Foot and Ankle Surgical Treatment Update – Mr James Walsh

Watch this video of  Mr James WalshConsultant Orthopaedic Surgeon specialising in the foot and ankle discussing ‘Foot and ankle surgical treatment update.’

This video was recorded as a part of SSC Online Public Information Meeting focusing on the Foot & Ankle.

Mr James Walsh is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic. specialising in the foot and ankle.

Hi my name is James Walsh, I’m a consultant trauma and orthopaedic surgeon working in Beaumont and the National Orthopaedic Hospital in Kappa and I’ve been working in the Sports Surgery Clinic for the last seven or eight years now since 2015. My talk this evening is going to be a bit of a whistle-stop tour around the foot and ankle. We don’t want to get too much into the weeds on this, but just to augment what David’s been saying and hopefully add a few other conditions that we might talk about also. I’m going to talk about common conditions that we might operate on in foot and ankle surgery.

Just to give you an overview, we’re going to start off with ankle instability probably the most common thing that happens in foot and ankle surgery. We’re going to talk about classic sprains high ankle sprains which really refers to a thing called the syndesmosis that is explained in a few minutes. Then we’re going to move to the Achilles tendon and talk about tendinosis or inflammation of the achilles tendon. I’m going to talk about a thing you may not have heard of called the plantaris tendon and how much that causes a significant amount of apparent Achilles problems. I’m going to talk about achilles tendon tears. We’re then going to move to the posterior aspect of the back of the heel which is the source of a lot of pain for a lot of patients and we’re going to talk about that before moving deep into the actual ankle itself to talk about ankle impingement at the front and at the back and then talk about deep ankle degeneration or osteochondral defects. We’re going to talk about plantar fasciitis bunions or hallux valgus and then finish off with just a bit on big toe joint pain and then we’ll summarize our findings and there’ll be time for questions afterward.

So to start off ankle instability we all saw this recently at the French open Alexander Zverev had a severe ankle sprain and actually underwent surgery in Germany about two days ago for this injury. So you can see there’s a pretty extreme version of an ankle sprain but most of us have done this, we’ve all torn our lateral ligaments at some stage in our careers so I suppose the question is who needs treatment for this and what exactly is happening. Well this is a classic inversion injury and conservative management is the mainstay of treatment the vast majority of these people will never present to a surgeon and certainly never need surgery a ligament called the anterior talofibular ligament is the most commonly injured ligament here and that spans from the fibula to the talus and that’s why it’s called the anterior talofibular ligament. There’s other ones such as the calcaneofibular ligament and the posterior telophibular ligament but we don’t really need to worry about those. The anterior ligament is the one that’s most commonly torn and is the one that is most commonly a problem, so what do we need to do with these well in the initial phases the classic rest, ice compression, and elevation works very well for the vast majority of patients that refers to non-steroidal anti-inflammatory drugs so drugs such as diphen, vimovo, archoxia and basic analgesics such as paracetamol works really well I find a combination of oral anti-inflammatories and analgesics and topical anti-inflammatory gels works really well for the majority of patients. In terms of intermediate things in patients that aren’t really settling down acutely, well then physiotherapy is the mainstay of treatment for lateral ligament injuries. You can consider injection therapy if you need to but other adjuncts such as an air cast or brace I find really useful. I prefer these to the soft neoprene braces that you can buy in most pharmacies this brace is available online. It’s also called an Andy Murray brace because if you notice his ankles he wears them when he’s playing tennis and it’s a semi-rigid brace that comes in three different sizes and it’s side specific and it’s really useful to augment physiotherapy it doesn’t replace it of course but it’s a very useful thing to use for patients who have ongoing problems or aren’t getting over the line with physiotherapy.

So in terms of surgery if these modalities don’t work what can I do if a patient is sent to me by a physiotherapist or by their general practitioner, well if the above modalities haven’t worked then we’re going to perform an ankle arthroscopy and that’s where we make two small incisions at the front of the ankle usually under general anaesthesia and look inside the ankle with a camera and see and assess any joint problems if I need to stabilize the ligaments I’ll have to make an incision on the side of the ankle and then I’ll sew suture anchors which are metal anchors with some stitches coming out of them that I can use to stabilize the ligaments or I can use a product called an internal brace which is a much stronger construct and I’ll use that sometimes in patients who have really severe ligament injuries or in certain patients who aren’t suitable for just suture anchors.

So moving to a different part of the ankle this is called a high ankle sprain it’s a slightly different mechanism you can see from the injury we showed you previously when you roll or invert your ankle. You get one type of ligament injury this ligament injury is higher and it’s called a high ankle sprain and it’s between your tibia and your fibula and this is referred to as the syndesmosis which is the joint at the top of the ankle these can be a lot trickier to diagnose and the history is really important. You can see from this picture below there’s a tackle going on here and it’s a dorsiflexion or the ankle going upwards and rotating externally. This is the type of injury that will cause a synthesmatic injury, an x-ray can easily miss this and it’s actually more of a clinical or MRI diagnosis. If you’re in doubt we’ll sometimes have to put a camera in and just check anyway because these much more commonly need surgery than do a lateral ligament repair. What surgery can we do for them? Well, the most common thing again is we put a camera in an arthroscope and have a look inside the ankle and see if there’s any other pathology and then we can use a product called a tightrope which is a simple band with two buttons on it that brings these two bones together and repairs the ligament indirectly and it works really well in the vast majority of patients.

Who needs to see a surgeon if they’ve got a lateral ligament or ankle ligament injury? Well again as I said the vast majority of these patients never need an operation so it’s only for patients with ongoing instability despite non-operative modalities patients often say i just don’t trust my ankle, I’ve had physio for six – eight sessions and I still don’t trust my ankle. Ongoing pain, do they have high ankle pain? This is something that the physios would send to us quite regularly and do they have associated deep ankle pain because that could suggest to you that there’s something more sinister going on and that might prompt either a basic x-ray or indeed an MRI scan so moving to the back of the ankle to look at the Achilles tendon we’re all familiar with the Achilles tendon but it’s actually made up of a number of different muscles your gastrocnemius muscles the pear-shaped muscle of the back of your calf and your soleus muscle which is a bigger thicker muscle beneath that and they form together to form your achilles tendon you can’t talk about the achilles tendon without talking about the posterior chain or the posterior kinetic changes, we often refer to it and that goes from our gluteals, the biggest muscle in our bodies and our backside our gluteal muscles, then our hamstrings, then the gastrocelius complex. As we refer to those muscles as this then becomes the achilles tendon sweeps down the back of your heel to become your plantar fascia, so it’s all connected in one big long chain and we call it the posterior kinetic chain.

Why is that important? Well, it’s implicated in a whole heap of the ankle, hindfoot, midfoot and especially forefoot conditions in the foot macro and it can help us to treat or help to diagnose a lot of problems in these areas so we always think about this when we’re looking at it and especially with the achilles you need to think about this. So, achilles tendinosis or inflammation of the achilles again physiotherapy is the main state of treatment you can use an ultrasound-guided injection as an adjunct. You’ve got to be very careful in this region you don’t want to blindly inject it because you can cause problems with the tendon, this is what a more or less normal or slightly inflamed Achilles tendon looks like and this is what a much thicker or more inflamed Achilles tendon looks like, with these the vast majority of these do not require direct surgery for Achilles tendinosis those that do we often see a small area at the back and it’s on the middle or the inside of your Achilles tendon if you have Achilles tendinosis and you’ve got pain in your Achilles, if you palpate the middle side of your Achilles tendon this might be the most painful area and if this is the case it can often be this tendon called your plantaris tendon which is what we call an accessory tendon, it doesn’t really have any function you know so we’ve kind of evolved out of it essentially, it’s a very small and rather insignificant piece of anatomy but it causes a lot of irritation and if this doesn’t settle we can inject the area with a high volume of local anesthetic or we can debride it as a day case procedure and in patients with achilles tendinosis in this region this surgery works extremely well.

Moving to Achilles tendon tears, something a lot of patients with Achilles tendinosis are terrified they will get but actually only about three percent of people will rupture an Achilles tendinosis tendon. This usually presents as a sudden pain in the Achilles and despite popular belief that this is because you didn’t warm up it actually usually occurs right relatively late in the activity and rarely at the start of the activity. This needs urgent assessment if you think you’ve ruptured your Achilles tendon you shouldn’t wait around on this, if in doubt if you’re not sure it needs urgent soft tissue imaging the mistake to make here if you’ve had a sudden sharp pain at the back of your Achilles usually during activity don’t get an x-ray, an x-ray isn’t going to help you here an ultrasound or an MRI scan is the diagnostic imaging of choice but an experienced clinician being a physiotherapist primary care practitioner or an emergency department doctor should be able to diagnose this quite easily without any imaging.

So what can we do with these? Well, we can manage them non-operatively provided you catch them early and that’s why it’s important to catch these early, if you do catch them early you have the choice of non-operative versus operative modalities and open surgical repair can be considered. Why do we do this if we can manage them non-operatively? Well, they’ve similar results in the long term but you’ve got a faster return to activity and a lower chance of re-rupture if you repair it surgically, that’s a very safe and reliable procedure. If you don’t treat this or you don’t realize that you’ve had an Achilles tendon rupture, because no one wants to rupture their tendons, so we’ll often pretend to ourselves that we’ve had a sprain.

What can we do for these? Well, they’re usually seen late on about three months, usually in a more elderly population. What we do is, we lay the patient down in the bed we take a look at the back of the patient that you can see here and on the left hand side you can see a chronic tear and on the right hand side we have a nice healthy looking Achilles tendon. We can still manage some of these non-operatively but the majority of these would be offered operative modalities provided they have nothing else. That means we can’t operate on them actually what we do with these tears you can see this chronic thickened area in the Achilles tendon on the left we take the tendon from your big toe called your flexor hallucis longus and we re-root it through the back of your heel and this works really well for these patients but it isn’t quite as good as your Achilles tendon as you would imagine. What do we do to rehabilitate these well doesn’t matter which way whether you treat them non-operatively or operatively you need to match them with early active range of motion and we start this at two weeks and progressively decrease your heel raises over the next few weeks but generally patients will wear some form of heel raise for about three months after surgery moving to the back of the heel posterior. Heel pain is another thing that’s commonly sent to physiotherapists and even orthopaedic surgeons at an early stage, what’s going on here, well it’s either the Achilles tendon as we’ve seen previously as it inserts into the calcaneus, your heel

bone or it’s a little bursa which is a fluid-filled sac behind your heel and it’s either in front of the Achilles which it’s called a retro calcaneal bursa or it’s a subcutaneous bursa as you can see in this case this photograph on the left-hand side. These can be treated with rest anti-inflammatories some physiotherapy and injections under image guidance but sometimes it’s caused by a body problem and this is called a Haglund’s deformity. You can see this rose torn a pin appearance of the headlines at the back of the heel and you can see this essentially eroding into the back of the Achilles tendon this causes a lot of pain and a lot of difficulties, typically these patients won’t respond well to physiotherapy and when they do get to see us they’re really in quite a lot of chronic pain.

The treatment for this is primarily surgical, what you do is you actually lift the Achilles tendon off the back of the heel, again under general anaesthesia, reconstruct it and shave the bone away that’s impinging at the back of the heel and then we reconstruct it using a thing called an Achilles speed bridge which is a really strong product and works really well and has changed radically changed our management of these conditions. It is a bigger injury than an Achilles tendon irritation and it needs a longer time to rehabilitate this will take you at least six months to settle down. When do I need to see a surgeon with regard to my Achilles? Well if you’ve got long-term irritation physiotherapy hasn’t worked here chronic limitation of activity in terms of normal domestic tasks or recreation or indeed work tasks, if you think you have an acute Achilles tendon rupture don’t delay go to an emergency department, if you think you’ve got your Achilles of course if you can see your primary care practitioner or you’ve got a relationship with a physiotherapist it’s very reasonable to see them provided they can act on it quickly and either send you to get imaging or send you to an emergency department if required.

So moving deeper into the ankle to look at ankle pain we’re going to talk about anterior and posterior impingement pain is anterior at the front of your ankle and you’ll have decreased dorsiflexion meaning you’ve decreased the ability to move your ankle up, you won’t complain of deep pain unless there’s a coexistent deep degenerative injury and we’re going to talk about those in a minute and the treatment for this is primarily a camera an arthroscopy and we resect these but sometimes we have to perform an open resection of these injuries or these problems. Moving to the back, well there are loads of causes for this you might have heard of things called an ostrigonum or a state process and essentially these are just

bony outgrowths at the back of the ankle joint an MRI scan is very useful as is a clinical examination and the treatment of these depends on the underlying cause and again in the majority of cases we can treat these non-operatively with injection therapy and physiotherapy depending on what’s going on what’s causing the problem moving deep into the ankle joint.

We’re going to talk about osteochondral defects just very briefly the talus or the talar bone forms the bottom part of the ankle that lives beneath the tibia and an osteochondral defect of this is a defect in bone or osteo and cartilage chondral again these are commonly caused by inversion sprains people going over in the ankle you get what’s called a kissing lesion where one bit of bone bangs off another bone and it damages and erodes the cartilage. Patients will complain of deep pain particularly pain after activity and it’s typically on the middle side or medial side of the ankle. It’s often as I said associated with an inversion sprain and a history of a lateral ligament injury and classically these are patients who really just don’t settle down with physio and have ongoing deep ankle pain.

So again initially with these, we immobilize patients and give them non-steroidal and analgesia. We can try an image guided injection and if those modalities don’t work, then we can go in and have a look with the camera and you can see here our tibia normal tailless you can see this little rim here that’s an osteochondral defect so when we resect this we take away the cartilage we actually put holes into the bone here and that stimulates cartilage to regrow not quite as good as your original cartilage of course but it does settle down a very significant number of patients. These are quite tricky things to treat them.

So when do I see a surgeon if I’ve got deep ankle pain or decreased range of motion? Well ongoing limitation of movement despite physio analgesia and ongoing deep ankle pain that suggests you might have arthritis or an osteochondral defect moving further south. We’re going to talk briefly about plantar fasciitis now extremely common and nobody gets any credit for this it is extremely debilitating as anyone who has this will tell you and it’s often under-treated. Classically patients get early morning pain or they get pain in their heel following prolonged sitting or driving

and when they initiate activity and get up from a seated position whether they’re driving or sitting at their desk. It often eases a little bit with activity while you get up in the morning and brush your teeth and settles down but then it comes back later, particularly during prolonged exercise and that’s because of the inflammation in the plantar fascia. I see this as a symptom of a bigger problem and typically the big problem here is the posterior kinetic chain as we talked about earlier its tightness all the way up and this is the weakest link in the chain causing pain. Often we’ll get referrals for heel spurs on x-ray and it’s really important to note that these bear absolutely no relationship to the presence or indeed the absence of plantar fasciitis.

So what can we do to treat these? Stretch the posterior kinetic chain, that’s the underlying problem that’s causing this emphasizing the calf muscles that we talked about earlier. A simple heel raise will work really well and off an off-the-shelf one you can buy in boots for five euro custom orthotics are really rarely indicated for this, oral non-steroidal anti-inflammatory drugs, you can try ibuprofen over-the-counter or you could get prescribed dark coccia or vimovo or even diphene, massaging the plantar fascia with your big toe extended works really well and I find the easiest way to do this is to actually cross one leg over the other and use your hand to massage a tennis ball or golf ball into the area that’s painful and extending your big toe tightens this and makes it a bit easier to do injections.

We’re commonly referred patients to see can they get injections and I always say well have you tried all these other modalities before we think of that because the vast majority of these patients will settle down with non-interventional modalities. PRP has been trialed extensively for this and there’s very weak evidence to support this and I don’t typically use this in the vast majority of my patients because simply put it hasn’t been shown to be any better than injection therapy and indeed non-operative modalities shock wave therapy will sometimes be used by your physiotherapy for this and has some evidence when used for about three sessions.

So when do you see a surgeon if you’ve got plantar fasciitis? Well surgery is almost never required for this condition this is an entity that should be treated by physiotherapists or sports medicine practitioners with non-steroidal anti-inflammatory drugs a simple heel raise to just settle symptoms down. While you’re engaging with physio an injection therapy should only be considered as an adjunct, it’s not a primary therapy and equally custom-made orthotics are almost never required for plantar fasciitis and they won’t solve it if you haven’t solved the underlying architectural problem and that’s primarily physiotherapy and stretching.

So moving on to the front of the foot, we don’t have time today unfortunately to talk about the various conditions in the midfoot, I’m going to talk briefly about hallux valgus from bunions. So what is it? Well, it’s an angular deformity of the first metatarsal phalangeal joint that’s your big toe joint at 90 of these are female, at the time of surgery you can see this is a nice significant bunion, the mean age of surgery is 60 but this is getting lower all the time and many people start young and progress. Most people will have bilateral or both sided bunions but with differing magnitudes.

So how do you manage these? Well you can either operate on the shoe to fit the foot by getting a wider shoe or the foot to fit the shoe and usually, it’s a combination of both things. So who gets non-operative management in these well people with a mild deformity mild symptoms normal footwear obviously this isn’t normal footwear so within reason patients who don’t want surgery or they can’t have surgery. We can use spacers in these kind of patients, some patients will come to us with a corrective bunion or bunion directors excuse me, that they’ve used and bought online, please don’t buy these they do not work.

