How To Maintain Strength, Fitness and a Healthy Lifestyle After Competitive Sport – Luke Hart

Watch this video of Luke Hart, Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine, discussing ‘Fit for Life: How to maintain strength, fitness and a healthy lifestyle after competitive sport’.

This video was recorded as part of SSC public information meeting as part of its ‘Fit for life series’ focusing on ‘How to stay healthy & injury free – From youth sport to the ageing athlete’.

Lorem ipsumLuke Hart is a Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine

Luke Hart, Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine.

“How to stay healthy & injury free – From youth sport to the ageing athlete.”

Hello, my name is Luke Hart, and today I am going to present how to maintain strength, fitness and how to keep a healthy lifestyle after competitive sport. My presentation will also cover any injury you may have had, applicable to many different situations you might find yourself in. We are going to talk about being fit for sport is being fit for life. If you’re fit for sport and have the health, the fitness and the strength and we can continue to play sports for as long as possible, that is the same as what we need to be fit for life and health.

So when we look at the difference between an elite athlete and those who have retired, it is very interesting to see that the bit we struggle to maintain after sports is the skill component of the sport. This is the so it’s the agility, the speed may be the throwing or the specific qualities of when you’re playing that sport, that is what we lose. We can see from the studies that the retired athlete and the elite athlete have the same physical test numbers, even though they have been retired from sports for several years. So what we see is that upper body strength, maximal strength in the upper body and running tests are the same in those who have retired to those who are still elite athletes. That is really positive because there are the key areas for us, people who don’t play sports anymore, there the factors we want to know about, the ones that will influence us on our health and our lifestyle. We need to know what to do after sport, whether it’s sports or GAA, soccer, football, or cricket. We need to maintain a healthy lifestyle and maintain as much of our physical fitness as possible and how that relates to our health.

The World Health Organisation about four years ago changed its recommendations. They added a couple of new recommendations that didn’t use to be there. We still have the usual 150 minutes of light activity, but often we would already get this in our sport. When we leave sports, we need to find something that will replace that, 75 minutes of vigorous activity, strength sessions at least twice per week, and minimising our sedentary time. Sedentary time is really the problem at the moment with COVID lockdowns and people working from home. People now have a much higher increased sedentary time than what they had even just a year and a half/ two years ago. This is also a problem after we finish sports if we were playing team-based sports. In Ireland it is very popular such as GAA, we could be out of the house 6 hours a week, 2-hour sessions three times a week. When we stop playing, we start to get a huge increase in our sedentary time if we don’t find something to replace that with. If we put working from home on top of that, we are looking at a bit of an issue, and we will discuss that later.

So what I would like to talk about today is three key areas: Strength & Power, Cardiovascular Fitness, and we will touch on BMI & Body Fat. I am going to start with Strength & Power. I am going to start with this that this fundamentally underpins all the other qualities we will talk about, and I am going to show you why. So when we look into strength, Muscular Strength is a predictor of all-cause mortality. A study was done on two million men, and women found stronger had significantly decreased risk of all-cause mortality, essentially decreased risk of death by any kind of disease. So it was the biggest factor that played a role in reducing people’s risk. We want to know how we can maintain our strength as we age and why it is that important. We can see here on the left is a 60-year-old woman, has muscle mass there, the black part is the muscle mass, and the white part is the fat mass. On the right-hand side, we have an 80-year-old woman again, and we can see the dark muscle mass and the white being the fat mass. What we want to do is, we want to try to maintain as much of that darker mass as possible. If you look at the graph underneath, you can see that the line’s slope is the drop of the number of muscles people have as they age. What we want to do is try to minimise that drop as much as possible. We want to try and get that line as flat as we can. It is okay if it’s ever-increasing. If you haven’t done much strength training before or fitness work before, you might see an increasing line as you age. The flatter we can get that line, the healthier and lower our risk will be as we age. You don’t have to lose that muscle, so what we can see here in a brilliant study by Wroblewski, they found that a 40-year-old tri-athlete had a great muscle mass with small fat mass in comparison to the 74-year-old sedentary man the fat mass has begun to invade the muscle mass, you can see that increased white mass around the muscle. We can see on the image below a 70-year-old triathlete had the same muscle mass as the 40-year-old tri-athlete. The best way for us to do this is through muscle training.

What is the best way of doing this? You can see in this study here the difference between doing maximal isometric leg press and maximal isometric bench press over a 21 week period. The strength and endurance group circled in blue had the best results. This shows while strength is important, it also shows the importance of strength and endurance. The combination of the two is the way to get the best results for yourself or anyone after sports.

I also wanted to touch on why strength and conditioning are important for other conditions as well. Mark will talk about this later on as well. ACL’s are a key kind of risk in field-based sports. We see them a lot in GAA, soccer, rugby and other sports as well. I’m sure many of you have had an operation on the knee or have had muscular issues or ACL issues. What we really want to know is how I prevent any issues down the line and for my knee. What we found is those with osteoarthritis, which is a common complaint after knee surgery or having any knee issues down the line, is that the people who increased their strength had a 22.5% reduction in pain and a 17.5% increase in their function when they’ve already had knee osteoarthritis. This will only be better if we start sooner. We also found those who had improved quadriceps strength, who already had knee OA, they had significantly improved gait and movement afterwards.

That brings me on, how strong is strong enough? What do you need to do? And how can you quickly and efficiently see whether you are strong or not? This test looked at a leg extension vs a sit-to-stand. There is a really good test that you guys can do at home. If you have a seat where your knee aligns with your hip, so a kitchen chair would be perfect. You have to see how many sit-to-stand you can do in 30 seconds. If you can achieve more than 11, that means you are above that low. If you can do less than 11, you need to do a bit more work. 15 would be the hitting average, and 22 would be in a good position. The younger we are, we would want to push that a bit forward if you are getting 27 plus. That is excellent. It is a really good test see to see where you are at. We can test this in more detail in our Fitness lab here.

Although that is a really good test at home, what do we suggest here at the clinic? For those of you that go to the gym, we suggest doing a front squat with 0.5-0.75 times the body weight. Let’s you are an average 80kg male, and you would want to be doing a 40-60kg front squat. This is the same across all genders and their body weight. A leg press of 1.5-2 times the bodyweight would also be a good alternative. For our posterior, the muscles at the back of our body so our lower back, sides and hamstrings, a deadlift of 1-1.5 times the bodyweight would be brilliant, hip trust of 1-1.5 times our body weight is also equally as good. Then lastly, for our upper body, which is important for females for osteoporosis as we age. 8-10 good quality push-ups would be absolutely fantastic. 1-3 pull-ups would be a great aim and target.

We are moving on to aerobics, fitness & physical activity and the role that they play in your health and fitness. Why is it so important? VO2 Max is something we use to test your fitness, so we use it here in all our health and fitness tests. We find it to be one of the most important tests to see how fit and how healthy you are. A Finnish study that followed 2226 males with no history of cancer for 16 years found that if you have a VO2 Max of 33.2 ml resulted in a 27% less chance of getting cancer and a 37% reduction in cancer mortality. Those that did 2 hours of moderate exercise reduced cancer mortality by 26%. An improved VO2 Max decreased the risk of lung, gastrointestinal and prostate cancer. Moving on to dementia risk, which is a big topic at the moment, those who have moderate to high fitness demonstrated significant reductions in dementia risk. So we say for every 3.5 ml. kg of oxygen improves, there is a 14& reduction in the likelihood of dementia mortality. Then for those that already have a moderate and high cardiovascular fitness group had a greater than 50% reduction in dementia Mortality. There is a lot of health benefits and significant reductions by having a higher fitness level.

Lastly, if we have increased fitness, we have significantly reduced the risk of cardiovascular disease. So if we have a moderate to high fitness level, we have a 53% reduction in risk of heart failure if we have a high VO2 max. An increase of just 9% in VO2 Max results in significantly decreased BP and Cholesterol levels.

We want to improve our fitness, so how do we do that? The first rule I have is to take care of the basics. That’s what we do without patients. What I mean by that is to take care of your daily steps. Anything after 6000 steps is a reduction in mortality rate. Every 1000 increase in steps reduces mortality risk by 23%. Rule 2 just start now, and yesterday would have been even better to start. People who do lifelong exercise see significantly improved data. Whether it is hard or easy, you will still see benefits. As we live for longer, we want to do the things we love longer. Continuing exercise throughout your life improves the condition of your life. Rule 3 intensity over the duration, so what previous studies have found is that if you do some high-intensity training, even just 60 seconds work with 75 seconds rest and ten times and three times a week in 5 weeks, you can have almost 10% improvement in your VO2 max. 10% improvement decreases many health risks. Secondly, what was found in the rating of perceived pleasure during HIT running than continuous running. This is really important because if we want to do this for the long term or as a habit, we need to make it official and enjoyable—a short amount of exercise with higher intensity. Continuous training also has lots of benefits, including mindfulness; you should stop this but maybe consider adding high-intensity training.

Lastly, I would like to talk about Body Mass Index and Body Fat % and the role that it plays in your health and fitness. This is the one that is spoken about in the newsletter the most and all over social media. There are some interesting studies; what we do find is that those wither a higher BMI and higher body fat percentage do have a significantly higher risk of all-cause mortality. There are some other factors that we need to account for. I would like to talk about those with Knee Osteoarthritis, which can be higher risk if we have had any operation or anterior cruciate ligament injury. We do find that body mass is important for those people. If you have had an operation on your knee or osteoarthritis, you should be trying to keep a lean body mass. So as social media and the newspaper say that BMI is the be all end, it really isn’t. Recent studies have found powerful older people exhibited an improved life expectancy of 9 years regardless of BMI.

What should we be targeting? The World Health Organisation is spot on. One hundred fifty minutes of low-intensity exercise golf is a great example of doing this. If we can include vigorous exercise every single week, about 1-2 sessions a week if we’re getting our low-intensity exercise if not 2-3 times a week. 2 strength sessions a week is vital as it helps to keep doing what we love for longer and is the key factor. A little bit of balance and mobility. We are maintaining a good diet of 80% /20% and hitting 7000 steps a day.

We offer a fitness lab here that is covered by VHI, Laya and Irish Life. We can give you all the information that we spoke about tonight and a personalised program and suggestions. VO2 Max Testing is a vital test as it gives you a great insight into your fitness. Contact us at 01 526 2050 to book in. Thank you very much for your time.

 

Q&A with Luke Hart.

Fiona Roche, Business Development Manager here at SSC, asked Luke Hart, Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine questions sent in by the viewers live during the event.

Q. I only have a limited time to train. Should I prioritise strength or some form of cardio?

A. As you saw in the talk there, strength underpins everything we do, so if we can stay strong, it allows us to do all the things we love to do, whether that is football, golf or tennis etc. Some part of the week should be dedicated to strength. The use the rest of the week can be prioritised to cardiovascular as that is also very important so like 60% and 40% in strength. We only really need one session a week to stay strong. We definitely need some strength in there because if we don’t use it, we lose it.

Q. What pace of running is needed over 60 seconds?

A. It depends on the individual. For over 60 seconds, you want to be working quite hard. We use a concept called the rating of the exceed excursion so how hard you work. You can track it by ten, being it being preseason, which is really hard, and one being like you getting out of bed. You should keep it at 6-7. It is individualised.

Q. Should I be using weights at age 50+?

A. Yes, absolutely, it provides great benefits for bone mineral density and tendon health or any who is prone to osteoporosis. An individualised program would be important if you haven’t used weights before.

Q. Do all health insurance cover the fitness lab?

A. It depends on your policy. VHI, Laya and Irish life all cover the fitness lab, but it depends on your policy. Check your policy; usually, the benefits are down the bottom of the policy. You can ring us here at sports medicine, and we can check for you or else you can ring your insurance company to find out.

Q. Would you recommend a 45 minute Pilate class as a strengthening method, or would this be more balancing and conditioning?

A. It depends on the type of class you do. We want to see something that is over and above our body weight to influence bone mineral decadency and other areas improvements. Pilates alone might not be enough to influence the bone mineral and provide all the benefits. You would need to add some exercise for strength. It depends on the Pilates class, whether it is more of a relaxing class or a harder class.

Q. 11 days post-surgery, how can I prevent significant muscle wastage?

A. This can be hard to prevent post-surgery as post-surgery you are going to get some level of muscle wastage. The most important thing is to get that muscle back activated as soon as possible to prevent that waste. There will always be some, but by doing some exercises, especially ones that are specific to the surgery and the injury, then we can maximise the amount of muscle mass we can retain. That is really important. All those early-stage exercises are there to maintain muscle mass. Try to do exercises to encourage that muscle in that area.

 Q. Can you overdue your sessions in a week?

A. If we do too many sessions in a week and don’t allow enough recovery time, that’s when we can experience burnout. We need at least two dedicated rest days per week. When we train, we break down muscle, and when we recover, we build and heal that muscle.

Q. Do you recommend protein shakes for recovery?

A. Protein shakes are good and available quite easy. I see them supplement your nutrition, not replace good nutrition. Immediately After or up to 30 minutes are training would be a good time to take protein. There is high protein chocolate milk or Avon milk that you can buy on the shelf, which is just as good. It doesn’t have to be used, but it is something that can be and supplement.

As you saw in the talk there, strength underpins everything we do, so if we can stay strong, it allows us to do all the things we love to do, whether that is football, golf or tennis etc. Some part of the week should be dedicated to strength. The use the rest of the week can be prioritised to cardiovascular as that is also very important so like 60% and 40% in strength. We only really need one session a week to stay strong. We definitely need some strength in there because if we don’t use it, we lose it.

Yes, absolutely, it provides great benefits for bone mineral density and tendon health or any who is prone to osteoporosis. An individualised program would be important if you haven’t used weights before.

It depends on the individual. For over 60 seconds, you want to be working quite hard. We use a concept called the rating of the exceed excursion so how hard you work. You can track it by ten, being it being preseason, which is really hard, and one being like you getting out of bed. You should keep it at 6-7. It is individualised.

It depends on your policy. VHI, Laya and Irish life all cover the fitness lab, but it depends on your policy. Check your policy; usually, the benefits are down the bottom of the policy. You can ring us here at sports medicine, and we can check for you or else you can ring your insurance company to find out.

It depends on the type of class you do. We want to see something that is over and above our body weight to influence bone mineral decadency and other areas improvements. Pilates alone might not be enough to influence the bone mineral and provide all the benefits. You would need to add some exercise for strength. It depends on the Pilates class, whether it is more of a relaxing class or a harder class.

This can be hard to prevent post-surgery as post-surgery you are going to get some level of muscle wastage. The most important thing is to get that muscle back activated as soon as possible to prevent that waste. There will always be some, but by doing some exercises, especially ones that are specific to the surgery and the injury, then we can maximise the amount of muscle mass we can retain. That is really important. All those early-stage exercises are there to maintain muscle mass. Try to do exercises to encourage that muscle in that area.

If we do too many sessions in a week and don’t allow enough recovery time, that’s when we can experience burnout. We need at least two dedicated rest days per week. When we train, we break down muscle, and when we recover, we build and heal that muscle.

Protein shakes are good and available quite easy. I see them supplement your nutrition, not replace good nutrition. Immediately After or up to 30 minutes are training would be a good time to take protein. There is high protein chocolate milk or Avon milk that you can buy on the shelf, which is just as good. It doesn’t have to be used, but it is something that can be and supplement.

How To Protect Our Young Athletes In Modern Sport – Tommy Mooney

Watch this video of Tommy Mooney Senior Strength & Conditioning Coach at SSC Sports Medicine discussing ‘How to protect our young athletes in modern sport’.

This video was recorded as part of SSC public information meeting as part of its ‘Fit for life series’ focusing on ‘How to stay healthy & injury free – From youth sport to the ageing athlete’.

Lorem ipsumTommy Mooney is a Senior Strength & Conditioning Coach at SSC Sports Medicine.

Tommy Mooney, Senior Strength & Conditioning Coach at SSC Sports Medicine.

“How to protect our young athletes in modern sport”

Thank you for taking the time out of your evening to watch this SSC series. My name is Tommy Mooney, and I am a Senior Strength and Conditioning Coach at Sports Medicine. Alongside my role here at the clinic, I work with a host of different athletes of all different ages from a multitude of different sports, including team sports, individual sports and tracking field etc., ranging in ages from 6 years old to 80 years young.

My presentation today is going to be about how we can protect our young athletes in modern sport. I am going to suggest a three prone model for optimum health and development. First and foremost, we are going to talk about the importance of multi-sport and using different sports to enhance our movement vocabulary. The more movements we learn, the more skills we can accomplish and showcase in our sport. I am then going to talk about training load and finding the balance between rest and training, and then thirdly, we will talk about strength and conditioning.

First, I would like to present a story to you. On the screen, we have two kids here, both 7-8 years old. Jack on the right here is a tennis player, adamant he is going to become the next big thing in tennis as well as his parents believe he is going to be a tennis player. Jacks life revolves around training tennis and getting as good training as possible. Jill, here on the left-hand side, plays a multitude of sports such as GAA, gymnastics, tennis and athletics outside of her busy social schedule. Jill wants to become a gymnast or an influencer when she is older. My question for you is, which child do you think will have a longer and more successful sporting career? Ultimately we can’t pick one, and we never know as many childhood progeny’s like Tiger Woods and Lionel Messi has gone on to grow from their childhood success, but despite that, we often would suggest that having a multitude of sport and playing many different sports is typically the optimum way to develop a broad range of skills and capabilities that can then lead on to your final sport at the end of your career or as you age.

Another benefit of multiple sports is that children are going to learn multiple different skills that are going to help burnout and increase participation for longer. It can also reduce the risk of injury, improve cognitive skills and decision making, is typically more enjoyable, offers breaks different in-between sports. We also know sports diversification leads to a long sporting career.

Forgetting about sport for a minute, we know that children nowadays are typically slower compared to children 30 years ago. They are weaker when compared they are less physically literate and less physically active. Introducing children who may not be playing sport to physical activities like strength and conditioning is going to be really important to know that less than 5 hours a week of physical activity can increase the risk of injury. Obviously, there is a bell-shaped curve that we know if we do too much training, that can also be a risk factor; I think this became much more clear of the back of covid where we saw an extended period of not training followed by a spike or increase of training in our training load, this is something we associate with an increased risk on injury.

What are strength and conditioning? The bottom left is an example of what it doesn’t look like as it is obviously too heavy and too young. Moving on then to the other pictures, we have multiple different movements such as crawling, jumping, landing, moving, lifting and squatting in an environment that is safe and fun, but also challenging and then as they get older, you can see the exercise progress and increase in load and make it more challenging.

Obviously, there are concerns and misconceptions around strength and conditioning. It is important to know that strength and conditioning is not only gym-based. It is speed & agility based, muscular endurance can also be enhanced by this, but we won’t talk about too much of these particular components today. We already talked about how it can have an improvement in our movement skills, balance and flexibility. As mentioned, one of the concerns typically is that it is dangerous, but it is important to know that sports, in general, is more dangerous. This video on the screen is an example of such. So we know sport itself is dangerous, so the better we can condition and prepare our young athletes for this, the safer they may be when they do take the field.

Some other misconceptions are around stunts in growth. This extends from anecdotal data that weight lifters are small and stocky; therefore, weight lifting must stunt their growth. This is similar to people saying that playing basketball will make me taller because all-athlete basketball players are tall; therefore, playing basketball will increase my height, this obviously isn’t the case. We spoke about the danger. Other misconceptions can be that it makes you slower. This isn’t true proper strength and conditioning can help you increase speed rather than slow it down. Building big muscles is highly unlikely in youth athletes as we don’t have the hormonal profile that is going to allow for this; it typically takes years of training to do so. Then lastly, growth plate injuries are more likely to occur in jumping or landing and field sport as opposed to our gym-based sport. There has been a host of research to back this up that weight training in youth is safe, that long term responses to it are positive.

