Ann Maria Byrne Elbow specialist SSC

‘Tennis Elbow: Is it all about the Backhand?’ by Ms Ann-Maria Byrne

“Tennis is a perfect combination of violent action taking place in an atmosphere of total tranquility” – Billie Jean King

 

“Tennis Elbow” or Lateral Epicondylitis causes pain over the outside of the elbow. Studies have shown that up to 50% of recreational “for fun” tennis players will develop symptoms at some stage[1, 2]. The condition occurs less in professional players, presumably due to better technique and equipment[3]. It usually affects both men and women between 30 and 50 years of age [2]. And, contrary to its name, the condition is linked to playing tennis in less than 5% of cases.

 

Tennis Elbow Sports Surgery Clinic
Lateral epicondylitis is essentially a repetitive stress or overuse injury. It can occur with any activity where there is repetitive extension and/or twisting of the wrist[3,4]. The condition is caused by degeneration or tears of the tendons attaching to the bone on the outside of the elbow (lateral epicondyle). The Extensor Carpi Radialis (ECRB) tendon is most commonly affected. This tendon is involved in extending the wrist joint and is active while gripping with the wrist extended – such as when holding a tennis racquet. Other activities such as prolonged use of a computer mouse and typing at a keyboard have been implicated. Plumbers, painters, carpenters, butchers and chefs are groups at risk due to their wrist motion in their line of work.

 

Elbow Surgery Sports Surgery Clinic
In tennis players, the backhand stroke causes injury by overloading the wrist extensor muscles attaching into the lateral epicondyle. This stroke can be performed using a one-handed or two-handed technique, however, the one -handed approach is more commonly associated with elbow injury[5]. Incorrect grip size of racket handle has been found to cause increased force transmission to the elbow increasing injury risk[6]. Also reports are emerging that decreasing grip strength and relaxing forearm muscles in the follow-through phase of the back- hand stroke can help prevent “Tennis Elbow” in recreational tennis players[3,5,6].

 

Tennis Injuries

 

Patients usually present with pain and tenderness on the outside of the elbow. They often describe a dull ache travelling from the outside of the elbow down along the extensor muscles to the wrist. Some have swelling around the outside of the elbow. Some complain of the following symptoms:

 

• Pain when the wrist is brought back into extension
• Pain when lifting a cup or kettle
• Pain when shaking hands or making a fist
• Pain turning a door knob

 

Other conditions can cause symptoms that mimic tennis elbow and need to be ruled out. These include arthritis of the elbow, ligament injuries, neck problems, nerve entrapment, and shoulder impingement. History and clinical examination usually guides your doctor to the diagnosis. Further imaging such as an MRI scan may help identify the severity of the condition, and any underlying pathology[7].

 

There is no consensus on the definitive treatment of lateral epicondylitis. However a period of non-operative treatment is recommended before considering surgery. Most cases are self-limiting and resolve with rest within 6 to 12 months. However, for some, especially the keen tennis player, this wait-and-see approach may not be feasible. Conservative treatment may involve a combination of eccentric stretching exercises with physiotherapy, bracing and injections[8, 9].

 

With a failed trial of non-operative treatment, surgical release and/or repair of the tendons at the lateral epicondyle can be performed. Studies of functional recovery after surgery have indicated that patients can typically return to play within 3 to 6 months [10]. Prevention programmes focused on warm-up stretches, and equipment modifications such as racquet grip sizing are important in the long term management of the condition[6]. Lifestyle changes may be required in those who have an occupational risk of the condition such as rest periods, equipment adaptation and avoidance of repetitive wrist extension.

 

‘When I was 40, my doctor advised me that a man in his 40’s shouldn’t play tennis. I heeded his advice carefully and could hardly wait until I reached 50 to start again’  Hugo L. Black

For further information or to make an appointment with Ms Ann-Maria Byrne, please call +353 1 5262345

1. Pluim BM, Staal JB, Windler GE, et al. Tennis injuries: occurrence, aetiology, and prevention. Br J Sports Med 2006;40(5):415–23.
2. Nirschl RP. Elbow tendinosis/tennis elbow. Clin Sports Med 1992;11(4):851–70.
3. Chung KC, Lark, ME. Upper Extremity Injuries in Tennis Players: Diagnosis, Treatment, and Management. Hand Clin 2017;33: 175–186.
4. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med 2003;22(4):813–36.
5. Riek S, Chapman AE, Milner T. A simulation of muscle force and internal kinematics of extensor carpi radialis brevis during backhand tennis stroke: implications for injury. Clin Biomech (Bristol, Avon) 1999; 14(7):477–83.
6. Rossi J, Vigouroux L, Barla C, et al. Potential effects of racket grip size on lateral epicondilalgy risks. Scand J Med Sci Sports 2014;24(6):e462–470.
7. van Kollenburg JA, Brouwer KM, Jupiter JB, et al. Magnetic resonance imaging signal abnormalities in enthesopathy of the extensor carpi radialis longus origin. J Hand Surg Am 2009;34(6):1094–8.
8. Krogh TP, Fredberg U, Stengaard-Pedersen K, et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial. Am J Sports Med 2013;41(3):625–35.
9. Gautam VK, Verma S, Batra S, et al. Platelet-rich plasma versus corticosteroid injection for recalci-trant lateral epicondylitis: clinical and ultrasonographic evaluation. J Orthop Surg (Hong Kong) 2015;23(1):1–5.
10. Solheim E, Hegna J, Oyen J. Arthroscopic versus open tennis elbow release: 3- to 6-year results of a case-control series of 305 elbows. Arthroscopy 2013;29(5):854–9.
11. Oki G, Iba K, Sasaki K, et al. Time to functional recovery after arthroscopic surgery for tennis elbow. J Shoulder Elbow Surg 2014;23(10):1527–31.

James Carolan Physiotherapist SSC

Back Pain in Gaelic Games – why does it happen & what should be done?

Back Pain Rehabilitation at Sports Surgery ClinicBackground

Back pain is the most prevalent musculoskeletal condition that effects the general population effecting approximately 15-20% per year. There appears to be a belief that low back pain is saved for the elderly, inactive, overweight or indeed those who are involved in heavy manual jobs. Unfortunately, sports people are not exempt from this problem. Up to 85% of athletes that participated in sports that involved high spinal load reported low back pain at some point in their career. (Baranto et al., 2009)

 

A study on Dutch soccer players found that 64% of players had low back pain at some point over a 12-month period and that it reoccurred in 59% of these.(van Hilst et al., 2015) Back related injuries in Gaelic football have been recorded as being between 2.5% and 15% of all injuries between 2011 and 2014. Similar figures have been reported for trunk injuries in Hurling over the same period. (Blake et al., 2015) Interestingly, research suggests that people who are involved in rotational based sports and who are less active during the day are more likely to experience low back pain. (Chimenti et al., 2013) This is particularly relevant to the footballer or hurler who sits at their desk all day and then can often have a long drive before rushing into dressing room and out into a warm-up.

 

Back pain has been shown to detrimentally effect physical performance in both men and women. As with most injuries recurrence rates are high. (Novy et al., 1999) Although lumbar spine injuries only make up 1-2% of new injuries during the AFL season, back injuries have been responsible for 5% of games missed over the past 10 seasons. (Orchard et al., 2014)

 

Although sports people receive more medical attention their short term recovery is thought to be poorer than the general population. This can be more problematic in amateur athletes who may incur loss of earnings as a result of their injury. Back pain can also take its toll on family and social life particularly when it becomes a chronic or recurrent problem.

 

 

What Structures are involved?

