‘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 ageing, 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

Heel strike when running – good or bad? by Colin Griffin

Colin Griffin, Strength & Conditioning Coach – This is a topic that has generated plenty of recent interest and debate among runners, coaches and sports medicine practitioners. Many runners change their foot strike pattern from heel strike to mid-foot or even forefoot strike. Others claim that there is nothing wrong with a heel strike.

Let’s take a look at the mechanics of running and the impact of a heel strike from an injury and performance perspective.


In the clinic, we see many runners with anterior shin or knee pain, and in many cases, calf pain and hamstring tendinopathy, who display a heel-striking pattern. With that we usually see over-striding – the foot making contact with the ground well in front of the centre of mass with a negative shin angle. This places greater shear loading on the shin with that narrow centre of pressure point as the foot makes contact with the ground. The foot has to flatten which eccentrically loads the tibialis anterior as it absorbs high forces.

Overstride Dorsiflexion Anterior torso tilt

In the case of calf and knee pain, because the runner lands with lengthened and poor recruitment of ankle plantar flexors and hip extensors, there is an inability to achieve joint stiffness and stability during mid-stance at the critical moment when highest peak impact forces are absorbed. The knee and ankle continue to bend placing excessive eccentric loading on the calf muscle and at the knee.

In the case of hamstring tendinopathy – when the athlete over-strides and lands with a heel strike, it puts the hamstrings at a mechanical advantage over the gluteal muscles. But with that comes a cost. The dominant hamstrings are elongated and experience increased shear loading and compressive forces at its proximal attachment.


When running at faster speeds, it is desirable to maintain a short ground contact time and a high rate of force development repeatedly to optimise performance. A heel strike at initial contact allows the foot to stay on the ground longer with prolonged deceleration as it flattens. Athletes in short events from sprint distance up to 1500m tend to favour forefoot landing, with midfoot landing more favoured over longer distances. When an athlete fatigues, there tends to be a favoured heel strike pattern.

Changing running gait

Altering a runners gait can be difficult particularly for highly trained athletes with deeply ingrained movement patterns. Certainly for the injured athlete with heel striking being a contributing factor; it makes sense to reduce heel strike to a closer to midfoot contact position to reduce the stress on the anterior shin. The heel strike on its own may not be as big a problem, but a heel strike while over-striding and perhaps a forward trunk lean can cause problems.

In the clinic, we tend to coach a vertical shin angle at initial contact with a slightly bent knee with the foot making contact just in front of the hip. This usually results in a reduced heel strike if the foot plant is coached well. A mid-foot strike allows for a larger surface area for the foot to absorb forces and dissipate evenly from the foot up the kinetic chain to the centre of mass.

In order to achieve that, we must look at that the leg does before landing. We look for an arc-like trajectory of the foot during swing phase. A linear foot trajectory closer to the ground (or a lazy swing leg) usually results over striding and heel strike. This is common in novice and recreational runners. If we increase the arc curvature by bending the knee more and picking the foot up as the leg swings through, this will allow the athlete to achieve a vertical shin at initial contact. The higher the speed the higher that arc angle will become, as the foot needs more space over the ground to apply and generate more force.

The downward foot plant will help recruit hip extensors and ankle plantar flexors to achieve optimal loading of the limb during midstance and greater power retained for propulsion with greater hip muscle contribution.

Successful gait changes can be achieved with appropriate coaching cues, running drills that have purposeful intent and a well-designed strength-training programme. There may be a short-term sacrifice for a long-term performance benefit!

Click here for further information on Running Services offered at UPMC Sports Surgery Clinic, or to make an appointment call +353 1 5262030.

Preparation Exercises for Golf

Our team of Strength & Conditioning coaches at UPMC Sports Surgery Clinic have created the following exercises aimed at helping you prepare for your round of golf and improve your overall performance.
• Cues: Sit back into a chair – Shirt logo facing forward – Belt buckle up
• Increase range (depth) throughout the set (maintain spine angle)
• 2 x 8 reps
• Cues: Split stance – Upper body quiet (statue) – Belt buckle up
• Carousel drop – Increase range throughout the set
• 2 x 6 reps each side
• Cues: Split stance with weight on the front foot
• Rock back and forward keeping the heel on the ground
• 2 x 10 reps each side + 10 second stretch at the end
• Cues: Extend one arm – Short grip on a band – Pull the bow
• 2 x 6 reps each side
• Cues: Hands behind the head (or hold a band or club)
• Fix hips – Rotate upper body (minimal lower back) – Increase range
• 2 x 6 reps each side



• Hinge over like your bowing to the crowd – Maintain spine angle – Belt buckle
• Increase range throughout the set (feel stretch through rear thigh)
• 2 x 8 reps each side
• Athletic stance – Quiet hips and lower body – Rotate upper body forcefully
• Arms remain locked out (stiff) and a wide arc is created
• 2 x 6 reps each side
• Band, stick or club rotate forward and back over the head
• Object remains on a wide arc -Posture remains tall and quiet
• 2 x 10 reps each way

You can download the exercise sheet by clicking below. A sample S&C planner is also available to download below.

