Archives: Recorded Events

My name is Ronan Kearney, and I’m a Sports and Exercise Medicine Consultant in the UPMC Sports Surgery Clinic. As we know, the UPMC Sports Surgery Clinic is made up of the main hospital as well as the Sports Medicine Department about 100 metres up the road. In that Sports Medicine Department, we have a number of consultation rooms, an injection room, a high-tech gym and rehabilitation facilities, and we’re lucky enough to have a full multi-disciplinary team with both Sports Medicine Consultants, specialist Physiotherapists, strength & conditioning coaches and player mechanisms all working together with our radiology colleagues in the main hospital.

Outside of the UPMC Sports Surgery Clinic, I’m lucky enough to work with a number of sports. I’ve worked in Golf both on the DP World Tour as well as the Legends Tour. I also work in GAA and the high-performance units in the Sports Institute Ireland, mainly with athletics preparing for Paris 2024.

Working in golf is very rewarding, and I hope I have learnt some things working in the league of golf that I can apply to the recreational golfer also. Today we’ll speak on a number of different golf-related injuries. It is first important to understand some of the basic biomechanics in the golf scene that relates to injury, as oftentimes, injuries are a result of biomechanics. Lower back pain is the most common golfing injury in both recreational and professional golfers, followed by the shoulder and elbow.

Firstly the golf swing is biomechanically fascinating in many ways; it is so impressive to see a top golfer show the control, coordination, power and precision to hit the ball. It is made up of a number of stretch-shortening cycles of muscle contractions. These are an important chain of events, with each cog in the wheel providing an important role, trying to ensure that the little white ball goes to the intended target. It is important to note that any weak link in the chain can have knock-on effects which can lead to either injury or, eventually, poor performance.

At each stage in the golf swing, there are different groups of muscles working in different ways. Not to get too bogged down by the different muscle groups, but if one or some of these groups are not working as normal for whatever reason, there can be knock-on effects that can lead to problems.

To give a background on the three more common mechanics in golfing that you might hear is the X-factor, Crunch Factor and Reverse- C we will speak a little more about this in the lower back section, but the X-Factor is a really a separation between the upper trunk and the pelvis at the backswing and during the downswing seen in figure A here. The Crunch Factor is a combination of the lateral complexion and axial angular velocity that impacts an early follow-through seen in the middle picture here. Reverse-C is the follow-through and trunk hyperextension; we will come back to that a little later.

Lower back pain in golf is very common; almost a third of amateurs and over half of professional golfers suffer from lower back pain at some stage. There are a number of factors that lead to back pain in golf; some are non-modifiable ones that we can’t change. Unfortunately, increasing age leads to an increased risk of lower back pain. If you have previously had episodes of Lower back pain in the past, you are more likely to have future episodes, and unfortunately, if you are male, you are more likely to have lower back pain also.

These are the modifiable risk factors for lower back pain in golf, and these are the factors that can be changed. This is where management can help. We know that BMI is where obese people or overweight, which leads to an increased risk of lower back pain,  poor strength, flexibility and coordination can also lead to lower back pain in golf. We will come to this a little bit later. Swing biomechanics play a role, and interestingly enough, a study has shown carrying a bag can increase the risk of lower back pain also. Back to the swing again, the swing is a repetitive motion with large angular velocities and loading force that is placed on the spine. We know the distance off the tee is associated with lower scores, and in professional games, it’s associated with higher earnings which many golfers are really trying to push for.

As a result, there has been an increase in golfers trying to adopt a modern swing technique, and there is much debate in golf, as you would all know about which swing is better. There is no right or wrong answer here in my eyes, and everyone is to be treated on an individual basis anyways. We know that generating more power and speed is associated with greater distance, but this can come at a cost; if the biomechanics or strength and conditioning are not right, this can lead to problems.

These are three different types of swing biomechanics that have been associated with lower back pain. An early extension where the hips come forward into the hand space as seen in the first box below, reverse C, which is at the end of follow through, which we get an increased lumbar extension and then a reverse back spine angle at the end of a back swing where again we see an overextension of the lumbar spine on the left-hand side. Overextension on the right-hand side suggests a crack spine angle, and again, this has been suggested in the literature.

With regards to swing biomechanics, a large review of biomechanics and lower back pain suggested that a number of factors in the swing can lead to lower back pain, I don’t want to get too technical here, but some are shown on the screen. The important part here is such mechanics are important to be identified, and those struggling with back pain are to work closely with their golf professional or coach to address these issues in their swing is an important factor in managing lower back pain in golf.

Flexibility also plays a role in management here, so we know that increasing and improving hip, shoulder, lumbar and thoracic range of movement can be a modifiable risk factor for lower back pain in golf, so another area we would focus on.

It is obvious that strength plays a large role in both the prevention and management of golfing injuries. The professional game has transformed over the last decade, with most of the top golfers putting in a huge amount of time and effort into strength and conditioning. The understanding of such interventions has led to a reduction in injury risks and improvements in performance. I think this principle can also be applied to recreational golfers.

These are just a number of types of causes of lower back pain that we commonly see in the UPMC Sports Surgery Clinic. They can be facet joint problems, nerve root impingement, disc problems, lumbar stress fractures common in the teenage athlete and sacroiliac joint problems.

So the importance here is that I suppose there are a number of differential diagnoses or reasons for the pain. To get to the root of the problem, the most important part of this really is proper thorough history and clinical examination; we are lucky that the UPMC Sports Surgery Clinic have a number of objective measures that we can test in terms of strength, flexibility and biomechanics related to golf injuries. We have excellent imaging facilities as well, which are a huge help when managing such injuries.

In terms of specific management, it will really depend on the diagnosis itself, and in general, these are the key core topics that need to be addressed with lower back pain in golf. Educating the person on injury and on the ways they can manage it is such an important part. Weight loss, as we mentioned, BMI earlier, is a modifiable factor. Improving muscle strength, control exercises and flexibility is a huge key part to play. Swing biomechanics would be mentioned working alongside the golfing professional with this to ensure there is nothing in the biomechanics side of things leading to the issue in the first place and then early golf-specific rehabilitation.

