the early stages of the condition. 

Nerve Blocks are also another injection style treatment to relieve frozen shoulder. With these injections, a small injection of local anaesthetic above the spine of the scapula is made, and an infiltration of a long-acting local anaesthetic around the suprascapular nerve is given. 

The long-lasting anaesthetic is usually given in combination with cortisone to reduce the sensitivity of the nerve, thereby reducing pain. This is normally done only when other treatments have failed to provide relief. 

One home remedy that can help with the pain is applying an ice pack to the affected area for 10 -15 minutes several times a day. The cold from the ice pack slows the flow of blood, causing vasoconstriction, which relieves pain. 

The removal of the ice pack then causes vasodilation which is when the blood rushes back into the veins. The blood brings along essential chemicals to the injury site that help speed up the healing process.

Most athletes should be very familiar with physiotherapy as sports injuries are part and parcel of the job. Physiotherapy is almost always recommended together with any other treatments and ultimately will be what helps revitalise the joint capsule’s elasticity and regain the shoulder’s full range of motion. 

The journey to full recovery may be long and arduous, but it is the most effective form of treatment known for this ailment.  

 

What Happens if Frozen Shoulder Is Not Treated?

A frozen shoulder may go away on its own if left untreated, but it may also increase the risk of a permanent loss of a full range of motion after the thawing stage. It could also lead to other ailments developing, such as tendonitis and neck pain – which often may only be resolved with surgery. 

Capsular Release is a minimally invasive surgery whereby the tight capsular tissues surrounding the shoulder joint are cut and then cauterised. The surgery is performed under local or general anaesthetic. 

Recovery time varies, but one can expect to fully recover from 6 weeks to 3 months after the surgery. Doctors will generally recommend not exerting or using the shoulder to carry things or reach above the head for a minimum of 2 weeks.

 

What Movement or Activities Aggravate Frozen Shoulder?

Frozen Shoulder in Athletes

Contrary to what most might think, keeping your shoulder immobile will worsen your condition. This will increase the number of adhesions that form and extend the period by which your shoulder will hurt and be stiff. 

This also does not mean that you should expose the shoulder to pulling, jerky or jarring movements, as these kinds of motions can put extra stress on your tendons and lead to the development of tendonitis. 

The secret here is to find a balance.

 

What Are Some Exercises for Frozen Shoulder?

There are several different types of arm and shoulder exercises that can help increase your mobility and heal your frozen shoulder more quickly. 

These exercises range from various kinds of stretching movements that make use of the arms, shoulders, and elbows. As mentioned, physiotherapy is the best-known form of treatment for getting your shoulder unfrozen and back into shape in the fastest time possible. 

 

Cochin International Orthopaedic Summit 2021(CIOS 2021)— “Complications in Orthopaedics”

Date and Time: Oct 14 2021, 18.40 – 19.40

Dr Ruben Manohara has been invited to speak at Cochin International Orthopaedic Summit 2021. Where he will be part of the session – “Upper Limb Complication – Shoulder”. Dr Ruben Manohara will be giving two talks. They are:

  1. My Worst Case Around the Shoulder
  2. How to Avoid Complications in Clavicle Fracture Fixation

He is honoured to be part of the CIOS 2021 faculty and happy to contribute to the international orthopaedic community.

CIOS 2021 will feature an innovative combination of engaging interactions with international experts, cutting-edge surgical demonstrations, and instructional symposia that will offer live Q&A with premier faculty and renowned regional hosts about Complications in Orthopaedics from various branches of Orthopaedics. 

Fellow doctors can register for the Orthopaedic Summit via this link https://ciosonline.com/

 

Cochin International Orthopaedic Summit 2021, CIOS 2021, Dr Ruben Manohara, Shoulder Elbow Orthopaedic

Treatment Options For Massive Rotator Cuff Tears | PhysioActive Talk

Date and Time: April 30 2021, 12:30pm – 2:00pm
Guest Speaker: Dr Desmond Ong, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic

Dr Desmond Ong joined our partners at PhysioActive to discuss rotator cuff tears and how they are a common cause of shoulder pain.

Rotator cuff tears become more common with age and can rob many of their ability to do the things they enjoy and their independence in their golden years. Dr Desmond touched on how non-surgical treatment options can improve one’s pain.

