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Osteoarthritis at SSC Santry

Living With Osteoarthritis. In conversation with Dr Barry Sheane.

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Arthritis IrelandSSC is delighted to support Arthritis Ireland with their BePrOActive Campaign. Launched today, this campaign is a new awareness campaign that looks to help people living with osteoarthritis (OA) by providing expert information about living with the condition, including the role of physical activity and healthy eating.

Osteoarthritis (OA) is a long-term chronic disease characterised by the deterioration of the cartilage in joints which results in bones rubbing together and creating stiffness, pain and impaired movement. The disease most commonly affects the joints in the knees, hands, feet and spine and is relatively common in the shoulder and hip joints. While related to ageing, OA is also associated with obesity, lack of exercise, genetic predisposition, occupational/sports injury and gender. Research indicates that significant numbers of people with OA are living with other chronic conditions.

Osteoarthritis is one of the ten most disabling diseases in developed countries and affects 18% of women and 10% of men over 60 years.

The prevalence of OA is increasing due to population ageing and an increase in related factors such as obesity. According to the CSO, by 2051 one-third (1.8 million) of the Irish population will be aged 60 years and over; up from one-fifth (866,000) in 2016. This represents a significant societal and personal challenge.

While frequently described as a ‘wear and tear’ arthritis, this is an over-simplification of the underlying pathology. It also frames OA as an inevitable feature of life and of ageing, over which people have little control.

This awareness campaign, therefore, looks to change the conversation around osteoarthritis in Ireland, by encouraging people living with the condition to take a proactive approach to the management of their OA.

To learn more about Osteoarthritis watch this video of Dr Barry Sheane, Consultant Rheumatologist at SSC discussing the causes of osteoarthritis, symptoms, how OA is diagnosed and treated with Grainne O’Leary, CEO of Arthritis Ireland.

Dr Sheane also looks at pain management in osteoarthritis, the role of physical activity and diet, managing if you’re living with other conditions and the role of surgery.

About Dr Barry Sheane

Barry Sheane RheumatologistDr Barry Sheane is a Consultant Rheumatologist specialising in Osteoarthritis at UPMC Sports Surgery Clinic in Santry, Dublin.

Transcript of Dr Sheane's interview with Grainne O'Leary, CEO of Arthritis Ireland.

This is a transcript of Grainne O’Leary (GOL) discussing Osteoarthritis with Dr Barry Sheane (DBS).

GOL: Hello everybody and you are very welcome to this broadcast about living with Osteoarthritis. I am Grainne O’Leary, Chief Executive of Arthritis Ireland. I am delighted to be joined today by Dr Barry Sheane, Consultant Rheumatologist.

So by way of introduction, osteoarthritis is the most common form of arthritis, affecting millions of people worldwide and thousands of people here in Ireland. It can affect any joint in the body, but it commonly affects the weight-bearing joints of the knees and hips.

So Barry you are very welcome and thank you for joining us here today. I am going to start off with the first question ‘What is osteoarthritis’?

DBS: So osteoarthritis is the most common disease of the joints in the world. It is a condition that involves the whole joint.
We commonly talk about osteoarthritis being about cartilage and cartilage wearing down, but we actually feel that cartilage breaking down is the end process of the whole disease, and the actual disease itself possibly starts in other structures in the joint, for example, the bone underneath the cartilage, in the joint fluid perhaps, in the lining of the joint (the synovial membrane), and perhaps the cartilage and all of those structures.

What are the symptoms of Osteoarthritis (OA)?

GOL: What are the key signs and symptoms of osteoarthritis?

DBS: So the main symptom that would alert somebody that they may have an issue with osteoarthritis is pain. It might be pain when somebody is doing an activity, towards the end of the activity, or maybe just after the activity.

Some people will report that they have some stiffness if they have been sitting for a long while, or if they haven’t been using an affective joint for a while. It can progress to involve pain at night that keeps people awake and even joints can change shape and become deformed.

GOL: We will talk a little bit more about what actually happens in osteoarthritis. You mention the term wear and tear – it’s a term we often hear people referring to their type of arthritis as.
So can you just tell us a little bit more about what is actually going on there?

DBS: So we all use the term wear and tear; Rheumatologists, Orthopaedic Surgeons, Physiotherapists, all of us involved with treating osteoarthritis, but most of us recognise that the term is most likely inaccurate.

There is certainly causes of Osteoarthritis that relate to damage and wear and tear but most of the issues and causes of OA involve other processes, for example, the genes that you are born with are probably the biggest factor. If you are overweight? Being overweight will affect not just the weight bearing joints like the hips and the knees but also is a risk for hand OA.

If you are female? That is an added risk compared to being male. If you have damaged the joint from a sports injury or some type of injury in the past? And getting older is also a risk factor.

Can you prevent OA?

GOL: Are there things that people can do to prevent getting osteoarthritis? You mentioned there about genetics – I guess we can’t do much about the genes we are born with but are there other risk factors that we can maybe reduce in order to prevent it?

DBS: So there are things that you can’t avoid like your genetics, but there are some things that you can certainly do, and one of those things is to stay as fit as possible, to exercise regularly and to try and maintain your optimum weight – the weight when you were approximately 21 years of age. If you can get to that weight, get close to it or even lose some weight if you are carrying some more pounds than you should be, you have a significant risk of reducing your risk of osteoarthritis.

For every extra pound or kilogram, you carry, you are putting an extra four pounds or kilograms of pressure through your knee. Also in that regard, if you lose a pound or kilogram of weight you are taking that pressure multiplied by four off the joint which could be significantly beneficial.

Is OA an Inevitable part of Aging?

GOL: You sometimes hear people talking about getting older and it is inevitable you are going to develop osteoarthritis. Is osteoarthritis an inevitable part of ageing?

DBS: It is not inevitable – there is a higher chance that when you get older you will develop it. Two-thirds of people who have osteoarthritis are under 65, about 15% of the general population will have osteoarthritis.

So yes, the risk of it increases as you get older, but it is not inevitable. People who are an optimum weight and who exercise regularly, do have a lower chance of osteoarthritis. For example, if you can lose 5 kilograms of weight, you reduce your risk of osteoarthritis by 50% – but easier said than done.

GOL: You have mentioned there about damage to the joint or injury. What about people who have been in accidents or experienced for example sports injuries when they were younger, are they at greater risk of developing OA?

DBS: Unfortunately yes. One of the things that is important if you are going to be exercising, is that you try and ensure that you have supporting structures around your joints that are as strong as possible, particularly the muscles, and if we are talking about knee or hip arthritis, you are talking about strong thigh muscles, strong buttock muscles, strong core muscles.

Unfortunately, we know that significant injury will potentially lead to osteoarthritis. For example, half of the people who rupture their cruciate ligament will go on to develop osteoarthritis and possibly need a knee replacement.

How is a diagnosis of Osteoarthritis made?

GOL: In terms of the people who are experiencing signs and symptoms, how is that actual diagnosis of osteoarthritis made?

BDS: The diagnosis is made usually with clinical skills rather than actually needing fancy tests. So when you approach your doctor, you will have some of the characteristic symptoms like I said earlier; pain when you are moving your joint or afterwards, maybe some stiffness in the morning when you wake up first thing or after sitting for a while, pain towards the end of the day, maybe the joint has changed shape, maybe it has been swelling – they are things that your doctor will use to help diagnose.