This table here shows the incidence of injury in youth sports, so it’s looking at some popular field sports such as rugby, soccer and GAA, it is looking at injury incidences over 100 hours of match play. What we can see on the table is that incidence of injury in these field sports are considerably greater than our weight lifting activity. By weightlifting, we are referring to the sport of Olympic weightlifting. We see two studies here boys and girls as young as seven had 0 incidences of injury over one and two years. This study here where there was one injury happened with a weight plate falling on the foot, not even the sport itself but rather maybe from not paying attention during the down period within the activity—emphasising the safety of these when done properly. Injuries in these activities are typically a result of poor technique, excessive loading, training whilst fatigued and a lack of qualified supervision. This is an important point to note that we need to make the people who are organising and running these sessions are qualified. I’m sure there are a host of coaches and parents on the call here who work with these young age ranges. I know how difficult It can be to keep them engaged and supervised, so I have a lot of respect for those working with these young athletes and young groups, but it is important that whoever is leading these strength and conditioning sessions is appropriately qualified.

The benefits then of strength and condition, it can help increase our strength & power, bone strength & density, balance & coordination, speed & agility, reduce injury risk, enhance our sports performance and our outlook on physical activity.

On the screen is another example of time-loss injuries in elite soccer academies, so this is Arsenal; prior to 2013 and Des Ryan and his team taking over, they had quite a high incidence of injury. After 2013 when they implemented a world-class strength and conditioning program, they significantly reduced the number of injuries over the next couple of seasons. Obviously, we can’t completely irradiate injury as we already mentioned; sport itself is already injurious and particularly risky, but we can do with good strength and conditioning, we can decrease those numbers.

When can we start? How young is too young? This study by Myer, Lloyd, Brent & Faigenbaum showcased that those who started in pre-adolescence achieved a greater level of motor capacity in adults in comparison to those who only started in adolescence, who only practised sport and those who did no sports.

I am going to go through the stages of strength training in more detail. Stages one and two are going to be largely based around bodyweight training and mastering the basic exercises and movement patterns, progressing into maybe some soft resistance things like med ball & sandbag the progressing onto your barbell training. This is similar to our power progression, and it is important to note that strength underpins power; although both are important, utilising some power exercises can help ensure that we the maximal transfer across from our strength training. Okay, again, similar here were interested in jumps, hops and throws, then gradually introducing then some light resistance before we consider moving on to more weighted or loaded progression.

When do we progress from bodyweight to barbell training? When we have good control over our own body and limbs. Good position & patterns for the six major bodyweight movements. So, for example, these six movements may look like this. This is an example from a youth scoring table, so when you can achieve 18 points in each of the exercise categories, that’s a sign you have mastered or you are competent with your own body weight and are ready to progress on to loaded variation. So, for example, here we get points relative to the number of repetitions that you do, the points add up over the different tests and that allows us to achieve our 18 points; again, those scores may be different for our male youth athletes.

Advice and summaries for parents, I would encourage everyone to try and get their children engaged in PE; that way they’re going to see a multitude of different sports and skills, to get out and play with their friends, to incorporate at least one rest day a week, try and play different sports in the off-season, communicate across the different sports they do, try to reduce training load during a growth spurt,

Introduce resistance training under supervision and to make sure have fun as the more enjoyable and engaging we make sport the longer we participate and have more benefits in the long term. Thank you for listening.

 

 

 

 

The consultant will have clear guidelines to give you as it depends on what stage you are in, such as in the early stages of post-op you are probably not going to be doing as much as well as it depends on where they’re taking the graph from. In reality, you want to try and keep the knee as calm and happy as possible, so not doing anything that is going to aggravate the knee. Do what you can. The key thing is not to aggravate the knee in the process.

That’s a tough one; it can be challenging. The most important thing is the player and coaches relationship, make those communications channels as open as possible, look at the link between sports and monitor that. The first important thing is communication, and then the second is asking the athlete how do you feel?

During periods of a growth spurt, that’s maybe when you want to reel in training a little bit and reduce the training load a little bit, that maybe when you can focus on strength and conditioning activities or not as much heavy load on the pitch. There are also other things you can do in terms of monitoring training, such as watching the minutes you spend on the pitch, how many training hours you are doing in a week and just making sure that it isn’t spiking at certain points a year. It is important to make sure there are periods of the week/month where there are low periods of training.

It is hard to say; you need to consider the individual case, how many sports are we talking about, do the two sports cross over, are they quite different etc. At about 18 years is when you’re going to start to specialise in developing special skills in that sport and dedicating as much time as possible to that sport to optimise your performance. It is also important to ensure they’re not doing too much.

Yes, absolutely. We spoke about the importance of seeking professional guidance, and that’s where maybe touching base on it may be a local S&C coach or you can come into the clinic here that is going to be beneficial, rather than getting a generic program you would probably want something a little more specific so it is tailored to the individual, to their training needs, their sport and then to their injury risk if there is one as well.

ACL Injury and Reconstruction – Mr Mark Jackson

Watch this video of Mr Mark Jackson, Consultant Orthopaedic Surgeon specialising in knee injuries discussing ACL Injuries and Reconstruction.

This video was recorded as part of the Sports Surgery Clinic public information meeting as part of its ‘Fit for life series’ focusing on ‘How to stay healthy & injury free – From youth sport to the ageing athlete’

Mark Jackson Knee Surgeon Mr Mark Jackson is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic specialising in knee surgery.

“ACL injury and reconstruction – an overview”

Hi, my name is Mark Jackson, and this evening I am going to be talking about the Anterior Cruciate Ligament Injury and a brief overview of the reconstruction. I am an Orthopaedic Surgeon here at the Sports Surgery Clinic. I am a Knee Specialist. I see patients and their injuries from 12 and upwards. Patients come from pretty much the whole country and are referred in by their GP’s, sports therapists, physiotherapists and other surgeons.

My work is split 50% of the work I do in sports and soft tissue injuries that incorporates the anterior cruciate ligament injury. The top three pictures are with a camera in the knee, and that is just looking at cartilage type problems. The bottom right and middle pictures here are actually cruciate ligament tears. Then the other half of the work that I do is more degenerative in nature which means osteoarthritis, and this can be offering patient’s procedures half or partial knee replacements, full knee replacements as you can see in the bottom left, more complex revision, complex primary total knee replacements and other procedures.

Today we are going to cover the Anterior Cruciate Ligament Injury. This is a very big topic. It has been heavily researched over decades. It is till I guess not completely understood, but we are getting better at helping people with this injury. Ì will try to keep it simple and not too surgical. I am going to go through some of the main points, such as what is the Anterior Cruciate Ligament, how the ACL is injured, treatment options and consequences of an ACL injury.

What is the ACL? As you can see in this picture, on the right-hand side, we are looking at the right knee from the front. The anterior cruciate ligament stands here with the joint in the middle. There are actually two cruciate ligaments, cruciate meaning crossing, so the posterior ligament is tucked in behind the ACL here in the front. The other two ligaments are the ones around the sides called the collateral ligament, so the medial or in the picture it is called the Tibial Collateral Ligament, which we often call the NCL and on the outside the LCL.

These next images are from cadaver specimens; the right-hand picture is looking from the front view of a flexed left knee; we can see these two ligaments in the middle of the knee and then the ACL, which is joining the two bones together. In most individuals, there would be a region of about 3 centimetres long and about 8-10 centimetres in diameter. It is shaped a bit like a ribbon.

So what does it actually do? Well, it is an important and primary stabiliser of the knee. It protects other structures. It is like the guardian of meniscal cartilages. It is particularly important in rotation. If it’s torn, this is An ACL deficiency which leads to a lack of confidence in typical movements. It is a fairly small ligament with a big job to do. In humans, it hasn’t evolved to be put through the rigours we demand of it. If we compare it to a mountain goat, they have a much thicker and strong ligament as it has evolved.

How can the ACL be injured? Anybody can injure their cruciate ligament. There are certainly some high-risk groups. It usually occurs in a competitive environment. Frequently it is a rapid pivot movement such as a push-off, a turn, twist, awkward landings, deceleration’s and hyper-extension. Most commonly, it doesn’t involve heavy contact or collision.

The image here in the middle shows the position of the knee when it is torn, the foot flat and twisted out, the knee falls into a position that we call valgus, buckling down and in on itself and often hip is what we call abducted, taken away from the side. This skeletal image shows us it is being damaged.

What does the typical cruciate ligament injury say? Well, usually, the history is of a sensation at that ‘the knee popped’, ‘the knee buckled’ and ‘the knee went in and out of place’. Generally, there is immediate pain, and severe pain and the patient has to be helped off the pitch. Sometimes people feel like they might want to try and continue, they get to the sideline and don’t feel too bad, but then usually, they try to run again and realise this isn’t going to work out. Generally, over 24-48 hours, the knee looks quite swollen, there is pain on weight-bearing, the patient is limping and may even need crutches for a couple of weeks while things settle down. The knee than can actually start to settle and feel ok day to day; by then, the patient is advised to see advice from a physiotherapist, A&E or their GP. The initial examination can sometimes be difficult if the patient is swollen and sore. An MRI is generally indicated. Sometimes patients are told their knee is too swollen to scan or to wait until the swelling has gone down; I don’t think this is necessary; just crack on and get the scan as soon as possible.

What does it look like on a scan? The left-hand picture here shows a very clear black ribbon structure crossing the joint, joining as we saw in the picture earlier the fibia down onto the tibia. The middle picture shows a ligament that is torn. This picture on the right shows a different sequence of the MRI, so the black line, the ligament, is torn and ripped off the bone. An MRI scan is a very accurate way to indicate this injury.

How common is it? Well, it is actually quite common. It is very difficult to incidence data in Ireland the UK but referring to other big studies and academic studies around the world; we would have approximately about 4000 ACL injuries across Ireland a year. The majority are between the ages of 12 and 35. This next study is interesting looking at high school athletes in America; it gives us again an indication of how common this injury is. They looked at ten studies that accessed high school adolescent’s males and females involved in the sport such as their local clubs and in schools, not in elite sport. They found if you follow an average adolescent sporting female in a year who maybe go from their soccer season into their basketball and lacrosse season, that’s training and playing, and they accumulate an annual risk of 2.5% risk per annum of ACL injury, which is obviously quite high. This figure is higher in females than males by about 1.6%. There are reasons for that, but we won’t go into too much detail today.

There is again, a difference between looking at an adolescent amateur athlete and comparing that to somebody who is involved in very high elite sport, and actually, the relative risk of an elite premiership footballer tearing their anterior cruciate ligament is relatively low, this study looked at 28 teams of Elite European Soccer teams, relatively the risk is quite low, so the standard male elite squad would probably only get one ACL injury every couple of years, so it is quite different to an amateur teenage type individual as these individual are quiet strong and involved in injury prevention type programs.

At the clinic here, we have a registry that we put most of our ACL injuries into so that we can look at the data and follow up results. We found that the mean age, we have about 6000 individuals on that registry now, but we found a mean age of about 25. It is important to look at the red circled groups on the screen that at least a third of our individuals are actually under the age of 20. We do operate and see more males than females, but that just reflects that males are most tensely involved in sport than women generally in terms of numbers than females.

Then talking about the Mechanism of Injury, again, as we already mentioned, the ‘non-contact’ injury is far more common than contact injury, and most of these Injuries occur in competition as opposed to training. The distribution of sports in Ireland is unique compared to some other countries because of the amount of contact in field sports that are played, So about 80% of our injuries occur in a field sport, the highest number being Gaelic football, the second-highest number being soccer, followed on by rugby and hurling. The other ones are minorities such as simple accidents etc.

There is clearly a problem that exists with an ACL tear. It seems to be an issue in very young and physically active individuals with high demands who want to get back into sports. It can be quite debilitating and life-changing with the potential for long term consequences. A lot of high-risk sports in Ireland, and not everyone is the same; we do have vulnerable and differing risk groups.

Maybe you have gone and seen someone myself; an ACL is torn; what happens next? We will discuss the options. There is a responsibility to advise and give the patient a perspective on this injury. In the short term, what we are going to try and do is the knee is the restoration of confidence, return to sports and activities and no symptomatic instability. In the long term, we would need to cancel out potential problems.

There are three main stakeholders here with this injury. Primarily the first one is the patient, and they just want a few things clear in their mind, such as fixing it, when is the surgery, when will I return to normality and how long until I return to sports. Then the physiotherapist, they’re going to very important, they’re going to have to have appropriate rehabilitation pathways in place, they will have to give guidance on what’s appropriate and what’s not appropriate of the various stages of rehabilitation and guide that individual along the way onto hopefully a successful outcome. Then the surgeon clearly needs to make the diagnosis and have a good ability to be able to interpret what we see on the scan. We need to talk about what surgery might suit that individual and to have a good reliable procedure to get the best possible outcome.

The problem with an ACL that is torn is what we talked about; the knee ‘gives way’, it does not have the ability to regenerate itself like some other ligaments might, and it doesn’t have the ability really to heal, so that person usually reports a sensation of instability not necessary any pain or stiffness. The majority of patients that I see are going to want to resume their activities when we start thinking about options, particularly surgery, but some individuals don’t have sporting goals, but they still need a stable knee for their jobs such as a Garda, the military, people with construction type works, manual labours and farmers. So even if they don’t want to go back to the sport, well often they will still about wanting surgery. This video here demonstrates the instability of someone under anaesthetic just before they’re about to have their cruciate ligament surgery. This is a movement called the pivot shift. What we’re doing is trying to reproduce the motion that happens, so the knee is kind of bent and clicking you feel it gliding in and out of place. That is an indication that the knee is unstable.

So is an operation always needed?  No, non-operative treatment can be reasonable to people in certain scenarios, that might be someone with low demands or somebody who is a little bit older, so for example, if I tore my cruciate ligament and I’m in my 40’s, I don’t play contact sport or football anymore, I would probably see how I went with a good rehab program first, strengthening for 3-6 months and only then I would undergo surgery if I have failed that.  If I was in my 20-the 30s or teens, I would just get on and get the surgery done as soon as possible. Some individuals are not in a position where they can commit to the time out and rehabilitation; the procedure then can be safely delayed once they can commit to a bit of gym work and take on board some of the ‘do’s and don’ts’.

If you do go down the route of non-operative treatment, some studies have been done of this and have demonstrated that at five years, even with rehabilitation, at least half of the individuals have crossed over and got their ACL reconstructed, but these are very difficult studies to do as it is very difficult to get a set of thousands of sporty young people who have torn their ligament and separate them in who is getting their ligament done or who isn’t.

For the majority of young people wanting to return to sport, I would talk to them about an ACL reconstruction. The return to sports rates are good, and most individuals will get the outcome that they want. These two pictures here are arthroscopic, showing what a knee first looks like when the camera is put in, there is such a cruciate ligament on the bone, and then this is a picture of where we put the graph in so this is the ACL reconstruction. So how do we do this? We harvest something called a graph, and there are two main options that I would discuss with patients; we prominently only use this graph called the bone patella tendon-bone. We harvest a bit of tendon from the front of the knee to get a new ligament, which we can then feed into the joint. There are hamstring tendons, and we can stick together to make a construct like this that can be fed into the joint, then hopefully become a new ligament.

In a nutshell, I’m not going to get into too much detail. What we then do is clean out the old cruciate, we drill tunnels up into the bone, and that graft we have already harvested we then have to pull out and pass into the joint; what we are then hoping is that the graph takes the mole of the original ACL and heals, but this Is a slow process, and it can’t be sped up, this is a biological healing time, and even in the best-case scenario, the whole thing takes a minimum of 9-12 months to try and get the best results. That’s how long it takes a premier footballer, and that’s how long whoever is going to be out for as well. There is also a lot of hard work to do in the gym as well while all of this healing is going on. This video shows the graft being pulled out.

Our registry is pretty reassuring, and the good news is that most individuals are going to get back into playing a sport, about 85% will, and that would be in key with lots of other studies that have performed around the world. Now re-injury is an important topic as that can be devastating, not just for that individual in the short-term but also can, unfortunately, be the end for some people in terms of their sporting environment. We can do another ACL reconstruction, what’s called a revision. It’s not easy for results or going to be as good. It’s particularly a concern in our younger aged groups, there have many studies on this, and particularly this one, patients under 25 may have a secondary injury rate of at least 23%. If you look at this Australian group results, in particular men under 18 had a very high re-injury rate of 28..3%

Long term consequences are important as what we are given people is not a normal knee, the cruciate we are putting in is not a tendon, it is usually good enough, it gives a good function and outcome, but there still are potential problems down the line. This is down to arthritis. These individuals, even 20 years later, are still experiencing problems. I would have done several knee replacements in the last few months, and men generally in their 50’s may have had a cruciate ligament injury in their 20’s. These back this up; if you look at individuals’ maybe 20 years after having an ACLR and you x-ray them, you will see at least 40% are showing signs of early arthritis and about a ¼ of them are getting symptom’s. Then looking at how common it is to get knee replacements, if you look at 15 years results, about 1% of people have unfortunately already had a knee replacement against an uninjured group.

It would be ideally nice if we could prevent ACL injury. It’s never going to be zero because of the unpredictability of contact sport. There have been studies done and programs instigated that we can actually reduce the injury rate, particularly in younger athletes and female athletes up to 50%, which is clearly very significant.

So finally, just some take-home points, this is a common knee injury, third of our patients are unfortunately young under 21, we tend to offer an ACL reconstruction to these individuals who are demanding to want to get back into sports, we want to try to give them more stability and allow them to return to the sports they love and hopefully be able to reduce further damage, the majority will get the outcome done once and get back into activity. The surgery approach is individually based. There is a need from parents, GP’s, coaches and individuals to appreciate that prevention programs work, that we do underplay a little the prognostic implications of ACL tear because of the increased risk of osteoarthritis; I always tell younger individuals this can be a problem in secondary injury rates. It is a very significant injury that we do have procedures for, but then there are issues that you need to appreciate and understand. Hopefully, that wasn’t too difficult to take on board, and there are a few points that people have taken home. Thank you.

The chance they get back is good, but unfortunately, the chance of re-injury in that age group under 21 years old is quite high. There shouldn’t be any rush; they need to tick all the boxes. I can see someone is saying their child had passed all the tests here at SCC with flying colours but, there are physiological barriers that people have to go through as well if they’ve had sequential injuries at a young age.

There is going to be a risk every day; there is some things you can change and some things you can’t, such as genetics, the shape of your knee, collagen, which is what your ligaments are made of its not unusual to operate on twins or brother and sisters. If it was my kids, I would let them return if they were able to, but if they kept getting re-injured, then you would need to have the talk if it’s worth carrying on in that sport.

That’s often one of the very first questions people ask; generally, it is important for people to understand that it’s not time-dependent. There is a biological healing phase, which everyone has to go through. It doesn’t matter if you’re a premier footballer or not. There is a ligament healing time, but after that, you shouldn’t be time-dependent; in the past, it used to be, you could go back to play after six months, but we have moved away from that because of the realisation that most people are nowhere near ready at six months.

I tend to recommend 9-12 months, a minimum of 9 months. At nine months, there is an assessment from my perspective on how does the knee look, how the knee feels, swelling, pain and movement good. There is also a test that we often arrange for individuals to see how symmetrical they are between legs, seeing how they are for their body weight, strength scores, and also getting them to do simple tests like landing and hopping tests. Very few people are actually ready at nine months, there shouldn’t be a rush in my opinion, particularly in a younger individual they have everything to lose and nothing to gain, trying to go back at nine months instead of 12-18 months. If that’s what a premier football needs, that’s what everyone needs.

To make an appointment with Mr Mark Jackson please contact markjackson@sportssurgeryclinic.com

Republic of Ireland Reimbursement Scheme

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 nationalcontactpoint@hscni.net 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 

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.

Surgery

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.