There are a number of misconceptions that appear to be commonplace in society and particularly in the sporting population with regard to the cause or contributors to back pain. Athletes often suspect a bone, joint or their pelvis being ‘out of place’ as being the source of their back pain. This was never more debated in the sports medicine world then in 2014 when Tiger Woods missed a major tournament citing his ‘sacrum being out of place’ as the primary factor.

 

The reality is that these phenomena are unlikely to occur and there is certainly no medical research to back up such opinions. A difference in leg length is also regularly offered as misconceived contributor to low back pain in athletes. Although there are a small number of hurlers/footballers who may have a leg length difference due to a fracture or birth defect there appears to be an over diagnosis of this problem in athletes who get recurrent low back pain.

 

The importance of an accurate diagnosis cannot be overstated. Understandably I see a lot of athletes that are very concerned because they think there ‘disc bulge’ won’t get better or that they have ‘wear and tear’ in their back.

 

Research on people without back pain shows evidence of disc degeneration (91%), disc protrusions (32%) and disc bulges (56%). (McCullough et al., 2012) These changes are more common at the lowest 2 levels of the spine in the athletic population. (Ozturk et al., 2008) There is little sports specific data on the sources of low back pain. Low back injuries that result in significant nerve related problems make up 5-10% of presentations. Nerve injury or compression that may causes pain, weakness and/or numbness in the leg in an athlete is most likely to be as a result of a disc prolapsed.

 

The majority of the remaining back problems (up to 90%) are difficult to attribute to one specific structure in the lumbar spine and are referenced as non-specific low back pain. These are most likely to be as a result of soft tissue strains, sprains or overload of the superficial/deep muscles of the lumbar spine or of the small facets joints the allow for movement of the lower back. Imaging in the form of MRI is generally not warranted in these presentation.

 

My work in the Sports Surgery Clinic allows direct access to a multi-disciplinary team including Sports Medicine Consultants, Radiologists, Strength and Conditioning Coaches and Consultant Neurosurgeons. Being able to call on these services ensures that we can make an accurate diagnosis and identification of the factors driving the issue relevant to the athlete and ease people’s fears with regard to their prognosis as many radio-logical findings are present in healthy pain free populations.

 

 

Why does back pain occur?

As with the majority of musculoskeletal injuries, causation is generally considered to be multi-factorial. Contributors can be divided into extrinsic (external to the athlete) or intrinsic factors. The primary extrinsic factor that may be key to a hurler or footballer experiencing low back pain is their training history. Training load and intensity need to be evaluated to ascertain whether players have had a sharp spike in load or indeed the opposite could be a contributor where players are not adequately prepared for the required demands of competition. Overall training load and spikes in training load have been shown to result in increased reporting of low back pain in a number of individual and team based sports. (van Hilst et al., 2015, Bahr and Krosshaug, 2005).

 

Lack of rest or recovery strategies employed by teams may also be a contributing factor. Liaising with the team physio, S&C coach or manager can be very effective in this incidence particularly when there is a trend of injuries within a team. Environmental factors such as weather and the type/quality of surface players are training on (i.e. Astroturf vs grass) may influence training load or increase the risk of contact type back injuries.

 

Back Pain Injuries Santry
Fig 1 Anterior Pelvic Tilt

 

The type of training undertaken may be of importance. In my own experience there seems to be a group of athletes who report back pain after longer running distances while having little difficulty tolerating speed and acceleration work.

 

These athletes tend to over-stride which can result in a more pronounced anterior pelvic tilt (black arrow figure 1) and curve in the lower back. Fatigue can often result in an accentuation of these movement patterns leading to increase loads in the lower lumbar spine and the lumbosacral junction.

 

This type of movement pattern is commonly encountered in juvenile stress fractures.  Lateral pelvic drop is also a common finding when assessing running style. This is often associated with trunk side flexion to the side of the pelvic drop. Poor lateral hip strength in the presence of low back pain should be addressed.

 

The gym based environment is a key part to most club and inter-county players training schedule. The exercises chosen/equipment used and the expertise of coaching are key factors in the possible prevention/reduction to low back pain in our athletes.

 

Unfortunately, I would consider poor lifting technique as commonplace in GAA players.

 

As it is relatively new to our game players may not have been coached in the basics of movement patterns from a young age. These patterns are essential when developing safe and effective lifting form. Gym based environments can foster a competitive culture leading to a focus on weight lifted rather than control of movement. Although athletes may not have any adverse effects in the short-term, use of poor technique while lifting large loads is likely to have unwanted consequences at some stage in their sporting career

Back Injuries Sports Surgery Clinic
Fig 2 Dead-lift Hyperlordotic
Back Pain Dublin
Fig 2b - Deadlift Good Top Position

The amateur nature of GAA and the fact that the majority of playing members are in full-time employment or education brings may expose players to yearly or seasonal risks such as prolonged sitting during exam periods or jobs that involve high spinal loads such as tradesmen, defence forces and exercise professionals.

 

As with most injuries assessing for any strength or mobility deficits not only in the lower back but through the entire kinetic chain is essential. A study on elite AFL players found an increase in size of the lager torque producing muscles of the lumbar spine with a concurrent reduction in size of the smaller spine muscles that are implicated in controlling the individual levels of the spine as the season progressed. (Hides et al., 2011) Reduced endurance of the low back muscles has been found in people with low back pain. (Latimer et al., 1999)

 

Lack of hip range of motion has also been implicated as a contributing factor for development of low back pain in rotational based sports. (Harris-Hayes et al., 2009) It is likely that athletes with insufficient range about the hips, shoulder and thoracic spine will place greater rotational forces through the lumbar spine in movements such as cutting, catching and kicking/striking the sliotar. The assessment needs to be individualised for the player taking into consideration the sport (football or hurling), their position on the field and the type of playing style they have.

 

For example, loss of shoulder mobility may be more important for a midfielder that is the main high fielder in the side compared with a corner forward who wins ball in front of the defender. Conversely loss of hip rotation range may have greater consequences for the corner forward who is repeatedly changing direction compared with a midfielder who is making mostly longer straight line runs.

 

The athletes conditioning for the demands of the sport is one of the key drivers in back pain in Gaelic games. All aspects of physical fitness need to be investigated in order to design a comprehensive rehabilitation plan or prevention program. Each players running mechanics will be assessed when pain and mobility levels allow. Video analysis from behind and the side identifies any movement patterns that increase spinal loading (Figure 3). Slow motion playback helps educate the player on what deficiencies need to be addressed to reduce risk of recurrence and improve performance.

 

Running Injuries Santry Dublin
Fig 3 Running Analysis, Trunk Side Flexion & Pelvic Drop

Movement patterns that have potential to place greater loads on the spine need to be identified and challenged. These movement patterns may be individual to the sport such as striking the sliotar or may be everyday postures such as sitting, bending or standing. Access to 3-Dimensional analysis can greatly assist our analysis of these movement patterns.

 

A key element of low back pain that is being addressed more and more in the general population that appears to be largely neglected in the sporting population in the influence of psychological parameters on the onset and persistence of the problem. Poor coping strategies
and fear around low back pain along can affect
recovery in athletes.

 

The stress of an important upcoming match or anxiety around losing your place in the team because you are injured influences players recovery. It is essential that the medical team, coaching staff and the athlete address these features in order to achieve a successful outcome. There are a number of useful questionnaires that can help identify the effects of peoples understanding and thought processes in relation to their back pain.

 

Management

Exercises for back pain
Fig 4 Lumbopelvic Control Exercise

 

A recent piece of research investigating surgical or conservative management for lumbar disc herniation’s found no difference in the numbers of players returning to sport between the two approaches. Overall the numbers that returned to sport were high but there was doubt as to whether they returned to the previous levels of play. (Reiman et al., 2016)

 

This highlights the need to not just reduce pain and disability but to ensure that the players rehabilitation is effectively managed to ensure that he or she has the ability to play at the previous level. In cases such as disc herniation or non-specific low back pain gradual exposure to lumbar spine movement should be commenced when the initial inflammatory stage has subsided.

