THE WEAKEST LINK
How to recover from injuries to the most vulnerable joint in the cyclist’s anatomy: the shoulder.
In any fall from your bike, no joint is more under threat than the shoulder. This most mobile of joints enjoys its freedom at the cost of stability; think of the main shoulder joint, the ball-and-socket glenohumeral, as a golf ball on a tee. There’s not much socket at all. In the words of one of the experts we consulted for this article, it really is a bit rubbish at being a socket.
The potential injury list from a fall is lengthy: shoulder, or acromioclavicular (AC), dislocations, collarbone (clavicle) or shoulder blade (scapula) breaks, or soft tissue injuries, such as cartilage or rotator cuff tears. Such injuries are to cyclists what broken fingers are to cricketers, or anterior cruciate ligament tears to footballers: occupational hazards.
Unfortunately, the road to recovery from these sorts of injuries can be long. Because of the complexity of the joint and the difficulties of imaging it, diagnosis can be problematic, as can rehab. When stability is compromised, the four muscles that make up the rotator cuff, which contract constantly to keep the joint functioning, lose their synchronicity. What treatment you get, and how fast you get it, won’t always be the same.
Bone of contention
Dr Philip Holland is a consultant shoulder surgeon – and keen cyclist – at Friarage Hospital in Northallerton, North Yorkshire, a major trauma centre for northern England. He sees his fair share of cyclists, most often with clavicle fractures. “They’ve hit sheep or whatever else. It’s amazing what people crash into.”
The evidence regarding treatment of clavicle fractures is conflicting, he says, as to whether surgery, in which a metal plate is attached to hold the bone in place, is necessary or whether it should be allowed to heal naturally. While surgery is more invasive, it will allow the injury to heal faster. But all surgery carries risks and there isn’t always an absolute necessity
The shoulder joint is one of the most vulnerable areas of the cyclist’s anatomy. In the event of a crash, how canyoumakesure you’re back on the bike as quickly as possible?
for it, for example, if the grade of fracture doesn’t warrant it or if the break is at either end of the bone. The approach surgeons take also varies, he says, because of their own personal experience.
Collarbone breaks aren’t, generally, subtle injuries, particularly when cyclists are involved. “It’s the only bone that holds your shoulder in place,” says Dr Holland. “If you break it, your arm feels like it’s hanging off.”
He says you need to ask questions about your injury and be open with the surgeon about how a long lay-off might affect your life. “I don’t think all my colleagues would be as direct as me in fixing them. But if a patient says it’s really important for them to get back cycling quickly, or if a longer lay-off is going to cause them to lose their job, then the surgeon is going to be hardpressed to say no.”
AC dislocations result from the same mechanism as a clavicle break. The joint is located at the far end of the clavicle nearest the glenohumeral joint. Again, Dr Holland says there’s plenty of conjecture about the best way to treat them – and, again, it might come down to the patient’s needs and preferences. “If they’re completely displaced, they should be fixed [surgically]. If it’s 50:50 I tend to leave them for six to eight weeks to see how they get on.”
Tissue issue
While the problem with clavicle fractures is usually a question of whether to operate or not, at least the injury can be diagnosed quickly. It’s with other injuries, particularly soft tissue injuries following dislocations, where the labrum (cartilage) may be torn, or those injuries that even imaging like MRI isn’t sensitive enough to detect, where trouble lurks. Such situations can require persistence from the patient in getting a diagnosis.
You could be sent to a physio, rather than a surgeon. “Which is good to an extent,” says Dr Holland. “Just because you’ve hurt your shoulder, it doesn’t mean you need an operation. But if you’ve injured your shoulder and you’re not getting better after six to eight weeks, then you really need to see a surgeon to be getting some imaging done on it. If you ask your GP directly, they’ll refer you. If you don’t, you may find yourself going around the houses, and that’s the problem that’s out there.”
If you don’t feel like you’re getting anywhere, you can always seek out a shoulder surgeon privately for an opinion, which costs around £200, and roughly the same again for an MRI. A referral from your GP isn’t always needed. That’s a decent chunk of change, but nothing compared to paying for private physio over the long-term, which is what people often resort to after growing tired of waiting for NHS treatment.
Dislocation, dislocation, dislocation
Shoulder (glenohumeral) dislocation is another common traumatic injury seen in cyclists. There are three types of dislocation, but only two are worth discussing here: posterior and anterior dislocations. Posterior, in which the humerus is displaced backwards, are rare among the general population, accounting for two to four per cent of all shoulder dislocations; anterior, where the humeral head rolls out of the front of the socket, account for over 95 per cent of dislocations.
Professor Lennard Funk, a consultant shoulder surgeon based at the Wrightington Hospital in Wigan, sees more shoulder injuries through cycling than he once did. “It’s the growth of the MAMIL,” he says. “You can guarantee at least one [injury] per clinic and I’m doing four or five clinics a week.”
While clavicle and AC dislocations are the most common injuries he sees, traumatic shoulder dislocations are also, unfortunately, frequent. And although posterior dislocations are rare among the general population, he sees a higher proportion of them in cyclists.
Anterior dislocations happen when the arm is out to the side or overhead. Of course, they do happen in cycling, but diagnosis is often fairly clear cut – your arm sticks out in an exaggerated fashion and needs popping back into the joint.
Clavicle breaks are so common because the cyclist struggles to get their arms up in time, often taking a direct hit
“The collarbone is the only bone that holds your shoulder in place. If you break it, your arm feels like it’s hanging off”
to the shoulder. A direct hit is also the mechanism of injury for a posterior dislocation and getting an accurate, timely diagnosis can be problematic.
