The ACL & Common Knee Injuries

Watch this video of Professor Cathal Moran, Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic, presenting on The ACL & Common Knee Injuries

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on Knee and Sports Injuries

Professor Cathal Moran SSC

Professor Cathal Moran is a Consultant Orthopaedic Surgeon specialising in Knee and Shoulder Surgery at UPMC Sports Surgery Clinic.

This evening I’m going to speak to you a little bit about ACL injuries. I am not only going to be speaking about Anterior Cruciate Ligament injuries but I’m also going to show you a video of how ACL surgery is actually done.


The Anterior Cruciate Ligament (ACL) is one of the key ligaments of the knee. It’s the central stabilising ligament of the knee, here is a model. This bottom bone is the shinbone the area at the front is the knee cap or patella but if we look inside the knee we see a couple of key ligaments and the ACL is the one here in the middle of the knee which we find to be very important for athletes and players particularly those involved in what we call cutting sports which we have a lot of in Ireland like our GAA and field sports.

When a person goes to cut or turn or decelerate from a highspeed run that ligament kicks into action and provides a lot of stability through the knee. We know from injuries that very few athletes nowadays seem to be able to manage or cope to play when that injury occurs and we see it in all sports like rugby, hockey and GAA. What we do know is that it is primarily regarded as a non-contact injury. One doesn’t actually have to pick up a tackle or get hit for that to happen. It can simply happen by planting the leg going to cut and turn and classically the athlete or patient will describe the knee popping and giving way beneath them.

How does it happen? I suppose it happens in those field sports by cutting and turning the knee buckles and gives way and often the player or the players around them will hear a pop and they will suddenly see the players collapse to the ground. There are times a player might get up and try go again but unfortunately it often doesn’t allow it.

In terms of early assessment, the athlete will often try and get up and get going on the field of play again but classically it will give out and that is a key first sign.

Swelling is very typical in the early stages following these injuries certainly in the first 24 hours and often even in shorter periods and there are only a few things that can cause the severity of swelling that the ACL injury is associated with.

Nowadays, thankfully, most teams have physiotherapists be it on the field or a follow up of an incident where they can get assessed and rapid access and history gives the game away as to what has actually happened and from there one would typically come onto a specialist in sports surgery for assessment like our own and we use a number of evaluations. We go back over the story, we do take the history again, we will examine the knee and that means we can see the knee when it is evaluated that there is a certain amount of instability. We can see for example a Tibia in a torn ACL will slide forward a little more when we evaluate it and that is what we call the Lachman test. The next thing we typically go onto do then is use an MRI scan and the MRI scan is usually the icing on the cake and it gives us all some final information as to what might have happened.

In addition to confirming that the ACL is probably torn we can also see some other clues like a pattern in bone bruising where we see bruising within the thighbone and the shinbone which often documents the mechanism of injury which would haver happened.

Other ways a torn ACL can happen is through hyperextension or there are some other more unusual ways but the most common is what we call the pivot shift.

That now brings us to the athlete with the torn ACL and where we go from there and as I’ve said we do know that up in 20% of GAA injuries are ACL injuries at this stage.

In a country so interested in field sports there is a lot of interest in getting these athletes back to play. There’s often some debate about whether athletes can cope with an ACL injury and may not need surgery and they are the type of things we discuss here in the practice with you when you come along to discuss the ACL.

There are certain patients who are involved in sports like cycling and swimming who may get away without ACL reconstruction but for the vast majority for the ages between 15-25 playing a lot of field sports that the ACL does need to be reconstructed. A lot of work needs to be done before we actually get to the ACL reconstruction phase. The first thing we do following any knee injury is to realise that its not just an ACL injury but it is an injury to the whole knee as we get soft tissue damage of the entire knee and we get a fear of movement and in the early stages we go down the line of what we call prehabilitation or recovery of the knee essentially after injury. This classically is something we would do with the help of your treating physiotherapist from home. We can work with it we have our own internal team of clinical specialists here in the practice both in a Sports Medicine and nursing background and also a physiotherapy and rehabilitation practice but we also look to work with physiotherapists and specialists all around the country and we find that that form of communication always gives the best results we can and in the early phases the first thing is to diagnose the injury and reassure the athlete and reassure the parents if they are in the picture as to the nature of the injury and what we might do about it.

What about the preparing for surgery phase? I suppose it is really about getting normal homeostasis by getting the knee back to normal and that is done by getting the swelling down, returning the knee towards normal movement, really ensuring full range movement if we can and so on.

The other thing we like to do in the early stages is to do an MRI scan to try and identify any comorbid injuries whether there is any damage to the cartilage the lining of the knee joint. Whether there is any lining or damage to the meniscal soft tissues the little wedges that act as shock absorbers within the knee. They are what is known as prognostic indicators as they can influence how well the knee will do over time. They can also influence whether we need to intervene rather urgently or if it is something that we should wait a few weeks for before intervening. Sometimes where there is a large tear of a meniscus we call it a bucket handle tear and if an athlete has this they will need to go a little earlier to surgery to get that settled down. We like to give anywhere between 4-6 weeks in the early stages to get the knee settled, get the swelling settled and then get the knee ready for surgery. The next step, just to explain to you how surgery typically happens is when a surgical procedure is required for an ACL reconstructive surgery in my hands it is typically done doing a one night overnight stay in the hospital and as the athlete or patient they would typically come in the day of surgery and stay the night.

What I’m going to do now is take you through a video of how I do an ACL surgery and it is a small animation just so you can understand. Ill speak a little bit about graft choices as I do and take it from there.

Now, we are looking at an animation of a knee and here is the ACL in the middle of the knee which is the key ligament that gets torn and we need to reconstruct.

To the side we have 3 of what we would call graft options. In the middle we have what is my preferred graft choice known as the patellar tendon graft and it is my preferred choice because at the end we have bony attachments and these will integrate well into the tunnels which I will create.

Another option we have is known as the hamstring graft which e use on occasion and also a quads tendon graft. These grafts are used to reconstruct the ACL as need be.

When we are undertaking a procedure the first thing we do is actually obtain the graft and as I mentioned the patellar tendon is my preferred graft of choice and where you see it coming from is here at the front of the knee at the knee cap.

This is the tibia and essentially, we harvest an area of about 70-80 millimetres in length and this essentially will be used for the ACL graft at the end of the day.

One of the first things I do when I’m doing the ACL reconstruction is go into the knee with a camera and shaver to remove the old torn ACL.

The next step then is to drill little tunnels into the shinbone and into the thigh bone and its through this area that the new ACL graft will be placed we do this again all in a keyhole manner, keyhole technique.

Here you will see it being pulled into the knee with what we call our guide wire which puts our graft into place. It is now that the ACL reconstruction is being undertaken.

The last aspect of the surgery that is key is the fixing in place of the new ACL with screws and that is really it, that is our new ACL in place and once this is done we essentially bring the patient back to the ward and allow them some rest and commence rehabilitation.

That is the key aspect of ACL reconstruction by the use of a patellar tendon graft and that’s the whole story really.

Firstly, we have the diagnosis, then we have our rehabilitation then we move into what is known as our post op rehabilitation phase. I suppose the first thing an athlete needs to know is they typically will be using crutches for two or three weeks following the procedure to allow the healing to start and I suppose the emphasis on the post-operative phase is to ensure we are working with our own clinical team and indeed other clinical teams around the country, getting the knee back to it’s full range of movement, getting the swelling down and getting the athlete or patient moving in order to be comfortable again.

Once we get early movement going on in the first 6-8 weeks we move into something that is known as the strength phase and that involves building up the strength in the quads and building up the core to essentially move this over the following 3-4 months towards the knee and the limb will then be strong enough to start a return to play programme.

There really is a multidisciplinary approach to this obviously a lot of it is based around physiotherapy early on then we have strength and conditioning and we follow specialist guidelines in this regard but there are other key aspects that are very important and these are often neglected and we see many athletes report of this as this often involves proper nutrition, proper hydration, proper sleep and I suppose being able to maintain the proper motivation and the psychological support that go with being able to keep your training going often in isolation, often over winter periods where the teams are playing away.

These are key aspects as to why we would have regular follow ups with the athletes and patients over the few months that follow, giving feedback to their physiotherapists, to their families and so on these are all key aspects of doing well in the long run.

It is not solely a time dependant manner but it takes anywhere in the region of 8, 9 or 10 months and sometimes even longer not just to rehabilitate but to bring that athlete back to a level where they will eventually be able to return to sport.

We do that and then eventually we do something that we call biomechanical testing and isokinetic testing where we get some measures at our Sports Medicine centre here at UPMC Sports Surgery Clinic and that allows us to guide the athlete further. Some of it is clinical and part of it is what we feel and see the athlete doing but there are also some objective measures that we use.

Eventually, at the end of the period together we will decide in relation to turning the athlete back to play. I suppose the one thing to think about is that when the return to play period comes that has to be handled very carefully, we know that fatigue can set in very early in athletes towards the end of their programmes and it is important that they gradually build up their time that they are able to do their cutting and that they are able to do their basic activities in a non-contact manner before they went to full contact and even when they get back to full contact and build up their play maybe 20 minutes at a time then they don’t just launch into full scale games because that would probably just increase the risk of re-injury so that’s really just the classical stuff around ACL care and there are some key points that I would like to make because I suppose there high risk groups that you will see us taking particular care with we know for example the rate of ACL injuries in females is much higher than males I think part of that has to do with the way the body and the knees are set up but we also think there might be some flexibility or hormonal issues that play a role so we take particular care around certain athletes to ensure they are given the proper support.

The other group we would like to discuss are our youngest athletes because we know if you have an ACL injury under 16 years of age your chances of having another substantial knee injury or ACL injury in that same or other knee might be as high as 20-25% so it is very important that they get treated, assessed and guided back towards a proper rehabilitation programme and that we take our time in getting them back to play.

That brings us back to the bigger question of ACL prevention and thankfully nowadays there is an increasing interest around this. The GAA have programmes and FIFA have programmes out there where what is most important particularly at a local level with athletes of all ages in addition to playing are putting some time into basic strength and conditioning to gain some basic flexibility there is a tendency nowadays to be playing a lot but perhaps with some emphasis on background training and background warmups and one of the key things I would like you to take from this talk this evening is that this is key to preventing our athletes from injury to the ACL and indeed injuring many other structures as well.

What about research then? There is a lot of clinical research going on here at UPMC Sports Surgery Clinic going into not just why these injuries are happening but optimising our rehabilitation programmes, how we can get athletes not just back to the game but back to staying in the game that is probably the most important thing of all and we are constantly doing research as to how we can get our rehabilitation programme better and see what other factors we can address. These are all small increments to get our athletes back safely in the game.

Other research we do is that I’m working with a group in Trinity College Dublin and were doing some bioengineering research where we are looking at how we can out mend ACL healing where we don’t actually have to replace or reconstruct all ACL’s for some it is actually possible for it to heal and we need to look at them groups where it might be possible and how it might be possible with synthetic grafts.

The last thing then I’m going to address is something people might be concerned on and it is the long-term effects. When you have any substantial injury to a knee joint or to any other joint of the body we do recognise nowadays that there can be long lasting effects and the one many people worry about and know about is called post traumatic osteoarthritis or wear and tear over time.

We do know that 20-25% of athletes that do have an ACL injury might need another surgery on their knee over the next 7-10 years and it is not a major surgery it is usually just a little keyhole surgery to clean out scar tissue or damaged cartilage or damaged meniscal tissue. Often the ACL is the start of some issues in the knee and I suppose that is why you need to have it cared for under specialist care in specialist hospitals and it is important so you can get the correct diagnosis early on and if little niggles do arrive then we can help you address them.


In truth, I would have to make the declaration that there are no true stem cells available in orthopaedics outside of clinical trials.

Unfortunately, there are a lot of false suggestions made by clinicians that they have stem cells available for use and they are not really, they are mixtures of stem cells from the body but true stem cells are not available for use.

Evidence would suggest that there is some role for them in reducing inflammation there has been no proven benefit as of yet that they can actually prove or manage regeneration so really it is just another pain modulator.

It is important though that when patients do go down the line of using stem cells or speaking to people about them that they are properly consented in the centre where they are properly informed.

Menisci are some of the key structures internally in the knee we regard them as playing a role in shock absorption and weight distribution.

I think as such they are naturally going to wear out over life so when we get into our 40’s, 50’s 60’s and so on if we have an MRI of the knee then your knee will show some form of a meniscal tear a so on.

The vast majority can be treated with the out surgery they can be treated literally with exercise, movement and so on. There are times though when we have to go into the knee and clear out the damaged tissue as it may be causing mechanical problems or it is not responding to exercise but the key thing I would say to most patients would be to keep moving and keep exercising.

The last thing I suppose is to know that there are some meniscal tears that can be acute large meniscal tears in our younger athletes and they are often something we should give an opinion on and have a discussion with the athlete about whether or not we would intervene some can be repaired and some not but that is when an opinion should be sought.

It is like the stem cell question, there is no real evidence that plasma should be used instead of a cortisone injection.

I think what they really need is a proper assessment with a high qualified sports med physician or an orthopaedic surgeon sometimes the pain can be arising from elsewhere like cartilage and underlying bone damage it is often tempting to think on the MRI reports that the meniscal tear is creating the issue but it really goes back to a proper clinical assessment.

I think firstly it goes back to the proper clinical assessment as to what is going on. Knee support is fine but really people with knee pain should be on a proper physiotherapy or strength and conditioning programme and wearing a support if you are not doing the background work probably is not the way to go, they don’t do any harm but again in a properly cared for environment a proper assessment is what you should get but they can play a role.

It can but I think what is tempting to think about is always the meniscal tear and the surgery and so on.

I think what people might be best focusing on is a more wholesome approach to their overall health looking at their weight, looking at their movement, looking at their activity level and keeping themselves strong. I think those factors play an as big if not bigger role than simply a discrete meniscal tear and meniscal tissue loss.

While it is true to say that there is probably an increase in association with meniscal loss and arthritic change I think it would be important to keep in mind that specialist surgeons and sports surgeons would be well aware of not removing tissue but just the damaged tissue and hopefully facilitating an increase in movement and function that should keep the athlete healthier overall.

I think it is. I think that goes back to having proper expectations, proper counselling I think it is something we often take our patients through, there are many different types of meniscal tears, cartilage damage and so on. It is not just simply whether or not you have a meniscal tear but it is the pattern of the tear, the location, what the underlying cartilage is like and then it goes back to running but I suppose when we talk about running it comes down to the frequency, the intensity, whether or not there are breaks involved and maybe a mix of sports like cycling or swimming often help as well.

Certainly, the overall message would be that you can remain fit and active even after having these little injuries and we would often encourage proper supports to be done.

I think whenever anybody has any type of acute knee injury that we need to get the proper programme in place and a lot of it often requires elevation and icing with some movement.

A well-qualified physiotherapist really should be able to identify a knee that is very unstable that means not just a knee that has an ACL tear but a PCL tear a lateral tear.

Some of these knees might benefit from a little support from the brace for the first few days before they go and see a specialist about it.

I would generally say a bigger fear we have though is of people getting stiff often the past patients that have not been assessed would maybe be locked up in braces and not having proper access to physicians and that stiffness can often be an undoing or at least a delay in treatment.

Similarly, afterwards, I would have worked in centres, I would have seen it documented internationally people are using braces. I suppose people that work with me would be very aware that I would be pro getting it fixed properly not as such anti-bracing but I think getting that knee moving certainly works better and I think that is the ideal way to go.

Just moving away from ACL’s alone in isolation. I think it is well accepted at the moment that we have a couple of problems brewing.