Learn how to better care for patients suffering from rotator cuff tears and the various treatment options available and how each option brings its own set of benefits. For more information on rotator cuff tears and the respective treatment options go to https://sportsinortho.com/.

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options, Insight and Evidence

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Joint Preserving Options, Classic Transfers

The Reverse Total Shoulder Replacement | How Can It Help Your Patients?

Date and Time: Jan 6 2021, 12:45pm – 2:00pm
Guest Speaker: Dr Ruben Manohara, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic,

Dr Ruben Manohara was invited by EISAI to speak to over 65 fellow doctors on the reverse shoulder arthroplasty and how it is considered one of the most significant technological advancements in shoulder reconstructive surgery over the last 30 years.

It reliably decreases pain and improves function for patients with rotator cuff-deficient shoulders. Such has been the success of this procedure, that it has led to a rapid expansion of the indications, to include more complex elective and trauma cases. Initially used in the more elderly patients, there is an increasingly higher demand in active ‘young seniors’.

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

Subchondroplasty | An Alternative to Knee Replacement Surgery

Date and Time: 6 June 2019, 6.30pm
Venue: Peach Garden at Hotel Miramar
Guest Speaker: Dr Bernard Lee Chee Siang, Orthopaedic Surgeon at Sportsin Orthopaedic Clinic, Gleneagles Medical Centre

Dr Bernard Lee was invited as a Guest Speaker by Eplus Healthcare and Zimmer Biomet to give a talk about Subchondroplasty to a group of Orthopaedic Surgeons. He is one of three pioneer surgeons in Singapore who has been trained to perform this procedure.

Dr Bernard Lee, Eplus Healthcare, Subchondroplasty

Below are some of the main takeaways from his talk:

What is Subchondroplasty?

Dr Bernard Lee, Eplus Healthcare, Subchondroplasty

Subchondroplasty involves injecting a bone substitute into painful, damaged parts of an arthritic knee.

This surgical procedure can help patients with knee osteoarthritis. This has been shown to reduce knee pain and improve knee function significantly, without having to resort to joint replacement surgery.

70% of patients who underwent subchondroplasty avoided a total knee replacement for two years or more.

Radiologic Assessment before operation.

Your doctor may do X-rays and an MRI scan to assess the extent of your knee problem, and to determine if subchondroplasty is a good option for you.

Subchondroplasty has seen relatively good results in patients. It has helped some of them continue their lifestyle and work:  

Case-studies

1) A 67-year-old PE teacher was having severe knee pain and had difficulty climbing stairs and bringing his students for lessons.  Being an active person, he was not keen to undergo joint replacement surgery. After a few months of trying alternative forms of treatment, he underwent Subchondroplasty.  As the weeks passed, his pain improved, and he was able to continue working as a PE teacher. Currently, he is two years from his surgery, and his pain is almost completely gone.  He can still go for long walks every day and is still working as a PE teacher!

2) A lady in her early 50s was having knee pain due to knee arthritis that was aggravated by having to stand for long hours in her sales job.  After having tried other forms of treatment and supplements to no avail, she underwent Subchondroplasty. Now at two years after surgery, she only has occasional pain and can stand and walk for long durations at work without difficulty.

Subchondroplasty may not work for everyone.  However, it does provide an alternative to joint replacement surgery in certain patients.  Results will vary, and it is best that you discuss this option thoroughly with your Orthopaedic Surgeon.

For more information, please visit:

https://www.zimmerbiometcreativelab.com/zimmer/iframe_scp/index.html

http://subchondroplasty.com/patients.html

How to Prevent and Treat Osteoporosis?

Key Hole Surgery

Often when the topic of surgery comes up during the discussion with my patients, the question of how big will my scar be or how many stitches will there be comes up. The pleasant surprise will then commonly be that with current technology, many sports related joint injuries can be treated via small key holes now.

 

New Technology?

Truth is “Minimally Invasive (MIS)”, “Keyhole”, “Bandaid”, “Scope” surgery is not exactly that state of the art nowadays as it has been around for almost a century now and can safely be considered to be the mainstay treatment for most sports injuries.

