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Causes of shoulder pain and the Big Four
Written by: Professor Mohamed Imam

There are multiple joints and bones in the shoulder that connect with tendons and muscles to provide a wide range of motion in the arm. The tendons that keep the arm bone in the shoulder socket are called the rotator cuff, and this is where the range of motion comes from. However, problems may arise from such mobility. These problems may be temporary or continue and eventually require medical diagnosis and treatment. Professor Mohamad Imam,  specialising in upper limbs, talks about shoulder pain and ‘The Big Four’.


How is the cause of shoulder pain diagnosed?
Typically, the diagnosis of a certain shoulder condition is best made from a patient’s history, a clinical examination, and special imaging tests. All of these are used by doctors in conjunction with each other rather than individually to find the diagnosis.

What are the treatment options for shoulder pain?
The cause and the severity of the shoulder pain will determine the treatment. Physiotherapy, exercises, steroid injections, and/or surgery are some of the options to treat shoulder pain.

What are the Big Four?
Majority of shoulder issues fall into four major categories:

fracture (broken bone)
tendon inflammation (bursitis or tendinitis) or tendon tear
instability
arthritis
Other causes of shoulder pain include tumours, infection, nerve-related problem, injury from manual labour, playing sports, or simply from repetitive movement. Particular diseases involving the cervical spine (neck), liver, heart, or also the gall bladder can also cause pain that travels to the shoulder.

Shoulder fractures
Common shoulder fractures concern the clavicle (collarbone), humerus (upper arm bone), and scapula (shoulder blade) and present with swelling, deformity, bruising, loss of function, and severe pain. Elderly patients tend to fall from standing height and it is often the cause of a fractured shoulder. Alternatively, younger patients tend to get shoulder fractures from high energy injury, such as road traffic accidents or contact sports injuries.

Shoulder tendon pathologies
Bursitis: inflammation and swelling of the bursae, which are small, fluid-filled sacs acting as cushions between bones and soft tissue located in joints throughout the body.
Occasionally, excessive use of the shoulder causes bursitis between the rotator cuff and the acromion, a part of the shoulder blade. This condition is known as subacromial bursitis and is two-thirds of patients in outpatient clinics with shoulder pain.

Rotator cuff tendinitis often accompanies bursitis. With many tissues inflamed and painful, daily activities such as combing your hair or getting dressed may become difficult.

Impingement: when the acromion (top of the shoulder blade) puts pressure on soft tissue as the arm is lifted away from the body. When the arm raises, the acromion impinges on (rubs) the rotator cuff tendons and bursa. As a result, bursitis and tendinitis may occur, causing pain and limiting movement.

Tendinitis: A tendon is a what connects muscle to bone. Inflammation in the tendon is what usually causes one of two types tendinitis:
– acute—caused by exercises such as ball throwing or other overhead activities during work or sport
– chronic—caused by repetitive use due to age or degenerative diseases like arthritis

The four rotator cuff tendons and a biceps tendon are the ones most commonly affected in the shoulder. Your upper arm is kept in the shoulder socket by four small muscles and their tendons covering the head of your upper arm bone.

Tendon Tears: Acute injury or degenerative changes may cause splitting and tearing of tendons from reasons such as sudden injury, advancing age, long-term overuse and wear and tear. A tear can be partial or a complete separation from the bone. The most common of these injuries are rotator cuff and biceps tendon tears.
Shoulder instability
Shoulder instability occurs when the shoulder is dislocated or frozen.

A dislocation is when the head, or ball, of the upper arm bone is forced out of the shoulder socket partially (subluxation) or completely. Sudden injury or overuse may both cause shoulder instability.

Dislocations happen repeatedly after the ligaments, tendons, and muscles around the shoulder becomes loose or torn. When raising your arm or moving it away from your body, partial or complete recurring dislocations cause pain and unsteadiness. There is an increased risk of arthritis in the shoulder with repeated episodes.