On one hand we have a group of children in certain parts of our country that maybe are not moving enough by looking at obesity epidemics to diabetes and so on. Another area then is the opposite where kids are going game to game, sport to sport and probably not doing enough strength and conditioning and I’m not talking about being in the gym lifting weights but proper warm ups maybe at least acknowledge that they need to do a strength and conditioning programme once or twice a week there’s GAA and Rugby teams u12 and u14 training young lads training 3-4 times a week playing matches on the weekend relentlessly the year round and I have to say I’m not quite sure that is the way to go I have children myself and they are very active in sport but I do think it is important to keep the balance between training as well as playing I think that is more important.

I think footwear could play a role but I think one of the great things we see nowadays is that there are many more females partaking in sport and not just participating but being supported to participate at multiple levels in multiple schools.

Again, though one of the biggest things we need to see is to keep introducing the importance of strength and conditioning to those programmes and not just playing because its not just playing sports but it is about being in sport. There can be huge dropout rates following injury and I think doing that in the background is more important for a child or a teenager to have a game and a training session maybe a couple of sessions instead of just playing all the time and it is not just ACL injuries because we see a lot of over use injuries, some back problems, through to knee problems and again it just needs to be proper warm-ups proper strength and conditioning ad playing.

I suppose with the baker’s cyst has it been diagnosed clinically or with an MRI as it can be tempting I suppose sometimes to assume that is the cause of the pain but essentially first of all a baker’s cyst is a collection of fluid at the back of the knee and what happens is a knee is probably producing excess fluid because of the excess inflammation over the wear and tear and so on. The fluid sneaks out through a little crack in the cartilage and in the meniscal lining and it builds up because it acts as a one way valve so its fine maybe about taking the fluid out of the back of the knee with aspirating which means sucking it out of the back of the knee but unless you deal with the internal problem it will just be like any other problem and just come back.

It is important to know that it is not a growth and it is not a legion or cancer or anything like that. It is a collection of fluid and if it is bothersome consider what might be causing it and if it is not just leave it alone.

In the best of conditions at a young age even with healthy tissue and so on, being able to undertake the repair of a meniscus is often unlikely that it will heal so the person assessing it should have the skillset to decide whether or not it would be likely to heal so an inappropriate repair has been undertaken just pre-disposing the patient to another surgery.

Secondly, as I said earlier on when we are in our 40’s, 50’s and 60’s our meniscal tissue does become a little worn out certainly very few people who have meniscal tears go on to having a joint replacement which is an extreme endpoint for end stage arthritis. You might lose some rotation in your knees as the years go on but you should keep your weight in order and keep fit and active they can often be factors that keep things at bay.

Yes, Partial Knee Replacements are possible and Total Knee Replacements are too but that is for end stage arthritis so that is a whole different level of symptoms than a meniscal tear might be causing.

There are but again it would take a proper assessment because we need to go into what might be causing it you think with patellar tendinopathy’s it would be overloading mechanics and altered hip mechanics we would often think about the knee but we would go back to the body down through the quads down to your shins through the back to the hamstrings and so on.

Looking at the balance there, looking at the movement maybe figuring out why the patella is overloaded that is really driving the pain so rather than the different exercises you can do.

Again, it is possible to work through it with physiotherapy but first of all to diagnose what might be driving it.

For further information on Anterior Cruciate Ligament (ACL) Reconstruction, please contact

Knee Osteoarthritis: What You Need To Know

Watch this video of Professor Brian Devitt, Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic, presenting on ‘Knee Osteoarthritis: What you need to know.’

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on Hip Replacement and Knee Replacement.

Professor Brian Devitt is a Consultant Orthopaedic Surgeon specialising in Knee and Hip Surgery at UPMC Sports Surgery Clinic.

I’m going to speak about Knee Osteoarthritis and what you need to know. I always like using a picture of a patient. This is a lady who I performed a knee replacement on in Australia and this is 18 months following her knee replacement on a charity walk to Vietnam and she was able to manage the steep inclines with her new knee. This is one of the successful patients who I have performed a knee replacement on and the vast majority of people do very well following a knee replacement.

When we were in Vietnam I also came across a number of quotes from Confucius who was a Chinese Philosopher and this is one of my favourites, “It doesn’t matter how slow you go as long as you do not stop” and I think its particularly relevant when dealing with Knee Osteoarthritis.

My children always say to me, “Tell me something I don’t know” and the purpose of this educational even6t is to inform you about Knee Osteoarthritis.

Initially we are going to talk about the basics What is Osteoarthritis? What treatment works best? We also want to talk about the evolution of surgery which is quite interesting and what does the future hold? Most people say Knee Osteoarthritis is just a bit of wear and tear and it can be but it can also be an awful lot worse. Try telling this patient that this severe arthritis is just a bit of wear and tear. There is a lot of bony debris in this patient’s right knee even though the patient was complaining about his left knee being his sore knee.

People come in all shapes and sizes and when we see people with Osteoarthritis we see 3 main varieties of the appearance of someone’s legs. First, is the normal variety and that is just the straight leg. You can see someone with a bow leg which is what we describe as Varus or there can be people with Knock knees which we describe as Valgus. These all have different patterns of wear and that is for us to know as surgeons and you can often distinguish where the arthritis is going to be based on the shape of the patient’s legs.

What treatment works? Many patients come in and we have to be careful about what treatment we recommend because we want the one that will work the best for that patient. There has been a lot of studies on this topic and as you can see in the chart here these are all conservative treatments. Physical activity is very important and it is really important to maintain.

Weight loss is probably the most effective means of reducing pain from arthritis and I will discuss this a little bit more later.

Acupuncture hasn’t shown to be very effective.

Massages can be somewhat effective as we can massage the muscles if they have become tight above or below the knee which can cause pain.

Braces can sometimes be effective in early arthritis. Insoles, likewise, can be somewhat effective as they can offload the side of the knee that can cause trouble.

Glucosamine based on these studies have said it is not effective but it is a very inexpensive medication, even if it has a placebo effect it may help someone.

I’m going to bring you back to talk a little bit about physics. One of the things that helps arthritis is weight loss so we will do a little bit of maths. If you are just walking normally twice your bodyweight goes through your knee at each step. If you are walking downhill then up to 4 times your bodyweight goes through your knee. If your running then up to 8 times your bodyweight goes through your knee. If we do a bit of calculation and get a 100kg male who may be slightly over weight when he walks downhill there is 400kg going through his knee. If you were considering running that’s 800kg going through the knee that’s just shy of a ton. If a person loses 10kg that’s 10% of his body weight which would be 40kg per knee per step when walking downhill.

We also recognise that exercise is important and we recognise that trying to do exercise that doesn’t exacerbate your knee pain is really critical in the early stages so the likes of Pilates is good or low load exercise like cycling or swimming can be very effective to improve the strength of the leg and reduce the pain within your leg.

Pharmacological Treatment then, Anti-inflammatory medication is effective and the reason it is effective is because it reduces the swelling in the knee. When you have swelling in your knee you tend to shut down muscles around your knee so they stop working as shock absorbers and when the muscles stop working then you tend to get much more impact particularly when walking down stairs.

Steroid injection can be helpful especially if someone has swelling or inflammation within their knee and its normally done within the early period.

Hyaluronic acid by these studies has not been found to be effective in isolation but we tend to combine it now with steroid and that can be a little bit more effective.

Platelet Rich Plasma can be effective in certain places particularly in the early arthritis cases.

Now we will look at surgical treatment and that’s what most people come to me for. Arthroscopic Washout, in the past I used to call it the ‘wash and go’ you used to come in and get an arthroscopy wash out some of the debris and go home but we realised that is not effective as it does not address the arthritis issue and now we try to avoid that as best we can. We can look at Arthroscopic Meniscectomy so taking away the meniscus. Now in the setting of arthritis if you have a meniscal tear we wouldn’t do an Arthroscopic Meniscectomy but if you have very early arthritis and there is a meniscal tear which has flipped or is causing mechanical symptoms then that may be appropriate but it is done on a case to case basis.

We also look at Osteotomy and that is where we adjust the alignment of a person’s leg to offload the side of the knee that’s worn and that can be effective in some cases but it is usually in young patients presenting with arthritis. Joint replacement which we will discuss a bit further is a very successful surgery in the right setting at the right time.

I’m just going to discuss some knee replacements now and there are various different ways to do knee replacements and what we found over the past is that we have knee replacements that can use specific implants. We can get a patient’s knee and we can take a CT of that knee and use these cutting blocks to give a specific cut for that individual. They have been found to be reasonably successful but no more successful than a high-volume surgeon doing routine knee replacements so it is important that we do not get carried away.

We now will look at robotic surgery and that has seen a huge researches particularly in the USA and the robot uses something that we call navigation so we can plot that persons knee in space we can also do a CT scan before hand and what it allows us to do is do very accurate cuts with this robotic arm and its assisted surgery but in the long run it is no more effective than a surgeon how carries out many surgeries and has a lot of experience so we wont get carried away too much but there is certainly a place for robotics in knee replacement surgery.

We are going to look at the suppliers of our implants that we put in our patients and each of these companies have their own robotic offering and its important that the surgeon you go to that first of all they are an experienced surgeon and if they offer robotics or not it is really incidental. I think that they want to be a high-volume surgeon which is really important.

I’m going to give you a few case examples now, this is an example of what we would do when a patient comes in to see us and we get a weight bearing x-ray of their knees. Here on the right knee you can see that the space between the Femur and the Tibia is nicely preserved on the outside and very diminished on the inside and we can see that on both sides so this person would likely have slightly bow-legged deformity so we know they have arthritis within the region of the inside of the knee.

We look at the knee from the side as well and we see that the space between the knee cap and the front of the knee is slightly tight so they have arthritis in not just the inside of the knee but also on the front of the kneecap but we always would address the patient’s symptoms and where they are having pain in that knee. We look at this persons MRI scan we look at it from the front of the knee and we can see the presence of whiteness which indicates fluid within the knee but if we look at the inside here we see whiteness of the bone which indicates that bone is under severe stress within the knee and that is where the site of the patient’s pain is.

Often x-rays are sufficient but sometimes we take an MRI as it can be effective in looking further into the knee to get a better idea of what is going on and that person has likely had just that side of the knee replaced.

This is another example of a patient of mine who presents with severe pain on the outside of the knee and it is a slightly different configuration of what we saw. We see that the space on the outside is largely reduced compared to the space on the inside and the nice thing about having both of these x-rays is that we can compare both sides so we see the outside of the knee on the left is nice and preserved where as on the right it is reduced and you see the extra bone has formed and this is where the arthritis exists.

In this patient you can see they have arthritis under the knee cap as well so of the 3 compartments in your knee the inside, the outside and the front of your knee all of the 3 parts are affected so this person is likely to have a Total Knee Replacement as opposed to a Partial Knee Replacement on just the affected side. As you can see this is what this lady had and she has a nicely balanced knee, so it looks a lot like the other knee and this is the joint replacement I was using when I took these x-rays in Australia and you can se it from the side where we have resurfaced the knee in addition to the Total Knee Replacement this lady went on to do very well after surgery. Once again, we go back to that x-ray of the isolated arthritis on the inside of the knee and what we do now is something called a Partial Knee Replacement so we just replace the inside of the knee as that was the part that was affected.

We mentioned about robotics and the role that robotics might have in joint replacement and it is important to be aware of it. This is a slightly older picture of my extended family and this was taken in 1922 and I have a massive interest in what the future holds because my future probably holds a joint replacement for me.

This is my grandfather back in the day and you can notice he is not wearing any shoes like all of his brothers. My grandad had a hip replacement and his 2 other brothers had a hip replacement. This allows us to realise that there is genetics to arthritis and unfortunately we can’t change our genetics but it is important to know that this is what the future holds to be able to look and tell people who are at risk of developing arthritis and maybe in some way mitigate the development of arthritis in those individuals but I think the key is to maintain your body weight and I think that is something we all have some choice over and I think that is really key if you have a high risk of developing arthritis it allows us to look after ourselves with age but we are not quite there yet in terms of the genetics of arthritis.

What we do know is that exercise is very important and we are getting smarter by using these smart fabrics and being able to identify which muscle groups are weak and the future holds being able to look or tailor rehabilitation to further advance our ability to postpone the inevitable joint replacement for some people and looking how we can fully maximise rehabilitation.

We are about to embark on a joint lab where we look at patients with arthritis pre and post joint replacement to see if we can identify the muscle groups in which they were weak in and I think this will make great advancements in terms of how we manage patients going forward but we use all of these smart fabrics and technologies in years to come.

People always ask us about stem cell therapy for knee arthritis and I think it is really important because we all look for the next best panacea when treating arthritis and most people are weary and for good reason undergoing joint replacement because you can’t go back on it so they look for other lesser modalities but unfortunately the literature is just not there in terms of the use of stem cells. In fact, if you look at what the experts say from Australia where I was working for 10 years that the position statement is saying that the use of stem cells is very complex and that really, we don’t understand the effectiveness in arthritis but they also say that they would not support the evidence to use stem cell treatment as a clinical intervention and outside a clinical trial setting.

A lot of people who heddle the use of stem cells for treating Osteoarthritis are not doing it as part of a clinical trial setting it is for monetary gain only so its important to be a little bit circumspect about those scenarios but I think there is potential there but we have to do it in the setting of clinical trials firstly.

I’m going to finish now with another quote from Confucius and he said “Choose a job you love and you will never have to work a day in your life” and we as orthopaedics have a great job because we give people back their mobility, we give them a new lease on life but its very important that you only choose to have arthritis when you have exhausted non-operative means, when you have gone through the effect of non-operative measures and then get to the point of a joint replacement because you will do much better at that point from a rehabilitation perspective

Yes, I do carry out Partial Knee Replacements and increasingly more frequently than I used to and the reason for that is people tend to do very well with Partial Knee Replacements and do have a slightly quicker recovery.

The prosthesis typically lasts 15 years and what normally happens is that other parts of the joint tend to wear out. It is a relatively easy conversion from a Partial Knee Replacement to a Total Knee Replacement.

In terms of recovery, patients tend to have quite a quick recovery following Partial Knee Replacements, so they normally walk a bit quicker with less pain and in terms of getting back to their normal activities, it varies from anywhere between 3 months and six months.

In general, patients with a Partial Knee Replacement tend to recover quicker than those with a Total Knee Replacement.

Knee sleeves essentially are sleeve you pull over your knee so they provide compression to your knee so they are effective and they give a bit of feedback to your knee when you have swelling. They don’t necessarily reduce swelling but they do give a little bit of support to your knee.

When you have bone on bone arthritis they are probably less effective. Typically, patients with bone on bone arthritis complain of a dull, aching pain in their knee so it will provide a little bit of support but I don’t think it will eradicate the pain entirely.

It is very interesting, its an area which I’ve looked into quite a lot and I used a lot of robotic surgery when I was in Australia and since I have come home I have reverted back to manual surgery and the outcomes are the same. I think robotics are the future but we don’t have any compelling evidence to suggest that the outcomes following robotics surgery are any better than any surgeons who carry out high volume knee replacement, that means they do a lot of replacements but I think as we evolve and the next generation of robotics surgery comes in I think it will improve things and we will have better results in the future. For now, if I was choosing, I’d choose a high-volume surgeon and not a surgeon that does robotic surgery for having a knee replacement.

There are a variety of symptoms you can have, I suppose you should look at the age of the individual. Typically, patients who are towards their middle ages and elderly patients are more likely to develop arthritis they usually present with pain so pain at rest or pain at night is one of the hallmarks of arthritis.