At the UPMC Sports Surgery Clinic, we are lucky enough to have access to a broad range of secondary management options if the first-line options aren’t working. Some of these options help the golfer provide a window of opportunity where pain doesn’t prevent the progression of the rehab.

Now to focus on shoulder injuries, which are a little bit less common than lower back pain in golf, but then again, eighteen percent of golfers in their lifetime are likely to have a shoulder injury. Mostly because of overuse or repetitive strains rather than an acute traumatic injury, more common in the lead shoulder, which is the left shoulder in right-handed golfers and the right shoulder in left-handed golfers. There are a number of certain risk factors for shoulder use in golf, such as overload, where there might be a deficit between muscular strength and flexibility and overuse.

When we look at the golf swing, the shoulder obviously moves through a significant range of movement through the swing. In the back swing on the left shoulder, there is large shoulder adduction and right shoulder external rotation before an explosive follow-through with left shoulder external rotation, left shoulder abduction and right shoulder adduction. So, again looking at the mechanics of the swing is important to see at what stage of the swing the pain occurs.

Potential shoulder injuries in golf include Subacromial impingement, Rotator cuff tendinopathy, a rotator cuff tear, acromioclavicular joint arthrosis, shoulder joint osteoarthritis and shoulder instability. There are many different types of shoulder problems involved.

Some symptoms to look for; so as we mentioned, where in the swing is your pain is an important question to ask yourself; the painful arc at what degree of movement of your shoulder brings on the pain gives us a good idea of where the source of the pain might be coming from, did you have any weakness in overhead activities, if you are struggling to lie on your side at night, or the movement of the shoulder joint just isn’t right, or if you have some pain or pins and needles down your arm and if your shoulder feels not fully stable or it feels like it is subluxing. These are important symptoms that give us a good clue in terms of what’s the cause of the pain or the symptoms.

Again looking at some investigations for shoulder injuries in golf, as I mentioned before, a really clear and thorough history and clinical examination give us a really good idea of where the issue lies. Strength assessment and flexibility assessment, as well as biomechanics, are important facets, especially in the developer, to address potential areas for improvement. Again imaging plays an important role in many situations where access to MRI is often used, and there are other injection options and other diagnostic options that we do have available to ourselves in the UPMC Sports Surgery Clinic.

Management of shoulder injuries and sports again brings us back to the main key facets; as I said before, management will really depend on the type of injury that you do have and what we really try to address are these key facets firstly. Educating on the injury itself and the importance of self-management, some strength-based individualized rehabilitation, and movement mechanics, as we have already mentioned in the shoulder, is important, as well as specific golf rehabilitation. Medication can sometimes be helpful as well, but we don’t over-rely on these.

We do have at our disposal a number of other ultrasound-guided injection therapies, including platelet-rich plasma, Corticosteroid, potential Nerve blocks or hydrogenation.

What is Platelet Rich Plasma or PRP? Many of you might be wondering if it is a form of regenerative medicine that harnesses the body’s ability to increase growth and healing factors to improve injury recovery. How it works is a blood sample is taken during a blood test. It is inserted into a centrifuge and spun down. Then the PRP portion, which contains the concentrated healing cells and factors, is injected actively under ultrasound guidance to target the tissue. PRP is shown to have less of a side effect profile than the traditional steroid injections in many cases, and in many cases, it is shown to outperform the steroid injection in the long term for many of the musculoskeletal side conditions, and we use it quite a lot in the UPMC Sports Surgery Clinic.

Elbow pain in golf, like shoulder pain in golf, elbow pain is mainly an overuse injury rather than an acute injury, and it happens in females more than in males. Most of the time, it is actually the lateral side of pain, so pain at the outside of the elbow typically turned ‘tennis elbow’ generically. In many ways, tennis elbow should be called golfers elbow, given the numbers.

There are a number of risk factors for elbow pain in golf, including overloading the area; if your grip is too tight or slippy, this can affect how tight you grip the club, and it will have an effect on the tension and force through the elbow. If you are hitting the ground before the ball or hitting some bad shots, unfortunately, that can lead to overuse elbow injuries and impact through the elbow, and some swinging changes that happen over too short of a period of time can also lead to overuse injuries in the elbow. It is important to consider the neck when having elbow pain, and this is often the source of the referred.

On the mechanic side of things and elbow pain in golfers, we talk a little bit about the wrist flexor burst, which is really that wrist hinge at impact and those with an increased risk hinge put more force through the lateral elbow in the lead elbow or the lateral side of the elbow in the lead side of the elbow and then the medial side forces in the trail elbow are increased with this increased risk hinge. It is so important to bring this into your grass swing over a slow period of time, or if you are having elbow pain, just ask your golf professional to have a look at your risk hinge and to see if there is an issue there.

Some of the different causes of elbow pain in golfers, so we will speak more on Epicondylopathy, which is your epicondylitis; tendon tear can also lead to elbow pain and golfers tendinopathy, nerve entrapment, elbow arthritis and, as I mentioned, some referred pain from the neck. There is a number of different types of causes of elbow pain in golfers, not just tennis elbow or golfers elbow. As I mentioned, these are the two commoner causes of elbow pain in golfers. Typically it is a golfers elbow on the outside of your elbow, or it is a tennis elbow if it is on the inside of your elbow.

Some symptoms to look for are a pain in wrist movements, burning forearm pain, pins/needles in the forearm, weakness in wrist movements, stiffness in elbow movements and the next day after activity. Elbow pain is another one to look for, which might be suspicious of your epicondylopathy or tendinopathy.

Similar to shoulder and lower back investigation, start with a thorough history and clinical examination, strength assessment, flexibility assessment, biomechanics assessment and further imaging if required.

