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Episode 2 Shoulder Dislocations
27 Plays5 months ago
Chris Woakes has dislocated his left shoulder playing cricket for England. In this episode we discuss why and how a shoulder dislocates and whether we think he will be fit for the Ashes this winter.
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Transcript
Introduction to Injury Time Episode 2
00:00:01
Jonathan Bird
Okay. Hello everybody. ah This is episode two of Injury Time. I'm Jonathan Bird and with me again as ever is Ian Beasley and Shabazz Murgle.
00:00:13
Shabaaz Mughal
Hey.
00:00:14
Ian
Evening.
00:00:15
Jonathan Bird
um So, ah ah do hope everyone liked last time. It was two weeks ago. um we could try and do it every week as much as we can. We missed it last last weekend. I was on call.
00:00:27
Jonathan Bird
Shbaz was away. um But we will try as much as we can and do one every weekend. um So this week, we thought we would talk about shoulder dislocations.
00:00:39
Jonathan Bird
ah Main
Shoulder Dislocations in Sports
00:00:40
Jonathan Bird
reason being is that as far as we can tell, um Chris Wokes, playing currently in the final test against India, um dislocated his shoulder whilst fielding.
00:00:53
Jonathan Bird
um It's not being officially confirmed just yet at the time of recording, but Stuart Broad revealed that he had dislocated his shoulder on commentary. um So we thought we would talk about that. So anyway, like if I don't know if anyone saw it, but it was it was the classic way that you can dislocate a shoulder in that it was a kind of Superman mode. He had his arm out in the air as he was trying to stop a ball from going for four.
00:01:25
Jonathan Bird
And he landed on the ground, arm out straight, and popped his shoulder out.
Why is the Shoulder Prone to Dislocations?
00:01:32
Jonathan Bird
Now, I thought we'd start first with what exactly is a dislocation. So a dislocation is where the joint comes right out. So the ball, most joints are a ball and socket or a variation of a ball and socket and the ball comes right out of the socket. um And the shoulder joint in particular is quite susceptible to that.
00:01:55
Jonathan Bird
It's a joint that has a huge range of motion. i You can put it up, down, forward, back, all over the shop. But the downside to that is that it's it's it's quite shallow. So it's the way the way that the the shoulder joint is built is that it allows, to allow that amount of movement, um the socket is quite shallow.
Notable Shoulder Dislocations in Sports
00:02:18
Jonathan Bird
So the way it works is that the bony socket, the bone, the ball the bony part of the socket
00:02:25
Shabaaz Mughal
Thank
00:02:28
Jonathan Bird
is quite shallow and the body has lots of gristle which makes up the rest of the socket. So that gristle, that soft tissue, the capsule, is pretty easy to tear if you put enough force through the shoulder.
00:02:42
Jonathan Bird
Whereas, say, the knee is essentially a hinge joint and it's very hard to dislocate. And the hip is quite a deep bone, bony socket, and again, very, very hard to dislocate.
00:02:54
Jonathan Bird
So the shoulder is much lower easier to dislocate because of this this gristle. um
00:03:04
Jonathan Bird
So we thought we'd talk about shoulders and how you manage them in the elite setting. Now, Shabazz and Ian have been involved in elite football.
00:03:12
Shabaaz Mughal
Thank
00:03:17
Jonathan Bird
But actually shoulder joints come out in football as well. in And in case in point, um the way that Wokes dislocated a shoulder, that can happen in any sport. um We know that Pope at Newcastle, the the the keeper last season, he dislocated a shoulder. So obviously it's more of an upper limb activity being being a keeper.
00:03:37
Jonathan Bird
But there have been a ah few players. I can think of Theo Walcott, for instance, who fell off the shoulder. fell down with his again with his arm outstretched dislocated his shoulder.
Managing Shoulder Dislocations On-Field
00:03:49
Jonathan Bird
So Ian Shabazz, have you had any experience yourself of in in elite football of shoulder dislocations?
00:03:59
Shabaaz Mughal
I'll go first. Yeah, I mean, it's not as common as you'd think it would be, um but it does happen. and i can kind of think of a handful occasions when it did. um and There's only there was two sort of main things that I always remember with shoulder dislocations. One is, um you know, trying to to relocate or put it back in its joints.