 

Arthroscopic surgery has been reported since the 1910s but the technology and application greatly took off after the invention of fibre-optic cable when images can be projected into a television monitor. This saves us from having to struggle peering through a small peephole lens. This plus high definition lenses and monitors has made doing such procedures much clearer, easier and thus safer. Afterall, a surgeon should only operate on what he/she can see clearly.

 

So what exactly is KeyHole surgery.

KeyHole or Arthroscopic surgery is a type of orthopedic surgery that utilizes an instrument called an arthroscope which essentially is a lens connected via fibre-optic cable to a monitor. It is so called keyhole or minimally invasive as it can be performed requiring only small incisions, usually around around ¾ of a centimeter. These incisions are called portals. The word arthroscope is from the Greek words meaning “to look at joints.” The arthroscope is made up of a lens and a light source, and is connected to a video camera. The surgeon can view the inside of the joint directly through the arthroscope, or an image may be displayed on a monitor. This image gives the surgeon a clear view of the tissue inside the joint. The surgeon can then use other tiny instruments specially designed for arthroscopic surgery to perform necessary procedures. Arthroscopic surgery can be used as a diagnostic tool, or for therapeutic procedures ranging from easing the pain of arthritis patients to mending torn ligaments. This range from shoulder stabilization, rotator cuff repair, capsular release for frozen shoulder, acromioclavicular joint reconstruction (dislocation of the outermost part of the collar bone which many cyclist suffer from after a fall), tennis elbow release, knee meniscus debridement (clean up)/ repair, ligamentous (anterior and posterior cruciate) reconstruction, hip labral debridement repair. This is on top of the diagnostic arthroscopies we do for the joints and debridement of these joints.

 

Why KeyHole?

 

First I must quantify that although this technique is and can be used for many sports related injuries when all non operative options have been exhausted, it is not for every patient and every condition. In certain situations, trying to struggle through 4 to 5 small holes each around ¾ cm may cause more damage then just doing a simple mini-open procedure with a 3-4cm incision,

Nevertheless, extended exposure of joints during open surgery prolongs recovery and increases pain and risk of complications, such as infection and stiffness. Minimally invasive surgeries, in general, result in less pain and swelling after surgery than open techniques. As a result, arthroscopically treated patients tend to heal faster and begin rehabilitation earlier and, subsequently, return to normal activity and work sooner.

Technically, using a lens also allow surgeons to see certain parts of the joint that would otherwise be inaccessible through a limited mini-open incision as the lens can get into awkward corners of the joint easier.

Arthrocopic surgery has made some previously very long and arduous ones a lot more controlled and straightforward. This allow us to provide our patients a more predictable outcome in terms of results.

In some surgeries, arthroscopic techniques have become mainstays over open procedures like shoulder stabilization surgery, rotator cuff repair, acromioclavicular joint reconstructions, knee meniscus and ligamentous reconstruction. This is to an extend that the open surgery is only reserved for complex or revision (repeat) surgeries.

Another benefit of arthroscopy is that a lot of these procedures can be performed in an day surgery setting which can often reduce cost.

 

So what’s the down side?

As of all surgical procedures, there are risks. Like in all joint surgeries, risks include bleeding into the knee joint, damage to the cartilage, meniscus/labrum, or ligaments in the joint, blood clot in the leg (deep venous thrombosis), injury to a blood vessel or nerve, compartment syndrome when the fluid we use to pump into the joint to work (yes we work in an underwater environment) leaks into the calf area of the leg, infection in the joint and joint stiffness. Unique to arthroscopy, equipment failure accounted for a significant part of the complications. Arthroscopy is a technical procedure requiring a wide range of equipment (camera and monitor, surgical equipment, pump, tourniquet, etc.) that can malfunction or break during a procedure.

Conclusion

Arthroscopy, one of the greatest advances in orthopedic surgery in the 20th century, has been around for a almost a century. It offers a minimally invasive alternative to standard open surgical techniques, which often require extended incisions for adequate joint exposure to the extent that it has become the mainstay for many conditions. Decreased complications, pain, shorter recovery, and the resulting cost savings are proven advantages. Without a doubt, the advances of arthroscopic surgery will allow us to return our patients back to their peak performance a lot faster and with a lot less pain and fuss. With improvements in fibre-optics, lens and monitor technology, it will also allow surgeons to see clearer and as a result do better work for our patients, producing better results and allowing our patients not to have to live with their pain.