When do I see a surgeon for hallux valgus or bunions? Well if you’ve got pain difficulties with normal shoes this isn’t an operation to allow you to wear 10 stilettos to go to Tesco nor is it reasonable to be going to a wedding wearing Birkenstocks. We’re looking for a patient with reasonable expectations who’s having reasonable problems in normal footwear. Second toe problems, often second toe or hammer toe, the problem is caused by the bunion and the hammer toe is really a secondary symptom of this but it can be seriously debilitating transfer metatarsalgia. Well what is that? That’s pain over your lesser metatarsal heads or overload and you can see there’s a thick velocity at the bottom of this patient’s second foot but the problem here has actually been primarily caused by the bunion and that’s what needs to be treated along with the second toe. Should you get this operation done because you don’t like the appearance of your bunion? The answer to that is categorically not don’t get this done for cosmetics.

So in terms of operative management, well the typical surgery before this is called a scarf osteotomy which is an open osteotomy and it works for most bunions. It’s very stable and strong gives a very powerful correction and you can wear a shoe for six weeks and note that swelling can take at least three to four months to settle down but it’s got a very high satisfaction which the crucial thing about bunions. Before we move on to big joint pain is that while they’re progressive they’re very slow in doing so and not everyone progresses past a certain point so if you’re not bothered and you’re wearing normal footwear to do normal things you do not need your bunion corrected.

So in terms of our final topic, we’re going to talk about big toe joint pain or first metatarsal phalangeal joint pain it’s also called hallux limit us or hallux rigid because we like making latin sounding names in medicine. The vast majority of these are treated conservatively using anti-inflammatories rest modifying your footwear. Orthotics can be of benefit but in very limited circumstances and you can see there the picture here there’s a big bony spur on the top of this toe with a big inflamed toe and this is painful particularly when anybody dorsiflexes or lifts up their big toe.

So what do I recommend in terms of running shoes for forefoot problems? I really like Asic’s glide rods, they’ve got a very nice curved forefoot but your foot actually sits quite straight in these and I find they work really well for patients who like walking or even like jogging and work really well for these because they allow you to move forward without actually raising your big toe up. Hoka runners or Brooks runners are also good but in any running shoe you’re looking for, you need to look for a good solid heel counter, a supportive midfoot and then I like these curved forefoot running shoes, they work very well.

So when should you consider surgery? Well, when non-operative modalities fail achilectomy is the surgery that we would typically use for these and what we do is make an open incision under general anaesthesia of the joint and we take away the impinging bone and soft tissue as you can see in the middle picture and then the lowest picture shows the improved range of motion in the joint. Again, it’s a day case procedure and four to six weeks in a post-operative issue depending on what we see inside there and about 10 to 12 weeks depending on what’s being done and what other problems are on their inside in the joint. Are there replacement options? Yes there are but unfortunately they haven’t been the panacea that we’ve thought they would be, you can get half a replacement put in a joint toe spacer in the middle or even a total joint replacement option and while we’ve tried and looked at these they work in limited numbers of patients and surprisingly enough the most effective treatment for big toe joint arthritis, when it gets too severe, end-stage arthritis is actually this a fusion most patients are horrified of the idea of getting effusion until they actually get it and it works really well in about 94 or 95 percent of patients. You stiffen the joint with a plate and screws and it’s been the gold standard for a very long time at this point it’s very reliable allows patients to wear normal footwear and a heel of about one and a half inches but the toe doesn’t move again and that’s important to note however it’s a really effective operation.

When do I see a surgeon if I’ve got pain in my big toe? Well if you’re having problems with normal footwear and as I said this isn’t an operation to wear very high heels but it’s not unreasonable to want to walk into somewhere like Arnott’s a big department store and say I’d like to buy a nice normal pair of shoes reasonable behaviour for reasonable feet if non-operative modalities fail and if they’re affecting your everyday work or recreational activities.

So, in summary, there are loads of different pathologies around the foot and ankle joints that’s why we like being foot and ankle surgeons it requires a multi-disciplinary approach and predominantly one of physiotherapy intermittent use of orthotics and podiatrist’s new strategies and surgery work really well in conjunction with non-operative modalities and when non-operative interventions are unsuccessful there are multiple operations available in the achilles the ankle joint the ankle ligaments the hind foot and indeed the forefoot and the high patient satisfaction.

There are loads of options for that including non-surgical ones like orthotics injections and some physio to strengthen up the area as well that’s usually our first protocol for those type of things. So it may not actually be time for surgery and in terms of getting checked out it’s very reasonable if you’ve got a lot of foot pain and if you’re up to the point where you’re taking opioids to ratchet your mid foot pain and I think that’s time to get checked out and trying to at least get weaker and views of your foot and ankle and maybe even MRI of the foot and that’d be something to consider getting referred on by your GP.

We don’t take direct referrals in the sports surgery clinic from patients we do take them from physiotherapists and podiatrists and from GP’s but if you’re having ongoing pain that’s to the point where you’re taking opioids, I think you’d be working to chat to your GP and say listen this really isn’t working for me in terms of non-operative modalities are non you know further investigation modalities and I’d like to be referred to somebody to see about getting a scan or maybe the GP could get a scan and further investigate it and I think I would at least be looking at getting some physiotherapy getting the physio to assess your mid foot and see where you’re at with that because really in terms of long-term opioids I’d certainly agree with that I don’t think they’re a solution for anybody’s foot pain in the long term.

It all depends on how you’re getting it done and some people do these arthroscopically I do an open procedure because I think it gives a better fusion rate and it’s a stronger construct with large platen screws at the front of the ankle, so the ankle will be fused with a plate running down the front here like this and then screws go directly across the ankle like that.

My patients and I and they’re two other foot ankle surgeons here in SSC I think we probably all are quite similar with our post-op plans. My patients are non-weight-bearing for, the first six weeks but you can rest your foot in the ground to balance then after that for the next four to six weeks, your weight bearing is tolerated in a boot, you can expect swelling for about four to six months depending on how the ankle goes and it takes about a year for it to fully settle down.

It’s important to note when you’re getting an ankle fusion this is a big operation in a small place, it takes about twice as long to do an ankle fusion as it does to do a hip replacement so it’s a much bigger operation in terms of recovery. Pretty much anyone you go to I would imagine would keep you non-weight-bearing for six weeks post-op.

It’s absolutely not a given and the most commonly injured ligament in the entire body is called your anterior tail fiber dimension, that’s on the outside of your ankle near the skinny bone on the side of your ankle and if you’ve had that reconstructed and there’s no damage to the dome of the tails, here this is your tailless bone, here the ligament in the side of your ankle is running along here called your anterior talofibular ligament that’s the one that’s most likely torn and the one that’s most likely been prepared for you.

If you don’t have any degeneration inside the ankle joint you’re not at any increased risk of getting arthritis in that joint. If you did have degeneration in that at the time of the injury and maybe it needed to be fixed at the time with an arthroscopic procedure then yes you do have an increased chance of arthritis in the future but just for an isolated ankle ligament no there’s no increased risk of degeneration once it’s been stabilized and successfully stabilized.

There are a number of options it really depends on what your activity levels are and what you’re doing on a day-to-day basis could even depend on whether you’re working in an office or you’re going up and down a ladder and standing around all day wearing work beats and the first thing you do non-operative modalities will include injections anti-inflammatories and supported braces and these can go up from just a simple supportive brace to custom-made boots and custom-made footwear.

Moving to the surgical side of things, it really depends on if all the cartilage is gone. Well then they’re down to two options, you either fuse it or you replace it. So there’s two schools of thought on this replacement is the future, I don’t personally think that it’s as good as I would like it to be yet, so I don’t currently offer ankle replacements but I’m hoping to do so within the next couple of years and when better replacement options come out, the long-term results for me just aren’t quite there yet they’re almost there but they’re just not quite there. For the vast majority of my patients, so if I have somebody who is very keen on looking for an ankle replacement I’ll refer them to one of my colleagues, but in terms of my practice where I see patients with severe agile arthritis I would generally offer them a fusion now obviously that depends on age activity and so on as well.

That’s a fantastic result 20 years after severe injuries like that, I’m amazed that you can run. In terms of the injured joints fusing without a triple arthrodesis, they’re very unlikely to fuse spontaneously at this point and we don’t really see that much in post-traumatic patients. We see it sometimes in inflammatory arthritis conditions like rheumatoid arthritis and psoriatic arthritis, patients will spontaneously fuse and over time we can really solve their problems themselves effectively.

In terms of infusing by itself, at this stage, it’s almost guaranteed not to fuse by itself and I got to say it’s very impressive that you’re running and walking and doing this level of activity without any surgical intervention, at this point it’s unlikely to fuse at this stage without any surgery you know.

Well for me plantar fasciitis is a clinical diagnosis it’s very easy to diagnose. Clinically you just press on the bottom of the foot, if you look at the bottom of the foot underneath the arch of your foot, you go on the middle side where your big toe is, if you lift up your big toe you’ll feel a band running along underneath your foot just around about here, everyone thinks it’s a tendon but it’s not it’s your plantar fascia.

Your plantar fascia is just a thick bit of tissue that binds up all of your muscles we have and we have fascia in all of our muscles in our body and for obvious reasons, it’s thickest in your feet and in your hands because that’s where we put our hands and our feet on things.

So if you feel the band here and you work your way back towards the heel and just as you join up to the heel that’s typically where you’ll get the majority of your plantar fascia, it’s called your medial plantar bound and it’s really a clinical diagnosis. We use an MRI to see what it isn’t, we’re trying to see is it something else like a rarer cause of pain around that region, like a stress response in the calcaneus or rare conditional carceral tunnel syndrome and x-rays aren’t really any good for plantar fasciitis, they’re a very good broad view of what’s going on in the footbank give you a good idea of the architecture and I’d always stress when I’m talking to people who are getting an x-ray make sure it’s a weight-bearing x-ray. You need to know what the foot’s doing when you’re standing on it people often get referred to us with a plantar calcaneal spur which is just a little bump just there and the presence are the absence of a calcaneous burn on the bottom of your foot, there’s no resemblance to the presence or absence of plantar fasciitis and it is essentially a useless point.

I have no interest in whether or not somebody has a plantar calcaneal spur because it doesn’t make any difference as to whether or not they have plantar fasciitis. So in summary this is really a clinical diagnosis for me and I think an x-ray is a very useful, a weight-bearing x-ray is a useful way to see if there is anything else globally going on in the foot and if you’re really not sure that’s plantar fasciitis an MRI is a useful way to confirm your diagnosis or to tell you that it isn’t something else.

Nerve pain under the heel bone stabbing like electric shock sounds much more like plantar fasciitis there are rarely those baxter’s nerves, rare nerves you get rare neuropathies around the heel and you can get in you can get nerve pain true nerve pain in the heel much more likely it is plantar fasciitis as I said briefly answering the last question and you can get a thing called tarsal tunnel syndrome that can give you pain around the heel but by far the most common cause of pain in this region is plantar fasciitis and the other thing would be that you can get a stress response or stress fracture even with the calcaneus that gives you that severe sharp pain.

Plantar fasciitis it’s really important that it gets no credit, this drives people absolutely insanely, it’s extremely debilitating and the problem with it is if you’re sitting behind a desk for hours all day you get up out of your desk with plantar fasciitis you’re living but if someone sees you 15 minutes later in Tesco you look like a fraud because you’re walking around without a problem because plantar fasciitis settles down very quickly after you get moving and then as you move for longer during the day as anyone with plantar fasciitis will tell you their pain becomes more prominent as your inflammation rises later on and say an hour of walking. Around the heel, it’s much more likely to be plantar fasciitis, if you think it’s nerve pain it would need to be diagnosed by somebody and usually, that would be diagnosed by a thing called a nerve conduction study and which would be rare that would be in the heel.

Yeah absolutely metatarsalgia is something we treat quite commonly, so by metatarsalgia these are these bones here are metatarsals and the bones at the bottom of the feet is really where you get metatarsalgia. So you’ve got bones underneath your big toe, you’ve actually got two small bones here called sesamoids we won’t get into that that’s a little bit more complicated but the most common place you get metatarsalgia is in your lesser metatarsal heads and the most common place you get it is in your second and third and what this is typically actually caused by and you saw in my talk, posterior kinetic chain tightness again if you think of your foot here and you think your gluteal is way up at the top of your backside if they’re tight your hamstrings are tight the muscles in your calf are tight and then this causes a pull on the heel and that drives the foot into the floor.

Now there are some other conditions you can have with the shape of your foot that can lead you to have metatarsalgia but that’s the most common cause of tightness and that can be alleviated by physiotherapy. One of the other things that can be done for metatarsalgia is to get a metatarsal pad or bar and this should be fitted by a physio, it doesn’t need a custom-made orthotic, almost never needs a custom-made orthotic, you can get one done but you should start with non-custom orthotics because a lot of the time you just get a simple basic off-the-shelf orthotic and add a little pad and the crucial thing for it is not to put the pad where the pain is. That’s the most common mistake that we all make because it’s sore but actually if you think about it you just focus the pressure on the area that was under pressure.

So what you should do is move the pad behind okay so that’s your physio to stretch that out the posterior kinetic chain to offload it with a pad, if it’s very painful you should get a plain film x-ray to see if there is any arthritis or anything in that and you can check as well because another thing that can give you pain in this is a thing called a Morton’s neuroma and that’s most commonly operating between the third and fourth toes and it gives you kind of burning stinging pain and it can also be described as a known pain which you know sounds quite counter-intuitive but the reason you’ve got that is because you’ve got damage to a nerve there, so the information going back to your head is garbled, so you get this horrible sensation of I’ve got this burning pain but it’s there but it’s not there and it’s really hurting in the bottom of my foot but when I go to press on it it’s kind of not there and that’s actually a great explanation of nerve pain.

So metatarsalgia can be caused by pressure or it can be caused by nerve or degeneration in the area there. So what I would do is if you’ve got metatarsalgia, my first protocol would be to see a physio and see what can be done from that point of view, if that’s not working the next step would be to get a plane film x-ray and maybe go see somebody from a foot manipur point of view and you may need an MRI scan.

Prior to getting anything done but there are lots of surgical treatments that can be done for that such as shortening the bones and ejecting them. From a non-operative point of view and even if it’s very arthritic you can replace the lesser metatarsalgial joints and they’re very reliable because they don’t take a lot of load through them and replacements work really well if you have to do that in that region. So there’s lots of treatments both non-operative and operative for metatarsology.

To book an appointment with Mr James Walsh please email or call +353 1 5543638

Rehabilitation of Common Ankle Injuries – David McCrea

Watch this video of David McCrea, Senior MSK Physiotherapist discussing ‘Rehabilitation of common ankle injuries’.

This video was recorded as a part of SSC Online Public Information Meeting focusing on the Foot & Ankle.

David McCrea is a Senior MSK Physiotherapist at SSC Sports Medicine.

Good evening everyone, my name is David McCrea, I am one of the Senior Physiotherapists at the Sports Surgery Clinic specialising in foot and ankle rehabilitation. I am going to talk to you tonight about the rehabilitation of some of the more common ankle injuries that we see here at SSC.

Our first discussion point tonight is going to be on lateral ankle sprains and another condition called chronic ankle instability which is really a by-product of multiple lateral ankle sprains. I taught a good point to start with would be to review the anatomy of the lateral ankle complex. What we can see here is that on the outside of the ankle joint we have a series of ligaments which bridge the gap between the lower part of the shin bone to the upper part of the foot, so mainly we have 3 main ligamentous structures, one called the ATFL at the front here, one called the CFL at the side and one called the PTFL at the back and these ligaments are thick collagen based structures and what they do is they provide the outside of our ankle joint with a lot of structural integrity and stability, so how we injure there ligaments is classically referred to as a rolling or twisting of the ankle so what we can see in this picture here is we have what’s known as inversion which is essentially when the foot rotates inwards on itself kind of following the line of this blue arrow here, we have what’s called plantar flexion is when the toes are pointed downwards and then crucially what we have is wearing bearing and speed so its very uncommon for someone to tear these ligamentous structures without a high speed or high velocity movement and also rare for them to do the same without them being in a weight bearing position because then these thick ligament structures won’t be stressed enough to the point where they’ll sprain or tear.

Ankle sprains, how common are they? We can see across various different sports if we take GAA, rugby, hockey, and soccer as some of our more common field-based sports, lateral ankle sprains are consistently cited as the most common injury in these sports so they are a big issue for athletes. Secondly then what we can see is that lateral ankle sprains account for about 50% of all sporting ankle injuries, they also account for 85 of all ankle ligament sprains, so if you have a sporting ankle injury there’s a good chance it is going to be an injury to the lateral ankle and then if you have a ligament sprain it’s a very high chance that it’s going to involve some of these ankle ligaments that we discussed there on the previous slide and then finally what we can see is probably one of the biggest issues for athletes and for doctors and physios trying to manage these injuries is that lateral ankle sprains have the highest reoccurrence rate of any lower limb injury so unfortunately if you have one ankle sprain there is a higher likelihood that you then might have a second or a third ankle sprain and this thing can have repercussions for your sporting career but then also for you later in life. It is very rarely just a sprain, this is a common phrase regarding these injuries.

This is a big question for a lot of people following an incident where they roll their ankle or twist their ankle, should I get an x-ray or do I need an x-ray? As physios and doctors, we will use a set of rules to determine who needs an x-ray and who doesn’t and they are really quite a sensitive set of rules meaning that they are very good at picking up someone who actually might have a fracture associated with their sprain so we can see here that if someone is presenting with bony tenderness so meaning that there are painful to palpate along the outside of the ankle or the inside of the ankle. If they’re painful to palpate along the outside of their fifth toe or painful to palpate in this zone here a bone called navicular that there’s a high likelihood they will need an x-ray to rule out a fracture.