Then when your doctor examines you they may see some of the characteristic changes they see in osteoarthritis, such as restriction in how the joint moves, certain types of noises we call crepitus when the joint moves, maybe changes in the shape of the joint, boney swelling.

X-Rays can be used to help diagnose the condition but they are not essential. MRI tends not to be used unless absolutely necessary. Blood tests unless the treating physician feels that there could be another cause for the joint condition such as gout or rheumatoid arthritis are generally not needed either.

GOL: I think a lot of people sometimes feel that what doesn’t show up on an x-ray it is not osteoarthritis, but that does not really build the whole picture does it?

DBS: It is absolutely true and what you often see is somebody come into your clinic and they will have an x-ray of their knees on the screen and you will look at the x-ray and the right knee might look much worse than the left knee on the x-ray and you will sit and talk to the patient and find that they have absolutely no symptoms in their right knee and it is all affecting the left knee. So the x-rays can help but they are not everything.

What other joints besides Hips & Knees are often affected by OA?

GOL: We mentioned the hips and the knees being the key weight-bearing joints that are often affected by osteoarthritis but what other joints can be affected by osteoarthritis?

DBS: So one of the most commonly affected joints is what we call the thumb base or CMC joint and this is one of the most used joints in the body.

So it is common for people with osteoarthritis to develop pain in this area and this can manifest as pain also coming into the web space here or down into the thumb.

Other joints that can be commonly affected is what we call the first MTP joint, the base of your big toe. Your neck or cervical spine, your low back or lumbar spine are also areas that can be affected.

How is OA treated?

GOL: So moving on, let’s have a look at how osteoarthritis is actually treated – can you tell us a little bit more about that?

DBS: There are many societies and international bodies that meet on a regular basis to discuss recommendations about how to treat osteoarthritis, and every single one of those organisations recommends exercise as the core treatment for osteoarthritis.

Also, and we mentioned earlier, is optimizing your weight.

That doesn’t mean you have to lose ten kilograms or 10 stone, it means that you might just have to lose some weight and take some pressure off your joints.

So they are the core things; good diet, maintaining your weight, and exercise

Then you have other measures such as painkilling treatments. We prefer those types of medications that limit side effects, so for example the anti-inflammatory gels. There are many studies that would say the anti-inflammatory gels are nearly or just as good as the anti-inflammatory tablets, so we are familiar with medicines like Ibuprofen and Nurofen which are simple anti-inflammatory medicines.

They are actually very effective treatments for osteoarthritis, however, we try and use them as little as possible because if you are taking those medicines on a regular basis, we worry that there may be issues with stomach ulceration, we worry about the cardiovascular system, and they can potentially affect the kidneys and your liver function as well.

Nonetheless, many patients with osteoarthritis will need anti-inflammatory tablets and they can work really well.

Paracetamol or Panadol is also a medication that you will hear used. That has lost a lot of favour in the last number of years as an effective tool. It is felt to not have a very good painkilling effect.

If we compare the painkilling effect of exercise to the anti-inflammatories, the studies will say that they have a very similar painkilling effect, in fact, exercise might outperform the anti-inflammatories and that is a scientifically proven fact and it is interesting.

Then you will also hear of people having steroid injections into their joints. Steroid injections can work well but they would not be a tool you would use first off, you would try exercise, supervised physiotherapy, and then some of the other measures.

Increasingly many of us are using something called Hyaluronate. Hyaluronate is a natural component of your cartilage and your joint fluid. In a synthetic form when injected into the knee joint, it can have an anti-inflammatory effect and can help with pain as well.

Then there are other measures, for example, unloader braces which are contraptions you would wear over your knee if you have as we call it malalignment or the alignment of your knee is not perfectly straight. They can help certain types of osteoarthritis of the knee and then at the end of the line if those measures are failing and somebody is in pain and they can’t carry out their activities of everyday living, you have to visit the surgeon and discuss maybe a joint replacement.

What can Patients do to help manage OA and their Pain?

GOL: In terms of the patient, what can they do themselves to help manage osteoarthritis and their pain?

DBS: In terms of helping themselves, exercise once again, and I am sounding like a broken record, but that is the key treatment. Now the problem with exercise is that if you have never exercised before, it feels like a huge barrier or mountain to climb. Exercise doesn’t mean preparing for the Olympics or preparing for the Tour de France, it might mean getting off the couch and walking five hundred metres, or even one hundred metres, and going home and trying to do that every second day for a month and slowly but surely trying to increase that.

Overwhelmingly the evidence would say that if you are going to start an exercise programme, you should engage with a physiotherapist or a physical therapist to help guide you and the encouragement you get from somebody else also tends to lead to better outcomes because you’re more likely to do what you are told and if you have someone supporting you, you may have a better outcome.

Then in terms of other measures, for example, say if you take up an exercise programme, you may find that after exercise the joint plays up a bit – that you have more pain in your knee, or your hip, or your shoulder, or whatever joint is affected. There are things you can do to limit that pain, for example, you can ice a joint that is affected. Now it sounds very archaic, but taking a frozen packet of peas, wrapping it in a J cloth, and placing it over the affected joint for a minute and leaving it off for a minute and repeating that for five minutes can help.

Some patients will take painkillers pre-emptively, so, for example, somebody is going to go for a thirty-minute walk, they know at the end of the walk they may take an anti-inflammatory or rub on their anti-inflammatory gel before they go on their walk.

So there are different things you can try. One of the things to look out for is developing pain after your exercise when the pain is prolonged. If the pain is prolonged after you start exercising you are doing too much and you have to go back and maybe just reduce the duration and intensity of your exercises and try and build it up slowly. But that again is where a physiotherapist or a physical therapist can be useful.

What can people with other conditions on top of OA do to manage their situation?

GOL: For people watching as well, we actually have company videos on exercise and also on diet and healthy eating as well. Just a word to people who are watching this.Just some discussion around osteoarthritis and other conditions. Many people who are diagnosed with osteoarthritis might be living with other conditions as well such as diabetes, obesity, maybe osteoporosis, cardiovascular disease you mentioned as well. What can people do to manage in these more complex situations as well?

DBS: So that is a really good question, I am not going to mention exercise as the first answer because it will get monotonous. The anti-inflammatories as I said are very useful medication for osteoarthritis. But as I also mentioned there can be issues with side effects, so if you are diabetic and you have associated kidney disease, or you are at risk of heart disease, then the anti-inflammatories will be generally discouraged, so the anti-inflammatory gels or Paracetamol may be more useful.

It is the same thing for kidney disease, the same way for people who have heart disease or stroke. But getting back to exercise, if you have heart disease or suffer from obesity or have diabetes, exercise is a key treatment that patients who suffer from those conditions should be engaging with.

Does the weather cause osteoarthritis and does it make it worse?

GOL: Moving on now to some of the myths of osteoarthritis, I would like to discuss a few of those. So one question we get asked a lot about in Arthritis Ireland is what about the weather? Does the weather cause osteoarthritis and does it make it worse? I am sure this is something you are familiar with being asked about.

DBS: Well, believe it or not, I have a bit of osteoarthritis in my hip. So when I know when it is a tiny bit colder or damper I will get a tiny bit of discomfort in it. Cold or damp weather doesn’t cause osteoarthritis, but it can sometimes make the symptoms somewhat worse.