00:04:23
Shabaaz Mughal
um which ideally if you can do as quick as possible before the muscle gets really tight and tense then that's great.
00:04:35
Shabaaz Mughal
um But in my experience, very difficult to do pitch side. And I think Ian, you're saying now the teaching that for pitch side doctors is that we shouldn't try and put the the shoulder joint back in.
Dislocation vs. Subluxation: Recurrence and Treatment
00:04:49
Shabaaz Mughal
um And then the second thing with shoulder dislocations that I always find, which we'll talk about, I think we'll come to is whether they then need to have an operation or not, essentially, as in the longer term ah view.
00:05:07
Shabaaz Mughal
um And just, John, if I come back to you about that, it's a bit technical, but... Can you just describe the difference between a subluxation and a dislocation, just so that all the the sort of listeners understand the difference?
00:05:24
Jonathan Bird
So a dislocation is where the joint completely comes out. So there is no, so the ball and the socket are completely apart. And in the shoulder is usually to the front and down, sort of downwards. So it sits kind of down, it down, down sort of in front of the ribs, as it were, sort of almost in the, in the armpit.
00:05:47
Jonathan Bird
And a subluxation is where it kind of half pops in and pops out again. And people who have, problems with their shoulder, usually they've had at least one dislocation in the past.
00:05:58
Jonathan Bird
They've not had a surgery and they have a feeling of their shoulder kind of half coming out. And they but kind of, they have this, what's called the subjective, this feeling in themselves of the shoulder feels like it's about to come out.
00:06:10
Jonathan Bird
And that I suppose would be ah kind of subluxation. i so As a knee surgeon,
Surgery: To Opt or Not?
00:06:14
Jonathan Bird
I see it more often with the kneecap. So a true knee dislocation where the whole joint comes dislocated doesn't happen unless you've got really quite high levels of energy.
00:06:25
Jonathan Bird
But the kneecap can come out quite commonly. And that subluxation, you can feel it just pops in, pops out, back in really quickly.
00:06:32
Shabaaz Mughal
and if
00:06:32
Jonathan Bird
Less common with the shoulder, more with the shoulder. It's a feeling it's about to go as opposed to it's half comes out.
00:06:37
Shabaaz Mughal
And if you do this okay ah you if you dislocate your shoulder, um can it go back in by itself or do you generally, someone has to help put it back in?
00:06:40
Jonathan Bird
Sorry, go on.
00:06:48
Jonathan Bird
Well, I mean, there are conditions um where you get a thing called a multidirectional instability where people who have a lot of um laxity, lots and lots of the, you know, they people say that they're double jointed.
00:07:03
Jonathan Bird
So people who have a lot of that can have a condition where their shoulder I mean, literally, they can they can pop it almost by themselves. Just their muscles can pop it in and out. They can pop it in and out 10 times a day, 10 times an hour. And they really it it's and it's almost and they they have to be trained by the physiotherapist to not do that.
00:07:21
Jonathan Bird
um
00:07:21
Shabaaz Mughal
This sort of setting that we're talking about in a sports setting, we're talking sort of it's happened from a a trauma, so some sort of incident, and it generally tends to be the first time it's happened, maybe the second time, but it's not that same.
00:07:34
Jonathan Bird
Yeah, yeah. Yeah.
00:07:36
Shabaaz Mughal
They generally don't go back in themselves, do they? No.
00:07:40
Jonathan Bird
No, no. A first time, a true dislocation where the shoulder is out and it will not go back in unless someone else puts it back in. Paramedic, the pitch doctor, someone in A&E.
00:07:54
Jonathan Bird
that's that that's That's not a subluxation. That's a proper dislocation. you don't get You don't suddenly get um sort of subluxations. um without without first having a proper dislocation.
00:08:08
Jonathan Bird
Unless you've got
Surgery vs. Rehabilitation: Athlete's Career Impact
00:08:09
Jonathan Bird
something very abnormal, you're born with something quite abnormal in your shoulder.
00:08:15
Shabaaz Mughal
Ian, what are your thoughts?
00:08:16
Ian
Yeah, I mean, um it's interesting is that I've seen quite a few shoulder dislocations in football. It's always that sort of action, that Superman fall where you're sprawling forwards and trying to stop yourself. You put your hand out and pop, your shoulder comes out.