Common sports injuries faced by women

Disclaimer: This article first appeared in Shape Magazine as an Interview with Gleneagles

1. What are some of the most common sports injuries faced by women?

Women are increasing involved sports locally and the incidence of sports injury has increased as a result. Common injuries include those affecting the shoulders, elbows, wrists, back, hips, knees, foot and ankle. Different sports places increase stresses in different anatomical parts of the body and thus result in varying injuries. Sports injuries are broadly divided into 2 main groups

  • Traumatic injuries (sprains, muscle pulls, fractures, dislocations etc)
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc)

Even in running, looking at the scientific literature, we can see that women indeed do, on the whole, get injured more often than men do.  But the difference is not quite as drastic as popular wisdom might hold—a 2002 study of around two thousand patients at a Vancouver, Canada sports injury clinic found that women represented 54% of injuries, with men taking up the other 46%.  But among some specific injuries, women are at significantly higher risk such as Anterior Cruciate Ligament (ACL) Tears.

2. What musculoskeletal and biological makeup differences between both genders contributes to sports performance and injuries?

There are many factors that attribute to the differences in injuries between the genders. The main reasons include

a. Anatomical Factors

Taking ACL injuries as an example: these factors include pelvis width, Q-angle (the angle between a line connecting a point on the front of the hip bone and the center of the kneecap and another connecting the kneecap and a point on the upper shin-bone), size of the ACL, and size of the intercondylar notch (where the ACL crosses the knee joint). Larger pelvis width, Q angle, smaller ACLs and a smaller intercondylar notch places females at a higher risk.

*  – Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;
    – an increased Q angle is a risk factor for patellar subluxation;
    – normally Q angle is 14 deg for males and 17 deg for females;
           – Agliettis et. al. Clin. Ortho 1983:
           – 75 normal males:    Q angle = 14 deg (+/- 3)
           – 75 normal females: Q angle = 17 deg (+/- 3)
    – biomechanics of patellofemoral joint are effected by patellar tendon length & the Q angle;

b. Biomechanical/ Neuromuscular factors

Women have been found to have differences in biomechanic movements of the knee seen when pivoting, jumping, and landing — activities that often lead to an ACL injury. There is also a relatively greater imbalance between quadriceps and hamstring muscles (with the quads being stronger in females), which can contribute to knee injuries.

c. Training/ Conditioning factors (doll games vs ball games)

Until recent years, males are involved training actively for competitive sports at an early age compared to females. As such they are physically better conditioned to withstand sports injuries. Hence, boys being involved in ball games as compared to girls being involved in doll games at an earlier age. Nevertheless, the combination of the greater susceptibility and a 10-fold increase in the female sports population since the inception of Title IX in the United States has resulted in a dramatic increase in the number of ACL injuries in females. Locally, increased emphasis in sports and fitness has also allowed us to witness a large increased in the number of females involved in recreational and competitive sports and consequently an increase in the number of injured females.

d. Hormonal factors

Female sex hormones (i.e. oestrogen, progesterone and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and decrease neuromuscular performance and, thus, are a possible cause of decreases in both passive and active knee stability in female athletes.

3. Are there certain sports that put women more at risk of injuries than men?

In view of the factors that lead to an increased risk of certain sports injuries, high demand sports involving planting and cutting, jumping with a poor landing, stopping suddenly or changing directions quickly (Soccer, Volleyball, Skiing, Lacrosse, Football, netball etc) can put women at a higher risk of knee sports injuries compared to men. Extrapolating this to other injuries including the shoulder/elbow/hip/ foot and ankle, women may also be at a higher risk of sustaining certain injuries compared to their male counterpart. For shoulder injuries, the combination of not having strong shoulder muscles, including the rotator cuff and periscapular muscles, and having generally supporting tissues that are more lax can lead to instability in the shoulder.

4. What are some sports that put women at an advantage compared to men? How so?

There are some sports where flexibility may play a greater role such as gymnastics where women are at an advantage. Interestingly, women are at a lower risk of hamstring injuries compared to men in a National Collegiate Athletic Association’s (NCAA) Injury Surveillance System (ISS) regarding all hamstring strain and rupture injuries in male and female soccer players between 2004 and 2009. Men were significantly more likely to suffer a hamstring injury during the in-season than women. Men are also more likely to suffer recurrent hamstring injuries.

