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Heterotopic ossification (HO) is the abnormal growth of extraskeletal bone. Joint involvement may result in chronic stiffness and pain causing considerable functional impairment and the inability to perform the activities of daily living. HO affecting the shoulder joint is rare and little is known about its clinical course or treatment. Here, we describe the first reported case of glenohumeral HO following anterior dislocation. This occurred in a 70-year-old man following a fall onto outstretched hand. Due to persistent stiffness and pain at 8 months from initial injury, he underwent plain radiographs and MRI scans that confirmed rotator cuff tear and HO. He was managed conservatively with physiotherapy and non-steroidal anti-inflammatory drugs. At 1-year follow-up, the patient maintains a good functional outcome.

Tennis elbow is a common condition: one of those aches and pains of middle-aged collagen. Often provoked by overuse but sometimes spontaneous, it is usually a self-limiting condition. However, when symptoms are troublesome patients are likely to seek help at least to tide them over until it settles or if not, to provide a cure. These two papers complement each other and help the reader to consider all the options. In the first article, Messrs Kumar and Stanley give a concise but comprehensive summary of the treatment options: non-operative, minimally invasive and surgical. They also introduce two relatively new techniques: platelet-rich plasma and arthroscopic release. Most readers will probably have heard about these; having read the article they will appreciate the evidence and understand the indications. In the second article, Messrs Burke and Mullett address one of these newer approaches. The anatomy and surgical technique is elegantly described; the rationale and evidence for its use is presented. Having read both articles, the reader who deals with tennis elbow will perhaps take a different perspective and consider other ways of treating this common but often disabling condition.

Root cause analyses were intended to search for system vulnerabilities rather than individual errors, using a human factors engineering approach. In practice, root cause analyses done in the NHS may generally fail to identify components where there are organisational failures, as there may be an inherent desire to protect institutional reputation. A human factors approach to root cause analysis looks at system vulnerabilities, considering the entirety of the environment in which an individual works and taking into account factors such as the physical environment and individual mental characteristics. Other human factors include group dynamics, task complexity and concurrent tasks. It is time that the growing evidence of the potential shortcomings of root cause analysis, especially as frequently applied within the NHS, is heeded. At present, rather than assisting learning it may be an impediment to patient safety. The authors propose that root cause analyses should be performed by a group of people who are not managing the service. External organisations such as the General Medical Council, Nursing and Midwifery Council, Care Quality Commission and Practitioner Performance Assessment are heavily reliant on this tool when concerns are raised. If the flaws in root cause analysis can be eliminated, drawing on the available evidence, cases such as those of Dr Hadiza Bawa-Garba and Mr David Sellu might be avoided.