00:08:33
Ian
um I've seen, you know, most of the players I've seen have had surgery. I saw one player who had prolo therapy, a sort of injection therapy into his shoulder um to stop it dislocating.
00:08:48
Ian
um And unfortunately, he was transferred to another club after that. So I never really saw what the outcome was. but So that's an unusual thing. But I have seen players who... have not to have surgery and have done their rehabilitation, strengthened all their muscles and and we just keep our fingers crossed that it won't occur again because we all know that if you've had one dislocation, you're very likely to get another. the the whole It's interesting you talk about subluxation.
00:09:15
Ian
um When I was working abroad, we used to screen all the national athletes in the place I was working and we used to see lots of handball players And I remember examining a handball player and saying to his physio, ah he's got, you know, it looks like he's going to pop his shoulder. and And the physio said, yeah, they're all like that.
00:09:38
Ian
So handball players have developed this looseness at the front of their joint because of the way they throw the ball. And they that like ah must do that 200 times a day, professionals. So it's interesting, it depends on your setting and where you are, but in football, not that common, but it's a real pain because if you want to opt for not having surgery um and it doesn't work, whatever time between the accident and opting for surgery because the rehabilitation hasn't worked is considered time wasted.
00:10:13
Ian
That's
Surgery or Rehab: Impact on Player Availability
00:10:14
Ian
time when you've done rehabilitation, but we're not going to make it better.
00:10:14
Jonathan Bird
Yeah.
00:10:18
Ian
and We might as well beat down at time zero to start because surgery is going to take a while.
00:10:24
Jonathan Bird
So yeah, so I think that that leads on to how you manage So once you've got it back in, it's interesting to hear that you tend not to put the shoulders back in pitch side or yeah or in the in the in the medical room.
00:10:37
Jonathan Bird
um And i think sort of leading behind the scenes on that, that sometimes if you're very unlucky, you can dislocate the shoulder and you can fracture it.
00:10:40
Shabaaz Mughal
Thank you.
00:10:50
Jonathan Bird
And the worry is that with the untrained medic, i.e. not an orthopaedic surgeon and not with someone who's got x-rays right there and then, when you put the shoulder back in, you you could make the fracture worse.
00:11:06
Jonathan Bird
um I mean, that's pretty rare, but there's no real massive disadvantage to waiting to get the player into the local A&E and get the shoulder back in. But then, so short so so so short-term shoulder goes back in.
00:11:21
Jonathan Bird
Medium to long term, this is where the controversy starts. And most joints, you don't need to have surgery immediately after it's gone back in. If you can't get it back in, then you need surgery put it back in.
00:11:35
Jonathan Bird
And if there's been a fracture that means the joint doesn't stay back in, then you need surgery. But once it's back in, the point of the s surgery is to stop it happening again. And the evidence is, and when we as doctors, we just bandy around where's the evidence. And what that means is that we've we've got the records of lots and lots and lots of patients.
00:11:57
Jonathan Bird
Or we do a trial where we try one thing, like we try no surgery or we try surgery and we see what the how many people recur how many people would dislocate again in the group with surgery or no surgery.
00:12:12
Jonathan Bird
And the evidence is clear that for the young athlete, and when I say young, the cut off is 30, the rate of recurrence is much lower if you have surgery.
00:12:23
Jonathan Bird
So what that means is that if you opt not to have surgery, and you're a 21 year old professional footballer, that does not mean that you inevitably will then dislocate again.
00:12:34
Jonathan Bird
It just means that the chances of dislocating again are higher. So Chris Wokes, for instance, is apparently probably going to have surgery, and which means he will probably miss the ashes.
00:12:48
Jonathan Bird
But, you know, I mean, who knows? Who knows what conversation he may have with the team doctor, with the shoulder surgeon he sees.
00:12:51
Shabaaz Mughal
Thank
00:12:56
Jonathan Bird
It's his non-bowling arm. maybe Maybe they'll opt for conservative treatment. He's not that young Chris Wokes. Maybe he wants to not go for so for surgery and try and see if he can make it to the ashes.
00:13:08
Jonathan Bird
I mean, do you,
Shoulder Injuries and Team Strategy
00:13:10
Jonathan Bird
Sue, you were saying, Ian, that you've had players who have not opted for surgery despite being elite athletes.