5. As a member of the medical panel for the upcoming BNP Paribas WTA Final Singapore presented by SC Global, do you foresee any common sports injuries that the professional women tennis players will likely encounter? Perhaps our humid weather and brand new court grounds may play a role in altering their performance?

Tennis injuries are also of 2 broad types:

  • Traumatic injuries (sprains, muscle pulls, fractures, etc) make up about 1/3 of injuries seen in tennis, depending on the age and activity level of the player. Most traumatic injuries occur in the lower extremity. They are not easily prevented, nor are they particularly related to tennis technique.
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc) comprise about 2/3 of injuries experienced by tennis players. Overuse injuries occur in all areas of the body, and may be related to technique or to alterations in the athlete’s musculoskeletal system.

Common injuries include tennis elbow, shoulder injuries such as rotator cuff tears, stress fractures, muscle strains, knee ligament strains/ tears, ankle sprains/ ligament tears and also back injuries.

Specific to ACL injuries, tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground. Clay courts seem to be a better option for ACL deficient players.

6. What are some common injuries faced by recreational female tennis players?

Similarly, tennis injuries will include both traumatic and overuse ones. However, we do see a larger number of overuse injuries in recreational players. One of the reasons can be because of less consistent technique and form.

7. How can those tennis-related injuries be treated, and avoided?

There are multiple causes for the overuse injuries in tennis, including the need to perform repetitive forceful motions and strokes, inadequate rest and recovery, incorrect tennis specific conditioning, acquired inflexibility, and strength weakness/imbalance. Each injury may have unique causes that must be evaluated to avoid repeated injury, suggest proper conditioning programs, and allow safe return to sport. Because many parts of the tennis player’s body experience high loads on a repetitive basis, the musculoskeletal system must be prepared to withstand these loads. Much research has shown that an athlete cannot just play a sport to get in maximum shape for that sport, so a tennis player’s training plan should include a structured conditioning program that includes more than just playing tennis. Conditioning for tennis requires the exercises to be specific for the demands of tennis, and to be performed in a periodized manner in order to balance the workout load between conditioning and practice/play. As such, the roles of off the court strength training, conditioning, pre-game warming up and post-game stretching are very important.

When injuries occur, depending on the type and severity of injury, a consultation with your doctor will be advised. After a thorough medical examination and appropriate investigations, your doctor can then advise an appropriate management plan which will often include rest, cold compression, pain killers, anti-inflammatory medications, physiotherapy and rehabilitation. Surgery will be considered in cases where non operative management is not suitable.

8. How can a women’s menstrual cycle affect her sports performance? Is there a best and worst time for sports, according to the menstrual cycle?

There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. This is postulated to be due to oestrogen and relaxin’s direct effect on collagen metabolism and behaviour.

Oestrogen levels reach their peak during the follicular phase of the menstrual cycle just before ovulation and remain elevated until just before menstruation.

The effect of oestrogen on bone and ligaments include:

  • Inhibition of bone cells that breakdown bone (osteoclasts)
  • Inhibition of the development of new cells that breakdown bone
  • Promotes the survival of cells that build bone (osteoblasts)
  • Promotes the production of collagen in connective tissue including ligaments

Relaxin is produced during pregnancy; and in non-pregnant females during the luteal phase (2nd half) of the cycle. It peaks within 14 days of ovulation.

Effects of relaxin include:

  • Inhibition of collagen production
  • Promotes collagen breakdown

Taking into account the effect of these hormones, you might expect that women would be more vulnerable to injury pre-menstrually or at the beginning of the period when the ligaments would appear to be at their loosest. However, studies have shown inconclusive results. There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. However, some have shown a greater than expected percentage of injury mid cycle where you would expect the tissues to be at their stiffest and thickest.

ACL Tears in Tennis players

Tennis players did not admit to significant impairment when performing the majority of tennis strokes such as forehand, backhand, volleys, and serves. The major limitation referred to was landing after hitting a smash. This task has often been perceived by ACL deficient subjects as being difficult to carry out with confidence.8 Many players from the study group referred avoiding the smash entirely.