After we have got to the root of the diagnosis of your elbow pain, we progress on to management. Our key main topics, as we have spoken about already, are education, strength-based rehabilitation, biomechanics and golf-specific rehabilitation. There is some evidence that suggests that support braces can be helpful for tennis elbow, and increasing grip size can potentially improve elbow pain as well, again something to consider on an individual basis.

Second-line options if first-line options are not working include medication options as well as ultrasound-guided injections such as PRP, corticosteroid and nerve hydro-dissection. There is a number of different options if the original first option didn’t go to plan.

We often use Extracorporeal Shock Wave Therapy in golfers or tennis elbow. How shock wave works are the shock waves that carry energy to the injured tissue, the shock waves can then generate tissue responses that can produce many advantages such as pain relief, increased blood flow, cell growth and, where needed, disruption of calcium deposits in the tissue a combination of these effects have leads to increase recovery and with specific rehab exercises. It can be an additional management option for you.

I’m sure some of you who are listening might be frequent flyers into physio and know what it’s all about; others might be listening to this thinking, I have no idea what to expect when I have back pain and attend a physiotherapist.

Firstly, your Physiotherapist will ask you to provide them with a history of your back pain. When did it start, how long has it been ongoing, and are there movements that make it worse or better?

Then a physical exam will examine how your back and hips move, and some strength measurements will be taken.

At the end of the session, there will be a conversation where you can ask questions, and we will go through some advice on treatments.

So physiotherapy sessions are usually divided into three sections, the history, the exam, and the treatment.

As healthcare professionals, physios are obliged to work within evidence-based treatment guidelines. This means that we have to offer and be up to date with all the evidence and research coming in through our field. If you’re going to see a physio, you should ensure that they are CORU registered to ensure they are keeping up with evidence and standards.

So the first thing is back pain can be really scary, but it doesn’t need to be. I hope this presentation will help alleviate some of the fears associated with low back pain.

I find with patients that their fear often comes from not understanding the source of their pain.

If you find yourself in this situation, I recommend you tell your Physiotherapist what is worrying you at the beginning of your consultation.

Now we will keep returning to this notion of the fingerprint. While back pain can be very straightforward to treat, it can also be complex. Think about your back pain as you would think of your fingerprint.

It is very specific to you as an individual. We will develop this idea later in the presentation but remember that your treatment needs to be tailored to your specific needs.

Looking at the background of low back pain, the picture at the top is from a paper published in the Lancer, a very well-respected Journal. In 2018, they did a vast series of documents highlighting how common and prevalent low back pain is.

It is the leading cause of disability globally, and at any point in time, about 550 million people are experiencing it at any one time, which is vast. Most people will experience it during their lifetime at some point.

I hope talks like this will help put the correct information out there and that people learn that low back pain isn’t necessarily something to be frightened of.  It is unpleasant, but it is very treatable, and people should know what to do and not do when they suffer back pain.

The biggest thing to take from this slide is that if you’re playing a numbers game, most cases of back pain must settle within six weeks. Somewhere between 80% and 90% of episodes will settle within six weeks if you do nothing without any treatment from your GP or Physio. That’s an empowering statistic because your back is always working behind the scenes to settle that pain.

Another thing to remember is that serious causes of back pain are extremely rare. Less than 1% of patients have something that is serious or requires ongoing management or investigations or has a serious underlying cause. So it is very rare.

But why do so many people feel there’s something seriously wrong?

When I talk to my patients, they believe something is seriously wrong with their backs, as their pain is excruciating. Back pain can be really sore. In the best cases, you are uncomfortable, unable to do the things you want to do. In worst-case scenarios, people experience excruciating pain so naturally, believe something to be seriously wrong.

I would like to reassure you that the pain and damage aren’t the same and that you can be sore but safe.

We break back pain into two categories. Specific and non-specific.

Specific back pain relates to 5% to 10%  of cases depending on which research you read. Specific means you can point to something or know the cause of your pain. It might be an infection because say you’ve had surgery. If there’s an infection in the back that’s a specific cause, or you’ve had a fracture in your back that’s a specific cause, we know exactly what’s causing it.

Everything else is called non-specific. So 80% to 90% of people fall into this category, and it’s unsatisfactory. It’s extensive, and I will explain why it’s so broad, but most people are in that non-specific low back pain category.

Timeline is another way to categorise back pain. Acute backpain refers to the first six weeks and persistent back pain for six weeks and onwards.

Why are so many people in that non-specific low back pain category and why can’t we tell exactly what’s causing their back pain?

Part of the reason is due to the anatomy of the lower back.

if you look at my finger here you can localise my anatomy around my finger, But if you look at the picture on the left the yellow bits are the spinal nerves and in between are joints. Two joints might be a centimetre apart on the left and a centimetre apart on the right and there’s a lot of anatomy within the same area. All of these body parts have a nerve supply so your skin, your muscles, your ligaments even the nerves of your discs have a nerve supply and they’re all very close together.

So if you’re lifting, carrying, moving or bending forward you’re going to be moving all of them so it’s very hard to say well look it’s absolutely one or the other causing the pain.

If you look at the picture on the right in terms of your lower back you will see the anatomy is very complex. There are a lot of muscles covering this area so we used to think we were able to diagnose precisely the cause of it every time – it’s just that the anatomy is too complicated to let us do that.

Discs have a nerve supply, so some problems can be very painful, and some discs can have degenerative changes. It’s just like getting arthritis in our knees, arthritis of our hips or growing hair and wrinkles. It’s part of our ageing process and doesn’t necessarily cause any pain.

Think about how your body adapts to that. If your discs change slowly over time, your body doesn’t see that as a problem. But if somebody has a sudden injury,  they fell down the stairs, and there was too much pressure or force, causing a sudden change, that disc can be painful.