 

Simple motor control exercise (Figure 4) can usually be commenced early on to target athletes that have difficulty controlling the lumbar spine in bending and/or extension positions. These can then be progressed in difficulty as the pain subsides and the athletes control improves.

 

Strength deficits should be targeted as soon as pain allows and appropriate movement patterns are achieved. Each athlete that I review will have their lifting technique assessed in order to correct any flaws (Figure 5). This will reduce risk of injury in itself but will also ensure that players are getting the maximum benefit from their gym program.

 

The specificity of exercise selection is essential taking the athletes position, deficits and goals into account. Individualised training plans should not only improve strength but assist in better movement control that can transfer to pitch based training and games. These plans need to be monitored and updated on a regular basis in order for the player to be challenged to a suitable level.

Rehabilitation of Back Pain
Fig 5 Trap Bar Dead-lift
Spinal pain Santry
Fig 5b - Trap Bar Deadlift finish

The majority of strengthening programs will include posterior chain exercises. However, anterior chain and rotational exercises should not be neglected in athletes involved in kicking and multi-directional sports (Figure 7).

Physiotherapy of lower back Pain
Fig 6 Anterior Chain & Rotational Exercise
Strength and Conditioning Santry
Fig 6b - Rotational Exercise

When the athletes’ pain has resolved and adequate control and strength is achieved any modifiable flaws in running mechanics are addressed. Some of the common running faults mentioned previously are best addressed by improving certain strength aspects. However, use of linear running drills can greatly assist the development of a more efficient running style (Figure 7).

 

Use of hurdle or cone running drills are useful in reducing over-stride in athletes. Excessive ground contact time during running can be reduced with the use of marching and skipping drills while concurrently working on the players’ ability to control the movement. Acceleration and deceleration drills are utilised towards the end of rehabilitation to ensure the athlete can control these movements while maximising their efficiency in these highly recurrent tasks.

Running Acceleration drills
Fig 7 Running / Acceleration Drills & Altering Running Mechanics
Running Drills at SSC
Fig 7b Running Acceleration Drill

It is often possible to introduce some running to the players’ program while still working on control, strength and running attributes mentioned above. When available, GPS can do the work for you however simple rate of perceived exertion combined with time and distance covered are generally sufficient. A common mistake is to return to longer distances at slow speeds which can result in less efficient running mechanics. Completing shorter and more game specific runs can encourage more efficient movement patterns. The volume and intensity can be altered as the player adapts to the training volume.

Similar to the linear drills, multi-directional drills can be used to challenge control and efficiency of movement. Other elements that should be considered prior to return to training include jumping and landing mechanics. Striking technique in hurling should also be addressed when it is considered to be a contributor to the players pain. Similarly those involved in kicking from the ground may be at greater risk than those kicking from hand and require technique analysis.

Although back pain is quite prevalent in sport outcomes are usually very successful. Accurate diagnosis and appropriate intervention to the factors driving the athletes symptoms, be they strength, mobility, running technique or sports specific skill, are key to and efficient and successful outcome. Like all injuries adherence to appropriate training loads and exercise technique will minimise the risk of initial injury as well as ensure a successful return after rehabilitation.

For further information on this subject or to make an appointment please call +353 1 5262040 or email physio@sportssurgeryclinic.com

BAHR, R. & KROSSHAUG, T. 2005. Understanding injury mechanisms: a key component of preventing injuries in sport. Br J Sports Med, 39, 324-9.
BARANTO, A., HELLSTROM, M., CEDERLUND, C. G., NYMAN, R. & SWARD, L. 2009. Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc, 17, 1125-34.
BLAKE, C., MURPHY, J. & ROE, M. 2015. GAA National Injury Surveillance Database: A Review of Injuries in Intercounty Gaelic Games from 2007 to 2014. 1-76.
CHIMENTI, R. L., SCHOLTES, S. A. & VAN DILLEN, L. R. 2013. Activity characteristics and movement patterns in people with and people without low back pain who participate in rotation-related sports. J Sport Rehabil, 22, 161-9.
HARRIS-HAYES, M., SAHRMANN, S. A. & VAN DILLEN, L. R. 2009. Relationship between the hip and low back pain in athletes who participate in rotation-related sports. J Sport Rehabil, 18, 60-75.
HIDES, J., HUGHES, B. & STANTON, W. 2011. Magnetic resonance imaging assessment of regional abdominal muscle function in elite AFL players with and without low back pain. Man Ther, 16, 279-84.
LATIMER, J., MAHER, C. G., REFSHAUGE, K. & COLACO, I. 1999. The reliability and validity of the Biering-Sorensen test in asymptomatic subjects and subjects reporting current or previous nonspecific low back pain. Spine (Phila Pa 1976), 24, 2085-9; discussion 2090.
MCCULLOUGH, B. J., JOHNSON, G. R., MARTIN, B. I. & JARVIK, J. G. 2012. Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology, 262, 941-6.
METKAR, U. 2014. Conservative management of spondylolysis and spondylolisthesis. Seminars in Spine Surgery, 26, 225-229.
NOVY, D. M., SIMMONDS, M. J., OLSON, S. L., LEE, C. E. & JONES, S. C. 1999. Physical performance: differences in men and women with and without low back pain. Arch Phys Med Rehabil, 80, 195-8.
ORCHARD, J., SEWARD, H. & ORCHARD, J. 2014. 2014 AFL Injury Report.
OZTURK, A., OZKAN, Y., OZDEMIR, R. M., YALCIN, N., AKGOZ, S., SARAC, V. & AYKUT, S. 2008. Radiographic changes in the lumbar spine in former professional football players: a comparative and matched controlled study. Eur Spine J, 17, 136-41.
REIMAN, M. P., SYLVAIN, J., LOUDON, J. K. & GOODE, A. 2016. Return to sport after open and microdiscectomy surgery versus conservative treatment for lumbar disc herniation: a systematic review with meta-analysis. Br J Sports Med, 50, 221-30.
VAN HILST, J., HILGERSOM, N. F., KUILMAN, M. C., PP, F. M. K. & FRINGS-DRESEN, M. H. 2015. Low back pain in young elite field hockey players, football players and speed skaters: Prevalence and risk factors. J Back Musculoskelet Rehabil, 28, 67-73.

15 facts about running by Colin Griffin

Running is the second most popular form of exercise in Ireland
According to the most recent Sport Monitor figures from Sport Ireland, running is the second most popular form of exercise in Ireland with almost 9pc of the Irish population engaging in running on a regular basis.
There are plenty of road races and mass participation running events organized throughout Ireland each year. Runners constantly seek ways to improve their performance and the coaching, and sports science and technology market has become equally competitive with more choice available across different marketing platforms, some with questionable evidence to support their claims.

1 We are born to run

Humans are adapted to be efficient at running long distances according to Harvard University professor in human evolutionary biology, Daniel Lieberman. Over the course of five million years, humans evolved by developing short dense muscle fibres around the hips to produce power, long thin muscles and tendons of the lower leg to act as springs to store and release energy, as well as shedding their fur coating to dissipate heat from the body and conserve energy.

2 Fitness test

The key physiological indicators for endurance running that can be measured are VO2max, running economy and lactate threshold. Two runners with the same VO2 max can have significant differences in performance due to one having a superior running economy. In fact, well-trained athletes reach a point where they can no longer increase VO2max and must find other ways of improving their efficiency. Lactate threshold tells you the speed or effort at which lactate begins to accumulate at a rate greater than it can be cleared and by increasing lactate threshold you can improve endurance performance.

