Shoulder injuries decimate team lists ahead of the Rugby World Cup

rugby shoulder injuriesThe Rugby World Cup may be a year away, but some of the sport’s biggest stars are already out of the tournament. Ireland’s Garry Ringrose, New Zealand’s Nehe Milner-Skudder, South Africa’s Jaco Kriel and Australia’s Izack Rodda, have all been impacted by shoulder injury which sees them potentially missing out on World Cup glory.

Rugby is renowned for its increased risk of shoulder injuries, but the incidence rate appears to have increased in recent years. Not only are rugby-related shoulder injuries becoming more commonplace, but their severity is also increasing too. Here, we’ll explore the type of shoulder injuries common in rugby players and what could be done to prevent them.

Which types of shoulder injuries are rugby players commonly exposed to?

There are a lot of different types of shoulder injuries rugby players are exposed to. However, the most common appear to be:

Labral tears – Out of all of the different shoulder injuries rugby players face, labral tears are one of the most common. The Labrum is incredibly important for proper shoulder function. The cartilage basically provides additional support for the bones within the shoulder. If it tears, it can have a significant impact on the shoulder movement.

In rugby players, a labral tear can occur due to an awkward fall, dislocation, direct impact, or overuse of the shoulder. It’s a painful injury, with the pain worsening when the arm is lowered or raised. Some patients may also hear a popping sound alongside movement of the shoulder.

Rotator cuff injuries – Another common injury, the rotator cuff can become damaged during rugby tackles, or due to an awkward fall. It’s typically injured when the player lands with their arm extended, causing pressure to push the arm too far backwards or downwards.

There are different grades of rotator cuff injuries, with full tears of the tendon being the least common, but most severe a player could face. These types of injuries are also more difficult to treat.

Shoulder instability – Players can develop shoulder instability due to overuse or a sudden injury. With this condition, the upper arm bone is forced out of the shoulder’s socket at the head.

While shoulder instability is most commonly associated with overhead sports, it can occur gradually in rugby players; particularly if they have suffered previous dislocation of the shoulder.

What could be done to prevent shoulder injury in the rugby player?

There are a number of ways rugby players can reduce their chances of suffering shoulder-related injuries.

Firstly, building up strength and flexibility within the upper body will help protect the joints. The more flexible the shoulder joint is, the less likely it will become damaged during a bad fall or direct impact. To prevent injuries caused by overuse of the shoulder, it is important for players to adequately rest between training and matches.

Although it is possible to prevent some rugby-related shoulder injuries, in direct contact sports there is always an increased risk. If you do develop a shoulder injury, the best thing you can do is seek treatment as soon as possible. Problems arise and careers are ruined, when players do not seek immediate treatment. The longer a shoulder injury is left untreated, the worse it becomes and the higher the risk a player will have long-term shoulder issues.

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Optimising Outcomes From Shoulder Arthroplasty in York

downloadLondon Shoulder Specialist member Mr Steven Corbett is attending the British Shoulder and Elbow Society meeting tomorrow on optimising outcomes from shoulder arthroplasty. Held in York, this is the annual meeting of BESS working groups dedicated to driving standardisation in shoulder and elbow arthroplasty, particularly in relation to optimising outcomes for patients.

There will be presentations in implants, procedure techniques, peri-operative care pathways, physiotherapy provision and developing national guidelines for managing joint infections. Mr Corbett is working with colleagues on an approved management care pathway for infected shoulder replacements.

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London Shoulder Specialists at the Fortius International Sports Injury Conference

This week, the Fortius Clinic hosts FISIC ’17, a multidisciplinary sports conference covering sports injuries ‘from start to finish’. Aimed at orthopaedic surgeons, sports physicians, physiotherapists and other healthcare professionals with an interest in sport, at all levels, it takes place at The Queen Elizabeth II Conference Centre in Westminster, London, on 27th to 28th September.

FISIC ’17 has been awarded 12 CPD points from the BOA, 15 points from the RCP and 12 points from the RCR.Members of the London Shoulder Specialist team are on the faculty for the event, covering a number of different sessions.

Mr Andrew Wallace is chair of a session on upper limb throwing injuries on Wednesday and one on progression from shoulder instability to stiffness on Thursday. In the Wednesday session, fellow colleague Ms Susan Alexander will cover throwing injuries shoulder pathology in relation to the SLAP and biceps.