Ten years ago, a significant study was conducted on 3000 people on this subject. A cohort of people between the ages of 20 to 80 who were not suffering from back pain was given an MRI.

MRI showed that 30 % of people in their 20s had disc bulges but no back pain. The figure was 50% for those aged 50 and over which is a significant amount of disc bulge with no symptoms of back pain.

So the MRI findings need to fit in with your own personal history and with your clinical patterns. You are subjective, and I think getting advice from your Physio or Healthcare practitioner around that is essential in order to interpret them correctly.

I spend a lot of time with people who are just given reports and understandably have a long list of things that come up from an MRI, and a lot of it is like grey hair and wrinkles; it’s part of how the body ages and not something to be worried about.

I like to focus on evidence-based exercises and treatments for low back pain. You may have heard of NICE or The  National Institute for Health and Care Excellence.

They are a huge research body that provides guidelines for rehabilitating things like low back pain or obesity, and smoking.  The same applies to Cochrane.

The following guidelines have been approved by these two bodies.

They are divided into Acute Low Back Pain and Persistent Low Back Pain.  As a reminder, Acute Low Back Pain is what we have from zero to six weeks, and this table is taken from the paper I referenced earlier on, and I have the reference for you at the very end of this presentation.

What is the evidence advising during the first six weeks?

The first advice is to remain active, but look at and pacing yourself, and manage what you need to do.  For example, if you have an irritated back in the first six weeks, this is not the time to try and run a personal best or do a big clear out in the house or swing the grandchildren around. It’s about doing what you can, pacing yourself, and maybe keeping yourself moving without overdoing it.

The interesting part here is exercise therapy has limited use in selected patients, so from a physio point of view, I tell people to do the movement things that they enjoy. I try to give them some basic exercises if needed. It’s more like telling people they’re sore but still safe, and I try to get them back into things they need to do.

You’ll know they’re at the very bottom for things like manual therapy, spinal manipulation massage, and Hands-On work should be in conjunction with the education and remaining active, so it shouldn’t be done by itself it’s if you’re seeing a Physio and they’re doing some Hands-On that’s fine. However, it still needs to come with advice and education as well.

To recap, here are the dos and don’ts for low back pain. If you want to take a picture of this slide, I don’t mind.

So do keep moving. You could talk to your pharmacist about pain relief; you can use hot water bottles and gentle mobility exercises to encourage normal movement. It is really important to stay at work where possible and don’t panic. Back Pain can be very sore but we want to try to get the body out of this fight or flight mode and back into a more relaxed state.

The advice 20-30 years ago was to stay in bed. Try not to stay in bed. Get up and move around every 20 minutes to half an hour. If you’re sitting, resting, standing up, sitting down, walking to the kitchen and back, and just trying to keep yourself moving.

I would say to patients at this time that they are sore, but they are safe.

Can pain be a good thing?

I’m sure everyone thinks that there’s no way pain can be a good thing and that I am actually like Pinocchio and that I’m telling lies, but I promise you I’m not especially in the acute phase of back pain.

Imagine your pain is your body trying to talk to you asking you to change your behaviour. There are a group of people with this genetic mutation who cannot feel pain. This sounds wonderful but their bodies don’t have a way to tell them if they have an infection or have broken a bone.

Their mortality rate is relatively high, so we need our pain system to work, and tell us what we need to pay attention to. It’s you’re body letting you know that we’re not going to go to the gym today and that we will do more gentle exercise. So our pain system must be there because it keeps that warning system in place, which is good.

Persistent Back Pain.

Persistent low back pain is when the pain is there longer than six to twelve weeks. If you are suffering for this amount of time I would recommend you visit your GP or Physiotherapist because you’ve suffered for long enough and there are lots of treatments available so there is no need to suffer.

The advice or evidence here is slightly different, so the advice is still to remain active and educated is still essential.  However, exercise therapy now becomes the first treatment. It’s as crucial that its used in conjunction with manual therapy, and actual hands-on treatment which is secondary. Exercise advice and education are all the first things that need to be part of your physio program, and some hands-on work can be used, but it needs to be done in conjunction with the above.

What are the challenges in treating persistent low back pain?

We are going to remember that this is like your fingerprint and pain has a context so the best example I can give for that is imagine that you’re having a really good day that you fall up the stairs at work and it’s really funny you think oh my gosh look I’ve landed on my knee and I’ve hurt myself. Imagine you’re late for work and you’ve got soaked going in from the car you fall off the chair land on your knee and everything is the worst you’re really sore.

The same thing has happened but the context is different so our thoughts, our feelings and our beliefs can shape the way we shape our pain experience remember that if we have an irritated or grumpy back that back is attached to a person in their lived experience so and all of our lived experiences are completely different. I will expand on this in a minute.

The paper I referenced earlier shows different factors can be at play in terms of feeding into low back pain. Things like genetic factors and biophysical factors. So there is strong evidence that people with low back pain have some changes in their strength and coordination. There are other comorbidities like anxiety, depression, social factors and things like stress that can add to the causes of low back pain while not necessarily being the root cause.

Remember that our pain and why low back pain has been persistent and more complex to treat is because everybody is going to have a different interplay or some people might have absolutely no stresses in life and none of that going on, and really all we need to focus on is the muscles and strengthening. For other people, the strengthening is not a big factor we need to focus on pacing and management so it really just depends.

Why is exercise important for treating back pain, and why is it recommended?

The American College of Sports Medicine has published guidelines on physical activity for adults. This is what we all should be doing anyway as healthy adults. Ideally, everybody needs 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity a week. In addition, we should be building our strength on two days or episodes a week.

This is quite a high amount of exercise, but it’s what we should be doing not just to be fit but to maintain a baseline level of health. So sometimes, patients with low back pain can miss out on the benefits of general exercise because they’re sore.

Why do we recommend our patients undergo strength or resistance training at SSC?

We encourage our patients to do some strength or resistance training here in Sports Medicine for several reasons.  In this slide, the bottom left is a picture of a cross-section of the human back.