00:13:15
Ian
Yes, yeah, I have, yeah. And so far, um hasn't re-dislocated. Very diligent player who is very good about doing his rehab.
00:13:28
Ian
And when I say rehab, he'll be doing his rehab two or three times a week in the gym, specifically to keep his shoulders strong.
00:13:29
Shabaaz Mughal
oh
00:13:36
Ian
And it's very interesting how this sort situation then starts to feed into team selection because it may be that a 75 or 80% fit Chris Wokes is better than the replacement that they're going to get at 100%. So he may be being counselled, hold on a minute, do your rehab, we'd love you to come.
00:14:01
Ian
um but you're not going to be 100% fit, but yeah they may consider him to be better than the next person down the line. Now, that's how these things always fit into team selection, and that then becomes less of a medical issue, but much more of a coaching management issue.
00:14:22
Jonathan Bird
Yeah, but then you know you think you know fast bowlers um in the not-too-distant past, in between ah and you know when they weren't bowling, they'd be at third man or yeah know deep you know deep cover. there They would they be somewhere where if the ball went straight to them, they would field it.
00:14:41
Jonathan Bird
and they'd And they'd make half an effort to cut off a boundary, of the but they were expected to not be doing that much running.
00:14:47
Shabaaz Mughal
Thank you.
00:14:48
Jonathan Bird
Whereas now with the modern game, fielding is the is this is the third discipline and they're expected to, you know, absolutely, you know, sprint as hard as they can and to dive to to to cut off a run, which is what happened with with Chris Wokes. But, you know, when you've got the option of, if you're a footballer, you do your shoulder in and in March, April, and you've got a tournament coming up in the summer, the World Cup or something.
00:15:15
Jonathan Bird
And you, you know, what clearly is quite, it it would, to be told that you're definitely not going to be playing in the World Cup if you have surgery, but you might if you don't. So what do you think?
00:15:28
Ian
yeah shabelle i don't know what you think exactly and and this is where it becomes less of a medical this is the evidence type of conversation it becomes much more of a where are we at where are we at in the season where are we at in your contract is your contract up to the end of the year no one's going to sign you with an x dislocated shoulder that might go again so you've got to get it done um all these
00:15:52
Jonathan Bird
Well, unless unless you can then demonstrate that that that you've rehabbed and you are integral to saving your team from relegation, and my shoulder's fine.
00:16:00
Ian
Well, that's the next thing. So is he is this player so important to the team and you're a relegation battle, you need everyone, you need all hands on deck. So you're not going to chance it, no matter what his contract is.
00:16:14
Ian
All these things come into play and you just, and that's why, like I said, it becomes a less of a, this is the evidence. That's not the evidence. It becomes less of a conversation about that.
00:16:25
Ian
And it then balloons out into what the total situation is for that player and their club. So it's a tough one.
00:16:35
Shabaaz Mughal
It is. i think
00:16:35
Jonathan Bird
Thank
Timing of Surgery and Recovery
00:16:36
Jonathan Bird
you.
00:16:36
Shabaaz Mughal
there's a few things that you you have to consider.
00:16:40
Shabaaz Mughal
And the biggest one is timeframes, because if you have surgery, you're looking realistically at 12 weeks or three months before you'll play again, and which is a big chunk of whether it's the season or even the off season, because you're not, even if it's in the off season, you're still going to miss part of the season, which think um again I again, don't know anything about it, but just looking at the pictures, looking at the the media, but Jude Bellingham, I think, has gone for a shoulder ah operation.
00:16:58
Ian
Yeah.
00:17:11
Shabaaz Mughal
after the Club World Cup and it may well be that he had a dislocation at some point. They've managed it through and then decided this is the most appropriate time to do surgery, which all sounds very reasonable, but it's still going to miss part of next season.
00:17:27
Shabaaz Mughal
um So really the time timing is crucial.
00:17:27
Ian
yeah
00:17:30
Shabaaz Mughal
If you don't have surgery, I mean, I've seen players come back sort of within a couple of weeks, maybe two to four weeks, they've come back without having surgery. Um, but the caveat to that is there's a big risk of it happening again, but equally,
00:17:48
Shabaaz Mughal
Surgery doesn't guarantee it's not going to happen again either. So there is still a small risk of a recurrence after surgery. So these are all the things you've got to weigh up. But I think the thing that sort of really defines it is the instances where people do take their time, do their rehab, do everything properly, and that might take four weeks, might take six weeks, and then it still happens, and then they've lost all that time, and then they have surgery. And I think in football, there's always this thought, probably in professional sports, the same where surgery is like the definitive answer.