3 Training programme

A runner who has a busy work schedule and perhaps a young family should tailor their training to allow for these additional stressors and maintain a healthy balance by focusing on the most important training sessions in the week. This would include one longer run, and interval session and medium distance run, along with some resistance training. One long run in the week that is one-and-a-half to twice your race distance if you are racing over shorter distances. If you are training for a marathon, a handful of runs between 18-22 miles in the final three months should be sufficient. Interval training should be done close to your target race pace.

4 Running technique

The best runners in the world display some common features. They make running look easy as they bounce along the ground in less than 200 milliseconds each step.
Beginner runners find their own efficient style of running over the first 10 weeks, according research by Dr Isabel Moore of Cardiff Metropolitan University, who’s subsequent meta-analysis showed that ground contact and limb alignment at push-off influences running economy.

5 Injuries

Injuries occur when an area of the body cannot cope with the repetitive stress placed upon it. Poor technique, poor distribution of ground impact forces and lack of strength, coupled with large fluctuations in training volume or intensity, are common contributory factors to injury. Thirty percent of beginner runners get injured in their first three months. Research carried out at the Sports Surgery Clinic in Dublin showed that gait retraining is effective at alleviating shin splints and calf injury.

6 Strength training

There is extensive evidence to support the inclusion of weight training and plyometric training to improve running economy and performance. Research carried out by the University of Limerick showed that a combination of weight-resistance training and plyometric training, improved running economy by 3.5pc among a group of competitive runners. Plyometric training involves exercises such as hopping and bounding that improves the elastic storage properties of tendons that can conserve energy during running. Like interval training it is important to progress strength training by increasing the amount you lift or how fast you move against resistance.

7 Stretching

Stretching is popular among runners and regularly advocated. Runners need enough flexibility and mobility to move well without any limitations. Static stretching is best done separately to hard running sessions. A small amount of dynamic stretching where a stretch is repeatedly held for only a few seconds at a time, is more desirable during a warm-up so as to maintain a muscle’s optimal tension and elasticity. Having greater flexibility and mobility than required has no additional benefit. Hyper-mobile athletes can be more injury-prone.

8 Hill training

Hill training can provide a useful training stimulus for most runners as it has been associated with improved running economy and race performance. Hill training can be included once or twice per week with repeated short hill sprints, long steady efforts or undulating hills mixed in with a medium or long run. Many distance-running coaches assume that hill training provides enough resistance-training stimulus to substitute strength training, but this has not been proven to be the case.

9 Running Surface

Whether you run on the roads or on grass, your body still has to absorb similar impact forces. On softer surfaces the ground contact times are longer, meaning muscles have to work harder for longer. There is no evidence to suggest that road running increases injury risk greater than on softer surfaces. It can be beneficial to vary the surfaces you run on as a small amount of running off-road on trails or softer surfaces are more demanding and can help improve conditioning of the lower limbs.

10 Footwear

Many runners are told that they have flat feet or high arches or that they pronate or supinate and need a certain type of shoe or insert support. Pronation and supination occur naturally at different stages when the foot is in contact with the ground. Every person has a different foot signature and there are many different shoe types available, making it impossible to prescribe an ideal shoe type or foot posture. Advances in shoe design and technology over the last 30 years have not reduced the incidence of running injuries. According to Dr Benno Nigg, a leading foot biomechanics researcher at the University of Calgari, selecting a shoe that is comfortable and allows the athlete to maintain a good movement appears to have the greatest impact on reducing injury risk.

11 Nutrition

New diet trends can become popular based upon limited evidence. Once such example is a low-carb, high-fat (LCHF) diet, with the assumption that by reducing carbohydrate intake and increasing intake of fat, the body becomes ‘fat-adapted’ by using fat for fuel which is said to be more efficient. However, a recent systematic review by the Australian Institute of Sport found no additional performance benefit of a LCHF diet compared to a regular carbohydrate diet. LCHF diets may suit some athletes competing in ultra-endurance events, but for athletes competing at higher intensities, performance may be impaired.

12 Hydration

The hydration needs of a runner are specific to the individual, environmental conditions and duration of exercise. Certain individuals who sweat more, need to consume more fluids with some additional sodium added. Fluid intake should increase in warmer and more humid environments. Over-hydrating can be just as detrimental to performance as dehydration.

13 Recovery

Sleep is the most effective recovery strategy and therefore efforts should be made to improve quality and consistency of sleep. High levels of stress which cause an untimely release of a stress hormone called cortisol can make it difficult to wind down at night. Other interventions such as ice baths, anti-inflammatory and antioxidant supplements are best saved for when short-term recovery is desirable.

14 Cramping

Exercise-associated muscle cramping was previously believed to be as a result of dehydration. However, researchers at the University of Cape Town presented the strongest evidence that cramping is a neuromuscular condition where altered nerve signals cause a muscle to continually contract. It is usually relieved by a brief stretch. Pickle juice is most effective in treating or preventing muscle cramps.

15 Running for your health and wellbeing

You don’t have to be competitive to enjoy running. Running can help improve your physical and mental health. You may be busy at work or study and finding a particular task overwhelming; dropping the pen or leaving the computer and going for a run can leave you refreshed and you may find a solution!
Colin Griffin is a former Irish international athlete who represented Ireland at the 2008 and 2012 Olympics. He is a strength and conditioning coach at the Sports Surgery Clinic in Dublin.

‘Technology in Orthopaedics’ by Gavin McHugh

Gavin McHugh Knee and hip Surgeon Sports Surgery Clinic
Technology (whether some of us like it or not!) is all around us. The field of orthopaedics is no exception. Over the last number of years, methods of fixing fractures and dealing with joint problems have changed dramatically. Specifically, with regard to knee replacements, recent advances include the use of computer navigation to increase the accuracy that surgeons can perform the procedure.
The technology doesn’t actually perform the procedure and the same knee replacement is inserted, it just provides the operator with a lot more information so that they can adjust accordingly. Computer navigation uses special markers placed in the bone for example to tell the surgeon that a particular cut is 2 degrees off – almost akin to a spirit level!  A knee replacement essentially involves a number of cuts to the end of the thigh bone (femur) and shin bone (tibia) onto which the new knee will be inserted. The precise angle of these cuts then determines how the leg will look and feel. The surgeon’s task is to achieve a straight leg that is well balanced. Balance refers to the stability of the knee and is determined by the ligaments surrounding the joint.
Many people have a belief that knee replacements do not function or last as well as hip replacements. These is little doubt that recovery after a knee replacement involves more rehabilitation than after a hip replacement. However, when we look at joint registries that assess the outcome of all replacements performed over the years, knee replacements last just as well as hip replacements. The UK registry for example (unfortunately the Irish National Joint registry is currently just being set up), tells us that 96% of knee replacements are still lasting after 10 years – exactly the same as the figure for hip replacements. Hopefully we can expect them to continue to last a lot longer – 15 even 20 years.
We are also performing more partial knee replacements that replace only the worn section of the joint. Whilst the main aim of any joint replacement is to treat pain, the function of the joint afterwards and ability of patients to get back doing the activities that they want to participate in is also of paramount importance.
For the moment, hip and knee replacements can’t be performed by your mobile phone but no doubt with a few more updates……
For further information please contact gavinmchugh@sportssurgeryclinic.com or call +353 1 5262367

‘Management of shoulder dislocation and instability in GAA’ by Edel Fanning

Shoulder Injury Dublin 9
Shoulder problems may not be the most talked-about condition in gaelic football and hurling. Most of us are more familiar with cruciate knee injuries or groin problems. However shoulder problems are among the more common of GAA injuries with the reported incidence in the literature for shoulder injuries been approximately 17-19 % of all GAA injuries.
Shoulder dislocations in particular can be serious and can result in up to 6 months out before returning to sport. Due to the joints construction and the demands placed on it in contact sport, the shoulder has a high recurrence rate of dislocation. Studies have shown that the recurrence rate can be as high as 29% post keyhole surgery in collision sports.
If a player has sustained an injury in one shoulder they are at higher risk of sustaining an injury on the opposite side. Repeated dislocations can rob athletes of valuable playing time and negatively influence performance. However with early and appropriate management players can make a very efficient and successful return to sport following shoulder dislocation.
Common mechanisms of injury for shoulder dislocation in gaelic games include the tackle, gathering possession overhead, falling onto an outstretched arm, the shoulder tackle and collisions.
Understanding the shoulder and the demands placed on it in football and hurling can help prevention, faster recovery times and reduction of overall injury rate. The purpose of this article is to guide players through the management options available following shoulder dislocation. More importantly it will provide an insight into how players can help prevent shoulder problems altogether.