Also on Wednesday, two of the LSS team will be presenting on upper limb problems in the cyclist, chaired by Mr Steven Corbett. Mr Andy Richards will be discussing traumatic injuries of the clavicle and, then, Mr Corbett will present on ACJ dislocations. Then, Mr Richards will discuss forearm stiffness in the injured forearm session.

Thursday morning sees a session on sport after arthroplasty, drawing Fortius consultants from all disciplines. Mr Steven Corbett will focus on returning to sport after a total shoulder replacement (TSR).

A key session on the Thursday will focus on football and return to play at an elite level. Mr Andrew Wallace will be discussing contemporary management of shoulder injuries in elite football. He’ll also be reflecting on when to operate on a full thickness tear in the session focusing on the rotator cuff. The role of allograft reconstructions will also be featured in this session, presented by his colleague .

Two Stryker sponsored workshops on superior capsular reconstruction will also be presented by Mr Ali Narvani.

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Early Surgical Intervention in Rotator Cuff Tears Produce Long-Term Benefits

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A new French study has revealed the benefits of early surgical intervention in isolated rotator cuff tears. According to the study’s findings, if surgery is performed early enough for supraspinatus tears, it helps to improve function and strength, amongst numerous other benefits.

Here, we’ll look at the findings which have been published in The Journal of Bone & Joint Surgery and what it means for patients.

Can the findings be trusted?

The study was conducted by an Orthopaedic Surgery Research Group in France and it followed a total of 511 patients. However, only 288 patients went on to have a follow-up, leading some experts to question the results.

The 511 patients had undergone surgery to repair full thickness supraspinatus tears in 2003. Results of the study were written up at a 10-year follow-up appointment. Out of the 288 patients who did go back for a follow-up, 210 received a magnetic resonance imaging (MRI) scan. This revealed the majority of patients had experienced significant improvement.

The standard Constant score was used to assess shoulder strength, motion, pain and daily activity abilities. In the majority of patients, their score had risen from an average 52 to 78. The scans also revealed around 80% of the tendons had healed, but there was still a minor residual tear found in most cases.

The follow-up also revealed patients who were found to have a build-up of fat in the repaired muscle didn’t heal and recover as well as those who didn’t. Fat build-up within the muscle is a sign of muscle degeneration.

Although the researchers themselves do admit there are limitations of the study due to the fact so many patients didn’t return for a follow-up, they still feel it provides a reliable analysis of how surgery could help to improve the outcome of supraspinatus tears. It’s certainly the longest-term study carried out to assess the benefits of surgery in isolated rotator cuff tears.

What are supraspinatus tears?

There are four major tendons within the rotator cuff of the shoulder, and the supraspinatus is one of them. It is also the most common type of rotator cuff tear patients suffer with. A tear, either partial or full-thickness, can occur because of a trauma, or through repeated micro-traumas.

The majority of full-thickness supraspinatus tears, tend to start out as partial tears and they worsen over time. This backs up the results of the French study in the fact surgery should be carried out early to prevent the condition worsening.

What treatment options are available?

Treatment is decided based upon the severity of the tear. Surgery currently tends to be used as a last resort. Instead, specialists prefer to start out with a physical therapy treatment plan; especially if the tear is only minor. This is because in the past, surgery was known to come with long, often painful recovery times.

However, surgical techniques have advanced and as the French study shows, surgery could be the most effective treatment for early supraspinatus tears. One thing all experts can agree on is the earlier a patient seeks treatment for this type of rotator cuff tear, the better the outcome will be.

Overall, the study’s findings are promising and they do give a good indication of the long-term success rates of early surgery in supraspinatus tears. It also showed the success rate remains the same regardless of whether open or closed surgical techniques are used.

The Shoulder Symptoms You Shouldn’t Ignore

Shoulder problems are extremely common, yet they’re also often ignored. Although some find the issue resolves itself without intervention, the majority of shoulder injuries and conditions will worsen over time.

shoulder symptomsThe impact of musculoskeletal conditions on the economy cannot be underestimated MSKs are one of the primary causes of absenteeism and the UK has one of the highest rates in Europe. Statistics released from the Health and Safety Executive, found that in 2015/16 there were 3,138,000 working days lost due to Work Related Upper Limb Disorders, with workers in the construction industry and skilled trade occupations having significantly higher rates of upper limb disorders.

Here, we’ll look at some of the most common shoulder symptoms you shouldn’t ignore and why it’s important to seek a diagnosis as early as possible.