“When a shoulder dislocates out of the front there’s nothing much other than soft tissue [preventing it from coming out], so the shoulder completely dislocates and it’s very obvious,” says Prof Funk. “With posterior dislocations, it isn’t.”
Because the joint has more bony structures at the back that help to prevent posterior dislocations, the forces involved in a high-speed cycling crash make it more likely. Patients with posterior dislocations, he says, often present with pain, rather than anything visibly alarming.
“Because posterior dislocation is uncommon, clinical tests for assessing it aren’t widely known. Unless a clinician suspects this injury, it can be easily missed.” While X-rays often show a normal shoulder, even an MRI scan, says Prof Funk, has only a 50 per cent chance of spotting it.
Given the lack of, or late, diagnosis, an untreated posterior shoulder dislocation can cause serious problems for cyclists. The trauma of the injury can cause soft tissue injuries, such as torn labrum (the cartilage lining the socket) and bone fractures, which increase pain and instability. And even if the rotator cuff escapes damage, the trauma of injury and subsequent healing can leave it badly misfiring, leading to secondary soft tissue problems such as bursitis and tendinitis. Because of the difficulty picking this up on X-rays, and the slow progress typical within the NHS, the patient can often wait months, even years, for proper diagnosis. Research has shown a misdiagnosis rate of up to 80 per cent following initial diagnosis of this injury.
After the initial dislocation, “cyclists develop more symptoms because of the position they are in on the bike, which loads the back of the joint,” says Prof Funk. “They can end up with chronic posterior instability.”
This means that the onus might be on the cyclist to push for further tests if they’ve suffered a serious shoulder trauma and haven’t received a satisfactory diagnosis after two months, despite suffering continuous pain. That may well mean private treatment, and paying a consultant for further assessments, but at around £200, that could be a price worth paying to get you back cycling pain free.
Prof Funk says it’s important that patients are as clued up on their injury as possible, so that they can ask a surgeon questions about it – his website, shoulderdoc.co.uk – has a comprehensive guide. “Clinicians can seem intimidating, but you should never be afraid to ask questions, such as how often they’ve seen this type of injury before,” he adds.
Phil Burt, former head physio at British Cycling who now runs Phil Burt Innovation, his own cycling performance centre in
“Cyclists develop more symptoms because of the position they are in on the bike… They can end up with chronic posterior instability”
Manchester, says he encourages his patients to think carefully about what they want to find out from a surgeon. “Write down all the questions you want answers to and don’t be rushed. Often you are hurried in and they have a massive clinic, but they’ll be keen to answer interesting questions, because it engages their brain.”
Need for speed?
How much time you take before you get back on your bike after surgery, or during a non-surgical rehab, varies depending on the injury and the rider. We’ve all seen images of professional riders on home trainers days after clavicle surgery, but whether that’s appropriate for an amateur rider is open to debate – and a decision for each individual to make.
“It’s a question of how important it is to you [to get back sooner],” says Dr Holland. When compared to pro athletes, amateurs should “probably” be waiting a bit longer to come back, he believes.
For the collarbones of pro cyclists that Prof Funk has operated on, the average return to cycling is two and a half weeks, compared to six for amateurs.
“In the first week after surgery, getting sweat in your wound isn’t a great idea, so giving it a week will help prevent infection,” says Dr Holland. “After that, you need to look at how much weight you’re putting through your arms – if you put your turbo in a very upright position, and you’ve got some supervision, you can get back very quickly. But if you’ve got a keen amateur, I think you’d find they push themselves too much, so I’d suggest six weeks (before riding) to be on the safe side.”
Riding before six weeks runs plenty of risks of crashing and your plate falling to pieces, “which is where things get very complicated,” says Burt. “The problem with plating is that it gives instant relief – you feel like Superman again, but you need to remember you’ve got a healing fracture supported by a bit of Meccano.
“First week post-surgery, I’d suggest not doing much at all. On the second week, get on the turbo and increase cardio fitness. I’d suggest turning your handlebars upside down, so you’ve hardly got any weight through your shoulders. Cycling like this helps to keep your knees healthy too – I’ve seen many people come back from a shoulder injury and develop a knee problem.
“Between weeks two, three and four, you begin to edge your bars back down – progress is individualised. Move it down so far that your shoulder doesn’t ache.
“When you finally get back onto the road, don’t ride with anyone else, as your reactions might not be as good as theirs. If you live in the inner city, drive out to the countryside, where it’s less built up. British Cycling riders would drive out of Manchester to the Cheshire lanes.
“For building strength, start with wall press-ups, then a kitchen top and build towards a full press-up. Once you can do that, your shoulder is as it was before.”
The rehab for shoulder dislocations is much different – and longer. If you don’t have surgery, you’re looking at 12 weeks of strength and conditioning to get the joint back to where it was. And whether or not you have surgery, you’ll always have a bigger risk of further dislocation. You’ll be in a sling for four to six weeks, but evidence now supports getting you out of it as fast as possible, as stiffness can cause problems.
If you’re lucky to get your dislocation, or other soft-tissue injury, diagnosed quickly, there’s still plenty of work ahead of you.
Surgery or not, Burt says it might be worthwhile to invest in private, specialist physio. “The NHS is set up to get you going again. Most shoulder surgeons work with a specific physio, because their surgery stands or falls on the strength of the rehab. They’ll probably work closely with someone and if you wanted to pay for someone, it’s this person you see.
“It’s worth seeing someone who specialises in shoulders. Having the right exercises to do gives you the best chance of getting better. Shoulders need a lot more strengthening than other joints. It’s a vulnerable joint – and even more so once it’s been damaged.”