Arthritis of the knee Santry

‘Moving forward with Knee Arthritis: what does the future hold’ – Professor Brian M. Devitt.

Watch this video of Professor Brian M Devitt, Consultant Orthopaedic Surgeon specialising in the Knee, presenting on ‘Moving forward with Knee Arthritis: what does the future hold?’.

This video was recorded as a part of SSC’s Online Public Information Meeting, focusing on Knee Arthritis.

Professor Brian M Devitt is an internationally trained Orthopaedic Surgeon with subspecialty expertise in Knee Surgery. He has a particular interest in sporting injuries, including Anterior Cruciate Ligament (ACL) Reconstruction, Meniscal Repair, Cartilage Restoration Procedures, Multi-Ligamentous Knee Reconstruction and Hamstring Repair.

In addition, he cares for patients with Degenerative conditions, such as Knee Arthritis, and performs Partial and Total Knee Replacements as well as Osteotomies.

Good evening. My name is Brian Devitt. I am an Orthopaedic Surgeon working at Sports Surgery Clinic in Santry, and I am a hip and knee specialist.

I have recently returned from Australia, where I have been working for the past eight years, and prior to that, I was in the USA and Canada. So it is a great pleasure to be able to speak to you today regarding Knee Osteoarthritis.

The title of my talk is ‘Moving Forward with Knee Osteoarthritis.

This is a picture of a lady I operated on a few years ago who is on a charity walk-through to Vietnam 18 months following her Knee Replacement. We learned a lot about Confucius while we were in Vietnam. Confucius has a great phrase, which is, I think, particularly for osteoarthritis. It doesn’t matter how slow you go as long as you don’t stop.

These are my three children, and they’re very cheeky, and when I try to tell them something, they say, Dad, tell me something I don’t know, so the idea behind this talk is to share with you some information you may not know about, and I’m happy to answer any questions afterwards.

We are going to talk about the basics.

What is Arthritis? What treatment works? The evolution of surgery, and what does the future hold?

We often hear this quip, it’s just a bit of wear and tear. Well, it can be, but typically when people require intervention, it’s more than just a bit of wear and tear.

Try telling this gentleman with his right knee that that’s just a bit of wear and tear. We can see severe arthritis with all this extra bone debris, and it’s amazing that people can actually cope and live with a knee that’s as badly Arthritic as this. In fact, he was complaining of pain in his left knee as well, which doesn’t look as bad but also has ‘a bit of wear and tear’.

We often see different varieties of arthritis when we look at people’s legs. You can see this as you walk down the street; you can see Normal alignment where people have pretty straight legs; you can see Varus alignment, where you’ve got both legs different; and finally, where you can see knocked knee alignment, which we refer to as Valgus.

Knees come in all different types and shapes, and we have to be able to manage them all.

What treatment works?

Here is a great quote from William Shakespeare which I learned when I was doing my Leaving Cert.

‘Eye of newt and toe of frog,

Wool of bat and tongue of dog,

Adder’s fork and blind-worm’s sting,

Lizard’s leg and howlet’s wing,

For a charm of powerful trouble,

Like a hell-broth boil and bubble.

But none of them works whatsoever for Arthritis!

We often get people asking us to put crystals on our legs. Would it work if I took out some spices? Is that going to work? Today I’m going to tell you about the proven methods that work from evidence-based literature.

Conservative Treatment

If you look at the conservative methods that work – these are very effective.

Physical Activity is important; just like Confucius said hundreds of years ago you have to keep moving.

Weight loss is probably the single best method of treating Arthritis non-operatively, and the reason for this is simple physics. The less load you have going through your knee, the less stress on your joints.

If you consider when you’re walking 1 to 2 times, your body weight goes through your knee. When you start walking down steps up to four times, your body weight goes through your knee. So if you could lose five kilograms, that’s 20 kilograms less going through your knee with every step. So it does work, and it’s the most effective means of conservatively treating arthritis in the knee.

Acupuncture has been shown to work well.

Massage can make you feel better if your muscles are a bit tight, but it hasn’t been shown to be hugely beneficial.

Bracing can help in certain circumstances but not all. Insoles – the same.

Glucosamine in fact hasn’t been shown to work, although it doesn’t cost much and it doesn’t do any harm. I’m not too bothered if people want to take it.

We recognise physical activity – so a lot of physiotherapists introduce Exercise Programs and Exercise Prescriptions, and I thoroughly recommend these as the first line of treatment for Arthritis because they are very effective.

Pharmacological Treatments

We look at pharmacological treatments and see which are effective.

Anti-inflammatories are effective because they reduce the swelling within the Knee. The swelling has an adverse effect on your knee in that it shuts down your muscles, particularly your quadriceps. So your quadriceps are important for stance when you have fluid on your knee, you have a decreased ability to stand properly. You would have this sense that your knee gives way or goes back when you take a step. So Anti-inflammatories are effective.