Common shoulder symptoms to watch out for

Many people underestimate the severity of shoulder symptoms and the effect it can have on their lives. The shoulder is the most mobile joint within the body, making it extremely vulnerable to injury. Symptoms which develop within the shoulder can pinpoint to a number of injuries which is why they need to be checked out as quickly as possible. The most common symptoms to watch out for include:

Pain: The most common shoulder symptom patients experience is pain. Unfortunately, it can link to a wide range of different injuries and conditions, making it difficult to diagnose a specific cause purely from this symptom alone. For example, it could be a sign of a rotator cuff tear, shoulder instability, arthritis or a dislocation.

It is common for patients to put shoulder pain down to overusing the arm, misalignment while sleeping or as a temporary symptom brought on by injury. However, pain in the shoulder should never be ignored, especially if it is severe or brought on due to injury.

Stiffness: Shoulder stiffness is another common symptom often ignored and, like pain, it can be a sign of a more serious issue. Frozen shoulder is a common cause of stiffness within the shoulder joint and it is often mistaken for arthritis. If the condition is behind the stiffness you’re experiencing, you will notice it becoming gradually stiffer and more painful over time.

Stiffness can also be a sign of a dislocated shoulder, a shoulder separation or rotator cuff calcific tendonitis, amongst others.

Swelling: You may notice swelling directly after an injury, or it may develop gradually over time. It can also present itself either on the top of the shoulder or all over. Again, this symptom will typically be accompanied by pain and though it may go down on its own, swelling could pinpoint a more serious injury.

Weakness: If you’re struggling to move the arm or carry out daily tasks due to weakness in the shoulder, this absolutely shouldn’t be ignored. It could be a sign of shoulder impingement, a rotator cuff injury, or shoulder instability.

Locking: This is another potential symptom of shoulder instability. If you notice the joint popping, clicking or locking as you move the arm, you should get it checked out as soon as possible.

The above are the main symptoms to watch out for, but any issues you have with the shoulder should always be looked at by a doctor or a shoulder specialist. If these symptoms relate to a shoulder injury, the earlier you seek treatment the more likely it is to respond to conservative management.

Overall, if you’ve been experiencing pain, stiffness or numbness in the shoulder, it’s important to get it looked at as soon as possible. Never ignore shoulder symptoms, especially if the pain is becoming increasingly worse.

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Awake shoulder surgery – it’s not as ‘new’ as you might think!

Recently, we read with interest a news story featured in the Evening Standard about a “pioneering initiative” known as awake surgery.

Referred to as a groundbreaking treatment option, it highlighted the benefits of patients undergoing shoulder and elbow surgery under new ‘awake’ regional anaesthesia. The newspaper claimed that a shoulder and elbow surgeon at a London hospital was one of the first to offer this innovative technique on upper limb injuries, having carried out 50 of these cases over the last year.

While it’s true that awake surgery does deliver some benefits over surgery carried out under general anaesthetic, there were a couple of significant errors in this news story. This isn’t a new technique and it is used routinely in orthopaedic operations. Our shoulder specialists have been carrying out awake regional anaesthetic procedures for over 15 years, equating to approximately 3,000 cases.

And, for some patients, a general anaesthetic combined with regional anaesthetic techniques to ensure optimal pain relief and earlier mobilisation will always be the preferred option.

Below, you’ll discover everything you need to know about the awake surgery technique, its benefits and the importance of choosing a reliable, highly experienced surgeon.

What is awake shoulder surgery?

Awake shoulder surgery enables the patient to stay awake throughout the procedure. However, most patients choose to be sedated to some degree.

An anaesthetist will inject medication near the nerves surrounding the shoulder and the surrounding area. This will numb the area where the surgery will be performed. It takes approximately 30 minutes for the anaesthesia to be injected and take effect.

The types of awake surgical procedures vary and will be selected based upon the injury being treated.

Benefits of awake shoulder surgery procedures

So, why are awake regional anaesthetic procedures being described as a pioneering technique? Some patients can suffer from side effects from general anaesthesia, such as nausea and dizziness, and, if patients have suffered from these side effects in the past, then these can be mitigated with awake sedation techniques.

In general, though, a general anaesthetic is very safe and well-tolerated and for many patients, shoulder surgery performed under a general anaesthetic augmented with a regional block can be the best option, depending on the patient’s health and fitness and whether major surgery of a much longer duration is required. Both patient and surgical factors will be taken into account in the pre-operative planning stage.