In terms of symptoms you tend to have people who have decreased range of motion within their joints that is another main symptom and you also see deformity particularly in knees when arthritis gets worse but it tends to be based on symptoms so if someone is in pain or has stiffness and swelling in a joint

It’s very interesting because I think road running is a bit of a myth of a cause of arthritis and if you look at the typical body of a runner or certainly a marathon runner they are quite skinny people normally so they tend to have lower bodyweight and therefore they are less likely to develop arthritis but there was a really interesting study carried out a few years ago that I had to review which looked at the evidence of arthritis within a group of marathon runners and found it was actually lower than that of the normal population.

What people always often blame running because they often revert to running in their 40’s and 50’s but they probably played more rigorous sports in their early life and that’s where they took a chunk out of their cartilage and the running just caused the end result or just exacerbated it but people who are active and have a low body weight tend to have less arthritis than people who are over weight and more sedentary

It is mentioned in my talk a very simple equation of how much body weight goes through your knee when you walk so obesity is a big factor and loosing weight is the best non-operative treatment for arthritis. Whether there is a metabolic factor or not I’m not so sure if that’s proven but certainly weight is a huge factor.

Whether it is unilateral or bilateral you can kneel after any knee replacement, it does feel a bit strange when we typically make an incision we make it through the front of the knee and therefore there’s slight numbness on the outside of the incision so it feels a bit odd when you kneel down. There’s no reason you can’t kneel on your knee but it just feels a bit strange.

Ironically, when you have bilateral knee replacements they both feel the same so it doesn’t feel as odd, one doesn’t feel different to the other but someone gave a nice analogy it’s like wearing a pair of sandals at the start of the summer they chafe and feel a little bit unusual on your feet but as your skin hardens up your able to manage without any problems so there is no contraindication to kneeling after any knee replacement.

It depends on how bad your symptoms are and we often have people coming in and saying I’m better off having it when I’m young rather than having it when I’m old and it would be easier to recover but you need a knee replacement when you need it and when you start having pain at night, when you’ve pain at rest, when it affects your quality of life and I say to patients as if it’s the last thing you think about before you go to bed, if you can’t sleep at night and it’s the first thing you think about in the morning because you have pain in your joint you probably need a joint replacement so I think based on that then that’s really my answer.

We are very selective about the patients we choose to do bilateral knee replacements on so they have to have evidence of pain and arthritis in both joints and typically they are as bad as each other.

The advantages to having them both done are you reduce your rehabilitation time and you’re up and running straight away you don’t have to go back and have the second one done.

The disadvantages are that it’s a bigger undertaking and as I joke to the patients you don’t have a good leg to stand on so it can be a bit more challenging in the early period of rehabilitation, the risks are slightly higher but they’re not significantly higher nowadays because we have refine dour surgery and it’s a fairly quick operation so doing the both together under the same anaesthesia so really it is on a case by case basis but patients who have profound arthritis and have really a really decreased range of motion tend to do very well when they have bilateral knee replacement done because they can move both legs the same

It depends on what age the patient is and what the indication was for the arthroscopy but we often find people who have had a meniscectomy or had some of the soft tissue cartilage removed from their knee and if they’ve done it twice that would suggest that they have had some ongoing issues with that knee.

What typically happens in them situations are the hard cartilage of the knee tends to wear out and really in those situations we’d investigate with weightbearing x-rays or potentially an MRI to see if the joint has worn out. If the patient is young and it’s relatively isolated to one joint then they may be a candidate for a partial knee replacement but it’s done on an assessment and where the pain is in particular.

I think with any individual like that you can get post-traumatic arthritis and that unfortunately afflicts younger people all of the time so we would always be hesitant to go to a knee replacement unless we absolutely had to.

The same principles apply here as I mentioned in my talk by maximising non-operative measures such as body weight, occasional anti-inflammatory medication, maintaining the strength of the knee is really important. If they’re not settling with oral anti-inflammatory medication one could consider an injection of local anaesthetic and steroid or maybe hyaluronic acid can be effective in some cases.

If it is a traumatic case with metal work in place and they are heading for a knee replacement sometimes even just removing the metal work can improve some of their symptoms and that would be necessary before a joint replacement and indeed advisable before a joint replacement so that might be a temporising measure to help the person along the way but we try to do everything to delay a knee replacement typically.

Those two examples are good because there is no contraindication to playing those sports.

I suppose if you look at sports that put a high level of load through your knees such as running or running marathons you wouldn’t really advise that after a Total Knee Replacement and potentially after a Partial Knee Replacement and nowadays were less strict about what we would consider contraindications for people to participate in.

When I was living and working in Australia lots of patients came in wanting to surf and that’s a fairly rigorous sports as you have to get very low. I’d say if they’re able to surf I obviously have no problem with them doing that but obviously everything comes with risks but we let people participate in sports because it’s good for them

No, it’s not and I think that’s where we are very particular in terms of choosing patients that are at the right time for a knee replacement and I think one of the important things we spend a long time talking to people about is informed consent and as part of informed consent we have to explain the alternative options and I’ve mentioned them in my talk but also the risks related to surgery which is really important so one of the things I’d explain to patients is that we are paranoid about infection and infection occurs in less than 1% of patients but we try to do everything that we can to avoid that.

The other thing which people complain of after knee replacement is stiffness and we find that patients have to really engage in the rehabilitation if they don’t get engaged or they have too much pain and they can’t engage then they do become stiff and that can be a pretty miserable experience for the patient so we try to do everything that we can to mitigate the risk of complications but unfortunately they do occur but when they do occur we tend to treat them very aggressively and very early.

For further information on Total Knee Replacement (TKR) or Partial Knee Replacement, please contact

Common Problems Around The Hip

Watch this video of Mr Gavin McHugh, Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic, presenting on ‘Common Problems Around The Hip.’

This video was recorded as part of UPMC Sports Surgery Clinic’s online Public Information Meeting, focusing on Hip & Knee Replacement.

Mr Gavin McHugh UPMC Sports Surgery Clinic





Mr Gavin McHugh is a Consultant Orthopaedic Surgeon specialising in Total Knee Replacement, Total Hip Replacement and Partial Knee Replacement at UPMC Sports Surgery Clinic.

I am going to be talking about common problems around the hip. I will firstly talk about the kind of patient that you see and to start you have the ‘In Denial’ patient and thee are the type of people that just get on with things and they are often the last person themselves to notice that there is a problem. Everyone else in the family has noticed that this person has been on a downhill spiral for the last 2 or 3 years. They are maybe slower at getting around the place, they are often grumpy because they are not sleeping at night due to pain and they are considerably immobile. It is a classic with the hip in many ways because it often presents in such a slow and insidious manner it just creeps up in patients and I often describe it as a farmer in the mid 60’s as the classic stereotype but not often by any means and a lot of people can surprise you. If they come to a consultation with their partner they will always look across and say their not too bad and their partner is rolling their eyes up towards the ceiling and this type of patient tends to present with a lot of stiffness they struggle with things like getting their socks and shoes on, they might have problems if they are a farmer with things like uneven ground and walking distance can be reduced as well but they just knuckle down and get on with it.

There are sometimes people who just don’t like taking painkillers or you might get people who live off pain killers and anti-inflammatories for the last couple of years just to get through the day as I said they might not have even been able to put on their shoes and socks for the last couple of years so I just described the classic in denial patient. In general, they are walking with a really obvious limp but they are masking things quite well. They’re x-rays will generally show that they have advanced arthritis and really when it comes to having something done it is a little bit of a no brainer in terms of progressing with a hip replacement but as I say talking them in to going ahead can be half the battle sometimes again usually with the help of family members.

The second patient I like to present is the supergran type of character and people say “my mum is 85 and last year she was getting around the shops no problem and suddenly she has just really slowed up in the last while”. The reason I present it is because often it’s put down to something like getting older and I really don’t like the phrase that someone is getting deconditioned because they are getting older and generally they just have a warn hip and that is normally just a mechanical issue that is really slowing them down.

Sometimes patients will turn around to me and say am I not too old to have my hip replaced and I think to myself no your too old to not have your hip replaced because when you get older and your strength starts to reduce anyway then the last thing you want is to have a warn and painful hip and quite often I’ll suggest to patients that do go ahead with it that it represents their best opportunity or chance of getting back to normality afterwards and its pretty strange that as opposed to the insidious decline in the last patient quite often this can deteriorate quite quickly and some of the patients say that 3 months ago they can do something an now they no longer can. They say things like they can hardly get up to put the kettle on in the kitchen and as I say in terms of your mobility you will often jump down a level of mobility very quickly with any deterioration in that someone who is completely independent will go down to 1 stick then they will go down to a crutch or even 2 crutches and then as you see there they move onto the walking frame.

In many ways the more we can intervene to correct a mechanical issue the more we can keep people independent for longer and certainly I am of the belief assuming from a medical point of view that it is possible that hip replacement is not what it was like years and years ago in terms of what it takes and involves for the recovery process. Yes, the risks are there but they are considerably lower than many years ago when blood loss was considerably more throughout the surgery.

The third patient then that I will present is the 40 year old weekend warrior and this is someone who used to play a lot of sports so they may have played a lot of GAA growing up or football and they play 5 a side 2 or 3 times a week and again it just tend to come on, they may have been aware of the hip or niggle in their groin for quite a while, sometimes they are getting treated for a groin strain type of issue for the last year or so and it slowly is starting to creep in with them and they are finding it more and more difficult to go ahead with their indoor football or 5 a side or whatever it is they enjoy doing again it could be multiple different sports. It can progress quite slowly and often times they will appear going with a problem but not in bits so they are not able to go ahead with their day to day activities but more so their sporting days are becoming that bit more difficult and this is something that represents a dilemma because often they have a significant amount of arthritis in their hip but ultimately the only option for them is going to be a hip replacement but it is a real one to web. As opposed to the first two cases this is really one where you have to sit down and have a chat with regards to the risks and benefits of going ahead and whether or not the hip replacement is going to live up to your expectations and what you want and quite often these patients can be happy enough knowing what the problem is, knowing how to handle it and if that means taking an anti-inflammatory twice a week before playing their indoor football they can do that and manage things pretty well but in due course it will deteriorate with time but as I say there is a time and a place for everything but just jumping into a hip replacement is often not ideal in this type of patient cohort.

It can occasionally be worth trying a guided injection into the hip joint itself and again I’ll talk about that later but what I will often do with patients like this is and it sounds kind of strange but I say to them “the option is a hip replacement you come back when you’re ready” and the question they ask then is how will I know and I just say to them “you will know when” and sure enough they come through the door maybe 2 years later and say yeah I’m ready and what has triggered that is maybe it waking them up from their sleep during the night and that’s often the trigger, they may have noticed more difficulty with their day-to-day activities that they haven’t had before so even like trying to get through the day in work is more of a struggle and even things like getting into a car can require a manoeuvre as can putting on socks and shoes and that’s all the type of triggers that allow the patients to realise that they need something done.

This patient I will talk about now is the topic at the moment with the new documentary on Netflix which is very mesmerising and this patient is what I call the cliff edge patient and this is the patient who suddenly deteriorates and I’m talking about someone who goes from being completely normal to almost having a broken leg level of discomfort and this can happen over night after a minor twist and when I quiz these patients they may have been aware of a little bit of stiffness or the occasional bit of stiffness after sitting but then all of a sudden deteriorating rapidly to the point where they might come in on 2 crutches.

Often from a mechanical point of view what can happen is part of the cartilage that was worn has just flaked off or sometimes the bone beneath has just collapsed a little bit and it just gathers a large amount of inflammation and sever pain. It’s unfortunate that these are the type of patient that can’t wait a huge length of time to be seen as it is cruel to see the degree of pain that they can come in with and often although it may seem as an aggressive bit of action they are just better off going ahead with a hip replacement is the way to treat these it is almost the same as a broken leg with the same level of discomfort that they will present with.

The next patient that we see is called the double nappies and this is the patient who has had previous issues with their hip either as a child for example having a click in their hip or their mum saying they had to put on double nappies for a few months when they are younger. Occasionally they actually have been under the paediatric service and had procedures done to try and help their hip or essentially, they were born with a shallow socket or the hip just completely out of the joint. The procedures would have been to try and put the hip back in the socket and keep it there with time. These hips often function really well for a number of years but as I often say if you think of a analogy with regards to cars when you weren’t given the Mercedes of hips and if the hip is a little bit shallower then it will wear out at a certain stage. Some of these patients may have had a little limp especially more after demanding activities the problem is they do deteriorate early and that’s when I say they weren’t given the Mercedes of hips and often times they can be in their late 20’s early 30’s and this patient asks why have I got arthritis in my hip and as I say like a lot of things in this business it is purely a mechanical issue and because that socket is shallower it will wear with time and it leads to the development of premature arthritis in many ways and no different from all the other patients in general the treatment whilst we try and prolong things for as long as are reasonably possible the ultimate treatment for these patients is going to be a hip replacement and once again the odd one of these can get some improvement with an image guided injection with a course of physiotherapy to strengthen their glutes and muscle area in general can help and improve things.

With regards to physiotherapy in terms of the hip specifically I have no problem with strengthening activities in general ill often say to avoid lots of stretching activities and I often find if anything lots of stretches around the hip tend to aggravate the hip and make it worse and I have seen it make things worse and often that is the reason that they need to just pull back a bit from their stretching and they can get longer out of their hip essentially before they progress into having a replacement.

The next patient is the typical 50ish year old female who either attends reformer pilates or a yoga class and has started to notice some pain in their groin area, they may notice that some of the exercises they are doing in the classes allow them to notice that one leg is a bit different than the other but often they don’t have an awful lot of symptoms at this stage other than when they are doing their classes. This is often the patient where they’re not always sore but they are getting some degree of pain from around the hip and it is quite often that they come in expecting a hip replacement as such and they are thinking to themselves that they are ready for one. When talking to this patient about the pros and cons about everything I am a firm believer in thinking that if your range of movement in your hip is almost the same then a hip replacement isn’t going to make it an awful lot better and the fact is the movement in the joint afterwards can actually provide a bit of discomfort afterwards it’s very easy to irritate a lot of the muscles that work around the hip joint and you can be lead to be somewhat underwhelmed with the result of a hip replacement in this cohort of patients, I would certainly recommend an image guided injection in and around the area and quite often patients will get improvements from this and buy quiet a bit of time before progressing onto a hip replacement.

The common theme of this talk is injection versus hip replacement and why is that? Well keyhole surgery in the hip offers a very limited set of indications and in general these are younger patients who have got liberal tears which are the cartilage tears around the hip and in general if someone comes in and sees me in their 40’s, 50’s, 60’s with hip pain then there is no option for something like keyhole surgery on the hip so we are left with doing nothing, trying an injection and anti-inflammatories versus some kind of a hip replacement and again these patients have to be very strong in deciding whether or not they are going to go ahead with it.

The next patient is the high-level endurance athlete and they might not be an ultra-marathon runner but they might just love running 10km’s regularly, they might’ve done a Dublin marathon or competitive running in the time frame of last year. These are the people who are left really disappointed to find out that they have arthritis in their hip and it is quite strange as it may have been developing for several years but because they are fit and active they are not really aware of it and as I said they are quite disappointed to discover they have well established arthritis in their hip and ultimately all I can offer is a hip replacement.