Steroid Injections can be effective in certain cases, particularly when you’ve lots of inflammation. But when you have bone-on-bone Arthritis the steroid is not effective.

We would look at Hyaluronic Acid, which is not effective according to the literature. In certain circumstances where you have very young patients, you might try hyaluronic acid, but it hasn’t been shown to be beneficial.

In every case, Platelet-Rich Plasma (PRP) is another treatment where you take the blood, spin it down, take all the good bits and inject it back into the knee. This is effective in certain circumstances, but it’s typically the early Arthritis cases where it is effective. The evidence is still slightly dubious about its effectiveness in all cases.

Surgical Treatment

Then we look at surgical treatment such as an Arthroscopic Washout. If you have Arthritis with a narrow joint space, there is very little role for Arthroscopy. Maybe 20 years ago, the treatment would have been to wash it out, but it doesn’t really help in the long term and can cause increased pain in the medium term in some cases.

Arthroscopic Meniscectomy, we have to consider that some people are on an early spectrum of developing Arthritis but might have a displaced or flipped meniscus – removing that offending article may be effective in some cases, but when you have a lot of Arthritis, it’s not very effective, even when you have a meniscal tear.

Some people describe a sensation as similar to having a stone in their shoe, but in their knee, and in those situations, it may be a flipped meniscus, and we can trim them, but we’d have to do X-rays to make sure you don’t have Arthritis as a background.

Doing an Osteotomy, so cutting the bone and realigning the bones, making those bow-legged knees straight, can be effective, but we typically would save that for younger patients as it is a harder surgery to get over.

And then Joint Replacement in the right setting is a very effective means of treating Arthritis.

Knee Replacement

So then we look at the different types of Knee Replacement that we have available – Total Knee Replacement (TKR) and Partial Knee Replacement.

When we look at a Total Knee Replacement, you can see we’re replacing the whole joint. The Total Knee Replacement is used for patients who have arthritis widespread within the knee and not just in one compartment.

Unicompartmental Knee Replacement (Partial Knee Replacement) is very effective if you just have isolated Arthritis on the inside of your Knee and no pain elsewhere. If you can point with one finger and say my pain is there, it’s on the inside doing a Unicompartmental Knee Replacement is a very good procedure.

It doesn’t take away the ligaments, which allows some early rehabilitation, making it easier for the patient and kinematics or the knee movement, which is more like their native knee, so people tend to do very well with that.

We also can do a Lateral Unicompartmental Knee Replacement, but it’s not as common, and you can also just replace it under the kneecap as well, but equally, that’s not as common.

The Unicompartmental Knee Replacement has had a resurgence because we’ve seen how effective it is for patients.

Methods of Knee Replacement

There are also different methods of how we can do a Knee Replacement. This is an example of Patient-Specific Instrumentation. We conduct CT scans beforehand to get a map of the patient’s knee so we see all the patient’s arthritis, and you can use these specific implants that you place on the patient’s Knee and they allow you to make the cut so you can get an accurate cut that’s specific to that patient.

These came into prominence probably around 15 to 20 years ago and seem to be a way of maybe improving the accuracy of Knee Replacement, but really, the outcomes haven’t been shown to give greater effectiveness to the standard of instrumented Knee Replacement that we currently do.

People have also looked at other methods of doing replacements you may have heard of Robotic Knee Replacements.

Now it’s not some robot coming into the room and replacing the surgeon! This is the surgeon controlling the robot that does the knee replacement.

The idea behind this Knee Replacement is that we can get really accurate measurements of how the knee moves and measurements of the anatomy that you’re dealing with CT  scans before the surgery, and the robot then allows us to do very accurate cuts, and these are cuts accurate to the micro millimetre so that we don’t have much variation when we’re applying the prostheses and you can also look at ways of balancing the knee very nicely so that the patient can move without any major difficulty.

But once again, there haven’t been a huge number of studies that have shown a proven benefit to having a Robotic Knee Replacement compared to an experienced Knee Surgeon done with standard instrumented techniques.

But I think Robotic Knee Replacement is likely to be the future of knee replacements, but the technology is constantly evolving. However, you’re better off picking an experienced surgeon for your Knee Replacement rather than just picking the fancy robot on the brochure in my opinion.

We look at all the companies, and robotics is obviously the new vogue and as surgeons, we’re like followers of fashion with different cuts of suits with different ties and shirts. We like to change the prostheses every now and again.

We do so based on registry data. Registry data is very important data that we take from people who follow up on knee replacement, there is a huge registry in Australia which is very informative, and it looks at how those prostheses go, how the knee replacement from the different companies are doing over time, and it can identify those prostheses that aren’t doing very well.

They’ve shown some of the early data with robotics that it is very effective, and they seem to have very good outcomes in terms of not requiring revision, as to whether they improve the patient outcome in terms of how they live, which is yet to be determined.

