The Surgery

A couple of weeks ago I wrote a blog entitled Out Of Action. I've now had my shoulder surgery and a number of people have requested a follow-up, with a bit of detail about the diagnosis, the procedure itself and the beginnings of a recovery.

Warning: this blog post has got very little to do with bikes, other than the fact that dislocated shoulders are something that a lot of riders have to deal with. Since I wrote the first out of action blog, I've been contacted by a lot of people with shoulder problems; riders who think they may need a similar surgery or are considering whether or not a surgery is worthwhile. There's a lot to consider, when you take into account the waiting time, the potential pain and discomfort of the operation itself and the possibility of a lengthy recovery. When I was making my own decision, I had access to plenty of official medical advice but very little insight into what it would really be like to live with. So my purpose in this piece is to lay out how my own surgery went, along with the initial recovery period and what the next few weeks will have in store.

Another Dislocated Shoulder

The last time I popped my shoulder was at the 'Ard Rock Enduro. I spent the first day out on course with my friend Gee who was filming, then the evening before the race was mucking about with some mates in the campsite. I tried to throw a Nerf ball a bit too hard and literally threw my arm off. That was the end of my weekend. It had become so easy to hurt myself I had to get it looked at properly.

A quick visit to the GP later and I had a referral to a shoulder consultant. It's worth noting that they took into consideration the fact that I own a mountain bike business and that the injury affects my livelihood. This came up at every point of consultation and I found it interesting that this didn't seem to be a purely medical thought process; the gravity of the injury for me personally was taken into account.

I had a choice of consultants. The NHS site gives you all the different specialists, where they have clinics and their average waiting times - both for a consultation and for treatment. I chose Mr Wright at the Thornbury in Sheffield, and had a month to wait to see him. Again it's worth noting that the initial choice set the path for my entire treatment, so I was to stay with the Thornbury throughout the process. This wasn't made clear at the outset so if you find yourself with a referral, take this into consideration.

Unlike the 2 minute GP appointment, Mr Wright gave me a full half hour, and discussed everything in great detail, answering all my questions. Then at the end of the consultation he signed off a form that he'd already filled in. He's so used to these injuries, he knew exactly what the next step would be: an MRI Arthrogram.

A physical examination confirmed that the joint was unstable but to determine the exact nature of the damage, a detailed MRI scan was necessary. We started off with a series of traditional X-Rays, and then prepped for the MRI. I was given a local anaesthetic to the shoulder, before a contrast medium was injected into the joint using a long needle. This apparently increases the visibility of the joint in the scan. The MRI itself was relatively straightforward, but you do have to remain completely motionless for around 40 minutes. It's a bit like being inside a very loud dot matrix printer.

It took another fortnight to get another consultation, at which point the surgeon - Mr Shahane - could make a solid diagnosis.

My Diagnosis

The original incident was an anterior dislocation of my right shoulder, a common injury amongst active people, in particular mountain bikers, skaters and skiers. I caught the bars on a tree whilst cornering at high speed, which sent me over the bars, landing on my shoulder, forcing the arm out of the joint forwards and down, into my armpit. The specific damage caused was:

Bankart Lesion

"The glenoid labrum is a fibrocartilaginous rim attached around the margin of the glenoid cavity in the shoulder blade. The shoulder joint is considered a ball and socket joint. However, in bony terms the 'socket' is quite shallow and small, covering at most only a third of the 'ball'. The socket is deepened by the glenoid labrum". (source: Wikipedia) In my case, the foremost portion of the glenoid labrum was torn and detached, meaning the glenoid was no longer a 'socket' and was therefore unable to retain the 'ball' of my humerus.

Slap Lesion

I also has a slap lesion, which means the labrum had torn all the way around to the point where my biceps tendon attached to the shoulder. This didn't show up on the MRI scan and only became apparent when the general anaesthetic took effect; my arm literally fell out of joint. Since August it had been held in place by willpower alone.

Hill Sachs Lesion

A dent in the bone at the back of the humeral head, which occurs when the dislocated humerus impacts against the front of the glenoid. This causes a number of arthritic symptoms, and if left untreated will deteriorate over time.