00:18:26
Shabaaz Mughal
ah But you've always got to balance that with, surgery isn't a guarantee either and it doesn't guarantee the surgery will go perfectly smoothly it probably does in the majority of cases but there'll be the odd case where it doesn't go as planned so you've got to weigh all of that up and have that discussion and then and then reach the conclusion and you know there's a lot of people involved in that discussion yeah
00:18:48
Ian
ah I agree. And that's why I say it's not it's not just a, oh, this is the evidence, this is what it says. You can present that to the player. If the player doesn't want to have surgery, they're not having surgery.
00:18:59
Shabaaz Mughal
Hmm. Hmm.
00:18:59
Ian
They sign the consent form, I don't sign it for them. And I think that, you know, and you're right Shabazz, there's this whole thing, as I said before about, you know, if you miss six, if you do six weeks of rehab, four weeks of rehab, whatever it is, and and as soon as you get out on the pitch, you fall over and it goes again, and you have surgery, the perception is that that four to six weeks is wasted.
00:19:23
Shabaaz Mughal
and
00:19:24
Ian
you know, we could have had him back on the pitch four weeks before. Bear in mind, if, you know, if you have surgery and then you miss pre-season, know, it
Injury Management: Elite Athletes vs. Amateurs
00:19:34
Shabaaz Mughal
be behind him.
00:19:34
Ian
it's not like they get back in a couple of weeks and are back fully fit.
00:19:38
Ian
They're not.
00:19:38
Shabaaz Mughal
Hmm.
00:19:39
Ian
It takes a long while to get up to what you would consider return to performance rather just return to play. So it's you're right. it's It's all about timing. And if you're going to have surgery, you know, do you have it tomorrow because you did it today?
00:19:55
Ian
Or do you temporise and wait until it's expedient for the player and the club?
00:20:03
Jonathan Bird
So in in terms of the in terms of the rehabilitation, is it, do you think, I think for the listeners to try say, is there a big difference between how you manage a shoulder injury in the elite sport or in, you know, Sunday league or village cricket?
00:20:23
Ian
but not no No, I don't think, sorry, Shabazz, there's no difference.
00:20:23
Jonathan Bird
You don't think so?
00:20:27
Shabaaz Mughal
yeah
00:20:27
Ian
The only difference is is that football players have the luxury of having a gym upstairs or downstairs and can do it every day on the so under the supervision of an expert.
00:20:37
Jonathan Bird
Yeah.
00:20:37
Ian
Whereas if if I dislocate my shoulder, I'm at the David Lloyd doing it on my own.
00:20:43
Shabaaz Mughal
And you might get to do it once a week or something.
00:20:44
Jonathan Bird
Yeah. and
00:20:46
Shabaaz Mughal
Yeah.
00:20:46
Ian
Once a week, yeah if you're lucky.
00:20:48
Shabaaz Mughal
Yeah. Yeah.
00:20:49
Jonathan Bird
But also I think that, you know, just if you, um whoever the surgeon is that Chris won't see will be someone who's likely to, will also work in the and NHS. and And if they see someone who's done their shoulder fielding,
00:21:04
Jonathan Bird
in village cricket this weekend, then they'll get the same treatment. It'll take longer. The inevitable answer the inevitable ums it will take longer to for for the to get the surgery. and But of course, not just about the surgery. Exactly as you say, Ian, they've got access to world-class physios.
00:21:20
Jonathan Bird
um you Well, I mean, not to undermine the physios that you would get in NHS. I've got some incredible ones at my hospital, but but you don't get access to them every single day.
00:21:27
Shabaaz Mughal
Mm-hmm.
00:21:31
Jonathan Bird
And the rehabilitation is absolutely key for any injury, isn't it
00:21:37
Ian
The most important thing. I
Advice for Young Athletes with Shoulder Dislocations
00:21:40
Ian
mean, to ah you know, not not decrying surgical services, Jonathan, but in my eyes, a surgeon is a technical service.
00:21:48
Ian
All the stuff happens after the technical service, you know, happens with the physios and the and the strength and conditioners.