Osteoarthritis is prevalent throughout the world at the equator and in warmer climates. So it doesn’t have a role, but it can sometimes make the joints feel sorer.

What about Diet?

GOL: What about diet?

DBS: So diet is something I am always asked about and patients are very interested in their diet which is always really encouraging. Often people go to extensive lengths to eliminate foods that think, read or hear about are causing their arthritis.

For some reason tomatoes have a bad reputation, citrus fruits will not in any way affect your osteoarthritis. They will have much more beneficial health effects rather than a detrimental effect on your joints.

A healthy balanced diet is what everybody needs. You will read about an anti-inflammatory diet, essentially an anti-inflammatory diet are plenty of foods, plenty of fresh foods, vegetables, fruit, some oily fish, limiting your exposure to processed meats and foods, drinking plenty of water, not cutting out bread you don’t have to go gluten-free if you have osteoarthritis, trying to limit how much alcohol your drink, not smoking, and trying to maintain your weight.

Those measures essentially constitute a healthy diet. Also making sure you get enough protein in your diet is important because one of the main structures that helps support your joints are your muscles and if you are not getting enough protein you may not be able to replace the musculature adequately. So your diet is essential, but that does not mean you need to eliminate things from your diet. The people who are drinking pints of apple cider vinegar every day should probably stop doing that because it is not very nice either.

GOL: One of the other myth’s, there may be people watching who may have grown up with that belief that exercise is bad for their arthritis.

DBS: That’s nobody’s fault, if it is anybody’s fault it is probably the medical profession because many of us over the years have said you need to stop exercising now or propagated the myth that running is bad for your joints. There is some very nice research that has shown that people who are sedentary get much more severe osteoarthritis of their knees than runners.
Exercise is not bad for your joints.

If you have pain in your joints because of osteoarthritis, the damage essentially is done and what exercise has a number of ways of helping the joint. First of all, if you don’t exercise, your joint fluid starts to deteriorate in quality so when you start exercising, you help to maintain and replenish healthier joint fluid. Your joint fluid is important because it acts as a shock absorber and if your joint fluid is not healthy then it might contribute to your cartilage breaking down quicker. Also, exercise helps to maintain strong muscles which support your joints.

There are so many reasons why exercise is the most important treatment for osteoarthritis. But we have to challenge what many peoples impression of exercise is and I think the videos you mentioned are very helpful in that regard. Once again it does not mean that you are going to become a professional athlete or you are going to spend hours in the gym trying to exercise, far from it. Just getting up and moving might be the first step.

When do surgery and joint replacements become the best option for people?

GOL: Moving on now to issues around surgery and joint replacement. At what point do those interventions become the best option for people and is there a percentage of people who go on to need surgery that are living with osteoarthritis?

DBS: So the only cure we have for knee and hip osteoarthritis is surgery. That is essentially a cure. But it is an extreme cure. If you can avoid surgery then you should. However, the outcomes from hip and knee surgery are absolutely excellent but ultimately what we want to do is try and avoid surgery if we can.

The risk of knee and hip osteoarthritis is approximately 25% and 45% respectively throughout your life, so in other words, you have a 1 in 4 chance in your lifetime of developing hip osteoarthritis, but you have a much smaller percentage chance of needing a hip replacement or knee replacement. I can’t give you a precise percentage but it is much lower, so if you have hip or knee osteoarthritis you are much less likely to need surgery than anything.

What does the future hold for OA?

GOL: Lastly, what does the future hold for osteoarthritis? I sometimes hear people speaking saying there is not a lot happening in this area when you compare it may be with other types of arthritis you see great advancements. Is there research going on in this area, is the future looking brighter with osteoarthritis?

DBS: I think we are on the cusp of major improvements in definitive treatments for osteoarthritis and there is a lot of research going on worldwide
Remember that osteoarthritis is costing the global economy billions every year because of lost days in work, expensive surgery like knee and hip replacements. So there is a real incentive for us to get definitive treatments and cures for osteoarthritis.

There are a number of treatments that for the first time where results have started to be published in the medical journals and some of these treatments are looking at repairing cartilage, so allowing cartilage to regrow, some of them are looking at stopping cartilage breaking down, some of them are actually looking at ways to prevent pain. One of those particular medicines is a protein called nerve growth factor and those medications may well be becoming available soon on the market but they would be for people with severe osteoarthritis.

So there are many positive things that are emerging and I think over the next 5-10 years, we are going to see an explosion in new therapies.

For further information or to make an appointment with Dr Barry Sheane please contact info@sportssurgeryclinic.com
Dr Philip Carolan Cavan GAA

Anglo-Celt Cup visits SSC

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We were thrilled to welcome the Anglo-Celt Cup to Santry on a beautiful sunny day yesterday.
At SSC, we are honoured that two of our physiotherapists Stephen Murray and Bryan Magee, are part of the Cavan Senior Football team that brought the Ulster title back to Cavan in 2020, following a historic victory over Donegal in the Ulster Final.
Stephen and Bryan would be the first to acknowledge the fantastic support of their medical team lead by Cavan Team Doctor and SSC Consultant Sports Medicine Physician Dr Philip Carolan and Cavan and SSC Physiotherapist Risteard Byrne.
Well done to all – we are all very proud of you, and best of luck in the 2021 season.

Sports Injuries – Huge increase in injuries when people who played sports returned to competitive training.

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Older people will need rehab after lockdown, GP warns

Unsupervised Covid-19 lockdown exercise regimes keeping physios busy

This article by Sarah Burns & Brian Hutton was published in the Irish Times on Mon, Apr 5, 2021, 03:24

The health service is going to have to concentrate on rehabilitating older people who were previously fit but have experienced a drop in mobility due to the Covid-19 pandemic, a Dublin GP has warned.

Dr Ray Walley said the biggest problem he was seeing among older people was the loss of power in their thigh muscles as they are not getting out and exercising as much as they would have prior to Covid restrictions.

“A lot of older people, who were perfectly mobile before, are not mobilising as much as they would have previously, they’ve put on some weight, their energy output has reduced, this is not just older people but once you reach 40 you lose 2 per cent of your muscle mass every year,” he said.

Click here to watch a video of SSC Fitness lead Luke Hart demonstrating exercises designed to keep you fit as you get older.

“There needs to be a push on educating people to the fact to keep activity going in the same way, for example, the Department of Health advised that everyone over 65 should be on vitamin D.”

Dr Walley said he was advising his older patients to clear their back gardens of any obstructions and to walk around its perimeter repeatedly.

“We need to adapt and have ambition with that adaptation. It is quite amazing many of my older patients have adapted to using the internet and things like that,” he added.

“Beaumont provides a lot of mental health advice and a lot of other advisories with regards to exercise, they just need to be signposted.

“Some of our elderly, by way of their children or grandchildren, have adapted to a lot of the stuff but we can’t afford to leave other people behind though.”

Hip fractures

Dr James Cashman, consultant orthopaedic surgeon at the Mater Private Hospital, said he had also seen “a concerning uptick” in older patients presenting with hip fractures.

“These would typically be patients who have been isolating or cocooning and they wouldn’t have been getting their regular exercise and then when things opened up they were getting a little bit of exercise but would have been a little frail, fell and broke their hip,” he said.

