Inside The Shoulder

The patient had a proximal humerus fracture and scapular fractures. He had no scapular spine. He had no deltoid. Eighty per cent of his trapezius was gone.

Mohammad Jomaa searched the literature and found nothing. Not in the shoulder literature, not even in the sarcoma literature. There was no described solution because nobody had described the problem.

So he invented one. And he is emphatic that every solution he has invented since rests entirely on the basics he was taught during his fellowship.

Now leading a shoulder and thoracic outlet unit in Beirut, Mohammad traces a path that began with a last minute decision. In Lebanese high school he took the pathway built entirely on mathematics and physics, with no biology at all, and excelled at it. His whole extended family expected engineering. In the summer between school and university he chose medicine instead.

He describes orthopaedic training in Lebanon in terms that are hard to process from Australia. The most competitive program in the Lebanese University, taken by roughly the top twenty per cent of the cohort. He ranked fourteenth out of a hundred. Residents rotate through ten different hospitals across five years. And the hours: 24, 48 and 72 hour shifts. As he puts it, the hospital is the first home and your mother's house is the second.

There is a warm section on the difference between a mentor and a boss.

Max Lavaill says the quiet part out loud a few minutes in. Researchers gravitate to the knee and the hip because those joints are simple, a hinge with one or two degrees of freedom. The shoulder has enormous range of motion and enormous potential instability, which is exactly why so few people have studied it properly, and exactly why he chose it.

Max is a French biomechanist doing a postdoctoral fellowship at Queensland University of Technology. He grew up in Châlons en Champagne, the son of two GPs, and came to Australia after a holiday in 2017 convinced him Brisbane was where he wanted to be.

He opens up the machinery of academic research in a way researchers rarely do publicly. He explains musculoskeletal modelling, the h index, why impact factors multiply the value of a citation, and why he thinks the entire metric is distorting science.

He is equally candid about grant funding. His Advanced Queensland Fellowship was worth $160,000 towards a $400,000 project. The application took two months of his life across roughly fifteen drafts, and he might have got nothing. Without a grant, a postdoc is unemployed.

The current project is scapular dyskinesis, where the literature still cannot agree whether it is a cause or a consequence, and where he is chasing sub millimetre accuracy in tracking a bone buried under muscle and fat.

Keigo Honoki dislocated his shoulder sliding into a base. It came out again. And again. More than ten times, eventually during ordinary daily activity rather than sport. His wife learned to put it back in for him.

He has had two arthroscopic Bankart repairs. He never played competitive baseball again, the sport he had built his childhood around.

That injury is why he became a shoulder surgeon.

Keigo talks about the Japanese medical system and a training path that looks nothing like the Australian one. The account of Japanese schooling is remarkable. Cram school from the age of eight, five hours a night after ordinary school, finishing at eleven. Later, a three hour daily round trip by train, every hour of it spent studying. He left home at 6:30am so he could study before class started.

He also explains something counterintuitive. Because Japan's health system is public and salaries barely differ between specialties, orthopaedics is not the fiercely contested field it is in Australia or the United States. He simply chose it.

The clinical thread is arthroscopic latarjet surgery, which he had never seen before arriving in Brisbane and which remains uncommon in Japan. He is frank that he does not yet feel confident performing it alone, and equally frank that he applied for this fellowship three or four years running before he was accepted.

Tristan Shuker had done the GAMSAT. He had done the application. He had been offered an interview at the University of Queensland, the thing he had worked towards for five years.

You get one day to accept the offer and book the slot. That week he had gone through a breakup and was, by his own account, not in his own head. The day passed.

He woke at 1am in a cold sweat because he had just remembered. He called. He emailed. He had missed it.

He never reapplied.

Now the research assistant at the centre of a rapidly growing research program, Tristan talks about what happens after a plan collapses. He is a self described perfectionist, and his reasoning for not going back is precise rather than bitter. If he is going to do something, he wants to do it properly, and he no longer believes he could commit to medicine that way.

Before this role he was part of the team behind the preclinical work on ex vivo heart perfusion, keeping donor hearts viable long enough to survive an eight or nine hour flight between Australian cities. More flights, more transplants, more people alive. He calls it one of the North Star moments of his life, and notes drily that the roaring crowds are somewhat smaller in science.

He has taken the research program from six projects to more than twenty in four years, and is quite open about still having imposter syndrome.

Lucy Angelini's mother developed frozen shoulder in both shoulders, one after the other. She is one of the most capable people Lucy knows, and she could not lift her arms away from her body.

The official medical advice she was given was to go and hang out the washing.

Watching her mother get real help from a physiotherapist instead, at the practice Lucy would later work for herself, is what decided her career.

Lucy is the shoulder physiotherapist who works alongside Ken in clinic, with twenty years of getting people back to their lives behind her. She explains frozen shoulder clearly for anyone who has been given the diagnosis and left none the wiser. The capsule of the joint becomes inflamed and thickened and simply stops you moving. It is brutal, nobody can predict who will get it, and the one mercy is that it does eventually resolve.

She also describes something few physiotherapists get to see. Her husband had major surgery to his scapula when their children were very young, and for six weeks she watched what living in a sling actually looks like from the other side.

The patient she has never forgotten needed a rotator cuff repair, six weeks of passive movement only, and had three year old triplets.