Timeframe

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: info@sportssurgeryclinic.com

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: info@sportssurgeryclinic.com

Diagnosis and Management of Plantar Fascia Injury in Runners – Dr Philip Carolan

Watch this video of Dr Philip Carolan, Sports & Exercise Medicine Physician  discussing ‘Diagnosis and Management of Plantar Fascia Injury in Runners’ .

This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.

Dr Philip Carolan

Dr Philip Carolan is a Consultant Sports and Exercise Medicine Physician at Sports Surgery Clinic specialising in Plantar Fasciitis.

My talk this evening is on plantar fasciitis. My name is Dr Philip Carolan. I’m a Sports & Exercise Medicine Consultant in Sports Surgery Clinic in Santry. I’m also the Cavan team doctor, and I’m currently the Ulster senior football champions.

I have been asked this evening to talk about plantar fasciitis, which is a very common condition. It seems in many areas of life, I know this evening’s talk has to do with running injuries, but plantar fasciitis can affect the general population as well as runners.

My objectives this evening are to review the pathophysiology of plantar fasciitis, review the underlying causes – there are numerous treatment methods, and I’ll go through them and give some evidence-based facts with regard to these treatments, describe a rehabilitation program and recommend a return to play a program.

In my working week, I can see effectively about 20 odd cases of plantar fasciitis. I see patients that have been referred with initial review with an original problem or patients who’ve been sent to me that have already received modality of treatment and still have not made any headway in getting over the problem.

It is a very common condition, and I have just shown some statistics here.

It affects 10% of runners. It also affects other athletes such as soldiers, soccer players & basketball players. In America, over 2 million patients are treated per year and have a significant interference in the athletic population and in competition. It accounts for between 11 and 15% of all foot symptoms requiring medical care

.

As I said, this slide is an overview of what we might see in the clinic ourselves, between 32 to 40 new presentations a week. It is 15% of all foot presentations, and it’s the third most common running injury.

The pathophysiology of plantar fasciitis: the plantar fascia is a big thick broadband connective tissue that spans from the heel bone through the arch of the foot into the toes. It originates in the medial tubercle of the calcaneus, which is the heel bone. It inserts onto the proximal phalanges, which are the small bones at the start of the toes and inserts at the flexor sheaths. It forms both the longitudinal arch and the medial arch. It supports the arch as the weight is transferred over the foot from heel-strike to toe-off.

This is just a schematic drawing of the plantar fascia. On the left is a drawing and on the right is a cadaver specimen. You can see it’s a big thick band tissue that starts at the heel bone and fans out into the base of the toes.

The term plantar fasciitis was the original term, but I classically call it plantar fasciosis because it’s a chronic degenerative condition that is characterized histologically by cell changes fibroblastic hypertrophy, which is a fibroblast of the cells causing inflammation and disorganization of the collagen, which in turn causes you to have an inflammatory reaction and causes pain.

Simplistically it is micro-tears of the fascia from repetitive trauma, i.e. repetitive foot strike, that causes degeneration of collagen. With degeneration of collagen, we try and cause a healing response by inflammation; hence it’s called an inflammatory response but really is caused by degeneration, so I call it fasciosis rather than an ‘itis’. In medicine, ‘osis’ is degeneration, whereas ‘itis’ is inflammation.

You get cycles of tearing and healing, causing chemical mediators of inflammation to produce pain. That eventually causes myxoid degeneration and weakening of the fascia, which causes pain from scar tissue and calcification.

This is what causes the calcaneal spur – it’s interesting at times when people come into me and say to me, “I have a heel spur doctor” – that’s not actually what’s causing their pain. It is more the fascia rather than the bone because the spur is due to the recurrent calcification that occurs during the cycle of degeneration, heating and inflammation.

The causes of plantar fasciitis – there is numerous. It’s generally seen in people with high arch feet and flat feet. It is seen in people with a tight plantar fascia, with tight and weak calf muscles, if you can appreciate the plantar fascia attaches to the heel bone, which is intimately linked to the Achilles tendon and hence intimately linked to the calf muscles.

So if you have a tight calf muscle, you invariably have a tight plantar fascia. It’s also seen in tight hip flexors. There’s also the effect of activity, so it is seen with increased mileage, increased weight. Also, the type of footwear you’re wearing, i.e. big ram running shoes rather than having a nice heel and shock absorbency, and it’s also very common in HLA B27 spondyloarthropathies.

We describe in medicine there are two types of risk factors, which are intrinsic and extrinsic. Intrinsic is what the body is made up of, i.e. your anatomical, your functional, age, and inflammatory conditions. Extrinsic is what happens outside the body, so it’s your surface, footwear and the modality of motion.

So anatomical, we talk about the high arch foot or flat foot – pes planus, pes cavus, also about the way your foot strike is. Functional is regard to the muscles, be it the intrinsic small muscles of the foot, or even tight gastrocnemius or soleus muscle complex, and they can be weak as well. The age effect, we talk about collagen degeneration as we age – as we age, your collagen gets weaker, which causes weakness in connective tissue. Also, gout is a common cause of resistant plantar fasciitis.

The extrinsic causes, of course, are overload too much, too often, which causes muscle fatigue and breakdown of collagen. Running gait as we talk about heel strike, forefoot strike and of course, footwear.

So they’re the risk factors for people who develop plantar fasciitis. I talk about intrinsic and extrinsic. We try and talk about the body makeup and the structures that we run on, the surfaces we play on and our footwear.

The symptoms of plantar fasciitis are the classical presentation is heel pain first thing in the morning when you get out of bed. This may improve through the course of the day but tends to hurt again by afternoon and evening. It reoccurs upon standing after prolonged sitting, and it is worse walking barefoot and walking upstairs.

So it’s not a very difficult area to do a physical examination on because most patients describe tenderness to palpation on the anteromedial aspect of the heel. With ankle, dorsiflexion is limited by calf tightness, and you also get pain increased by great toe extension or by standing on their toes, and this is known as Windlass Test.

This schematic shows the areas that we would see most frequently affected by pain with patients who have plantar fasciitis or fasciosis. I think it highlights the central area on the posterior aspect of the heel of the posterior back of your foot, where 52% is just right on the medial attachment of the plantar fascia, and it can radiate out among the medial, central and lateral branch.

We do get patients who have pain in their forefoot – that generally acts like nodular plantar fasciitis. We get slight lumping in the plantar fascia rather than a pure inflammatory response.

The differential diagnosis that I would deal with when I see patients with heel pain are, especially patients who are doing a lot of mileage or calcaneal stress fractures, fat pad inflammation.

You can appreciate the plantar fascia acts like a sling or a strut to support the medial arch, and then under the plantar fascia, there’s a layer of fat to give cushioning and protection to the whole foot structure, and at times you can get flat fat padded inflammation or changes in the fat pad that can mimic the pain of plantar fasciitis.

Also, there’s a tendon that runs very close to the medial arch called the tibialis posterior tendon, and it can also get injured.

One of the things that can commonly mimic plantar fasciitis is medial calcaneal nerve entrapment. I will normally look into medial calcaneal nerve entrapment if I have a patient that is really struggling with the treatments we have used and still struggling with quite a severe heel pain.

Radiology, is there any value in doing X-Rays, MRI or Ultrasound? Lots of patients I would see will come in with an X-Ray report saying they have a calcaneal spur. I would normally start off with it is rarely useful, not needed in most cases, and then you get the question ‘What about the heel spur’. I think they’re probably negligible. There’s about a 13% prevalence, and they don’t cause any pain, and as I showed there only 5% of those with calcaneal heel spur complain of heel pain.

I think the use of radiology really is for three main issues: the diagnosis of a calcaneal stress fracture, especially on people who do a lot of running, and also, we get a lot of patients who’ve had chronic plantar fasciitis who present with quite a severe heel pain, and they can be very useful in diagnosing a tear in the plantar fascia.

What I use MRI to confirm is an inflammatory response, enthesopathy, intrasubstance tear, or just chronic thickening of the fascia. So the inflammatory response, you will see a thickening of the plantar fascia, with some inflammatory cells on the dark layer of the plantar fascia.

Enthesopathy is where a tendon or the plantar fascia itself tugs on the bone where it’s attached, and it will cause some bony bruising or bone oedema in the heel bone, which is a sign of both bone and fascia pain are together, and this is more difficult to treat.

Intrasubstance tear, you will see that on MRI because you will have a fluid layer within the plantar fascia, and then the chronic events for the chronic people you will see a big thickened plantar fascia and possibly some bone oedema.

So regard to the helpfulness of this modality is that under the layer that line of inflammation enthesopathy, we have got an idea of what sort of exercise program you might put them on, i.e. intrinsic exercises for their foot, concentric, eccentric and posterior chain exercises.

So we break them up again in what we would feel is the best modality of treatment, i.e. Depo, which is a steroid injection, ESWT, which is shockwave therapy, ACP which has a platelet-rich plasma, and chronic that has had some treatment done already, put them in a boot.

On the bottom there, you can see I put in surgical – in my 13 years of dealing with plantar fasciitis. I haven’t sent on anyone for surgery for their plantar fascia.

This is just an MRI scan of a thickened plantar fascia just in under the heel bone, and you can see some white area in the heel bone, and that’s endoscopic changes. There’s a smaller tear in that fascia, and I would be recommending to that patient that they would have a platelet rich plasma injection.

That brings me on nicely to treatments. I get a lot of patients that come into me, and they have had some form of treatment done already, or they’ve gone to foot solutions and have had orthotics made, and they are getting no better. So I start off with a simple algorithm that I use, and I tick off the boxes that have been covered or not covered and move on from there.

So if running and a lot of physical activity are causing them to have severe heel pain, the first thing I tell them is to modify the activity that they are doing and give themselves more rest time. There’s talk about shoe inserts, orthotics taping support of shoes – I do believe with a taping and some form of shoe inserts, as I mentioned earlier, one of the causes is high arch feet and flat feet

. I am very easy with regard to orthotics, and I just recommended going out and get simple over the counter. Our supports offloads the medial arch until their heel pain settles down, and then you can make the diagnosis with regard to an altered gate or another gate to prescribe orthotics.

One of the great treatments out there for early-stage plantar fasciitis are night splints, and I would prescribe this regularly for a new patient. The stretching programs involve the arch, calf, soft tissue, massage of the calf, and ice. We use non-steroidal anti-inflammatories early on, but I wouldn’t recommend keeping people on non-steroidal anti-inflammatory medication long term.

Then we move into the intervention stuff that we regularly use in Santry, either steroid injection, shockwave therapy or platelet-rich plasma injections.

The principles after rehabilitation exercises, you need to have the overall flexibility and put less strain on the plantar fascia, so you need your Achilles to be flexible, the longitudinal arch to be flexible, and the calf. That involves working on the intrinsic foot muscles, ankle stability, and also looking at the way you run to try and reduce the number of forces that are going into your heel by causing relaxation and greater calf strength and flexibility.

I would normally talk about an Achilles stretching once to twice a day hanging over to the edge of the stairs, barefoot heel/toe/backward walking while carrying weights, towel toe-grabbing the intrinsic foot muscles – these are the mainstay of the rehabilitation exercises.

There was an interesting paper in the British Sports Medicine journal recently where they looked on loading the plantar fascia with intrinsic foot exercises, and it had some effect early on in healing, and the paper was called ‘Load Me up Scotty’, and so it’s another one of the newer research that has been done on plantar fascia pain.

I would normally say to patients who initially come in to see me before you get out of bed in the morning, get a towel put it around your foot and stretch the plantar fascia for a number of minutes prior to getting out of the bed because as I said earlier, the plantar fascia acts like a tendon, and it shrinks at night, so when it shrinks, if you put weight into it first thing you stretch it, and that causes severe pain and inflamed or injured tendon. So if you stretch it or get it activated first thing in the morning before you put it on the ground, the pain will be less obvious.

Also, we talk about running a golf ball or a tennis ball – this image shows a tin under the heel of the foot or under the foot that helps stretch out the plantar fascia.

I suppose it’s a form of an oxymoron, in the sense that one thing we’re saying is that the plantar fascia is a strut, yet we’re saying we can stretch it – both cases are probably true. It does act as a strut to the medial arch but also shrinks to act like a tendon, and so it can stretch. As you can see, the slant board stretch the stair stretch act like eccentric exercises for the Achilles but are very beneficial in treating plantar fascia pain.

I mentioned the night splint. I’m a firm believer that the night splint is underutilized in the treatment of plantar fascia pain. It’s a splint that keeps your foot in full dorsiflexion at night, so it prevents the plantar fascia from shrinking. There are different variations out there, and I’ve shown a number of splints.

The sock third over on the right is known as a Strasburg Sock. It’s less cumbersome than the boot, and a lot of patients find it more comfortable at night, but this would be one of my mainstays of treatment initially for a new patient with plantar fasciitis.

There’s been a number of studies performed on the night splint – Batt et al and Probe et al in 96 and 99 showed that with the tension night splint and heel cup, 100% were cured and ones that failed with non-steroidal anti-inflammatory stretching and shoe changes attention night splint improved our outcome. There were mixed results, but I would always use it first off.

Orthotics is a very difficult topic to talk about on its own. I’m not a firm believer in prescribing orthotics when people don’t have a normal foot strike or biomechanics because of severe heel pain. As I said earlier, I would normally recommend that the patient would go out and buy simple, over the counter arch supports to give the arch a little bit of support as they are going through a rehab program.

There is definitely no evidence to show that getting custom orthotics improves the rate of healing of people with plantar fasciitis. There’s been a number of studies out there in 1999, and they randomly assigned patients to five different groups, and over the counter arch support, full length felt 81% noticed a good improvement. With the custom three-quarter length polypro orthotics only 68% noticed an improvement. The problem with that study was that was only three quarter length orthotics used rather than the full length over counter arch support.

I am moving on to the interventional modalities that I would use with most of the patients that have tried a lot of stuff that I’ve mentioned earlier with regard to physiotherapy and calf stretching. So, I would then discuss the types of treatment that I would use, which is extracorporeal shock wave therapy, steroid injection, or platelet-rich plasma injections.

Extracorporeal shock wave therapy is non-invasive. It involves using a gun, like the pictures here. You deliver a certain dosage of shots at 10-hertz frequency, and you increase the bar of pressure to allow patients to tolerate up to a pain scale of six to seven out of ten.

The modality is a cascade effect – you put the probe onto the degenerative plantar fascia with the energy transferred across the fascia it causes an activation of the healing cascade response, which enhances blood flow into the tissue, which causes tissue regeneration.

We would normally do shockwave three to four treatments a week apart and then get the patient back two to three weeks after that for a top-up treatment.I find shockwave a very good modality. It’s not invasive, and lots of patients do very well with it.

The next option is a corticosteroid injection, which we would do under ultrasound guidance. This is an image of the ultrasound probe and a needle being directed at the plantar fascia, and you can see the ultrasound image on the right-hand side. You can kind of see a little mountain in the middle of the image and the thickened grey part on top of that is the plantar fascia.

I’m slow at recommending a steroid injection straight off. There’s definite evidence that it provides quicker pain relief at one month, but there’s no long term advantage. There has been a number of studies that have shown that steroid injections, there is a recurrence rate of 45 to 50% at six weeks.

The big risk with using steroids is that it’s toxic to the plantar fascia and that it may cause tendon or plantar fascia rupture. In the olden days, this is the only treatment we had, and it was regularly used and was successful, but as I say, the statistics show that one and two have a recurrence rate at six weeks.

A newer treatment we’ve started using is platelet-rich plasma, and we use the Arthex ACP separation kit. What we do is we take blood out of your arms, spin it down in a centrifuge and then, under ultrasound guidance, inject that back in the plantar fascia.

The biggest problem with the plantar fascia platelet-rich plasma injection is it does involve a certain amount of immobilization, and we put you in a boot for two weeks, pre-injection and two weeks post-injection. I would generally use this for patients who have a tear in their plantar fascia or for patients who have chronic fasciosis and have not seen any results with any of the treatments that we offer to date.

What it is, it is simply whole blood that is centrifuged that is spun down in a machine to create an increased concentration of platelets, with or without the white blood cells. In the image at the top of the screen, you can see nice and clear gold fluid at the top, that’s the enriched plasma, and at the bottom, that’s the separation layer of the red blood cells and white blood cells.

So what’s so special about platelets? They activate various growth factors within the tissue, and that makes them special because it enhances an inflammatory response to promote healing and repair of the damaged plantar fascia.

The effects of the growth factors on tissues, there are three different factors of the immediate, it causes a second messenger stimulation, and, i.e. the macrophages stimulate the tissue to cause interleukin response to cause healing. That’s within five minutes, then early between 30 minutes and four hours, you get messenger RNA stimulation to cause protein synthesis and chemo taxes of further healing enzymes to the tissue to promote further healing. Then the late responses within 24 hours, you get fibroblast mitosis, which then encourages collagen deposits and the rate of healing after the damaged plantar fascia.

PRP is not stem cells. We get asked this all the time with stem cells, it’s not lymphocytes, and it’s not bone marrow. It is simply platelets in plasma that promote an inflammatory response to promote healing and repair. As I said, it promotes inflammation, so the reason we put you in the boot is to try and let things be absorbed and adhered around the plantar fascia, and let things rest for a period of time, so there is better uptake of the plasma.

We don’t allow patients to use anti-inflammatory medication for 72 hours after the injection because it stops the cascade inflammation reaction that does promote the healing of the plantar fascia.

It is effective in chronic plantar fasciitis and in tears of the plantar fascia. There are lots of papers being written, and they all seem to highlight that plantar fascia pain that has not succeeded with other treatments do very well with platelet-rich plasma injections.

My typical treatment protocol for a new patient – I profile and try and limit the amount of activity to control the abuse of the fascia. I normally give them two weeks of anti-inflammatory medication.

I talk about ice massage and rolling the medial arch four times a day, over the counter arch support, give them handouts on exercises to work on their calf, Achilles and their plantar fascia and follow up in two weeks just to reinforce whether to do their exercises, get an MRI to see how badly damaged the plantar fascia is, and then discuss interventional therapies.

There are unusual things that can mimic the plantar fascia as I mentioned earlier, and if patients are still suffering from pain after three to six months and have not responded to treatments, which I may say, I have at times thrown the kitchen sink at plantar fascia pain involving all three modalities of treatment.

If at that stage they haven’t responded to treatment, I would always think of other conditions that may mimic it, like a fibrous sarcoma of the tissue, a foreign body within the plantar fascia that is not evident on X-Ray or on MRI. Older diseases like Paget’s disease or TB, and also gout as I mentioned earlier, gout is one of these arthropathies that can cause plantar fascia pain to linger, despite shown a lot of treatment in it and a simple uric acid blood test and treatment of gout gets rid of the plantar fascia pain.

The one thing that I see quite regularly is when I’ve shown a lot of treatments that the plantar fascia is a nerve entrapment syndrome. In the past year, I would have seen probably six or seven nerve entrapments is of the medial calcaneal nerve and sural accessory nerve. If treatment is not going well, I would normally refer these patients for EMG studies and getting the entrapped nerve flushed with saline, and local anaesthetic generally helps relieve the pain.

Prognosis is excellent for plantar fascia pain, although patients I see who have it don’t feel the prognosis is good because they’ve had it for so long. 80% are generally better in 12 months. The literature explains that it is a self-limiting condition, and it can burn itself out, but you cannot put a timeframe on it. Most patients who get no treatment and get by through the pain cycles generally would say to me that after three and a half years that it would burn itself out.

We have treatments there to try and help patients, and anyone I see, I would start them onto a treatment plan, try and reduce the amount of time you suffer from heel pain. Surgical intervention is very rare, and I don’t think, as I said, I haven’t referred anyone for surgery over the 12 years that I’ve been involved in treating plantar fascia pain.

The take-home messages from this talk are that plantar fasciitis is very common. It’s a degenerative condition and not inflammatory. Strength is key. What I mean by that is that your calf muscles and your Achilles need to work synergistically to take the load out of the plantar fascia. Adjuncts do help. The heel raises, the soft heel gel pads, and over the counter arch support are all very beneficial in trying to help reduce the pain.