Future Of Knee Replacement

So what does the future hold in terms of knee replacement?

This is a picture of my family. My grandfather is this little fella here in Tipperary in the early 20th century, and notice he isn’t wearing shoes. And of this family, my grandfather had both knees replaced, his brother had both knees replaced, and his older brother had both knees replaced.

So I think I know what’s in my future in terms of knee replacement. But we do recognize with Knee Replacement that there is a genetic predisposition for replacements, and perhaps the future is trying to identify those individuals who have a predisposition for Arthritis and being able to alter genes or look at different methods of managing that individual.

What’s also in common with all of my predecessors is they’re all athletes. They all ran and played Hurling and Gaelic Football. So I think that’s probably as much a part of the genes as well is that you’re interested in playing a sport, and unfortunately, that can have its effect later on in your life.

But we also looked at other methods in terms of what the future holds.

We have a lot of smart fabrics nowadays that can help us with our rehabilitation, they can tell us which muscles we are activating,  how our range of motion is with our knee, and follow us up with apps that can help us remind ourselves when we need to ice our knee, remind us when we need to do our exercises set goals for us.

I think that once we have this biofeedback, as we describe it, it’s very effective in improving the outcomes following surgery, but also the rehabilitation before surgery and hoping to avoid surgery as long as you can.

After all, I tell patients that their objective is to avoid people like me for as long as they can, but when you come to have a Knee Replacement, it’s a very effective procedure in that situation.

You might have heard of Stem Cell Therapy for Knee Arthritis, and this is an area where I get a little bit concerned because I am a professor of Orthopaedics, and we do a lot of research to see what the evidence base is. You didn’t see stem cells on my list earlier because the evidence isn’t there yet.

Unfortunately, a lot of people make a lot of money by trying to offer you the great panacea to treat arthritis without surgery, and this is not the way to do it, in my opinion.

Be careful what you read in the papers, and this includes scientific papers. If we look at the injection of Platelet-Rich Plasma for early-stage Osteoarthritis, we find that this study shows that it’s good; this other study shows it’s not so good when there is an equivalence between Hyaluronic acid and platlet-rich plasma, and this study shows that there is no difference between the two.

So it’s important that you take a lot of this information with a pinch of salt.

This study says that case in point, that we really have to do further analysis of these treatments to see if they are truly effective.

When it comes to stem cell therapy, obviously recently, I came from Australia, and the Association of Rheumatology and the Australian Orthopaedic Association have issued a warning regarding the use of stem cells that they should only be done in the setting of randomised controlled trials, which are carefully performed.

So people shouldn’t be selling this commercially to make money from patients. This should be part of the study so we can understand more about the effectiveness of stem cells.

So just be cautious if people are offering it without being part of the study, which is further evidence of that.

How long does it take to recover from knee surgery?

While recovery can be variable following knee surgery, typically, if you look at the different stages, most patients walk without crutches by roughly 4 to 6 weeks following surgery. In terms of pain-free existence, people tend to have some pain at night in particular, which lasts up three months, but the time it takes for people to feel like they haven’t had a Knee Replacement can be anywhere between six months to 12 months.

So it can vary, but most of the time, people feel an improvement in knee pain reasonably early afterwards, but they may have some pain related to swelling.

When can I drive following a knee replacement?

I think it depends on the individual. In terms of your ability to move your foot is not that much hampered by knee replacement. It’s not like you’re driving a combine harvester, so you don’t have to flex your knee quite a lot.

I always recommend that people shouldn’t be on any narcotic medication and should feel comfortable in themselves to drive. So it’s typically anywhere up to six weeks where you’d recommend driving, but it’s on an individual basis.

 Could you explain aspiration as a way of reducing swelling of the knee caused by aggravated osteoarthritis? Does it help?

This is a very good question. We recognise that swelling in the knee can be quite painful and also result in a sense of instability because when you have fluid in your knee, it stops the muscles in the front of your knee from working correctly. These are very important for your ability to stand.

The difficulty in terms of aspiration is if you consider the presence of fluid in your knee as analogous to smoke in a room. If your removing fluid from the knee, it’s the same as opening the door to let the smoke out of the room. However, if you don’t put out the fire, the smoke will just re-accumulate once you close the door again.

So the key is to understand why the fluid has developed. If it’s not settling with anti-inflammatory medication perhaps an aspiration and an injection of steroids may be beneficial, but I wouldn’t recommend repeated aspirations as every time you stick a needle in a joint you run a risk of introducing infection.

Jane has had two arthroscopies on her right knee, one was in March 2001. Now her knee is very sore, especially after walking, and it is swelling. Any suggestions on what she should do?

Well, I would certainly advocate getting an x-ray, a weight-bearing x-ray, for this lady just to assess if there is Arthritis.

Some of the simple non-operative means are very effective. I mentioned weight loss in my talk. If you are carrying any weight, just reducing your weight by two kilos can have an effect of eight kilos less going through your knee when you walk.