“So when things opened up, particularly after the first lockdown, we saw an uptick in hip fractures which are quite a significant injury.”

Click here to watch a video of Mr Gavin McHugh Consultant orthopaedic Surgeon at SSC discuss ‘Common Hip issues’.

Dr Cashman said “ideally” everyone should be continuing to do some form of exercise, but older people who had been cocooning should “take that extra little bit of caution” if they were out exercising.

“From my point of view, I think swimming is a huge loss for older people because running and field sports don’t really work for a lot of people and even walking, people might be worried about walking out in the environment with social distancing and that,” he said. “As an exercise, I think swimming is a huge loss. People have lost out on that as an outlet in a big way.”

Sport injuries

 

Meanwhile, Dr Enda King, head of rehabilitation at the UPMC Sports Surgery Clinic in Santry, Dublin, said he had seen a “huge increase” in injuries when people who played sports returned to competitive training.

Dr King said there was a rise in injuries when team sports returned to training last summer following the easing in lockdown restrictions.

“People who play recreational or more competitive sports in non-Covid times, when they go back to their sports we’re finding a huge increase in injuries. Even though they’re doing exercises at home, they’re doing their 5km runs or whatever else, it’s not reproducing the intensity or the demands of a movement type that are specific to their game,” he said.

“For example, at the intercounty level, club GAA or rugby, lots of teams are in better shape than they’ve been for a long time aerobically, both male and female.

“However, when they go back to sport, because of the demands of change direction and high-speed sprinting, especially under competitive circumstances, you’re seeing a large spike at all levels in soft tissue and joint injuries.”

Dr King said those who were hoping to return to team sports over the coming weeks and months should be getting exposure to high-intensity activity such as sprinting twice a week.

“If team sports gets the go-ahead at junior or league level over the next few weeks and everyone else a couple of weeks after that, you’ll see people making a big burst in training to get back playing matches very quickly without necessarily having enough time to build back up that level of intensity,” he said.

“You can do all the running and aerobic work you want, but it’s much more demanding when you have to sprint and accelerate and change direction in response to a ball or a competitor. You see that people just aren’t prepared for the demands of that.”

Another trend physiotherapists are dealing with during lockdown is people “over-training” because they are not being supervised at a gym or by a club coach.

Over-training

Bob Firo, of the Dublin Sports Injury Clinic, said frustrated amateur athletes were “doing too much, too quick and for too long”.

“This week I had five patients who were over-training,” he said.

“Because they don’t have access to the gym, people are mostly running or doing home workouts. Unfortunately, because they don’t have a programme to follow and they have more time on their hands, they are doing too much of it.”

Firo said some people presenting at his practice were exercising every day without taking any time for recovery.

“It feels good at the start, almost addictive and it’s one of the only things people can do,” he said.

“But at some stage something will go wrong, because the body needs to recover as well. You have to give it a break, and look at your food and your sleep as well.”

One man who attended his clinic during the week couldn’t understand why he had a sore, swollen knee. It turned out he had been running 24km every week since the start of the first lockdown in March last year.

“That might be fine for six weeks, eight weeks, 10 weeks but not for a year,” the physical therapist said.

Firo has noticed a lot of people turning to running in particular during the restrictions.

“If you take up running seriously, you need to have a plan,” he said.

“People are running without any plan, any goal, because there are no organised runs or marathons at the moment. People are just running to do something, sweat it out and feel good.”

For further information on Sports Injuries or to make an appointment with a member of our Sports Medicine Team call 01 5262030 or email sportsmedicine@sportssurgeryclinic.com
Enda King

Melbourne to Santry: The Physio prolonging AFL Careers

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This article by RTE Sports Journalist Maurice Brosnan was published on www.rte.ie on Monday 31st August. 

There is nothing unusual about the consistent incidence of recurring injuries in a sport as physical as Australian Rules. What is surprising is their increasingly popular foreign resolution.

In recent years, several players have fled Australia and sought an answer at the UPMC Sports Surgery Clinic in Santry, Dublin.

Essendon star Joe Daniher and James Stewart both travelled at the start of 2020. GWS Giants midfielder Callan Ward and Irish-born defender Aidan Corr are also known to have made the trip.

“It was so great for me and my career,” explains Corr. His family moved from Brocagh, Tyrone to Perth when he was just a child. After an injured-plagued few years, the 26-year old is now a stalwart in Great Western Sydney’s defence.

“The tests were pretty intense, they quickly found weaknesses in my body,” he says. He was assigned a programme initially tailored so that he could do it in his hotel room. After two weeks, he returned to Sydney where the club took over his recovery while the UPMC Sports Surgery Clinic remained in consultation. It is a holistic approach attuned for elite sport.

Conducting the tests and overseeing recovery is Head of Performance Rehabilitation, Enda King. Alongside Dr Andy Franklyn-Miller and renowned surgeons like Ray Moran, the team quickly garnered a notable reputation.

“I think there are two reasons why players come,” explains King. “One is another player’s recommendation. That can’t be understated. That is why we’ve seen so many players from Australia in recent years.

“The second is that when you have a chronic or recurrent issue, people are looking for another option. So, my goal is not to say the rehab you have done is or isn’t working. My goal is to say physically I can profile you in great depth and say this is where you are now, and this is your target. All we want to do is get you from A to B.”

King has personal experience in this area. A former Cavan footballer, his career was constantly stalled with hip and groin issues.

Surgeries and pain medication did not help. It was a never-ending search for someone to fix the pain without ever standing back and asking why it was there. That is the thought process that now steers his approach.

One part of that is 3D biomechanical analysis. It is the same system Disney/Pixar use to digitise actors. By digitising athletes, they can focus on the cause rather than the effect.

“Fundamentally, how you move influences where load is distributed in your body. We have numerous papers looking at biomechanical changes post-athletic groin pain and how athletes have gone from symptomatic to symptom-free.

We have a number of other papers coming out in relation to ACL cords. There are biomechanical differences between healthy athletes and those who have ACL reconstruction.

“Look, there are certain injuries that just get better. These are all young athletic and healthy males and females. If you tweak something, it will recover. But if there is something that is causing chronic or recurrent issues, very often the strategy is to keep focusing on that tissue. ‘I pulled my hamstring so I keep strengthening my hamstring, but I keep pulling it even though it is strong.’

“Surely there must be some other reason then? Why did you reach the point of overload injury?

“If you are pulling your hamstring when you sprint, surely your running mechanics are playing a role in that. I don’t care where their injuries are but I care more where their strengths or deficits are and how they move.

“You often see recurrent issues where they keep doing the same thing over and over. It’s not working. That is the definition of insanity. At some stage we need to look at the other contributors.”

Ireland’s top athletes often find themselves at King’s door following a severe injury. One of the most serious of all is the torn anterior cruciate ligament. Amidst all that trauma, there is also the opportunity to learn from it. Over 1,000 ACL reconstructions and rehabilitations per year means over three million data points. Information that can be studied and analysed to garner improvements in rehab strategies.

Last February, King published a two-year follow-up study on the factors influencing return to play and second ACL injury rates in Level 1 athletes. It left him with several significant takeaways but primarily, it reinforced his view that a full recovery is unquestionably attainable. The ‘dreaded ACL’ moniker irks him.