Oppositely, frozen shoulder is when the range of motion is limited due to the capsule contracting. As a result, lifting your arm up actively will be a struggle; passive limitation of movement will also happen, where lifting your arm will not be possible even with help from your other arm or another person.


Shoulder arthritis
Many types of arthritis can cause shoulder pain.

Osteoarthritis, also known as degenerative arthritis, is the most common type and may be related to chronic wear and tear, sports injuries, or work injuries. It develops slowly and, over time, pain worsens. Symptoms include:

swelling
pain
stiffness, usually beginning during middle age
Other types of arthritis may be associated with joint lining inflammation, rotator cuff tears, or infection. To lessen arthritis pain, people tend to avoid shoulder movements. However, this can lead to painful motion restriction due to tightening or stiffening of the joint’s soft tissue parts.

When should you seek medical help?
Contact your doctor if you experience:

fever
inability to move your shoulder
lasting bruising
heat
tenderness around the joint
pain that persists beyond a few weeks of home treatment
If the shoulder pain is sudden and not associated with an injury, call help immediately, as this may be a sign of a heart attack.

Causes Of Shoulder Pain And The Big Four

Cubital tunnel syndrome
Written by: Professor Mohamed Imam

The elbow is an extremely fragile part of the human body and can become inflamed and severely swollen if not taken care of properly. Cubital tunnel syndrome is a condition that can affect the elbow and can occur quite frequently if we bang our elbow off firm objects. Here to talk us through the condition in more detail is experienced consultant orthopaedic surgeon, Professor Mohamed Imam.


What is cubital tunnel syndrome?
Cubital Tunnel Syndrome is a term used to describe Ulnar Nerve Entrapment at the elbow. Cubital tunnel syndrome occurs when the ulnar nerve, which passes through the cubital tunnel (a tunnel of muscle, ligament, and bone on the inside of the elbow) is injured and becomes inflamed, swollen, and irritated.

The cubital tunnel is the tunnel of tissue where the ulnar nerve travels under a bump of bone inside the elbow. This bony bump is called the medial epicondyle. The spot where the nerve runs under the medial epicondyle is commonly referred to as the funny bone. The nerve is close to your skin at the funny bone and bumping it against an object can tend to cause a shock-like feeling.

The ulnar nerve is one of the three primary nerves in the arm. It travels from the neck down into the hand and can be compressed in multiple places along the way, such as beneath the clavicle (collarbone) or at the wrist level. The most typical area for compression is behind the inside part of the elbow. Ulnar nerve compression at the elbow is called cubital tunnel syndrome.

What are the symptoms?
Patients usually present with dull aching pain on the inside of the elbow, with most symptoms occurring in the hands. These symptoms typically include tingling in the ring and little fingers, especially when the elbow is bent.

Some people wake up at night when their fingers are numb. Patients with cubital tunnel syndrome usually report the feeling of the ring and little fingers “falling asleep” especially when the elbow is bent.

Finally, if the nerve is compressed for a long period of time, you can develop severe muscle wasting in your hand. Once this happens, muscle wasting is irreversible. For this reason, it is essential to consult your physician if symptoms are severe or if they are less severe but have been present for more than six weeks.

What are the causes of cubital tunnel syndrome?
In most cases, the precise cause is unknown. We know that the ulnar nerve is especially vulnerable to compression at the elbow as it travels through a confined space with little soft tissue to protect it.

Several factors can cause pressure on the nerve at the elbow. Bending on your elbow for long periods can place tension on the nerve. When your bend your elbow, the ulnar nerve must stretch around the bony crest of the medial epicondyle.

Unfortunately, this stretching can irritate the nerve, and keeping your elbow flexed for long periods or repeatedly bending your elbow can cause painful symptoms. That is why when many people sleep with their elbows bent, they wake up at night with their fingers asleep. In some people, the nerve is unstable, and the nerve slides out from behind the medial epicondyle when the elbow is bent. Over time, this sliding back and forth may irritate the nerve.