Segmental load is used to offload, so as I said, that new paper in the British Journal of Sports Medicine, ‘Load Me up Scotty’, is trying to load the plantar fascia early, so it reduces the pain. That is a new paper that may show added benefit over the next number of years. As I said earlier, I would normally use shockwave therapy or platelet-rich plasma injections, and surgery and steroid treatments are rare.

Again, I’d like to thank you for letting me give you this overview on plantar fasciitis. I can tell you I’m a sufferer of the condition myself. I had it for a number of years, and I understand and empathize with patients who have it.

As I said, I’m a Sports and Exercise Physician, and I work in Sports Surgery Clinic. This is a final slide of myself with three of the physios who work in the clinic who were all involved with the successful Cavan Ulster Champions of 2020.

Thank you very much, and I’m more than happy to take any questions from you.

At this event, Dr Philip Carolan (PC), answered questions from our live audience asked by Fiona Roche (FR)

FR: Katherine’s did an eight-kilometre walk with a small bit of light jogging in January, and the next day she couldn’t put any weight on her left foot. It took four weeks before she could walk comfortably again. MRI showed no injury. She still gets a lot of darts of pain in the base of her big toe after walking or lights running. She is asking why?

PC: Catherine, that is a very interesting question. You put a big load into your big toe on your walk and light jog, and there are two bones at the base of your big toe called sesamoid bones, and they have a great risk of getting inflamed, which is known as ethmoiditis and sometimes you can get a stress factor.

Generally, they would settle down after four to six weeks or even a bit longer, but on an MRI, you should see a sesamoiditis definitely, and you should see a stress fracture. There are two tendons that insert onto the base of the big toe as well that can get inflamed from overuse and increased force by doing too much activity too quickly, but the likelihood it sounds to me that it is probably more like a sesamoiditis which is an inflammatory condition with the sesamoid bone and your big toe. Generally, it affects the fibular, which is the one on the outside sesamoid bone, but it is quite common and generally settles down by wearing a hard sole, firm shoe for four to six weeks.

The only other thing is big toe pain can be related to Gout – unusual to come on after exercise, but it is something that you need to bear in mind if you have got someone with an unusual presentation with big toe pain is to probably get a uric acid blood test done to check for Gout.

FR: Mark says can PF come and go, or is it mainly a steady increase until it becomes chronic?

PC: The literature states that plantar fasciitis is a degenerative condition, and if someone gets it generally should burn itself out over time. I do see people who would inform me that they have had plantar fasciitis in the past, and it disappeared, and now it has come back as bad as ever.

It does become a chronic condition, and that is when patients generally require treatment. I can empathize with anyone that has PF, I had it myself for three and a half years, and at the time, I was doing a lot of research on it, and everywhere I read, the literature states it should disappear by itself and burn itself out. I just did the simple physiotherapy exercises, got no treatment, and eventually woke up one morning, and it was gone.

We have treatments out there to manage it, and I definitely would recommend patients get it managed because it does have a big effect on their quality of life.

FR: Darragh says, how long will the shockwave therapy session last?

PC: That is an interesting question because shockwave therapy is evolving – there is a lot of different machines out there at the minute between radial shockwave therapies.

It depends on the machine because the one we use in Santry is a Swiss Dollar Cast machine which we treat plantar fasciitis at 10 hertz of frequency which is a fast pulse treatment. Generally, it is 2500 shocks at 10-hertz frequency, which generally lasts between 8 and 10 minutes – it just depends on how fast the frequency of the shockwaves are.

When we started off doing shockwave, we had an older machine, and it was a 2 hertz of frequency, and it took 20 minutes to do it. So it depends on the machine. There is a set dosage for PF with all the machines, so you just put in the dosage, which, as I say, is 2500 with our machine at 10 hertz, and it comes down through the machine.

FR: Would you class a recent increase in weight gain as a risk factor for PF? If so, what would be a significant enough weight increase?

PC: This is a challenging question because, from my talk, you would have seen that we do mention that weight gain or carrying extra weight is a risk factor for PF. Anyone who gains some weight is putting a greater force into their heel and into their plantar fascia, which is acting as a destructive medial arch.

I don’t blame weight gain on being a true source of PF because people who are not carrying weight and have a normal BMI get PF as well – athletes get it, a lot of runners and sprinters get PF who is not carrying any weight, so I don’t like to use that as a true cause but of course, if you are putting weight on it is putting a greater load into the fascia so it can make it more painful.

FR: If an X-Ray showed a large increase in the size of a heel spur over a couple of years leading to heel pain and surgery, is surgery ever considered or is an increase in heel spur a secondary effect?

PC: From my talk, I mentioned that the heel spurs don’t cause pain – you can do X-Rays on a population, and there is a prevalence in about 15% of the population who have no pain from a heel spur. 10 % of heel spurs might give some pain – over my time as a consultant, and I never referred anyone for surgery for a heel spur.

What causes a heel spur is the repetitive degeneration of the plantar fascia, and as the fascia degenerates, you get the inflammatory response which causes calcification. It is a chronic evolution of the plantar fasciosis that causes calcification to make the spur, and if it is going on a long period of time, of course, you will get an enlargement of the spur, but I still think the pain is generated by the fascia rather than the spur.

FR: I suffered from my left foot three months ago. The metatarsal up to the shin is now started over on my right foot. The left foot is still not great, I had an X-Ray to rule out a stress fracture, and I have just been fitted with new runners. Is there anything I can do to help with this? Pain is in the top of my feet.

PC: This is a difficult one because, unfortunately, an X-Ray is not great for diagnosing or ruling out a stress fracture. The X-Ray will prove that you either have a fracture or not a fracture. Stress fractures don’t always give you the dreaded black line in an X-Ray, so I can’t say you have definitely out ruled a stress fracture, although the way you described the pain radiating up to the shin, it sounds like there is more nerve irritation and it could be more in neuroma causing the pain and the risk is always that it could be bilateral which is both sides and both feet.

I suppose if it is not settling and it is now radiating into another foot, I would recommend probably getting a scan of the foot to make sure there isn’t anything else going on.

With regard to footwear, I would say I am not great at giving the names for footwear for patients – my attitude is footwear should be comfortable and supportive, so a firm soul, comfortable runners, is what I recommend to try and help alleviate the pain.

FR: Plantar Fasciosis was explained as micro-tears and inflammation. We do also see a substantial group of people younger who have normal findings – any comment?

PC: I suppose the PF is a degenerative condition and can affect anyone. I saw someone today, a 15-year-old who had PF. There is some evidence of inflammatory change within the fascia on the scan. It is described as micro-tearing, but it is tearing within the cell particles, which generates an inflammatory response.

For further information on Plantar Fasciitis or to book an appointment with Dr Philip Carolan  please contact sportsmedicine@sportssurgeryclinic.com
Knee Injuries in Runners

Common Knee Injuries in Runners – Mr Mark Jackson

Watch this video of Mr Mark Jackson, Consultant Orthopaedic Surgeon specialising in knee pain discussing ‘Common Knee Injuries in Runners’.

This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.

Mark Jackson Knee Surgeon

Mr Mark Jackson is a Consultant Orthopaedic Surgeon at Sports Surgery Clinic specialising in knee surgery.

So just to introduce myself, my name is Mark Jackson. I work as a Consultant Orthopaedic Surgeon and am now predominantly a knee specialist.

I get referrals from across the country, predominantly through general practitioners, physiotherapists, A&E departments and other surgeons. This can involve treating and assessing patients of all age’s right from the age of 12 up to no limit upper limit really, I often see patients well into their 80’s and 90’s. Children who are under the age of 12 tend to be looked after more through the pediatric system.

I am based predominantly here in the Sports Surgery Clinic. I also work a little bit in the Blackrock Clinic, but my practice is then split pretty much down the middle between looking after patients with sports-related injuries and issues, sometimes we call these soft tissue injuries and those that are more degenerative in nature which for the main means problems with arthritis.

So just to go through a few aims of today’s talk, clearly, we would all like to look like the runner on the right here but I just want to give you some basic anatomy so that we can understand the common conditions that we deal with, go through some of the more frequent conditions that I tend to see in the running population, explain often what a role of a knee surgeon can be and give you then a walkthrough and a talk of some examples of patients I have seen in the last few weeks, then just finding a few general tips and advice for people out there who are currently running or perhaps wondering about their injury.

Anatomy is key to any surgeons life and we need to know this in a lot of detail, but just basically if we look at the picture on the left hand side here this is a picture of a knee from the front with obviously all the skin and fat removed and we can see a few things that we may just touch upon today.

The top is the muscle the quad muscle, quad meaning four so there are four bellies of muscle if you like that blend together to form a quadriceps tendon that is seen in this area here blending onto the top of your kneecap and then below the kneecap is the patellar tendon attaching onto the top of your shin bone here in the tibia.

This whole area is called the extensor mechanism – a very common source of pain in runners. The iliotibial band we hear an awful lot about and that’s this structure here but it extends a lot higher than this right all the way up towards the pelvis and if we look at the structures then on the right with a lot of muscular and soft tissues now removed we are going to be seeing the bones which as we mentioned the tibia being the shin bone, the femur which is your thigh bone, the kneecap here is the patella is reflected out of the way just for the picture.

We can see the joint surfaces which are usually very smooth and have low friction. We see ligaments in the middle so we hear a lot about the ACL the anterior cruciate ligament and then in between the bones there are these things called the meniscal cartilages and you have got one on each side of the joint. We will touch upon a few of these issues as we go along.

If we look at these pictures, the picture now on the left-hand side of the screen is the dissected cadaveric specimen with the knee opened up. Again we see the joint surface here this lovely, smooth, glistening surface. This area here under the LFC is the lateral side if they need the later thermal condyle, this is how it should look.

On the inside of the knee on the medial femoral condyle, there is a patch here somewhere developing, not too bad but it is certainly happening in this specimen and the ligaments in the middle. If we were to put a camera in the joint down here and have a look, this is what the viewers get in our keyhole surgery procedures, this is called an arthroscopy. The camera there shows us the meniscus here sitting wedged in between the surfaces and again in this example here this is completely normal with lovely white smooth articular joint surfaces

The last picture on the right-hand side again shows how these meniscal cartilages one here, one here, wedged in and interposed between the weight-bearing portions of the joint.

It’s important just to understand the differences when we talk about the term cartilage. The meniscal cartilage is often referred to as torn cartilage. So if someone says they have torn cartilage, they’re referring to these things here meniscal cartilages.

The joint surface cartilage we often refer to as chondral, or articular cartilage, and that’s these white smooth surfaces.

Half of my work I mentioned is on sports-related issues and soft tissue injuries. Just to give you a few pictures here the top three pictures of keyhole surgery is looking after meniscal cartilage damage, so here is the tear and this is when we removed it. Here we’re doing some stitching and repair of cartilage and things can get quite complicated. We tend to sometimes offer this in very specific indications in sports injuries only.

The bottom three pictures are maybe more the ligamentous type work we might have to deal with, with the middle picture at the bottom being a very typical torn ACL, or anterior cruciate ligament. Once we’ve cleaned it out, we put in a new one in for patients who are desiring a return to their sports, in particular, it would look like this and this would be a before picture, and after picture when we reconstructed and made a new ligament.

Then finally this last picture on the left is when we have to open surgery for complex injuries when somebody has essentially dislocated their knee and tore apart lots of these structures, we’re talking about.

Then the other half of the work will be the more degenerative and arthritic problems. Just a few examples here, what we might end up having to do for people, top left are the two components of what we call a partial or half knee replacement. This is a full total knee replacement. This would be somebody who’s having to undergo another knee replacement so this is a revision total knee replacement, and this is a procedure called an osteotomy.

This is a younger person with arthritis that we’re trying to delay this individual getting a knee replacement, but don’t assume all these people are old – plenty of these patients we see are in their 40s and 50s. It is not infrequent that we’re doing new replacements on people at that age. Most however are going to be into their 60s and 70s.

How common is a runner’s knee injury? The answer is extremely. You go to any race, you are going to see if people are like in these pictures all taped up wearing straps and bandages. This article here is from the American Journal of Sports Medicine, which is probably our most respected journal within orthopaedic surgery and sports sciences.

It looked at a two-year study on 300 runners who were initially uninjured and followed them up respectively over two years. They’re aged between 18 and 60 and running for at least 10 months per week, and at least one overuse injury was sustained in two-thirds of these individuals over that two year period, with at least half of those individuals getting more than one injury.

The knee was the commonest site of injury, with again almost 30% of all those injuries being at the knee, and the patellofemoral region of the joint, which we mentioned being  extensive mechanism was the most common. The most frequent group that were injured were the amateur and inexperienced athletes, the female sex and the middle-aged man.

If you have picked up an injury and you have a problem, what tends to happen next? People will discuss usually with friends, their family, maybe some fellow runners and people who have had similar experiences and what did they do.

The next step might now be for people to pick up their mobile phone and type things into Dr Google and see what their advice is there online. Maybe they decide to take a break from running for a bit and see what happens, see a physiotherapist, maybe some treatment has begun. If things go well and things settle down, fine, but if not, maybe then is taken further. Maybe a sports doctor gets involved, maybe patients go straight to their GP. Then obviously orthopaedic surgeons can become involved too. I would see patients sometimes referred directly to myself, straight from a physiotherapist or even self-referrals, or sometimes we are the very last people to be involved, because everything else has already been tried, tested, and maybe it is found.

When I do see patients nearly everybody I see is going to have had an MRI scan, and that certainly helps me to give the individual the best diagnosis I can possibly give them and give them a guide to what the best treatment options going forward are likely to be.

So one of the common conditions, we won’t go into this in too much detail, these issues here are very, very common. The tendon type pains, quadriceps tendon. The patellar tendon, hamstrings, and these are the issues also commonly seen.

They can be however divided up a bit more simply into two groups. We have the overloading and overuse type injuries, and we have the degenerative type problems and injuries.

The overload injuries are a bit different, they tend to be fine, they tend to resolve – as long as appropriate treatments are initiated, which are generally non-surgical, and these then can be reversed with most individuals attaining a good outcome. They are also in the main preventable. This picture here just shows a schematic picture of a patellar tendon being inflamed, tendonitis being a very common condition.

The degenerative issues however are a bit different – these are irreversible and need a little bit more careful management and advice. Surgery can occasionally play a role. Is degenerative change inevitable? Yes and no – some people are lucky they escape and they don’t seem to get too many problems, but everyone gets older, everybody’s going to get grey hair and wrinkles. I’m afraid people’s joins do start to show you the strains of the ageing process and some just get it earlier in life more obviously than others.

So what is overload and overuse? Well, it can begin really with some risk factors, those are going to be usually patients have some inadequate strength or strength imbalances, maybe they have quite poor running biomechanics and some inappropriate training regimes. Then there becomes this imbalance and it’s the imbalance between what the body can cope with and respond to what it can heal, and against the load that’s being delivered. If there is too much load and the body can’t respond to it, and heal and become accustomed to that new pressures and loads, then there is this imbalance and overload problems can begin

The majority, as we’ve said, are manageable without surgery. Most of them will have no long term consequences with regards to the development of osteoarthritis, but it is important to have somebody guiding individuals, taking on board advice from experienced therapists, and the sports medicine doctor or GP can sometimes help out. Sometimes investigations are necessary, and injections are necessary, maybe we need to rule out other pathology is there an issue with the spine, is there an issue with the hip, are there rheumatological conditions? So there are sometimes further investigations that are warranted but for most that isn’t going to be necessary.

So what is my role as a surgeon? Well, I can be a good cop or I can be a bad cop. We need to obviously assess the condition, we need to usually take a good history, we’ll examine the knee, and see what we find, help them come to a diagnosis. Interpretation of the imaging and giving this context. The radiological reports vary in quality from around the country and from radiologist to radiologist.

It is really just detailing what is seen on the scan and as we say we don’t necessarily treat the scan we treat the man, so we have to put it in context for individuals and explaining what is relevant and what isn’t relevant. Hopefully, though we are able to then guide people and get them back and keep them running, and if we do that generally then that’s the good cop side of things.

However, we also sometimes have to advise unrealistic expectations, bring people back down to earth a little bit, and also counsel on potential long term issues. In some of my role as well as being a surgeon, which is obviously what we’re trained to do, we enjoy a lot of it can sometimes be a bit of counselling and advising that it is time to perhaps stop running.

The challenge that we face sometimes in a runner’s knee is that both of us see it differently, but we have very similar goals – we both want people to be active. We want people to stay involved in the things that they enjoy doing, but we also don’t want to do this at the behest of having long-term problems.

The runner I see is often very anxious about having some time out, wants to obviously improve symptoms and pain, and some patients are often incredibly surprised that they have picked up an injury. There is often an expectation that we’re going to be able to fix everything and have a very quick fix for it, but you may be saying I have a race coming up in four weeks, I’ve committed to doing a triathlon in Barcelona in two months-time.

We also get a lot of individuals in the current day and age stating that they want to be able to keep running because it’s so important for their mental health. From a surgeon’s perspective, I need to make a diagnosis, I need to know what I can offer somebody, and clearly want to give that person the best route possible to their highest possible function, but we do have that responsibility too that we don’t want people to damage themselves irreversibly and warn of potential implications that can occur down the line.

I don’t want to offend anybody here obviously but there are some challenging runners out there. The retired sportsman or woman who is a keen runner can be a difficulty, they may have picked up quite a few issues in the past, they may have had cruciate ligament injuries or reconstructions, they could have cartilage surgery from their teens and in their 20s, and this is now catching up. That can be sometimes difficult to take.

The runner who is constantly injured, going from one injury to another, from the groin injury to the heel injury, to their knee injury – again these are difficult and challenging people often don’t have quick fixes and aren’t necessarily sometimes taking on board some of the perhaps preventative measures that can be instigated.

The weight runner, again, a bit of a challenge, putting a lot of pressure and force on joints and running in my experience for people who are overweight isn’t necessarily the best way to control weight, certainly not in the long term, there’s usually a lot of other things that should take priority, with regards to diet and lifestyle over just being out running.

Running as a physical job can be a challenge, somebody who’s on a construction site all day or someone who’s farming, who is very heavy on their knees, and that expects to be able to run that evening and over the weekend during long distances that can be quite a difficult need to manage.

The inexperienced and new runner, often in their middle ages. They can be difficult because they’re coming into things maybe with a very poor baseline of fitness and they are enjoying their new running, and they’re feeling the benefits of being able to bounce and being healthy and active, and then gets somewhat surprised when they run into difficulty and have complaints and issues that can’t easily be fixed.

Then there is the perpetual knee abuser – somebody who isn’t listening to the advice, is getting sore swollen knees and keeping on going, has an operation keeps on going, has another operation keeps on going. But eventually usually the penny does drop and people come to terms with their challenges.

As a surgeon, one of my roles is clearly who needs surgery? Actually, for runners, it’s relatively few, but there are some specific indications that we can sometimes help with, as we’ve said the majority of injuries in runners can be resolved with a good diagnosis and expertise from a rehabilitation program.

We do need to have some realistic expectations though, and patience is very important as the change in strength, the changing of biomechanics takes time. This is not necessarily just measured with a few physio sessions over a week or two – this can take months and months and it does often require motivation and dedication.

So just to go through a few surgical examples of patients I’ve recently looked after. This is a very elite level runner in fact hoping to make qualifying times from 1500 meters for this year’s Olympics for Ireland and was referred with symptoms of mechanical nature, symptoms of locking and jamming, and overall it’s fairly unusual to see elite-level runners with knee problems.

It’s a somewhat unusual referral, but he had a very clear problem, he had a condition with osteochondritis desiccants, and what we can see here in the keyhole surgery is me retrieving a loose body that’s floating around in the joint, and this has been generated off the joint surface here. When it moves around in joint like this it can get pinched and caught, but as soon as it’s removed the symptoms resolve and he made a very quick rapid recovery and was back running within about three or four weeks, and is now back up to speed and back on track again hopefully for his goals going forward.