“I just think it is unnecessary to be scaremongering. It is unnecessary to be overly downbeat. It is not a nice injury and you don’t want to get it but once you get over it you can be very successful and have a long career.”

There are certain choices made during recovery that need to change.

“I would like to see clear decision-making based on recovery of multiple factors. What your strength levels are like, what your power and plyometrics are like. Most of the research compares legs. My injured leg to my non-operated leg. That does not mean the non-operated leg is good enough. It is about trying to set thresholds for those going back to high demand sports.

“Look at the biomechanics. Numerous papers shown a common injury pattern. A certain amount of that is reducible, a certain isn’t. If you never want to get injured, don’t play multidirectional sports. At times, your knee is at risk.

“But overall, we can really raise the bar.”

“There was a point when a ruptured ACL was a deathly blow, but the entire process has evolved. King cites Dublin’s Jack McCaffrey and Bernard Brogan, who under the rehabilitation of the Dublin GAA medical team led by James Allen, made full recoveries and went on to win All-Ireland titles.

“At the forefront of this progression is technology. It is only beginning. The industry could soon see a revolution.”

“The analysis of movement in clinics and in training grounds will massively grow over the next ten years. Whether that is 3D biomechanics or alternative software, it will be the get to a stage where it is not about how long have you rehabbed. My work will be judged on how they move and look physically.

“That is phenomenal. It really challenges your programme or coaching. If they have done six-eight weeks work and don’t look different physically, is that my problem or theirs? It makes me really review what I am doing on an ongoing basis.”

At the same time, not everyone has the means to tap into that. Nor do they need to. Well-executed basics, King stresses, can form the bedrock for success.

There are simple steps a coach at any level can take that can have a seismic impact.

“There are numerous studies that show prevention programmes when done systematically can reduce ACL injuries by 50%. Straight off the bat. Especially in female athletes.

“There is huge research that shows specific warm-ups are effective at reducing soft tissues and knee injuries. There is heaps of research to support that.

“Even in a gym facility, you are looking to do two things: improve your robustness and improve your athletic capacity.

“Sometimes, guys and girls are improving their athletic capacity, getting stronger and more powerful, but developing poor movement strategies. Squatting or deadlifting with a big arch in their back, tipping into pelvic tilt, anterior pelvic tilt. These are risk factors across knee injury, pelvic and groin pain etc.

“We should not overestimate good practice.”

For further information on ACL Injuries or to make an appointment with an ACL Specialist at UPMC Sports Surgery Clinic please contact info@sportssurgeryclinic.com

Dr Andy Franklyn-Miller discusses Body Composition with Clare McKenna

Posted on | by Fiachra O'Connor | Leave a Comment on Dr Andy Franklyn-Miller discusses Body Composition with Clare McKenna

Dr Andy Franklyn-MillerListen to Dr Andy Franklyn-Miller, Consultant Sports & Exercise Medicine Physician and Director of SSC Sports Medicine as he discusses Body Composition and the benefits of SSC’s Health Lab Services with Clare McKenna on Newstalk’s ‘Alive and Kicking’ podcast.

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For further information on Health Lab Services at UPMC Sports Surgery Clinic please contact sportsmedicine@sportssurgeryclinic.com or phone +353 1 5262030

I am here with Dr Andy Franklyn-Miller and we are having a look at my results, but before we get into that can you just remind us of the health scan and the programme, and what I went through and why?

Health Lab has really been designed to look at health all round, to give a snapshot of stress and how the body is handling both diet, exercise, work stress and particularly at the moment in this very strange and unique time, how the body is reacting to these extra stresses of the environment that we have been put under, so it’s about the tests: both patient questionnaires, understanding how you view various parts of your health, dietary understandings (some blood tests) and a body composition scan; looking at how body fat is distributed between the central organs like the liver and inside the abdomen, but also around the outside of muscles, and also stress heart rate variability as a marker of exercise and how you are getting on with sleep and life in general.

We compare and contrast how that changes over time and then look for any warning signs of possible potential health issues in the future, but also try to optimize things for you, so rather waiting for things to happen, what we might be able to change in a positive way to give you more energy, better sleep, better lifestyle and then reduce some of those risk factors for diseases of high glucose and high-stress levels.

One of the focuses was on body fat, and where your body fat percentage is in your body composition. Now I know we’re all focused on the aesthetic and that’s a different story (wanting to look lean), but why is our body fat percentage an indicator of where we are health-wise?

One thing that we forget quite often is that body fat is we can see it distributed around ourselves around our tummy, our back, our chest but also our organs. The bits of us that deliver vital functions can also accumulate fat and one of the big health risks here is fat deposits in the liver because it stops the liver being able to function, to break down products and waste and is one of those early signs of disease.

So whilst looking at how you look and taking callipers of how much body fat you have around the outside of you, a body composition scan can look at how much is internal and external so you get some early warnings of those organs that might be struggling as well.

You have come under some criticism over time that looking at lifestyle will never replace medication and you are not suggesting that people stop taking pills if they need them but it is very important that we have a picture of our general overall health and lifestyle changes we can make to affect this?

Absolutely and look, we know that morbidity or risks to health from inactivity and poor diet really are an enormous problem for public health around the world. We are getting older as a population, we are also getting fatter and less active over time and of course, that’s not everybody. There are some people who are incredibly active, lead very healthy and very focused lives, but not most of us and there is an ever-increasing reliance on more and more medication to try to treat these conditions.

What we are really trying to say here is that there are some scenarios where changes to lifestyle, diet exercise are of enormous benefit and there has been a lot of work gone into how we might use that. Do we need to call it lifestyle medicine? Of course, we don’t. We can call it ‘Exercise and Health’ and we can look at those risk factors. What we are really saying is let’s look at our health, let’s look at how we can improve our lifestyle while we still can rather than waiting for these diseases take effect. What we are really saying is let’s look at our health- let’s look for area’s where we can improve our lifestyle- when we still can rather than waiting for those disease processes to take effect.

So a reminder; I had the body fat composition, the DEXA scan back at the end of January, my bloods, my heart monitor and then I headed off with a programme and an idea of what to do and here I am. Obviously we were a little delayed with the global pandemic, but nonetheless I have carried on and remained focused, so how did I get on after my DEXA scan last week?

As you can see from your numbers here you have done ok. Across the 7 months, you have decreased your body fat by about 1 or 2 per cent.

You have got lighter, you have lost nearly 2 kilograms in weight. You can see that all of your fat loss has been 1 and a half kilograms, you have gained a little bit of lean muscle mass so some of the gym training you have been doing has increased that muscle mass and you can see that sometimes bodyweight itself isn’t the best indicator of actually you losing fat but we can see when looking at the distribution you have lost fat both on your internal organs and around the trunk, maybe less so on the arms and legs but that is normal in terms of that process.

But overall you have probably lost less than we would have expected after focusing on lifestyle change and exercise and you have been working really hard in terms of that process and so I guess it probably starts to raise the question that we need to look at some of the reasons that may not be the case.

I thought this was interesting because I couldn’t fully work out the numbers but a lot of it is graphs so I could tell it hadn’t gone down that much. Now I hadn’t lived in deprivation mode or anything like that, I have lived normally as per the advice of Daniel Davy, the Performance Nutritionist. I stuck to what he said, was consistent with my exercise, so also I expected to see more. But you think it’s less about that and more about my bloods that’s what gives you an indicator about what is going on?