It’s interesting while some surgeons do allow their patients back running I tend to say that in general from a mechanical point of view it doesn’t make a lot of sense to me doing a lot of running after a hip replacement. I absolutely would look at a hip replacement as an opportunity to get back to the vast majority of things that you enjoy doing and if that is football, tennis, golf all of these activities are absolutely fine I even have no problems with skiing but if you are the type of person who runs 10km 5 times a week I think that from a mechanical point of view it is likely to catch up with that hip and cause premature failure of the hip and I think getting more focused on something like swimming or cycling will buy them a lot more time with their hip be it replaced or not. It is the type of patient who is really disappointed to learn that they have arthritis in their hip and in due course their only option is going to be a hip replacement. Over the last generations we are pushing boundaries more and more and their not even in their 40’s but they are in their 50’s, 60’s and I have seen 70’s I remember one gentleman who ran a marathon in his early 70’s and it is just incredibly demanding on your body and whether we like it or not as we get older in age our collagen is changing and as it changes it makes us more and more prone to developing injuries and sometimes they are in the form of tendon injuries and tears or sometimes they are just discomfort in tendons or they are joints starting to give way and be weight bearing joints whether it be the hip, knee or ankle and as I said it can be frustrating to know whilst their mind is fully focused they have a joint that is letting themselves down.

The next patient then I will mention is my common patient that is females around the age of 50 who enjoys walking and a lot of middle-aged females enjoy walking and it’s great because it coms with so many additional benefits but quite often these people are often either just perimenopausal or postmenopausal and it’s a particular I suppose in some ways something that I see quite frequently is that they come in presuming that their hip is worn and in actual fact their hip is absolutely fine and where they’re sore or painful is over the outside of the hip itself or just to the side of the buttocks, essentially they can’t lie on that side as it is incredibly sore so to even press the bony prominence over the side and as I say this is completely unrelated to the hip joint itself which usually presents with pain in the groin area and that the pain is on the outside but it can be extremely severe as well and really stop people in their tracks. This as I mentioned in terms of tendon is where your gluteal tendons insert into the tip of the ridge counter and unfortunately, they are put under a lot of demand when we’re walking, the insertion becomes either inflamed or just mildly degenerative and I often describe it as a frayed rope in terms of how it’s presenting and giving symptoms.

These are the patients who not needing a hip replacement need a course of physiotherapy and can potentially get relief with a steroid injection over the area and quite often it will take a second or third injection to settle this down and sometimes people’s own GP will be able to give this. Sports Medicine will often do a lot of these as well and I’ll do some myself. It’s not the actual hip that is the cause of the problem extremely common, I had one clinic last week and I must’ve seen 12 people in a row with a similar problem and it just seems to come in ways potentially around this time of year as well people are trying to do more walking over the summer and it’s only after a couple of months that it really starts to limit them in their tracks and on one hand whilst I think the exercise is really good and comes with multiple benefits not just from a musculoskeletal point of view but it is activity related and some times it does mean pulling back on the walking a bit. In general, stopping the activities isn’t going to work in with these degenerative types of conditions as if you stop the activity as soon as you start back a few weeks later it will come back with a vengeance so you have to try limit your activities and to strengthen the area up with some physiotherapy, steroid injection and I’ll often suggest a talk with their GP in terms of the assumption that they are perimenopausal that the formulations of HRT that are available now can make a considerable difference and I think there is no doubt that oestrogen plays a very important role, obviously it’s well beyond the remit of my expertise but as I say it’s just something that I see quite frequently.

Even though arthritis is quite common it can present in a multitude of different ways with pain and discomfort and at the end of the day it makes a lot of sense to get these issues addressed and treated to potentially prevent them getting worse with time.

I would say in general if you are not in a lot of pain you probably don’t need a hip replacement just yet, particularly if you are younger I would say it is a case of just getting a bit more out of it.

I spoke about the disability aspect of things as well and I am conscious sometimes in younger people that a lot of stiffness can really cause trouble and catch up. Again, that’s where the consultation comes in we’re seeing someone and seeing how much they act and behave and how it is interfering with things as that helps make the decision.

The number one question to ask yourself is “is it impacting on me on a daily basis?” and that determines whether you not need it as such but if you would benefit from one.

My general answer to everything is yes. The only thing I allude to is long distance running and that is something I recommend you stay away from but the kayaking specifically would cause quite a bit of flexion but there are precautions we put in place for the first few weeks until everything heals up. After that, I ideally want someone to have as close to a normal hip as they can so I’m happy with whatever.

Years ago, the risk of a hip dislocating or popping out of a socket was considerably higher when not to get too technical but we used a lot smaller of a head in comparison to what we would use now. In most females now, we would use a 32-millimetre head and in males it would be a 36-millimetre head and as you can imagine it has to jump the radius in order to get out whereas years ago the head was only 22-millimetres and it was much smaller. It should enable people to enjoy a lot more activities as such.

Absolutely, we actively give people the Nordic walking poles usually a couple of weeks post operation and that’s just to promote the style of walking, the Nordic style is actually really beneficial after a hip replacement in terms of getting you upright and getting the weight going through the hip and getting a normal gate pattern without limping so I would actively encourage it.

Probably not is the answer. Injections in a hip can be a little bit hit or miss and they do seem to work a lot better on the knee but I do think if you get it early in the hip there is a real role for it and some people can get lucky and get 8/9 months out of a single injection but it’s not going to do any harm but is it going to help anymore? Possibly not.

In general, I would say yes. I often describe that a hip’s own worst enemy is itself and the general consensus in among the public is that hips are fantastic and easy and have no problems.

Knee’s on the other hand are not as good and the outcomes are not as good so I think people come in with a lower expectation for knees and a lot of the happiest people you will see are people that have had their knees replaced and they say it was a complete game changer.

On a similar level with a hip, if someone comes in with a little bit of discomfort either over the side which I spoke about or the occasional pinch in their groin that they were almost quite disappointed with it because they were expecting it to be perfect.

At the end of the day it is a replaced joint it is generally a replaced joint that is far better than the one that was in 97/98% of the time and half of them would have forgotten that their hip was replaced. Some people do just have that conscious sensation that it just feels a little bit different whether that is psychological or not I don’t know.

The ball is in the socket so it should not move within the socket, bar a millimetre or two but just normal walking it is articulating in and against the socket.

Anything can happen to the socket as well, the socket can migrate in the bone that it is fixed in but it’s extremely unlikely and other things can happen but it is so rare now a days with hips thankfully because they rarely move once they’re in and we sometimes see hips that are 20/25 years and they start to cause problems such as actively loosening or wearing away the plastic liner that tends to be older hips that have been in place for years where the plastic wasn’t the same high quality as it would be now, we don’t really see it on modern implants.

Most people would start with their GP referral and I think occasionally that is important as well especially because people will be going through their insurers and more often than not you will see insurers asking their clients for the GP referral as it is just one little obstacle that they like putting in the way, I think you should attend the GP anyway but I think it can make things safer for them in the long run also.

The problem with a bilateral in the first two days means you are almost like a tortoise on its back because the single hardest thing is getting out of bed so you actually have to start with the hardest activity. Normally if you have one side done you can use the other leg to help yourself up a little bit but with both hips done its just that little bit more challenging.

Once you get over that first day or two it is almost like the two hips recover at the same pace and I have patients coming back 6 to 8 weeks post operation and there really is no difference in the bilateral in comparison to the one side done on a hip replacement.

It is the same with bilateral knees from my point of view there is no motive behind me to do the two but I have seen it work so often and I think it really is an opportunity for patients sometimes to get things fixed rather than push it out for another six months to a year.

If it’s on the same side in general the consensus would be that you would start with the hip above because the hip will occasionally refer the pain to the knee but a knee will not refer pain to the hip so we tend to address the hip first.

On the odd occasion I have actually done the hip and knee together at the same sitting it is a little bit more unusual than say both hips together and both knees but it really just depends on the patient.

For further information on Total Hip Replacement Surgery at UPMC Sports Surgery Clinic, please contact

Common Injuries in Rugby 7’s

Watch this video of Dr Stuart O’Flanagan, Consultant Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic and Leinster Rugby, presenting on ‘Common Injuries in Rugby7’s.’

This video was recorded as part of UPMC Sports Surgery Clinic’s online Public Information Meeting, focusing on Common Rugby Injuries, Causes and Prevention.


Dr Stuart O’Flanagan is a Consultant Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic and Leinster Rugby.

Good evening my name is Dr Stuart O’Flanagan and I’m delighted to speak to you this evening on this rugby themed webinar series. I’m going to be talking about Rugby 7s’ and some common injuries. It is a very exciting time for the men’s 15s’ as they start their world cup journey. For the first time were going to have two Irish rugby teams in the 7s’ competition competing in the Olympic games in Paris in 2024. I thought it would be good to share some insights into the programme there.

I will be going through an overview of Rugby 7s’, The IRFU National Sevens Programme, Common Injuries, Injury Prevention and also the approach we take here at UPMC SSC Sports Medicine.

Although played on the same size pitch and has the same size ball Rugby 7s’ is much more amenable and has many more similarities to other field sports like Gaelic Games and Soccer.

My background, I am a Consultant Sports and Exercise Medicine Physician here at UPMC Sports Surgery Clinic Sports Medicine. I also look after the medical side of the Irish National 7s’ team and I am also a Team Doctor with Leinster Rugby.

Rugby 7s’ is exactly how it seems. It has 7 players on a full-size field. The games consist of two 7-minute halves and typically a tournament will have 2-3 games in one day in a tournament which is usually over the course of a weekend. Typically, there are 3 forwards and 4 backs so a scrum will have 3 people in it as opposed to 8 in a 15 aside game and what that does is it provides a lot of space around the pitch for people to gain ground. It certainly rewards the people who are fast and athletic. Not only are they good at running in straight lines but they are also very good at changing direction, side-stepping, weaving through players. Speed, pace power and quick footwork are all highly rewarded in the game of 7s’.

The IRFU 7s’ programme was established a number of years ago and has rapidly evolved. They are now made up of 2 squads, Men’s and Women’s and they have about 20 players per squad. The majority of which are professionally contracted. They are based in the IRFU performance centre which is in the National Sports Campus in Abbottstown. The facilities are state of the art. There are 3 outdoor pitches. There is a half-sized indoor pitch to be used when the weather is less pleasant, they have a fully equipped gym, medical and recovery rooms, hydrotherapy pools, rooms for video analysis and a canteen with some full-time chefs who provide the players meals throughout the week. The players are here Monday – Friday and then travel all around the world to take part in 7s’ tournaments. Our two squads competed in the world series which has recently been rebranded and there is 8 venues across 5 continents. Men’s and Women’s competitions mirror each other. The competitions are played in exotic destinations like Dubai, Cape Town, Perth. North American venues such as Vancouver, LA. Asian venues such as Hong Kong and Singapore. Finishing in Madrid where the Men and Women will be competing in.

This year will be a very big year for our teams as mentioned as mentioned they have qualified for the Olympic Games in Paris in 2024. Our Women’s team qualified earlier in the year in Toulouse by finishing in the top 5 in the world series for the first time ever. Shortly followed by our Men’s team who qualified in Krakow in Poland through the European games earlier on in the Summer. It will be our Men’s second visit to an Olympics having qualified for the last Olympics in Tokyo which was played in July of 2021. I was very fortunate to have travelled over to that to a very different games during Covid-19 times where essentially all of the games were played behind closed doors. We have approximately 80% of our men’s team who have been to an Olympics along with our staff who have a lot of experience going into Paris it will be a huge experience for everyone.

I’m going to touch on the types of injuries that we see in 7s’ Rugby. While there are lots of similarities with the 15s’ game, this game is much faster, quicker and as I said rewards quick, powerful, evasive players and it’s all about finding space and avoiding contact.

The types of injuries that we see can be categorised into a few different areas. Contact Injuries vs Non-contact Injuries. Contact injuries occur in tackles and rooks. Whereas, Non-contact injuries are related to running and sprinting in particular which we will touch on shortly. Now let’s look at Injuries in relation to training and games. What is the type of injuries that happen in a training session and what are the types of injuries that happen in a game? Games are obviously a lot higher intensity due to the amount of running at high speed, much harder collisions and often the injuries in games can be related to contact situations. Then we often look at injuries in terms of incidence and severity so how many injuries of a certain type are we experiencing every year and how severe are they? We might have lots of muscle injuries that are keeping players out for a week or two but we might have more severe injuries such as a broken bone or a sprained joint which may even take longer. These are the kind of things we look at when we talk about injuries in 7s’ Rugby.

In the IRFU we perform and annual injury & illness surveillance and what that does is it helps us look back at the year just gone but also allows us to compare the years prior in terms of what kind of injuries we are receiving in our squads so is there trends that we can look at to try and reduce or prevent future injuries and are there things that we have addressed that have been issues in the past that we are now better at? In the last 12 months we have had a good overview of the Men and Women’s squads with some similar type injuries. The most common injury in training for Women is Ankle Sprains and the average time from injury to return to play is around 24 days. In games, calf injuries are the most common type of injury that we see and statistically players recover within 15 days. When we look at the Men’s side Hamstrings seem to be the most common injury that we have seen in training. The average time to return is about 27 days and in games which are more contact related injuries the most common injury we see is Ankle Sprains which statistically take about 25 days to recover. You can see that on average a player may be out for 3-4 weeks when sustaining an injury in a game and it tends to be the lower limbs so the joints and the muscles of the legs that have been impacted the most.

What are the most common causes of injury? I eluded to it previously, sprinting and high-speed running are really the big things and with less players on the pitch and with more space means more time is spent sprinting and running away from people and often those sprint efforts will be anywhere between 20 and 80 metres. They could be running the length of the pitch and they could be doing it repeatedly in the 14 minutes of the game that they are playing and Hamstrings are common across all sports especially field sports, Gaelic Games, Football and 7s’ is no different a lot of our players have previously been involved in Athletics and have done running so we are very well exposed to sprinting and running at the intensity at the World Series but Hamstrings still always tend to be one of the main issues. The Calf is another muscle injury which is more commonly found in the Women players this season but again for the same purpose and as well as the videos that I showed earlier, Jordan Conroy weaving in and out of players and changing direction is a big thing in 7s’. There is a lot of demand on the ankle as players sharply decelerate, change direction, side step and go again. That is certainly one of the reasons that we have seen a number of injuries to the ankle this year as well as the contact situations where players get caught up in tackles and their feet get planted in the ground, they are twisting and turning trying to get out of tackles where the ankle can roll or turn and be injured.

Treating Hamstring injuries is something that we are very familiar with and it is really important to have a good understanding of the anatomy and how the muscles work and in turn what the demands of the players are so we can treat the injury.

As you can see on the MRI scan this is what we use to diagnose injuries. It allows us to grade it between a 1,2&3 which allows us to determine when it is a player will be able to return. This gives us an indication of how hard or how quickly we can push an injury and also when they are going to be next available

Similarly, with the Calf a very important group of muscles the two Gastrocnemius muscles on the outside and the Deeper Soleus muscles all 3 equally as important as they combine and run into the Achilles Tendon and again we use modalities such as MRI to assess for injury to help us understand what the type of injury is but also what the timelines will be for the return to play for these athletes.

A big area of focus for us is on ankle stability and as you can see on the side of your screen there is a lot ligaments stabilising the ankle both on the inside and the outside as well as the top of the ankle and one type of injury we see more commonly in the last few years is a high ankle sprain also known as a Syndesmosis. Which is a ligamentous structure keeping the joint stable at the top of the ankle both at the front and the back and this is something we have seen probably more related to the surfaces that our players are playing on around the world in terms of harder pitches in warmer climates as well as some of the stadiums, particularly in North America they can be Baseball or NFL stadiums where the ground is artificial grass and the ground is harder and there is more impact going through the ankles.