Activity modification, so avoid doing things that hurt you. Taking anti-inflammatory medication and engaging in low-load exercises such as cycling, swimming and pilates.

Avoid walking on uneven ground and hiking, for example, as that type of walking can be quite painful.

What about walking in a swimming pool following a Total Knee Replacement? Does it help recovery?


Once the wound is healed, I’m happy for patients to get into the swimming pool almost immediately. So after two weeks or so. Hydrotherapy, as we refer to it, is very, very effective because your body weight is eliminated. What you can do on dry land you are able to do way easier in water, and it improves your range of motion. For the best part, it’s enjoyable, gets you out of the house and helps get your independence back.

That’s what it’s all about.

What sports can’t you do after a knee replacement?

Well, I wouldn’t start running ultramarathons – it wouldn’t be the best idea, nor playing rugby, but certainly, I’d be happy for people to get back to cycling, and walking too.

Running is probably not the best idea in that you tend to wear out your joint a bit more quickly, but if you want to do it, go for a little run.

When I was working in Australia, they all wanted to surf, so that’s quite a level of knee flexion. If they’re able to do it, I’m happy for them to do it.

Golf is absolutely fine, but it’s a good walk ruined, is it not?

Do Hyaluronic Injections help against Knee Replacement?

A person has been recommended to get an injection of Arthrosamid for knee pain as an arthroscopic procedure has not worked. Any information on this?

And as far as I’m aware, there’s always a variety of these trade names. But I think Arthrosamid is hyaluronic acid. So it’s like the jelly I mentioned in my talk. It can be effective in early or very osteoarthritis. Once you get to bone a bonus of arthritis, it’s not all that effective. But, you know, if you’re a young person, we try to avoid joint replacements, as I mentioned, for as long as possible. So it might be an option in those situations.

What is the lifespan of a knee replacement? I’ve been informed that I’m too young for one yet.

As for the lifespan of a knee replacement, I’ve heard a very nice description of this. If you consider the failure rate of a knee replacement is probably 1% per year. So if you get to 20 years, the chances of you retaining that joint replacement are 80%.

The reality is the earlier you have it, the more action you’re going to put through that knee. So therefore, it’s probably going to fail more quickly if you’re younger.

If you’re 80 years of age, when you have your knee replacement, it’s going to outlast you, I would say.

Fiona- How often can you have a steroid injection?

It depends. For some reason, this number of three seems to come up. I only have it when the symptoms are cured by the injection, or at least helped by the injection.

If you’re getting an injection and pain coming back in six weeks, I’m assuming that you haven’t put the fire out. So you need to look more deeply at what the problem is.

Can Knee Arthritis cause thigh muscle pain?

Yes, any arthritis can cause a huge amount of pain. I think sometimes the thigh muscle pain can relate to the position the knee is held in. If your knee is held in flexion, you put a huge amount of stress through your quadriceps, which are the muscles at the front that can cause thigh pain.

But we would often investigate this and other sources. You can get pain from your hip, which also goes to your knee. So it would be very advisable to look at the hip in addition to the knee if you’re investigating that as a physician.

If you’ve had one knee replaced, will you have to replace your other one in the future?

It depends on what the reason for the arthritis is. If you’ve had a traumatic event on one knee, you may not get pain in the other.

If it’s more of a genetic issue, you will likely have the same problem on both sides.

I often tell people if the pain had a gender, the pain would be male because men can’t multitask. So you only get pain one joint at a time. So once you’ve got rid of the pain in one joint, the other often becomes painful, unfortunately.

A person has a diagnosis of osteoarthritis. Is it common to experience cramp-like pain in calf muscles because of this?

It’s very common. Yes. A lot of the time, it’s because you have fluid at the back of your knee. You’ve often heard the phrase a Baker’s Cyst.

A Bakers Cyst is not pathological -it’s where the fluid collects. So just like the bakers, when they’re reading on the ground with arthritis in the front of their knee, what happens is the fluid collected at the back, and that’s why they could see it or feel it, and your calf muscle is attached to the back of your knee hence you get calf cramping.

It’s probably not a great idea to constantly take anti-inflammatories. So If somebody is taking a lot of these, should they seek guidance from a Physician?

Yes, I think so. It happened a lot in the past. That’s why Joint Replacement was such a revelation when it came to prominence because people were taking anti-inflammatories or aspirin, earlier versions of drugs. They were getting gastric ulcers as a result.

So, anti-inflammatories should be intermittent use for swelling and shouldn’t be taken long-term.

If I have to get a Knee Replacement, what kind of medical checks should I have?

Brian– I suppose it depends on someone’s age, really, and their fitness level. At Sports Surgery Clinic, we engage people in our Pre-Assessment Clinic.