A lateral ankle sprain will often have a few key or distinct symptoms. So first of all you can see am image here on the left, where we can see sort of a diffuse swelling and a diffuse bruising which might track up into the outside of the shin which covers a large portion of the outside of the ankle and then even into the heel bone or the forefoot here. They’ll have a loss of ankle function so that might be an inability to put weight properly on their foot it might be a restricted range of motion and it might be a loss of strength chronic ankle instability then is really a by-product of recurring ankle sprains so this patient will describe multiple ankle sprains may be over a fairly short period of time, they’ll have a feeling of ankle joint instability and they may have episodes of giving way at the ankle joints and this is a condition that again is associated with an increased rate of post-traumatic arthritis so it needs to be taken seriously and needs to be rehabilitated.

Secondly, then we’ll touch on ankle joint osteoarthritis, so the ankle joint in terms of the bones that comprise the joint, we can see here is the tibia and the fibula where it meets a bone called the talus. This bone here the talus and the bottom portion of the tibia is lined with a cartilage structure and this joint space is filled with a fluid called synovial fluid which is almost like a lubricant within the joint.

Now following maybe a first-time ankle sprain or following repeated ankle sprains, what we can see here is that the joint starts to almost dry out so we lose some of that natural fluid and lubricant within the joint, we get a wearing of the cartilage and we get some bony growth on the edge of the joint.

How does ankle joint arthritis occur? Firstly during an ankle sprain, whether that’s a first-time sprain or recurring sprain we get a degradation of the ankle joint surfaces, so we can actually get damage to those cartilage surfaces during the incident or during the spring itself. Secondly then if we have multiple sprains we can get an ongoing instability within the joint which can lead to different bio mechanical loading which can then start to lead to cartilage degeneration. If we get cartilage degeneration and if we get a loss of fluid within the joint then we’ll get a narrowing of the joint space and we can start to get impairments out of our ankle function.

A few key symptoms that will be present in someone suffering from ankle joint osteoarthritis, so they’ll usually have a gradual onset of joint pain they might not be able to recall an incident where they’ve hurt themselves recently it might be something where they have a history of recurring ankle injuries. They will usually present with stiffness either early in the morning or after a period of that inactivity so for example they might explain a stiffness following a period of sitting down or first thing in the morning after getting up out of the bed but the stiffness will often dissolve within 30 minutes as they get moving and as they get exercising but there’s also a limit as well so if they exercise or if they weight bare for too long they might describe a progression of their symptoms as well. Across all of these conditions what common deficits exist? So from the first time spraying to the recurring sprain to the year’s later osteoarthritis what common impairments do we see in these patients? So first of all we’ll see restrictions in joint range of motion, particularly a motion called dorsiflexion which essentially is a closing of the ankle joint or the closing of the hinge joint which we’ll demonstrate later on. Secondly, we’ll see impairments of ankle joint strength so we’ll lose muscle strength in a few key muscles around the joint and finally we’ll have impairments in static and dynamic control so these ligamentous structures on the outside of the ankle play a key role in the stability of the joint and stability of the leg as a whole if we damage those ligaments either first time or reoccurring, we can start to see impairments in that control. So when it comes to rehabilitation really what we’re trying to do with any of these patients is restore normal ankle function. This might depend on the activity that person wants to return to, so for example the demands of someone who wants to maybe just walk with the dog a couple of times a week versus someone who wants to get back to playing rugby or Gaelic football will be quite different. However, if we look at the physical attributes of how a normal ankle functions the focus of our rehabilitation is really to try and restore that.

Firstly we talk about deficits or loss of range of motion as we mentioned dorsiflexion in particular, earlier on which is the ability to kind of close or hinge the ankle joint it’s a crucial motion for us walking jumping, and running, so I have a couple of exercise examples here of ways to improve that. So on the left-hand side we have a colleague of mine lying on the bed with his foot elevated nice and high now this can really help anybody who’s suffering from swelling for example because the elevation and the movement will allow for a little bit of drainage of the swelling. Now in this position, we can work on our range of motion, so you can see here that we’re working on full hinging backward and forwards as well as full circles left and right. In the second video, we’re using a tail for a simple joint stretch so we’re pulling the toes back towards our face and using the tail for a little bit of over pressure pointing the foot as far away as we can. Finally the knee-to-wall test, here is a test we can use to actually measure the performance or the range of motion of that ankle, it’s also an exercise we can use to try and improve the performance of range of motion of that ankle. We can see here the foot is flat on the ground we’re trying to drive the knee towards the wall without letting the heel lift up, encouraging this ankle joint to hinge as much as we can get it. A way of measuring your performance is measuring the distance between your toe and the wall to see how much the ankle can hinge, if we then shift our focus to restoring strength to the ankle. We have a couple of simple progressions here of a calf raise exercise, so the calf is one of the most powerful muscles around the ankle and really crucial for us when we when we’re walking, when we’re jumping and when we’re running. On the left we have a calf raise hold, so Niall is pressing up on two feet transitioning over onto one foot and holding, so the calf muscle is doing the majority of the work here however Niall’s working hard to maintain a neutral heel position, so as his heel goes straight up and straight down he’s fighting hard to not let that heel wander left and right and by doing so he’s working some of the smaller muscles either side of the ankle to stabilize that ankle position. Finally, then we have a single leg heel raise but this time with extra weight, so there’s a 10-kilo dumbbell there to make this harder and demand more from the calf muscle and demand more from those stabilizing muscles on either side. Similarly, then we want to work the calf muscle but in slightly different ways, the calf muscle is comprised of two main

muscle groups the gastroc which is the first set of exercises, and now the soleus which is a deeper-lying calf muscle that is going to be worked harder in these set of exercises. We’ll use a seated calf raise to try and strengthen the soleus. So Niall here has a heavy kettle bell resting on his knee, he’s then pressing his ankle up and trying to hold for a few seconds, the second video here he’s working a little bit more dynamically pressing that heavy weight up towards the sky and trying to slowly lower down. Then finally we’re using what’s called a smith machine to try and add even extra weight, so a lot of gyms have smith machines available to them this is a great way to load the calf muscle even more as it allows the barbell to take on the weight. We’ve discussed then restoring the ankle range of motion, we’ve also discussed restoring some strength to the ankle and we also mentioned earlier on that following a first-time ankle sprain or recurring ankle sprains that there’s a loss of control at the ankle because of the important role that these ligaments play in our control. So to restore landing control, one of the more common ways of damaging your ligaments is by landing during a sporting task so on the left-hand side we’re practicing some drop landings on two feet and on one foot. We’re standing up nice and tall it’s like someone is pulling the rope from underneath us we’re trying to drop down and stick the landing. What’s really important here is that we’re not in a rush to stand straight back up, that we actually want the ankle to work hard to stabilize us at the bottom position. Secondly, then we can add a little bit more height to this exercise, so we can drop off a box in the gym or we can box off jump off a first or second step on our stairs. Again we can do this on two feet or on one foot, what’s important again is that we don’t immediately stand up and jump out of this exercise we actually train the control element which is staying down in that position and then finally starting to work in different directions, so the lateral ligaments are going to be most stressed moving in side to side and multi-directional motions so we can do the same thing coming off a small box in the gym or coming off a first or second step in our stairs and trying to stick the landing like that.

Now these set of exercises are maybe more useful for someone who’s looking to get back to running or looking to get back to a field-based sport and these are targeting a quality known as reactive strength, it really refers to our explosiveness or our spring-like ability so our ability to absorb our body weight and naturally spring ourselves back out which is what we do all the time when we run and when we jump or we twist and turn playing a match. On the left-hand side we’re looking at an exercise we call ankling, which is staying nice and tall and trying to bounce from left foot to right foot while maintaining a nice stiff ankle. On the right-hand side is the same thing but a little bit more dynamically, so again trying to spend as little time in contact with the ground as we can making it nice and springy and nice and explosive. If we want to focus on a little bit more power output then we can look at things called pogo jumps. So again you can see here we’re spending very little time on the ground but we’re really relying on that reactive strength and that reactive spring to get us nice and high up off the ground we can do this on two legs and we can also do it on one leg and as I mentioned earlier most lateral ligament sprains happen when we are moving in multiple directions or when we encounter maybe an uneven surface that we’re not anticipating so again we want to look at that natural spring in multiple directions.

So Niall here is now working on a drop step off a box trying to spend as little time on the ground as possible trying to kick off the ground straight back up onto the box as fast as he can, similarly then we can challenge the ankle stability even more by looking at some lateral pogos so trying to bounce side to side trying to spend as little time on the floor as possible. So there are some example exercises of restoring normal ankle function following say the first-time sprain or following multiple sprains or chronic ankle instability and it’s also worth noting that exercise has been proven to be one of the most effective ways of restoring ankle function but also reducing the risk of future injury. The other thing that has been proven conservatively to manage or reduce the risk of future injury is bracing and strapping, so wearing a brace or strapping the ankle as you can see in the pictures here actually can reduce your risk of re-injury, this is probably most applicable to the people who are coming back from their first time spraying or recurring sprains it might not be as useful for people that are suffering from maybe osteoarthritis-related changes within the ankle. Here is some references for anybody who would like to read a little bit more about where I sourced my information for today’s presentation.

Hopefully, you guys learned something from this, so thank you for having me I look forward to answering any questions you might have. If you’re interested in any more information please feel free to contact me or any of my colleagues at the Sports Medicine department, the phone number is on the screen there and so thank you and look forward to any questions that you might have for me.

This is a common situation we would find ourselves in every day really in SSC, where patients have maybe had pain for a number of years following an incident that wasn’t necessarily diagnosed at the time. I think maybe my first step would be to be assessed by either a physio or a doctor again and then to make a decision on whether an MRI scan or an x-ray would be indicated at this point.

It’s probably unlikely that she’ll need an x-ray six years on but she may want an MRI scan to help with her diagnosis and then following on from the diagnosis there might be a management plan put in place, whether that’s a surgical or conservative management plan but the first step will definitely be to get assessed and then get the relevant imaging.

It is unfortunate to hear that that’s the pain has returned but it might not necessarily be a true ankle pain that you are experiencing. When you’ve had an L4 L5 lumbar disc issue essentially the pain can refer further down into the lower limb and sometimes as far as the foot and the ankle, so even though you are experiencing pain in the ankle it might not be a true ankle issue it might actually be an issue stemming from her lower back.

My first piece of advice for you might be to attend either her GP or to go back to the surgeon that performed the microdiscectomy and either the GP or the surgeon might be able to then decide whether rehabilitation would be beneficial for you.

Metatarsalgia is kind of an umbrella term for pain within the ball of the foot and it could be it could be a number of issues um but the metatarsalgia itself is sort of just an umbrella term for maybe a few different things so I do think getting assessed would help to maybe narrow down the diagnosis a little bit further and then based on the diagnosis we could try to devise a management plan for that.

Orthotics are common and they have probably mixed results and varied results, but some people can benefit from them. I think a cornerstone of managing something like metatarsalgia will be to manage the volume of weight-bearing exercise that you’re completing but also make sure that you’re actively rehabilitating your foot to make sure that your foot and ankle is at full function for those weight-bearing tasks or those long days on your feet for example.

The heel spur I suppose is exactly what it sounds like it’s a small little bony protrudance at the bottom of the heel, the calcaneus bone, and years ago it probably was taught that heel spurs were one of the main drivers of people’s heel pain but what they found was really that the heel pain surgeries were not having great success.

The heel spur might not be the main driver for the heel pain that they’re experiencing so when it comes to managing heel pain I think the first step is to get assessed again by either a doctor or a physio once you’ve been assessed we can try and highlight maybe factors that are aggravating your heel pain and also some factors that maybe help ease your heel pain and then devise and build a management plan for you where you can look at strengthening some of the intrinsic muscles within the feet strengthening some of the key muscles around the ankle and managing the volume of time you’re spending on your feet as well so you allow it to settle down in the first place.

When you fracture the bone it usually takes well depending on the bone that’s been fractured it can take roughly six to eight weeks for that bone to heal and fuse back. Now some fractures are severe enough that they’ll need surgical fixation which usually happens, though initially after the surgery the doctors in A&E department are very good at picking up on who will need a surgically fixed fracture and who won’t.

It’s common though for people kind of months and and sometimes years later to still be feeling the repercussions of that fracture and that can present in the form of say swelling, pain or joint stiffness, all of those can be helped through conservative treatments meaning things like physiotherapy and rehabilitation and they also can be helped sometimes with injections and sounds like you had some benefit to one injection but sometimes repeated injections can have a sort of a waning effect.

This is a very common picture we would see a very common scenario we’d see where people suffering from plantar fasciitis and one of the cornerstones of treating plantar fasciitis is managing the volume of weight-bearing exercise this person is doing. You mentioned that you’re in agony following your walks, so that would probably suggest that the walk your currently undertaking might be a little bit too much for your current capacity, so it’s flaring up your pain and potentially is slowing down your recovery rather than speeding it up.

The first thing would always be to try and get a good grip and a good handle on how much weight-bearing exercise they’re completing and in the background then looking at a rehabilitation program which might make them stronger and slightly more robust so they can manage more time on their feet and they can manage more walking volume.

CRPS is either complex or chronic regional pain syndrome and it’s not a common presentation following a traumatic injury but it usually does follow some sort of traumatic injury. In our presentation for tonight, it might be something like an ankle sprain and years or weeks or months later someone might be still struggling with diffuse pain within that injured area, they’ll also present with things like sensory changes to the skin so they might have redness in the skin they might have hair growth or they’ll often present with things like shiny skin and really what’s happened is the traumatic event has sparked sort of a chronic inflammation and this does go away for most people however it can be helped with rehabilitation. If this 16 year old boy is not currently working with the physio on a regular basis I probably would advise that they will because this is an injury that requires an active approach to work to solve it and a rest or a wait and see approach might just prolong symptoms.

It would be useful to have laser electrostimulation massages and how much do you have to focus on the range of movement and on the strength in terms of weeks. The achilles tendon rupture is similar to the ACL injury earlier, where it’s quite a long undertaking or quite a long rehabilitation process. It could be upwards of nine to 12 months to get back to full fitness following that. Initially, after rehabilitate or after the surgery they’ll be immobilized in a boot for roughly six weeks but then it’s important that the ankle starts to move so if the ankle is kept immobilized for too long the ankle can start to stiffen the muscle can start to atrophy as well so a big focus in the first phase following this surgery is actually going to be to restore the range of motion and to start strengthening the calf and the Achilles tendon.

In terms of massage and electro stimulation and things like that, it might offer some element of pain relief however it’s not going to restore the function of that ankle if you think about the achilles tendon as a big elastic band essentially the structural integrity of that has been compromised and no massage is really going to improve that or return that.

One of the kind of cornerstones of treating osteoarthritis alongside things like medication is strengthening exercises, so the joint is suffering and essentially losing its structural integrity a little bit as the years go on. So we need to try and use strengthening exercises to support that joint and to try and support the support structures around us.

The main couple of tips and advice in terms of strengthening if you have osteoarthritis is that the exercises by and large should be pain-free so it’s not a case of maybe no pain no gain it should be largely pain-free and we should be able to progress those exercises week on week, so the exercises week and weeks you’ll be able to get a little bit progressively harder because you’re getting stronger.

X-rays and MRI’s might not be too useful or indicated really in this case at the moment, however working with a physiotherapist to try and guide their strengthening program certainly would. So if she’s struggling to walk any prolonged distance strengthening exercises are going to be one of the foundations there to try and help her walk further and the physiotherapist is probably best suited or a strength and conditioning coach is probably best suited to actually help them in that regard.

To make an appointment please email or contact 01 526 2300

Republic of Ireland Reimbursement Scheme

UPDATE: The DoH has allocated a further £5m to continue to operate the scheme beyond the planned 30 June 2022 deadline. New applications will be accepted from 1 July 2022. These will be processed in chronological order and the scheme will continue until the additional funding has been committed. Further information on the scheme will be provided on this website. (NHS Website)

The Republic of Ireland Reimbursement Scheme, formerly known as the EU Cross Border Directive, provides people living in Northern Ireland and on a waiting list for orthopaedic surgery with the option to travel to Dublin for their surgery.

This webinar hosted by Sports Surgery Clinic focuses on the Republic of Ireland Reimbursement Scheme, covering the application process and how to apply for the ROI Reimbursement Scheme. It also focuses on the costs involved and what patients can expect when travelling to Santry for their orthopaedic surgery.

This event consisted of presentations from members of SSC’s team and was followed by a live Questions and Answers session on the Republic of Ireland Reimbursement Scheme.

How to apply for the Republic of Ireland Reimbursement Scheme

by Fiona Roche, Business Development Manager at SSC.

I am now going to talk about the Republic of Ireland Reimbursement Scheme, formerly known as the EU Cross Border Initiative Scheme, which most of you may know it as.

This is a picture of the hospital, as you can see. We are very close to Dublin Airport. The Sports Surgery Clinic is the leading private orthopaedic hospital in Ireland. We look after all joints, muscles and bones etc., for example, from your hips to your knees, backs, neck, foot and hand.