Absolutely, we know from looking at your heart rate variability and activity monitoring that you have actually increased the amount of activity you were doing, therefore, you have increased the amount of energy/calories you are expending.

You have been careful, had a balanced diet, but you have not really been excluding any specific foodstuffs.

When we looked at your bloods, your blood glucose is normal and so therefore from a normal set of bloods we expect nothing to see.

What is interesting to look at is insulin sensitivity. What that really means is how your body reacts to surges in glucose- it produces insulin to mop up the excess that you don’t need.

We can see from your HOMA-IR (a measure of simply comparing the ratio of glucose to insulin sensitivity) that actually you are struggling a little bit in order to produce enough insulin to cope with those increased glucose levels.

We see that that progresses to and there is some good research demonstrated that this leads to increased risk, particularly in female patients, of developing type 2 diabetes or insulin resistance. And that certainly can explain why it is more difficult to lose body fat if you are struggling to control circulating excess of glucose in the body.

So if you are somebody who has this sensitivity what is the best way to get this under control?

Well for those patients who have been diagnosed with type 2 diabetes and that’s not where you are at and does not necessarily mean you will get to that level, but in those patients, we often say that lifestyle changes are the first step.

What does this really mean? Dietary manipulation is certainly a part of that and one of the easiest things to do is to control or restrict the amount of glucose that we eat. The easiest way to do that is to control the amount of carbohydrate. Does that mean we have to be extreme and go for a sort of carnivore only diet? No, it doesn’t, but certainly significantly reducing the number of carbohydrates has been seen to improve the amount of glucose circulating in the body.

Some increasing interest in 24 hour live monitoring of glucose through a skin sensor that can measure both glucose levels continuously, in the same way that many diabetics will do in order to measure the amount of insulin they were giving and that would be a type 1 diabetic who doesn’t produce insulin normally, rather than a type 2 diabetes which is more control issue with the response of insulin. By measuring glucose over 24 hours we can get an idea of which bits of food or diet in meals that you have that cause significant spikes, and that is different for everyone

We are understanding more about how you adapt to metabolise food and so for some people eating a bowl of porridge might be an excellent way of giving a sustainable low level of glucose, but for many others it might give a significant spike of glucose that the body has to work quite hard to absorb, and therefore can easily lead to excess.

So what might be perfect nutrition in terms of a balanced diet for one person might well cause significant glucose spikes for another and then lead to high circulating levels of glucose. Controlling diet, looking at the circulating levels of glucose and reducing levels of carbohydrates is certainly step 1 in this, in combination with looking at an exercise programme and making sure that it’s a progressive increase rather than just staying the same with what you might be doing.

It is interesting what you say about everyone being different and yet across the board we are seeing an increase in diabetes and type 2 diabetes. What is causing the health pandemic? Is it because we are living in a world of plenty so we just eat too much is that the bottom line?

Well on a simple level people would say this is about calories in and calories out, so how many calories you burn and trying to balance that with the amount of food that you eat. But it’s really not as simple as that because although a steak and a banana might have been matched in terms of calories if we balance them up specifically, obviously they are very different in what the body does to metabolise them.

A steaks protein will take longer to metabolise, very unlikely to see that spike of sugar, whereas fruit can be broken down much more easily which can cause a big spike. So it’s not as simple as calories in, calories out. Really I think that a lot of it’s about convenient food; people live busy lives, a lot of processed food is high in carbohydrate because we feel full quickly. Elite athletes are no different, often we see athletes who will go for a fast sustainable carbohydrate source immediately after but equally think nothing of grabbing a bag of Haribo’s after training because they are feeling very tired as they’re blood sugars are low.

The exact same thing happens to them, just that their overall work load/energy expenditure is so significantly higher they can often get away with it on the odd occasion whereas many of us with a lower level of exercise don’t get away with it.

So where does this leave me? My initial goal was to try and prove that it’s actually relatively simple to be healthy and through the experts I have worked with they have given me a lot of information on the emotional side of why we eat what we eat and why we may go off track of our health which adds a layer of complexity. But this also adds a layer of complexity; that everybody’s different and it could be something to do with your processes within your body. But is the bottom line still that it’s quite a simple lifestyle and dietary change to fix it. Is it still simple underneath?

I think it is still simple. I think what we have identified in your case is that there might be a reason why it is a little bit harder than it is for someone who is exactly the same otherwise in how they approach life to you. You may have taken on the same challenge but have lost more body fat or may have not lost as much body fat and you have been successful in many ways in this process. But in your case we have identified that actually your control of glucose is a bit harder, and so therefore you need a bit more help in terms of getting that right, but once that balance is there and we get an idea of what you need to do, but if that will work for you and so then it is very much self-managed and I think there is more to it than just looking at body composition, because your liver enzymes are very normal, your vitamin D is gone back up into the normal range which is very important at the moment in terms of immune function and there’s a lot of positives here as well as identifying an area where might need a bit more focus.

So what is your advice to everybody? Find out the info, find out what’s going on in your body particularly if you have an indicator whether it’s poor sleep, poor energy levels or you feel overweight and sluggish- find out what is going on within.

There is always an answer here. So for many people, restricting carbohydrates they are likely to see almost immediate results such as losing body weight, feeling more energised, improving sleep. But if it is not working for you then that may be the time at which there is a need to look at it a bit more in depth and understanding perhaps potentially insulin sensitivity is one way at looking at that glucose control, looking at body composition is a way of understanding where that body fat is distributed and then some other information markers and liver function can give us some early ideas about what’s going on as part of the overall picture. You mentioned it earlier on stress, lifestyle, sleep are incredibly important components of this. It can be that actually stress and sleep are the main problem here and we know in your case that this is very well managed but not always in many people there are different areas of focus for people who are struggling one way or the other and it is not one size fits all.

For further information on Health Lab Services at UPMC Sports Surgery Clinic please call +353 1 5262050 or email healthlab@sportssurgeryclinic.com

Enda King discusses the latest SSC research on ACL Injuries with IMeasureU’s Dan Savin.

Posted on | by Fiachra O'Connor | Leave a Comment on Enda King discusses the latest SSC research on ACL Injuries with IMeasureU’s Dan Savin.

Dr Enda King, Head of Performace at SSC Sports Medicine discusses the latest SSC research on Anterior Cruciate Ligament (ACL) Injuries with Dan Savin on IMeasureU’s Research Review.

About Enda King

In early 2019 Enda completed his PhD through the University of Roehampton in London exploring the influence of 3D Biomechanical analysis on outcomes after ACL reconstruction.

His greatest areas of expertise lie within hip and groin related, as well as knee / ACL rehabilitation, and he is committed to performing innovative research to develop robust methods for injury prevention and rehabilitation in elite sport.

Enda has over 20 peer-reviewed publications and regularly travels to speak at international conferences on groin injuries, ACL Return To Play and Return To Performance After Injury. Enda also authored the hip and groin chapter in “Sports Injury Prevention and Rehabilitation”. Enda in his presentation will explore the role of 3D biomechanical analysis in RTP after ACL Reconstruction.