The two dark circles at the very bottom are the back muscles. Resistance training can improve the amount of fat within a muscle. Another reason for promoting resistance training is it is very good for maintaining joint range of motion in our spine, inner hips and all over the body. It is excellent for building bone strength as well as building muscle strength.

Our lives require us to have a level of strength so if you think of pushing a shopping trolley, opening a heavy door, lifting grandchildren or walking to work, all of those things require us to have a certain level of strength, so it’s being able to meet the demands of your day-to-day tasks as well as the positive impact it has on our mental health.

Our Physiotherapy Department at UPMC Sports Surgery Clinic takes self-referrals. You can phone us on 01 5262040 or email sportsmedicine@sportssurgeryclinic.com for further inf

Do you have any recommendations for exercise that a person can do to help relieve pain from spinal arthritis in all three parts of the spine?

yeah I think so there’s some um there’s lots of great questions coming in and we’ll try to answer as many as we can but certainly with marks in terms of exercises like we spoke about in in the Talk looking at things that you enjoy so try to sometimes pay people with spinal arthritis they find that extremes of movement so it might be do yoga but maybe avoid an extreme back bend or stream front Bend if that doesn’t feel right to you so what I’d say in terms of guidelines and pain from spinal arthritis is that the odds nip or pinch with pain is okay if an exercise feels like you know you really don’t feel good afterwards it’s really making that pain worse that one isn’t for you so examples of things with spine arthritis there’s no limits you could run you can do yoga you can swim really looking at what trying to meet those recommended guidelines that I spoke about earlier try to get your enjoyment in but there’s no Bible or gold standard of the thing you absolutely have to have to do and that links in with Maureen’s question which that she spoke about having um some fusion due to arthritis so what that will mean if somebody has lots of arthritis down at the bottom of their spine some of the movement around that region isn’t going to be as good which we’d expect but what if you what you want to try to do is maximize the movement that you do have and maximize the areas above where the fusion is or where the arthritis is and below so it might be making sure you’re getting good hip range of motion and making sure you get good Lumbar and thoracic range of motion so from a treatment an excise point of view Mobility work, yoga will be nice and resistance training would be nice, medical questions I’ll leave I’ll leave for Matt, for that but it really is like our guidelines from earlier on is trying to meet recommended guidelines, do something that you enjoy and if something doesn’t feel right or is painful or if you want more specific advice I think I would chat to your own physio or GP.

A patient has been diagnosed with scoliosis-like species in the past year with grade one slippage of the vertebrae onto the L5 S1 nerve, causing severe back pain and groin weakness. He has been going to Physio and a chiropractor with limited results.

okay so I think my guess is follow-up questions to this patient, and we’re trying not to answer this more broadly because I haven’t assessed them myself. Still, certainly, it depends if you’ve been giving us a good go with a physio or a chiropractor treatment. Indeed, if it’s been going on for a while, I think Hands-On work from a physio or a chiropractor probably sounds like it’s not working, so I think a different approach might be worth there going back to the GP and looking for a second opinion.  So what all those terms mean for anybody who’s not familiar with them is just that there’s a little bit of movement of one of the vertebrae, which is putting pressure on a nerve. Some injection options and others depend on how severely you’re impacted from a particular exercise point of view, so certainly, I think if it’s not working with a physio or chiropractor, my first question is, what type of things are they doing with you? If it is more Hands-On, I would put a pin in that go back to the GP looking for an opinion and move from there.

I was wondering how long it takes the muscle condition to deteriorate within an activity, especially in the lumber area, okay?

That’s a great question, so I wonder whether that came from seeing the cross-section of the spine in the presentation earlier. I showed pictures of where there were lots of fatty infiltrates that can level of infiltrate for years, so that’s not something that would happen over weeks or a month, so that level of infiltration when someone is very sedentary takes years, so in terms of deconditioning so you can lose some muscle strength within two to three weeks. Still, you can get it back again really quickly, so I don’t want people to worry or necessarily that if they’ve been on holiday or if you’ve been, you know, unwell for a period that you know your muscle strength completely goes it doesn’t and what you want to try to do is to get your muscles in good condition as best you can. So you’ve noticed the difference in, say, if you were in the gym and what you would lift if that’s a good level of muscle strength. It might be well you know I lifted my grandchild before I went to my six week holiday and have come back to I feel they are bit heavier you might notice some impact in your function after several weeks a very significant deterioration where there’s a tremendous amount of fatty infiltrates that takes years. Still, you can notice lower grade changes within a couple of months. I hope that answers that.

Hello everybody, good evening; I hope you’re enjoying the evening. I’m delighted to be able to join you and discuss the sports medicine doctor’s role in managing low back pain. My name is Dr Matt Cosgrave or Matthew, and by introducing a little bit of my background, I studied in Belfast at Queens University. I originally trained as a GP, working through various Specialties in the NHS. Then I moved down to Dublin to pursue a career in sport and exercise medicine and did my speciality training in Dublin outside of working in the clinic here at Santry. I work with a number of sports teams, but over the last three or four years, I’ve had the pleasure of mainly working with the Irish Women’s National Rugby team and, over the last couple of years, with Connacht rugby men’s senior team. From the point of view, what I hope for you to get out of my talk today is to answer these three questions do I need to see a sports medicine physician? Do I need an MRI, and do I need an injection? Before we get into things, I’d like to reassure you all that when we talk to patients, these are the three most common emotions that they present with in relation to low back pain worry over some underlying disease process or pathology that maybe they’re missing, confusion over often why their pain isn’t getting better or why their pain comes and goes unpredictably or apathy which is really a down to a lack of motivation around managing their pain and that no matter what they seem to do they’re always suffering. Interestingly enough, these three CM emotions are often what positions physiotherapists or General Practitioners experience with low back pain because it can be tricky. Still, hopefully, I will try and uncover some of the Hidden Truths Behind that today.

