Case Study
Chronic Shoulder Dislocation; glenoid labrum repaired by minimally invasive surgery.
Ah Keung is a football fanatic. "I was the goalkeeper in my team. During a game my shoulder dislocated when I overstretched my arm, trying to save a goal," Ah Keung remembered a small but life-changing incident that occurred 10 years ago.
Weekly Shoulder Dislocation
Ah Keung thought everything would be the same after his shoulder was put back in place at the Hospital Emergency Room. Shoulder dislocation, however, returned after 6 months and occurred again and again thereafter. Whether he was swimming or doing warm-up exercises, or even doing movement as simple as lifting his arm, his shoulder would just go out of place almost instantly. Sometimes the shoulder dislocation might happen once every 1 or 2 months, or even every 1 to 2 weeks, and he began to get used to it.
"At first I would just have my doctor put it back in place. After the fifth dislocation, I simply put it back by myself," said Ah Keung. "The crux came one night 2 years ago, when I could have been trying to lift my pillow or do some scratching in a sort of half-dazed way during sleep, my shoulder dislocated again. I woke up in pain. Since then I set my mind on surgery."
Surgery for Repairing Torn Glenoid Labrum
According to Dr. Wong, a specialist in orthopaedics whom Ah Keung consulted, the shoulders have a greater degree of movement than other joints, thus were more susceptible to dislocation. Most patients think it would be fine as long as the joint is put back in place by the doctor or a "bone setter". They will soon realise that the supposedly healed joint simply dislocates again and again.
A Swedish study suggested that the younger the patient has his/her shoulder first dislocated, the greater the likelihood of recurrent shoulder dislocation. If recurrent shoulder dislocation occurs, surgical repair of Glenoid Labrum can solve the problem.
Minimally Invasive Surgery Changes Everything
Dr. Wong said Ah Keung's condition was attributable to the torn long head of the biceps tendon, which connected the humerus and glenoid ligament. The injured anterior glenoid labrum also contributed to the anterior shoulder recurrent dislocation. To resolve the problem of recurrent dislocation, three suture anchors are fixed into the glenoid, and the torn ligament sutured using surgical thread to tighten the labrum.
Dr. Wong used minimally invasive procedure to resolve Ah Keung's problem. Three portal holes were made in the shoulder through which surgical instruments were inserted via cannula to do the repairs.
Since the successful operation, Ah Keung completely recovered and resumed his normal activities. He is no longer worried about his unstable shoulder while playing football and swimming. "I dared not swim for almost 10 years for fear of a sudden shoulder dislocation. I was scared to death about the possibility of drowning," said Ah Keung. "But now, I just feel that a great weight has lifted off my chest."
Case II: Raymond Chung (Age: 28)
Raymond suffered from ACL (Anterior Cruciate Ligament) tear while playing football. He had undergone ACL reconstruction. Raymond was able to resume jogging six months after the ACL reconstruction.
During an alumni football match in early May 2008, Raymond collided with his opponent players and fell to the ground. At that moment he felt only little pain in the left knee. He stood up after 2 minutes, limped off the field and rested. He used pain relief spray for soothing the painful knee.
"I thought nothing of it as I could still walk and run. I went back to the field and played some more. A little bit later as I turned around I felt increased pain in the knee. Then I called it quits," said Raymond.
Raymond visited an orthopaedic clinic the next day. The preliminary diagnosis was common sprain injury. His doctor suggested an MRI examination for a more thorough diagnosis, and the result was beyond everything he could expect – a complete ACL tear.
"To me it was a bolt from the blue. It was just like the end of the world."
Dr. Wu, a specialist in orthopaedics, suggested either Raymond could undergo ACL reconstruction, which might take 6 months for recovery, or undertake intense training of the thigh muscle for knee protection. Dr. Wu warned that, without surgery, Raymond's knee would feel like dislocated throughout his life. And nothing was more devastating than that as he could no longer ski, play tennis or football.
As a lifelong sports enthusiast, Raymond decided to undergo ACL reconstruction.
Facing his very first surgery, Raymond was understandably worried about its risks. All worries vanished after a detailed explanation by Dr. Wu. "It was just like a dream. My left leg was swollen," Raymond recounted his first feeling after waking up from surgery.
While staying at the hospital, Raymond received physiotherapy and walked slowly in the corridor every day. He was able to leave his cane and wear a knee pad two weeks after surgery.
"It was a quick and satisfactory recovery, all due to my not missing the timing of surgery, i.e. three to four weeks after the incident. At that time, my injured knee was no longer swollen, said Raymond. "Dr. Wu reminded me that the first two months after surgery was crucial to my recovery. That is why I insisted on receiving physiotherapy four or five days a week, each session lasting two to three hours. It helps make my left leg flexible and improves joint movement."