00:21:49
Jonathan Bird
it?
00:21:52
Jonathan Bird
Yeah, absolutely.
00:21:56
Ian
um ah To see the work that some of these people brought into players, to one player, to get them back playing in three months is unbelievable. And getting them fit, you know making sure they're running, they're doing all the other stuff that they need to do, not just a specific rehab for their injury.
00:22:15
Shabaaz Mughal
I think having said all of that, I guess the question for the listeners is if you injure your shoulder, if you dislocate your shoulder, what would we advise? And I think given what I've seen and so the sort of patient populations I've seen, i think if you're sporty, if you're athletic and you're young,
00:22:38
Shabaaz Mughal
probably do need surgery because there's a high, you see just as such a high risk of recurrence and inevitably, and and know you said inevitably it may not happen, but you generally tend to see them recurring if they don't have surgery.
00:22:52
Shabaaz Mughal
I don't, what do you
00:22:52
Ian
yeah
00:22:53
Jonathan Bird
Yeah, and but but but but it's not everybody, though, is Shabazz? The cutoff the cutoff is is is is the age of 30, and yeah like teenagers, like ah ah like a 17-, 18-year-old who dislocates their shoulder at school playing rugby, it is it's almost inevitable that their shoulder will dislocate again, sort of 80% chance. I mean, they absolutely just have to have surgery.
00:23:15
Jonathan Bird
um Someone who's 40 who is... who is play cricket, say, village cricket, falls over, does the same as Chris Wokes, they almost certainly don't need surgery.
00:23:27
Jonathan Bird
They might do, but but they would they would be advised to rehabilitate and see how it goes. You know you would not advise someone who's 40, 45, to have surgery after a first-time dislocation.
00:23:38
Jonathan Bird
They may well have a different problem, may have an injury to their rotator cuff, but in terms of recurrence of dislocation, it's relatively low.
00:23:47
Ian
And I think that the other thing is is that you know weekend warriors, they've got jobs. like you know they can't They can't afford the time to have to keep dislocating their shoulder and doing this, that and the other. you know they've got ah you know They do have to think definitively.
00:24:03
Ian
Sometimes that means to people that play sport weekends, maybe they can't play that sport, unfortunately.
Challenges for Non-Professionals with Shoulder Injuries
00:24:10
Ian
So I think that's when our responsibility is in some ways much greater than it is in the pro game, because in the pro game, it's relatively straightforward.
00:24:19
Ian
You know, someone injures their shoulder, ah dislocates their shoulder, they go to an orthopedic surgeon, and orthopedic specialist within a couple of days after um MRI scanning and ah and a decision is made.
00:24:31
Ian
between the player of the club and the agent and the surgeon. um In the next couple of days after that, it's relatively straightforward. I think, you know, if you're working on a building site and you dislocate your shoulder, it's it's a disaster.
00:24:44
Jonathan Bird
Yeah.
Conclusion and Future Topics
00:24:46
Shabaaz Mughal
It depends on the situation.
00:24:47
Jonathan Bird
OK, look, so um I think we've got to, we're trying in these these early podcasts to try and go relatively short. we We're up to 25 minutes now. um ah We will eventually have some music.
00:25:00
Jonathan Bird
We'll eventually have some titles or something. Watch. We can work out how how I can work out to do that. Talking of a athlete as a knee surgeon, middle-aged knee surgeon, trying to work out the media, how to how to cut, how to edit a podcast and send out media clips.
00:25:17
Jonathan Bird
I'm not quite on that yet.
00:25:18
Ian
didn't find you.
00:25:18
Jonathan Bird
But anyway...
00:25:19
Ian
didn't find.
00:25:19
Jonathan Bird
we would we we would We would welcome, we know we do have a few listeners, and we'd welcome some some questions. um And if you can email us on theinjurytimepod, all one word, theinjurytimepod at gmail.com.
00:25:35
Jonathan Bird
um We've already had a couple in from ah Matthew and Alan who have asked about insurance for players who are out long-term injured, which we can come back to perhaps next time.
00:25:50
Jonathan Bird
But um thank you for listening. um Thanks from Ian and thanks from Shabazz. Thank you from me. um And we will see you next time.
00:26:02
Jonathan Bird
Cheers.
00:26:03
Shabaaz Mughal
Cheers. Thank you. Bye-bye.