This again is a common presentation – a 41-year-old recreational runner, as a physical job. There was no injury, came on gradually and steadily, but he’s now got to the point where he’s had to stop running, pain is interfering with life, maybe sleep, maybe he’s waking at night and he is limping.

When we put the camera in the knee, this is the problem, this is a tear here in the meniscus in between the joint surfaces. However, the rest of his knee is perfect. This is the other half of his knee, with a normal meniscus and normal joint surfaces. These surfaces are normal, so when we take out the tear which is what this picture is here, so this is the before picture and this is the after picture because the rest of his knee is normal, he can have a very good outcome and indeed he did go back into things and settled very quickly.

This is a similar type of issue and there is a meniscal cartilage tear. It is a bit different, it’s more degenerative and again we can clean this up. So this is taken to this, but the difference, in this case, is that there is some joint surface damage starting. We have to take this a little bit more cautiously because there is the propensity for this to still cause a few issues and pains, and if this progresses over the next few years then it could be more challenging for that individual to stay involved in these kinds of impact and running type activities, and as is often the way there are similar symptoms also developing on his other knee.

This would be an overload problem, again recreational runner. We’ve seen quite a lot of that in the last 18 months with people perhaps doing more running, the normal increase in the load, running more days, maybe running frequently, maybe running for longer distances. This is a reaction in the bone, so in this MRI scan this is a view of the knee from the front. This is the femur, thigh bone, tibia here, and in this bit of bone, you can see a white pattern. This is a side view showing the same pattern in the bone. What this represents is bone stress, bone bruising if you like or bone oedema.

This is indicative that this bone isn’t enjoying this new load and is reacting because it isn’t getting a chance to heal. This though is in the background of the knee that otherwise looks good. So again, this is rested and protected, the bone will heal, symptoms will usually subside, but it can take time, and this type of condition can sometimes take at least three months, sometimes longer, before we allow that person to then start to up that load and increase their running again, and in the background need to be seeing a physiotherapist to be working on their strength and seeing if there are some preventative measures that can be put in place before that person returns into their desired activity.

This thing gets a little bit more challenging because this is now significant arthritis in a young age. This individual again has been a regular runner over a good few years, and seems to remember there was an old hurling injury, probably tore his ACL ligament, but didn’t need any surgery at that stage, but he’s now at the point where on the scan that this is a very worn-out joint, and when the camera is put inside the knee, there are areas of bare bone rubbing on bare bone. So this is now 100% game over for this individual. This they have to accept, there is no good fix for this, and running is unrealistic. However, there should be other activities we can get this person into the gym, bike, cross trainers, weight training, and we can then hopefully maintain some good function of years, but we’ll have to accept that there are more major surgeries down the line, and we need to delay these for as long as we can.

Somebody who’s been overweight and running as we’ve mentioned can be a challenge. This individual weighs 120 kilos and is using running as his way to control his weight. However, now he’s getting arthritis in the knee underneath the kneecap here on his scan. He also has a poor program of running, very poor basics and is weak. This is very vulnerable to progress and it won’t be long before other areas of his knee also catch up and start to wear down. This is not again a surgical case, this is just about education, telling people what’s going on, interpreting the scan and giving the expectations going forward. This individual needs to now look at alternative ways to control weight as opposed to the impact of the activities and running.

One final case again premature osteoarthritis again in a very active individual in their 40s who has been heavily involved in doing triathlons and long-distance running over about a 10 year period. This is on the background of having a previous cartilage surgery, about 10 years ago. These are both of the knees, the right knee here is bone on bone with a stress reaction again bone oedema, and the left knee less advanced changes, but this right knee, in particular, is in big trouble, his left knee may settle down. This gentleman has persisted with his running despite being sore, hasn’t really listened to his knees. By the time it comes to get attention and be reviewed, things have really moved on, and again this is an individual who probably will need treatments down the line and it is a matter of not delaying this for as long as we can.

Then we get the serial abusers. This would be somebody who’s very vulnerable to getting problems, a daily runner, someone who every single day goes out running without rest and does nothing else, and has been aware of symptoms over time but is now getting worse, still running though, determined to keep running, not prepared to take time out and rest, and as well as the run will often walk for 10 kilometres a day. So what’s happening now is this person is getting arthritis again similar to the overweight case we just discussed, with the kneecap wearing out in front of the joint, but there’s also a stress reaction and stress fracture here in the inner side of the knee. Although this may settle and improve if he/she doesn’t do this can deteriorate quite quickly into a much more significant arthritic problem. So again, education, not necessarily surgery.

A few hard truths about osteoarthritis, it’s obviously great that our life expectancy and things have improved, but it does bring with it the challenges of osteoarthritis, we as yet don’t have good medical treatments.

This graph at the bottom right-hand side shows how the rates of as we say here the prevalence of arthritis in percentage terms is rising through the age groups, so 40-50, 60-70 and 80. At the age of say 70, 40% of the population have screened for osteoarthritis we’ll find that that’s the case.

Prevalence is different to symptoms. A lot of these people still may be relatively unaware of their symptoms, but if we MRI or X-ray people, there are these findings that are developing, and we can see here the significant increase risk and prevalence in women, as compared to men.

Everybody there has an individualized risk, we are not all the same. There are clear risk factors, first of all, a few here, age, and whether male or female, but the other risk factors here which are independent are obesity, which plays a massive role now in the patients we see that arthritis at a younger age, and also those that have significant prior injuries, and the things we can’t do much about like genetics, you can follow your favourite football team and find that there are players who are just constantly being injured, and some of them seem to go through a massive pretty long career without ever picking up much of an injury.

A lot has to do with genetics, how are your limbs lined up, what are the shape of your bones and joints, how is your collagen made up, what are your ligaments like, are you somebody who’s very naturally loose-jointed which can lead to problems, are you, somebody who’s very tight jointed which can lead to problems, are you a responder to training people respond differently? Some people’s muscle hypertrophy comes very easy, some doesn’t, what are your muscle types? There are lots of genetic factors that will probably play into osteoarthritis in itself, some of which we still don’t really understand. We have to remember the surgical treatments for arthritis are often significant and in general, are not going to be procedures that are going to allow patients to return to their running activity.

So, to get towards the end of the talk, my top 10 tips here for runners would be to stay active, but don’t just do running. To get stronger, get some resistance training going maybe get a good rehab person to evaluate and improve your technique. Please don’t try and use running as your primary weight control measure there are other things you can do, and it is important to recognize that the running may not continue forever or you may pick up an injury, so you do need alternative ways.

Similarly, don’t rely purely on running to manage mental health issues – this is clearly a complicated matter, but if you suddenly find you’re out of running for a period of time that can obviously add into anxiety and mental health concerns.

It’s good to get to know an experienced physiotherapist, usually, unfortunately, there aren’t quick fixes or miracle cures and it is important for individuals to accept sometimes timeout is necessary to try to recover and rehabilitate, and you need to listen to some of the warning signs of irreversible joint damage, so in the main, that’s going to be a lot of swelling after activities, stiffness and pain. If these things are happening, please don’t ignore and get somebody to interpret these symptoms for you.

However, if all feels good, and you are managing your load well in your training, well it’s fine to continue, and people will continue well into their 40s 50s 60s and sometimes beyond, but it’s not for everybody at that age group and we just have to be realistic.

In general, even though I’m a surgeon and it is what we enjoy doing in a way and what we’re trained to do, surgery can often be avoided, and it can be a slippery slope. You don’t want to just be looking for quick surgical fixes and find within a few years things have gotten a lot harder to manage.

In summary, we all have the same goals – we want people to be active, we want them to be healthy and enjoy their sports. Most of these conditions that runners will present us with are not going to necessarily be going into anything surgical, and I do encourage you to listen to your knee symptoms, get them checked out if you’re concerned, commit them to some prevention measures which involve some alterations perhaps in your training, and accept that unfortunately injuries relatively common, and you may need on occasion to have a break and some time out.

At this event, Mr Mark Jackson (MJ), answered questions from our live audience asked by Fiona Roche (FR).

FR: Are supplements beneficial for knee injuries?

MJ: Supplements is obviously a fairly big topic – the common ones that people talk about are going to be things like glucosamine, chondroitin, fish oils and then there are things like turmeric which are sort of a popular one which people are purchasing and trying at the moment.

From a purely scientific standpoint, the evidence for these supplements is pretty weak. People are welcome if they like to try them, some patients I get seem to report that they get some benefit, but scientifically there is no good evidence to show that it slows up the process of wear and tear, rests the process of arthritis or really gives much symptom relief over placebo.

I always tend to say it is up to the individual – they can try it and by all means, they may get lucky and it helps them but I don’t tend to routinely say you must be on this or that supplement. That is the problem with arthritis generally, we don’t have great medical treatments as of yet.

FR: How do you know the difference between normal aches or pains after say a long run if the aches and pains are normal and the warning signs of an impending injury?

MJ: A lot of people might get a few aches and pains – that isn’t necessarily the problem, it’s the degree of pain and the restrictions it causes maybe afterwards. The warning sign in the knee is the knee that reacts badly to that activity that evening and the next day. People may feel that the knee swells within a few hours, maybe you go to bed that evening and waking up with pain, and then coming down the stairs sideways the next morning limping a little bit and then it eases off and then two days later maybe they feel they can run again.

That is a bit of a vicious circle you are getting into. That is what I mean about sometimes listening to the knee symptoms that is your knee telling you there is a problem. I think those are the times I would encourage people to get looked at and maybe get some imaging particularly if there is a lot of swelling and just to make sure you are not running into trouble with significant chondral damage and arthritic issues, but if it is a little ache that doesn’t seem to hold you back too much or doesn’t seem to have like a hangover effect, you are not having to take loads of painkillers and anti-inflammatories, a lot of those can probably be ignored, but it is obviously going to be different from person to person.

FR: Jennifer damaged her patellar tendon three months post-pregnancy. She is not new to running and had no knee issues before. She slowly built up running again 20 minutes wearing a knee trap. How likely are these types of injuries in returning again and any tips on how to avoid them happening?

MJ: Reading the question it is a bit difficult when it is specific to an individual. It sounds like somebody is returning to running after pregnancy. One of the issues with pregnancy is there is obviously a lot of weight gain which puts a lot of stress on the joints and there is also a lot of hormonal changes. Some of these hormonal changes can lead to ligamentous laxity and joint pain in itself and because sometimes a lot of core weakening may happen so with the pregnancy and the stretching of the abdominal muscles and stress on the back, it takes a long time to restore strength in around the core and the glutes. It is not uncommon then that someone even if they have been a runner in the past can return to activity and they are running into a bit of that overload and overuse issue which we talked about in the talk there.

I would think that the predominant thing is to go back to real basic strength and conditioning exercises, work a lot on core. Wearing knee straps I don’t find particularly useful but I know a lot of patients seem to like wearing them. I find it very difficult often to explain to patients what they are doing, the type of straps underneath the patellar tendon and things – I think you are better off going down a goof rehab route as opposed to trying to rely on a strap.

FR: Leanne says her knee hurts when she used to go up and down the stairs but it has now eased, now it hurts only when I lunge. It does ease when I stretch my hamstring and it doesn’t hurt when I run.

MJ: This is one of the commonest knee symptoms for everybody, not just runners, so this is patellofemoral pain, so in front of the knee bone. It won’t think it has anything to do with bicep femoris, which for people is one of their hamstring tendons and I don’t think it will relate usually to the IT band syndrome issues. It is the loading position of the patellar tendon, so that going downstairs is sometimes worse than going upstairs, any single-leg squat, split squats, Bulgarian squats or those kinds of issues and the lunge.

So my feeling on that briefly on the history there would be much more patellofemoral pain, and that can then be the crunching and noises that people get and would be very common in those positions as well, particularly from the patellar tendon joint so the rehab will be focused there.

FR: Bronagh says she is a keen runner, meniscus resection 10 years ago, knee pain has resumed in the last 2 years, MRI is showing Osteoarthritis medial compartmental cartilage meniscal damage. She is recommended to have a uni knee replacement, will she be able to resume running after this?

MJ: Again these are some of those challenging conditions that we talked about there. I don’t know what age this individual is but obviously having had a significant meniscus resection in the past has led to accelerated wear and has now got to what we call unicompartmental advanced arthritis.

It would depend a little bit on the patient’s age. Unicompartmental knee replacement is a good option for day to day life but not for returning to running in my opinion. I do partial knee replacements and unicompartmental knee replacements often, but these implants are not designed for running, they are designed to give people a better quality of life in their day to day routine.

Activity expectations are going to be for walking, hiking, and if they do well then they are into the next level of activity which could be your golf, maybe playing some light doubles tennis and that is as far as I usually recommend people take it.

Obviously cycling, gym work there are things that you can do but actually going out on the road and running with a knee replacement is not going to be advisable. If you have a uni you want that to last and no moving part lasts forever. If you are in your 50’s and getting a partial knee replacement that is a stepping stone to a total knee replacement usually and you want to look after that knee. So stay active but don’t go into those surgeries with a goal of returning to a heavy impact activity like running.

FR: Peter has torn his meniscus in both knees in the past 12 months, can he expect that it is likely to happen again? He is 55.

MJ: This is the degenerative meniscus issue, again often you do find people who have very similar experiences on both their knees. Somebody who has got a meniscal tear on one knee obviously been followed up by a similar problem on the other side. Those issues at 55 are evidence really of a degenerative type process that is going on.

I wouldn’t be necessarily concerned about the meniscal tear itself happening again, you would be more worried about the consequences of the damaging meniscus and the damaging joint, so that would mean getting into problems of arthritis, so in terms of having a meniscal tear happening again I wouldn’t be too worried, it is more the consequences of having the tear in the first place that I would be a little bit more concerned with.

FR: Karen is a 49-year-old runner currently approximately doing 20 -25 miles a week, including speed sessions. She has a history of distance running and very mild knee pain from time to time but it’s not problematic on both knees in the last year. They are making a crunching, grating sound – should she be concerned?

MJ: It would be interesting to do a survey on everyone who is in this talk about crunching and grating from the knees. I can tell you my knees crunch and grate all the time. Almost every knee I examine is going to have some clicks or noises. Crunching and grating in itself can often be very benign and mean absolutely nothing or it can sometimes mean there is a bit of wear and tear, and that is going to be again around the patellofemoral joints around the kneecap, so those up and downstairs clicks and grinds that an awful lot of people experience generally from the patellar femoral joint, so again in the gym the squats, lunges, leg presses put force on the patellofemoral joint and as I said, it can just be quite benign and if it is not associated with huge pain and swelling I wouldn’t be too worried.

FR: Can chondromalacia be treated with surgery?

MJ: All chondromalacia means is soft cartilage and it means chondro is the surfaces of the joint, so soft surfaces of the joint and the common term you hear is chondromalacia patella which is soft cartilage on the kneecap. It is a very umbrella term. It doesn’t in itself mean very much and chondromalacia patella is often talked and it is not usually very responsive to surgery.

In simple terms no, chondromalacia does not usually lead to surgery. It is a process going on of the surface of the joint starting to get a little bit damaged and if it is on the kneecap in particular most sports surgeons would be nervous to recommend surgery for a bit of damage on the back of the kneecap because often it doesn’t change that much, certainly not as much as the rehab probably would.

 

To make an appointment with Mr Mark Jackson please contact markjackson@sportssurgeryclinic.com

Managing Running Injury Risk Factors – Colin Griffin

Watch this video of Colin Griffin, Strength and Conditioning Coach specialising in foot and ankle rehabilitation discussing ‘Managing Running Injury Risk Factors’.

This video was recorded as part of Sports Surgery Clinic’s Evening for Runners in July.

Colin Griffin is a Strength and Conditioning Coach in  the Sports Medicine Department specialising in Foot and Ankle Rehabilitation.

Good evening everybody. Thanks for tuning in. So my presentation is going to be covering how you manage the injury risk factors in runners. So just a little bit about my background before I start, I work as a Strength and Conditioning Coach in the Sports Medicine Department where I am lead clinician for foot and ankle rehabilitation and also lead our Run Lab services.

I’m also undertaking a PhD in Achilles rehab and lower limb biomechanics. I am an accredited Strength and Conditioning Coach with the UK Strength and Conditioning Association and the Sport Ireland Institute and also an Athletic Ireland level 3 Endurance Coach.

I’ve also had a background in athletics for the last two and a half decades. My previous career as a race walker was where I competed internationally at European World and two Olympic Games and retired after the London Olympics in 2013. Since then, I took up running as a means to still enjoy keeping fit and taking part in competitions.

I suppose it still gives me a feel for the sport, and I work with a lot of runners as well, so it’s good to have that little bit of a connection.

In the outline of the webinar, we’ll be looking at the biomechanical demands of running how that might affect injury risk. We’ll discuss some of the common running injuries, now again you would have heard from Dr Carolan and Mr Jackson on some knee pain and knee injuries, and Dr Carolan will cover plantar fascia pain, so I am not going to touch on those too much, but I will discuss some of the other common ones, and we’ll also discuss the role of Strength & Conditioning as a means of managing running injury risk factors.

Most systematic reviews of running injuries and where they occur show that the knee is the most common injury site for running-related injuries.

In the most recent systematic review in 2018, 28% of running injuries occurred at the knee, 26% were in the foot and ankle area.

But the main thing you can take from this is that most running injuries, probably about two-thirds of 70% of running injuries, occur from the knee down.

So there’s probably a message in that in terms of the biomechanical demands of the lower leg and how we might maybe try and condition that in our strength and conditioning program.

With running biomechanics, there are basic physics involved here, so when we run when we strike the ground, it is like a collision with the ground, and the earth gives us a force back that goes through the body. It’s like Newton’s third law, so for a reaction, there’s an equal and opposite reaction.

If you look at the example here, so if you imagine you’re running over a force plate as in this video here, you’ll see that the force increases through the ground.

If I play the video, you will see foot strike if you watch the green line and watch the cursor move up. So the initial peak as the ankle sort of decelerates the initial impact, and there is the second peak as the force peaks, as the foot is under the hip.

So, if I was to stand, or if you were to stand up, your body has to be able to produce force more than your own body weight in order to not fall over. If you want to walk or move forward, that force is going to be one and a half times your body weight, and if you jog, it’s going to be twice the body, and if you’re on a steady speed, it’s going to be three times the body weight, and sprinters that max speed will be hitting maybe five or six times body weight.

(1:49:10)

So the faster you go, the more force or ground reaction forces you got to try and corporate, and the more force you got to train your produce to be able to accommodate us and to propel the body upwards and forwards.

So we’ll talk therapy as the external force that goes through the body. Well, as I said, in order to do, there are internal forces that are going on. And there are lever systems at play here as well, because when the Ford schools through the body, our center mass lowers our knee joint, and our ankle joint, bend, as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons or ligaments or cartilage, and so on, while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a tennis meter track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, suppose upwards through the body. And I said, depending on how fast you’re going, that can be two times the body weight, even for jogging that can be four times the body weight, if you’re running at a steady-state speed.

With force going through the Achilles tendon as it stretches. So the calf muscles contract and the Achilles tendon stretches that can be six to eight times the body weight and again depending on the speed but the contact force at the joint level of the ankle joint, that’s 10 to 14 times bodyweight that’s like a suction force, where you’ve got bone on bone contact, and that’s where the cartridge is going to play and try to help shock absorb that.

So, higher joint contact force at the ankle, a little bit less with the neighbours, so the significance of 7 to 11 times the body weight. And at the hip, something similar seven to 11 times bodyweight and again at the hip joints in a ball and socket joint is this like a suction force. It’s important that the muscles of the lower leg, and from the torso down, are conditioned to be able to accommodate that efficiently.