Understanding the shoulder

The shoulder is the most mobile joint in the body. It is reliant on static structures (bone, labrum, ligaments, capsule) and dynamic structures (muscular components) to provide stability. All these systems must work in harmony to give a balanced and high functioning athletic shoulder. The labrum is a small fibrous cartilaginous rim that circles and deepens the socket.
Figure 1 
Shoulder Injuries Dublin 9
When the shoulder dislocates anteriorly (out the front), which is the most common type of dislocation, damage to the anterior part of the labrum (the front of the labrum) occurs (Figure 2). This is referred to as a Bankart lesion.
The shoulder is much less likely to dislocate posteriorly (out the back) however if a player gets a shunt that results in a tear of the posterior part of labrum (back of the labrum), they sustain a reverse Bankart lesion (Figure 2 on the right). Alternatively if a player suffers a traction type injury, such as landing with both arms stretched out in front
they are more likely to traction part of the biceps tendon which attaches on to the top part of the labrum.
This is referred to as a SLAP lesion. Lesions can occur in isolation or together depending on the type of trauma.  Often, the more complex the labral tear, the longer an athlete may be off from sport (varies from 14-30 weeks).
Figure 2
Shoulder dislocation at Sports Surgery Clinic
Surrounding the shoulder is a group of muscles called the rotator cuff. The rotator cuff is crucial in maintaining the stability of the shoulder (Figure 3). It is particularly important in vulnerable positions where the shoulder ligaments are less effective such as the tackle position. In recent years there has been a surge of exciting literature emerging on the function and role of the rotator cuff which is considerably improving how we rehabilitate the shoulder.
The rotator cuff must counterbalance translation of the ball on the socket by large muscles that produce movement of the shoulder such as the pectoral, deltoid and latissimus dorsi muscle groups. An imbalance between these torque power muscles and the muscles that provide stability can predispose a player to injury. Unfortunately we often see many GAA players presenting with weaknesses in their rotator cuff.
The rotator cuff is small and hard to isolate and is often not necessarily targeted in the usual gym exercises such as the bench press, overhead press and rowing exercises. GAA players should consider adopting rotator cuff strengthening routines, coupled with shoulder blade exercises into their gym programmes for optimal shoulder function and control.
They are typically simple exercises that involve rotating the arm against resistance. It is important not to use a lot of resistance as the aim is to build endurance rather than power in these muscles.
Figure 3 Rotator Cuff
Shoulder Physiotherapy at Sports Surgery Clinic Santry
Shoulder stability is not solely reliant on the strength and control of the shoulder muscles. The quality of shoulder function heavily depends on the function and power of the legs and trunk. The kinetic chain (the interlinked relationship between segments of the body) generates the force and helps regulate load at the shoulder particularly in activities such as striking the ball in hurling. Weakness and altered co-ordination in the legs and trunk muscles can increase demands on the shoulder. When rehabilitating the shoulder, whole body movement should be assessed and treated as part of the overall problem.

What are the risk factors for shoulder dislocation?

There are some factors we know can predispose athletes to shoulder instability. Athletes that have laxity in their shoulder, which refers to a ‘loose’ ligament/capsule complex, tend to have excessive range of movement in the shoulder and are at higher risk of dislocating their shoulder.
There are studies supporting that players in contact sport who have poor isokinetic strength (the ability of a muscle to contract at a constant speed) of the shoulder may be at risk of injury. Athletes with asymmetry in their range of movement of the shoulder, particularly asymmetry in their rotational movements, are at greater risk.
Impaired performance and/ or injury of the trunk and legs can increase the risk of shoulder injury, particularly in overhead sports. There is some evidence suggesting that tackling fatigue in other contact sports such as rugby, leads to a decreased sense of shoulder joint position and this is a potential increase risk for injury.

What structures are injured in a shoulder dislocation and when is surgery indicated?

Structural damage from shoulder dislocation can be grouped into two categories, major damage and minor damage.  Major lesions can have a greater affect on the stability of the joint. These include a bony Bankart where some of the bone of the socket is damaged alongside the labrum, an injury where the labrum is peeled off alongside the fibrous tissues surrounding the bone (ALSPA lesion) and an injury that results in damage to the important ligaments of the shoulder.  If a large rotator cuff tear occurs when the shoulder dislocates surgery is often required to repair the muscle. The timing of the injury is taken into account by the surgeons. If major damage is identified late into the season and a player is unable to return to play then surgery will often be considered at this stage.
Minor injuries including an undisplaced labral tear (a small lift of the labrum) and a partial rotator cuff tear can often be treated conservatively with specialised shoulder physiotherapy input, particularly if they occur early in the season. If a player continues to have problems surgery may then be considered.
Most stabilisations are performed through keyhole surgery. However some high risk groups for recurrent dislocation or patients who have dislocated in the past may require an open stabilising procedure called a Laterjet procedure.

What investigations are required?

It is common and safe practise post shoulder dislocation to have a check x-ray to ensure the shoulder has been relocated. X-rays are also useful to show if any bony damage has occurred. A routine x-ray will show if bony damage has occurred to the ball of the shoulder joint (Hill Sacs lesion). A special view can be ordered by a doctor or surgeon who can assess bony damage of the socket (bony Bankart).
To assess labral / capsular damage an MR Arthrogam or CT Arthrogam is the preferred choice. A plain MR scan can be useful to assess the integrity of the rotator cuff muscle however it is often not sensitive enough to assess the integrity of the labrum.

Rehabilitation post dislocation

Whether a player undergoes surgery or not, the principles of rehabilitation are similar. At the Sports Surgery Clinic our rehabilitation process is patient specific, tailored to suit player’s position and requirements. It is a team approach where we work closely with the surgeon and the patients own club medical team. Most of our athletes will see both a physiotherapist and strength and conditioning coach to formulate a safe and timely plan for return to play.
The first step is often an assessment of an athlete preoperatively which includes a local assessment of the shoulder, global assessment of the body and an assessment of their general level of fitness and condition.
Phase 1: Rest and recovery phase
Post surgery, athletes are put in a sling with the time frame dictated by their surgeon, often depicted by the extent of injury and type of surgery. We work closely with our shoulder surgeons to establish ‘a safe zone’ where the athlete can start exercising without putting strain on the repair. It is essential that the rehabilitation team work closely with the player’s surgeon to get the balance right.  Strict immobilisation can results in rotator cuff inhibition and  muscular atrophy. Closed chain exercises (where the hand is in contact with a surface) are frequently used in the protective phase. This type of exercise creates relatively small joint movement, decreases joint shear and stimulates sense of joint position while protecting the repair.