We cover all those surgeries. Most people are interested in hip and knee replacement surgeries. We also do joint replacement of those, shoulder replacement and some ankle replacement but not as many. Spinal surgery may also be an interest to some of you, we do some spinal fusions, but some of our surgeons do not do it as part of the reimbursement scheme, but if that is what you’re looking for, come and talk to me about it. We then also do foot and hand surgeries.

As I said, we are very close to Dublin Airport, about a ten-minute drive away, and we have underground parking here.

This slide is about the scheme, and this is what a lot of people want to know about.

The  Republic of Ireland Reimbursement Scheme Application Process

The one thing you need to apply for funding and to be eligible for it is that you must be on a waiting list. You can get proof of your GP or the hospital that you are on a waiting list for surgery.

You will need to provide evidence of being on a waiting list when filling out your application form.

A lot of people think they are on a waiting list for surgery, but sometimes they are only on the waiting list to see the Consultant, not for surgery yet.

If this is your case and you may have to wait another year to see the surgeon, you can come and talk to me, and we can talk about other ways you can get on the list.

We can find a way to get on the waiting list and see a surgeon rather than waiting even longer before the scheme ends. As far as we are aware, the scheme is going to carry on until July 2022.

Once you have approval on the scheme you do have nine months to get your surgery. If you are unsure whether you want to go ahead with it, still apply, and then you have up to nine months to make your decision.

To apply, you can email or download the application form from their website or on our website.

It takes about 4-6 weeks to hear about approval; they are very busy at the moment.


Payment wise, you pay it all upfront before your surgery. We take the payment a week before the surgery.  Once the surgery is done, and you are discharged, you are given a receipt from us, and you hand that in with an application form to the Belfast office, where you get refunded about three weeks after that.

We have a team here at the hospital, including myself, Glenda Thorne from the finance side, Rebecca Lenagh and Margaret Cromwell.

All of us each talk to you about your individual cases, and we will provide the phone numbers at the end.

What’s included in the price you pay SSC?

When it comes to the surgery, what is included in the price?

The following is included: Hospital stay in semi-private accommodation this means there could be up to two people in a room, there is never more than two. Pre-assessment and cardio echo, if required, is included. The surgeon, anaesthetist fee, the surgery and hospital stay, pre and post-operative x-rays and two post-operative appointments plus x-ray is all included.

The price also includes a covid swab, so what we are saying to people is if they want to get the covid test done closer to home instead of driving up here 72 hours before the day of your surgery, you can get your test done closer to home and when you arrive for your surgery, we will take the cost off just be sure to let Glenda know when you are paying.

What is not included?

Any additional consultation’s you may require, for example, if you go for pre-assessment and they find you may have a heart condition or something came up in your blood, you might need to see another consultant to get clearance.

You can do this with your own Consultant at home; if not, we have a cardiologist here that you can see, but you will have to pay additional for this.

You may need to get additional CT scans or MRI’s which you will have to pay for. It is rare.

Any investigation not normal to the surgical process is not included in the package.

A private room is also not included in the price, so a room on your own. If you want this, you can contact Glenda and she will let you know the additional fee and other relevant information.


With regards to surgery, some people may have a preference for a particular surgeon they would like to see or have been recommended. We are happy to pass that information on to the surgeon’s secretary. If not, we are here to help you to make that choice.

All of our surgeons are specialists in Orthopaedic surgery. Appointments and surgery can be completed within 6-8weeks.


For a lot of people, this can be another pain, not knowing how long they will have to wait. Some people would prefer to have their surgery in 4 months’ time or around the Christmas holidays or after. That is okay; we can organise that by letting the surgeon know your preferences, and we can organise the surgery around that time for you.

To save you from doing too much travelling, we do book all your appointments on the first appointment on the same day as per assessment to avoid numerous journeys. The only time you would have to travel back down after your assessment is if you are getting your covid swab done down here or you want to see another consultant.

Appointments can be made on receipt of you getting approval from the ROI Reimbursement Scheme.

If the scheme is going to take 4-6 weeks to get approval, you can begin the booking process for pre-assessment; you just can’t book the actual surgery until approval.

Hospital Stay 

After surgery, many people wonder how long they will have to stay. It depends on the surgery you require, your surgeon and how you are feeling.

Generally 2-3 nights for joint replacements. There are local hotels available for relatives who want to stay as we currently cannot take visitors at this moment in time, it could change, but now we are following Covid guidelines.

If you do have a relative that wants to stay, there are local hotels. The Crowne Plaza is closest but is currently being used as a quarantine hotel that may change, but as now it is not available, but the Carlton Hotel on the Dublin road is about ten minutes away from here.

If you need any convalescence or social care packages at home, you are still entitled to this under the NHS. Let us know beforehand what you will need. You are also entitled to your physiotherapy under the NHS if you are waiting longer than ten days. Book privately. Don’t wait.

Frequently Asked Questions

Do I need Insurance? No insurance will cover this trip.

What happens if there are complications? If it is not related to your surgery, for example, a problem with your bowl or liver, we may have to admit you to the public hospital. This is rare and has only happened once or twice. We have a good relationship with the other hospitals, so we have that option. There is a global card that will cover you if we admit you to another hospital. If readmission occurs within 30 days to do with your surgery, it is rare, but just so you know, there is no charge.

As you can see on the map, we are very close to Dublin Airport.

Thank you for listening tonight.

The Republic of Ireland Reimbursement Scheme overview from a surgeons perspective by Gavin McHugh Consultant Orthopaedic Surgeon at SSC.

Hello everyone, I’m Gavin McHugh, Consultant Orthopaedic Surgeon based in the Sports Surgery Clinic in Dublin. Fiona has kindly asked me to say a few words about the cross border initiative based on my perspective of it, I suppose.

My area of expertise is hip and knee, and I mainly do a lot of hip replacements, knee replacements, partial knee replacements and soft tissue knee work, which is arthroscopies and cruciate knee ligaments (ACL Repair).

Within the clinic itself, we have a broad area of expertise that covers all the subspecialties such as the spine, upper limp, shoulder, elbow and hand, then obviously foot and ankle as well. Over the past few years I have been here, a really huge growth of my practice has come from the cross border directive, and I have dealt with a lot of happy customers from the north.

From my point of view, people are coming down a little bit sceptical of what exactly is involved, and I always say to people I have never really seen any catches in the whole process, it has actually been quite seamless, they have done a lot of work on the cross border initiative to make it as easy as possible for patients. From a principle point of view, lots of people have issues in regard to moving away slightly from the NHS. I completely understand that, but from my point of view, I have seen patients that are in a really bad way, and they are looking at waiting lists that are really long, potentially years-long and ultimately, you need to make a call that is right for yourself.  We have a similar process here that lots of patients end up going the other direction, and also, there are lots of waiting lists. That is when I say to patients there has to be a safety net there for people. The NHS is still responsible for your care. So if you’re on a waiting list for surgery and I perform your surgery, if there is a problem down the line, your consultant up north is still bound to look after you and the same works both way here’s. You won’t be left behind on. In terms of what you get,

the care you receive in the sports surgery clinic is state of the art, one of the best in the world, and I am happy to say that.

There are no real catches in the care. I say to everyone this is something we really fought for over the years. The price the clinic pays you is the price you pay for a job. If there are any problems and you may need to stay an additional few nights, there are no issues in regards to this. We want you to do well following your surgery. We want you going home safe and ultimately doing well.

In terms of what I do, the breakdown of the vast majority of patients that I see here is for hip or knee replacements. The time people have developed a lot of pain in the hip, it is time for a hip replacement, and there are various methods of doing so. Knee replacements have slightly more options, such as partial knee replacements rather than just full knee replacements. Quite often, patients tell me they have been told they needed a full knee replacement when often I have only needed to give them partial, which has its advantages such as maintaining the knee that they have half and the recovery process.

One other area where I have really developed an area of interest potentially has either joint done at the same time, as in both hips together or both knees together. This can sound daunting to patients initiatively, but obviously, the huge advantage of this is getting both operations done in the one and one recovery progress. It offers huge advantages to people that may be in a bad or painful way. The partial knee is easier to get both knees done, it’s not an easy thing to go through, but it is a case of getting your life back again in one go. We try to get to your pre-assessment and consultation on the same day to make it straightforward for you. It is as seamless as we can’t make it. I am happy to see everyone and give my opinion. I often laugh when people say when doctors suffer, patients suffer, which is not the case. It is important that I am happy to do it and see you beforehand. I look forward to seeing many more patients.

Q&A Session – Republic of Ireland Reimbursement Scheme

The following questions were asked live by the public and answered by Fiona Roche and Glenda Thorne.

How long do you stay in hospital after hip surgery?

2-3 nights depending on your surgeon and how well you are recovering.

What happens after the operation? Do I attend my own doctor or hospital for updates?

All post-operative reviews are here in the sports surgery clinic. You should only need to see your own doctor for wound review or stitches removal. Other than that, all post-operative reviews are done here.

Do you need to be on the NHS waiting list for orthopaedic surgery for a specific length of time to qualify for the scheme?

No, you only need to be on a waiting list to qualify.

How long does the whole process take from applying to getting the surgery?

Approval at the moment takes 4-6 weeks. Allow six weeks. You can wait 4-8 weeks for surgery with us as it is our busy period, each surgeon has different times. You can contact us to find out specific waiting times.

How soon can you pay before surgery?

We need the payment completed five working days before admission as paying on the day can delay admission.

I’m in need of 2 hip replacements. How much could I expect to pay after everything is taken into account?

There is specific pricing for a specific procedure. You can contact Glenda Thorne for more information. You can also now get a bilateral hip replacement, so both hips are done at the same time, or you can do it separately. It is interesting to know for one single hip replace place you will receive 6,500 sterling pound back from the cross border scheme.

How can you pay?

You can pay by direct bank transfer, over the phone through Glenda Thorne, Online portal and bank overdrafts. Contact Glenda Thorne for more information.

My wife, who is 82, is in urgent need of a hip replacement. The Orthopaedics has said it will be at least three years before she can obtain one in Northern Ireland.  A member of the Orthopaedic team advised me to contact you re the reimbursement scheme.   Any advice would be gratefully appreciated.

You can apply for the reimbursement scheme once you have a letter of evidence of being on an NHS waiting list for surgery. The application form is available on our website, or you can contact us if you have any more queries.

My Mother was referred by a GP for x-ray revealed arthritis in the rotator cuff. GP referred her for a scan on 03/21, which was done privately on 04/21 as the NHS waiting list was too long. Further scan in 06/21 privately was to have surgery by 08/21 (privately) Private appointment cancelled due to covid pressure. Does she qualify?

In order to qualify for funding, you must be on an NHS waiting list. If your mother is not on a waiting list and went privately, you do not qualify. I would recommend going to see a surgeon privately up north as you will be waiting a long time to see one publicly. You can ask a surgeon to put you on a waiting list.

I had MRI / X-Rays completed years ago for hip impingement, but as I have been waiting eight years for surgery, perhaps those scans are now outdated and no longer relevant. Do I need to go get MRI’s and X-Rays again?

You don’t always need MRI. We do an x-ray for you on the day of the pre-assessment. I recommend making the appointment first, as you do not even need an MRI.

Will Santry clinic have all up to date relevant information about me if I go this route to surgery?

We would not automatically have your information. You will need to provide or ask your GP for a printout of your medical history and bring it on the day of assessment.

If I have not yet submitted an application yet, should I go ahead and book my consultation with a surgeon to start?

Don’t make any appointments until you have submitted your application form, as this can take up to 6 weeks.

As you can have all your appointments booked and you may not have heard back yet.

Is it possible to have your consultant appointments in the North if the surgeon works in ROI & NI?

No, it isn’t. They won’t cover the appointment you have in the North. You are only covered for appointments outside of the North. Although some of our surgeons work in the North, you will not be covered. You need to come down to Dublin anyways for your pre-assessment.

What is included in the pre-assessment? Does it include X-ray & blood tests?

Included in the pre-assessment are X-rays, blood, ECG, cardio echo etc.

The only thing not covered is any additional MRI or tests not related to your surgery that may need to be done if any issues are found or a cardiologist if needed to be seen. Some assessments are done through the phone since covid, which is cheaper.

Is 100% of the cost covered by NHS?

No, usually, you would get between 40-60% back.

Are Cheilectomy performed at Clinic, please?

Yes, they are, that is, foot and ankle. All prices are done in euro as we do not accept sterling.

Do you have to self-isolate before surgery?

You need to get a covid test done 72 hours prior to surgery, and we do recommend self-isolating after getting your test done up until the surgery.

Do all the surgeons vary in a package price?

No, they all charge the same. All surgeons have an agreement with us as a part of this scheme. It doesn’t matter what surgeon you choose. They will all charge the same.

Are many people turned down for funding? And if so, why?

We have not heard of anyone being turned down so far in the last eight years. Once you are on an NHS waiting list, there should be no complications.

Can you get two knee replacements at the same time?

If you don’t want to get them done bilaterally, most surgeons wait eight weeks between each surgery, depending on the surgeon and how well you did in the first surgery.

If you need more physio, is it organised back in Northern Ireland?

It depends on what surgery you are having. Usually, you’re GP would organise this, and yes, it would usually be in Northern Ireland as it would be too far to be travelling back and forward.

If there are any emergency complications after you are home, will the NHS take over?

If you got very sick at home, yes, they would take over. If you had any complications to do with your surgery, yes, you would come back down once you are fit and able to travel. If you need to be Re-admitted within 30 days, there is no fee.

If an emergency happens at home, of course, the NHS will step in.

Do you do laminectomy for Spinal canal stenosis?


Yes, we do. Consultants will want to see your letter of referral and evidence of being on a waiting list. Spinal surgery is more difficult to price as there is a lot more surgeries and codes.

Once you have approval, do you have nine months past July 2022?

Once you get approval, you have nine months to get your surgery done.

Can pre-assessment be booked if verbal confirmation has been given of approval?

No, you must have a letter. You must provide a letter of evidence of being on a surgical waiting list in Northern Ireland.

What is the cost of a private room, please?

If you wish to take a private room, the difference from a semi-private room is approximately 1000 euro. A semi-private room only has two people.

How successful is knee replacement? How many have been completed within the last month?

It takes up to 12 months for a full recovery and hard work. Everyone is different, and this should be discussed with your surgeon. You should contact your surgeon. We do about a thousand a year, one of the highest rates in comparison to other hospitals in the country.

I’m just wondering if it is means-tested to determine which percentage is refunded?

Whatever happens, there is a standard price. They don’t do means-testing. For example, if they give you 8000 for a hip replacement, that is what you get no matter where you go. There is a set price, and that is the standard price

Who would supply specialised seating etc., for aftercare for a hip replacement?

You will need a high toilet seat that is included when you are going home from here after surgery. If you need anything else like seating or other equipment, you would need to go through the community for that and occupational therapists for that. Sometimes you cannot request these things until you are a patient in the hospital, but anything like that will be discussed when you come for pre-assessment, and that is when you talk about what you may need when you go home.

Click here to download the Republic of Ireland Reimbursement Scheme Application Form.

For assistance with completing this form please contact Fiona Roche: +353 1 526 2168; or Glenda Thorne on +353 1 5262071 or Email:

If you have any questions at all regarding the Republic of Ireland Reimbursement Scheme, the application process, pricing or any query relating to a potential hospital stay, please do not hesitate to contact Fiona Roche: +353 1 526 2168; or Glenda Thorne on +353 1 5262071 or Email:

Sports Injuries of the Shoulder at All Ages – Ms Ruth Delaney

Watch this video of Ms Ruth DelaneyConsultant Orthopaedic Surgeon specialising in the shoulder discussing ‘Sports Injuries of the Shoulder at All Ages‘.

This video was recorded as a part of  SSC Online Public Information Meeting focusing on the Shoulder.

Ms Ruth Delaney is a Consultant Orthopaedic Surgeon here at the Sports Surgery Clinic specialising in the shoulder.

Hello everyone my name is Ruth Delaney, I am a shoulder Surgeon at SSC and I’m going to talk about sports injuries and conditions that can affect the shoulder at various stages of life. A little bit about my background I spent 6 years in Boston doing my orthopedic training and most of that time was spent at this institution as a shoulder fellow so in my last year of training I got to spend some time in France before coming back to Dublin in 2014 and my practice is exclusively focused on the shoulder.

Shoulder pain is quite common the majority of us are going to experience shoulder pain during our lives at some stage and a quarter of people who have shoulder pain report that they have had it before as well so t can be a recurring thing. It can be quite debilitating in terms of sleep disturbance, in terms of affecting daily life and work and it can come from a variety of different sources it can be a little bit hard sometimes to figure out exactly where it is coming from.