In the 7s’ programme we put a lot of focus on prevention. My area of interest is more on preventing injuries rather than dealing with them initially. If we can prevent them coming, knowing what we know from the last 12 months or perhaps, maybe the last 36 months we can try and address that in the weekly schedule. Here is an example of a week for a player and this is all the work that they do outside of rugby. We often do quite a lot of work in the gym to prepare for pitch sessions. The focus would be on movement health so getting the spine and hamstrings warm and loose as well as getting the muscles around them active. We put a lot of focus on the shoulder as you could imagine because rugby tackling requires good shoulder health as well as putting some work into ankle balance, control and strengthening the muscles surrounding it. We put big emphasis on what we call posterior chain or hamstring and gluteal strength as well as neck strength which is something we use to help prevent concussions and this might be done on a couple of days during the week as you can see on the schedule. There is always preparation for training and playing but also preventing injuries based on what we have seen before and of course we also have the team approach but we also have the individual approach so some exercises will be very specific to a player and their injury history in particular. You can see an awful lot of work and thought goes into preparing a player during the week and this is an average week outside of tournament times.

The kind of things we look at are for the hamstring strength and the high-speed running. High speed running is the equivalent of a vaccine for our players in terms of hamstring injuries so we look to ensure they get a number of exposures where they are running at very high speeds. We constantly work on the strength of the hamstring and the muscles surrounding that and similarly in the calf the 3 muscles I mentioned we look at training them regularly with heel raises with a bent knee and a straight leg as well as sprinting and endurance running. Running volume is important for the calf and our players cover long distances repeatedly so it’s ensuring they have enough in the tank particularly when the intensity is very high and the temperature and humidity levels can be different also. As I mentioned, strength so you can see some jump testing in the bottom picture there where we are getting real stiffness into the ankle to allow players to withstand falls as they run jump and evade the opposition.

Our approach here at UPMC Sports Surgery Clinic is very similar. We look at any athlete that comes in and as I said a lot of the injuries that we see in 7s’ I see now on a daily basis particularly now at the moment as it is championship time in Gaelic and Hurling. Also, Soccer and Hockey we also get many from Athletics in at the moment as well and many of them have transitioned to 7s’ over the years. We look at the History thinking what has the injury been? Also, focus examination. We often utilise imaging such as MRI’s to make the diagnosis to allow us to understand what structures have been injured and also to give us an idea of the timeline. There is very big structures in the hamstring including muscle, fascia overlying the muscle and tendon which runs through and each of those has a different way managing and helping a player return to play often with strength and then running and indeed high-speed running in time before re-integrating into playing and training. We look at other measures such as strength, we do a lot of isokinetic dynamometry testing as you can see some strength testing of the thighs in that picture and we also look at jump testing as well as a measure of reactive strength. Ultimately, that culminates in a rehab plan for the athlete to allow them to return to sport. The aim here really is prevention trying to get them back once and for all and to reduce any risk of future injury as a result.

Ankle sprains are really common and this injury is probably the most common presentation of a joint injury that appears in an A&E clinic or a Physiotherapy clinic around the country.

The biggest predictor of a future ankle sprain is a previous ankle sprain so prevention is really key.

Once you manage the early stage of the sprain like the swelling and the pain, making sure that there is nothing more serious than physiotherapy is really important making sure we restore the balance of what we call proprioception and improving the strength of the muscles in the ankle which can drop off really quickly, particularly in the calf and the muscles around the gastrocnemius and gastrocsoleus which I mentioned in the talk are really critical for that and once you have got a good level of strength you can start turning to hopping and jumping and once that is all good you may return to running and move back into sports and specific drills.

In my perspective, prevention is the most important part because it is the most common injury and it is really about managing that well so you are robust enough to return to play sport or do any direction change in certain activities.

The big thing with that high-grade injury is that you have damaged all the ligaments. I’m guessing it is on the outside of the ankle, the lateral ligaments. It is the clinical assessment that is really important.

When you have that level of injuries you have the potential to have ankle instability and as I mentioned the thing that we want to prevent is recurrent sprains because you can get damage to the joint, the alignment and the cartilage. It’s really about trying to improve the balance, proprioception and making sure that the athlete feels stable and not vulnerable.

If all else fails then you should be looking at getting some help from foot and ankle orthopaedic colleagues and on occasion rehab doesn’t work out or the joint is not stable then we look at procedures to stabilise the joint using surgery. We try the best we can to see how well we can manage it and you would be surprised I have had capped rugby players and All-Ireland hurlers with really high-grade injuries who do very well but when you involve all 3 ligaments or even the ligament higher up the syndesmosis that’s more of a challenge and it all depends on the clinical picture and the assessment, function and reassessing it in short intervals.

There is quite a bit, even though the ball is the same shape and the same pitch the sports are quite different. As there is more space on the pitch in a 7s game that requires more running and also high-speed running.

Players tend to be lighter and quicker. There are heavier players but generally, they are like sprinters or track and field athletes. They have similar profiles to GAA athletes.

I remember a couple of years ago we had some players who came across from one of the 15 aside provincial teams and they did more high-speed running in a warmup for a training session than they had done in the whole season and that was measured on the GPS units that they wear on their back.

There is lots more running and lots more adaptations required to protect people from the likes of hamstring and calf injuries.

Hamstring strains and injuries are another big thing that we see a lot of in the clinic here and by the time they end up in my clinic. Often, they would maybe have 5 or 6 and often try to make their own return by trying some physio and rehab or sometimes they try to just take some rest, and the big thing is getting the diagnosis from the start.

We use MRI here quite often because it tells us what type of injury it is whether it is a muscle injury or if it is the tendon which runs through the muscle, and that gives you an idea of the timeline sometimes people injure because they come back too soon and sometimes there is no way of knowing without a clinical assessment or an MRI.

In general, the stronger the hamstring, and the muscles that support it around the hip and pelvis the more robust people are, but sprinting is also like a vaccination. In addition, if you are playing a sport where there is lots of high-speed running then you have to be strong but you also have to be used to running fast. They are all the things that we love to do to try and prevent injuries.

We worry a little bit less about flexibility its not really as important but if your muscles are ready for running and changing direction we can then work around hip mobility and movement around the back, and that’s the principle we take with things like strength, sprinting and then making sure you have the right diagnosis from the start.

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Rugby & Concussion: An update from Amsterdam Consensus

Watch this video of Dr Jamie Kearns, Consultant Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic and Munster Rugby, presenting on ‘ Concussion – an update from Amsterdam Consensus.’

This video was recorded as part of UPMC Sports Surgery Clinic’s online Public Information Meeting, focusing on Common Rugby Injuries, Causes and Prevention.

Jamie Kearns Sports medicine Physician Santry

Dr Jamie Kearns is a Consultant Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic and Munster Rugby.

I am going to be giving an update on concussion in relation to the Amsterdam Consensus meeting in October of 2022.

This was a group of world-renowned experts both clinicians and researchers who came together to discuss the research that has been done in concussion over the last 4 to 5 years and try to collate the most up to date research in regards to both concussion identification, management and long-term outcomes. The publication of this research was released in July of 2023 in the British journal of Sports and Exercise Medicine.

The first thing about concussion to understand is the definition and how you define it specifically in relation to sports is “A mild traumatic brain injury caused by a direct blow to the head, neck or body”.

It is important to know that the definition doesn’t exactly have to be a head impact, a force that can be transmitted to the head from a knock to the body or neck can also cause a concussive episode. It’s important that with regards to that that you are not waiting for it specifically to be a head impact and it’s also important to know that symptoms may be delayed on set while the majority of symptoms may be presented immediately they may also evolve over the next few days particularly over the next 72 hours after a head injury episode to be aware that not all players or individuals will present symptoms directly after the episode. To note no abnormality is seen on standard scans or imaging so things like CT Brains or MRI Brains would be normal after a concussion and these tools or devices are used to out rule any serious pathology, particularly something like a brain bleed or something of more serious concern but unfortunately the current technology won’t be able to diagnose a concussion from a scan or an imaging test that you have done.

The range of symptoms do not always involve loss of consciousness and I think that is important to be aware of as it can be less than 25 percent of concussions that actually contain a loss of consciousness so you shouldn’t be waiting for a loss of consciousness in order to be checked for a concussion. It’s really important that people do understand that you don’t have to be knocked out to have a concussion and that’s an important message to be aware of and I think the message has been acknowledged overtime and it’s good to see that people are much more aware of this. What happens is, there is a cascade of events that happen internally that we can’t specifically where the neurotransmitters in the brains energy systems are affected and that’s why the signs and symptoms can evolve overtime and lead to different presentation of symptoms and indeed at different time points.

In the context of Irish Rugby, I’m making this relevant to us in our presentation. The Irish study which has been taking part in Limerick since 2016 would look at the rates of injury across amateur rugby and schools senior cup. Within that, it has been noted that over every season concussion has been noted to be the highest injury in terms of prevalence and incidents and likewise in school’s rugby concussion would account for approximately 14% of all injuries within the AAL game its somewhere between 11% and 14% and slightly higher in the women’s game between 10% and 19% depending on the season. Certainly, this is a common injury and it is something we need to be aware of and well clued in on in terms of managing it and also be up to date with the research. The average length of time off from a concussion within the amateur game is approximately 27 days for men and about 51 days for women so certainly within the amateur game there seems to be a delayed return to play within the female game and whether that’s down to lack of access to medical care or even prolonged symptoms is something that needs to be investigated further but overall the research would suggest that there is a difference in return to play between males and females in sport in other settings. That might be a level of reflection on the amount of medical care that maybe people are getting in the female game and the delay in diagnosis is what might be causing this. In school boys the average level of duration off is about 30 days and again some of that is going to be mandated by the IRFU with regard to their mandatory stand down of 23 days for u18’s and 21 days for the over 18’s in the amateur game.

The key part in terms of education and to manage concussion really is about the recognition and with regard to that one of the newest tools that was developed within the consensus meetings was the Concussion Recognition Tool 6. This is a specific tool used for non-medical personnel for example, those attending a game whether it be a coach, parent or even a medically trained assistant at a game. Within this there is a framework of different things that are important to look at and one of the most important things is at the start point and it is the red flags or things that we look for which may suggest something more serious than a concussive episode or would warrant further immediate medical attention. Within that, you will see the middle section has a red flag section of things that would warrant the contact of the emergency services. On the following page, it has a breakdown of things that would help us to identify a concussion after the red flags have been ruled out. Within that, they would look for things such as visual clues or things that the injured individual might describe in terms of loss of consciousness, loss of balance or things like a brief seizure or unsteadiness. After that, it is then a question of what the individual may present with or the symptoms that they report. In this situation they might describe some physical symptoms, emotional symptoms or even changes in their cognition or thinking. Sometimes, people may present immediate symptoms of confusion or disorientation or potentially they may not be aware of their surroundings. Anyone presenting immediate symptoms particularly headache or dizziness on the pitch should be removed straight away as these are people who tend to have prolonged symptoms if it is not recognised. Finally, they give an advice section to give to someone with a suspected concussion if they are not being transferred to the emergency department for further onward referral. These should be medically assessed before any return to play, they shouldn’t be left alone in the first 3 hours as this is a time period where worsening of symptoms might warrant medical attention. They shouldn’t be on their own and again use recreational drugs that may confuse a situation as it may lead to altered cognition and presentation which would then loose the presentation of the individual if they were to have further, more serious underlying conditions. Again, they shouldn’t drive a motor vehicle until clear to do as there is a concern about a post injury seizure and obviously that could end in a serious road collision or accident if someone was to drive in that situation.

The number one thing that can be done for a person in this certain situation is to remove them from play and this should be common across all sports games. The saying is “IF IN DOUBT SIT THEM OUT”. The reason for this obviously is to prevent any further episode so people who continue to play with symptoms of a concussion will go onto develop a much more severe concussion if they were to develop a second episode which will lead to much more prolonged symptoms. Certainly, by removing them from a second injury you would reduce the severity of a concussive episode or indeed shorten the duration of symptoms post that injury. A serious thing to look out for is something called 2nd impact syndrome. This is where someone received a second injury or a 2nd concussive episode or head injury that there can be rarely an episode of significant brain swelling which can be serious and lead to seizures and also in some places can be fatal. This is obviously a very important thing to recognise and prevent from happening.

With regards to those who have been diagnosed with a suspected concussion particularly within an amateur setting where there hasn’t been a medical input it is definitely been shown that the earlier someone receives medical attention after a concussive episode that it shortens the duration of that episode. Within the medical setting, whether that be with their primary care physician or sports physician or someone who specialises in concussion that the player should be re-evaluated. Once it’s past 72 hours they have a device called the SCOAT 6 which is the Sports Concussion Office Assessment Tool. There is also a child-based version of this for those 12 and under. This is a multi-modal assessment which involves a symptom checklist, neuro-cognitive testing, some balance assessment, assessment of  vestibular function, autonomics neuro-system assessment and also a neurological and vital assessment to out rule any other serious pathology’s that need to be treated prior to managing the concussive episode. It does incorporate screening for underlying issues such as anxiety and depression and these are not mandatory but maybe optional if the person was to present with prolonged symptoms that maybe are being complicated by the development of maybe some anxiety symptoms or some depressive symptoms that can commonly occur after a concussion but also if present prior to a concussion it can lead to more prolonged symptoms. As I said this is best used within 72 hours to 30 days post injury and can be used within the setting of a primary carer. It takes a bit of time to do but it can give us a very good direction towards whether or not treatment needs to be directed in terms of rehabilitation this can help guide that.

With regards to the rehabilitation of concussive episodes I think its important to be aware that most episodes are self-limiting and that will resolve spontaneously on their own. It is important to be aware though that 30% of people will experience Post Concussive Symptoms (PPCS) or what are now called persisting symptoms and there is a slightly higher rate in those under the age of 18 as they will tend to take a little bit longer to resolve from symptoms. Prolonged rest is no longer recommended and I think this is an important message to us in terms of a return to activity after a concussive episode and it has been shown that those that were prescribed prolonged rest actually take longer to recover and that a self-limited and self-directed return to activities of daily living within the first 24-48 hours is actually important. Allowing people to do normal low-level activity in terms of walking and activities of daily living but maybe reducing screen time for the first 48 hours has been shown to reduce the persistence of symptoms. After that 48-hour period I think it is important then to encourage a return to exercise in a very graduated and personalised way. Within that, its worthwhile aiming for a low level of activity with up to (if its not prescribed) 50% of what we would consider the maximal heart rate that produces symptoms. If that is something that you’re not prescribed by a physician or a physiotherapist then aiming for about 50% of your heart rate in terms of a low-level 15-20 minutes on a bike is a helpful starting point. This will then be progressed on as symptoms are tolerated and you can then progress on to a running based activity over the following 24-48 hours. We’re happy that as long as there is only a mild exacerbation of symptoms then it is ok to progress on. Within a mild exacerbation that would really be graded as something where it’s approximately a 1 to 2 out of 10 in severity. As long as the symptoms are not increasing above 1 or 2 out of 10 and are resolving quite quickly then we are happy for people to progress on in their rehabilitation to allow them to return to activity as this has been shown to be the best treatment in terms of reducing the prolonged nature of symptoms after a concussive episode.

Within that return and rehabilitation, this is a simple guide that would guide the staged graduated progressions. Within it you can see the first few days so step 1 is a symptom-limited activity that don’t exacerbate symptoms and then generally progressing onto that light exercise of up to 50/55% of a max heart rate. That can simply be calculated by a simple formula which is 220 minus age. Within that, that might be a stationary bike and that’s usually quite beneficial as it prevents any head movement and then progressing onto similar maybe moderate activity and then increasing heart rate running based activity. The first light blue section is safe to progress on without the need of medical clearance and this is really designed to help to return to activity which is both helpful but also good for progression back to incorporation in training and sport. The second darker blue section can be used after somebody has been cleared to return to maybe a training-based activity. The upper section would be one were there is a low risk of any further injury and there is no risk of any head impact at that stage. Whereas, once you progress into that lower section that is when you are at risk of a subsequent head injury starts to increase and that’s why we delay that bit until medical clearance.