As surgeons, we don’t like surprises at the time of surgery, so if you can be fully optimised for surgery, that is the best thing. That means it’s safest, and the anaesthetist is happy; we do an ECG and some blood tests. If necessary, there is cardiology, we can do an echocardiogram to assess the function of the heart.

So all of these things are important but not always necessary for every individual.

How soon after a knee replacement can I play Golf?

You can start putting if you wish inside six weeks. You can start chipping after that, but before you get the big dog out and start doing a Happy Gilmore, I would look at three months.

How long does it take to recover from Kneecap Resurfacing?

It depends on when and how it’s done if it’s an isolated procedure or part of a joint replacement.

If it’s an isolated procedure, it’s a similar recovery to TKR you’re talking six weeks to three months.

If done as part of a joint replacement, it makes no difference in terms of recovery from normal joint replacement

Where can I learn more about how the knee works?

You can learn more about how the knee works here. You can learn more about Total and Partial Knee Replacement here.

For further information on this event or any other queries, please email
Knee Replacement Santry

Enhancing Recovery from Knee Replacement – Dr Neil Welch.

Watch this video of Neil Welch, Senior Strength & Conditioning Coach and Head of Lab services at SSC, presenting on ‘Enhancing Recovery From Knee Replacement‘.

This video was recorded as a part of SSC’s Online Public Information Meeting, focusing on Knee Arthritis.

Dr Neil Welch is a Senior Strength & Conditioning Coach and Head of Lab Services in SSC’s Sports and Exercise Medicine Department.

Hi there, everyone. My name is Neil Welch. I’m the head of the Sports Surgery Clinics and Lab Services within the Sports Medicine Department.

I want to start off by saying thank you to everyone taking time out of their day to watch this presentation on a Tuesday evening or watch it later.

I want to talk to you today about enhancing recovery from Knee Replacement surgery.

Why do we need Knee Replacements?

Osteoarthritis is a scourge that affects a large number of people all over the world. As we can see here, around 250 million people worldwide are impacted. Those most susceptible are obese, patients over sixty-five years of age and, in particular, females. About 35% of females over sixty-five suffer from some form of Osteoarthritis.

From a population perspective, given the ageing population that we have in Ireland and the growing sedentary lifestyles and obesity levels within the population, this means it’s a condition that we’ll have to get used to dealing with.

So, in particular, Knee Arthritis. We often hear the term wear and tear used, and this is a point echoed by Brian this evening as well. Knee Osteoarthritis is not just a wear and tear condition.

The important point here is that we tend to treat our body differently if we feel wear and tear is a big driving factor. It conjures up imagery of sandpaper wearing away wood, and that’s not how these conditions work, as a large inflammatory component also sits within osteoarthritis as well.

There are multiple factors that are thought to contribute to the changes in the joints. Trauma is one. So we know that following certain surgical interventions earlier in life increases the risk of knee Osteoarthritis.

Mechanical forces play a role. Simply it is the amount we do, but also the other factors such as inflammation, which is where obesity plays a role and biochemical reactions within the body.

Changes within the joint fluid itself and then also the metabolic changes that we might go through, changes in activity levels and hormonal changes throughout our life.

So there are lots of contributing factors to this condition.

What does knee osteoarthritis look like?

What does it look like? So this is a photo from within the knee. The curved shape at the top of that circle is the end of the cycle, and the bottom is the Cartilage that sits on top of your shin. This is what it looks like in very good condition.

Now, the next image I’m going to show is the other end of the spectrum, and there’s a whole scale of changes that happen within the knee joint between here. I don’t want everyone thinking just because they have a sore knee that their knee looks like this.

But essentially, this is what Osteoarthritis is. It’s a change or a death in the Cartilage cells within the Knee. That can either happen, as I said, because of trauma or the change in the fluid around the knee that causes the cells to die throughout our lifetime. Okay, So not every knee that is sore looks like the ones on the right.

Oftentimes, we can have changes within the knee joint that don’t result in pain. That’s why it’s not as simple as just simply scanning the knee.

We can now start to see what the changes look like within the joints. In order to go from one end to the other and get to a position where we’re considering knee replacements, we have changes in our physiology, and we have changed within our function.

So from a physiological perspective, we will lose the size and strength of the muscle because of pain. These are in the background to what we see change throughout our lifetime as well.

This image is of a thigh. The white banding around the outsides is fat that sits beneath the skin, and the dark grey images are of the muscles within the leg. This is what a strong well-conditioned leg looks like in our 20s’.

This is the same leg 30 years later. What we can see here is how lifestyle changes can impact us. We see that the banding of fat increases as we have a larger layer of fat underneath the skin, and we can see this marbling occur in the darker area of the muscle. That’s called Intramuscular Fat Infiltration.

The muscle becomes deconditioned, and we get layers of fat and fatty deposits within the muscle. This can change the way that we use the muscle – we get weaker essentially, and we can’t send a signal to the muscle as clearly through our nerves, but it’s also a large storage site for inflammatory metabolites, and that’s where the relationship with inflammation starts.