Phase 2: Progressive loading

Recruitment of the rotator cuff muscles is often affected post dislocation/post surgery and a systematic approach is required to optimise function and facilitate return to play. Exercises should be prescribed that ensure timely recruitment, endurance and strength of the deep stabilising muscles. Emphasis is also put on rhythmic stabilisation exercises and perturbation training (exercises to improve reaction times) in this phase (Figure 4). This type of training helps the shoulder to develop force rapidly; a requirement for all parts of football and hurling. One of the key factors to success is to rehab in controlled positions of vulnerability that re-educate muscle synergy into all the positions the athlete requires.

Figure 4 Rhythmic Stabilisation Exercises and Perturbation Training

Shoulder Physiotherapy Dublin
Shoulder Surgery Dublin
Physiotherapy of the Shoulder Santry Dublin
Rehabilitation of the Shoulder Santry Dublin
Shoulder Surgery Ireland
Phase 3: Return to play
The primary focus at this stage is to maintain muscle balance, maintain reactive stability and re-introduce graded return of exercises required for the athletes game e.g. ball skills, contact skills, drop and landing drills. The emphasis switches to increase the power (the ability to generate force quickly) of the shoulder muscles, which builds on the strength phase developed in the first two stages.
Average return to play time can vary from 14 -30 weeks and is dependent on an athlete reaching set goals. Return to play is both player specific and surgery specific, taking into account the quality and type of surgical fixation achieved. ‘Return to play criteria’ is used to help ensure the safe return of an athlete to contact training. This often includes an assessment of the isokinetic strength of the shoulder. With the help of the strength and conditioning team the aim is to ensure the athlete is globally fitter and stronger then their pre-injury presentation.
Shoulder dislocation is an injury risk in GAA sports and can result in a prolonged absence from sport. However with appropriate rehabilitation and exercise selection post surgery it is possible to make a very efficient and successful return to sport.
For further information on this please call +353 1 5262040 or email physio@sportssurgeryclinic.com

‘Fit for living’ by Mr Gavin McHugh

Athletes aren’t just considered the people we watch at games or on television but an emerging generation of people who refuse to succumb to a sedentary lifestyle as they get older; the 80 year old gentleman who still cycles 10 miles a day; the 76 year old lady who likes to climb Croagh Patrick; the 69 year old who enjoys completing the Dublin marathon every year.
With aging, various changes occur within the articular cartilage that lines the surfaces of joints. Arthritis produces quite different changes; water content increases and other collagens and proteins decrease. Rather than offering a histology lesson, this serves to show that arthritis is not the inevitable consequence of getting older. We should look at arthritis like any other disease that can be successfully addressed if and when it starts interfering with your normal activities or your quality of life.
With regard to the knee, various options are potentially available depending on the problem. A total knee replacement replaces the entire joint but sometimes it is possible to replace only a portion of the joint, a partial knee replacement. These are generally smaller operations with a quicker recovery time and usually a more normal feeling knee afterwards. Return to certain sporting activities is also more likely – swimming, cycling and even things like doubles tennis are fine but most surgeons recommend avoiding prolonged jogging. In general, surgery makes it more rather than less likely to return to activities.
New and improving technology also allows us to insert a knee replacement more accurately so that not only is the leg straightened in a more natural way but it should also feel more stable. This is known as computer navigation and I now routinely use it for all my knee replacement surgeries.
Also we know that weight bearing exercise is actually good for joint surfaces. Think of the cartilage like a sponge that fills and empties its water content with each step and this allows nutrients to flow within it. It also has the advantages of increasing bone density and thus avoiding osteoporosis and also stronger leg muscles are strongly associated with maintaining independence as we get even older.
So get out and about and enjoy your hobbies again and if your hip or knee is stopping you from doing that, maybe it’s time to get it seen about.
For further information please call +353 1 526 2367 or email gavinmchugh@sportssurgeryclinic.com

Is it time for Total Knee Replacement (TKR) surgery?

Knee Replacement Surgery at Sports Surgery Clinic

KNEE OSTEOARTHRITIS

Osteoarthritis (OA) is the third-leading cause of life-years lost to disability worldwide. By the age of 65 years half of the population have OA, and this prevalence is expecting to rise as the population ages in demographic terms.

Nearly 1 million knee replacements (TKR) are performed annually in United States. Rates of TKR surgery tripled in the last 20 years and projections in US show further increase in demand by 6 fold (673%) by 2030.(1,2) A similar rise in TKR surgery is also expected in Ireland.

Since 1970’s, when first performed, TKR surgery has been a successful procedure that gives mobility and independence back to people suffering with knee arthritis.  However TKR surgery comes with risks. The risks of clot formation, pulmonary embolus, infection, and fracture range from 0.1 to 1.0%, with higher risks among older persons and those with a higher number of coexisting conditions.(3,4) Also, the procedure is not always successful; approximately 20% of patients after TKR have residual pain 6 or more months after surgery.(5)

There are other non-operative alternatives for treatment of moderate knee arthritis and I have written about those in a previous article – “The Young Arthritic Knee”. Clinical trials have shown that physical therapy (including exercises and manual therapies) can reduce pain and improve function in patients with moderate and advanced knee osteoarthritis.(6-8)
Until now, we have lacked rigorously controlled comparisons between TKR surgery and its non-operative alternatives.

THE SCIENTIFIC EVIDENCE

A prospective randomized control study is the gold standard for a clinical trial and provides the most credible evidence when assessing different treatment effects on patients. These are carefully designed and executed studies to eliminate bias and establish the best available treatment.

Recently (October 2015), New England Journal of Medicine, a highly esteemed medical journal, published a study entitled “A Randomized, Controlled Trial of Knee Replacement”. Interestingly, prior to this publication NEJM published only 4 original articles on arthroscopic knee surgery and all with ‘negative’ results. I have made reference to those articles in one of my previous article (“The Young Arthritic Knee”).

The recent study was performed by a Danish group of researchers over a number of years and involved 100 patients with symptomatic moderate and severe knee osteoarthritis.  Patients were split in two different groups and assigned to undergo either total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (TKR group) or to receive only the nonsurgical treatment (Nonsurgical-treatment group), which consisted of supervised exercise, education, dietary advice, use of insoles, and pain medication. Improvement in pain and function was assessed at 1 year after initiating treatment to see the effect on both treatments on the similar group of patients.

IS TKR SURGERY BETTER THAN NON-OPERATIVE TREATMENT FOR MODERATE KNEE ARTHRITIS?

TKR surgery proved markedly superior to non-surgical treatment alone in terms of pain relief and functional improvement. The percentage of patients who had a significant improvement in pain after 1 year was 85% in the total-knee-replacement group and 68% in the nonsurgical-treatment group. In fact, one in four patients in the nonsurgical-treatment group elected to have TKR before in the first year, and more patients are likely to cross over as follow-up extends further.

It is noteworthy that more than two thirds of the patients in the nonsurgical-treatment group had clinically meaningful improvements in pain and that this group had a lower risk of complications compared with the TKR surgery-treatment group.

When discussing treatment options for moderate and severe knee OA patients face choices that are associated with different levels of symptomatic improvement and risk

TAKE HOME MESSAGE

When compared with non-operative treatment, TKR surgery gives better pain control and better function despite the inherent higher risk of adverse events.

The right time to have knee replacement surgery is when the patient is having symptoms that are affecting his or her quality of life and they want something done about it. This is a personal and very subjective decision. I always advise patients to take their time, really think it over and have surgery when it suits them.

I certainly stress to my patients that surgery of any kind carries risks and it is important for them to fully understand what they are. However, in the hands of a good surgeon, experienced nursing staff and in an excellent hospital facility, complications are unlikely.