Important for students and even those returning to work is this return to learn process and again this is individualised and the majority of people will have returned to full learning at approximately 10 days. However, it is important to be aware that up to 40% of individuals may have some academic dysfunction or disability when it comes back to learning in terms of struggling in the school room or struggling in the classroom in the first couple of days after a concussive episode and by not recognising that it can lead to prolonged symptoms again. Again, these are really the people who would struggle in this situation and those with the greater initial symptom burden so those who present with maybe very severe symptoms on day 2 to 3 after a concussive episode they are the ones who maybe are more likely to benefit from a personalised approach to their return to learn where maybe there are some modifications around the length of time that person goes back to school or maybe reducing the amount of homework in the first 24-48 hours will help with the return to activity and the return to normal learning.

With regards to the return to sport, the average time to symptom free is approximately 14 days and the return to sport is approximately 19 days for most athletes. Again, this does intend to vary between males and females but there is a slightly longer duration for those under 18 up to 16 days versus 15 days for those over 18. Factors that would increase that time tend to be that delayed removal from a game like someone who suffers an injury within a game and then plays on with persistent symptoms. As mentioned earlier, delayed access to a healthcare professional can also be associated with the delay in the return to play and also initial higher symptom burden and severity of symptoms at the time of presentation has consistently been shown to predict how long someone will take to return to play.

With regards to onward referral those who are struggling with persistent symptoms those who are experiencing recurrent episodes of concussion and those who are being affected with a complicated mood disorder like anxiety symptoms or a low mood even complications with sleep or reluctance to engage in activity and those with parental concern or the athlete themselves is concerned should really be referred onto a specialist who look after individuals with concussive episodes and would understand the management going forward.

One of the new areas that they have looked at within the consensus statement is the ability to reduce the number of concussive episodes. There is increasing evidence for the use of mouth guards and this would’ve come from Ice Hockey within Canada but certainly some of the previous studies in rugby would suggest while non-statistically significant that the use of mouth guards has shown to be beneficial in reducing the number of concussive episodes. Other ways we can look at that in terms of policy change and obviously the IRFU have brought in the reduction in tackle height which has been shown both in France and abroad that has reduced the overall incidence of concussion. The reduction of contact within practice sessions has been known to reduce the episode of concussion within the NFL and has been taken across to rugby where the level of contact has been reduced in training to prevent the number of concussive episodes in training and that is evident in the statistics in both the Irish study which shows that the number of concussive episodes within training is actually very low and the majority of concussive episodes seems to happen within the match setting.

Another thing that has been shown to reduce a number of concussive episodes is a neuromuscular training warm up which was shown in England to reduce concussive episodes and all injuries and this is something that can be co-ordinated through the strength and conditioning coaches prior to a training session. What is also important is the early identification of a concussive episode to reduce any recurrent episodes as early identification management reduces the severity of the subsequent episode and how long that person would take to return to play. Again, early identification, recognising and removing that individual is probably key to preventing further episodes.

Finally, a question we get asked is when should someone consider not playing contact sport anymore? This isn’t specific to rugby but it can be across all sports. I think while there is no specific set guidelines and no specific evidence to guide this in terms of factors we would look at people who maybe have had prolonged symptoms or persisting symptoms after a concussive episode. Obviously, if you have neurological abnormalities on a physical examination then them people should not be cleared to return to rugby until they are fully assessed. Any deficits on neuropsychological testing, despite time away from contact sports again would suggest a need for re-assessment. It should really be a multi-disciplinary approach where the person is seen by a number of specialists who work in concussive management who would be able to guide the decision around returning to contact sport or avoiding contact sport. One of the things we look at is concussions that are evident after maybe a lower impact like a transmitted force in concussion that we maybe previously wouldn’t have. Anything that has structural abnormalities again would be warranted further neurosurgical or neurological review and these are all things that need to be taken into consideration. It should obviously be balanced by the benefit of participation in activity and physical activity which are all shown to reduce the incidents of both mood and neurological disorders as well as the benefit of team-based sport for reducing the likelihood of anxiety and depression and isolation that can occur when these are removed.

In conclusion, it’s important to re-emphasise that early recognition reduces the severity of concussive episodes. Avoid strict rest as this will only prolong symptoms and the earlier someone can return to activity then the shorter the duration of symptoms will be regardless if they return to play. Using exercise in a prescribed way and a progressive manner is also beneficial as treatment for a concussion. Early referral is warranted and will reduce on going symptoms if the person is not responding to the usual care.

POTS, I assume she means Postural Orthostatic Tachycardia Syndrome which is a sympathetic overdrive and it happens after head injuries, it can also happen after other injuries but in essence this is a disturbance of the autonomic nervous system and this is a recognised occurrence in concussive episodes.

I think it was actually under recognised but is now on the standard concussion assessment tool, particularly the office-based tool. This is a recognised complication that can occur but if it has been managed well and symptoms have been resolved then that’s a really positive outcome because a lot of times this is under recognised. It’s a positive outcome because it has been recognised and managed well.

In relation to the second concussion, I think it depends where you talk to people but I suppose the biggest risk of having a complicated concussion is having a previous concussion. Generally, what you find is the biggest risk or things I ask people to look out for is either a concussion is taking a long time to resolve or one that happening with less and less impact. Let’s say someone is having a recurring concussion and it’s only from a blow to the body or their holding a tackle bag and they get a concussion versus a significant trauma. There is some groups who will say that once you have been rehabilitated fully and symptoms have settled from a concussion and everything is clear there is no increased risk of concussion. Again, that is possibly debateable because I think there is always some risk but you have to balance that out versus the desire to continue playing a sport, the social inclusion and the benefit from a physical point of view. All of those things are positive effects of playing rugby and playing sport. I suppose, it’s a balance, there is always some elements of risk but it is just balancing out what the benefit is and then making an informed decision that way.

I think this is where the new concussion guidelines give a lot more direction and give people more control about what they can and can’t do and what they should and shouldn’t do and probably the key bit is the early introduction of exercise after 24-48 hours below a level that brings on your symptoms so actually getting out.

Firstly, not staying in a dark room for 24-48 hours would be the previous advice so obviously reducing screen time in the first 1 or 2 days will reduce symptoms and the severity of symptoms but after that resuming activity is tolerated, getting out meeting people, simple exercise in the form of walking and then a symptom limited return to activity maybe on a bike and building it up to a level by going through steps as in the return to play criteria.

What has also been shown to reduce the risk of a worse concussion or prolonged symptoms is an early interaction with a qualified professional, the people who see a physician early do better. They don’t tend to have prolonged symptoms and get guided towards the right rehabilitation for those people that need it early.

UPMC have a concussion network established around Ireland at the minute, so there are available clinicians in lots of the country now covering a large part. From Dublin across to the South, Southwest, Midwest and North as well.There is certainly good access if you go onto the UPMC website and look at the concussion network.

There is an availability of clinicians there who have access to neurocognitive testing, neuropsychological testing, online impact testing and then also specialist physiotherapy and vestibular rehabilitation so there is a good network there if people want to look on that as a guideline for maybe players that need assistance with complicated concussion.

Without seeing the person or knowing the situation, I think the ability to weight bear after 3-4 days and get the swelling down is usually the key bit. Once a player in our care in the rugby club, as you can imagine we would look at maybe some loaded exercises in terms of their ability to do a calf raise or do a weighted calf raise and then we have a guide in terms of our return to run which will involve a number of hopping exercises before introducing some straight line running and changes in direction. Once that is clear in the person then we would be happy to re-introduce them back into training.

I think the important bit with the common ankle sprain is that a lot of people will suffer from on going symptoms and recurring ankle sprains. They are the ones that can cause problems long term, I think whatever about the initial injury it’s the recurrent injury that we have to watch out for as we can cause serious damage to the ankle joint if they are not managed properly. They would be the ones where if you are getting someone with recurring ankle sprains it would be worth linking them with a physiotherapist or a sports medicine doctor just to get a proper assessment in that situation.

In relation to the second part of the question I think it’s really just important to be able to walk and weight bear pain free, being able to hop both forwardly and laterally you want them to be clear and then introduce some straight line running and change of direction. If they are all clear then I think there is no issue. Again, once someone has suffered an ankle sprain we would normally strap their ankle for a period of time afterwards because of their risk to injury.

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‘Summer & the living is easy! Staying on track with Knee Arthritis’

Watch this video of  Professor Brian M Devitt, Consultant Orthopaedic Surgeon specialising in the Knee, Presenting on ‘Summer & the living is easy! Staying on track with Knee Arthritis’.

This video was recorded as part of UPMC SSC’s Online Public Information Meeting, focusing on ‘An Evening for Hikers/Walkers’.

Brian Devitt is an internationally trained orthopaedic surgeon with subspecialty expertise in knee surgery. He is particularly interested in sporting injuries, including anterior cruciate ligament (ACL) reconstruction, meniscal repair, cartilage restoration procedures, multi-ligamentous knee reconstruction and hamstring repair. In addition, he cares for patients with degenerative conditions, such as knee arthritis, and performs partial and total knee replacements and osteotomies.

Brian completed his medical school training at University College Dublin, Ireland, and carried out his specialist training in Trauma & Orthopaedics at the Royal College of Surgeons in Ireland. He also achieved a Masters in Sports and Exercise Medicine. Brian pursued a career in academic orthopaedic sports surgery and completed three years of fellowship training. The first year was a research fellowship at the Steadman Philippon Research Institute. He then completed a clinical fellowship in sports surgery at the University of Toronto. Finally, he completed two clinical fellowships in Melbourne; the first was a knee reconstruction fellowship at OrthoSport Victoria (OSV) and the second at Hip Arthroscopy Australia. Following his fellowship, Brian worked as a consultant orthopaedic surgeon at OSV and Epworth Healthcare.

Brian has a keen research interest and is a Full Professor and Chair of Orthopaedics and Surgical Biomechanics at Dublin City University. He has extensive research experience focusing on clinical outcomes and biomechanical studies. He has published widely and frequently speaks at national and international meetings.

Good evening. My name is Brian Devitt, I’m going to speak to you about staying on track with knee osteoarthritis, and this is with relevance to walking and hiking. I want to first off show you a picture of a former patient of mine. This is a lady who’s in her seventies, and she has embarked on a charity walk in Vietnam; she had previously had a total knee replacement eighteen months ago, so there are a few features I just want to point out first of all if she’s smiling! She’s doing very well following her knee replacement; secondly, she’s using a stick to help her get up what is a relatively steep slope; she’s wearing the appropriate shoe wear she doesn’t have too much to encumber her in her hike in terms of carrying a lot of load, and she’s willing to help or receive help from the tour guide who’s bringing us along so when in Vietnam we learned an awful lot of things but one of the most important things we learned to some of the quotes from Confucius who is a Chinese philosopher, and he told us it doesn’t matter how slow you go as long as you don’t stop I think this is hugely relevant when it comes to the management of knee arthritis but also activity in the setting of arthritis it’s really important that we keep on going.

We all come in different shapes and sizes, and it’s the same with respect to our needs. We look here on the left side of the screen we see what a normal alignment, just two straight legs is; we see various alignments of what we know as bow-legged and common pylons, and we also see knock knees or valgus alignment where on the right-hand side of the screen now all the people who come in this in these different shapes normally but when it comes to pathology we also see people develop these shapes of their knees as time goes on and this is quite relevant in terms of how the ways when we walk goes through our knees when we’re in a neutral position the weight goes directly in the middle of the knee which is equally shared in this bow leg position the way it goes on the inside of the knee and in this knock knee position the weight goes on the outside of the knee so this has an impact in terms of how we progress with wear and tear as Life Goes On.

I’m going to show you a few picture examples or X-ray examples, and one of the things we use as orthopaedic surgeons to diagnose arthritis it’s key to take the history from the patient as to where the pain is and when it occurs, but an x-ray is very helpful the most important thing about the x-rays the person is standing, and we can see on both legs here that there’s very little space on the inside of the joint both of the right leg and of the left leg and we refer to this as decreased joint space or also what is known as bone on bone osteoarthritis so this happens in a situation where someone has bowed legs we also look at the kneecap, and that’s really important when it comes to walking because as you walk down the hills or down stairs or even upstairs it puts a huge amount of stress through your kneecap so it’s really important that we would look at this and this kneecap is not too bad it’s got a little bit of decreased space, but there’s plenty of life left in that yet.

We often get patients referred to us with an MRI scan and MRIs will diagnose a lot of the soft tissue conditions but we can also see arthritis so I’m going to explain initially we’re looking at this MRI looking at your knee from the front so this here is your kneecap I’m going to work our way towards the back anything that shows up as white on these scans indicates fluid or increased stress within the bone I’m going to point that out as we go so we’ll work our way back through the MRI it’s a little bit shaky so excuse me and I’m looking at the fluid in these we know that this knee is not in a great state and we can see that the bone in this area on the inside of the knee is very white and that indicates that this bone is under a huge amount of stress and the reason it’s under stress and I’m going to go through that again is because the meniscus which is a shock absorber in the knee has been damaged so you see this black structure is the meniscus and you see it’s being put down to the side of the knee and underneath you’ve no cartilage on this inside of the knee and that’s why a lot of people come to us to think they have a meniscal tear but in fact the horse has long since bolted its arthritis is the situation so this is how we see it on an MRI and the previous x-ray that we saw where your bone and Bone arthritis is how we see it on an X-ray so we do use all of these modalities to diagnose the injury and the presence of arthritis .This is another x-ray which shows arthritis not on the inside of the knee like previously but on the outside you can see the shape of the leg is different from the normal leg which is nice and straight we see on the outside of the knee you have wear and tear here with extra bone forming here in this region here and you can see there’s bone and Bone arthritis on the outside of the knee we look at this example of the kneecap we see that there’s a lot of extra bone around the kneecap and no space between the front of the kneecap and the femur so this is an example of someone who has not only wear and tear on the outside of the knee but also wear and tear on the front of the knee so you imagine they’re going to have an awful lot of pain walking down stairs kneeling or any type of movement going from a seated to a standing position.

Now we’re going to have a little bit of physics to understand why we have pain in the knee when we have arthritis and we walk and physics so this is a pictorial example of Isaac Newton so Isaac Newton discovered gravity but he also discovered a lot of other important physics and equations and theories and one of the things that he recognized is that gravity is a huge part to play but also within the knee as we expect we extrapolate that to the load going through our knees when we walk it is very important so if we look of just walking the weight that goes through our knees each individually when we walk is twice our body weight when we walk downhill that increases to four times our body weight and if we were to run that can go up to as much as eight times our body weight so that’s why if someone might be fine while standing but when they walk the pain increases it’s because the load going through the knee also increases so let’s do a small little calculation so we’ll take a hundred kilogram male so that’s a big man may be carrying a bit of extra timber so 100 kilograms that person walks down here 400 kilograms goes to each individual knee with that action now if he was to lose a moderate amount of weight which is ten kilograms or ten percent of his body weight which would take a bit of effort he would find that forty kilograms less goes through each knee as he walks downhill so this is a very important to remember in terms of the loads that go through our knees when we walk and also as a means of treatment for arthritis it’s very important.