The biggest benefit of awake surgery is a faster recovery time from the anaesthesia, however most shoulder operations are relatively short in duration, hence even with a general anaesthetic combined with a regional block, most patients are able to go home the same day. Whilst some people like to watch their own surgery, for others, this is not so desirable!

The importance of choosing an experienced surgeon

As you can see, there are plenty of excellent benefits that come from undergoing awake regional surgery. However, to enjoy these benefits it’s important to choose an experienced surgeon who has been performing this type of operation for many years and can advise on the best option for you.

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Will new T20 competition increase pressure on cricketers and increase injury risk?

cricket shoulder injuriesA new T20 competition is set to provide the biggest overhaul in English cricket since the sport was started. The city-based competition is said to be due to launch as early as next year and is designed to rival the Big Bash and IPL.

The proposal submitted by officials of the England & Wales cricket board, has taken months to prepare. If it gets given the go-ahead, new teams will be able to take part in the tournament and the matches will be sold to broadcasters with an estimated one match each week being broadcast on terrestrial TV.

However, could this new tournament increase pressure on cricketers and in turn increase their risk of injury?

Some studies show Twenty20 cricket does not increase injury risk

A study was actually carried out on Australian cricketers who partake in the Twenty20 competition back in 2010. Interestingly, it showed that players taking part in the competition were less likely to develop an injury than those partaking in other types of cricket games.

It measured the injury rate of players based on 1000 days of play. Around 145 injuries occurred in domestic based Twenty20 cricket. When compared to the 219 injuries suffered by those playing in domestic one-day cricket, you quickly see that Twenty20 provides a much lower risk.

Of course, that isn’t to say there is no risk involved. What studies have found is that fast bowlers taking part in Twenty20 cricket are at the biggest risk of developing shoulder-related injuries.

Increased competition puts pressure on fast bowlers

A study has found fast bowlers in cricket are at an increased risk of injury when their workload is increased. So, those taking part in T20 cricket could find themselves susceptible to shoulder injury. During the study, data was collected from a total of 28 fast bowlers. They had bowled for 43 seasons, over a period of six years.

The results of this study are unsurprising. After all, fast bowlers use more strenuous shoulder motions to deliver balls at high speeds. This, combined with a more frequent work schedule is going to increase the likelihood of injury pretty substantially.

If the T20 competition is approved, coaches can decrease the risk of injury by rotating their bowlers. It is also suggested that the rules of the game should be altered to reduce the severity of injuries if they do occur.

Overall, introducing this new competition in England could help to further give the game a boost and increase the amount of money made by teams. There is talk of new grounds being built at sites such as the Olympic Stadium, where fans would be able to purchase tickets for the games. However, it is important for coaches to take the increased risk of injury seriously. Cricketers are renowned for developing shoulder-related injuries and increasing the number of times they play is only set to make the risk even greater.

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Understanding SLAP tears

londonshoulderspecialistsAfter appearing in just two games for Sussex, Bangladesh fast bowler Mustafizur Rahman’s England cricket season came to a premature end in July with a shoulder injury that saw him undergoing surgery last month with Mr Andrew Wallace of the London Shoulder Specialists at Fortius Clinic to treat a SLAP tear.

SLAP tears are diagnosed when the top part of the labrum becomes torn due to injury. Responsible for stabilising the shoulder, the labrum is made up of strong tissue which runs in a ring around the shoulder’s socket. SLAP is an abbreviation for Superior Labrum, Anterior to Posterior, and refers to the area of the shoulder that’s been injured.

There are actually various types of SLAP tears a patient can experience, all relating to the severity of the tear. It’s most common in those who play contact or overhead sports and is therefore a common injury suffered by fast bowlers like Rahman.

Understanding the different types of SLAP tears

When a SLAP tear is diagnosed, it is classified as a specific type:

Type 1: A partial tear, including degeneration of the superior labrum. The edges of the free margin are frayed and rough, but the actual labrum itself is still attached. Treatment typically includes cleaning the edges, a process known as ‘debride’.

Type 2: Diagnosed when the labrum has totally come away from the glenoid, this is the most common type of SLAP tear. It tends to occur after an injury such as dislocation and a gap is left between the labral attachment and articular cartilage.