With modern technology, implant design, materials and surgical techniques, knee replacement surgery has become one of the most successful operations available to patients with moderate or severe knee arthritis. Successful knee replacement surgery reduces or eliminates knee pain and improves joint function, enabling patients to get back to a normal active lifestyle.

Read more from Mr Mihai Vioreanu at www.mrmv.ie

Fuelling ‘on the run’ during a marathon race – by Colin Griffin

Sports Surgery Clinic
Race day nutrition is a topic of interest among many marathon runners. Questions such as ‘should I take a gel’ or ‘how many gels should I take during a marathon’ or ‘what type of gel is best’ are commonly asked.
There are a number of factors to consider when planning a race-day fuel strategy. These include:
·         Sources of energy
·         Amount of carbohydrate you need to (or can) consume
·         Your ability to digest products on the move
·         How often should you consume carbohydrate
·         Pre-race fuelling

Sources of energy

The sources of energy can have a small but significant impact on absorption and performance. Mixing sugar-based carbohydrate sources such as glucose, fructose, dextrose and starch-based sources such as maltodextrine and maize; can enhance carbohydrate absorption into the blood. It can be useful to look at the ingredients label on a particular gel or energy drink powder formula. You can analyse carbohydrate sources and also the sugar content under the nutritional value label. Most products have a one third sugar content of carbohydrate. For example a product containing 30g carbohydrates of which 10g is sugar-based.

Amount of carbohydrate

A carbohydrate intake of between 30-60g carbohydrate per hour is generally recommended for optimal gastric emptying and intestinal absorption. There appears to be an upper limit of 75g per hour, above which will have no additional benefits and may in fact inhibit absorption and cause stomach issues. Most gels contain 25-35g carbohydrates. Most self-prepared sports drinks with a 6% carbohydrate concentration will contain close to 30g carbohydrate per 500ml, which can be diluted accordingly. You can calculate this by looking at the label and knowing what 1 scoop or 100g contain.
Nutritional content of a typical sports drink
Nutrition Sports Surgery Clinic
Nutritional content of a typical gel product  

Your ability to digest carbohydrates on the move

The key objective is to keep blood glucose levels topped up during a race by consuming carbohydrate-based fuel. Whether that carbohydrate comes from a gel, solid food or drinks powder mix, is a matter of individual preference for the athlete. You will see from the above referenced labels, that a 500m energy drink mix with 30g carbohydrate content or one gel with close to 30g carbohydrate content; still provides the same amount of energy. It depends on how well the athlete can digest the product. Some athletes prefer to take a solid fuel such as a gel, a piece of energy bar or some jelly sweets; while others can only tolerate liquids. It is something that should be trialled and practiced on a few training runs well in advance of race day.

How often should you consume carbohydrate?

It is recommended that an athlete consume between 30-60g of carbohydrates per hour of activity if their event last longer than 1 hour. There are usually personal drink stations every 3 miles or so during a marathon race. A 2 hour 30 minute marathon runner, who consumes 250mls energy drink containing 10-20g CHO every 3 miles; should achieve sufficient fuelling throughout the race.  The athlete could substitute a gel for an energy drink every third or fourth 3 mile segment. For an athlete who may not be in a position to consume prepared drinks on the course and relying solely on water stations, could carry some gels with them and consume with water. It is best to begin fuel intake early on in the race, perhaps from the first drink station.

Pre-race fuelling

Many athletes ‘carbo-load’ in the days leading up to a race by increasing their carbohydrate intake. There is little evidence of any additional benefits of carbo-loading longer than 24 hours pre-race. When you taper your training but still consume the same amount of carbohydrates in meals and snacks, you will be increasing glycogen stores regardless. Some athletes don’t like the lethargic and often bloated feeling of being carbo-loaded.
The best advice is to maintain normal meal portions and carbohydrate intake the week of a race, with perhaps a little extra intake in the meal the evening before the race. Have a pre-race breakfast meal that has worked well in training and previous races. Carbohydrates consumed in the 60 minutes before the race should be liquid-based, but only in small amounts. One must also factor in race day anxiety and nerves, which can affect digestion and absorption. Sometimes ‘less is more’ in terms of food intake and perhaps allow for an increased pre-race digestion window than you would usually in training.

Conclusion

The most important fuel the athlete has available on race day is the glycogen stored in the muscles. Between 10-30% of carbohydrates consumed during a race is actually utilised. Most well trained athletes will have sufficient muscle glycogen stores to sustain a 2-hour effort. It is a good idea to include some occasional steady state runs in a low glycogen state to promote fat utilisation for energy. It is also good to complete other workouts in an adequately fuelled state to as to have that metabolic flexibility so that our bodies are trained for both fat utilisation and carbohydrate utilisation. Our bodies our smart at self-regulating! With a good aerobic engine and some fine-tuning, along with adequate fuelling; our bodies will find the most efficient way of fuelling performance early on and keeping energy reserves for the latter stages.
Click here for further information on Running Services offered at Sports Surgery Clinic, or to make an appointment call +353 1 5262030.

‘The growth of hip surgery in Ireland’

 

How common a problem is this?

Hip and groin pain are common time loss injuries in sport. This is particularly common in Gaelic sports, especially football. Our clinic has seen large numbers of GAA players over the years with hip and groin injury and footballers outnumber hurlers nearly 4:1. It is often argued that kicking is the main reason why football causes more groin injury but this is probably a little simplistic. Football by its nature requires more running and contemporary ‘transitional’ defensive systems require even higher fitness levels combined with sharper twisting and turning. Ball retention is a focus meaning a short hand-pass is often favoured over a kick-pass or longer kick. The old adage of ‘let the ball do the work’ doesn’t hold in this system – meaning players work harder. Players at all levels around the country are now also undertaking varying levels of conditioning. From unsupervised to one-on-one sessions, most teams perform gym-based conditioning over the winter months and pre-season. The combination of torsion forces (twisting the upper body relative to legs) higher load (how many metres you run a week) and less recovery time (more training sessions plus work/school/college = less time to recover) all add up to an overload pattern which is at the root of many of the hip and groin problems we see.

Why is it such an issue?

Hip and groin pain is the third biggest time loss injury in field sports like GAA, rugby and soccer. Long before a player begins to miss games their performance tends to drop – sprinting, direction change and cutting all see decrements in performance. Worse still, because athletes often continue to play and train and there are no stitches or crutches to be seen, it can be hard for other athletes and coaches to understand why the athlete is not better. Similarly the medical team often struggle to manage the symptoms and a pretty classic tactic is to move the ‘blame’ for this onto the athlete- you would be amazed how many athletes are relived to ‘have a diagnosis’ that things are not in their head. Worse again is the lack of an end point to when the problem will be resolved.
This is an emotive issue where a player, their manager and medical team will try anything to get them back training and playing. To be told hip surgery will sort this problem will make this better is “great news” for all involved. We all love to have an end point- “you will be back playing in 4 months”. Often this is delivered in tandem with them the news that if the surgery is not performed you will have arthritis aged 40. This makes surgery almost mandatory.
These are pretty emotive areas with some pretty scary outcomes. When fear, loss and anxiety are mixed into the decision process making a clear choice can be difficult. This article is aimed at taking the emotion out so some of the questions and answering it with the scientific information that is out there.

How much hip surgery are we seeing?