In terms of the injuries we get while walking, I’m going to give you a couple of examples of how to avoid injury, to begin with, so you don’t end up in my office at any time. So first of all, it is knowing your limits so when you start walking or if you’ve gone from a period of sedentary period to an active period, it’s important that you go gradually; you don’t go start hiking Mount Everest when you’re just starting you’re walking so it’s very important to know your limits I think that’s one of the things we saw after covet is when people were relatively sedentary they went out to walk every day of the week we saw people with a lot of issues developed quite quickly so if you’re starting to walk just start walking on the flat first and if you want to then engage in some steps that are appropriate if you have no pain or then walk up and down Hills as you see fit. it’s often best to be preconditioned so you want to improve your ankle strength and balance and nowadays we recognize that Pilates is really a great treatment for all types of ailments and it’s incredibly important with regard to improving your core strength but also the strength of your quadriceps and hamstrings and also your ankles if you’re particularly when you see reformer Pilates these can be very effective as an all-around holistic method to improve your strength and balance we recognize hugely as I saw in the picture at the start is that the use of hiking poles is really important particularly when you’re going up and down hills because it allows you to take the load off the front of the knee and share it with the load in your arms it also gives you an improved workout with your upper body so using more walking poles is actually very sensible when it comes to hiking so that’s something we would recommend very much so the use of appropriate Footwear so going hiking in a pair of sandals is not appropriate because you’ll end up rolling your ankle or you’ll load inappropriately particularly on uneven ground and that tends to put increased stress through your knees or a little needle there are some blisters that you’ll try to you’ll walk a bit more you walk differently and that puts increased load through your knees so that’s it and not a good wise thing to do is to wear inappropriate Footwear and we recognize wearing properly fitted Footwear with appropriate socks and trying to avoid getting the likes of blisters because they do change the your gait and it’s important that you try to maintain a normal gait that you equally distribute the weight throughout your knee and not in one certain area and then just common sense and  hydrate adequately when you’re tired of fatigue you tend to stress our knees quite a bit more so just have an appropriately distant walk so you’re not very fatigued at the end of it or you’re walking in incorrectly which puts more stress to the front of your knees it’s really important that your general health is well maintained as well .

Let’s just look at arthritis unfortunately if you can’t avoid injuries and you do get some injuries or arthritis how do we manage them it’s really important that you understand this so I like this quote from Macbeth I’ve used it before in different talks where it says ‘ Eye of newt and toe of frog, Wool of bat and tongue of dog, Adder’s fork and blind-worm’s sting, Lizard’s leg and owlet’s wing, For a charm of powerful trouble, Like a hell-broth boil and bubble’ if we got the lighting to come on as well give it a bit more impact but this is a quote from Macbeth but none of these things work for osteoarthritis you can rest assured you don’t have to have any far-fangled poisons or potions to get you to improve your arthritis these things don’t work I oftentimes get patients coming into my room and they’ve consulted Dr Google and they come in and say well this laser work doctor and really I try to keep it very simple there’s a few tried and trusted things that work for arthritis and I would encourage you to follow the trial and trust it and not the far angle treatment so these are the treatments that do work so physical activity is important just like the lady who’s walking after a knee replaced and walking beforehand can be effective but we try to avoid heavy load activities that put more stress to our knees weight loss is really they’re probably one of the best treatments but it’s not an immediate treatment to lose weight so weight loss is very helpful as per Isaac Newton’s knowledge and equations earlier on acupuncture has not been shown to work massage can be helpful for tight muscles bracing can occasionally be helpful and maybe a compressive brace can give you a bit more feedback in your knee in Soles likewise have not been shown to be hugely helpful but they do make footwear fit more appropriately and glucosamine has not been shown to be extremely helpful but it doesn’t do much harm and it’s cheap so I wouldn’t be overly against the use of glucosamine as an oral tablet.

We then look at pharmacological treatment and we recognize that anti-inflammatories do work so if you have swelling in your knee it shuts down your muscles so if we can get rid of that swelling it allows your knee to function much better a steroid injection and can be helpful particularly if you have swelling but it’s not it’s not a long lasting effect it just has a short-term effect the use of hyaluronic acid in this recommendation and that’s from the American Academy of orthopaedic surgery has not been shown to be effective it may be more effective in younger patients but not in patients with Bone arthritis and then plated rich plasma can be helped in some circumstances but it’s not the go-to in every case and then we look at surgeries and what stuff that we do as a surgeon so washing the joint out with the camera that is not effective it used to be an old-fashioned treatment but we don’t do that anymore sometimes if people even in the setting arthritis have a flipped piece of soft tissue like meniscus remove that can give them and some temporary relief but it doesn’t remove the arthritis it just removes the soft tissue which might be impinging or getting in the way, doing an osteotomy which means cutting the bone and changing the shape of the leg can be helpful in certain cases and then a joint replacement has been shown to be very effective in the right setting at the right time so, one of the take-home messages I always say to patients is your objective is to avoid people like me as long as you can.

When your arthritis gets quite severe we are very helpful in terms of believing that pain and getting you back on track so the effective method just to reiterate our weight loss modify your activity if you’re doing things that are hurting you a lot like walking down stairs or and you know walking down slopes then I try to avoid that as best you can and it’s also important to maintain the strength of your of your muscles and do so in a manner that doesn’t hurt you so much so doing the likes of cycling swimming if you have advanced arthritis can be very good to maintain your motion the use of anti-inflammatory medication is very important there’s a limited role for arthroscopy and knee replacement when ready and when I tell patients they know they’re ready when they pain at night or pain at rest that really affects the quality of life and that’s where it’s really important so I’m just going to give an example of this is a knee replacement so this is one of the ladies earlier on who had the wear and tear to the outside of the joint and the front of the knee and this is what we did we gave her a knee replacement and this lady was back walking and hiking and it’s not quite the picture of the woman I saw at the front but very similar back to a very active quality of life we see how straight we get the leg afterwards and this is replacing the kneecaps that was extremely badly worn with a resurfacing of that kneecap or patella as we talk about so allowed her to walk downstairs without any major problems we also sometimes just replace one part of the joint so on this right leg here we see the inside part of the joint has arthritis and decreased joint space and extra bone here and in this case we just replaced this side because the rest of the side was relatively well maintained and allows patients to get back to a very good level of function very quickly after surgery so patients often ask me how active can I be with a knee replacement and I often remember a patient of mine who is a farmer from an area in Victoria when he’s working Australia called Gippsland and I remember this patient came in and he came at six months following surgery and he asked him that his knee hurt and he said occasionally it hurt I said when does it hurt he said well after shearing 50 sheep it became a little bit painful and he told me a very good quote which I often tell patients when I see them in the clinic and what this said he said was I quickly realized that it was a case of my knee getting used to me and not me getting used to my knee so this is a real paradigm shift in my mind in that when you have a knee replacement just go off and do what you want to do if you Molly coddle that knee and if you don’t move it you’ll be storing sore and stiff you could off and do what you want to do whether it’s um cycling whether it’s playing tennis whether it’s surfing whether it’s shearing sheep just do what you want to do and your knee will follow suit so I’m very happy to take some questions later on and I hope you get back on track with knee arthritis .

Why do I have discomfort in my groin while walking?

Well, it’s quite common to guess growing pain while walking. I suppose it depends on the patient’s age, but typically if someone has pain, it’s either a muscular injury or strain or can relate to arthritis. It’s a very common site to get arthritis within the groin, and it’s typically a pain that comes on after exercise as it gets more severe. You can get it at rest or at night, and that’s when you really should have something done about it.

Question from Anne is a walking stick helpful for hip issues?

Yeah, a walking stick can be very helpful. Essentially it’s typically used in the opposite hand and essentially offloads some of the weight going through the hip, and the muscles that are attached to the side of your hip really undergo quite a bit of stress when you have arthritis because the joint is irritable and this is an ability to offload that by using the walking stick around the opposite hand typically.

The Walking poles are they a good idea?

Yeah, for the same reason walking forwards are an excellent idea, and people tend to use two poles nowadays. I know the picture I showed at the start of my talk was just the solitary pole, but she used two poles. I think they refer to it as Nordic  walking, and where they use two folds is great because you’re able to particularly going uphill but also going downhill, you’re able to take some of the load off the front of the knee, so you use your arms to push you up and keep the stick and quite vertical, and it allows you to exercise your upper body but also offload the knee and takes a lot of the stress off the front of the knee and makes it somewhat easier

in relation to weight, how much is it associated with the level of General inflammation in the body and when it comes to pain with osteoarthritis?

well as I referred to with Isaac Newton and the importance of gravity and weight are hugely important in terms of the load going through a joint, so, not just your knee joint but all your joints of your body, so if you’re carrying excess weight, you will put a significant amount of weight multiple times your weight through that joint and in terms of excess ways and inflammation I think the excess load is going to give rise to further inflammation within your joint, and I know there are further studies that probably have looked at obesity and inflammation in general but specifically with the joint it’s very much the load that goes through the joint causes the irritability.

What is the best type of knee support wear, or would you recommend support or not?

The new support can be helpful in certain circumstances. I think you know you can go from very fancy braces, which offload one particular compartment of the knee and they can be somewhat awkward to wear but can be effective, to a simple sleeve which essentially can give some feedback or what we call proprioception is where you know knowing where your joint is in space and sometimes you have swelling in the knee using a compression sleeve is very effective and but there is no proven evidence that they’re going to reduce the progression of arthritis they just make you feel a bit better during exercise sometimes.

A question about a jumper strap still has pain and doesn’t know whether to wear it or not, so would it be better that she just doesn’t use it, or why would that be?

Yeah, I think the jumper strap refers to the strap that just goes at the bottom end where your patellar tendon attaches to your tibia; that’s where I see a frequently, and you know, I think the whole idea is of trying to offload the tendon somewhat, and to take the stress off it and really just using common sense if it’s not that effective I’d stop using it, to be honest with you, and maybe you have to look a bit more deeply into the problem.

What’s your view on stem cell injections?

I just think we’re not there yet. I think, realistically, stem cells offer a great possibility, perhaps in terms of the management of arthritis, but we really don’t have the answers yet. I follow the research quite closely on this issue, and really we don’t have the evidence to support the use of stem cells. One of the things which are very interesting is some of the guidelines from Australia, where I worked previously; they said you shouldn’t really be involved or go to someone who is delivering stem cells without it being involved in a randomized control trial, and you’ll find that most of the people who supply stem cells are doing so too for a commercial gain it’s not based on research or evidence so I would say beware in those circumstances because you can find yourself out of pocket a lot without any proven evidence it works.

‘Hiking / Hill Walking: Reducing the risk of injury’

Watch this video of David McCrea, Senior Musculoskeletal Physiotherapist, presenting on ‘Hiking / Hill Walking: reducing the risk of injury’.

This video was recorded as part of UPMC SSC’s Online Public Information Meeting focusing on ‘An Evening for Hikers/Walkers’.

Thanks, Fiona. Good evening everybody. My name is David McCrea, and I am a senior physiotherapist working at the SSC Sports Medicine department. I’m going to talk to you tonight about strategies that you can employ to reduce the risk of injury for walking Hill walking and hiking.

I just thought I’d start by actually looking at the gait cycle initially. It’s always good to have a good understanding of what is happening during the gait cycle and what the demands on our body are for this.

You can see here it’s broken down into a few different phases. The first two phases are really a phase where you’re trying to absorb energy. The heel strike where we made contact with the ground, and then we progress to a flat foot. During this phase, the muscles and tendons in the lower body are really trying to absorb the energy and stop our foot from just slapping hard onto the ground. Once we move into the next phase, which is the mid-stance and push-off phase in the middle here, this is when our muscles and tendons contract to generate some power to actually push us away from the ground and propel ourselves forward into the next step. Then finally, we have the swing phase, which is the final three diagrams here; this is when the leg is off the ground and what we have is the muscles in the hips lifting and bringing the foot into position for the next step. As a series of muscle contractions in different ways that happen time and time again as we walk further longer, and then this changes as we start to walk up and down hills.

Then I thought it would be a good idea to have a look at the anatomy of the foot and ankle in particular but have a look at the muscles and tendons that are responsible for allowing this movement to occur.

Here we have a diagram of the foot and ankle anatomy. We can see it’s a combination of bones which articulate with one another to form joints. Those joints are then held together by ligaments and then you can see the pink and white structures on the diagram; here are muscles and tendons; our muscles and tendons are what allow our joints to move.

Within the foot and ankle, we have quite a lot of muscles and tendons and all of them play a slightly different role during the gait cycle. We might touch on a few key muscles and what they do, and why they’re important.

The first one is the muscle at the front of our shin here called the tibialis anterior this is almost like an endurance muscle. When we hit the ground with our heel, this muscle is working hard to absorb that impact and stop our foot from just slapping onto the floor; with every step we take, this muscle is really working quite hard to control the movement.

On the inside of the ankle, we have a series of muscles and tendons that run into the foot here, called the tip post and the FHL. On the outside of the ankle here, we have almost the opposite called the perennials. These muscles are stability and control muscles; if you imagine you’re walking on an uneven surface, maybe that is sand, maybe you’re walking up and down hills with slightly uneven terrain underneath your feet, these muscles are working hard to contract and control the ankle. If these muscles are struggling to do so, we can often then end up rolling the ankle which is a common hill walking or hiking injury.

Finally then, at the back of the shin, we have our biggest set of muscles, which is the calf muscle group. These are the muscles that work hardest when we’re standing and walking and these are the muscles that are responsible for propelling us forward each step that we take.

When we get to the exercise session later on, I have some sample videos to try and target some of these key muscles because they are responsible for our movement, and they do work very hard when we hill walk or we walk for any sort of prolonged duration.

We mentioned that these muscles have different roles, and we also mentioned that they can work quite hard but I thought it’d be interesting to review and see how hard they actually work because walking is a task that we might take for granted because we do it every single day but when we walk for a prolonged period or when we walk up and down hills it is a taxing task on the lower body. There have been some interesting studies that try to quantify the loads and the demands and the different joints and muscle groups.

The first line you can see here quantified how much work is done at the ankle or how much body weight is absorbed in the ankle during walking on a flat surface, and this study showed that it can be up to five times your body weight every step that you take on a flat surface is exposed to the ankle joint.

If we shift our Focus higher up to the knee, we can see a similar pattern that the knee is responsible for absorbing two to three times an individual’s body weight when walking on a flat surface.

Now when we start to walk uphill or start to walk downhill, those forces can change and the contribution of different joints can change as well. For example, when we’re walking downhill, we place greater demands on our knees and our quadriceps muscles because on our way down a hill, the knees and the quadriceps absorb the force to slow us down and act like a brake system for the body. When we walk uphill, we have less work to do with the knee joint but we have more work to do at the ankle and at the hip joint. It requires more energy to propel ourselves up a hill, and the main movers for this are the calf muscle and the big muscles around the hip, like the glutes and the hamstrings.

Often what we’ll see in the clinic is that people get this balance slightly off. They’ll come in and they’ll have got the load they’re placing on their body a little bit too high, and their physical capacity is maybe not quite able to match that. An example of this might be that the demand they’re placing on their body in terms of walking volume is the same that they’ve always done. However, the ageing process is taking effect, so it’s taking them longer to recover between walks, they’re losing muscle strength and endurance and they’re maybe losing aerobic fitness.

What we might focus on next, then, is what, again, you can do from an exercise standpoint to keep yourself physically prepared for the amount of walking and hiking that you might be doing. We have a series of exercises here. There are six videos in total, and each of them is going to focus on a slightly different joint or a slightly different muscle group but they’re all the muscle groups that we discussed earlier that we know are going to work hard when we’re walking for any prolonged period.

These first two exercises are focused on calf muscle strength. The first exercise on the left here is a seated calf raise; we can see where you’re sitting on maybe a kitchen chair with your foot elevated onto a step or onto a book with a heavy weight on top of your knee; that is a 30-kilo kettlebell on top of Niall’s knee here and what we’re trying to achieve is that the calf muscle is responsible for driving that weight up and down.