Six months after surgery, Raymond's joint can move as freely as it was before. In February 2009, he participated in a local marathon event and finished the half-marathon in 1 hour 28 minutes, implying a full recovery of his knee.
Case III： Paul Lee (Age: 34)
Ankle sprained while playing volleyball Paul's ankle was injured during a game of volleyball. The recovery is so far satisfactory.
It all happened during a volleyball practice in November 2008. After a forceful spike, Paul stepped on his teammate's foot, twisting his ankle outward with a clicking sound. Feeling uneasy, Paul left the game immediately. He tried to relieve the pain by applying ice wrapped in a towel to the injured area.
Sprain Needs Specialist Care
To a sports enthusiast like Paul, who loves all kinds of sports including football, hiking, jogging and swimming, it was hardly his first sprain. "The doctor on duty at the public hospital arranged an X-ray examination for me. He said the injury was not severe and allowed me to return home and rest. The whole consultation was rather short and simple, giving me no details about how bad my ankle was or if there would be any side effects," remembered Paul.
However common it is, sprained ankle is anything but trivial. It might result in bone fracture and complete ligament tear. Without proper treatment, an apparent trivial injury might worsen and become a more problematic one. It may become a recurrent sprain ankle. One might find the sprained area hurts much more than the last time, and finally could not do any vigorous exercises due to the unstable joints, or even arthritis.
First Apply Ice, then Compression with Bandage
"When I woke up the following morning, my foot was greatly swollen. I had to limp my way to the Hospital," said Paul. "Dr. Wong, an orthopaedics specialist, examined my ankle, then checked my ligaments to see if they were lax. He suggested X-ray examination to see if the bones were fractured. This revealed a few fragments of bone from the previous old injury. The joint was otherwise fine."
According to Dr. Wong's assessment, the injury was not serious. However, the bruises and swelling had to be relieved before further treatment. Dr. Wong applied ice to Paul's sprained ankle, which was then wrapped in elastic bandage with compression to fix the position.
Dr. Wong also prescribed anti-inflammatory medication for 10 days and a pair of protective footwear. The footwear resembles air-filled boots in design but with straps inside, so that one could protect and secure the injured area by either tightening or relaxing the straps. Paul was also given canes to assist walking. In the three months thereafter, he had to wear the protective footwear to relieve weight on his ankle until improvement showed.
Satisfactory Recovery after Meticulous Care
"As soon as the swelling subsided, Dr. Wong suggested physiotherapy. As I live away from the Hospital, he taught me a rehabilitative exercise to practise at home," said Paul. "It is mostly concerned with protecting the bones and ligaments by enhancing the leg muscles' flexibility and balancing muscular strength. It also helps relieve weight on the foot joint and thus lets the fasciitis heal in time."
Generally speaking, mild sprain could recover within a few days or two months at most. Of moderate injury, it might take three to six weeks. Full recovery might take several months or even a year in severe cases.
Almost two months after the injury, Paul was satisfied with the progress of recovery. No longer walking with a cane, now he can even jog as the pain keeps lessening. Dr. Wong suggested that, if the fragments of bone did not interfere with his ankle function, there was no need to extract the broken pieces through surgery. Given the high demand on mobility, balance, agility of his occupation, i.e. a firefighter, Paul may need to discuss with Dr. Wong on any further treatment at the next follow-up consultation.
Optimal Use of Bandage Prevents Repeated Injury
As the saying goes, "Prevention is better than cure". It is of utmost importance for Paul to have a proper understanding about sports as well as sports injury prevention. For instance, he should i) maintain a good degree of flexibility and balance of his muscles; ii) beware of his condition and take rest if he feels uncomfortable or tired; iii) do adequate stretching and extending exercises before sports activities, etc.
Paul said this might be an accident as he always had adequate warm-up exercises. He is grateful to Dr. Wong's suggestions. Whatever impact sports he takes on, now Paul will first wrap his old wound with bandages to protect the ankle, thereby preventing another injury or any after-effects, like rheumatoid arthritis.
"Currently I feel stinging pain in my foot whenever it is raining. To prevent it from getting worse, now I pay extra attention to safety and protection during exercises," said Paul.
Case IV: Derek Kwik (Age: 40)
Acute Achilles Tendon Rupture while Playing Dodgeball; Tendon Repaired with minimally invasive surgery. Derek Kwik is the first Chinese to have raced across four deserts. Derek Kwik is a top-notch marathon runner. His Achilles tendon was torn earlier while he was playing in a dodgeball game. The Achilles tendon injury stopped Derek from playing all sports for a while.