I don’t think we help ourselves by calling ourselves Sports Medicine Physicians; this is a common misconception that the only people that we treat are people who do sports or athletes; we are musculoskeletal Physicians, so yes, we do look out for teams, yes we do look after athletes, but we look after any active individual which from the point of view of day to day that’s the general public and the vast majority of the patients that we see in care are general public and are not high-flying athletes in any shape or form. About eighty percent of people at some stage in their life will experience low back pain. Interestingly, about eighty percent of these cases will improve on their own or with very little treatment within about six weeks. My rule comes into it whenever we have this huge chunk of 20 percent who are not improving over the three to six weeks or the three-month to six-month period, which can be a substantial number when you cross when you break it all down.

Really what the sports medicine physician does is considers do we need to order other investigations now this may be a scan of some description a CT an MRI or it may be some blood tests really the main role for us is to confirm a diagnosis often once we have the diagnosis actually managing the problem can be quite straightforward sometimes when we’re in the dark about the diagnosis we try and we almost have a trial and error process but if we can confirm a diagnosis it’s often fairly straightforward to get on a plan to recovery excluding severe pathology is a big part of this and this falls into the worry side of things for patients a big concern that patients often have is there some sort of underlying disease process such as cancer and that is extremely rare when it comes to low back pain but nonetheless when back pain has been going on for a long time it’s always something that we have in the back of our mind and it’s always something that we make sure we exclude we’ll also review the treatment plan that the physiotherapist or the GP has already put in place and we’ll see can we add to that we rarely change things significantly but we’ll make small adjustments and then finally we think about treatment adjuncts so rehab is a huge part of what we do here in the clinic but there’s always options for some additional help and often for us that falls in the way of injection therapy which I’ll discuss for you in a little bit further detail later.

The simple answer is no, not everybody needs an MRI, and most patients with low back pain don’t require an MRI. This great graphic explains why we don’t all need MRI. These are findings on individuals who are asymptomatic so people with no back pain have a variety of changes, and the percentage of patients who have changes increases with age; just for one example, this degeneration in this top area which is often reported on scans and often causes concern for patients nearly 100 percent of patients in their 80’s will have this degeneration but even more interesting at the age of 30 one in every two patients will have some degree of disc degeneration on their scan even if they are asymptomatic. Hence, a scan is not always necessary.

So when is the scan necessary?

We use scans; this is what the sports medicine position is looking for if we go clockwise from the top left; this is a condition called sacroiliitis. This is an inflammatory process where you get some inflammation in the base of the lumbar spine where the sacrum, a little triangular bone, fits into the pelvis; we look for sacroiliitis because it doesn’t normally respond to Conventional treatment. Usually, it’s caused by some inflammatory process in the Blood, and therefore we often need to give medication to reduce that inflammation in the blood, which will then reduce the inflammation in the joint; this is not very common and but when it does present it tends to be in the younger person. If we move over to the right, then we have this condition called facet irritation; this is a lumber spine from the side; the square blocks on the left are the vertical bodies, and they sit on top of intervertebral discs the vertebrae then communicate with each other and the back through something called a Facet Joint now this Facet Joint like any joint in the body a knee, a hip they can become irritated and inflamed so when we look at MRI scans of backs or patients who are not improving we’re often looking to see are there any individual joints that are irritated or inflamed that could be contributing the symptoms and therefore is there a Target for some injection therapy. In the bottom left, this is the view of a spine in cross-section, so this is like I’ve taken you lying down and then chopped you along, and I’m looking down the body; this pointy bit at the back is called a spinous process, and this is the area that we feel when we feel down in the back. In patients, again usually young patients who are very active and who do sports that involve a lot of bending off the back, so gymnastics or tennis, there is a risk of developing something called a porous fracture or a stress fracture, so in the younger patient especially this is always something that we want to exclude. Finally, which you’re probably most familiar with when it comes to low back pain is this condition in the bottom right called disc degeneration; the black circle in the center is the spinal cord the yellow marks to either side are the nerve Roots. When you get a disc bulge or a disc protrusion, the center of the disc, a jelly-like material, pushes out a little bit, and it causes the disc to bulge the disc itself doesn’t move. It creates a little bit of a bulging on the outside edge; now, this bulge can do a few things; one is it can create irritation around the nerve. The other is if it’s bad enough, it can put some pressure on the nerve, and then if we think about treating this often, what we think about doing is delivering some injection therapy, usually a steroid in and around this area to reduce inflammation and irritation and to reduce any pressure that’s on the nerve itself. Hence, these are the four main reasons why we do MRI scans, but we know specifically what we’re looking for; we’re not doing the scan and hoping that it gives us the answer we’re doing the scan because we think that we already know the answer and we’re trying to confirm or exclude that. From a disk point of view, I just wanted to give you a little bit more detail so from a disc bulge point of view, the reason this is important this is a spine on the left from the side this is the spine on the right from the front these grey areas that are running down the side and then are coming out on either side on the image on the right these are nerve roots your nerve Roots Supply your sensation and your part to different levels along your lower legs so when you come into us with symptoms what we do is we try to correlate whereabouts on the leg front, or back your symptoms are and then when we do your MRI scan we try to look at the disc at that level to see if it’s causing some pressure around the nerve root.

In many cases you will have disc bulging it doesn’t relate to your symptoms so you may have disc bulging at this L1 L2 level but your symptoms may be coming from L5 or L4 for that reason MRI’s are not useful in that they can create confusion for patients and sometimes for Physicians as well because we see disc bulging but it doesn’t marry up with what’s going on in the history .finally sorry I want to make a quick note on something which Katie has probably already discussed which is a degree of fatty  infiltration in the low back when we are less active we see a change from the left hand side where the muscles are nice and grey kind of like a fillet steak to on the far right hand side when the muscles are not being used because other areas of the back are having to work harder for example the facet joints then the back becomes weaker and we see this fatty infiltration if we see this on a scan it’s a very good indicator to us that you’ll respond well to rehab so in summary from an MRI point of view we’re looking to exclude significant disease we’re trying to correlate what we see and what you tell us with what we find on the image or on the MRI scan it’s really not guesswork and we’re not asking for the MRI to give us the answer.