On the right-hand side, we have a standing version of that exercise. You can see how this might closely mimic the demands of walking up and downhill. What we want to make sure of is that the calf muscle is primarily responsible for all of the movement here, and we’re minimizing the work done at the knee or higher up at the hip. We’re focusing on slow and controlled movements, making sure that the calf muscle is having to work hard to generate the power.

The second two sets of exercises focus on more of these smaller muscle groups that are responsible for stabilising the ankle and responsible for supporting the bottom of the foot. The first exercise here we have a single-leg balance exercise. This exercise is to try and place a demand on the muscles on either side of the ankle that play an important stability role; we can see here standing on something slightly unstable, this could be, for example, at home a cushion or a pillow, and we’re trying to create a little bit of instability and we’re trying to work the muscles either side of the ankle to maintain a neutral or a flat foot. On the right-hand side, here we have an exercise that’s designed to try and build strength and the muscles along the sole of the foot. We have a band tied around something like a bannister and then tie it around the top of the big toe. All of the weight is then on one leg and it’s up to the muscles along the sole of the foot to generate power to pull the band downwards; after 10 to 12 repetitions of this, we should start to feel muscles along the sole of the foot along the arch become fatigued.

If we were to shift our focus slightly away from the foot and ankle and move up the chain towards the knee, the quadricep muscles, and the hips for the hamstrings and glute muscles, we have two exercises here where you might get a lot of bang for your book. The first exercise is a split squat, so you try and split your feet apart and have an extra bit of weight over the front of your body like a kettlebell or a dumbbell, and what we’re trying to do is almost mimic the demands of walking downhill so we’re trying to go slow and controlled on the way down and make the quad muscle on the front of the leg work hard to control that motion and then we’re demanding that the quad muscles and the hip muscles drive us back up to the top.

The final exercise we have here is a hip thrust so that you can set yourself up with your shoulders on a couch, coffee table or a bench, all of the weight on one leg; what we’re trying to achieve is that the back pocket and the muscles in your backside are responsible for lifting you upwards towards the sky. After 10 to 12 repetitions of this, what we should start to feel is the back-pocket region starting to fatigue.

There we have six exercises which ultimately could be done probably in about 15 to 20 minutes. We’re focusing on the main muscle groups around the foot and ankle, main muscle groups around the knee and main muscle groups around the hip that are responsible for prolonged walking and responsible particularly for any sort of up and downhill walking.

A question we’ll often guess is how often I should do this and how much I should do it is better, and not necessarily the goal of these exercises is to progressively strengthen these muscle groups to help the joints that are working hard during walking. If you do these exercises every single day of week one, you might be eating into your recovery time between your walks and finding that you’re actually quite tired when you start your walks or two, you might be underdosing yourself a little bit, meaning that you’re not making the exercises hard enough to actually see the benefits of it so the way we tend to move now is we recommend that people do it on three days a week basis which could be every second day or every third day. For each exercise there, we’d recommend that you do three sets on the left leg and right leg, and then within each set, we’re looking to complete about eight to twelve repetitions as a guideline. When you reach your last repetition of each set, it’s important that you feel like the muscle that you’re targeting in the exercise is getting to a near-maximal fatigue state, meaning that if you hit your 12th repetition, it should be close to your limit, if you feel like you could go to 20 or 25 repetitions again you might be under-dosing the exercise meaning that it’s not challenging enough for you actually to get stronger. We would focus on three days per week, three sets for each exercise, and make sure the dose of the demand in that exercise is strong enough for you actually to see an improvement.

That is a brief overview of managing your risk of injury for any walking, hiking or hill walking. As you can see from today, it’s a combination of education around managing the demand you’re placing upon your lower body with your training and then making sure you’re meeting the physical capacity for that level of training. If you have any questions, I’m more than happy to answer them now in the Q&A session. If you’re interested in maybe getting assessed or working with a physiotherapist or a strength conditioning coach, the number for the sports medicine department is on the screen there and we are accepting referrals.

 What advice/recommendation would you give in terms of managing ongoing sciatica with walking or hill walking?

Yeah, that’s a good question. My main piece of advice initially, and I’m not sure if Dermot has already explored the sort of diagnostic side of things because sciatica is a term that’s used to refer to pain that stems from a specific nerve root. If he hasn’t had any investigations previously in terms of MRI scans, it could be a useful tool because, based on what’s found on the MRI scan, there could be different treatment options available to him to manage that. For example, if it was found on his MRI scan that there was a disc which was impinging the nerve route, sometimes an injection can be of benefit there to reduce pain and symptoms. The second thing then would be to; probably alludes a little bit to my presentation earlier on at having a look at what he can control in terms of his walking and hill walking level. For example, look at how often he is walking, how far he’s walking and what sort of terrains he’s walking on because those things are going to increase the demand on his body. He may or may not need an extra day or two between walks to be able to recover and then go again, so my main advice for him would try and get to the bottom of what’s causing sciatica in the first place. There might be different treatment options that are available off the back of that once you have a clear diagnosis and a clear cause, and then once you have that clear diagnosis and cause, maybe we look at the training variables in conjunction with a physiotherapy program to continue to manage this long term.

 ACL tear, seen orthopaedic consultant two months post-injury; not going to have surgeries discussed with the consultant as it’s not an unstable ACL but any advice on rehab?

Yeah, I mean, if you’ve already discussed and reviewed with your orthopaedic consultant and agreed that you’re going to go the conservative roof rather than the surgical route, that’s fine. The rehabilitation should largely look the same as the surgical route as well then. It’s something we see quite an awful lot of at SSC Sports Medicine. We have a huge amount of ACL injuries that come through our doors every year, and off the back of that, we’ve been able to develop a system for testing and rehabilitating these injuries, so might be our first protocol is maybe to look into attending SSC for a testing session, the information that comes from that testing session then can really inform what you need to focus on the most in your rehabilitation, and these could be things like improving your range of motion, improving your strength of key muscle groups around the knee and then also the stuff we discussed earlier on around managing the amount of load and training that you’re actually doing to keep the knee comfortable and keep the knee happy as well.

A lot of pain in the ball of my foot. I’m trying physio with lots of stretches of the toes and arches, but after six months still, I still have pain any advice?

Yeah, this is probably a common scenario that a lot of people end up and they come through our doors where they’ve been doing something for months and not really getting any success with it and it sounds like Mary is doing quite a lot of things for it in terms of stretching and different stuff but one thing that may be missing from that is maybe a strengthening component. For example, when we’re standing and when we’re walking, our foot is the first point of contact with the floor and it actually takes on a huge amount of strain and a huge amount of weight bearing and all of the stretchings in the world might not be able to help that it might actually need some strengthening exercises for the key muscles around the foot. The second thing I might say is if it’s pain around the ball of the foot, but again you’re maybe not exactly clear on what’s actually causing that pain, there might be a role here to see either a sports medicine doctor or a physio to help with the diagnosis piece because if you have the diagnosis correct, it helps you to manage or devise a management plan for it.

 Why do I suffer from shin splints when I walk fast?

Shin splints is a kind of umbrella term for pain around the Shins and it can be again a few different things. So, for example, it can be bone stress related, so it can be a bony stress response or even progressing sometimes to a Bone stress fracture; it can also be things that are maybe a tiny bit less sinister, like an overload of the tendon structures that stem from the shins this is often called tibial stress. First of all, again, I might go back to the idea of maybe being assessed by a physio or being assessed by a doctor to come up with a clear diagnosis because when you have that diagnosis correct, you can then decide what needs to be done to manage it. When we walk fast if you can see from my presentation earlier on, whenever we walk fast or whenever we walk up or down hills, the demand on the muscle groups and the tendon groups around the shin can really increase, so there may be a role here for strengthening the key muscles around the kind of lower part of the shin, foot and ankle region as well.

Are we going to upload copies of the leg exercises?

We are going to once this is over today and the whole webinar’s finished. We will have it on our website in the next few days, so you can go in and look at it at any time. Also, one of the tabs there is downloads exercises, so there are some exercises on there as well.

Any management for plantar fasciitis after hiking and how to avoid it?

Yeah, plantar fasciitis is essentially an overload of the plantar fascia where it inserts onto the inside aspect of the heel bone and it can vary a little bit; sometimes it can be an overload and an inflammation of those tissues, and sometimes it can be small micro-tearing that occurs in that region as well. Depending on what’s seen, maybe on diagnostic scans, there is a role for an injection followed by a period of offloading in a walker boot. If there are no tears, usually this is rehabilitated conservatively just through exercise and again, it might come back to trying to progressively strengthen the muscles around the foot and ankle as well as managing the amount of stress and strain all of the strengthening in the world might not help if you’re continuing to overload the structures and not allow them to actually settle down so it’s a little bit like the slide on my presentation today where you’re trying to manage the amount of strain you’re putting on it and you’re trying to maximize the amount of stress that these structures are going to undertake.

 A question from Judy she’s osteoarthritis in both knees and does exercises like lunging. Could she do squats instead? She’d find it difficult doing the lunging, or can you suggest an alternative to lunges?

Yeah, if you have osteoarthritis in any joints strengthening is one of the kinds of key cornerstones to managing that long-term, so it’s good that she’s trying to lunge and thinking about doing these things. Lunging is really an exercise to try and improve the strength of the Quad muscle at the front of your thigh and sometimes as well the glute muscles around your hip, so to an extent, it doesn’t necessarily matter massively what exercise you do as long as you’re able to engage and strengthen that muscle. If she finds, for example, squatting is a more comfortable alternative but allows her to strengthen her quad muscles, then that is a perfectly feasible sort of alternative to the lunge and I would have no issues with that.

I had surgery for a ruptured Achilles tendon in September. Do you have any advice on time scales for getting back into hiking and running, any advice on rehab?

Yeah, this is an area I see an awful lot of because my PhD is actually investigating Achilles tendon ruptures and how people get back to activity and sports following that. In terms of time scales, it can vary from person to person but in terms of getting back to running, I think a six-month time frame is a realistic time frame for most people that might be average and there are some people that are faster and there are some people that are slower than that. What I would put more value in is not necessarily the time that’s passing on the calendar. I put more value on the patient or the patient hitting key criteria that indicate they’re ready to run again, and that might be at four months, that might be at six months, it could be at eight months, but having key markers that indicate you’re actually ready to run again is what’s most important not necessarily the time scale.

How to avoid cramps after walking, or do you have any advice for tight calf muscles?

Yeah, cramps, to an extent, are a little bit unknown as to what causes them and what they really are. Years ago, it used to be tossed and it was dehydration or a lack of potassium and everyone was drinking water and eating bananas, but it really doesn’t make a huge difference; the current thought process around cramps is that it’s actually muscular fatigue so that the muscle cramps when it starts to reach a really fatigued state so if you’re cramping after your hill walk or you’re feeling really tight in your calf muscles after your hill walk it’s probably an indicator that these muscles have just undergone a huge amount of stress and strain and now they’re struggling to recover afterwards. If I were you, I would probably look at two things, one can I prepare my calf muscles a little bit better for my hill walking by doing maybe some exercises, and two, can I do things after my hill walk that makes me recover a little bit better so that might be for example eating, sleeping and drinking well enough to replenish the energy that I’ve lost on the hill walk.

 I have a question about the Achilles here from Brendan. He’s got problems with the Achilles tendon on his left foot. It comes on after a hill walk. It takes quite a long time to heal and remains either steen or sore. It can often reoccur after a few weeks, particularly after a challenging walk. Any other exercises or treatments that you would recommend?

Yeah, what Brendan’s describing sounds quite like an Achilles tendinopathy hard to say without meeting him and going into it, but it sounds like what’s called an Achilles tendinopathy, and this is when the Achilles has a painful response to the amount of strain that has been put upon it, and it usually presents after exercise and sometimes even 24 hours after exercise so the two key things for managing tendinopathy are managing the workload smartly. For example, if you know your tendon is struggling to tolerate a certain volume or intensity of walking, maybe try to reduce that a little bit to keep it happier and the second one then is to try and load the tendon using exercise, and that can be really guided by a physiotherapist.

What’s the best way to handle Morton’s Neuroma?

Morton’s neuroma essentially is an inflammation of a small nerve that runs through the metatarsal bones in the foot. There are conservative treatments which are, again, you can look at things like footwear, so there can be small changes in footwear which can make a big difference, or small inserts into footwear which can make a big difference. You can also use exercise as a way to try and alleviate that pain. There are slightly less conservative options as well where you can have injections and those injections usually are Guided by findings on an MRI scan or findings on an ultrasound, so you’ll probably have to see a sports medicine doctor to go there in that route they often work well in conjunction with one another.

Any kind of features or degree of support in walking or hiking shoes that are best to prevent injury?

Yeah, not necessarily in terms of preventing injury. A lot of research has gone into what type of footwear is best for hikers, walkers, and runners; in terms of preventing injury, no particular brand or no particular type of shoe seems to be the best or at the top of the pile. There are certain shoes that might be better suited to you and that depends on what activity you’re actually doing. It can depend a little bit on your foot shape and your foot type; an example might be if we go back to someone who’s dealing with an Achilles tendon issue. They tend to prefer a shoe that has a slightly higher heel in it compared to a flat shoe because the higher heel takes a little strain off the tendon when they’re walking, so there’s no brand or type necessarily; there might be a certain type that suits you a little bit better or your current injury.

Follow-up question on running after Achilles tendon rupture surgery. You mentioned key markers to indicate progress. Can you give examples of those markers?

Yeah, some of the key markers would relate to, for example, flexibility and mobility; another key marker would be around calf muscles, strength in calf muscles, endurance and then finally, we’d put some value as well in what we call reactive strength which is really almost like a power measure where you’re using the calf and the Achilles a little bit faster and more explosively, and that would paint a picture then that the Achilles and the ankle are ready to tolerate running again rather than kind of I suppose rolling the dice and hoping for the best and that’s something I see personally a lot of in the sports medicine department and we have the testing infrastructure available if he was interested in coming in.

A question from Deirdre she still gets pain six months after losing crutches. She got a screw fixation for her fifth metatarsal, where she had a break. She did physio religiously for three months once losing the crutches at the start. Should she double down and get back to exercise if she’s still in pain? She was in a boot for three months prior to surgery, so it sounds like six months she’s been in the boot and trying to do physio. What would you suggest?

I think those fractures at the base of the fifth metatarsal can be really tricky, so that’s not an uncommon scenario Deirdre finds herself in. The main thing would be guided by her orthopaedic surgeon that they’re satisfied with the healing and they’re satisfied with the actual fixation of the break itself and then definitely when you’ve been in a boot for three months prior to surgery six months in total what happens is the foot becomes sort of used to not having to weight bear a whole lot and so you lose things like muscles strength even the bone strength can be compromised a little bit because it hasn’t had that weight-bearing stimulus so exercise really is your sort of key to getting back to your normal life there in terms of bone health in terms of strength and muscle health as well so I’ve definitely look to start your rehabilitation again if you’ve stopped but maybe be guided by a physio through this process again.

Any tips for recovery after a long hike? I think you did speak about hydration, but anything else, David, before we sign off?

Yeah, I think the big thing when it comes to recovery the main one is sleep. Sleep is where the body really recovers and repairs itself, so make sure you’re getting good quality sleep. Secondly would be your hydration and your nutrition, making sure you’re replenishing the kind of energy that you’ve spent on the hike itself, and then you can look at other sorts of, I suppose we call them adjuncts to help, which might be things like foam rolling, stretching, massage and all these other things but it’s hard to do those things if you’re not sleeping, eating and drinking well enough in the first place.




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