Repetitive use of the elbow can cause fluid build-up in the elbow, ultimately leading to swelling that may compress the nerve. A straight blow to the elbow can produce pain, electric shock, and numbness in the little and ring fingers. 

Some other causes can put you at risk of exhibiting cubital tunnel syndrome. These include:

arthritis of the elbow
a hobby that involves repeated or prolonged activities that require the elbow to be bent or flexed
swelling of the elbow joint
previous injury of the elbow

How does it differ from carpal tunnel syndrome?
Carpal tunnel syndrome is a common condition that causes pain, numbness and tingling in the hand and arm. It occurs when one of the major nerves to the hand (the median nerve) is squeezed or compressed as it travels through the wrist.

Patients with carpal tunnel syndrome experience numbness, tingling, burning, and pain, primarily in the thumb and index, middle, and ring finger with occasional shock-like sensations that radiate to the thumb and index, middle, and ring fingers.

Are there any home remedies or exercises to help it? If so, what are they?
There are many things you can do at home to help relieve symptoms. The most helpful of home remedies include:

Avoid activities that require bending the arm for long periods.
When using a computer regularly, make sure that your chair is not too low and do not rest your elbow on the armrest.
Avoid leaning on the elbow or putting pressure on the inside of your arm. For example, do not drive with your arm resting on the open window.
Keep your elbow straight at night when you are sleeping by wrapping a towel around your straight elbow or wearing an elbow pad backwards.
How is cubital tunnel syndrome treated?
Unless your nerve compression has induced muscle wasting, your surgeon will most likely initially recommend non-surgical treatment.

If your symptoms have just started, your physician may suggest an anti-inflammatory medicine, such as ibuprofen, to help reduce swelling around the nerve. Although steroids, such as cortisone, are very effective anti-inflammatory medicines, steroid injections are generally not used because there is a risk of damage to the nerve.

To help the treatment process speed along nicely, your physician may also prescribe a padded brace or splint to wear at night to keep your elbow in a straight position. Some experts, meanwhile, believe exercises will help the ulnar nerve slide through the cubital tunnel at the elbow and the Guyon’s canal at the wrist. This is believed to ultimately improve symptoms. These exercises may also help prevent stiffness in the arm and wrist. 

Surgical Treatment
Your physician may recommend surgery to take pressure off of the nerve if:

non-surgical methods have not improved your condition
the ulnar nerve is very compressed
nerve compression has caused muscle weakness or damage
There are a few surgical procedures that will relieve pressure on the ulnar nerve at the elbow. Your orthopaedic surgeon will talk with you about the option that would be best suited for you.

Cubital tunnel release
In this operation, the ligament roof of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve. After the procedure, the ligament begins to heal, and new tissue grows across the division. 

The new growth heals the ligament and allows more space for the ulnar nerve to slide through. Cubital tunnel release tends to work best when the nerve compression is mild or moderate, and the nerve does not slide out from behind the bony ridge of the medial epicondyle when the elbow is bent.

Ulnar nerve anterior transposition
In the majority of cases, the nerve is moved from its place behind the medial epicondyle to a new place in front of it. Moving the nerve to the front of the medial epicondyle prevents it from getting caught on the bony ridge and stretching when you bend your elbow. This procedure is called an anterior transposition of the ulnar nerve.

The nerve can be moved to lie under the skin and fat on top of the muscle (subcutaneous transposition), within the muscle (intermuscular transposition), or under the muscle (submuscular transposition).

Medial epicondylectomy
Another option to release the nerve is to remove part of the medial epicondyle. This technique also prevents the nerve from getting caught on the bony ridge as well as from stretching when your elbow is bent.

What is life like after the treatment?
Cubital tunnel syndrome can be treated with rest and prescribed medicine to help with pain and inflammation. Exercises may help too. In some cases, surgery may be necessary and subsequently performed.