Finally, we’re looking essentially if there is an area for injection. Hence, if we see a disc bulge or a Facet Joint, that’s irritated. If it fits with where you’re sure and where we examine you, then that’s usually a good Target for us to inject the injection is only part of the treatment plan, which I’ll discuss and that brings us on nicely. Do I need the injection? Injections are not always straightforward, and often patients are a bit apprehensive about them.  injection treatments are put into two major areas; one is for nerve root impingement, so if we have this disc pathology or there are other causes of nerve management, but if we have nerve root impingement, we’ve got two options, we’ve got a coral epidural injection, or we’ve got a more sophisticated CT guided nerve root injection again we’re correlating our MRI findings based on where your symptoms are. We are deciding on what level you need the injection.

Sometimes it’s not always clear exactly which level sometimes you might have a disc bulge at a couple of levels and sometimes you might have symptoms that correlate with a couple of levels when that’s the case we’ll often do a call to epidural injection this injection is done right down at the base of the spine we inject some steroid and it flows up along and around the nerve roots and it beads the nerve Roots at those lower levels in steroid and it reduces any inflammatory or Earth and change around there it’s a little bit of a broad brush stroke and we’re hoping to tackle a number of different areas in one go the CT guided nerve right injection however is much more selective we do that when we are very confident that the image that we see on MRI fits perfectly with the way the patient comes in now this is not always the case but when we have this sort of scenario you get much more relief from us a selective nerve root injection than by doing the broad brush stroke of what we describe as I called epidural injection technically we call the epidural is slightly easier than the CT guided nerve root we perform the seat they call epidural injections in the clinic here as Sports Medicine Physicians we do this under ultrasound scan the selective nerve roots however we have to refer to our Radiology colleagues in the main hospital for this because it’s slightly more sophisticated and we want to be exactly precise about where were placing that steroid.

The next group of injections then is for the joints I mentioned to you earlier about this condition, sacroiliitis or inflammation around your sacrum again, normally the way that we treat this is with some medication to reduce inflammation in the Bloods, but on occasion, if you have it on one side it can be because the joint is irritated without inflammation in the blood, in that case, a steroid injection over that area can be very helpful again we do this in the clinic here. We use an ultrasound scanner to guide where we place the needle.

Finally, then is the facet joint injection, the Joint between the different levels of vertebrae same principle as a knee joint, like a hip joint. If it gets inflamed, they often respond very well to cortisone steroids; it is not the main way of treatment; it’s an adjunct, so we try to improve your symptoms a little so that you can then progress on and do whatever rehab is necessary.

Are injections necessary?

Not always, but we use them when patients are not improving or deteriorating in some shape or form. We only do them if the symptoms that you’re telling us or the findings that we have on examination match up with what we see on the MRI scan; if they don’t match, there’s something else happening, and that’s rarely the case. Finally, we do them if your symptoms stop you from doing good rehab. Suppose you’re too sore to rehab, and we have a focus on injection. In that case, these can be extremely helpful in trying to get you some pain relief so that you can do the strength work it helps to take the pressure off the back it helps to get you moving more naturally, get you feeling more comfortable and then get you back to living a healthy and happy life.

Very straightforward self-referral, GP referral or physio referral, and you can forward an email or a referral to sportsmedicine@sportsurgeryclinic.com, or you can call us at this number 015262030. You can have a discussion with one of the staff at the desk, and they’ll give you more direction about how to get in contact with us. I hope you found that helpful there’s a lot of information in there. You don’t need to take it all away. It’s really to give you a flavour of what we do here in the clinic and why our role as Sports Medicine Physicians helps to supplement the work that are very successful and very proficient strength and conditioning and Physiotherapy and Rehab teams do here in the field. Thank you very much.

what advice can you give  the L4,5 disc care with lumbar spondylosis other than pain management?

I suppose it to a degree it depends on what the symptoms are if they are what we describe as radicular symptoms so symptoms that are not in the low back traveling down the leg then we have the option for some injections and if we have a good idea where the pain is traveling to and it correlates well with the MRI findings then we could do a selective nerve root block if it’s a little bit broader or a little bit more difficult the ascertain and exactly where the pain is radiating to or if there is a little bit of discrepancy between what we’re seeing in the patient and what we’re seeing on the scan then something like a cold epidural would be a good option and so that might give some symptom relief and then we would always do some follow-up rehab work and that would be along the lines of the stuff that Katie discussed uh strengthening of the low back strengthening of what we described as the posterior chain which is the bone muscles the hamstrings the calf and just you’re trying to get the patient to move more comfortably and confidently.

Is Botox successful in managing muscular spasms caused primarily by spinal fractures?

Botox we would use on in a very select group of patients and usually patients who have some form of muscular spasm or contracture so these tend to be limited to patients who have an underlying neurological condition like cerebral palsy or somebody who has maybe a long-term contracture following a stroke it’s not something that we use in the clinic to treat back spasm and Botox is a it has a very broad effect on the system so we can’t target it to any specific muscle and for that reason we’re very selective about the patient group that we use and we don’t use it for back spasm treatment.

Can a protruding discs in the lumbar region be the cause of constant knee pain?

It certainly can and if the lumber disc prolapses pressing on the nerve root that supplies the sensation over the knee then yes it can be the cause and often that is a case of patients who we see who have maybe had a long-term knee complaint for a number of years when we see them we assess their need we scan their knee we maybe don’t find much and we get a little bit more in depth into the history we find that actually they have some underlying back condition or back complaint when we scan their back and we’ll find a disk or a nerve root compression that’s actually the main source of their knee pain so in in short yes that can be the case yeah.