That is where the specialist comes in, I suppose talking about the shoulder and sports, the sport that I know the most about is tennis and you can see wh, for example, tennis serve the shoulder is doing a lot of work there are different phases of the service and one of the important things about sort of keeping the shoulder healthy when you’re playing a sport like a tennis, is to remember that the shoulder isn’t working in isolation and so what’s important is from the ground up, so everything is connected and everything is part of what the physiotherapists and the S&C coaches will talk about as a kinetic chain so if you have good solid core strength, a stable base from your legs and core, then your shoulder is going to be that bit more protected when you’re doing things like playing tennis or swinging a golf club. The shoulder blade is also really important that’s a stable platform for the shoulder to function and if you think about the shoulder as a ball and socket with the socket relatively small and the ball having a lot of freedom of movement, its got to have a stable platform to work off and the socket of the shoulder joint is apart of the shoulder blade and that’s why I said when we send you to physoitherapy for your shoulder, the physio will often spend a lot of time working on your shoulder blader control and getting all those smaller muscles around the shoulder blade to work because they often go to sleep particularly when the shoulder is sore and a lot of the times when we go to the gym we train the bigger muscles and we forget about those small really important muscles around the shoulder blade, when the shoulder blade isnt really working well with the rest of the shoulder, its something we call scapular dyskinesis which is a broad term that just means kind of that the shoulder blade is out of rhythm and that in people who play overhead sports can increase the risk of shoulder pain, so again going back to for example a tennis serve so things that are going on with the foot position or with the knee bend can affect how the shoulder ends up having to compensate and lead to problems with shoulder pain the same thing with hip flexibility with trunk and the core strength and as we talked about the shoulder blade or scapula so that scapular position, all can feed into what happens when you try to go through the motion of a serve and a lot of us are stiff through for example the htoracic spine or that part of your spine between your shoulder blades and again that can have an affect on how your shoulder works so when you’re playing a sport that involves a shoulder having to do something there’s a lot more going that often needs to be addressed when your shoulder is sore playing golf not strictly considered an overhead sport but when your at the extreme peak positions of a golf swing those positions can provoke shoulder pain so abduction is bringing your arm away from your body, adducton is the opposite bringing it across your body and you can imagine that there are parts of a golf swing at times that will be in the maximal extremes of those positions and when you bring your arm away from your body sometimes you can end up with something called impingement or when the ball and socket is up like this the ball is up like this we’ve got the roof of the shoulder over top here what we call the chromium you can get some pain from inflammation under there when your arm is across your body or in adduction that can particulary in younger golfers and we see it in hurlers as well with a similar positionsa of the shoulder, that can sometimes leave the shoulder vunerable to a less common type of instability which is out the back or posterior instablity, the biceps is an interesting muscle it has two tendons at the top end and one of those longer one goes right through the shoulder joint and repetive motions like a golf swing can irritate that tendon leading to tendonitis in there and that’s something we see commonly in people involved in many different sports the nice thing about a sport like golf while it can place demands on the shoulder we usually see that people are very well able to get back to playing golf and pretty much at the same level as they played before even when we do pretty complex shoulder surgeries for example repairing rotator cuff tendons or replacing the whole joint.

Collision sports are a little different the most common injury we see in people who play things like GAA, rugby, or hling is instability or dislocating the shoulder and the more common type of that is the shoulder dislocating at the front so the ball and socket joint ball come out the front of the socket and the reason that the shoulder is susceptible to that is that the socket is relatively shallow as well as being small that’s what allows us to have so much movement of the shoulder but in certain positions, particularly for example with the arms overhead the shoulder can be vulnerable to install, it and if you dislocate your shoulder for the first time at an age under 25 there is a very high risk of it happening again as you get a little bit older than 25 so peoples in their 30s, 40s who dislocate their shoulder for the first time those people have a much lower risk of it becoming a recurring problem. Sometimes you can have other injuries that happen with it and which are more common in people over 40 for example tearing rotator cuff tendons but the likelyhoof of the instability having to be addressed is much lower in these younger players often we end up looking at surgery to stabilize the shoulder and there csn be broadly speaking two types of surgery, one is a soft tissue surgery where we fix the soft tissue surgeries or the cartlidge bumper around the shoulder socket call the labrum and the other one is where theres more severe damage to the shoulder often in cases of multiple  dislocations where we have to actually put a bone block on the front of the socket to stablise it and after those surgeries the rehabilitation time varies, it depens on the type of surgery, it depends on the type of sport that the player wants to get back to but the quickest would be typically about 3 months and it can often particulary the soft tissue surgeries take 6 months for the shoulder to be ready for the high demands of collision sport because those are probally the riskiest sports for the shoulder joint.

If we think about the type of symptoms that people typically get in the shoulder, the shoulder can be sore it can be weak, it can be unstable like we’ve just spoken about or it can be stiff. These are not mutually exclusive a shoulder can be sore and weak at the same time. The other thing that we often think about as well and it’s important not to forget is that a problem in the thneckco in the cervical spine can present as shoulder pain or weakness around the shoulder and equally a problem in the shoulder can give you some neck pain and a lot of people have both going on at the same time so it can sometimes take a while between the spine specialist and the shoulder surgeon to figure out between us okay wheres most of the pain coming from which should we tackle firstor often we tackle the two things in parallel sometimes injections might be part of that because as well as helping the inflammation and hopefully making your pain or symptoms better they also give us good diagnostic information if an injection into the neck does nothing for your shoulder symptoms but sn injection into your shoulder helps your shoulder a lot then obviously the pain is coming more so from the shoulder and we prioritize taking care of the shoulder so the kind of diagnostic work up of shoulder symptoms can often be complex and so the history that yiu as the patient give us is something that we learn a lot from because there a typical patterns of symptoms for some things and typical sotries and that’s why where the questions come from that we often ask people presenting with shoulder problems. We get a lot of information from actually examining the shoulder and during the height of the COVID pandemic when we were doing video consultations and trying to figure things out without being able to hands-on examine people, I think that made a difference with shoulders it was a little harder to figure things out sometimes and then imaging will often play a part too, plain x-rays are very good for certain shoulder conditions and sometimes are better than MRI’s for example if you have tendonitis in your rotator cuff and there’s some calcium in it or what we call calcific tendinitis we can see that much better on an x-ray than an MRI, we can see the bones much better on an x-ray than on an MRI so if you have a shoulder fracture or if you have shoulder arthritis where you want yo see the bones and the shape of them an x-ray will often help us more so than an MRI. The MRI helps us a lot for soft tissues so if you have a weak shoulder and we’re not sure if there’s a torn tendon that’s when we might look for an MRI or if there’s an unstable shoulder we might get a special type of MRI with dye in the shoulder which will outline the structures that get injured or instability. Sometimes we need other studies too, for example, a CT scan is sometimes useful for certain situations as well so which imaging is best depends on what we’re thinking the problem is and sometimes we need more than one type of image.

Some of the most common diafnosediagnoses see are rotacuff problems, frozen shoulder which ill explain in a few minutes, arthritis of the shoulder and instability, and course many other shoulder injuries can also present particularly in the context of sports things like broken collar bones, ac joint or the joint at the end of your collarbone getting injured during sports or fall but I think there four are probably the most common that we see. So if you have an injury and you end up getting to the point where it’s an injury that’s appropriate for surgery and you’re considering shoulder surgery, I think it’s important to get advice from a shoulder specialist. There is a lot of misinformation out there of course there is google snd all of that but even sometimes within the medical community because the field of shoulder surgery and shoulder care is evolving so fast that unless it’s a shoulder specialist that you are talking to you may not be getting the most up-to-date advice or the appropriate advice specific to your condition. Anytime we talk about surgery, its always a risk-benefit balance, any surgery will have risks even the smallest surgeries do even the minor keyhole surgeries there will be a small risk of infection, a small risk of stiffness, and a small risk of pain not resolving. While those problems are very uncommon, if they happen to you then that’s something you know is a real problem and can mean your recovery takes longer. The potential benefits of the surgery have to be bigger than the risk. If we offer someone surgery it means we think their particular problem will benefit a lot from the surgery and far outweighs any of the potential risks. The other thing about the surgery that is important to think about is the recovery and rehabilitation time, some shoulder surgeries take quite a while to recover from and the rehabilitation is quite intense. Preparation is important, that is our job to help you prepare and what to expect. The website also helps with providing information. I explain this information and you can read it back at home as well.

Going back to the main diagnosesgoingnd go through each of these sorts of broad groups. You hear a lot about the rotator cuff, it is a group of four muscles that are deep inside the shoulder attached to the shoulder blade and then they sort of coalesce and form a cuff if you like of tendons which is the white part you can see in the picture around the humerus, the right-hand side is the front view and on the left is the back view. They can be involved in various processes in the shoulder that cause pain, they don’t have a great blood supply so they do undergo normal wear over time, and sometimes in the context of that where the tendons can get inflamed, they can get inflamed just from repetitive use and cause some inflammation around them and that space, that is one of the most common things that we see. Other times the tendons can tear at a point where a little bit of the tendon detaches or it can tear from a sudden trauma/fall. There can be many different ways to handle it, you will almost see some sort of abnormality in the rotator cuff and MRI in anybody over the age of 25 or 30 because normal wear over time will show up on the MRIs. The inflammation I spoke about or bursitis or tendinitis will often respond to physiotherapy and working on the shoulder blade control. Sometimes we will add an injection into that space over the tendon and that can be very effective occasionally we will do keyhole surgery depending on how large the tear is as they are at risk of getting bigger and more painful. After rotator cuff surgery you will be in a shoulder immobilizer for 4 weeks, 6 weeks if the tear is larger. You start with gentle exercises initially and no driving during that time. Physiotherapy is key, range of motion or stretching is the most important part of the beginning and we don’t have the physios do any strengthing or weights or resistance bands until about 3 months as the tendon fibers have not healed enough to take any resistance by that stage. So typically it takes about 6 months to get over a rotator cuff repair. It is not a quick fix.

Moving on to something else in the shoulder is frozen shoulder. Frozen shoulder, is something we don’t understand exactly why it happens. Its other name is adhesive capsulitis so it’s an inflammation of the capsule of the shoulder so the lining around the ball and socket of the joint capsule gets inflamed often for no good reason more common in women, the typical age group would be the 40s and 50s. There are associations with hormonal changes like menopause, diabetes, and thyroid but it can affect anyone we see often in people who have none of those risks factors. What happens is the capsgets get inflamed and the shoulder can get quite painful and in the early stages it hant gotten stiff so sometimes the diagnosis is not clear in the beginning as that capsule gets more inflamed and thicker the shoulder gets tight and stiff and it becomes difficult to move and that can be a really difficult problem to have. Thankfully most of these cases resolve without surgery, the capsule is inflamed so if we use anti-inflammatory strategies those are typically very effective so anti-inflammatories that are not steroids things as neurofen or other drugs from that group. Sometimes we do use steroids, so cortisone injections can be very effective but it’s important as to where they are put. Steroid tablets we might use if somebody having a lot of pain just for a short course maybe a week.

To talk about shoulder arthritis it’s worth mentioning, people don’t tend to hear about it as much as hip & knee arthritis so it’s the cartilage wear of the main shoulder joint so again the ball and socket joint, the ac joint which is up at the top between where it says clavicle there and acromion so clavicle being your collar bone and acromion being your collar and the chromium being the pointer shoulder, that little joint up there id not your main shoulder joint and almost every single MRI will show some wear of that joint, so you may see the word arthritis in an MRI report but if it’s talking about the ac joint the that does not shoulder arthritis most of the time that doesn’t even hurt, sometimes that wear can get inflamed if your pain when someone right on that shoulder top.

There are different ways we can treat this similar to arthritarthritis hip or the knee, pain relief, physiotherapy can sometimes help, some people find it doesn’t help their arthritis so we tend to just try it out, if it’s not helping we don’t push it, injections can help they won’t change underlying arthritis but they can take down the inflammation associated with it which sometimes helps with the pain so cortisone can do that, there are other injections that are sort like a gel that mimics the joint fluid we call them viscosupplementation injections, sometimes they work for some people. There are various things we can try before surgery. In people with milder stages of arthritis, PRP can sometimes give pain relief, in some cases a younger patient with milder arthritis e might consider a keyhole surgery to clean it out but again were not going to affect underlying arthritis but we are may buy some time and get some pain relief. Ultimately the most definitive way to treat shoulder arthritis is to replace the joint. The implants where we replace the joint with metal and plastic just like in a hip. The longevity of those implants can be affected by heavy use of the shoulders or high-impact activities but a lot of sporting and recreation activities are just fine things like golf, swimming, tennis, and yoga all of those are well tolerated by the shoulder replacement. This is one of the situations where we get a CT scan because we see the bones much better on action than on any other type of scan and that allows us to plan your shoulder replacement in a very individualized way where we can figure out exactly what shape your socket is and which implants are going to fit you best. It is possible to return to recreational activities and often it’s easier to go back as you don’t have the pain from your shoulder arthritis. This is what a total shoulder replacement looks like. There is also something called the reverse shoulder replacement, you can see if we go back in the anatomic or primary total shoulder, the ball and socket are right where they used to be in the native shoulder, but we can also put the ball and socket the other way around and the reasons we might do this are if the rotator cuff was torn as well as having shoulder arthritis, the regular or anatomic shoulder replacement will not work unless they are intact rotator cuff tendons around it and this was a real problem up until a french man named paul Grammont discovered that reversing the geometry of the shoulder allowed the shoulder replacement to work without rotator cuff tendons so now if you have shoulder arthritis and a rotator cuff tear that isn’t fixable you can still have a shoulder replacement it’s just going to be reverse shoulder replacement. Similarly, if there’s an awful lot of wear on the socket of the shoulder from arthritis we can’t use the regular socket, the plastic socket that goes in anatomic replacement but the reverse shoulder replacement can handle that problem. Sometimes we even end up doing a reverse shoulder replacement for a very large rotator cuff tear where the shoulder is not functioning anymore even if there isn’t arthritis so if the rotator cuff tears the tendon tear is too big to fix and the patient has trouble raising their arm, if we reverse the ball and socket by doing this we can allow the big deltoid muscle on the outside of the arm to take over the job of raising the arm, obviously this isn’t meant for younger people we know it lasts pretty well for probably about 15 to 20 years so we don’t want to be putting it in a 40-year-old, but that’s what I mean we say that you probably have more options when you have a bigger rotator cuff tear at age 60 or 70 than you do when you’re younger. There are many things we can do to help those problems.

What’s involved in a shoulder replacement? They’re done under general anesthetic most people would spend about two nights in the hospital, four weeks in that same shoulder immobilizer so again you can’t drive after that first four weeks. People with shoulder arthritis often find the pain relief is dramatic even in the first few days, despite the fact we’ve just done a very significant surgery, the surgery pain is nothing compared to the arthritis pain has been for all those years. Physiotherapy works on regaining motion and then strengthening, it usually takes about 6 months to work through the rehab program. In terms of returning to recreational, it depends on what the activity is but golf is probably four or five months, swimming maybe a little bit earlier and tennis is probably closer to six months.

This is what we do we the ct scan that we have you go get before your shoulder replacement. It shows us in great detail the measurements and the angles, particularly about the socket of your shoulder and we can even order a model of the socket of your shoulder and a guide that helps us in surgery position the implants exactly where we planned on the software so it’s a way of doing the surgery on the computer before we do it in you its trial without error its sort  of like a flight plan for a pilot, it’s the same so pre-op planning is really important and something we have been able to introduce within the past year is using mixed reality which is where you overlay a virtual reality hologram of that patients individual shoulder and the shape of their socket and the guide over the real environment when you’re operating by wearing this Microsoft hololens which is what I am doing in the picture on the right and that improves our accuracy in implanting the shoulder replacement  so there are a lot of exciting things happening around the field of the shoulder surgery particularly replacements.

The benefits of staying active overall in terms of the shoulder and the body, in general, will usually outweigh any wear and tear issues that may come along and the shoulder is susceptible to ear and tear for all the reasons that we’ve spoken about before. I think doing simple things to receive your shoulder joint longevity when you play sports are worthwhile, ao thinking about that kinetic chain if you have some weakness in your core or your hips that may affect your shoulder especially playing things like golf or tennis, also play collision sports the kinetic chain is equally important and that’s why the strength and conditioning training all feeds in. Footwork is important especially in sports like tennis so you’re not overextending your shoulder, your tennis coach can help. Then having the right gear and be that for the weather, the footwear all of those things protect your body.

That is all in terms of my slides, id is more than happy to answer some questions afterward, thank you.

I suppose rather than the age as a number we look at the whole picture and so if somebody is of a certain age but in pretty good condition medically its often possible to go ahead, I would always defer to the genesis and our pre-op assessment clinic, so you know that particular person has a pacemaker, is on warfarin those things don’t prevent us from doing surgery there are some challenges in terms of warfarin being a blood thinner, making sure we talk to their cardiologists or whoever is in charge of that, that we have an alternative way around that to prevent too much bleeding and surgery but also keep them you know the way their blood the way it needs to be.

I don’t think we would write someone off and say they can’t have it, they’re having an awful lot of pain and other things aren’t working like medication injections sometimes the pain specialists can do nerve blocks so there are other ways if someone truly id medically unfit for the operation and the anesthetic but we don’t have a specific age cut off, I have certainly done people in their 90s.

It’s unusual with a frozen shoulder for the movement to get better and the pain still to be there so I would wonder if there is something else going on that maybe there was a frozen shoulder and that’s now sort of settled down that capsular inflammation is gone but there is still a pain for a different reason because the usual progression is for frozen shoulders is the pain settles first and the movement takes a bit longer so normally its only kind of when the pain has settled that the movement is possible to increase. Normally what you see is someone is left stiff but isn’t as painful anymore. If you are not stiff anymore but you are still painful I would say go back and re-evaluate with either your physio or a shoulder specialist.

It is certainly treatable, one of the big challenges in shoulder care is arthritis, now true arthritis of the actual ball and socket joint in a young patient because its rare but when it does present, it is treatable snd there are a lot of things we can do in terms of pain management.