For further information on ACL Surgery or to make an appointment with an SSC Clinician specialising in ACL Repair please contact info@sportssurgeryclinic.com
Interview with Enda King

 

It would be great if you could tell us a little bit more about who you are, what you do at SSC, and your journey to your role?

I have been at the UPMC Sports Surgery Clinic for over 10 years now. My current role is as head of performance. I am a Physiotherapist by trade. I have done my undergrad here in Trinity College in Dublin, and I have spent some time studying in Curtin University for my masters in Perth and have finished a couple of years ago with my PhD in 3D Biomechanics and ACL reconstruction in University Roehampton in London. I have picked up various strength and conditioning qualifications along the way through the UKSCA and the NSCA over in the states. My current role is probably three pronged: Number one is that I am involved in Business Development and Service Provision in the Sports Medicine Department in UPMC Sports Surgery Clinic. My main clinical roles are around residential rehab, so elite athletes and sub elite athletes come for biomechanical analysis and review, plus or minus intensive rehabilitation blocks. Off the back of that here with us in Dublin, I am involved in the academic research, principally around ACL and groin, but mostly around the use of 3D biomechanics in lower limb injuries in particular. So it’s a nice varied case now and it keeps everything interesting. It makes the weeks fly by.

I know you’re a busy guy and you’ve got a lot on your plate. I actually wanted to dive in in a bit more detail to your most recent publication. So I think it was back in February you published your two year follow up study, looking at the factors influencing returning to play and re rupture in class 1 elite athletes. So could you tell us a bit more about how that study came about and what the objectives of the research were?

I suppose one of the benefits of working in a place like the UPMC Sports Surgery Clinic is you get large volumes of the same kind of athlete/patient. We are very lucky to have a number of very experienced, talented and prolific knee surgeons in the clinic led primarily by Mr. Ray Moran our Director of Medicine, who would have a very substantial practice himself who would do about 600/700 ACL reconstructions per year, along with his colleagues Mark Jackson and Cathal Moran as well. We have this large cohort of a clinic that we are working through all the time and one of our expansion service wise was to enhance the physical assessment and follow up of these athletes post-surgery. These guys are doing a huge numbers of surgeries, but the outcomes physically can be a little inconsistent because of individuals of that athlete’s application but also they are going off to be rehabbed in different countries in the world. We wanted to try and offer some continuity, care and some systematic analysis to benchmark these athletes through. Our Director of Sports Medicine Andy Franklin Miller set up a biomechanics lab here in the clinic. We have two of them running concurrently and we set up a pathway to look at reviewing these athletes pre-op and at 3, 6 and 9 months after, and then obviously looking at the follow up after 2 years and we are currently most of our way through our 5 year follow up in this cohort as well. The idea being is that number one, we see lots of them, we think they do well- but do they do well? Number two is who or how many have issues and what are those issues. Number three is trying to rate that back from a biomechanical analysis point of view- can we identify through testing or through your demographic data or surgical data- who has a better chance of doing well or poorly, and can we intervene more proactively, because the majority of these athletes do quite well. There is a lot of scare mongering around ACL and outcomes and who gets back and re-rupture rates- clinically that didn’t necessarily follow up with what we were seeing, but unless you were tracking them all, we have 90/95% follow up in this cohort, unless you are tracking them and seeing what does happen, it’s very hard to make substantial comment’s one way or another. It was built off I suppose a desire to see how these athletes are turning out. Those who are not turning out as desired, how many are there, why is it happening and then can we be more proactive and evolve our care pathway to try and cater for them as much as possible.

With such a large study I’m sure that getting all the athletes back in through your doors for 2 years is a real challenge. Did you have much drop off or were you pretty successful in terms of what you were able to do?

I think you have to begin with the end in mind- when you lay out the journey for the athletes and how having your surgeries is the first step in the ladder, the testing is the next step, return to play is the next step but that we are with you not just to get you in and out and get your surgery and away you go, we are with you to make sure that it works out to the best outcome. The majority are actually delighted to get the follow up and be involved and see how things are going and are very interested in giving feedback on the process and how they’re doing. We spent a lot of work on trying to have a defined care pathway that all of the athletes fed into. People naturally opt out or move different country, however it captures the vast majority of these rather than cherry picking some athletes here and there or geography pertaining to it. The biggest job was getting a defined path in your place, making sure all the surgeons were feeding into it, and then it becomes self-fulfilling in that you’re coming because we have quite calibre surgeons but also you are coming for the package; you are coming because you know you are going to be looked after afterwards- you are coming with an expectation to be tested because your team mate has been tested or your cousin has been tested or whatever else. It expands beyond the ‘I’m coming because I ruptured by ACL can you fix me?’ to ‘Can you leave me back to where I was pre-injury?’ which is partly structural and partly physical. People want to give their story, they want to be followed up. We’re very lucky I think we had 95% follow up over 2 years and we are currently trending at over 90% for 5 years, so like people are buying into the process.

I appreciate it was a large study with lots of participants. Could you just touch on what your main findings were?

If you are looking for outcomes in relation to ACL, they are commonly related to return to play, to second injury and pain or ongoing issues of patients reported outcomes. I think that one of the unique things in this cohort/registry is that the mass majority of all were returning to field sports, so when you are comparing cohorts, I mean one of the best ways of avoiding ACL injuries is don’t change direction or land, so if you are looking for second injury groups you need to be focusing and analysing those going back to the highest risk sports- otherwise it is like comparing apples and pears. We have a high return to play rate over 2 years of 81% with the vast majority of those who hadn’t returned were for psychosocial reasons such as they didn’t feel ready or work getting in the way- very few, if any at all, hadn’t returned due to knee function. We found that the re injury rate for Patellar Tendons was 1.3%- which would be relatively low compared to the comparative literature, and 8.7% for our hamstring tendons. There seems to be a bias towards a higher second re rupture rate of our hamstring tendons. The injury rate in the Contralateral knee was about 6.6%. So the interesting bit also in return to play was that there was no relationship between time to return to play and second injury- so whether you return from 6 to 9 months, 9 to 12 months, or 12 to 15 months, that didn’t influence your re injury rate. There is a lot of discussion around that you shouldn’t go back for 2 years or 1 year etc., but there are a lot of athletes that successfully return without second injury at the 6 month mark, so we know that there is a healing process that needs to take place. We have no measure of that healing process- there is no way of testing how strong the graft is or how mature the graft is. We know that process can go to the 2 year mark and we know know the vast majority of athletes return without issue before 2 years. The role then of physical function and your physical capacity on your return obviously will take a greater importance and that is where our future research has moved on to. The other part is from our Pre and Intraoperative data, it was very difficult to predict who would have a second injury. So if you were to sit down in the office in front of Ray Moran and you were a male, whatever age, sport etc. and he has your Intraoperative findings, it is very difficult based on only on that data to say well you are more likely to do well or you are not more likely to do well, so naturally like all these things it is more multifactorial than that. Some of our future work now is looking to bring the demographic and operative data in with the biomechanical data to see if we can create more robust algorithms around that as well. I think the take home messages were that is that ACL reconstruction is a successful way of returning to high demand sports, the re injury rates are low overall, lower for Patellar Tendons. What we have done which is most cared for within this is, obviously there is the surgical data and it’s influences and outcomes, but it is also the influence of a pathway. If you have a pathway that reviews athletes at regular time points and provides objective feedback; that is it positive in a return to play point of view as they are motivated and goal driven to return, and is it positive in a second injury/pain point of view because you are catching them early physically below some of the benchmarks you’re looking for. Million dollar question is how good is good enough, which obviously is very individual. It’s amazing how many athletes do a lot of rehab and don’t look much different physically between 3 months, 6 month and 9 month reviews, our process is around not so much what you do or the what the right/wrong exercises are, but physically how you look now and how you look in X number of weeks/months time, which brings a huge degree of objectivity- its great from a practitioner point of view because your work is under the microscope the whole time. Now we would only rehab a small proportion of these because Geographically they span across the country, but if you are rehabbing athletes and they are re tested after 6 months, 9 months and you assess 3 main goals and those measures are not trending very strongly in the right direction, naturally we all blame the athlete/patient because they never do what they tell us, but the reality is maybe we have to look back at our coaching, periodisation, the way we are programming our exercises. So it is a phenomenal feedback loop in terms of a) objectively benchmarking you against other athletes but also b) benchmarking my programming because what is working for that athlete may not be progressing at the same rate as would be expected for the effort that another athlete is putting in.