Can cubital tunnel syndrome return after having surgery? If so, why?
Depending on the type of surgery you have, you may need to wear a splint for a few weeks following the operation. A submuscular transposition usually requires a longer time (three to six weeks) in a sling.

 

Your surgeon may recommend physiotherapy exercises to help you regain strength and motion in your arm. They will also talk with you about when it will be safe to return to your normal activities.

How can cubital tunnel syndrome be prevented?
There are many ways to prevent cubital tunnel syndrome. The main preventative measures include the following:

keep your arms flexible and strong
avoid resting on your elbows – especially on a hard surface
warm-up before exercising or using your arms for sports or other repetitive movements
keep your arm straight while at rest.
wear a splint while you sleep to prevent the elbow from bending.
try to avoid falls or direct impact to the inside of the elbow (near the funny bone)

Cubital Tunnel Syndrome

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Simplifying the complex: complex bone fractures explained
Written by: Professor Mohamed Imam

Bones make up the skeleton of the body. They provide us with the ability to lift our body up against gravity and move around, interacting with our environment. A crack or a break in a bone is a fracture. In this second article of a series on complex trauma, consultant orthopaedic surgeon Professor Mohamed Imam gives a detailed explanation of bone fractures and how they are involved in complex trauma.

What is a complex bone fracture?
The average person has two fractures during their lifetime. A bone fracture occurs when the bone is weaker than the physical force exerted on it. The fracture might be regarded as complex when it involves a joint or if it is shattered bone. Depending on the force of the break will usually determine the severity of the fracture. If the breaking point of the bone has only slightly been exceeded, it may crack as opposed to breaking all the way through. However, if the force is extreme, for example, the force from an automobile crash, then the bone may shatter.

If the bone fracture is broken in a way that bone fragments are sticking out through the skin or a wound is penetrating down into the broken bone, then the fracture is referred to as an open fracture. Open fractures can be devastating injuries that have the potential for infection, non-union, nerve or vessel injury, and long-term debilitating dysfunction of the limb.

What are the most common causes of bone fractures?
The most common causes of fractures are:

Trauma – a fall, motor vehicle accident, abuse, or tackle during a football game can all result in fractures.
Osteoporosis – this disorder weakens bones and makes them more likely to break.
Overuse – repetitive motion can tire muscles and place more force on bone. This can result in stress fractures. Stress fractures of the hand, ankle, tibia, or hip are more common in athletes, for example, caused by running.
What are the different types of bone fracture?
Different types of fracture include:

Closed (simple) fracture – the broken bone has not pierced the skin.
Open (compound) fracture – the broken bone juts out through the skin, or a wound leads to the fracture site. Infection and external bleeding are more likely.
Complicated fracture – structures surrounding the fracture are injured. There could be damage to veins, arteries, or nerves, as well as possible injury to the lining of the bone (periosteum).
Comminuted fracture – the bone is shattered into small pieces. This type tends to heal slower.
Avulsion fracture – muscles are anchored to the bone with tendons, a type of connective tissue. The tendon can be wrenched free and pull-out pieces of bone from a powerful muscle contraction. It is more common in knee and shoulder joints.
Compression fracture – occurs when two bones are forced against each other. The vertebrae bones in the spine may have this kind of fracture. Older people, particularly those with osteoporosis, are at higher risk.
Displaced Fracture – broken bone snaps so far out of place where two ends no longer line up straight. This fracture is more difficult to treat with immobilisation alone, and usually, surgery is required.
What are the most common bone fractures?
In the body, there are 206 bones, all with the potential to break in one way or another. It is no surprise that many people experience some type of bone fracture within their lifetime, as there is a vast array of accidents waiting to happen – for example, vehicle collisions, slips, falls, and other unfortunate incidents.