Derek works in the financial sector. With sheer determination and persistence, he has become the first Chinese to have raced across the four highest, driest, hottest and coldest deserts (the Gobi in China, the Atacama in Chile, the Sahara and the desert of Antarctica). However he met his unfortunate moment in June last year. He snapped his Achilles tendon while playing dodgeball. The complete rupture of the tendon meant he had to refrain from playing all sports.
"Sudden powerful" Movement Causes Injury
"Running is a linear sport. One is less likely to get the Achilles tendon injury even in running a marathon," said Derek. "But playing dodgeball is different: it demands swift movements or quick jumps. They are all about reflex, sudden movement and instant actions, causing tremendous stretching and tension in the Achilles tendon."
On that unlucky day, Derek was trying to dodge a ball. Suddenly from nowhere came a cracking sound, and Derek fell to the ground. He did not have a clue on what had happened, thinking he might have lost his concentration or been tripped by something. He tried to stand up, but the calf muscle above the Achilles tendon felt like being hit by bullets. From the outside, his calf looked deformed with the muscle contracting upwards, which made Derek unable to exert his leg muscle. Not to mention dodging a ball, he could hardly stand up by himself. For fear of more sinister consequences, Derek immediately went to the Hospital with his friends.
Doctor Suggests 6 Months' Rest after Surgery
"Dr. Wu said my Achilles tendon was completely torn, and I needed to undergo surgery immediately. It would take about an hour," said Derek.
Derek woke up as the anaesthesia wore off. His ankle was now cast in plaster and therefore was immobilized. He felt totally exhausted and took some anti-inflammatory and pain medication. Dr. Wu told Derek not to run for six months, which was a serious blow even to someone as tough-minded as him because he could not participate in the upcoming race across the infamous, inhospitable Amazon rainforest. His entire plan was in shatters within a moment.
Overcome Pain with Resolve
Derek began to retrace each moment leading up to the incident in search of causes of his injury. He clearly remembered that he had done warm-up exercises, and with all the years of training and practice, in fact warm-up was nothing but a habit to him. What he could explain was it happened in the wrong place at the wrong time.
But as a saying goes, "Pain is temporary. Quitting is forever." This time-honored wisdom helped Derek sail through all the pain and frustrations. Not only did he not give up sports, but with sheer determination he also tried to reach his limits, if there were any.
Dr. Wu advised Derek to stay at the hospital for three days. Derek refused. On the day after surgery he limped out of the hospital, even got back to work as usual.
"Dr. Wu told me to undergo physiotherapy at the hospital, but I was just too busy for that," said Derek. "That's why I chose to practise in my gym room. With my sutured Achilles tendon, I could only extend my leg as long as half of the normal length. I got to have intensive stretching exercises so as to resume its full length."
Quick Recovery Hinges On Rigorous Rehabilitative Training
Derek understands the importance of voluntary, disciplined and step-by-step rehabilitative training for quick recovery. The tendon might be torn again with wrong movements or exertions, sometimes leading to severe infection and complications. Extra care was a must.
As a disciplinarian, Derek kept on doing stretching and ankle-strengthening exercises every single day. Though these exercises could speed up the healing process, Derek was shrewd enough not to go to extremes. He would take rests to let the tendon relax.
The recovery was satisfactory. He entered a marathon event after just five months (November 2009). On 7 December 2008, he participated in the Macau Marathon.
"Doctor told me not to take on marathon until January 2009, but to me it was just too long to wait," said Derek. "He also reminded me not to walk or jog in excess as the nascent tissue took time to develop into normal tendon tissue after surgery. For normal exertion and speed, normally one might need six months for healing. I could walk slowly after four months."
After more than half a year, Derek thought his Achilles tendon was 99 percent recovered, while the remaining one percent needed time. At times he still feels mild pain in the ankle, yet he remains confident. And with iron-clad determination and proper rehabilitative training, Derek finished the full marathon in February 2009 in 4 hours and 45 minutes. It shows he can now resume his sportsman's life.
Case V： Ms Ling
Prolapsed intervertebral disc in cervical spine , probably incurred while doing yoga.
As an office lady working in Central, Ling loves yoga most among all sports. In the last six months, she went to yoga practice once every week, sometimes even two or three times. On a day in October last year, for no obvious reason her left upper back muscle felt like being spiked by a hundred thousand needles, and her left arm could barely move. In excruciating pain she gritted her teeth and consulted an orthopaedic specialist, Dr. Wu, who made a preliminary diagnosis that the pain was related to her cervical vertebrae.
Break Free from Pain through Professional Physiotherapy
Dr. Wu suggested MRI for Ms Ling. The result was prolapsed intervertebral disc in cervical spine, which pressed against the nerves and resulted in the swelling and inflammation of the upper back muscle tissues. Due to her acute condition, Ms Ling was referred to the Physiotherapy Department immediately to receive neck traction and muscle-relaxing treatment under professional guidance.