To be fair that brings me quite nicely onto my next question. Obviously we have seen a lot of athletes over a long period, and ultimately I guess the goal of any research is to inform practice and best practice at that. Have you used the results of this particular study or have you learned anything over the period of time that has caused you to change your practice?

In terms of this study I suppose it is potentially more pertinent to the surgeons, then to myself. I’m not going to select the graft type myself. Certainly I would wholeheartedly encourage Patellar Tendon grafts over hamstring grafts based on this information. A lot of the movement towards hamstring grafts and other grafts has been due to anterior knee pain. The primary reason you’re having your ACL reconstructed is to provide structure stability to the knee and not have a second injury. You want to pick whatever graft that does that first and foremost. Anterior knee pain is a rehab problem; certainly a Patellar Tendon graft may leave you more susceptible to anterior knee pain, the same way a hamstring graft may leave you more susceptible to hamstring injury- but that’s still a rehab problem, which means I need to go back and redevelop a programme and achieve the outcomes off the back of that. The second thing is I would put after the 6 month marker I would put more emphasis on your physical ability to return to play rather than time from surgery, as it doesn’t seem to be supported based on this data that time after six months leaves you at higher/lower risk. It is interesting how there is a larger percentage of people injuring the previously healthy knee than there is the operated knee- there are a number of studies that are in final review at the minute around the biomechanical factors related to re rupture or injury to the Contralateral knee and a lot of it is around the frontal plane and Valgus, which would have got a lot of the previous press/coverage in the literature. We are finding that a lot of it is to do with your performance during drop jumps and stiffness. Trying to set a high enough bar in relation to that is something we are putting a lot more focus on going forward.

I know you mentioned that this whole process is rolling over into a 5 year period and you just mentioned there that you got some papers in the process of publication. What other research can we expect from you and your team particularly over the coming months is there anything exciting that’s due to be published?

We have a PhD student who is looking at the influence of visual distraction and neuroplasticity during ACL rehabilitation compared to healthy athletes to see what role visual distraction has in our coordination and task execution, but also as a rehabilitation tool to influence our motor learning and our ability to bridge that gap quicker. We also have a number of papers looking at the biomechanics of female second injuries- so that the re ruptured data we have already outside of the registry, the biomechanical data has all been based on male athletes. We are also trying to use machine learning and AI to combine the biomechanical data with the demographic data and Intraoperative data to try and begin to profile people at various time points to say ‘your risk is higher/lower and these are the variables that are most relevant to you’. We naturally break an athlete down to your strength measures, power plyo measures, motor control during various tasks, all of which are inter related as well. Rather than just saying one test is good/bad, it’s when we look at a battery of tests to shed a greater light on things going forward. There is a lot of very interesting stuff from that point of view. There’s a lot of potential in terms of how we rehabilitate our athletes but also on how we advise our surgeons and referrers as to the current status of an ACL rehab and where things should go. People are always looking for the green light- however there are a lot of people who may be insufficiently rehabilitated or they’re poor movers and they don’t have a second injury due to not having enough exposure to the sport as they go back, maybe their genetics get in the way- it is multi factorial. But rather than saying when am I ready, the question is when am I fully rehabilitated? What does that look like? And can begin to say that when you go back to play that’s when you step on the journey. It is interesting how many athletes especially come back for re assessment every preseason saying they feel good, they’re moving well, they just want to just re calibrate and see what are their area’s they have to work on again. Again, there is no such thing as perfect because I don’t know what it looks like, but there is better and there is poorer and if we can place you somewhere on that spectrum, you can be much more targeted in what you are doing either from a performance or rehabilitation point of view as well.

Do you ever think we can get to a level where we can predict risk or chances of ACL injury through Machine Learning and all the things you have just mentioned there?

I suppose when you look back now at what we were doing from a medical and sports science point of view 50 years ago, it’s not even comparable to now. If you go forward 50 years they would probably be laughing at what we are doing right now, from a technology and practice point of view. You can’t get too proud of your current work/practices. I think only truly when all the factors can be brought into play, like genetic type, anatomy, biomechanics, surgical data etc., only when all of that is fitted into a model you will see more accurate predictions in relation to ACL. Our re rupture rates are very low which when you’re looking to predict, the easiest thing from a prediction point of view is saying that ‘you are not going to re rupture’ because 98% of the time we’re going to be correct, so it is difficult to develop models off datasets where you have only a small percentage ending up having desire and undesired factors. So that makes things a little bit more difficult than let’s say a hamstring injury, where you know that a third of patients are going to have a second injury potentially. But I think will evolve all the time- technology will evolve in terms of how we can measure and how accessible it is. But I don’t think we will ever be able to say your magic number is this or that because it’s the chaos of the sporting environment doesn’t fully take into account of what we can objectively measure. But I think we will get better at getting people physically back to where they need to be. It’s amazing because I do various workshops with physios and teams and there is always a couple of ACL’s within the group, and despite the fact that they are practitioners how many of them have ongoing persistent physical datasets, just related to the initial injury and post-surgery periods and they just never restored their physical function independent of their joint stability etc. So I think if we can objectify it more towards not can I predict whether you are going to re rupture or not, because that will probably always be a bit of a challenge, but can I profile you to say that you are physically back to where you should be or not or back to normal whatever that is. That is the next hurdle rather than you can return in 3/6/9 moths or things like that.

Well you guys are clearly doing a good job if you need some more data for unsuccessful surgeries you obviously need to do a lesser job of the rehab and surgeons need to drop a couple of pegs

Well it’s like everything else. There will always be re injuries and the surgeons here will always be very proactive on injury and ACL prevention. They are not going to do themselves out of business because as long as you are jumping around and changing directions there are going to be primary and secondary ACL’s, but I think we can do a much better job here and everywhere in being more defined in the physical side of things. There are hundreds and hundreds on ACL reconstruction, very well defined process, yet there is almost no agreement/clarity on what you should look like at the end. So I think that is probably the biggest gap in where we can go going forward is our outcomes are good but where is the room for improvement. It’s restoring physical function. Ironically pain post ACL or intermittent knee fusion when they return to play is a much bigger issue than re rupture and second injury is. It is completely unnecessary. I think that’s where opportunities are going forward.