There is a great deal of practical advice here for anyone facing shoulder surgery. And a Wallabies player who was entirely unbothered by the operation and fainted when the stitches came out.

Anand Ashok Kumar's father started his medical practice in a cow shed. One room. Then a small clinic with three beds. Eventually a thirty five bed hospital, built from nothing with no help from his own family.

Anand watched that happen, and it is the reason he became a surgeon.

He describes the scale of medical competition in India in terms that are hard to absorb from outside it. Roughly 1.5 million people compete each year for a limited number of medical school places. The postgraduate surgical exam he sat was taken by 240,000 candidates, up from around 160,000 the year before. Three and a half hours, 200 multiple choice questions, and a career decided.

His younger sister came second in her school and still did not get a medical place. She missed by three marks.

Anand talks openly about the sleepless nights, the family expectation, and doubting whether he was capable at all. He also describes the moment that pushed him towards the shoulder: a manual labourer who had delayed surgery for months because he could not afford it, and who Anand later saw lifting his arm over his head. He had his livelihood back.

The episode also covers the personal cost of an overseas fellowship. For six months his daughter was in India, his wife was doing a fellowship in Sydney, and he was in Brisbane.

He returns to Vellore to build a shoulder and elbow service in a department that has never had a dedicated shoulder surgeon.

Back in Malaysia after training in Ireland, Ridzwan Namazie found himself responsible for the spinal injury unit. It had ventilated beds. He had no intensive care experience. He spent his shifts calling ICU for help with intubated patients who were, on paper, his.

He is careful about how he frames it. It is not that one system is better. Each is built around the needs of the population it serves. In Ireland, a patient needing a central line went to ICU. In Malaysia he put his first one in on the ward.

Now an orthopaedic shoulder surgeon in Brisbane working at STARS and in private practice, Ridzwan traces a route through four countries. Seventeen years in Malaysia, ten in Ireland, just over ten in New Zealand, and now Australia.

Born in Kuala Lumpur to two doctors, he grew up in Ipoh, went to boarding school, then to Ireland for medicine, where he deliberately chose a medical internship before a surgical one. His reasoning: a surgical trainee who does not understand the medical side of a patient will spend all their time working it out.

There is a lovely aside on Malaysian English, the "lah" at the end of sentences, and the way his accent reverts within days of landing back home.

He also admits he set out to be a spine surgeon, and that every five year plan he has ever made has been overtaken by events.

Freek Hollman sat the IELTS English exam five times. Every attempt he failed a different section. Without that certificate he could not register to practise in Australia, and the fellowship he had been selected for would not happen.

He passed on the fifth try, finished his PhD and his training program in the same year, and flew to Brisbane with his wife and two daughters.

The Dutch shoulder surgeon talks about the path from a childhood in a family of doctors to a consultant post in the south of the Netherlands. He explains why the shoulder pulled him away from every other joint. Four joints working as one, and a rotator cuff that only humans and the great apes possess.

He is candid about the Dutch system's hardest truth. Getting onto the orthopaedic training program is comparatively straightforward, but when he finished, almost half of his cohort had no job to go to.

He also describes what happened when he brought Australian technique home. The arthroscopic glenoid procedures and the brachial plexus release he had learned in Brisbane were met with open criticism from colleagues who thought he was crazy. He kept going, and now teaches the brachial plexus release on a European course with live surgery broadcast across the continent.

"If you want to be something, you also have to become it."

Kieran Hirpara read William Gibson's Neuromancer as a kid and became fixated on one idea in it: robotic limbs. He wanted to design them. To design them he needed to understand the hand. To understand the hand he needed to be a surgeon.

Other people ended up building the robotic limbs. He ended up with a career in upper limb surgery instead.

Now practising in Rockhampton, Queensland, Kieran has a genuinely unusual path into orthopaedics behind him. His father, from a farming village outside Ahmedabad in Gujarat, joined the RAF as a medical officer, and the family moved with the postings. Three years in Germany, three in the Middle East, and boarding school in the UK in between. He did medicine in Ireland, missed out on the orthopaedic training scheme on his first attempt, and got in on his second.

There is a substantial clinical discussion here that trainees and physiotherapists will find useful: why patients keep turning up with carpal tunnel syndrome after shoulder surgery, the mechanism behind it, and the sling related problems nobody warns you about.

Kieran also explains why he left hand surgery behind, and what it was like to finish training in Ireland during a recession, into a hiring freeze, then start again in regional Australia where he had a full day operating list within three months.

His closing assessment is honest rather than inspirational.

In this episode of Inside The Shoulder, Dr. Kenneth Cutbush is joined by Dutch shoulder surgeon Freek Hollman, currently practising in the south of the Netherlands.

Freek shares how growing up in a medical family with a surgeon father and a brother in medicine, shaped his early path, and how a third-year internship changed everything after being involved in an AC joint reconstruction. That moment sparked his passion for orthopaedics and ultimately led him to focus on shoulder surgery.

He discusses why the shoulder’s complexity continues to motivate him, how every structure must work together for function of the arm and hand, and why the diversity of shoulder surgery is so rewarding. Freek also explains what it really takes to become a surgeon in the Netherlands, the highly competitive training pathway, and the reality that many graduates struggle to secure surgical positions.

The conversation explores his upbringing, family life, and the key advice he would offer to anyone considering a future in orthopaedic and shoulder surgery.