Bone Loading, so, we would traditionally believe that impact causes increase bone loading, and it does a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at more thorough in the picture in that sort of midstance point for his foot soldier his hip, his knee is bent as much as one event is centralised at its lowest point is calf muscle contractions areas greatest gasp point peak or loading occurs particularly in the shin further around the tibia.

It comes much later after the initial impact. It’s not just the impact. It’s, it’s how you can absorb that or dissipate that, as your central mass lowers and as your joints continue to flex and as the force goes through the body.

So I guess we ask the question, why do most running injuries occur from the knee down. Well, we know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds.

We know that even at jogging speeds. Our calf muscles are operating at about 80% of their muscle capacity, of their peak force capacity, where the as quads might be operating more than 60% others, but that capacity is low, it doesn’t take much of that muscle to fatigue area than it should do.

A fatiguing muscle is going to affect how the force is distributed and how it’s absorbed. So that’s going to cause problems locally, so that can put a lot more load to the Achilles tendon and put more loading on the ankle joints. But also, if the ankle area gets tired, those forces tend to shift up towards the knee and around the hip, and that kind of big factor in how the knee is loaded and how the hip is loaded and perhaps increase in injury risk in those particular sites.

So we can safely say that when we jog, our calf muscles are pretty much our jogging muscles and particular storage soleus muscle, that deeper calve muscle, it has quite a high contribution to running.

So I suppose when you think about running and look at SSC programs, it’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and most probably more important, and if we were to prioritise things. But as I said, it is probably the most neglected area.

So we just look briefly at the calf muscles, so again, if you look at this MRI image, so if I was to take a slice of my leg from the knee down and look down at it, that’s what we would see. So looking at the LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscle, so if you’re looking at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles. So that’s your medial and lateral gastrocnemius muscle. So again, big muscles.

Quite a big volume, but if you look at the layer deeper than that, the soleus muscle, It’s quiet. It’s an even bigger muscle. So it has more than twice the volume of the medial gastrocnemius muscle.

But when you take into account its short fibers, so again, if you look in the image during the right, you see those short fibers that kind of run at an angle between the borders of the muscle. And it means that more fibers can be packed into a volume of muscle, and more fibers mean that more force can be produced more efficiently, so it’s got a bigger force. It’s got a bigger force contribution and bigger force potential, and against allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

But the calf muscles are also slow-twitch muscles, predominately slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued, but then say other muscles that are faster, which dominant.

So it’s really important that we train the calf muscles to use those big forces and to be able to recover quickly, and to be able to repeat it over and over again.

I said when we lack muscle capacity of the calf muscles, that’s when we got to be issued and if we see somebody coming in with a lower limb injury. It’s probably one of the most important areas that we assess.

So if you look at some of the common running injuries, you got runner’s knee, which can be an umbrella term for a couple of different knee pathologies, but most commonly patellofemoral pain syndrome.

Achilles tendinopathy, shin splints or any type of bone stress injury of the lower leg, a calf muscle strain but again that can be applicable to hamstring muscle strains are quad muscle strains, plantar fascia pain and proximal hamstring and Achilles tendinopathy, so they’re quite common running injuries.

So if you look a little bit at the runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail. The knee joints, being primarily is not designed for massive amounts of torsional rotation, and an order to control that, so again, what you have is an overload of the patellofemoral joint, and that could be a combination of a number of factors, it could be biomechanics and could be how you recruit your quads, hamstrings, and hip muscles in particular, and also the muscle capacity of the calf muscles below it. So when we look at a knee injury, we always access above and below the areas of the calf muscles below and even around the ankle and above us. We assess the quads, hamstrings, and hip muscles.

So again, they’re quite important, and particularly the lateral hip muscles, the hip abductors, so your glute, medius and part of the glute max has a role to play in terms of controlling hip internal rotation, and hip abduction and also your lateral hamstrings, your voice of Morris has a role to play as well in controlling internal rotation of the femur or the hip.

So they are areas we would access in terms of uncertainty if we see weaknesses or deficits in those areas we chase after them in terms of with a rehab program. In terms of running biomechanics and I’ll show you a video in a few slides time. We’ll also look and see what the knee controllers like when you’re running, so look at some from behind and see if the knee keeps rotating inwards. That might give us clues as to their ability to control those rotations from the hip down or from the ankle up.

Achilles tendinopathy is a common one that we see. It’s the main focus of my PhD. So some of the common risk factors for Achilles tendinopathy we can separate into intrinsic or internal risk factors and extrinsic risk factors, internal risk factors being calf strength. So for people who have poor calf strength.

There have been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles, and that can, I suppose, change how the tendon is loaded over time.

So perhaps the previous lower limb injury and we haven’t fully rehabbed it, but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, and people who have diabetes or a risk of diabetes, or poor cardiovascular health, and can be at risk of turning of developing Achilles tendinopathy, Because tendons are there is actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on around the body, as opposed to just running.

So if you look at some of the external risk factors that are associated within with this injury and training load, a big increase in volume or particularly intensity, that’s quite relevant given the last 15 or 16 months with our COVID restrictions on people maybe exercising more than normal because they’re working at home and trying to keep fit, or in the least sport, and particularly collective team training and field sports have been curtailed for several months and in the last two months where they’ve gone back again, and the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

The cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, and that can put people at risk of developing Achilles tendinopathy. In some cases, and also alcohol intake is also associated with the risk of developing Achilles tendinopathy.

So, again without going too deep into anatomy here, I just used this picture here to illustrate the difference between a healthy tendon and one that has tendinopathy. So tendinopathy is pretty much pain and impaired function, and in the tendon, and the Achilles, in this case, and again, what causes pain and impaired function. So, in a healthy tendon, as you see there, you go a nice orderly alignment of collagen fibers, and you got a very small level and each fibers kind of wrapped around by a sheet.

Between those fibers you’ve got other cells called Tina sites, and those cells are sensitive to any changes and load that the tendon undergoes, so when it experiences fatigue or when it experiences big strains or fast movements, those tendons can become more active, and they can react and cause I suppose a cascade of events that can change the structure and the makeup of the tendon.

So, when the load has been too much and the tendon hasn’t had a chance to remodel and adapted to that, you’ve got a change in the composition of the tendon, you’ve got the more type three collagen fiberals as opposed to type one, so type one being good collagen and type three being unhealthy collagen, its collagen that is not able to withstand elastic strains, you got those cells become a lot more disorganised, they lose that sort of elongate shape they come more rounded and you’ve got molecules that attract more water so it gives the tenant, more of a swollen or puffy feeling and then you’ve also got an in growth especially when the tendinopathy has become chronic, so if it goes on for several weeks even months, you’ve got new regrowth of nerve of blood vessels, and that normally don’t reside within the tendon but normally sort of in the space between them, and they tend to migrate inwards and they leave chemicals that cause the nerve endings to become more sensitised, and that can give you your pain feedback. And over time, the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulus, so total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Such tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain, around about 6%.

So again, this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little. So too much, you develop little sorts of micro-tears in the tendon, and the cells become more reactive, and it can become more catabolic so kind of degenerate, it’s weird itself, and it’s not able to adapt to that load If it’s not giving time to do that.

If we rest for too long, and we won’t expose it to not strain or enough loading, and again the tenants, again you get a bit of wastage, and the tendon becomes more catabolic as well, and it becomes less able to handle regular exercise. So it’s important to give it that sort of regular bout of loading, and even when it’s sore, we try to find a level of calf exercise that they can do without being too sore once the pain is okay, so as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

So a little bit more about muscle strain injuries, so you know we think of a calf tear or a calf strain or a hamstring strain. We think about the most simple of it, in fact, usually these cases there, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle departments that goes in the middle of it, So like a feather so see in the example on the left.

Usually, the muscle strain occurs close to where there is tendon tissue, so usually where the muscle fibers in the tendon sort of meets, and muscle tail junction are usually there could be a micro tear within the tendon itself or on the muscle.

That can have an impact on the grading of the injury and the prognosis of the injury, so if you’ve got a tear, say, for example, in the soleus muscle is more so than a central tendency, so again if you look at the illustration B there.

That can take longer to recover, then say it was just a muscle fiber tear. Whereas, if, if, if you had a small muscle tear, and that’s just the muscle fiber, even if it’s close to ten but if it’s only the muscle fiber and there’s no tendon tissue disruption that can recover a lot quicker, and you can have less disruption to your training.

It’s important that we get, we’re clear the diagnosis, we use MRI imaging to know the grading of the injury so whether it is a one, two or three or, even worst-case scenario four, whether it’s just pure muscle facet fiber or muscle tendon in the junction of a rescue or tendon tissue that’s disrupted, and that can impact us again if you look at the calf muscle on the side, you’ll see a cadaver image of the muscles, see the soleus you’ll see the two heads of the gastric muscle lateral immediate head. But if you look at the white tissue there that’s, that’s on the, on the image that is the tendon tissue that is in your muscles, and you’ll see different suppose segments of white tissue around the muscle, and that’s the tendon tissue so again, usually close those sites, is where the injury occurs.

So what about bone stress injuries, essentially what we know from people who have looked at and studied bone loading closely in response to exercise and also have developed either shin splints or stress responses to the bone or a stress fracture.

There’s usually a failed healing response in the bone, so when you run when we do impact type stuff when we run or hop or do something that has high impact. We’re temporarily breaking down bone tissue that gives the bone tissue stimulus to recover and remodel. So we’re constantly exposing it to repetitive stresses and strains and small bits of microdamage that occur, but again in normal situations, we’ve got a good healthy metabolism. If we have a good structure to our training, we’ve got enough time to recover quite quickly to that. But if we’re not able to adapt to it, the bone needs more time to adapt and remodel, and they haven’t got a chance to recover well, then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury so basically you have a suppose failed healing response in the bone.

And if you look at what happens within the bone. So when we stress the bone, we have the formation of osteoclasts and osteoblasts. The osteoblast is where the bone almost eats away at itself, and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the, where the injury is or where the microfracture is to be ready for new bone is far more with us, and then you got osteoblasts formation which is where the or new bone cells start to form, and the bone starts to load up again.

Essentially, when we have failed healing in the bone, we have more eating than, say, replenishing. So similar sort of energy deficit, so it’s important that we look at people with bone stress injuries that they have good nutrition as the bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

So if you look at a few common factors related to running injuries so basically, we have a mismatch between load and capacity, so the load we’re putting in the body is greater than our capacity to handle a lot, and it’s a very simple way of looking at it. I know there’s a lot of it’s very hard to say there’s one thing, but there’s an interaction of a number of factors.

So obviously, we try to locally assess someone we want to identify any potential overload factors and then we also assess their capacity. Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training related so if you have a busy work schedule, busy family life.

All those things can be an extra load on the body.

If you have capacity on the others side of things, and that can be poor muscle capacity and high sensitivity to changes and training loads. Some people are more sensitive than others, and people who are fitter or have a higher capacity than those who are people are less fit or have lower capacity to handle a training load, and fatigue, seven or more fatigue, your capacity is reduced.

If you have had a previous injury in the lower leg, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after injury and training age, probably comes along with fitness as well if you have a higher training age, a running for longer than someone took a running last year, you’re going to have a greater capacity to handle those train loads.

So, just, this is a nice graph, and again I’m not going to go through everything in detail those a few relevant points here so, but it’s what they did was able to quantify the loading have someone who is an elite runner who runs 10km when they’re fresh, on an easy day, then runs 10km when they are very tired, so they’re a little bit slower, so the pace is maybe 25 for 35 seconds for common of slower when they’re really tired, versus doing 10, 1k intervals on the track in spikes — the difference between being fresh doing easy running versus when you’re very tired—your step count increases by up to 13%. See more time your feet more or more steps.

If you look at the accumulated vertical ground reaction forces, that is a 6% increase, so just because you’re going slower for the same distance. The accumulated loading can actually increase, so you have more of a step count, and your accumulated forces have increased and looked at the Achilles tendon further down.

Running slow when you’re fresh but relieved and slower when you’re tired, that kind of 5% increases in indicators and forces. So, the main message I would take from that is that running longer and slower when your body is tired, for some people, can be a risk factor.

So, just important that we maybe want to run on an easy day that we just keep some sort of control on the total volume of running, or the duration of the run, so maybe just better, happier and easier run shorter thinking when you’re tired and if you were, if you’re an injury-prone runner, you know, for people who are well trained to a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has as high risk of injury and just got to be careful those days because that’s when the damage can be done because you’re not giving the body the best chance to recover or adding more load to it.

So some of our common assessments, when people present us with injuries or wanting to try and manage their injuries factors, we assess strengths. We assess their power and parametric ability, and we also look at their biomechanics that running biomechanics that are engaged.

So, when we’re assessing strength, we want to get a rough idea of whole-body strength. If someone does a squat, whether it’s a back squat or front squat, we like them to be able to get to a point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps, as a minimum. But again, if someone hasn’t squatted before, we’re not going to strap them on that they need.

They need probably a year or two of just basic conditioning to get up to this. And that’s where they get above those thresholds, that’s probably a good level to be asked and 70 for deadlift, the deadlift will probably target the posterior chain most of the hamstrings, glutes a little bit more than the squat would depend on how on your technique and how you clutch it. And you can always lift a little bit more. So again, we’d be looking at 1.2 times, by the way, for more for three reps.

If you look at calf strength, what we often do is measure them on a force bit fitness stand on one leg, with the bar sort of compress over the shoulders at the base pool if they’re trying to do a calf raise but the heel hasn’t got space to lift, and we would expect them to reproduce for us that’s more than two and a half times body wish. As I said, the calf muscles are our big court QC muscles, and they can produce those forces. They need to cope with those, and more and running.

So, that gives us a measure of total all the capitals, but again we’ve got three calf muscles or immediate gastrocnemius muscle or lateral gastrocnemius muscle and our soleus muscle.

So, because the gastrocnemius muscles cross the knee so when you bend the knee, that’s going to impact how much force they can matrix, so we bend the knee to 90 degrees, and we’re kind of dampening down the force contribution from those gastrocnemius muscles, but because the soleus muscle doesn’t cross the knee joint, it doesn’t matter what a straight or bent it is going to produce the same force anyway so if we want to get a rough idea of the soleus muscle force contribution.

We do a seated calf or asymmetric test for this session on a seat, and we’re only at 90 degrees and their heal slightly dropped with their foot on the block, and we get into a seated knee lift where the knee is compressed time and see how much force they produce, and we like to be seeing people hitting above one and a half times bloody weight, and for elite athletes, we try and get as close to twice by their body weight. If we want to get a good measure of their calf endurance, we have to do single leg calf raises. More than 25 of them in 50 seconds, so one raise every two seconds, with good height and good technique and good control.

And if you look good reactive strengths are their primary capability we might test them during a drop jump for them maybe drop off in 20 to 30-centimetre blocks, and try to rebound in less than a quarter of a second, and try to achieve the height of the box at the drop-off or close to that.

And, well, Michael didn’t have one leg and be able to do ten hops on one leg, while maintaining the time in the ground, perhaps, in less than point two eight of a second, without bending the knee too much so try to use the ankle to hop.

When we look at running biomechanics, we can get a 3d model of someone running so we can put some marker sets on them, and we have cameras that a 3D capture of them, and women that are running them, we can create that sort of stickman image of them we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on. And we can look at some of those rotational movements we are talking about at the knee and the ankle.

So again, a couple of some of the key things we look at here at hip pelvis motion.

So how much hip adduction and internal rotation occurs. Is there a purpose? Do they have a pelvis tilt that increases throughout the stance phase, or does your pelvis drop on one side if you’re looking at them from behind? We also look at high-end Shin rotation. We look at the motion of the heel and some kind of controller pronation fairly well or do they collapse and have short, poor control, which might cause more loading run around the foot and ankle area.

And we’ll also work out their contact time, their flight time, so basically the time the grand preferred strike, and the time in the air, and their ability to handle, and the ability to control how much the central mass drops and the most the knee bends as force close to the body, so it’s a measure of spring stiffness.

So why do we do that so again? Some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at the side view people who tend to lean forward a little bit more precisely, people who present with some common injuries tend to lean forward a little bit more land with the foot a little bit further from the body, so the shin is a bit more of an angle and the knee a little straighter.

So if you look at the illustration, a there on the left, versus those who are not injured, tend to have a bit more upright to the torso, land, more of a bent knee, and the shin and a bit more vertically aligned and a force, closer to where the hips are.

And if you look from behind. I can give an example of hip internal rotation and adduction, as well as the pelvic strap. So if you look at the female at least in the image there, you’ll see a little bit more drop of the pelvis at that horizontal line going from right to left a little more tilt us, and you see the line from the side of their hips today, centred the knee, angles, and that can cause more torsional loads at the knee.

It caused a lot more puts bigger demand on the hip muscles, but it can also have a knock-on effect for the foot and ankle because if, if the knee has to, if there’s if the tie has. Suppose the hip attorney rotates and jerks. And you’ve got that rotation but not the need, and there’s going to be more adjustments of the tibia over the ankle and so on, and all the foot under the foot area as well.

The first is who is able to have a more horizontal pelvis position and less of an angled line from hip to knee.

So, when you prescribe strength training, and some of the most important things you try to cover are some sort of a jumper hop exercise, And depending on the time of year, and where the rasp in terms of training program might be done from the start, and having a double like whole body accent like a squat or deadlift, a singular whole body exercise like a step up or a lunge or some variation of us having a calf exercise in their particular at certain points in the year to improve calf muscle capacity, and some sort of a function for exercise and to try and improve torso control.

So in terms of the qualities one is training to improve power or planet capability at a high intensity will hit the reps short, so we don’t want to be doing these long enough, or they’re going to get tired, and we’re power diminishes the way it’s not trained right things, so reps have about three to six reps, you know, for four sets, taking a longer recovery between sets because when you do something sports have you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve sort of power or reactive strength capacity, who might dial back the intensity but go for more duration, so we can work with up to 20 reps depending on what we’re trying to get out of this ever trying to improve strengths, and we do rep ranges between treated like a tour manager more wrestling sets for four sets again if I find a Bruce maximal or sub max strength.

Suppose we’re trying to grow muscle, so trying to improve hypertrophy, not the most important thing for distance runners because more muscle mass means more energy expended to try and carry around. But when someone comes in with an injury or chronic injury.

We often see that the muscle wastage and most of deconditioning so we see what a Muslim one side, smaller than the Muslim, the other side. So we probably will have to find the Muslim students to grow up back to the level of their side where it should be because the smaller muscle will, on the flip side, mean less, as well as capacity to handle those big forces.

In terms of frequency, and if we’re not rehabbing for just training doing strength training in order to improve performance, and we’re fairly good from an injury point of view, twice a week is probably enough. And if a racing week, you know, during, during the busy competition period for racing quite regularly, once a week there’s probably enough to maintain us. What if we are rehabbing and overcoming an injury, we probably need to have that other third in there for at least four to six weeks to try and front load those adaptations in front of us.

So we’re just going to take you to a couple of examples of common in exercises and how am I progressing, so if someone hasn’t squatted before, we’re not going to put up 80 kilos and the shoulders and the bathroom when it’s falling and make sure their squat technique is good and put a chair on them so they can sit back on their heels, and be able to squat smoothly at full technique, and then we can increase weight. So if we could get them to do like a goblet squat for the whole dumbbell, chest, and the nodes the chair on, and they could sit back from their heels and squat. I suppose, reinforce good patterns first, and then if you’ve got that, then we can take the chair away.

And if they’re well-coordinated. The balance they can sit on the heels, and be able to squat and maintain that sort of parallel torso and Shin angle, then we can move to a bar, so we often like, or we can you know for trying to introduce deadlifts, sometimes a hex bar can be useful way today that allows you to train a good technique in a safe way so again set in the bar, less for knee bend or trying to keep the knees a bit stiffer, to try and put more attention to the hamstrings are trying to keep the back 30 straight as well.