These types of tears are also commonly broken down into sub-categories such as posterior, anterior and a combined posterior/anterior tear. To treat it, the labrum will need to be reattached via keyhole surgery. The slap repair is carried out arthroscopically with suture anchors.

Type 3: In some cases, the tear in the labrum causes it to hang down into the joint, causing it to frequently pop and lock. Treatment is similar to a type 2 tear, using the same keyhole surgery technique. The only difference is the hanging section of the labrum, commonly referred to as a bucket-handle tear, is eliminated before the remaining labrum is repaired.

Type 4: A severe tear which extends within the long head of the biceps tendon. SLAP repair surgery will need to be carried out to reattach the labrum, as well as potentially repair the tear in the biceps.

How do I know I have a SLAP tear?

The first sign of a SLAP tear is pain, ranging in severity, throughout the top section of the shoulder. This will largely present itself when you’re performing overhead activities. Mustafizur Rahman noticed his SLAP tear after his second game of the season, experiencing significant pain when bowling.

The pain experienced is sometimes assumed to be associated with AC joint issues. A good way to establish whether you’re experiencing a SLAP tear or AC joint issue is to do a bench press. If you experience a lot of pain while going down into the press, it’s a SLAP tear. AC joint issues commonly cause more pain as you press out of the bench press.

As well as pain, clicking is another common symptom, along with weakness in the shoulder. You may also feel like the shoulder is going to pop out of place and there could be a deceased range of motion.

Depending on the type of tear and how it is affecting you – whether that’s your performance as a top-flight cricketer or your ability to discharge day-to-day activities – the London Shoulder Specialists can offer a range of non-surgical and surgical treatments.

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Living with shoulder instability: management and treatment

shoulder instability treatmentYour shoulder provides a much wider range of motion than any other joint in your body. However, this also makes it much more likely to suffer from instability. The cause of this painful condition varies between old and younger patients.

Whatever the cause, successful treatment often relies upon early detection. Here, we’ll look at how shoulder instability is typically managed and treated.

Shoulder instability treatment

There are several treatment options which can be used to treat shoulder instability. Patients who have never suffered a dislocation of the shoulder joint, will typically find physical therapy offers the best course of treatment.

  • Regular physical therapy sessions will focus on strengthening up the girdle; providing stability to the joint. In addition, electrical and ultrasound stimulation, along with massage can also be used to minimise the pain.
  • Placing ice over the affected area twice daily will also help to reduce pain and limit inflammation. In severe cases, the patient may also be given corticosteroid injections to manage the pain and inflammation.
  • If the shoulder has become dislocated, physical therapy alone will not always be enough to repair the problem. Just one dislocation could be treated without the need for surgery, but if multiple dislocations are identified, an arthroscopy may be needed.
  • The arthroscopy can usually be done as an outpatient procedure. It’s minimally invasive and has shown great success in the treatment of shoulder instability.

It’s worth pointing out, treatment can vary depending upon the age of the patient. Below you’ll discover more about age-related treatment options.

Shoulder instability treatment for older patients

The majority of older patients who present with shoulder instability, have developed the condition after a fall or traumatic incident.

If a patient is over the age of 40, treatment will usually be done non-operatively. A sling will need to be worn, ensuring the joint is immobilised for a set time period. This gives it plenty of time to heal. Once it has been rested, usually within a couple of weeks, physiotherapy will be used to help the patient regain motion and strengthen the shoulder joint to prevent future injury.

Interestingly, the re-occurrence rate of shoulder instability in older patients is very low. A full recovery is also expected within three to six months.

Shoulder instability treatment for younger patients

Younger patients are generally more prone to shoulder instability issues; particularly young athletes. In sports which require frequent overarm movements such as tennis, there’s an especially high chance of shoulder instability.

If the shoulder is dislocated, it is likely to end with future instability in the joint. It’s estimated that 80% of young patients who experience a dislocation, go on to experience recurring instability issues.

Treatment will very much depend upon the severity of the instability. If the shoulder has been dislocated fully, it will need to be reset. However, it’s worth noting that this doesn’t treat the actual instability issue.

The instability is most commonly treated with physiotherapy to start. To address the pain, anti-inflammatory medications may also be prescribed. If very little improvement is seen after physiotherapy, surgery may be the only other option.

Overall, shoulder instability can be treated, though the method and recovery period will depend upon several factors, including the age of the patient. As with any shoulder injury, the earlier instability is detected and managed, the easier it will be to treat.