There has been an 18-fold increase in the number of hip arthroscopies in the USA between 1999 and 2009. The FAI-surgery rate has increased by over 600% among newly trained surgeons from 2006 to 2010. In Ireland GAA insurance figures show 314 hip surgeries in 2014 compared to 80 in 2007- a rise of 392%.
I remember the first time I encountered a hip labral tear. I was consulting on an intercounty hurler in 2005. He had a history of tight groins and intermittent flares of groin pain. An MRI confirmed a labral tear. An intra-articular injection of his hip helped to settle his pain, but it returned a few months later. At the time hip arthroscopy was not readily available in this country and was not an option for this player. With modification of training and rehabilitation input the player continued to train and play at an elite level until 2012. So what has changed since to see such an exponential rise in surgery?

Morphology Vs Pathology

It is a worthwhile exercise to discuss some of the terms that are commonly mentioned in this area.

Morphology

This is a difference in shape from the norm (Figure 1) with either the ball (femoral head) or the socket (acetabulum) of your hip. It does not mean that there is a problem. This is commonly referred to as femoro-acetabular impingement (FAI). It means that you are at a biomechanical disadvantage compared to “normal” shaped hips. This does not guarantee that you will have a problem but does increase the chances of one developing. Its means there is a “possibility” of a problem developing. It is felt that morphology changes are far more common than we imagine and we know FAI morphology doesn’t guarantee you will have either pain or poor performance.
In ‘A’ the small solid arrow indicated the area of ‘extra’ bone seen in cam-type FAI. In ‘B’ the long interrupted arrow shows the head/neck offset we would label ‘normal’. It is worth noting that though the patient in ‘A’ had similar x-ray findings on both sides he was symptomatic on the right side only.

Pathology

Pathology is where morphology combines with other factors to cause pain and dysfunction. Pathology implies that there is a “probability” there will be longer term damage. Much has been written on this in scientific literature.
To develop pathology you have to have 5 things:
(1) Abnormal morphology of the femur and/or acetabulum- the abnormal shape is present.
(2) Abnormal contact between these two structures- this shape increases impact between the structures.
(3) Especially vigorous supraphysiological (high-level/high-intensity) motion that results in such abnormal contact and collision- the athlete trains or plays at a high level with poor ‘control’ worsening this impact.
(4) Repetitive inefficient motion resulting in the continuous insult- the athlete does this a lot ie trains/plays a lot.
(5) The presence of soft-tissue damage- labral tear or ligamentum teres tear, the biggest risk factor for injury is previous injury, so soft tissue injury can cause further issues.
So it is worth bearing in mind that even if you have 1 and 2 or even 5 if you alter 3 and 4 you may manage very well.
A prospective study in professional ice-hockey showed this very well. Twenty one players were followed for 5 years- 15 had labral tears in one or both hips. At 5 years 19 of the 21 were still playing professional hockey. The development of any hip and/or pelvis symptoms occurred in only 3 players (14%) within 4 years. Only 1 of the 3 players missed any games because of hip and/or pelvis symptoms (this was ITB pain which is most likely unrelated).1
Figure 2 A: FAI of both hips, B: focused x-ray of left hip, C: MRI of left hip showing bone change and labral tear (Arrow)

This is a training phenomenon

A number of recent studies from the Netherlands have confirmed what many clinicians in the field have believed for many years- in your adolescent years the more you train and the higher the intensity of that training the more likely you are to develop FAI morphology. The study looked at elite soccer players in Holland and compared the rates of development of FAI morphology. Basically the more often you trained and played at a higher level the more likely you were to develop FAI morphology.2
That’s why so many players who present with hip and groin pain on one side are often shocked to see the MRI findings of FAI are seen on both sides on imaging. This is a developmental issue, which may or may not cause an issue. It will only cause a real issue when the other factors outlined above are present.

But I have a tear in the labrum!

This draws many parallels to knee meniscal surgery (shock absorber often called ‘cartilage’ in lay terms). Efforts to improve meniscal repair and minimally invasive surgery are the hallmarks of the efforts we make to preserve the meniscus- this is a shock absorber which protects the rest of the joint and the articular cartilage. In the past the surgical approach was very aggressive and much more tissue was removed than is now the norm. Over time it became obvious that this strategy caused considerable joint damage in later years- hastening the onset of osteoarthritis.
Nowadays even when a meniscal tear of the knee is confirmed, unless there are mechanical symptoms such as the joint locking or recurrent joint effusion (joint swelling) we try to avoid operating on the joint.
A good lesson to learn from previous findings is that case series for other surgeries (eg, meniscus tear, shoulder impingement) are often favourable, but subsequent randomised controlled trials (best evidence level) show no additional benefit over non-surgical or sham therapy.
We are making the same mistakes with hip surgery. Studies have shown that labral tears are, more often than not, asymptomatic even in an athletic population.3 Studies have also shown that tears in the labrum as large as 3cm may be present while the labrum still does its job.4 Unfortunately it has also shown that removing the labrum increases the force across the acetabulum- which may in fact predispose the patient to arthritis.5

Movement patterning

Studies have shown that a number of movement patterns may predispose the athlete to develop pain in the presence of FAI- the athletes may develop one of the 5 issues outlined above.6 This is a factor of colliding variables. In the absence of a symptomatic labral tear it is a little simplistic to think surgery to the area will fix this. It is often proposed that if the athlete does not gain significant relief or in fact abolition of their pain on an intra-articular injection it is unlikely they will benefit from surgery. This is not supported by any research but is based on some sensible thinking- if we neutralise any pain source within the joint and the pain persists this suggests there are a number of soft tissue structures around the joint which are causing some pain- these should be cleared first.

Will I get arthritis 

I regularly hear from patients that they are going to develop arthritis of their hip if they don’t have surgery to correct their FAI. Although some information exists on osteoarthritis secondary to grossly visible deformities (severely abnormal ball or socket shapes), there is almost no information on the natural course of more subtle femoral or acetabular deformities as present in FAI.7 There is an association between symptomatic FAI and development of OA.8 We don’t know who will develop OA but we do know the risk tends to be less as we get older. If we are to be scientific in our approach to the medical management of this issue we must respect this information.
This has been highlighted in the work of one of the most respected hip surgeons in the UK, his 2009 work followed a group of patients (90) with FAI and found “mild to moderate osteoarthritis in hips with a pistol-grip deformity will not progress rapidly in all patients. In one-third, progression will take more than ten years to manifest, if ever. The individual geometry of the proximal femur and acetabulum partly influences this phenomenon. A hip with cam impingement is not always destined for end-stage arthritic degeneration.”9
Even more worrying, no study to date has supported that arthroscopic surgery of the hip actually changes the outcome of whether arthritis will develop or not.8 The timing of surgery poses other real questions, as the severity of joint cartilage damage is associated with worse outcomes following surgery and more rapid progression to total hip replacement.10 A sobering thought.

Evidence-based approach

Most scientists in the area of sports medicine agree that an evidence-based approach is in the patient’s best interests. They also agree that performing high-level research in sports medicine is difficult because athletes are in a hurry and want to ‘get the job done’. We need to take a moment here however to consider what we are trying to achieve. Taking the model of 5 colliding variables is a useful one to keep things sensible. Even though x-ray or MRI findings support bone shape changes or cartilage damage doesn’t mean surgery must happen. Of course there are situations where surgery is required, but it is imperative for those doctors and physiotherapists looking after teams to ensure 3 & 4 above (especially vigorous supraphysiological (high-level/high-intensity) motion that results in such abnormal contact and collision, repetitive motion resulting in the continuous insult and) are altered first.
I have listed references here in a manner similar to a scientific article as these facts are bound to irritate a number of people. I have tried to take some of the emotion and fear out of this topic and instead look at this from a scientific perspective. There are rarely black and white answers in sports medicine- the best option often being quite grey. Those trying to help and guide athletes must be prepared to look beyond what appears to be a quick fix and use the information out there to guide their decision-making process.
For further information on this subject please contact sportsmedicine@sportssurgeryclinic.com or phone 015262030