Interesting information was obtained about displacement while playing tennis. Injured players did not have significant impairment in forward running such as in “serve and volley” or “reaching a drop shot” movements. This finding was in agreement with previous studies—for example, Czierniecki et al found that running in a straight line may not generate sufficient rotational torque to initiate rotational instability in the cruciate deficient knee.9 In contrast, ACL deficient players show major limitation when trying to “stop suddenly and change direction”.

This type of stressful deceleration creates high anterior loading on the tibiofemoral joint.10 Both external varus‐valgus and internal‐external rotation place increased load on the knee joint during cutting movements compared with normal running.11 Varus‐valgus and internal‐external rotational movements are believed to be responsible for increasing knee joint ligament risk of injury. External flexion loads, valgus and internal rotation during sidestepping all have the potential to increase ACL and medial collateral ligament load substantially.11 The ability of normal subjects to undertake deceleration tasks without ACL rupture or giving way of the knee is attributed to the coordinated interactions among the ligamentous and other soft tissue passive restraints, joint geometry and congruency, friction between cartilage surfaces, active muscular control, and tibiofemoral joint compressive forces.10 Approximately 86% of shear forces are considered to be restrained by the ACL12; however, in ACL deficient knees these loads must be restrained by the articulating surfaces and the surrounding soft tissues.10

Most ACL injuries are indirect in nature yet occur during contact sports. Tennis involves tremendous forces during cutting, pivoting, and sudden deceleration manoeuvres; nevertheless ACL injuries are less common in tennis than in contact sports.13,14 In this series, most injuries occurred during contact sports such as soccer or rugby, but the exact mechanism (direct v indirect) was not determined. Sallay et al13 hypothesised that a tennis player is not as likely to sustain an ACL injury because of the ability of the neuromuscular system to coordinate muscular function in anticipation of each movement, with little surprise effect. Many investigators have indicated that anticipating a movement can change reflex responses and postural adjustments to minimise forthcoming perturbation and maintain appropriate posture.

Besier et al15,16 were able to confirm previous hypotheses indicating that knee joint moments increase under unanticipated conditions compared with preplanned manoeuvres, primarily because of a large increase in varus‐valgus and internal‐external rotational moments under unanticipated conditions. It is believed that unanticipated movement alters the external moments applied to the knee by reducing the time to implement appropriate postural adjustment strategies. Tennis may cause a low incidence of indirect ACL injury owing to the absence of frequent complete twisting manoeuvres and high jumping, as well as enough time for the player to anticipate strokes, especially from the baseline.

ACL injured players described significant impairment of their recreational tennis performance compared to preinjury level. Results from the present study may support the need for surgical treatment for competitive tennis players with ACL deficiency. Further studies are needed to determine the true incidence of ACL injuries in tennis, to analyse tennis motion knee biomechanics, and to establish the degree of improvement in tennis ability after ACL reconstruction.

Tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground.11,17 Clay courts seem to be a better option for ACL deficient players.

Limitations of this study include problems associated with questionnaires, and shortcomings related to retrospective determination of the preinjury performance level.

In summary, complete rupture of the ACL is a debilitating injury that causes significant alteration of knee joint kinematics. Untreated patients have joint instability, chronic articular degeneration, and knee dysfunction. Tennis specific limitations related to complete isolated ACL rupture were clearly identified. Tennis players with an ACL deficient knee showed significant impairment of subjective sport performance, limitation in landing after smashing, limitation in stopping and changing direction, limitation when playing a three set singles match, and limitation in playing on a hard court surface compared with healthy controls.

Don’t Live with Shoulder Pain

Pain in the Arm 

“You know that feeling in your shoulder. It is a nagging ache and it goes down your deltoid. You cannot lie on your favorite side when you sleep and now you cannot rest well. You are starting to have problems with washing your hair and don’t even get started with putting on T-shirts and hanging up your clothes. This pain is affecting your swing/ stroke/bat. Come to think of it, it is getting to your other shoulder too.”

These are the common problems my patients with shoulder pain have to deal with on a daily basis. Three main issues bother such patients. Pain, Movement, Function which is a symptom translated from the pain and lack on motion.