Clavicle (collarbone)
The collarbone, otherwise known as the clavicle, is the most commonly broken bone, thanks in large part to where it’s positioned. Sporting events and car accidents are the most common causes of collarbone breaks. A sling to prevent the shoulder and the arm from moving is how these are mostly treated, but in some breaks, the pieces of bone move too far out of place and need to be realigned.


Arms fractures
Arms are also broken frequently, being the second most broken bone among children. Breaks can happen in the upper or lower arm and are very susceptible to spiral fractures and compound fractures (multiple breaks in one bone). A specialist review is needed for the best treatment option as these injuries are always complex and can have adverse short- and long-term complications if not managed properly.

Wrist Fracture
The wrist is most likely to be fractured when a person suffers a fall on the outstretched hand and takes all the body weight through the arm. Whilst there are several bones in the wrist, the most common wrist fracture is a distal radius fracture which involves a fracture of radius (one of the long bones of the forearm). Sometimes the scaphoid bone also gets broken without notice and typically requires surgery to heal. Other fractures can be treated with a cast, splint, or open reduction and internal fixation.

Hip Fracture
Hip fractures are one of the most common and severe fractures in elderly clients. Normally, a fall on the side causes a break in the upper thigh bone, as well as osteoporosis causing bone weakening in the femur, typically one of the strongest bones.

Ankle Fracture
Ankles are also prone to breakage. If the ankle is stable, the fracture may be managed by conservative methods such as a medical boot to a short leg cast. If there is a significant displacement or loss of ankle stability, either a closed or open reduction and fixation with pins and screws may be required.

Vertebral Fracture
The 24 vertebrae in our neck and back protect our spinal cord. In people with osteoporosis, it is the most common break. Breaks are most commonly seen near the waistline and slightly above (mid-chest) or below (lower back).


Complex Bone Fractures Explained

Prof Mo Imam, our Consultant Upper Limb Surgeon shares invaluable advice and tips on how to ace your serve with confidence while preventing shoulder injuries. Discover the essential guidelines to enhance your serve, protect your orthopaedic health, and ensure long-term bone and joint well-being.

When playing lawn tennis, although the Wimbledon Championships fever might make you feel like a power hitter, considering a few exercises and techniques might save you a lot of post-game pain and tennis injuries. In this article, Prof Mo Imam, our Consultant Upper Limb Surgeon and a former tennis player himself, shares invaluable advice and tips on how to ace your serve with confidence while preventing shoulder injuries. Discover the essential guidelines to enhance your serve, protect your orthopaedic health, and ensure long-term bone and joint well-being.

Warm up and stretch before tennis

Before you step onto the court, it is crucial to warm up your body and stretch your muscles properly. Performing light aerobic exercises like jogging or jumping jacks will increase your heart rate and warm your entire body. Follow this with dynamic stretches that mimic the movements involved in serving, such as arm circles, shoulder rolls, and trunk rotations. Warming up and stretching properly will prepare your muscles and joints for the explosive movements required for a powerful serve.

Focus on proper tennis technique

Executing a powerful serve starts with mastering the correct technique. Begin by adopting a comfortable and balanced stance, ensuring your weight is evenly distributed. Use a continental grip or a grip variation that works best for you. Practise your toss, ensuring it is consistent and positioned slightly in front of your hitting shoulder. Focus on generating power from your legs, transferring the energy through your core, shoulder, elbow, and wrist. By using the proper technique, you can reduce the risk of strain and injury while maximising the power behind your serve.

Develop strength and stability

Building strength and stability in key muscle groups is vital for powerful serve and injury prevention. A strong and stable body will allow you to generate more power while reducing the risk of overuse injuries.