And then we moved to the bar from the floor, or maybe from an elevated position on the right there, so again trying to not bend the knees too much like squash, trying to target the hamstrings a little bit more. Keep that back fairly straight as we lift, and we shouldn’t feel the hamstrings, and that leads to most of the work. Here are some of our single-leg exercises, so a step up. We are stepping onto a box.

Ideally, if you can stay on, you would like to hold the position for a second to shore that rebalanced back to a nice control.

So really important, it’s one of my kind of staple exercises and covers a lot of boxes.

I’m going to do some server lunch variation or specified variation, so an example on the right of Bulgarian split squats, but a barbell rear foot elevators, dip and down name travel to fat forward. And again, we should feel this towards the area. We shouldn’t feel much pressure on the needy of this and want to find keep her back fairly straight as well.

So calf strengths I mentioned, bend the knee to break 90 degrees, and have the footstep the elevators, we can put a big load solace muscle on target.

So the seated calf raises.

And also standing calf raises, so again I like to go ahead and the cafe smith machine or leg presses and ideally with regards to starting the like pretty straight, pushing up onto the big toe. Pause at the top for a second to a background slowly and then plyometric exercise some poker hops on the spot, trying to be smooth on the ground spend a bit more time in the year, progress in dropping jump.

So can bouncing up a box as a 30-centimetre box trying to get off the ground in less than a quarter for the second and rebound is almost as high as the box jumps off, and then they’ll be doing single caps on the spot and the singular cups going forward as you see there. And on the far right.

So in terms of how this all fits in meetings but this seems like a running program into four phases or whatever way you want to do it. So general credit phase, we’re trying to prepare the body for the bigger running sets that are going to come.

So it finally approved tissue capacity and muscle capacity to diffuse after per week working on good movement patterns first. Maybe if we have certain weak spots that we’ve had a previous car for Achilles injury or an ankle injury, we’ll do a lot of calf work. If they’re a previous knee or injury, microdata quad and hamstring and hip work or for the previous hamstring injury or recent hamstring injury. We do a lot of hamstring and glute work as well, so again that’s the time to train owner those things so that you get good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards the specific preparation phase where you’re running starts to become more of a priority, and you’re increasing your distances bringing in those key sessions twice a week should be enough. We’re not going to spend as much time in the gym or doing those exercises. So quality is important, so maybe a couple of exercises done really well that’s a good intensity. So we’ll go heavy if it has enough training behind them. And we’ll also bring in Supplementary exercises.

And as we get closer to competition, we want to try and keep that sharp instead because traditionally, that’s for distance runners tend to sort of shove the residency program because there are training for that marathon in six weeks’ time. We’re going to be tired from all the runs, what, when they need to sit in that is probably the time when they need to be at our strongest. So if we don’t train something for a period of six to eight weeks, we can start to lose those qualities, so it’s really important that we keep somebody’s strength training there, in its several ways that doesn’t, that doesn’t that keeps supposedly nice and balanced, so we still try and keep in two sessions a week.

Keep it short and intensive to keep that sort of stimulus and edge they’re a bit more folks the plyometric keeping in touch with your heavy lifts, and they were in season and competing with try to maintain it once on one or two sessions a week if we’re racing in any given week one is probably not during the week—the shorter than normal. And we’re not racing on a given week. We’re probably the second tough session.

So in conclusion, more discerning injuries occur from the knee down, or cut forces, in particular, are probably the one muscle group that works sources towards full capacity even a slower running speeds, compared to quads and hip muscles, so it’s really important that we punish them for that. And, high-intensity strength training so talked about but in reverse also associate improving economy and performance.

And everyone is definitely so, you know, try not to. It’s very hard to give a one size fits all answer to when someone has a question about a particular injury or a hospital assigned training that they should do. It’s important that they come in, whoever if they have an SSC coach close to that’s reputable and experienced and get a proper assessment and have their training, sec program prescribed to meet their individual needs.

Sprinters at max speed will be hitting maybe five or six times body weight. So the faster you go, the more ground reaction forces you’ve got to try and cope with and the more force you’ve got to try and produce to be able to accommodate that and to propel the body upwards and forwards.

I talked there about the external force that goes through the body. As I said, in order to cope with that, there are internal forces that are going on, and there are lever systems at play here as well because when the force goes through the body, our centre mass lowers, our knee joint and our ankle joint bend as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons, our ligaments, our cartilage and so on while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a 10,000-metre track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, so it goes upwards through the body, and as I said, depending on how fast you’re going that can be two times bodyweight for jogging that can be four times bodyweight if you’re running at a steady-state speed.

The force is going through the Achilles tendon as it stretches, so the calf muscles contract and the Achilles tendon stretches, which can be six to eight times body weight again depending on the speed. The contact force is at the joint level, so the ankle joint that’s 10 to 14 times body weight, that’s like a suction force where you’ve got bone and bone contact, and that’s where the cartilage comes into play to try and help to shock absorb that.

Higher joint contact force at the ankle, a little bit less so with the knee but still significant so 7 to 11 times bodyweight, and at the hip something similar 7 to 11 times bodyweight, and again at the hip joint being a ball and socket joint, it’s like a suction force. It’s important that the muscles of the lower leg from the torso down are conditioned to be able to accommodate that efficiently.

So what about bone loading? We would traditionally believe that impact causes increased bone loading, and it does to a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at Mo Farah, there is that sort of mid-stance point where his foot’s under his hip, his knee is bent as much as it is going to bend, his central mass is at its lowest point, his calf muscle contractions are at its greatest – that’s when peak bone loading occurs, particularly in the shin, so they’re in the tibia, so it comes much later than after initial impact.

It’s not just the impact. It’s how you can absorb that or dissipate that as your centre mass lowers and as your joints continue to flex and as the force goes through the body.

I guess if you ask the question, why do most running injuries occur from the knee down. We know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds, we know that even at jogging speeds, our calf muscles are operating at about 80 % of their muscle capacity/peak force capacity, whereas the quads might be operating more around 60 % of it. If that capacity is low, it doesn’t take much for that muscle to fatigue earlier than it should do, and a fatiguing muscle is going to affect how the force is distributed and how it’s absorbed.

That’s going to cause problems locally so that can put a lot more load through the Achilles tendon, it can cause a lot more loading around the ankle joint, but also if the lower limb gets tired, if the ankle area gets tired those forces tend to shift up towards the knee and around the hip and that can have a big factor in how the knee is loaded and how the hip is loaded and perhaps increasing the injury risk in those particular sites.

We can safely say that when we jog, our calf muscles are pretty much our jogging muscles and, in particular, our soleus muscle. That deeper calf muscle has quite a high contribution to running.

I suppose when you think about training, and we look at SSC programs, there’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and more important if we’re to prioritise things, but as I said it’s probably the most neglected area.

So if we just look briefly at the calf muscles, so again if you look at an MRI image, so if I was to take a slice of my leg from the knee down and look downwards at it, that’s what I would see.

The LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscles, so if you look at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles as I said this remedial and natural gastrocnemius muscles. Again big muscles, quite a big volume, but if you look at the layer deeper than that, the soleus muscle it’s an even bigger muscle, so it is more than twice the volume of the lateral of the medial gastric muscle, but when you take into account it’s short fibres, so again if you look at the image on the right you’ll see those short fibres that kind of run at an angle between the borders of the muscle – it means that more fibres can be packed into a volume of muscle and more fibres mean that more force can be produced more efficiently, so it’s got a bigger force contribution and bigger force potential and again it allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

The calf muscles are also slow-twitch muscles, predominantly slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued than other muscles that are more fast and dominant.

It’s really important that we train the calf muscles to produce those big forces and to be able to recover quickly, and to be able to repeat it over and over again. I said when we lack muscle capacity in the calf muscles, that’s when we got issues, and then if we see someone coming in with the lower leg injury, it’s probably one of the most important areas that we assess.

If you look at some of the common running injuries, we’ve got runner’s knee which can be an umbrella term for a couple of different knee pathologies but most commonly patellar thermal pain syndrome, Achilles tendinopathy, shin splints or any type of bone stress injuries at the lower leg, a calf muscle strain but again that could be applicable to hamstring muscle strains or quad muscle strains, plantar fascia pain and proximal hamstring and gluteal tendinopathy, so they’re quite common running injuries.

If you look a little bit at runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail, but the knee joint primarily is just not designed for massive amounts of torsional rotation and in order to control that, what you have is an overload to the patellofemoral joint, and that could be a combination of a number of factors: it could be biomechanics, it could be how you recruit your quad, hamstring and hip muscles in particular and also the muscle capacity of the calf muscles below it.

When we look at a knee injury, we always assess above and below the area, so the calf muscles below and even around the ankle and above it we assess the quads, the hamstrings and the hip muscles so again they’re quite important, and particularly the quads, particularly the lateral hip muscles, so your hip abductors, your glute medius and part of your glute max has a role to play in terms of controlling hip internal rotation and hip adduction and also your lateral hamstrings your bicep femoris has a role to play as well in controlling internal rotation of the femur or the hip and adduction and controlling that sort of rotation around the knee joint.

They are areas that we would assess, and certainly, if we see weaknesses or deficits in those areas, we chase after them in terms with our rehab program, but in terms of running biomechanics and I’ll show you a video in a few slides time, we’ll also look and see what the knee control is like when you’re running, so look at someone from behind and see does the knee keep rotating inwards, and that might give us clues as to their ability to control those rotations from the hip down and from the ankle up.

Achilles tendinopathy is a common one that we’ve seen, again. As said at the start, it’s the main focus of my PHD, so some of the common risk factors for Achilles tendinopathy is we can separate them into intrinsic or internal risk factors and extrinsic risk factors.

Internal risk factors being calf strength, so for people who have poor calf strength, there’s been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain, it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles and that can I suppose change how the tendon is loaded over time, so if we have a previous lower injury and we haven’t fully rehabbed it but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, people who have diabetes or are at risk of diabetes or have poor cardiovascular health can be at risk of developing Achilles tendinopathy because tendons are actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on in the body as opposed to just running.

If you look at some of the external risk factors that are associated with this injury, training loads, so a big increase in volume or particularly intensity and that’s quite relevant given the last 15 or 16 months with our Covid restrictions and people may be exercising more than normal because they’re working at home and trying to keep fit or an elite sport where particularly in collective team training in field sports has been curtailed for several months and in the last two months they’ve got back again where the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

Cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, that could put people at risk of developing Achilles tendinopathy in some cases and also alcohol intake is also associated with a risk of developing Achilles tendinopathy.

Without going too deep into anatomy here, just use this picture just to illustrate the difference between a healthy tendon and one that has tendinopathy. Tendinopathy is pretty much pain, and impaired function in the tendon and the Achilles head in this case. What causes pain and impaired function? In a healthy tendon, as you see there, you’ve got a nice orderly alignment of collagen fibres, you got a very small level, and each fibre is kind of wrapped around by sheets and between those fibres you’ve got little cells called tenocytes, and those cells are sensitive to any changes in the load that the tendon undergoes so when it experiences fatigue or when it experiences big strains or fast movements those tendons become more active, and they can react and cause a cascade of events that can change the structure and the makeup of the tendon.

When the load has been too much, and the tendon hasn’t had a chance to remodel and adapt to that, you’ve got a change in the composition of the tendons, you’ve got more type three collagen fibrils as opposed to type one, so type one being good collagen, type three being collagen that’s not able to withstand sort of elastic strains.

Those cells become a lot more disorganised. They lose that sort of elongated shape. They come more around it, and you’ve got molecules that attract more water, so it gives a tendon a more of a swollen or puffy feeling, and then you’ve also got an in growth, especially when the tendinopathy has become chronic so if it’s been gone for several weeks if not months, you’ve got an ingrowth of nerve of blood vessels that normally don’t reside within the tendon. They normally sort of in the space between them, and they tend to migrate inwards, and they leave chemicals that can cause the neural veins to become more sensitised, and that can give you your pain feedback. Over time the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulant – total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain around about six per cent, so again this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little.

Too much and you develop little sort of micro-tears in the tendon, and the cells become more or more reactive, and it can become more catabolic, so it kind of degenerates, eats away at itself, and it’s not able to adapt to that load if it’s not given time to do that. If we rest for too long and we don’t expose it to enough strain or enough loading, you get a bit of wastage in the tendon, so it becomes more catabolic as well, and it becomes less able to handle regular exercise. It’s important to give it a regular bout of loading, and even when it is sore, we try to find a level of calf exercises that they can do without being too sore. A small amount of pain is okay and as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

A little bit about muscle strain injuries – we think of a calf tear or calf strain or hamstring strain, and we think about the muscle, but in fact, usually, in these cases, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle compartments that goes down the middle of it, so like a feather, so you see the example there on the left, and usually, the muscle strain occurs close to where the tendon tissue is.

Usually, where the muscle fibres in the tendon sort of meets and at the muscle-tendon junction or usually there can be a micro tear within the tendon itself around the muscle, and that can have an impact on the grading of the injury and the prognosis of the injury so if you’ve got a tear to say for example in the soleus muscle in the central tendon so again if you look at the illustration B there, that can take longer to recover than say it was just a muscle fibre tear, whereas if you had a small muscle tear that’s just the muscle fibre, even if it’s close to the tendon but if it’s only the muscle fibre and there’s no tendon tissue disruption, that can recover a lot quicker, and you could have less disruption to your training.

It’s important that we’re clearing the diagnosis – we use MRI imaging to know the grading of the injury where there is a one, two, three or worst case scenario four and whether it’s just pure muscle fibre or whether its muscle-tendon injunction or whether it’s pure tendon tissue that’s disrupted and that can impact on us. Again if you look at the calf muscle right inside, you’ll see a cadaver image of the muscle – see the soleus there being stripped off, and you’ll see the two heads of the gastrocnemius, the lateral immediate head, but if you look at the white tissue there that’s on the image, that is the tendon tissue the aponeurosis.

You’ll see different segments of white tissue around the muscle, and that’s the tendon tissue, so again usually close to those sites is where the injury occurs.

What are bone stress injuries? Essentially what we know from people who have looked at and who have studied bone loading closely in response to exercise and those who have developed either shin splints or stress responses to the bone, or a stress fracture – there’s usually a failed healing response in the bone. When we run or when we do impact type stuff, when you run or hop or do something that has high impact, we’re temporarily breaking down bone tissue, and that gives the bone tissue a stimulus to recover and remodel.

We’re constantly exposing it to repetitive stresses and strains. Small little bits of microdamage that occur, but again in a normal situation if you’ve got a good healthy metabolism, if we have a good structure to our training we’ve got enough time to recover quite quickly to that, but if we’re not able to adapt to it and the bone needs more time to adapt and remodel, and we haven’t got a chance to recover – then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury, so basically you have failed healing response in the bone.

If you look at what happens within the bone when we stress the bone, we have the formation of osteoclasts and osteoblasts – osteoclasts are where the bone sort of eats away itself and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the injury is or where the microfracture is to be ready for a new bone to form over that, and then you’ve got osteoblast formation which is essential when we have a failed healing in the bone, we have more eating than say replenishing, and so it’s in that sort of energy deficit.

It’s important that we look at people’s bones for injuries that we have good nutrition intake. Bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

If we look at a few common factors related to running injuries, basically, we have a mismatch between load and capacity – the load we are putting on the body is greater than our capacity to handle that load. It’s a very simple way of looking at it. I know it’s very hard to say there’s one thing, but there’s an interaction of a number of factors so. Obviously, we try to look when we assess someone we want to identify any potential overload factors and then we also assess their capacity.

Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training stresses either, so if you have a busy work schedule, busy family life, all those things can be an extra load in the body or a poor night’s sleep. If you look at capacity on the other side of things, that can be poor muscle capacity, high sensitivity to changes in training loads, some people are more sensitive than others, and people who are fitter have a higher capacity, people who are less fit have lower capacity to handle training load, and fatigue is similar, so if you’re more fatigued your capacity is reduced, if you have a previous lower leg injury, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after that injury.

Training age probably comes along to fitness as well – if you have a higher training age, i.e. running for longer than someone who took up running last year, you’re going to have a greater capacity to handle those training loads.

This is a nice little graph, and I’m not going to go through every little thing in detail, but there are a few of the relevant points here, so basically, what they did was they’re able to quantify the loading of an elite runner who runs a 10k when they’re fresh on an easy day, runs a 10k when they’re tired so they’re a little bit slower, so the pace is about maybe 25 or 35 seconds per kilometre slower when they’re really tired, versus doing ten 1k intervals on the track and spikes.

The main things here and the difference between doing an easy run when you’re fresh versus when you’re tired, your step count can increase by up to 13 %, so you have more time on your feet, more steps. If you look at the accumulated vertical ground reaction forces – that is a 6 % increase, so just because you’re going slower for the same distance, the accumulated loading can actually increase you’ve more of a step count, and your accumulated forces have increased and look at the Achilles tendon further down, again running slow when you’re fresh but running even slower when you’re tired that kind of a 5 % increase in Achilles tendon forces.

The main message I would take from that is that running longer and slower when your body’s tired of some people can be a risk factor. It is just important that when we’re on an easy day that we just keep some sort of control on the total volume of running or the duration of your run, so maybe it might just be better to have your easy run shorter. Picture when you’re tired and if you’re an injury, prone runner.

For people who are well trained, people who trained at a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has a high risk of injury, just got to be careful on those days because that’s when the damage can be done because we’re not giving the body the best chance to recover because we’re adding more load to it.

Some of our common assessments when people present us with injuries or want to try and manage their injuries we assess strength, we assess their power and play metric ability, and we also look at their running biomechanics, their running gate.

When we’re assessing strength, we want to get a rough idea of whole-body strength, so if someone does a squat, whether it’s a back squat or front squat, we’d like them to be able to get to the point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps as a minimum but again if someone hasn’t squatted before we’re not going to start them on that – they need probably a year or two of just basic conditioning to get up to that. When they get above those thresholds, that’s probably a good level to be at.

Similarly, the deadlift will probably target the posterior chain muscles, the hamstrings glutes a little bit more than the squat would depend on your technique and how you coach it, and you can always lift a little bit more, so again we’d be looking at 1.2 times body weight or more for three reps and if you look at calf strength what we often do is measure them on a force bit, so get them to stand on one leg with the bar sort of compressed over the shoulders and basically, they try to do a calf raise, but the heel hasn’t got space to lift, and we would expect them to be able to use force that’s more than two and a half times body-weight as I said the calf muscles are big force-producing muscles, they can produce those forces, they need to cope with those and a lot more in the running.

That gives a measure of the total of all the calf muscles, but again we’ve got three calf muscles: our medial gastrocnemius muscle, our lateral gastrocnemius muscle and our soleus muscle, so because the gastrocnemius muscles across the knee, when you bend the knee that’s going to impact how much force they can produce so when we bend the knee to 90 degrees, we’re kind of dumping down the force contribution from those gastrocnemius muscles but because the soleus muscle doesn’t cross the knee joint it doesn’t matter what a straighter bend does, it’s going to produce the same force anyway.

If you want to get a rough idea of the soleus muscle force contribution, we’ll do a seated calf isometric test where they sit on a seat with their knee at 90 degrees and their heels slightly dropped with the top of their foot on a block, and we get them to do a seated heel lift where the knees compress down and see how much force they can produce, and we like to be seeing people hitting above one and a half times body-weight, and for elite athletes, we try to get them up close to twice body weight.

If you want to get a good measure of their calf endurance, being able to do single-leg calf raises – more than 25 of them in 50 seconds, so one raised every two seconds with good height and good technique and good control. If you look for good reactive strength, their plyometric ability, we might test them doing a drop jump where they maybe drop off a 20 to 30-centimetre box height and try to rebound in less than a quarter of a second and try to achieve the height of the box that they drop off or close to that.

We might get them to hop on one leg and see if they are able to do ten hops on one leg while maintaining the time on the ground per hop in less than 0.28 of a second without bending the knee too much, so try to use your ankle to hop.