How could you get sciatica pain to improve?

It’s a multi factorial approach I suppose again it comes back to what are the exact symptoms of the sciatica what does the patient look like what are the Imaging findings do we have an option for injection therapy if we do have an option for injection therapy is it a selective nerve root injection or is it a call for an epidural injection and then following that can we get the patient comfortable enough to start to do some Rehabilitation and quite often this sciatica pain will resolve on its own if it’s very refractive then we do have oral medication options we have injection options and then we have some of the rehabilitation stuff that again Katie discussed that is often the next step to get patients over the line and back to full fitness.

what treatment exercise do you recommend for multi-level lateral stenosis?

Multi-level lateral stenosis again is quite a complex but broad diagnosis a lot of it really depends on what the symptoms are so the main aim is going to be getting the patient strong and getting the patient comfortable and confident moving again if they have some specific pain target or pain level in you know from that when we when we describe multi-level spinal stenosis we’re wondering is there an individual level in the spinal column that’s causing one problem more than the other if there is we have an option for a selective nerve root block again if the pain is coming from multiple levels and we’ve tried oral analgesia we’ve given it time and it’s not settling then a  coral epidural might be an option to give a little bit of a broad cover of a number of nerve roots in a number of different levels.

For five years someone is suffering from severe chronic like joint pain after twisting her back badly misaligned pelvis which she tried to rehab with exercise and a joint dysfunction steroid injection it did not work and what do we do with the joint Fusion at the clinic in the in SSC Sports Medicine?

We don’t do joint fusion um that would be a surgical procedure and it’s not something that I can recall having referred a patient for normally we are able to get enough relief of symptoms through injection therapy and Rehabilitation but by all means if there are refractory cases then we may refer them to a surgical colleague for an opinion so that would be either an orthopaedic surgeon or a neurosurgeon.

How big of a factor is ongoing strength and conditioning to prevent a disc bulge l45 for long-term prevention?

long-term prevention I suppose the key here is trying to keep people moving as naturally and as comfortably as possible any strength work is going to reduce the risk of any recurrence of low back pain and disc bulges will happen regardless of whether or not you do any kind of strengthening program or preventative program but if you’re stronger and you have better functional movement patterns then you’re much less likely to get symptoms and long-term symptoms from something like a disc bulge and if they can take you back to the slide that I used in my presentation there’s a huge percentage of people out there who have disc bulges and that’s not the source of their pain and quite often that’s what we find in patients who come into the clinic so it’s not so much that the strengthening or rehab and exercise programs prevent this bulge but they prevent low back pain in general and they’re very good at doing that.

A patient is just asking, he has a pacemaker which is not compatible with MRI what other scans could be used.

– Again it depends on the diagnosis or at least the question that you’re asking and if you’re asking for information in relation to a disc or a nerve root then you would we would have a discussion with our Radiology colleagues as to whether or not there there’s an option to work around to get the patient an MRI and there are some MRI centers available that can do MRI for patients with pacemakers in terms of if the question is not related to a disc or to a nerve root and it’s a bony finding that we’re looking for that a CT scan would be an option and then thirdly we have options for x-ray or bone scan but they would be used much less frequently and I suppose we get much more detail from our CT scans on our MRI scans but really it all comes down to what what’s the question that we’re asking is it a bone related problem or is it a disc and nerve related problem.

How long will pain relief last from injections and how many can you have?

It depends on what the injection it is that you’re using typically we inject steroid with some local anesthetic the local anesthetic is relatively short acting you’ll get a few hours of relief symptoms from that but it’ll wear off over the course of the day a steroid injection builds up over the first few days and usually you get your most benefit at around about seven to fourteen days and then we hope for around about three months on average some patients come to us for a steroid injection or an epidural or a selective nerve root we’ll get they’ll get one injection they’ll get enough pain relief to allow them to do some form of Rehabilitation and their pain will resolve fully so they’ll never need to repeat occasionally we’ll have patients who come and get one injection get a repeat injection three months later and then follow that pathway where they go on the resolution and then unfortunately there are some cases that are much more resistant to treatment and may need an injection on a kind of repeat three to six months basis we would usually only inject about once every three months so maximum usually about four a year but we’re always reassessing the situation and trying the ascertain are we doing the injection for the right reason is it for the same reason have things changed so there’s a lot of thought that goes into the process rather than just looking out three months injections for the foreseeable future.

Is there any downside to steroid injections?

Yeah I mean there are side effects to any procedure that we do and in general anytime we use a needle to pierce the skin there’s a risk of creating infection in the clinic here we quote more than twenty five thousand and we use a lot of stringent infection control procedures to try and reduce that risk but that’s the biggest concern anytime we do an injection is introducing infection to the site and from a steroid itself about a hundred percent of people can get something called a steroid flare where their symptoms can get a little bit worse before they get better and some patients can get pain at the time of injection which can last for a few days after and some patients don’t get any relief whatsoever and so they go through the process they go through the anxiety of getting the injection then they don’t get any relief, but by and large are they are the main the mean side effects steroid can also give you some minor side effects such as facial flushing which might last 24 to 48 hours it can also disturb your sleep for 24 to 48 hours and it can also have an impact on your blood sugar so if you have diabetes we always recommend that after a steroid injection you keep an eye on your blood sugars for a few days.

A woman had an x-ray which showed a fractured disc, had physio just physio for that but 10 months later she’s still in a lot of pain she goes for walks but it’s very painful when sitting any suggestions where she should go next?

It’s difficult  from the amount of information available yeah it’s difficult to sign posts, I mean if she feels that she’s not getting much benefit or she’s had almost a roadblock with a physiotherapist then perhaps it’s time to see a sports medicine physician you know another assessment a second opinion have a look at you know what information is there today and what investigations have been done and then decide on whether any further investigations need to be done and what other treatment options are available to the patient.