The pain often radiates down the arm but stops short at the deltoid because the inflammation of the bursae (fluid filled sac) extends there. There is usually no numbness of the arm unlike a pinged neck nerve (cervical spine radiculopathy)

Functionally, the patient cannot raise the arm and thus is unable to wash his/her hair or face. The pain affect his/her sports performance. Often, the patient finds that he/she cannot follow through during the golf swing, have weaker strokes at the baseline or is having a weaker pitch.


Not everyone with Shoulder Pain is Frozen

The shoulder joint is a ball and socket joint. It is akin to golf ball on a golf tee (with the ball 3 times the size of tee) within a House.

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

Looking at the diagram, there is a Roof (Supraspinatus tendon), a Front door (Subscapularis tendon) and a Back door (Infraspinatus and Teres Minor). Above the Roof, there is a Tree Branch (Acromion Spur). One of the reasons why there is a tear is because the Tree Branch keeps hitting the Roof and makes a Hole in the Roof (Cuff Tear). With a Hole, it leaks when it Rains and that can be quite a Pain!!

The Golf Tee (glenoid) is pretty flat and there is a CUP made of material that looks like Young Coconut Flesh (Labrum). This deepens the golf tee and makes the shoulder joint a more congruent one.

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic, Biceps Tendon

There are three main common causes I see. These are:

  • Rotator cuff problems
  • Instability (labral problems)
  • Frozen shoulder

In my practice, Rotator Cuff problems outnumber instability 3:1 and Rotator Cuff problems outnumber frozen shoulder 4:1. Therein lies the necessity for a proper diagnosis. This is where a “completely new and innovative INVESTIGATION” technique becomes extremely important.

Let me introduce: a Proper History and Physical Examination

Even before we look into doing any scans, I believe that through a proper understanding of the patient’s problems and symptoms, finding out what exactly is affecting the patient, followed by a targeted physical examination looking for specific signs; a proper provisional diagnosis can be made. Using this knowledge, the X-rays and scans can then guide us like a satellite navigation map to decide what needs to be done for the patient. I believe that patients are the ones to be treated and not the scans.

 

Cuff problems

This is commonly also known as五十肩 (50 year old Shoulder), Urat bahu bengkak and commonly includes:

  • Impingement
  • Cuff Tendinosis
  • Cuff Tears which can be incomplete, complete or
  • Massive tear which can be Irreparable
  • Cuff tear Arthropathy (CTA)

Frozen shoulder

This is also known as Adhesive Capsulitis. As its name suggest, the shoulder is FROZEN. This means that the shoulder is stuck both actively (moves by its own power) and passively (moved by the other arm or someone else). It can be Primary (no one really knows why type) vs Secondary (caused by something else). Risk factors for Primary Frozen shoulder commonly include:

  • Endocrine causes (Diabetes Mellitus, Thyroid problems),
  • Neurological causes (Stroke)
  • Heart (Heart attack)
  • Secondary frozen shoulder can be due to shoulder fractures, Cuff issues or Labral issues too.
  • Labral Injuries

These often occur after an injury. Patients may have had a dislocation or a subluxation (partial dislocation) previously and the symptom of the shoulder being unstable is recurrent now. The labrum may tear at different areas and in additional to instability; patients may often complain of pain and may have painful clicks in the shoulder during certain movement. A proper examination will include looking for signs of instability, other types of labral tears and signs of generalised hyperlaxity (Loose jointed).


Don’t live with it!  

“See your doctor cos something can be done”

I cannot emphasize enough that a Proper History and Physical Examination leading to targeted Investigations will then bring about a Proper Diagnosis. This will include locating the source of pain, Range of Motion tests and Special tests. For labral injuries, we look out for Hyperlaxity Signs too. Thereafter, Xrays, Ultrasound and/or MRI/ CT scans are done and interpreted together with looking at the patient’s problems.

 

Get back your Swing

This will be based on the diagnosis and looking at what exactly is bothering the patient. (At Roland Shoulder & Orthopaedic Clinic, We Help Patients not Treat Scans)

Cuff problems

This depends on whether there is a hole in the roof or not and how big the hole is and if it is a complete hole.