When we look at running biomechanics, we can get a 3D model of someone running, so we can put some marker sets on them, and we have got cameras that give a sort of a 3D capture of them, and when they’re running then we can create that sort of stick man image of them – we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on, and we can look at some of those rotation movements I’ve talked about at the knee and the ankle, so again a couple of some of the key things to look at here is hip and pelvis motion, so how much hip abduction and internal rotation occurs, do they have a forward pelvis tilt that increases throughout the strength phase or does their pelvis drop on one side if you’re looking at them from behind.

We also look at high-end shin rotation, we look at the motion of the heel, so can they control the pro-nation fairly well or do they collapse and show poorer control which might cause more loading around the foot and ankle area and we’ll also work out their contact time and their flight time, so basically the time on the ground per foot strike and the time in the air and their ability to control how much the centre mass drops and how much the knee bends as force goes through the body, so it’s a measure of spring stiffness.

Why do we do that? So again some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at in the side view people who present with some common injuries tend to lean forward a little bit more, land with the foot a little bit further in front of the body so the shin at a bit more of an angle and the knee a little bit straighter, so if you look at the illustration A here on the left versus those who are not injured tend to be a bit more upright through the torso, land with more of a bent knee and the shin a bit more vertically aligned and the foot closer to where the hips are and if you look from behind again give an example there of hip and turn rotation and abduction as well as pelvic stroke, so if you look on at the athlete the female in the image A there, you’ll see a little bit more drop of the pelvis – you see the horizontal line going from right to left a little more tilted and you see the line from the side of their hips to the centre of the knee a little bit more angled and that can cause more torsional loads at the knee, it puts a bigger demand on the hip muscles but it can also have a knock-on effect around the foot and ankle too because if the hip internally rotates and adducts, and you’ve got that rotation going on the knee then there’s going to be more adjustments of the tibia over the ankle and so on and around the foot area as well. For example, B who’s able to have a more horizontal pelvis position and less of an angled line from hip to knee.

When we prescribe strength training, some of the most important things we try to cover are some sort of a jumper hop exercise depending on the time of year and where they’re at in terms of the training program, it might not be done from the start. Having a double leg whole body exercise like a squat or deadlift, a single leg whole body exercise like a step up or lunge or some variation of it, having a calf exercise in there particularly at certain points of the year to try and improve calf muscle capacity and some sort of trunk control exercise to try and improve torso control.

So in terms of the qualities we want to try and train, if we’re trying to improve power or plyometric ability at a high intensity, we’ll keep the reps short, so we don’t want to be doing these long enough where they’re going to get tired, and our power diminishes otherwise we are not training the right things so reps of about three to six reps you know for four sets, taking a longer recovery between sets because when you do something explosive you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve power or reactive sprint capacity, we might dial back the intensity a little bit and go for more duration so we can work up to 20 reps depending on what we’re trying to get out of it. If we’re trying to improve strength, we’ll do rep ranges between three to eight with a two minute or more rest between sets for four sets, again if we’re trying to produce maximal or submaxim strength.

If we’re trying to grow muscle so try to improve hypertrophy is not the most important thing for distant runners because more muscle mass means more energy expended to try and carry it around, but when someone comes in with a chronic injury, we often see a lot of muscle wastage and muscle deconditioning so we see a muscle on one side, smaller than the muscle on the other side so we probably will have to try and give that muscle a stimulus to grow it back to the level of the other side where it should be because a smaller muscle will on the flip side mean less capacity to handle those big forces.

Now in terms of frequency, if we’re not rehabbing, if we’re just doing strength training in order to improve performance, and we’re fairly good from an injury point of view – twice a week is probably enough. During the busy competition period for racing, if we are racing quite regularly once a week is probably enough to maintain it, but if we are rehabbing an overcoming injury, we probably need to have a third in there for at least four to six weeks to try and front load those adaptations we are trying to get.

I am just going to take you through a couple of examples of common exercises and how we progress them so if someone hasn’t squatted before, we’re not going to put up 80 kilos in the shoulders and hope for the best we’re going to try and make sure their squat technique is good, put a chair under them so they can sit back on their heels and be able to squat smoothly, have good technique and then we can increase the weight so if we could get them to do like a goblet squat while holding a dumbbell or kettlebell held into their chest and they know the chair under them they can sit back on their heels and squat.

If we got that, then we can take the chair away, and if they’re well-coordinated and balanced, they can sit on their heels and be able to squat and maintain that sort of parallel torso and shin angle.

Then we can move to a bar, so if we’re trying to introduce a deadlift, sometimes a hex bar can be a useful way to do that, it allows you to train a good technique in a safe way so again standing in the bar, less of a knee bend as we’re trying to keep the knees a bit stiffer to try and put more tension in the hamstrings and we’re trying to keep the back fairly straight as well.

Then we move to the bar from the floor or maybe from an elevated position on the right there so again trying to not bend the knees too much like a squat trying to target the hamstrings a little bit more, keeping that back fairly straight as you lift and we should feel the hamstrings and the glutes doing most of the work here. I think it’s over to the single-leg exercises, so a step up so stepping onto a box ideally if you can stay on one leg hold that position for a second or two to show that we’re balanced and back down nice and controlled.

It is one of my staple exercises, covers a lot of boxes and we can do some sort of lunge variation or split squat variation, so an example here on the right of a Bulgarian split squat with a barbell, rear foot elevated, dipping down, not letting the knee travel too far forward and again we should feel this closer to the hip area, we shouldn’t feel much pressure on the knee doing this, and we are going to try and keep our back fairly straight as well.

Calf strength as mentioned, if we bend the knee to about 90 degrees and have the foot slightly elevated, we can put a big load through the soleus muscle, and target that was so doing seated calf raises and also standing calf raises, so again I’d like to go ahead in the calf raises so split machine or leg press is an ideal way to do that, just standing with the leg fairly straight pushing up onto the big toe, pause at the top for a second too and back down slowly.

Then plyometric exercises and pogo hops on the spot, trying to be smooth in the ground spend a bit more time in the air progress do a drop jump so again bouncing off a box that’s a 30-centimetre box trying to get off the ground in less than a quarter of a second rebound is almost as high as the box he jumped off and then maybe doing single-legged hops on the spot or single-legged hops going forward as you see there and then on the far right.

In terms of how this all fits in, we can split this season like a running program into like into four phases or whatever way you want to do it, so in the general prep phase, we’re trying to prepare the body for the bigger running sessions that are going to come so we’re trying to improve tissue capacity muscle capacity two to three sessions per week working on good moving patterns first maybe if we have a certain weak spot if we’ve had a previous calf or Achilles injury or an ankle injury we’ll do a lot of calf work if we had a previous knee injury we might do a lot of quad and hamstring and hip work or if we had a previous hamstring injury or recent hamstring injury we’ll do a lot of hamstring and glute work as well.

That’s the time to try and iron out those things so that you’ve got good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards specific preparation phase where you running starts to become more of a priority and you’re increasing your distance bringing in those key sessions twice a week should be enough we’re not going to spend as much time in the gym or doing those exercises so quality is important so maybe a couple of exercises done really well at a good intensity so we’ll go heavy if the athlete has enough training behind them and we’ll also bring in some plyometric exercises and as we get close to competition we want to try and keep that sharpness there because traditionally that’s where distance runners tend to sort of shelve the rest of the program because they’re training for that marathon and in six weeks’ time they’re going to be tired from all the runs but it’s probably the time when they need to get their strongest so if we don’t train something for a period of six to eight weeks we can start to lose those qualities so it’s really important we keep some of the strength training in there in a clever way and that keeps us nice and balanced so we still try and keep in two sessions a week, keep it short and intensive to keep that sort of stimulus and edge there, a bit more focus on the plyometric, keeping in touch with our heavy lifts and then when we are in season and competing we try to maintain it once one or two sessions a week if we’re racing it in a given week one is probably enough in the week a little bit shorter than normal and if we’re not racing on a given week we can probably do the second top up session.

So, in conclusion, most running injuries occur from the knee down. Our calf muscles are probably one muscle group that works close to its full capacity even at slow running speeds compared to quads and the hip muscles, so it’s really important that we condition them for that.

High-intensity strength training, so I talked a lot about the injury, but it’s also associated with improved running and performance, and every runner has different needs – it’s very hard to give a one-size-fits-all answer to when someone has a question about a particular injury or what sort of strength training they should do, it’s important that if they have an SSC coach that’s reputable and experienced they get a proper assessment and have their training SSC program prescribed to meet their individual needs.

At this event, Colin Griffin (CG), answered questions from our live audience asked by Fiona Roche (FR).

FR: How influential do you think reds have in the occurrence of running injuries? What is the management pathway you follow if you suspect this?

CG: Yeah, a good question actually and quite a common one particularly for probably for younger athletes and so if any parents of an adolescent athlete, doesn’t have to be adolescent actually they can be adults too or coaches, so red are running who doesn’t understand, it is relative energy deficiency syndrome, so quite common in female athletes and obviously mid to late adolescence even into early adulthood, and we would see a lot of them who have like recurrent stress fractures so the metabolism is a big factor and so definitely we would look at energy deficits are they getting enough calorie intake at the right time around training or are they in a constant state of depletion, looking at like hormonal profile have they got a regular menstrual cycle.

Even just looking at psychosocial factors as well and are they more conscious of their body type and body shape – with those types of athletes or runners, we would probably have a bit more of a holistic approach here because young athletes we want to try and involve the parents and the coach to make sure they’re on the same page in terms of how to manage them they may need nutritionist and psychologists intervention as well, but as I said it’s not just limited to female athletes, male athletes can be energy deficient and can have recurrent stress factors as well so we would certainly look for that and if we suspect that that’s a factor we would definitely push the nutrition side of things, careful load management and making sure that they have a good SSC program, a well-balanced running program that suits their needs.

FR: Can stress fractures in shins take a long time to heal? I haven’t run in six weeks. I’ve been told I have a grade three stress fracture. What am I doing wrong? I walk, cycle and swim. Could this be a delay in my recovery?

CG: Yes grade three can take a bit longer to heal like a standard sort of lower grade stress fracture you’re talking six weeks and probably trying to immobilize for a good bit of that as well to allow for early bone healing and remodelling to take place, then once that healing has taken place you want to try and get back into a gradual exercise program, so get back walking first to be fairly pain-free and have no sort of gait abnormality and then get back into some strengthening exercises because there will be some muscle wastage if you’re in a boot for a while and you’re not using those calf muscles and ankle muscles and foot muscles so definitely want to recondition those and then you want the body to be able to tolerate some little bit of low level impact so like doing things like hopping or skipping is a good bone stimulus just short 30 second bouts maybe once or twice a day is a good bone stimulus and to be able to tolerate that and then gradually get back running and then obviously make sure that your energy intake is good, calcium and vitamin d levels are good, and nothing more than a low level of pain or discomfort as you progress through it.

Obviously, if there’s a worsening or there’s a high level of pain that is not getting better, you may want to just get reassessed again and see how is there incomplete healing and does it need maybe a more long-term approach.

FR: Joan is saying she has had Achilles tendinitis for the past four weeks, not getting better is there anything she could do to speed up her recovery?

CG: Obviously, you want to be sure of the diagnosis that it is Achilles tendinopathy and nothing else. I suppose to find what you can do that’s not too sore and maybe what is a sticking point? So there’s a certain level of exercise that you go above where you’re going to be sore, but it’s really important to find some level of exercise that you can tolerate, and that’ll sort of accelerating tendon adaptation to exercise, so finding some sort of calf raise exercise if it’s just a static isometric hold or a half health position putting tension on the calf muscles throughout the tendon being too sore and trying to progress from that.

Again depending on how long it is, some of our sports med doctors might look at an injection that might help to settle the pain a little bit and allow them to exercise a bit more, they might maybe use something shock wave, and from a nutritional point of view we tend to encourage people to supplement with collagen and vitamin C which helps to give the tendon the important nutrients it needs to have to repair itself and remodel, but definitely trying to find a level of exercise that you can tolerate and progress on from there, and sometimes people just can stagnate on the rehab program, they can do things that may be too easy, the body gets too used to that, and there’s no progression or added stimulus there, and momentum can be lost, so again it’s very hard to cover everything there when I don’t know the full picture, but that will be my sort of general advice.

FR: What is the prognosis when diagnosed with possible hag Lund deformities? Struggling with Achilles problems for four years, and there is a bony spur on the right insertion.

CG: That’s a tricky one, the heel is kind of like a sharp enough bony structure as it is, and if you’ve got a hag Lund deformity which is an extra little bit of bone growth, you’ve got that bone kind of digging into the tendon on one side, and if you’re wearing shoes you’ve got the heel cup of your shoe digging in on the other side, and that could just keep annoying the tendon over and over again so if it’s not responding to rehab, it’s worth getting a surgical opinion on that, so I’d be kind of referring someone to a sports med doctor, so maybe to a foot and ankle surgeon just to see is another intervention required, because that might be the nature of it might be just you know constantly irritating it and maybe stagnating progress.

FR: What do you think about the barefoot type of shoes for running or walking in, and generally what type of shoes so? We’ll probably answer a lot of people’s questions there.

CG: Barefoot type of shoes, to be honest with you, it’s more the transition so if you’re used to wearing cushioned shoes and all of a sudden you go barefoot or you go minimalist, and you don’t adjust your training load you’re putting yourself at a huge risk of injury because your lower muscles have to adjust a lot to that, they’re going to get tired quickly because they’re not used to that and if you’re trying to do the same amount of miles or train the same intensity, you’re putting yourself at risk of injury.

If you’re going to do it for whatever reason you’re doing it, there’s no necessarily one sort of clear right or wrong here if you need to do it.

Just allow a gradual adjustment time. I think it’s good to do some exercise in minimalist or even just without shoes just to try and train foot a little bit more, but it was a bit of a swing towards minimalist and barefoot maybe in the last five to ten years it’s kind of going back a bit more if you look at all the new shoe technology in races, they’re going back to more towards cushioned shoes with special sort of spring cushioning in them along with the carbon fibre plate.

I’d try not to break a formula that that’s working for you already unless you’ve got a very good reason to do it, and I don’t know your full history to be able to give you a very precise answer on that.

FR: Lots of calf muscles generally strains at the moment. What’s causing this, and how long to rest for?

CG: Probably the simple answer there, given we’ve seen in the last few months, is you probably have weak calves and trying to ask the calves to do more than they’re able to give you when you’re trying to run a certain level, so trying to increase calf capacity because they’re so important for running we demand a lot of them when they’re running and if the capacity is low it takes a lot less for them to get tired, to get sore, to get spasmed and for an injury to occur, so load up calf strength, find a management level running that you can tolerate and then try to increase gradually from there.

That would be probably right without knowing the full picture. That would be my best advice there.

FR: Allan says he’s got a pain in the space between his Achilles and ankle originally thought to be Achilles tendonitis. If he did not resolve the conservative strength exercises, an MRI of the ankle was unremarkable, an issue now suspected posterior ankle impingement. Is cortisone shot the best option from here?

CG: That is not my decision. I suppose the clinical test you can do that can differentiate between an Achilles tendinopathy and having a posterior ankle impingement, so if you’re quite sore, if you put someone lying on the front, bend their knee, and you try to force them into n range plantar flexion, so you’re trying to kind of squash the ankle bring the heel as close to the top of the ankle as possible and if they’re sore doing that and give the heel a few taps and it’s quite sensitive there’s a good suspicion that it is a posterior ankle impingement, quite common in dancers who spend a lot of time on their toes in those kinds of heel raise positions.

It can be managed conservatively. We do see a lot of them and that you can improve how you control the ankle, so people who are hypermobile have a lot of space to move, a lot more room for bone on bone contact – that can be managed by being more stable to the ankle, being stronger in the calves in those sort of heel raised positions and if not then yes it’s worth getting a sports med doctor to have a look at it and see if an injection might help to settle things down a little bit.

FR: Ann-Marie said they will running on grass reduce forces on the lower legs, and will this have a notable reduction in the risk of injury?

CG: It goes back to the changing shoes as well; it’s what you’re used to. If you’re used to running a road, and you go on grass, it can be greater stress on the body than doing the opposite. Your software is not always better.

When you run on softer surfaces, your muscles have to contract a lot more if the surface is quite soft, particularly grass in, say winter and springtime, you’re going to be on the ground that little bit longer, so muscles have to work a little bit harder and if you are not used to it they’re going to get tired a lot quicker, whereas on the roads you can use your natural spring system better you can use the tendons a lot more and they could save the muscle work.

There’s pros and cons. Personally, I actually hate running on the grass, but that is my own personal opinion. I wouldn’t force anyone else, but I think it’s a good idea to mix it up, do some runs be off the road or do some runs on the road and even just doing some off-road running can actually help just to improve strength and stability.

The force going through the body is actually the same; it’s just how you coordinate around the joints when the ankle, knee and hip can differ.

FR: What is the right rest period for shin splints from running? I have this from May. I’m nervous to start running again as I don’t want to prolong the injury time frame being any longer.

CG: Shin splints are kind of a pain on the lower inside of your shin, and I suppose it’s on the spectrum of a stress fracture, so it’s like an early stage, so the bone stress response we’re struggling to heal and adapt to what you’re asking to do so there’s no set time frame if it’s shin spins and it’s a low level of discomfort some people can run through it just adjust the training maybe space out the runs a little bit more, but I would definitely be looking at running mechanics.

I would be looking at your running load, make sure there’s no recovery time in there, staying below a threshold of running that you can tolerate that doesn’t cause pain or cause a worsening of it, make sure calf strength is good because again it comes down to those bone-bending forces and if the inside calf muscles and the deep calf muscles aren’t strong enough to cope with that, there is going to be like more fatigue in the muscles and a lot more loading going through the bones so make sure that’s addressed.

Then it’s a question of trying to progress back up again – if someone has a muscle injury or a tendon injury, we can probably let them train with a level of pain that might be like a four or ten on a scale, but for a bony type of injury like shin splints, maybe a little bit less than that maybe like a one or two out of ten that doesn’t worsen and the main thing is you can increase your running and whether it’s volume, whether it’s intensity or frequency without worsening symptoms.

It’s very hard to give a proper time frame and is also important then as I mentioned in one of the other questions is to look at your nutrition and look at energy intake and to make sure there’s good recovery, and you’re in good metabolic health to be able to adapt what you’re asking to do.

FR: Jim said he has an ongoing battle with gluteal tendinitis, he’s done full rehab, had running analyzed, and one issue was that she doesn’t lift her knees enough, which causes her hips to drop when she strikes the ground, is the only way forward to continue to try and change her gait?

CG: It’s one way forward, and it’s important to look at that, so again, as I mentioned there in the presentation, the example of a hip drop that causes a compression of the glute tendon against the bone and so if that’s happening every stride the tendon is going to be constantly annoyed because there’s an extra compression so the base of the tendon’s getting sort of squashed against the bone.

It is definitely important to look at strength around the hip muscles. There’s a few questions there people saying I’ve tried rehab it hasn’t worked, it’s like you know there are different ways of rehabbing, it’s like saying I’ve tried running, but I haven’t got any fitter or haven’t improved my pb so running isn’t for me you know or I need to do something else – just maybe the way you went about it might be the right way for you, and that’s not criticizing anybody else or that, people do things with the best of intentions.

But you may need to try a different approach, and you need to maybe get a proper assessment of your strengths and have numbers there that gives you an objective measure of where you’re at and then try and chase it, do a program and try and make sure that you’re getting changes in those type of measures and if you are looking for engagement, someone telling you you’re not lifting your knees enough, again I don’t think that’s the biggest issue, but the hip drop is one to look at, and you want to make sure you’re doing something to maybe modify that a little bit.

You mightn’t be perfect, but you can maybe reduce that a little bit, and that might take a little bit of load off the tendon, but it’s really important that strong hip muscles and also make sure the level of running you’re trying to do is manageable for you for your individual needs.

For further information or to book an appointment with Colin Griffin please contact sportsmedicine@sportssurgeryclinic.com