For further information on these exercises or to make an appointment with any of the following departments please see contact details below:

Sports Medicine: sportsmedicine@sportssurgeryclinic.com / 01 526 2030

Radiology: radiology@sportssurgeryclinic.com / 01 526 2060

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 UPMC 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 UPMC 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 UPMC Sports Surgery ClinicBackground

Back pain is the most prevalent musculoskeletal condition that affects 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, sportspeople 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 the dressing room and out into a warm-up.

Back pain has been shown to detrimentally affect 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 sportspeople 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 a loss of earnings as a result of their injury. Back pain can also take its toll on the 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 UPMC 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 UPMC 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.


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 UPMC 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 UPMC Sports Surgery Clinic in Dublin.

‘Technology in Orthopaedics’ by Gavin McHugh

Gavin McHugh Knee and hip Surgeon UPMC 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

‘How should I warm up before a run?’ – Warm Up and Running Drills

A thorough warm-up for running or jogging is often overlooked but remarkably important for improving performance and decreasing the chance of injury. Whether you are a track specialist or road runner the drills in this article will help to promote a more efficient, dynamic running technique, improve range of motion and muscular function, whilst providing the appropriate intensity for your intended training session.

Part 1 – General warm-up exercises

At this stage, you are probably feeling cold, tight, sore and not ready to perform. The aim is to loosen the muscles and joints here and start to warm the body system. The following movements can be incorporated into the general warm-up; the aim here is active preparation.

  • Light to Moderate Jog 400m
  • Leg Swings – Lunges – Squats
  • Grapevine – Side to Side Skip – Backwards Run

Note: Static stretching is not specifically included in the ‘active warm-up’ however if you have any defined areas that require specific stretching in order to improve range of movement (flexibility) this can be added here.

Part 2 – Pre-run drilling

The aim at this stage is to improve running efficiency and technique, enhance energy recoil from the ground and to promote a positive running gait (stride). E.g. running on the forefoot.


Purpose: Promotes correct leg action and active foot plant
Description: Hands on hips – Drive heel to butt – Stomp on forefoot under hips
Cues: Front of shoe points in the direction of travel – Heel of shoe pulls up to butt
Sets & Reps: 3 sets x 15m

Knee Drives (skips)

Purpose: Promotes recoil (bounce from the ground), switches on key muscles and is an active progression from the marching drill (drill 1)
Description: Similar to the march (drill 1) with a skipping action (small air time) included
Cues: Skip and actively plant foot back under hips Sets & Reps: 3 sets x 15m

Butt Flicks

Purpose: Promotes correct leg action in the swing leg – Builds towards running specific action and tempo
Description: Running action with heel coming to butt – Slowly transitioning forward Cues: Pretend there is a hurdle in front of each step – Fast leg recovery
Sets & Reps: 3 sets x 15m


Knee Drives (Skips)

Butt Flicks

Part 3 – Running/jogging specific intensity

The final stage of the warm-up should involve working your running efforts towards the intensity required for your specific run or jog. This will be extremely individual depending on the distance and speed of the session. The golden rule here is basic, you must get up to your race or planned session speed prior to competing or participating. For endurance-based athletes, you should take your body close to or above session pace for a short duration. It takes time for your body to start delivering oxygen to your muscles at its most efficient rate, thus it’s important to prime the system by ramping up intensity to the desired level. This will improve the start of your session substantially.

  • 2-6 minutes of near lactate threshold (beyond talking pace) running or of a similar rate to the planned session

For track-based athletes, the aim is to take your body to the speed at which you will run the session or competition.

  • 4-6 efforts of 60-100m building intensity from 80-100%
  • Maintain rest periods of 2-3 minutes between repetitions as the intensity increases

Nick Richardson, Strength & Conditioning Coach SSC

For further information on this topic or to make an appointment with a physiotherapist please email sportsmedicine@sportssurgeryclinic.com or call +353 1 5262030

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

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 a 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 a 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 9When 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 the 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 UPMC Sports Surgery ClinicSurrounding 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 UPMC Sports Surgery Clinic Santry

Shoulder stability is not solely reliant on the strength and control of the shoulder muscles. The quality of the 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 coordination 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 structures are injured in 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 effect 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.

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 practice 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 Arthrogram or CT Arthrogram 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.

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 an excessive range of movement in the shoulder and are at higher risk of dislocating their shoulder. There are studies supporting that players in a 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 a 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.

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 a 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 result 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 a relatively small joint movement, decreases joint shear and stimulates a 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

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.

The average return to playtime 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 than their pre-injury presentation.

Shoulder dislocation is an injury risk in GAA sports and can result in a prolonged absence from the 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