In the background, we have pain and change in function, we also have these lifestyle changes that we get throughout our body throughout a lifetime as well.

In terms of Knee Replacement, 95% of Knee Replacements happen because of Osteoarthritic changes in the joints. However, not everyone who has Knee Osteoarthritis has to have a Knee Replacement.

In the UK, there are 100,000 Knee Replacements completed each year and 700,000 in the US. Obviously, we can extrapolate those numbers down a little bit within Ireland.

In terms of selection criteria, patients would be undergoing moderate and severe pain over a long period of time and then associated loss of function. So we have changes in the quality of life and the ability to use the leg and haven’t responded to non-surgical treatment. Brian covers the conservative treatment elements within his presentation.


We also know from the larger registry papers around these Knee Replacements that 15 to 20% of people are dissatisfied with the outcome. Sometimes that can be a mismatch of perceptions. People expect to be coming out the other side of the surgery like the $6 Million Man and then not quite feeling that way when they have surgery.

It’s something we’re looking to try and get to the bottom of within the Sports Surgery Clinic is some of the reasons why people might be dissatisfied. Can we improve those outcomes?

At Sports Surgery Clinic, we completed 1385 knee replacements last year. We’ll be completing more of them throughout this year. We’re a centre that sees a lot of this type of surgery.

The average age of patients is 68 years old, although we have a range from 48 to 86. Those younger cohorts are starting to grow. I think this is partly due to those lifestyle changes or the increase in sedentary lifestyles and growing obesity in populations that we see.

What happens when I have a knee replacement at SSC?

What would happen if you had a Knee Replacement in the clinic? You’d be staying for two or three days following the surgery. This depends partly on your surgeon’s preference and how you respond to the following surgery. It might be a surprise to some of you that you’re out so quickly.

It’s important for a mind-set perspective to understand that you are not a very sick or critically ill patient when you’re undergoing replacements. That kind of mind-set is also important for your rehabilitation so you will be on your feet and out as soon as you are able.

On your first day following surgery, we will be working on your mobility, trying to get some movements into the Knee. The physiotherapist will show you your home exercise plan and how to use your crutches. You will be up on your feet on day one.

On day two, we will talk you through your exercise progressions, we will look at how to improve your use of crutches and then how to improve your gait on crutches and then stair use. Depending on your progression, this will be done on day two or three.

In terms of going home, you are looking for a 90-degree knee bend and moving independently with crutches. You can use stairs and can perform a straight leg raise. Then it’s on for physiotherapy.



Now I said before about changes in muscle mass throughout our lifetime and obviously throughout pain prior to surgery. We also have to take into account the surgery itself. The two pink circles up here, a slice, an MRI slice of a thigh, we have on the left-hand side before surgery and two weeks after surgery.

If you look at the areas specifically highlighted by this oval shape here, we can see the changes in muscle mass even as quickly as two weeks following the surgery, and the images below of the non-operated leg and even then, we can see a reduction in size. That’s simply because of the increase in rest periods due to the surgery and shows the inflammatory response to the surgery itself.

This is asked to play a role when we’re talking about rehabilitation. Over the longer term, in the first couple of days following surgery, we’re looking to restore your range of motion. We’re looking to try and build up the size and strength of the muscles around the quads in particular. While the muscles are affected, the hamstrings and the calf are as well, and we’re looking to restore their function.

We want you to use your leg the same as the opposite side and the same as we did before we started having these issues. I mentioned before about 15 to 20% of people have issues over the long term or are dissatisfied with surgery. One of the possible reasons for this is incomplete rehabilitation as well, and I’ll touch on that shortly. The aim is to get to a stage with a physiotherapist where you’re mobile, you can walk and then be shown the door again. I’ll talk you through those issues. For example, Poor pre-surgery condition, so not being yourself in the best possible way. You need to be in a healthy condition for surgery in order to give you a chance of a positive outcome.

I’m going to side with long-term guided movement patterns, changing how you use your leg to protect the Knee.  This can be quite hard to change. If you are looking to restore movement patterns, you will look to do it if you were exposed to increased hypersensitivity to pain again. When you experience pain over the long term, your body actually gets better at sensing it and reducing that pain.

Sensitivity over the long term can sometimes take a long time. Then the decision-making for surgery, people figure out that it’s much too much work to carry out because of the kind of injury I mentioned before about patients who had incomplete rehabilitation. We’re looking at an image of strength measurements of someone’s thigh throughout the course. This is four and a half months post-surgery. When the patient had been discharged from their physio, they were back playing golf and walking. They were getting some aching in the knee but wanted to come in and just make sure they were in a really good position.

The red line on that graph is the strength of the right leg, the non-operated leg and the grey line is the strength of the operated leg. And if you look at the bar charts on the dates and we will look at the lines next to where it says Peak, that red leg gets a score of 131% bodyweight strength and quite a good score from somebody who is 65, but the operated leg is 73%, so that’s a 45% difference, and this is a patient who’s been discharged from care.