"I was lying on the bed, my whole body feeling like being pulled to one side by the stiff neck," said Ms Ling. "With her deft hands, my physiotherapist softly rubbed and pulled certain key areas. My upper back felt relaxed significantly at that moment . It's just like going back to the heaven!" Since then Ms Ling understands why physiotherapy is important to those suffering from musculoskeletal problems.
Neck Traction Relieves Neck Pain
While the pain was receding, Ms Ling needed to stay in hospital for various kinds of medication, injections and physiotherapeutic treatment. On the day of her discharge, she still had to receive rehabilitative treatment, which included interferential therapy, neck traction, manual massage, ultrasound treatment as well as muscle –stretching and joint-mobilizing exercises. The aims of all these treatments were four-folds: to relieve joint or muscle inflammation, assuage pain, improve blood circulation and speed up tissue recovery.
Ms Ling continues with physiotherapy once every two weeks with good results for about three months. She cannot be too grateful for all her physiotherapists did for her recovery.
"They checked on my latest condition and gave me the most effective treatment," said Ms Ling. "For example, after only a few times of manual massage, I am relieved from the stiff and stinging pain."
Side Effect of Shoulder Stand
Though not sure about the cause, Ms Ling thinks yoga was the leading factor of prolapsed intervertebral disc in cervical spine. During the three yoga lessons within the week before the incident, she had done shoulder stand.
"I have been learning yoga for two years. I know yoga is complicated and injury-prone, and that's why my lessons were all one-on-one sessions during my first 18 months of yoga practice, " said Ms Ling. "For the last six months I decided to join group sessions, hoping I could get more practice. Honestly speaking, it would not be possible for just one instructor to take care of more than twenty students and give specific guidance. Injuries are bound to happen."
Wrong Neck Postures Raise Risk of Injury
In fact, it was a long story for her neck injury, which probably had something to do with her daily postures. According to Dr. Wu, office workers involving desk activities are the high-risk group of neck pain , their neck muscles being strained with the head bend down for a considerable length of time while working. It contributes to chronic fatigue or degeneration of the cervical intervertebral discs, which in turn leads to a series of problems and increases the risk of injury.
The best posture is to keep the neck straight and the back against the chair while working. One is advised to have a short break every 30 minutes and do some neck exercises or massage. At a greater risk of relapse, Ms Ling is reminded of taking extra care, or she might have to refrain from sports like yoga and skiing for a while.
Case VI: Sam (Age: 55)
Golf-Related Back Muscle and Achilles Tendon Injuries
Sam is a golf enthusiast. After almost 2 to 3 weeks on a business trip to Europe with no time to play golf, he went back to the golf course with his friends as soon as he returned to Hong Kong. When he lifted his arms trying to make a swing and sending the ball to fly down the fairway, he felt excruciating pain in his back that made him curled up to one side.
"I could not even walk. So I rested and asked my friends to take me home," recounted Sam. His wife applied "ointment" to his back, but to no avail. For that whole night he could hardly sleep at all because the back was extremely painful. He bore with the pain until morning and went straight to see doctor the next day.
Culprit- No Warm-Up Exercises
Dr. Wong, a specialist in orthopaedics, made a preliminary assessment for Sam, followed by an X-ray examination. It was discovered that Sam's back muscles were sprained. Sam admitted he did no warm-up exercises throughout his ten years with golf.
"My friends don't do warm up either, and everything goes as smoothly as it can be. So I think that was just an accident," said Sam. "But Dr. Wong told me that people of my age are prone to these kinds of injury. As I seldom use my back muscle as well, it is easy to get hurt when I do the club swings. That's why I need to do at least 10 minutes of warm-up stretching exercises before the game thereafter."
2 Months of Physiotherapy
Dr. Wong prescribed some anti-inflammatory and pain medication to Sam. Sam was later referred to a physiotherapist, from whom he received TENS treatment (using a Transcutaneous Electrical Nerve Stimulator for pain relief), heat therapy, back-strengthening exercises and stretching practice. For the first two weeks, Sam went for the treatments every other day, each time lasting from 30 to 45 minutes. Treatments were then reduced as his back condition improved. He was also reminded of getting adequate rest and refraining from vigorous exercises and sudden motions, such as making sudden turns.
"After one session of physiotherapy, I felt much less pain in the back. The doctor told me not to use any "ointment" next time and seek medical attention immediately," said Sam.
Sam fully recovered after more than 2 months from the time the injury. He has resumed playing golf again last weekend, but one thing is different: this time he came earlier to the course and stretched his whole body as warm-up exercises. Even his friends followed suit without hesitation.