Strengthen your lower body to improve your leg drive and stability during the serve through:

Squats
Lunges
Calf raises
Incorporate exercises that target your core to enhance rotational power and stability with:

Planks
Medicine ball throws
Russian twists
Additionally, strengthen your shoulder and arm muscles with exercises like:

Shoulder presses
Bicep curls
Triceps extension
Improve flexibility and mobility

Flexibility and mobility are crucial in executing a powerful serve and preventing injuries. Incorporate stretching exercises into your routine focusing on your shoulders, chest, back, and hips. Use exercises like shoulder stretches, pec stretches, and thoracic spine rotations to improve the flexibility and range of motion in these areas. Adequate flexibility and mobility will enable you to achieve a full range of motion during your serve and reduce stress on your joints and muscles.

Listen to your body!

Listening to your body and paying attention to any discomfort or pain during your serve is essential. If you experience persistent pain or discomfort in your shoulder, elbow, or any other joint, seeking medical attention is crucial. As experts in orthopaedics, we strongly advise consulting with a specialist who can evaluate your condition and provide appropriate guidance. Ignoring or pushing through pain can lead to serious injuries and long-term complications.

Practice smart and efficiently

Consistent practice is key to developing a powerful serve, but practising smart and efficiently is equally important. Focus on quality rather than quantity. Break down your serve into different components and work on them individually. Spend time on your toss, footwork, and racket path, gradually integrating them into a complete serve. Video analysis can be a useful tool to identify areas for improvement and track your progress. By practising with intention and purpose, you'll consistently refine your technique and hit powerful serves.

Mastering your two-hand backhand

Executing a two-hand backhand in tennis requires careful attention to technique and body mechanics to prevent injuries, improve shot accuracy and consistency, and gain a tactical advantage. Here are three important factors to consider:

Grip and hand placement:

Ensure you have a comfortable and firm grip on the racket handle. Typically, the dominant hand is placed on the bottom of the handle (e.g., right hand for right-handed players), with the non-dominant hand placed above it (e.g., left hand for right-handed players). The grip should allow you to generate power, maintain control, and ensure stability.
Body position and stance:

Your body position and stance play a significant role in executing a solid two-hand backhand. Stand with your feet shoulder-width apart, slightly staggered, and parallel to the baseline. Position your body sideways to the net, with your non-dominant side facing the net. Bend your knees slightly to provide a stable base, and rotate your shoulders and hips to generate power and maintain balance throughout the shot.
Swing path and follow-through:

The swing path and follow-through greatly impact the accuracy and consistency of your two-hand backhand. Initiate the swing by bringing the racket back with both hands, keeping it parallel to the ground. Swing forward and aim to make contact with the ball in front of your body and slightly to the side. Keep your eyes on the ball, focus on hitting it cleanly with the middle of the racket strings, and follow through by extending your arms forward. Allow the racket to finish high over your non-dominant shoulder.
Consistent practice and proper technique are essential for mastering the two-hand backhand. Consider seeking guidance from a tennis coach or instructor who can provide personalised feedback and additional tips to improve your shot.

The importance of tennis injury prevention

A powerful serve can be a formidable weapon on the tennis court, but it should never come at the expense of your health. Tennis injury prevention is crucial as it:

Preserves performance and consistency
Prolongs athletic careers
Minimises pain and discomfort
Reduces medical costs and time off
Enhances overall health and well-being
Promotes long-term musculoskeletal health
By prioritising injury prevention strategies, you can maintain a consistent training regimen, extend your playing career, enjoy the sport without unnecessary pain, lower financial burdens, and ensure the longevity of your musculoskeletal well-being.

 

By following the expert advice shared by Prof Mo Imam, you can minimise the risk of tennis injuries, improve your serve, and safeguard your orthopaedic health on the court. Remember to warm up and stretch before playing, focus on proper technique, develop strength and stability, improve flexibility and mobility, listen to your body, practice smartly and efficiently, and pay attention to injury prevention. By incorporating these strategies into your tennis routine, you'll enhance your performance, prevent injuries, and promote long-term bone and joint health.

How to avoid injuries on the tennis court: expert tips from a Consultant Upper Limb Surgeon

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