You can have a shoulder replacement at a young age and certainly, we’ve done it in some situations, people with aggressive rheumatoid arthritis type things but the problem with it is that the shoulder replacement we know last pretty well for 15 years many years so if you have a shoulder replacement in your 30s you’re going to be looking at a revision and also younger patients will tend to be that bit more active and be a bit harder on it because you’ve got such bad pain from arthritis and then you feel great when we do a replacement and you sort of overdoing it so somebody that age we would try and hold of as long off as long as possible from doing a replacement or we might do another type of surgery if the arthritis was mild to moderate where we do keyhole surgery. The options are varied to your age and the severity of your arthritis.

They kind of fall into the same category, where a labral repair is one type of shoulder stabilization surgery so the labrum is a cartilage bumper around the socket of the shoulder that contributes to the stability of the shoulder when you dislocate the shoulder, the labral almost always tears. If you have done no other damage to the shoulder and it’s pure just a labral tear, you may just be able to have keyhole surgery to repair the labrum and stabilize your shoulder that way.

If you play a collision sport or if there is a bit more damage to the shoulder in addition to your labral tear, if you’ve got some boney damage so the front of the stock that the bone can get worn down or the back of the ball as the shoulder sort of comes out the back of the ball hits the front of the socket and can have it sometimes repairing the labrum won’t be enough on its on to make that shoulder stable so then we do other types of stabilization surgeries that are often are open sometimes using a bone block at the front of the socket, so a labral repair is one type of shoulder stabilization surgery but there are a few different types depending on the situation.

I think if you have had 3 dislocations, then it is very likely that there is damage to the inside of the shoulder the labrum that we were just talking about, and possibly some of the boney structures that are leading to it being more likely to dislocate and easier to dislocate as it goes on and I think in that situation it would be a good idea to see a shoulder specialist and have a special type of scan called an MRI Arthrogram or a CT Arthrogram which is a scan where they put dye in your shoulder, where we can see those structure better.

Most frozen shoulders don’t have surgery and are treated without surgery and how long it takes can vary if you do nothing at all with a frozen shoulder theoretically it will burn out itself so the whole process will be that the inflammation in the capsule will eventually die down and without any intervention and that can take two or three years to happen. The idea of treating it with anti-inflammatories or injections or even sometimes steroid tablets is to shorten the time until it goes away, particularly to shorten that painful phase. A lot of times when we do an injection it can shorten that painful phase within 6 weeks the pain starts to decrease, and the movement varies from person to person. Only a small minority of people doubt get better with injections or stretching and end up needing to consider surgery.

To make an appointment with Ms Ruth Delaney please contact +353 1 526 2335 or email

Rotator Cuff Related Shoulder Pain: What Should I do? – Edel Fanning

Watch this video of Edel Fanning, Lead Shoulder Physiotherapist at SSC Sports Medicine discussing ‘Rotator Cuff Related Shoulder Pain: What Should I do?.

This video was recorded as a part of  SSC Online Public Information Meeting focusing on the shoulder.

My name is Edel and I am a shoulder physiotherapist at SSC. I am going to talk about rotator cuff-related pain and what should I do. So what is the rotator cuff? A rotator cuff Is a group of four muscles that attach to the shoulder blade and the rotator cuff along with the bursa which is a small fluid-filled sac that works together to move and control the shoulder and allows you to do activities like reaching up playing golf and carrying out a tennis swing.

What is rotator cuff-related pain? Rotator cuff related pain presents with pain loss of function and weakness with movements of the shoulder and so it presents very differently to some other types of shoulder pathology such as a frozen shoulder which very much presents with a stiff shoulder or shoulder instability and so it is very much to do with pain loss function and weakness. Its an umbrella term, you may have heard of terms like subacromial impingement, tendinopathy, bursitis, and rotator cuff tears, and factor co-related cuff pain is now a widely used umbrella term for all of these pathologies mainly because the management of these pathologies are very similar and we’ll talk through that a little bit. So what are the causes of rotator cuff-related pain? rotator cuff related pain is often the onset of rotator cuff related pain is often due to a sudden change in tissue loads so for example if you went ahead and played tennis in the spring or summertime and hadn’t played tennis all winter, that is a sudden increase in load on the tissues of the shoulder which may predispose you to shoulder pain and it may be as simple as you have been out in the garden and hadn’t been out in the garden for a while and you knew it and shrimp the hedges again its sudden change in tissue load and often doesn’t have to be a massive change and again it depends on the quality of your tissues and your body type some people are more predisposed to tendon type pain than others and we’ll go into that in a little bit more detail. Other things that predispose you to a rotator cuff related pain or any type of pain are lifestyle factors so things as poor quality of sleep now we know that inadequate sleep over a long period caused an increase in chemicals in the body that predispose you to increases in pain and decreases your ability to repair and recover and the same with smoking it releases chemicals into the bloodstream that travels to muscles and tendons. It can have quite a large impact on recovery. The same with nutritional choices, poor nutritional choices cause an increase in visceral fat, visceral fat surrounds your visceral structures, and similar to smoking this fat releases chemicals into the bloodstream. Lack of physical pain, stress, and anxiety all have an impact on our recovery. Other things like genetics, age, and hormonal status all have an impact on your likelihood to pick up rotator cuff pain or any type of tendon pain. It’s an accumulation of these that exposes us to tendon pain.

When it comes to diagnosis, MRI scans or ultrasound to assess the integrity of  rotator cuff muscles and now we’re fortunate unfortunate live in an age where we have access to imaging, and imaging can be very useful particularly if there has been a serious trauma, scans can pick up significant structural damage. In some other pathologies, we need to take a couple of things into account. The evidence is showing there is a really poor lack of correlation between changes in structures and pain, so the pain doesn’t correlate with the size of the tear, shapes of bones in the shoulder, calcium deposits, and bursa changes. Sometimes and a lot of times people have these types of changes and don’t get pain. Interestingly the biggest predictor of what you call rotator cuff pathology or morphology normal change is age so after the age of 20-25 we all get changes in our rotator cuff, so we all have small little intra-tenderness tears of our bursal types changes just like this the findings that I showed you a moment ago so what does that mean for you, in the absence of significant trauma often findings images are most likely not the reason for your symptoms and it is very important if you do have imaging for rotator cuff related pain that you do sit down with a healthcare provider who is familiar with these types of problems and will be able to explain them you.

There are lots of management options. The number one option like any type of tendon pain is to wait and see because often tendon pain does settle down by itself, often the pain will settle with a bit of relative rest and graded return back into playing tennis. If you haven’t played in a while every senile going back, you might do 20 minutes doubles to start with and gradually build it up. However, if it doesn’t settle with rest then it’s often time to seek further advice so other types of management options you may have heard of things like injections like cortisone injections. The evidence shows that for rotator cuff-related pain, injections help approximately 1 in 5 people, the transient relief from anything from 4-8 weeks, and often the relief is a small reduction in pain. So certainly a steroid injection is not the magic bullet sometimes it is useful in some cases, but it is important for this certain problem it only helps around 1 in 5 people. Next up we have a graded exercise program, there is positive and empowering news about exercise, and an exercise program for the shoulder. If shoulder symptoms aren’t caused by serious trauma, so you’ve had no major falls no major serious trauma research shows an exercise program together with addressing lifestyle factors will achieve the same outcomes as surgery plus exercise at 1,2, and 5 years follow up. Exercise tends to have the most positive impact on this type of rotator cuff pain.

When talking about a graded exercise programs that means it is a gradual progression, it’s over about 12-16 weeks, some up to 6 months it takes for rotator cuff pain to have a good response so you gradually build exercise up over those 3 months and often with a health care provider that can help guide you. For most of the rotator cuff pain that I see, I’ll often give them a program and send them away for two or three weeks because there almost not good enough to go to the next level and so most of it is managed by yourself and us guiding and coaching you n the exercises that we think our beneficial. The important thing here it takes a minimum of 12 weeks for rotator cuff-related pain to settle and some are longer. A couple of other things to consider is we have to consider load management, so how much are you asking of the shoulder? If we look at the left side the green tendon capacity so says, for example, your rotator cuff tendons may be working 60-70% of what they should be because it is painful and when we then ask on the red side that’s the low demand. So when we ask too much of that so we increase that load demand, it will tip that weighing scale. If you go back to playing tennis the tendon just can’t cope so when we go to try and manage this we might modify your load and we might drop it back by 30% of the tennis you are playing and then start increasing your tendon capacity, so gradually working on getting your tendons more robust to tolerate the load. You can do that yourself too, if you develop rotator cuff pain just drop back the load a little bit.

When it comes to pain and exercise, this is a frequently asked  question, is it okay to get some pain while exercising and does are good at telling you if they can tolerate the amount you’re asking from, so we often use this traffic light system you see here in the right-hand side so pain during exercise so say if you get a 3 or 4 out of 10, it is very reasonable to get a little bit of pain during exercise as long as it settles relatively quick afterward, say you do a bit of swimming or tennis or golf it’s a little bit sore but it settles within half an hour afterward, that’s a good sign that tendons are tolerating that load. When you wake up the next morning or the day after and you’ve got quite a spike or increase in pain that’s a strong sign that the tendons probably are under the muscles aren’t tolerating the amount you’re asking from them so it is quite important then to drop back the load a little bit and that is important that traffic light system through your graded exercise program and also through your activities that you’re doing in every day and also look at the trend of symptoms over time, that is important as rotator cuff related pain is very up and down depending on what you ask of muscles, so every 2 or 3 weeks we would expect a little bit of improvement, a little bit of a jump if you are following an exercise program.

The road to recovery, you want the road to be nice and smooth. Any type of tendon pain is prone to this type of zig-zag pattern that’s just because we have to use your shoulders in everyday function, so when we overdo it a little bit we have a little are-up it’s not, particularly a setback, its just yit’sasked a little bit too much of that tendon. It is really important to listen to your shoulder and listen to those responses. On the timeframe, bear in mind that 12-week minimum period and they take time to settle and recover, there isn’t any quick fix but the good news is most respond well to supervised exercise. The other important thing to remember here it’s not just about the shoulder, 50-55% of shoulder powers come from energy transferred from the lower limbs and pelvis. So if your healthcare provider is creating an exercise program for your rotator cuff they will include lower limb exercises as well as upper limbs. Expect a wobble along the way.

The other big caveat here is lifestyle changes so we spoke about those early on so we know lifestyle factors have a huge impact on recovery. So when we look at putting together an exercise program it is important to look at behavioral changes around lifestyle changes as we talked about smoking, nutritional, etc all affect our recovery. Try to increase physical activity by 150 minutes per week and if you are a smoker, trying to reduce the amount of smoking or indeed stop, their chances are not easy nobody is judging, it takes time and often you need support and help and that’s where you go/healthcare provider can come in and help and try to give your support to make better lifestyle changes. Stress and anxiety too can have an impact there create chronic low-grade inflammation in our body which predisposes us as I said to lots of co-morbidity, so when we are tackling rotator cuff pain we do have to look at the full picture. We also have the option of surgery when symptoms do not resolve after exercise-based programs for 3-6 months and lifestyle changes you may wish to consider surgery. Remember that research has not proven that surgery and post-surgical rehabilitation outperform surgery with rotator cuff pain. Like exercise, surgery has no guarantee. Lifestyle factors impact success rate. There is no quick fix.

I have a couple of take home points, some lifestyle factors may cause or prolong symptoms, imaging doesn’t make noses, injection reduces pain in 1 out of 5 people, no difference when exercise is compared to surgery in the absence of significant trauma, and shared decision making is really important to input into you best management option. Thank you so much for taking your time out of your evening to listen, it is a real privilege to have the opportunity to speak to you and try to empower you and share some information about rotator cuff pain.

Often when we get shoulder pain you can get iit n lit lots of different areas, the pec muscle is quite a common area to get it, particularly when the rotator cuff isn’t doing its job, often the pec, muscle which normally helps moves the shoulder forward as we lift it has to take over the job of the rotator cuff because the rotator cuff isn’t doing its job and thats why we can often end up with pain in some of the pec muscles, They’ve been the symptom as the other muscles aren’t doing their job so when it comes to putting a rehab program together, we will look at trying to get the rotator cuff to function correctly. The rotator cuff is functional through everything, so exercises in lots of different directions and all its different roles are generally what we do so we try to fire up those small muscles, those deep rotator cuff muscles. Once they are up and running often we’ll then put in quite functional exercises things you might be familiar with things like floor press, or an overhead press with a dumbbell to build up the torque and strength of the muscles and again it depends what you are trying to get and depends on on what level of activity you want to get back to whether it is tennis or rock climbing or just doing the gardening. It’s not just exercising the shoulder, we know that increased physical activity helps recovery and so certainly if you’re not normally physically active will often give you and say for example a walking program to start getting you more physically active which can have a positive effect on recovery. It is important to be consistent with exercise for 12-16 weeks, it’s not just one exercise.

Yes that’s no problem, At sports medicine in the sports surgery clinic, if you just contact Sports Medicine Admin, we have a team that works in shoulders so if you say you have a shoulder problem they will generally put you in with someone who deals with shoulders.

We kind of know cortisone injections are transient relief, they are never really probably getting to the root of the cause and often they’ll settle the shoulder down, you may get some transient relief, they don’t work for everybody but certainly, if you had one use that as a good time to optimize the function of the shoulder so you want to try and build up the tendon capacity in the shoulder again getting nice and robust to tolerate load.

As I have mentioned in the talk, be aware that it’s not just the local shoulder that could affect the recovery, it’s making sure lifestyle changes are appropriate to try and get the outcome that you want, as well as addressing local shoulder exercises.

There is a lot of history in that question as we don’t know the full story of what you have undergone over those three years. The general advice would be to exercise first, the evidence has very much shown exercise versus manual therapy or acupuncture in terms of recovery and it’s not that you can have those stuff but certainly having a structured rehab program over a 12 to 16 weeks period, if you feel like you have tried that then I think its always reasonable to have a conversation with a surgeon but just be aware there is no guarantee with surgery like there is no guarantee exercise. The same things affect recovery with surgery things like if you are a smoker and your lifestyle will affect your outcome. Make sure you know the risks before making an informed decision.

X-rays are really useful, we generally use them for bone pathology so if we are concerned you had a fracture and perhaps we think something sinister was going on and we wanted to check the bone quality and make sure nothing was going on from a bone point of view then we would order an x-ray. If we’re more concerned about the rotator cuff tendons, or if there was a trauma and we would get an MRI to have a look at the muscles and tendons rather than an x-ray.

Frozen shoulder is a bit of what we think more of a systemic pathology so often frozen shoulder and through frozen shoulder presents with stiffness and pain, its not necessarily have to be an injury or a trauma, it generally isnt. We think it’s a systemic process that sets off this process of a frozen shoulder. You generally get it between the ages of 40 and 65. It is more common in women than men and it is more common in the non-dominant arm, but we they don’t know a definite answer to why some people get frozen shoulder and other people don’t.  It is very common for 1-5% of the population will get a frozen shoulder. I think is one of the most painful conditions of the shoulder. We know when it comes to people with systemic issues like diabetes, cardiovascular problems, or thyroid issues are more prone to getting a frozen shoulder but anyone can get it.

Again like any other comorbidity out there, there is also a relationship with lifestyle factors, since the lock down activity levels have decreased and stress levels have increased and I have seen the most frozen shoulders in the last 6 months compared to previous years which I think is related to less physical activity over lock down and more stress with working and working from home. Treatment wise, as we know from earlier on there is inflammation in the shoulder and you would generally benefit from a steroid injection, which is very different from your rotator cuff tendinopathy the evidence is quite strong, and most frozen shoulders that present to me I would send them for an injection to calm down the pain and they do quite well with an injection. When it comes to rehab as it is quite inflamed you get this thickening and what we call the collagen thickens in the capsule, aggressive physio earlier on is not recommended.

The best type of exercise is gentle activity keep moving and often I give a supervised program and coach people through the process. Truly frozen shoulders last anything between 12 months and up to 3 years even longer. They are very painful but the good news is they do usually do well with an injection and supervised rehab to coach you through the stiffness stages. There is a small number that will have to consider surgery.

To make an appointment please contact +353 1 526 2030 or email

Hip and Knee Surgery An Overview – Mr Gavin McHugh

Watch this video of Mr Gavin McHugh, Consultant Orthopaedic Surgeon discussing Hip and Knee Surgery.

This video was recorded as a part of  SSC Online Public Information Meeting focusing on the Hip and Knee.

Mr Gavin McHugh Sports Surgery Clinic

Mr Gavin McHugh is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic specialising in the hip and knee.

Good Evening ladies and gentlemen, Gavin McHugh is my name, I am an orthopaedic surgeon based at the Sports Surgery Clinic, I also work in Beaumont and Cappagh hospitals as well. I have been invited along this evening to talk about a few problems regarding the hip and knee and hopefully, I can shed some light on these issues, find out simple advice as to what you can do with certain things and we will also have a bit of a chat about what’s involved with going ahead with things like surgery in terms of joint replacements and the recovery process and how to know when and how to go with the problem.