All strenuous physical activities should be stopped until the shoulder is strengthened and the pain is gone.

London Shoulder Specialist Ms Susan Alexander of the Fortius Clinic reiterated in a recent presentation on shoulder instability “the importance of a close working relationship, with good, open and regular communication between surgeon, physiotherapist and general practitioner to optimise the treatment of this complex condition.

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Frozen shoulder: the symptoms and solutions

It is estimated that one in 20 adults in the UK will suffer a painful shoulder condition at some point in their lifetime. One problem that people can develop is frozen shoulder, which is medically known as adhesive capsulitis. The condition can be confused with arthritis or other shoulder problems such as bursitis. Below, you’ll discover how to spot the signs of frozen shoulder and what solutions are available.

What is frozen shoulder?

Frozen shoulder occurs when the articular shoulder capsule – the lining that surrounds the shoulder joint – shrinks and stiffens. It’s a very painful condition that can affect sleep, reduces mobility and makes everyday tasks extremely difficult such as reaching for something or even just getting dressed. It usually affects just one shoulder at a time, but in some cases, both shoulder joints can be affected. If one shoulder does develop the problem, then there is a 20% chance that at some time point the other shoulder will develop the same problem.

The good news is that for most patients the condition is self-limiting and it will get better. The bad news is that it can take 18 to 24 months to completely resolve, and, in some cases, it can persist for even longer.

The exact nature of the problem is till under investigation.

Who is at risk of developing frozen shoulder?

Frozen shoulder most commonly affects those between the ages of 40 and 60 and women are more likely to suffer than men. Whilst in many cases there is no obvious cause,  some people are more susceptible to the condition, such as those with diabetes, Dupytrens disease, Parkinson’s or possibly thyroid problems. Additionally, patients who have had a stroke or immobility caused by an injury or previous surgery can be at increased risk.

Studies suggest frozen shoulder in diabetics is brought on by collagen glycosylation in the shoulder joint caused by high blood sugar. Those who are insulin dependent have also shown to be six times more likely to develop shoulder issues than others.

What are the signs of frozen shoulder?

Most cases of frozen shoulder follow a pattern, with symptoms worsening and then resolving within an 18 to 24 month period. Typically, the stages of frozen shoulder are classified as freezing, frozen and thawing.

Stage 1: Freezing

This is the painful stage and the sufferer starts to notice discomfort and the shoulder gradually tightening, limiting mobility. This can occur over a period of weeks but the pain is such that there will be significant night pain causing sleep disturbance. Discomfort and pain may also be experienced simply at rest. When the limits of movement are reached, again the shoulder is very painful. This period can last for six months or more.

Stage 2: Frozen

In this stage, whilst there is still some pain, this generally improves. However, the shoulder remains very stiff. making it difficult to carry out everyday tasks. Again this period can last for over six months.

Stage 3: Thawing

In this final stage, the movement in the shoulder gradually returns and any residual pain dissipates. It is unusual but not impossible to develop the same problem again in the same shoulder.

How is frozen shoulder diagnosed?

London Shoulder Specialists diagnose frozen shoulder by assessing the level of pain experienced and the range of motion present within the joint. An X-ray is likely to be requested to check whether there are any other issues in the shoulder which could be causing the pain and stiffness. Occasionally we may carry out an MRI to establish the full extent of the damage caused to the soft tissue surrounding the joint. An alternative might be to perform an Ultrasound scan.

What are the treatment options for frozen shoulder?

Once diagnosed with frozen shoulder, there are numerous treatment options available aimed at relieving pain and increasing or preserving mobility and flexibility in the shoulder. A recent web survey carried out in the Netherlands and Belgium, revealed shoulder specialists most commonly opt for non-steroid anti-inflammatory drugs along with intra-articular corticosteroid injections to treat the first stage of the condition. This can be very helpful in reducing the significantly debilitating pain symptoms, particularly those experienced at night. Usually, injections are limited to 1 – 2 episodes and sometimes the cortisone is combined with water (saline) to try to expand the capsule (hydrodilatation).

If the pain persists or if stiffness remains significant following injection, then an arthroscopy (keyhole surgery) can be considered, whereby a camera is put into the shoulder and the tight, thickened capsule is released. This technique has largely superseded manipulation of the shoulder under a general anaesthetic.

The role of physiotherapy in the first stage of the condition is slightly controversial, but there seems to be no question that it is beneficial in the second and third stages of the disease.

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