If there is no hole, an incomplete hole or small hole, NON OPERATIVE management lasting for 3-6 months is often started. (There is nothing CONSERVATIVE about not operating)

This includes

  • Controlling Inflammation and pain – Analgesia (pain killers) and/or  NSAIDs (Non Steroidal Anti Inflammatory Drugs)
  • Subacromial (below the tree branch) Hydrocortisone & Lignocaine injections (I usually use 1% lignocaine with Triamcinolone)
  • Physiotherapy
    • Mobility Exercises
    • Strengthening of the
      • External and Internal Rotators

  Biceps

  Triceps

  Deltoid

  Scapular Stabilisers

For patients with Acute tears (occurring after an injury), Large Complete tears or patients that have failed non operative management, Surgery is offered. In my practice, a large majority of cuff problems which require surgery is done through Key Hole techniques now. This includes

  • Arthroscopic Subacromial Decompression and rotator cuff repair which is shaving down the offending tree branch above the roof and repairing the roof and/or repairing the front door too if that is torn.
  • Arthroscopic Mumford procedure (distal clavicle resection) if that is giving the patient problems .
  • Addressing the Biceps tendon (Tenotomy/Tenodesis) if that is giving patients problems .

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

A large majority of shoulder problems are treated using key hole (Arthroscopic) techniques as they are can usually produce equal results to open surgery. Patients often have less pain, a shorter hospital stay and the scars are cosmetically more pleasing.

 

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

However, this is not suitable for all cases and this depends of the condition and severity of the problem.

 

Frozen Shoulder

Primary Frozen shoulders follow a process of Freezing, Frozen and then Thawing. The thawing process can occasionally, unfortunately, last for a very long time of up to a year or 2. Seeing a doctor early will allow us to:

  • Ensure that the it is truly a Frozen shoulder. (again through a proper history/ physical examination/ appropriate scan/s)
  • Find out if it is cause by another shoulder problem (Secondary Frozen Shoulder)
  • Speed up the thawing process or if necessary, BREAK the ICE!

Speeding up the thawing process includes:

Non operative management of Glenohumeral H&L (injecting into the house itself), Physiotherapy, Medication like pain killers and anti-inflammatory medications. It is important to treat underlying issues if it is a secondary cause.

In my practice, if all else fails, I offer to break the ice but under direct vision. I kinda like to see what I intend to break. As such, I offer an Arthroscopic Capsular Release

 

Instability

For patients with labral injuries, if recurrent instability is the main problem, surgery should be considered early. This is because in younger patients, the risk of persistent instability is very high. With each dislocation, the risk of getting a large piece of the golf tee being broken off (Bony Bankart) or the golf ball being cored in (Hil sachs Lesion) becomes higher. As such, I offer Arthroscopic Shoulder Stabilisation (Keyhole stabilisation surgery) where the torn labrum can be repaired. This is for patients without a large piece of the golf tee that is broken off or a large part of the golf ball being cored. Unfortunately, if that happens, open procedures to restore the bone loss usually at the side of the golf tee may then be suitable.  

For some patients with a SLAP (Superior Labrum Anterior Posterior) tears (top part of the cup) or a posterior labral tear (back part of the cup), pain and clicking is the main problem. For patients with SLAP tear, I believe that a trial of non operative Management should first commence. This must include Scapular Stabilisation exercises so as to provide a stable platform for the shoulder joint to mobilise. Only if that fails, I will then offer surgery to address the SLAP tear. In patients with posterior labral injuries complaining of pain and clicks, ASS can be offered to repair the cup.

 

What if the Whole House is Damaged?

For patients with Cuff Tear Arthropathy (damage to the shoulder cartilage due to prolonged roof tendon tear) and usually for patients > 65years, the option of a joint replacement is offered. This is because with the cartilage being worn out, a repair or replacement of the roof tendons will not resolve the arthritis causing the pain. In patients with CTA, a Reverse Shoulder Arthroplasty (RSA) is usually offered.

 

Shoulder Pain, Living with Shoulder Pain, Shoulder Elbow Orthopaedic

This is a replacement surgery and it offers excellent pain relieve, a good functional Range of Motion of 140-150 degrees of forwards flexion. Patients can return to daily upper limb activities like comb/ wash hair, wash face, brush teeth after surgery.

 

In conclusion, you don’t have to live with your shoulder pain. Seek help early if the shoulder strain simply doesn’t go away after 2-3 weeks. A proper History and Physical Examination and Appropriate Investigations will usually lead to a Diagnosis and proper Treatment.