We will start of with the hip and again it’s going to be really quite simple in terms of breaking down the problems that we see and the first problem that I would see, probably about ten times a week is an issue called bursitis off `the hip, so a lot of people think they have arthritis in their hip and they come to me and they point out over the side of almost the buttock area, so its out over right out on the outside and the first thing to say is that hip pain is actually right In the groin area, so often times when people have arthritis in the groin they have arthritis, they think they have a groin strain initially and that’s often that bursitis presents as a pain over the side of the hip so and classically patients come to me and say they’re having trouble sleeping at night, whenever they roll over on to their right side they get a pain out over the outside, generally they don’t have problems with things like moving the hip but going up things like up and down the stairs that involves quite a bit of hip movement can re-create that pain over the outside shall we say off the thigh area as well, sometimes it radiates down to the side of the leg as well, but quite often it’s just a localized pain and you know what straight away clinically is when you over the thigh area, patients generally hop and yell that’s really sore. I say it quite frequently the vast majority of times it can be settled down with some sort of physiotherapy to help strengthen the glutes abductors and posterior chain is generally and quite frequently I’ll also inject it as well and a lot of times GPs will be willing to inject this as well if not sports medicine physicians will often inject it as well. There are plenty of options there in terms of who to go with and who to deal with that. Quite often find it takes a second or even a third injection to knock it for six but generally we’ll be able to get that to settle down without an operation as such.

Straight on to the next problem which is just arthritis in your hip and how do you know when you’re getting arthritis in your hip. I suppose it’s a good question because a lot of the time, arthritis creeps up on people slowly and subtly over years and years and it can start with a little bit of an ache right in the groin area, and sometimes it comes on after say a couple of miles of walk initially, sometimes people notice that they’re having a little bit more trouble getting their shoes and socks on things like that. It’s usually only later in the process that they’ll get a lot of pain at night time and where it’s often waking people from sleep and so as I say it often comes on quite subtly initially. What to do initially, not a lot is the answer, simple allergies just taking paracetamol can often help, anti-inflammatory are usually the most effective painkiller for any musculoskeletal issues in general but obviously, they come with the risk regarding your tummy in terms of potential for ulcers and a small risk of other things like cardiac issues and stuff so, That has to be offset but at the same time you can’t be going around in pain all the time. What I often say to people is if you know you’re going for a long walk or if you know you’re going to be playing a game of tennis or golf or whatever you do, you might just take an anti-inflammatory just before that and quite often people can get through in a couple of years, before moving on to the next level. In terms of physiotherapy for arthritis in your hip, absolutely in terms of strengthening issues but I often find that people who put a lot of into deep stretching to try and improve the movement will frequently exacerbate the problem and I think that’s just where were basically what you’re causing is an actual pinch in the hip itself so part of the arthritis process involves more bone being formed around the ball itself and to try and force that movement as I say frequently just aggravates things rather than improving it. I tend to say to people to work really within their comfort zone in terms of the range and not to push those ends and movements too much.

How do you know it’s time to go ahead with something more substantial? In terms of arthritis and the hip the only real option is a hip replacement, Injections for the odd person can give some temporary relief but in comparison to knee problems, I find it’s often quite short-lived, it is not something that I would recommend a lot. Ultimately for me, all it comes down to is it is time or a joint replacement or not. It’s time for a joint replacement when you have pain daily that is significantly interfering with your day to day activities so if you find that you play golf or you play tennis or something and you’re saying no frequently to this because you know you’re going to end up in pain afterward and you pay that price for the rest of the evening or the following day and you’ve stopped and done well that’s when this time as far as I’m concerned to start to consider something more like a joint replacement. It’s not to say that it is still a significant operation and it’s an operation that comes with risks, why am I then so happy to recommend it? Well we know that patients with moderate symptoms shall we say are the group that ends up benefiting the most following the joint replacement surgery so it’s not the most severe group, the most severe group I often Say t people it’s almost nearly like the ship has already sailed whereas if you got moderate symptoms and you’re still just about clinging on to being able to do all the activities you want but that very easily you can get that back again after the surgery.

In the recovery process after hip replacement, in general, most people are back to see me in about six weeks and most are doing very well at that stage either of crutches completely or just using one walking stick or one crutch but it depends and varies from person to person. Overall by three months the vast majority of people are more or less completely recovered at that stage. In terms of hips, is there anything else? What I often get asked about is people who come with both hips and its something I have moved more and more towards over the years in terms of replacing both hips at the same time a few years ago it sort of came as a real shock to people that this could be done and its now something I would be a strong advocate for. If both hips where one is bad as the other, then as far as I’m concerned as long as your fit it, it’s an absolute no-brainer. You get to recover both at the same time. The risks of surgery that risks of having both hips replaced at the same time are lower than if you had one done followed by one done a few months later and there is evidence to show this.

Then if I just move on then to a few issues with regards to the knee. So first of all just in terms, which we see again all the time is meniscal tears or tears in the cartilage that people will talk about. Quite often patients in their 40s and 50s, they’re out walking or sometimes there getting up from a sleeping position and they feel a relatively sudden onset of pain in the knee usually associated with my swelling in the knee and uncomfortable over a localized area, most common in the inside knuckle of the knee. The vast majority of the time this will settle down with painkillers as we talked about, over time if it’s not settling down then it’s time to get the ball rolling in terms of going to see your GP and potentially getting more organized.

The first I usually do is to inject the knee, injections in the hip don’t often give lasting relief. Injections for cartilage in the knee will often give a few months of relief.  Then moving on overtime the knee shock absorber has been damaged and this over time leads to arthritis. From the arthritis point of view, pretty similar to the hip what goes well things like injections can work well to give you some temporary relief and there are plenty of injection options. In terms of more definitive treatment, you’re moving up into the replacement territory. In terms of replacement, I am a fan of partial knee replacement rather than full knee replacements. A full knee replacement is a significant surgery and day out of searching for what’s involved and the recovery. The recovery is 6 months, it’s certainly 3-4 months until you are back on track. A partial knee replacement, you just replace one knuckle on the knee, it’s a much smaller implant, and up to 50% are suitable for partial knee replacement, where the pain is localized to one area. It’s a smaller operation, smaller implant, and a lower risk of clots and injections, heart attacks, and DMTs. Reduced risks of almost a 1/3 in comparison to full knee replacements. It feels more like your old knee compared to a full knee replacement you can feel the replacement. They last almost as full as full knee replacement, almost as the remaining part of the knee can deteriorate over time but it’s only 2% over ten years.

In terms of what’s involved in the recovery, from the knee and hip, well here at the Sports Surgery Clinic you’re talking a 2-3 night stay after your surgery. When do you go home after a joint replacement? Well, you go home when your pain is controlled and you are safe and mobile. If that’s the following day perfect, if it’s 2-3 days later then that’s fine as well, everyone has their own pace. The partial knee is usually the day after or two. You give crutches when your here and you wean yourself off after a few weeks, some people that are 6 weeks other 2-3 weeks, you can do this by increasing your mobility around the house and then venturing yourself out. You are much better at taking your time instead of limping around. In terms of the recovery in general, Hips tend to find it easier, knees find it every bit as hard as they were expecting even more so. Quite frequently than with the last one that leads me to the point of both knees at the same time.

It’s something I do quite often. I have a very low threshold of doing both partial knees at the same, for both full knees and total knee replacement is a significant undertaking for people, but I would describe it as really grabbing the bull by the horn in terms of this is someone who rents to get themselves sorted and get recovered again. I always ask everyone that has both knees replaced was it easy, they say no it was horrendous, Then I ask do they regret having them both done at the same time and they say not as I wouldn’t have come back for the second one. With that sort of semi not so pleasant thought, they do end up coming back but another couple of years later when they have deteriorated, even more, it’s the reason I have come more around to it in fixing the problem as quickly as we can to get people back and the sooner we get people back fit and active, the better it is in so many ways in their overall health and the pain relief they get. If you are struggling every day it is time to get something done about it. Get it fixed back on track because there is no sense in sliding down that slope as such in terms of deteriorating further and further. I hope I raised a few issues today and I hope you found it interesting. Thank you so much for listening today.

It isn’t ideal to go ahead with a joint replacement in your 40’s or even 30’s or 20’s if necessary, but occasionally that is the case we find ourselves in but it just really just comes down to weighing up the potential benefits and the relief what you are potentially setting someone up for in the future all right.

If someone is in their early 40’s are they looking at having a joint replacement revised again in their 60’s or late 70’s. If you are in your 50’s there is a 30% chance roughly that you are going to end up having a revision done at some stage in your lifetime. In your 40’s that may rise to a 50 / 50 chance of having it done again. If you’re in your 30’s you almost certainly going to end up having something again. It just weighs down and boils down to sort of weighing that up with the potential benefits and how bad someone is. If someone is experiencing night pain and it is waking you up every night from sleep multiple times and it is holding you back from the things that you like to do day to day then potentially then you’re shifting towards having something done about it.

I would look at a joint replacement as in general an opportunity to get back doing things and the only sort of reservation that I would place on a hip replacement or even a knee replacement to a lesser extent is not going back for significant road runs and by that I mean it’s fine if you’re in the gym doing a kilometre warm-up or something on a treadmill but if you’re someone that loves going out for 3-10 mile runs per week then you know I would say pick up, cycling something like that.

Aside from that I mean I’m happy for people to go back playing tennis, I’m happy for people to go back playing indoor soccer, I’m happy for them to go back riding a motorbike absolutely and playing with the kids, that’s the whole point of getting a joint that you are able to do that after. In general, the answer is yes rather than no to activities like that for me.

It depends on what you define by out of action. The rehab starts that day quite often and you’re up to taking a few steps the day of the surgery by the time you’re going home which is 2-3 days later, you’re independently mobile right and I’ll often encourage people to get off crutches around the house one to weeks, not everyone is able to do that for a lot of people they might still require even one crutch at six weeks, they might still be using two crutches for 4-5 weeks when out and about.

As a guide it really depends, you’re not going to be lifting big lumps of children around the place, you could be talking around 4 weeks. People going back to office work, a couple of weeks is quite possible if you are self-employed but don’t make the mistake of selling yourself short. The most important thing is your own recovery, you have to say I’m going to be out of action for 6-8 weeks pending review and get it right as this is the most important thing.

It’s not essential by any means but you do certainly see some knees in particularly if people have been quite reliant on anti-inflammatories for a good period of time before surgery, I think they almost need to wean themselves of them and if they get a little bit of rebound inflammation, so yeah not frequently you’ll get someone who might need to take one every other day for a period of time but it’s just modulated by the swelling and in the joint, if it feels good then absolutely not, but if it is a bit inflamed then potentially yes.

Yes is the answer to that but actually, quite marginally so, the way I explain that to people is that you’re leaving 2/3 of the knee behind, so obviously there’s a chance that can deteriorate. If you look at the UK joint registry the figures for the 10-year survival for a total knee, an average for a total knee is 96 percent, for a partial knee which is the zookas that is the phrase that I use but I just have to compare it with something it’s 94 percent. So a 2 percent difference for keeping 2/3 of your knee. I’d often say to people even if that figure was 10 percent, I would take it tonight because the benefits more than outweigh those risks. Marginal but yes is the answer.

To make an appointment with Mr Gavin McHugh please contact 01 526 2367 or email

Joint Lab: Optimising recovery from your knee replacement – Neil Welch

Watch this video of Neil Welch, Head of SSC Lab discussing ‘Joint Lab: Optimising recovery from your knee replacement’.

This video was recorded as a part of  SSC Online Public Information Meeting focusing on the Hip and Knee.

Lorem ipsum Neil Welch is Head of Lab at SSC Sports Medicine.

Good evening everyone, my name is Neil Welch – Head of SSC Lab Services at the Sports Medicine Department in the Sports Surgery Clinic in Santry. I would like to spend some time talking to you about your health, your fitness, and rehabilitation. In particular, the journey we may take throughout our lives, how that journey can change depending on our circumstances, and hopefully give you an understanding of how important it is to try and adopt some activities whether it is fitness, personal training, or organized activities to help maintain your fitness throughout your lifetime.

The first thing I want to start by saying is everybody’s journey is different we all have our path that we follow throughout our lifetime. I don’t want to come across as judging anyone for the number of activities they do or don’t do. The aim today is simply to help you understand the impacts of the paths that we do follow and to give a little bit of guidance hopefully to paths that guide each of us to better health.

When I talk about fitness and health, I am going to split it into 3 categories. The first is Musculoskeletal, this is the health of the muscles and the bones and joints within the body. The second subject we are going to touch on is our cardiovascular fitness, the health of your heart, lungs, and pulmonary system. Then as a general health element, we will discuss your BMI and body fat percentage. To help us through this journey, I want us to try and imagine that we are either a twin or we have some twins and we are going to step through a fitness journey with this pair here. We are going to call them Jack and Sarah. Being the good parents that we are, we guided them through their early years and into some activities so like GAA, camogie, hurling, soccer, rugby, athletics, some organized sports for our children that we are always keen to do as parents I think, to promote physical activity.

By doing this we cover several positive developments in their physical developments. The first is around optimizing skeletal Health. So we stepped forward a bit into our 50/60s osteoporosis and osteopenia the elements we want to try and avoid. We avoid these by having healthier bones essentially and higher bone density and bone mass. Physical activity in childhood could be a way to protect ourselves in that going forward. So what this study demonstrated were the activities that we may undertake have a massive difference in the challenge that they offer the body. We can see from this graph at the very bottom is the amount of force that the body has to cope with while standing still, that dotted line while walking and then the spikes and ground reaction force, that the body has to cope with while running and during a landing task which we might also equate to decelerating change direction during field sport are all very different and very often the impact loads that are sustained during running and field sports are castigated being a negative thing, and they can be if we do too much of them, so if we have children who are very active and are training every single day and sometimes a couple of times a day, we can give them too much and we can get bony stress responses but for the most part these kind of impact loads are health and the body changes itself to be able to cope with so the bones become denser and they become stronger. By asking Jack and Sarah to pop down to their training sessions we are helping to strengthen their bones and limit the chances of these issues later on in life.

We often adopt physical activity and promote it amongst our children, to promote healthy body weight. We know that obesity particularly well throughout the whole population icon the rise and pediatric obesity is no different. This systematic review looked at studies around obesity in children and whether youth sports do anything to prevent it okay and then the results of this study are inconclusive, so we can’t say certainly that exercise is going to prevent obesity in childhood it seems like it’s a much broader topic and nutrition plays a much bigger role or as big a role as an exercise in preventing it. So moving away from junk foods and high sugar foods seem to be as or if not more important than exercise for saving off weight as youngsters. We also know as well that physical activity reduces cardiovascular risk factors in children, so a healthier heart and lungs, and circulatory system leads to fewer complications in children and this then carries forward into later life in part because we take on healthy lifestyle choices and habits so we maintain a lot more physical activity when were more active were young, so when we think back to jack and Sarah there’s a whole heap of benefits were given to both of them just simply by bringing them down to sport and helping them to participate inactivity.

Now we are going to step up upon a scenario, so we imagine jack who’s active and enjoys his football, come across some tricky times with injury, he’s unable to rebuild rehabilitate himself to a position where he can get back, he didn’t rehabilitate here but that ends his sporting journey, he gets to a stage where it is not worth him picking up the niggles and he stops playing sports and that’s probably a fork in the road that a number of us watching tonight have stumbled upon. Sarah on the other hand stays fit healthy, enjoys a sport, stays engaged with it, and continues playing sport throughout her adult life. So we end up with this little fork in the road, so what happens there. We think first of all around our musculoskeletal system so muscular strength is really important for reducing all-cause mortality which might come as a surprise to you but this is a large review study so there are over two million or approximately two million participants worth of data over 38 studies essentially the strong you are in the lower and upper body the lower risk of all-cause mortality in the adult population so essentially you live longer and this association was higher among females. So again if we think back to Sarah and Jack and by removing some of the strong stimuli that we might get with exercise we maybe predispose them to further issues in adulthood, similarly we remain active ourselves again maybe we are doing ourselves a disservice in terms of our longer-term health and we know that as we age we lose muscle mass anyway this is a process called sarcopenia and the example here is an MRI of the thigh and we can see on the left-hand side the muscle mass so that’s the grey elements around the white bone at the center now the white ring around the outside is subcutaneous fat, so it’s the fact that you have just sat below the skin. In the second image, we can see how that changes so the muscles mass reduces and the amount of the percentage fat we have increased and then graph on the right-hand side is it just indicates how the number of muscle fibers reduces throughout our lifetime so that’s the battle was trying to have as we go through the aging process. Activity can influence this, here we have an MRI slice of the thigh with a 40-year-old triathlete again the white thigh bone in the middle and the grey muscle around it, and a very thin layer and a tiny layer of fat around the outside. Then we have our 74-year-old sedentary man as an example so again we can see how the size and the quadriceps are reduced and the amount of adipose or fat tissue that can exist around the quads then. We can also see an example of a 70-year-old triathlete and we can see the difference in condition.

There are also cardiovascular effects and exercise benefits without going into too much detail, we reduce our risk of cardiovascular disease and cardiovascular mortality. The elements on there you will recognize are our reduced resting blood pressure and reduced blood pressure as well also reduce resting heart rate. So again lots of positives to remaining physically active. The dotted lines are those who didn’t do exercise and the black lines are those who did exercise throughout the 12-week intervention. The lines going down indicate that they lost weight. It doesn’t matter what diet you take as long as you run a deficit you will lose weight. In the future those who did not exercise gained weight. So we see these graphs here, they have split this up into an a and b, one for smoking and non-smoking. I think it’s worth noting from the data that we have and the changes in risk when we adopt certain lifestyles. So broadly speaking this is the world health organization, we know that maintaining a healthy weight and maintaining physical activity, reduce our chances of type two diabetes, cardiovascular disease, We reduce falls in depression, dementia and there’s a certain healthy body healthy mind element to that joint and back pain and cancers reduce just by simply being more physically active. We talk about being more physically active, so what does that mean, essentially we look at the bright green on the left-hand side and we think of this as being our cardiovascular fitness, so exercise that gets us out of breath, a bit sweaty. 75 minutes of vigorous-intensity exercise or 150 minutes of moderate exercise is going to lower those risk factors. Reducing our sedentary lifestyle so sitting less and getting up and moving around more and then some form of strength exercises like the gym or yoga to build strength at least two days a week.