Timescales

If you're anything like me, the first thing you want to know when you break yourself is, "how long until I'm back on my bike?". So it might be helpful for me to illustrate how long I had to wait for each stage of the diagnostic process leading up to the surgery:

6th August: Shoulder dislocated at the 'Ard Rock Enduro
8th August: Appointment with GP, referral to shoulder specialist
22nd September: Appointment with first specialist, referral to MRI scan
27th October: MRI Arthrogram and standard X-Rays
9th November: Appointment with second specialist to discuss scan results, referral to surgery
14th December: Surgery

So since the last dislocation, at which point I decided that I really needed to get this sorted, it took 19 weeks until I went in for surgery. And in many ways, the surgery is only the beginning of the recovery process. For me the impact of the surgery was always going to be worse than the latest injury; I was able to ride again after a couple of weeks. In many ways the surgery actually makes things worse in the short term. But the goal has to be a situation where I don't dislocated my shoulder every time I try to throw a ball. 

The Decision

With the benefit of hindsight, its easy to say the surgery was the right decision. But at the time it was a really tough call to make. From a medical point of view, it was pretty clear-cut: the shoulder was so unstable it could pop at any time, and I was getting arthritic symptoms every day, which if left untreated would only get worse. And that was even without knowing I had a Slap Lesion in addition to the Bankart Tear. The surgeon was very confident that the repair would eventually deliver near to 100% functionality, but only after a successful recovery, and therein lies the rub.

The 'standard' recovery goes something like this:

And only after that could I start to think about regaining the lost muscle mass, strength, stamina and dexterity required to ride a bike properly. So 3-4 months off the bike, ant at least a month with only one hand. My left hand, which is more or less for display purposes only (it's taken me several days to type this much).

Taking into account my own personal circumstances - a business to run, a four year old daughter and a very pregnant wife - the big question was really just one of timing. In other words, when rather than if to have the surgery. For anyone else considering the same question, it's really a personal thing, but for me the decision was made easier by the clarity of the operation date; there was an opening on 14th December, so no long wait. I decided to go for it, and knowing what I know now, I'm glad that I did.

Surgery & The Aftermath

Obviously I can't provide much of an account of what happened during the surgery; I was out for the count. If you really want to know what an Arthroscopic Bankart Repair involves, there's a good video on YouTube. Maybe watching an animated surgery isn't your cup of tea, but I have to say I was fascinated to find out how sophisticated  these keyhole procedures are now.

What I can do is give my own account of what it was like to be on the receiving end of this procedure, and how the first few days of recovery have gone. It's that kind of insight that I found hard to get when I was making my own mind up.

The Recovery

It's early days yet and I don't have my first proper physio appointment until next week. But I can draw a few early conclusions that might be relevant to anyone else in a similar predicament. Firstly, I now feel that I should have sought proper medical advice much earlier; I shouldn't have been fobbed off by my doctor after the first two dislocations, and I shouldn't have allowed myself to disregard the possibility that I might have done some permanent damage. It's clear that I've been living with a seriously impaired shoulder for several years now, which has made things harder than they should have been and it's also undermined any training gains I made in that time.

Secondly I underestimated the impact that the surgery would have and my ability to overcome it in the first few days and weeks. I just thought I'd walk it off, and didn't accept that the operation would pole-axe me for several days. For that reason I was underprepared and it's a good job I have awesome friends and family around to help me out.

When I was first told my arm would be in a sling for 4 weeks I remember thinking "that's just what they tell everyone; I'm not actually going to do that". But that's my old, bad habits talking. I now know that I really do need to take the advice and if I don't, the whole surgery might turn out to be a waste of time. Im taking my recovery much more seriously now.  

That's the good news - I'vm going to be off the bike for a while but I've got a new appreciation of how important it is to be fit, healthy and able to ride, and a renewed determination to recover well and get back to training. If it all goes according to plan, I should be able to get to a place where I'm riding better than I have for some years.

If there is interest, I'll post the odd update on the physio and recovery process.