Again, if I’m putting myself in that position and I want to make sure that I have a much smaller difference between legs, my number one goal is to try to return to my day-to-day life. Many people want to be very active in Knee Replacement and what we looked at to try and do in the sports injury clinic is improve outcomes.

Joint Lab is a project we’ve been working on. For one, we’re looking to launch Autumn Winter this year in order to try and help improve patient outcomes and reduce the 15 to 20% dissatisfaction that we see broadly. It’s off the back of our ACL service and ACL surgery, one you have following a traumatic injury playing field sports, and we’ve been conducting research and review services for almost a decade.

We’ve had thousands of patients with the data come through with over 15 scientific publications around us. If you read the literature around an injury, you’ll see this is a 20 to 25% screen upgrade. People go on to be injured for those patients who come through the research program or the review service and have the surgery with the excellent surgeons here at the sports surgery clinic, that re-rupture rate is about 2%. So we’re looking to try and do a joint map to see if we can do the same thing and understand what the important elements related to your rehabilitation for any of those are.

We are going to do that using a number of different tests. We’ve leaned heavily on biomechanical assessments.  In this image here, you can see the mark is attached to this individual. We use that to get measurements of the way you walk, the way you set the stance and the way you step up and over stairs and before and after surgery.

The idea is to try and identify the important factors for you to work on in your rehabilitation. We do this, rather than just looking at you, to get biomechanical information that we can use to identify the important areas.

You can see quite clearly this patient is limping following the testing, but again, we imagine this is somebody four, five, or six months after their surgery, and we haven’t restored full function for them. Similarly, you see this patient getting up and down from the side on the citizen task. It might look normal, but when we spin around and look at the front, we can see this patient is clearly putting more weight through the non-operated leg on the left-hand side.

What we’re looking to try and do is put numbers on there so we can identify whether or not somebody is improving throughout the rehabilitation. This is to be able to look at activity levels and see whether the amounts of steps we have taken immediately following surgery play a role in a positive outcome.  Then next to that is biomechanical testing which would be looking at the quad and hamstring strength, plus inflammatory markers and body composition, again, hoping to identify those who might respond better or worse to surgery so we can improve surgical decision-making to improve pre-surgery strategies for training before going into surgery, and then better guiding rehabilitation following surgery.

I’d like to thank you for your time. Thank you for listening. Hopefully, you found it informative.

Would cycling be beneficial as a non-weight-bearing exercise and good preparation for a Knee Replacement?

 Cycling is excellent preparation for a couple of reasons. One, it keeps the quads very active. As I mentioned in my talk, that’s a sight of muscle loss which is a really good reason for continuing on with the bike. Brian alluded to it in his talk as well. I think it’s a really important point around weight loss. Even just weight gain throughout the preparation phase as well. Performing some form of cardiovascular exercise, something where you get out of breath, is really important for not putting weight on. I think that’s also important and helps maintain your range of motion. So 100% get behind cycling.

Suppose a person has back issues, like a disc. It sounds like they may have a sciatic nerve problem. Is it a good idea to proceed with the Knee Replacement?

I think there are a couple of factors that you need to consider here. One of them is obviously which is a priority, and addressing that first. If you’re having more of an issue with sciatica-related back pain, you really want to get that sorted first and then also the impact it might have on the rehabilitation. Again, if you have a compression of a nerve, sometimes it can impact the way the muscles recruit down the rest of the leg. That might slow down your rehabilitation as well. A few things to consider are definitely getting a back checked out beforehand to see if there’s anything that can be done to put them in a better position before surgery and before maybe going ahead with the Knee Replacement.

When patients have had a  Knee Replacement, is it okay to continue to exercise when the Knee is swollen because it does stay swollen afterwards for a while?

Yes, a lot of exercises are going to be important in order to be able to help mobilize the joints, and Physiotherapists will be able to give good advice on how to improve your range of motion. Ideally, you’re looking for exercise that doesn’t cause more swelling, but anything that you mobilize the joint, you get it moving should make it feel a little bit better afterwards. But certainly, you want to be kind of cautious not to increase the level of inflammation afterwards.

I have been told I have a bit of arthritis is there any vitamins I can take to help?

It’s more the concern around Osteoarthritis, it is a diagnosis we tag on images of the knee on a scan, but everyone has changes in a joint, the vast majority of people who show up as having some form of Osteoarthritis don’t experience pain at all. It is important that she doesn’t overly worry about it. A change within a knee joint is normal. In terms of prevention, maintaining a well-balanced diet, reducing inflammation in the joint by conducting cardiovascular activities, and limiting drinking and smoking also. For normal bone health in the winter months, the Introduction of vitamin D.

How important is Physio after a Knee Arthroscopy?