That brings us to what we do here at the Sports Surgery Clinic to try and help individuals with their health and fitness. My job as the Head of Lab Services is to try to introduce testing and rehabilitation or training interventions for everyone and wherever they are on their fitness journey. We think that offering information and education is important for shaping your rehabilitation from surgery and injury. Within the fitness realm offering testing services to ensure that your exercise strategies are doing what they need for you. It is simply to give you an understanding of where your current fitness and strength levels are currently and to give you guidance on what you need to work on. Our rehab lab testing is what we do for our injured patients for example if you were jack and injured your ankle you would come in for some isokinetic testing, so we measure the strength of his joints to hip knee, and ankle to try and understand where he was weak and we might need to work on. As well as getting some biomechanical information, to understand anything in the individual’s movement that they might need to change. Fitness lab, we can do vo2 max test to measure cardiovascular fitness, we measure body composition, upper and lower body strength measures, and explosive strength measures and we also give you an individualized strength and conditioning program to target your needs. We are starting our Health lab service which is more tailored to weight loss, we measure your resting metabolic rate, blood glucose monitoring, blood inflammatory monitoring, and body composition. Thank you for taking the time out to watch this and I hope it has been informative.

If you start thinking of your exercises divided into two categories, one of them is around cardiovascular health, exercises where you get out of breath and sweaty, these exercises look after the heart and lung function. That becomes more biased as we age. The other categories to maintain muscle mass would be resistance exercises, these would be elements if you were a member of a gym where you might simply use some of the machines in the gym for the lower body exercises like the leg press and the leg extension are excellent for maintaining muscle mass.

In the upper body, especially in females, we see more of a loss in muscles mass and strength in females. Pushing and pulling exercises again there are machines. The exercises should be tough enough so they feel a bit sore. If you do strength exercises twice a week you can maintain and even gain more muscle mass. It is also very healthy for the joints and tendons as well, there is good evidence emerging of this.

Similar to what I was saying and without being an expert on the hormonal changes and systematic changes that join them during menopause. I’d say first of all if you have any severe symptoms then chat to your GP first before engaging in physical activity, but as a general rule doing stuff where you feel comfortable doing it would be a good guideline initially.

Then to just do what you can, if you go through periods where it is a real struggle through symptoms and pain then you just do what you’re able to and you’ll find there’s very often a certain psychological benefit to doing some exercises as well that might even give a little bit of a lift during periods where there’s more pain or symptom.

My first taught there is about the range of motion in the hip. If you are sitting in a kayak you would need 90 degrees plus of hip flexion, so if you can get your full range of hip flexion back then it shouldn’t be a challenge. Then there is a cardiovascular component to kayaking and a bit of strength loss with the upper body so I would be thinking from a cardiovascular perspective, you might be reliant on the bike, to begin with, to maintain their fitness and upper limb strength you can maintain again relatively straightforwardly in the gym, to limit the strength loss you will have from just not doing kayaking anymore. The main limiting factor would be I would expect a hip range of motion

Getting advice and finding a physiotherapist that you trust to give you some guidance on that and some things you will be surprised by how much you can do relatively early on the following surgery, the area that takes the longest period regaining the loss of muscle through that will have occurred following a long period of pain preceding the surgery and then also the surgery itself that’s what we find its re-gaining the size and strength of the muscles around the knee joint that is always the slowest.

What you are trying to do before surgery is minimize the muscle loss or gain as much muscle as you can beforehand but also there is a challenge there in that depending on symptoms, you don’t want any of your exercises to flare up lots of pain or symptoms around the hip as you want to preserve as much range of motion before surgery as possible.

Oftentimes when you exercise into pain you kind of speed the loss of strength anyways, so exercises in particular for your bum, the back of your bum so exercises like a glute bridge, for example, banded clam exercises for the side of the hip and then basic hip flexor exercises as well, anything that doesn’t cause pain but makes the muscle work hard is going to give you as much benefit as possible. You might find you can do more than this before your surgery, you might speak to someone before to get a more challenging strength program, which puts you in a better place before the surgery.

This can be quite dependent on and Gavin might expand on this, depending on what the knee is like before surgery and the period that there’s been a loss of flexion for. So if its been 5 years and you have only had 90-degree knee bend, then it’s unlikely that you are going to restore full flexion compared to the other side, so unfortunately I think it’s a how long is a piece of string kind of scenario there but you would expect whatever range of motion is going to come back, you should have that restored certainly within 9 months following surgery.

To make an appointment please contact 01 526 2030

Common Knee Problems & Golf – Mr Dan Withers

Watch this video of Mr Dan Withers, Consultant Orthopaedic Surgeon specialising in the knee discussing  ‘Common Knee Problems and Golf.’

This video was recorded as a part of SSC Evening for Golfers in January.

Mr Dan WithersMr Dan Withers is a Consultant Orthopaedic Surgeon specilising in the knee at SSC.

Hello, my name is Dan Withers, I am one of the knee surgeons here at the Sports Surgery Clinic. Thanks for watching my talk here on ‘Common Knee Problems and Golf’. To put a disclaimer out there, if anyone is watching this and is hoping to reduce their handicap, there is no money-back guarantee, I won’t be able to help you with that, but hopefully, I will be able to teach you a few things about the common issues with the knee and golf’

Just to talk about the background, as a knee surgeon most of the operations that I would perform are things like knee replacements – that includes partial knee replacements and total knee replacements. Then the other half of what I do is a lot of sports knee injuries, mostly the famous ACL ligament reconstructions, surgery on meniscus injuries and various other ligaments, and also doing some operations on knee cap patella instability. When you talk about the knee, the anatomy of the knee, what the knee is made up of its bones, ligaments, and meniscus. The bones that make up the knee include the Femur or thigh bone, the Tibia or shin bone, and the Patella or knee cap at the front of the knee, that’s are the 3 main parts of the knee. In between the main hinge parts of the joints of the thigh and shin bone, we have C shape cushions, on the inside of the Medial Meniscus and one on the outside of the Lateral Meniscus, essentially they act as little shock absorbers and distribute the forces that go through the knee joints. Then the other part of the knee is the ligaments, there are four main ligaments, you can see two green ones on either side there, that’s the medial collateral ligament, towards the inside part of the knee and then the lateral collateral ligament, that goes towards the outside part of the knee. The blue ligament there is the Anterior Cruciate Ligament and then the yellow one there is the Posterior Cruciate Ligament. The Anterior Cruciate Ligament is the main sort of stabilizer for the rotary and stability of the knee and then the Posterior Cruciate Ligament stops the backward motion of the shin bone or the thigh bone.

The most common issues that would relate to golf, now there js a lot of different knee issues, but two main ones that I would see would be related to Osteoarthritis of the knee joint and Meniscal Tears. They are defiantly two of the most common things. Funny enough, two of the most high-profile golfers, have those injuries, Brook Koepka had a dislocated knee cap, whenever he had his injuries, then Tiger Woods, he had a torn ACL, which he had reconstructed, but subsidence to the reconstruction, I think he had some ongoing issues because of the instability and he had a couple of other operations, they did a proper job on it last year.

The Articular Cartlidge of the knee joint, basically what happens in osteoarthritis is the ‘wear and tear’ thing, the main issue of Anterior Cartlidge, it’s normally that nice shiny tissue on the end of the bone that allows the joint to glide on top of each other. The main issue really with it is that it has no nerve or blood supply, so whenever it is damaged it doesn’t have the acute ability to regenerate itself. It affects pretty much every joint of the body, but very commonly it affects the knee and the hip, and also the neck and back, which would be other common areas that would be affected.

Sometimes you hear various people talking about different stages of Osteoarthritis (OA) and really what that means, these pictures here are from arthroscopic pictures of the knee, you can see the cartridge. In picture A there, you see the little probe pressing into the cartridge, it’s a little soft and you see the indentation there, this is very, very early stages of wear and tear of the cartilage and that’s stage one. Stage 2 is pictures B and C, at that stage, you start to get a little bit of fraying and fibration of the cartridge itself. In picture D there, you see some partial thickness loss of the cartilage and then in pictures E and F, it actually wears right down to the bone and sometimes you might hear people saying they have stage 4 OA or bone on bone, which is another common phrase people may use.

The risk factors for OA include age – everyone, as you start to get older develop some sort of wear or tear, and around about 50% of people, of adults over their lifetime, will develop symptoms at some stage or another of OA with around aboutb25% having symptoms related to the hip over their lifetime. Obesity causes more forces to go through the knee. The more pressure and the more wear and tear can develop, history of the previous injury, family history, overuse, and also muscles weakness and imbalance.  They can all be risk factors in developing OA.

However, there is a large proportion of people who are a-symptomatic of OA, as I say if you scan a lot of peoples knees, to some degree you might see a little bit of wear and tear, there have been studies performed before where people have had MRI’s of their knee and around about 40% of adults over 40 years old show signs of Osteoarthritic change on the scan, some may have been fairly minor ranging up to the more severe stage 4. Reasons, why you may not develop symptoms, could be to do a lot with the strength of the muscles around the joint itself and the biomechanics have an important role themselves in keeping the symptoms of OA. This is actually an interesting little study as well, sometimes people may get a little bit worried that they might need to go through some form of knee replacement or something like that, but actually, this study here that is from Spain and involved around 50,000 people and they looked at around 50,000 people, and everyone who was diagnosed with a GP with having OA change, only 30% of those people who had a diagnosis had to go through a knee replacement. As mentioned before obesity/increased weight was a risk factor that increased your risk of requiring some sort of knee replacement. As mentioned this is what OA looks like, you get wearing away of the cartilage and that wears down to the bone. You also may develop little bits of extra bone called Osteophytes as your bone tries to regenerate but does it abnormally.

The symptoms, well the main symptom is pain and the pain can be quite severe, some patients may have a limited range of motions/stiffness, swelling, pain after standing for long periods and walking around the golf and some people may develop night pain, that can be an indication of its getting quite bad where you may need to consider some form of knee replacement or some form of treatment. How do you diagnose it? A clean x-ray or MRI scan will show it up, as you can see here in the picture of the knee on the left of the screen where you can see very severe arthritic change here there is no gap between the joint, where the other knee here you can see a gap between the joint there.

Treatment – I would start with conservative management, taking simple painkillers, starting with a simple thing like paracetamol or anti-inflammatory, sometimes it’s not a bad idea to say if you’re going for a round of golf to take a few anti-inflammatory 1 or 2 hours before you go out to play and that may prevent a build-up of pain that may develop during the round or after. Weight loss – as we said would help and it is well known that around 7 times your body weight through the knee on certain activities, so even if you lost one kilo that’s 7 kilos of force less through the knee joint. Sometimes people ask about supplements – if you look at the evidence for supplements, there is no clear evidence that any supplement prevents osteoarthritis. There is some evidence to suggest things like glucosamine and chondroitin may have a small role in pain relief of symptomatic OA. It’s all about breaking the pain cycle, you will develop pain and because you have pain will start to become less active because you don’t want to be injured more, your muscles become deconditioned and less strong and more forced on the joint. It then turns into a vicious cycle, it becomes more painful and weaker.

This is something interesting here, everyone, as they get older, will have decreased muscle strength and this is an MRI scan showing quite clearly of someone who had an MRI scan of their thigh at age 25 on the left there and then at age 63, the same person who can see the muscle there is a lot smaller. The main muscle groups you want to strengthen up when you have issues with the knee are the quadriceps muscles and the glute muscles which are your bum muscles. You can do that by starting with some simples things like a bit of conditioning on an exercise stationary bike, there is good evidence that aquatic therapy is good for OA and reduces symptoms, Then there are some simple exercises that you could do like some straight leg raises and then you can do that with some resistance bands. You can do single-leg hip raise, hip bridge and wall sit, goblet squats. They can help a lot in terms of symptoms.

If you are still in a lot of pain, you might consider injections to help, there any many different types of injections – there is a standard Corticosteroid, Hyaluronic Acid, and Platelet Rich Plasma. If you have tried all these options and are still having pf pain, this is something you may end up having, this is a total knee replacement. This is an x-ray of that afterward, then this is something called a partial knee replacement which is also quite a good option, this is used on people who have very specific wear and tear and has slightly easier recovery and slightly quicker.

That’s OA, the other thing I mentioned is Meniscal Tears. Meniscal Tears are very common they occur frequently. If you scanned everyone over 40 years old you would see probably 30% of people would have a meniscal tear, not everyone will have symptoms, and the most common type of tear would probably be a degenerative tear. Normally the symptoms of Meniscal Tears would be a short history and it develops quite quickly, people tend to have sharp pain, sometimes people may have some catching and locking.

Diagnosis- Is done through an MRI scan as you can see here this is looking at the knee from the side, the blue arrow is posting to the posterior or the back part of the meniscus itself and on that scan, there is a distinct black triangle, you can see the white line at the back of the triangle in the back and that signifies a tear.

The treatment for it – initially should be conservative management, I would normally recommend people to try some physiotherapy for at least 6-8 weeks, if it’s very painful we would try an injection to dampen down that pain and then if it is not settling then an arthroscopy can be done to debride the tear.

At some rates, knee problems are extremely common and the most common for golfers would be OA and Meniscal Tears. Conservative management is feasible in most knee conditions.  I would always recommend trying this as first-line management. Physiotherapy strength and conditioning are extremely important. That is all I have, if you have any questions id be more than happy to answer except any on golf as I’m defiantly not going to be any help to any of you, thank you very much once again.

Yes, parameniscal cysts are very common and there quite commonly found on MRI’s, basically they occur from some degeneration of the meniscus tissue itself and then you get a little bit of a fluid collection around the meniscus. If it’s pain-free I would leave it alone, unless it started causing problems.

This is a very common finding, even people with normal knees can find that it can crack, pop, and do all sorts of things. It’s generally never anything to worry about and a lot of the time what it can be is a little bit of roughness of the joint surface underneath the knee cap, and if it is not causing any pain at all, it’s generally fine, and it’s not to worry about that there doing any damage. I would just carry on as normal.

Knee replacement is a quality of life operation, so really it depends how bad the pain is and how much that is impacting on your quality of life and restricting all your daily activities, so if it gets to the point where you are on painkillers every day, you might not be able to walk more then 5-10 minutes before you’re getting paid, you’re having a lot of swelling, maybe you can’t even sleep at night with the pain, those are all sort of factors that you might start saying would indicate it’s time to get a knee replacement.

For me, age doesn’t matter as much, it’s about the symptoms and how much that’s impacting your quality of life. With regards to getting back to say something like golf, it would probably take I would say at least 3 months before you get back to any type of golf.

it’s much like the knee, I always say to everyone to some degree all of us will have a little bit of wear and tear in our joints, in our knee and your hip and some people may be affected with symptoms of it and others may not.

It depends on your symptoms and there was a slide there that I mentioned that around 30 % people of people in their lifetime would need a knee replacement and haven’t had a diagnosis of OA, so there is a large majority of people I would say of people who have wear and tear and don’t have the symptoms that would fit to need something like a hip replacement.

I suppose the short answer is yes, some people get relief off it, others don’t, it probably would help in the more mild-moderate cases of OA. It is as I mentioned one of the first-line treatments either hyaluronic acid or steroid injection or a platelet-rich plasma injection, it would be the initial treatment for me to try conservative management, so you inject it and get some physiotherapy.

Then give it a period of around 4-6months and see what type of benefit that would have and then you know to base your decision on whether or not you need to do something further based on how long relief that they’ve had from it.

If you look at a lot of the evidence on this, there’s not t great deal of evidence to say that any brace is actually going to do anything physically but what I normally say to people is if they feel as if it’s given some sort of symptomatic relief then I would say you can try it, normally I would say not too spend too much on any sort of fancy braces but yeah if it is given some type of relief, I would say go ahead yeah.

That’s very, very common and what it is normally, maybe as I mentioned in the talk there are two main parts of the knee, there Is the main hinge part between the thigh bone and the shin bone and then the other part is between the knee cap and the thigh bone, your patella, so it’s extremely common to get a little bit of wear and tear underneath the patella and when you have patellar wear when you’re coming downstairs or inclines, that’s the moment that part of the joint is being loaded more, so roughly about seven times your body weight that goes through the knee on these activities and that’s why it’s probably more sore doing these activities.

I have to say but whenever people do have patellofemoral degenerative changes it can be very well managed conservatively and generally doesn’t end up needing any knee replacement as such because it’s only really on activities such as going downhill or going downstairs.

If you have a meniscus tear and you’re pain-free I would say, yeah you should play on, it doesn’t mean you’re not going to cause any more damage to it, and if you are completely pain-free then sometimes you may not even need the surgery for it because as I mentioned before meniscal tears they can be a-symptomatic as well so if your managing fairly well and you’ve got the tear it doesn’t necessarily mean that you need to go and have the operation.

It depends on what type of tear it is, the orientation of the tear but generally the most common type of tear is degenerative meniscus tear and those types of tears don’t heal as such but what I normally say is they can become a-symptomatic whereby yes you have a tear but it does cause any symptoms but it doesn’t necessarily heal itself.

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