It is a much quicker rehab, the surgery is much less invasive. A lot of the time, physiotherapy after that surgery is to undo what happened as a result of the injury beforehand; the likelihood would be there would have been a lot of knee soreness before surgery, and you would’ve lost the size and strength of the muscle around the knee. It is not a major concern after the operation because getting the range of motion back is relatively straightforward, but you will need the advice to get the muscle strength and size back up. I would say it is important following surgery, yes.

If both knees require partial replacement, is it a good idea to have them done at the same time?

I think this is a challenging one. It’s kind of something to kind of talk over with your surgeon and the pros and cons of having both done obviously from a recovery perspective; you’re not going down the line of doing rehab on one and then staring down the barrel of another, say, six months of rehab on the other one. So while it might be worse at the beginning, kind of like having twins, I guess, is to make it a little bit easier in the longer run, I’d say.

Can you still experience Arthritic pain in the Knee after a Knee Replacement? If not, what’s constant Arthritic-like pain in an operated Knee indicate?

The pain that you feel isn’t necessarily down to that, and when we talk about Osteoarthritis, it’s the change in the joints because the joints have resurfaced. It’s unlikely to be related to the condition of the joint’s surfaces, but the pain has many inputs, and it comes from many different sources. Sometimes when you’ve had pain in a joint over a long period of time, you just have heightened sensitivity within that joint, and it takes a long time for that sensitivity to reduce, particularly if it’s been something that’s been playing on your mind over a really long period of time. I talked about the guarding movement patterns within my talk. Those are something that can remain over a long period of time. You could continue limping for 12 months after if you know you’ve had the replacement and not simply because it’s sore. A lot of that can be driven by pain. So pain following the surgery is quite common, and it takes quite a while before it reduces fully.

How do you access the Joint lab?

It’s through referral. If you speak to your surgeon, they will refer you in, and the idea is we organise your pre-surgery appointments at the same time as you have your pre-assessment clinic. You then come over to us in Sports Medicine, and then in six months, you have a follow-up.

What role does a scan have in determining the state of a knee joint and muscle condition to perform an intervention?

Scan less for the muscle, a scan would be done routinely before a knee replacement. A lot of this is done by me to see if the muscle size is reduced compared to the non-sore leg and strength testing so you can determine if there is a big difference in strength and condition of muscle you don’t necessarily need the MRI to tell you that. In terms of scans of the joints, in particular joint replacements, the surgeons rely more on the X-ray side of things, but an MRI scan can tell you if there is a degenerative change in the joint as well. It is not something you’d necessarily do unless you had an issue specifically.

How long after having one Knee Replacement, will they have them staged? How long should they wait to get the second one done?

Again, there are lots of factors that kind of contribute to this. Logistics is one. Often, it depends on what time of year, how it fits around people’s lifestyles, work, holidays, and all that sort of stuff become factors in how the recovery goes. You might feel after having the first one done that you might want to kick it down the road a little bit longer just because the recovery takes a while. It’s a good bit of work, too, from a rehab perspective. But if you are staging them, you want to make sure you’re functioning on the other ones. A good few months would pass, and pain would be reduced and just so you can say, when you rehab on the other side, you’re going to put a lot of weight on to the first operated leg. So you want to make sure that it’s in good condition to be able to take on that workload for you.

Stairs are to be avoided when dealing with pain and swelling in the knee. Or does this help to strengthen the leg in general?

Well, not necessarily just because of functionality. You can’t avoid them, particularly in the house. It’s not that they make things worse. It’s, as I said before, like relating to wear and tear. You’re not going to be necessarily creating a bigger problem; although it’s uncomfortable, you might be able to find ways around that. There are techniques where if you come downstairs leaning forward a little bit more to offload the knee joints, well, I wouldn’t necessarily say avoid it. Obviously, it’s easier for me to say when you experience some pain going up and down. So there’s no physical reason to have to.

How long should you continue exercise after Knee Replacement?

You are probably speaking to the wrong person because you should probably continue exercising throughout your lifetime.  Yeah, exactly. There is a point where it’s like maintaining functions of our life, we should be performing some form of cardiovascular exercise regularly. Some sort of exercise to get out of breath three or four times a week. We should be performing some resistance training two times a week where the muscles are challenged. If we do that, we maintain a function, look after our joints, look after the size of the muscles, and slow down many changes that happen throughout our lifetime.  In terms of rehab, to me, it’s getting symmetry, getting the size and strength back in the muscles in terms of looking after yourself over the long term that’s a lifetime commitment to me.

Should you rest after getting a joint injection into the knee, and if so, for how long?

Everyone has different protocols for this and different protocols depending on the type of injection normally, it is a couple of days, but the individual doctor will give you guidance.

When is the time when replacement is necessary?

Normally, you want to be in a really bad way before you have the Knee Replacement because it won’t necessarily bring you back to 100% now. You want to make sure it’s sort of you feel the improvement from it, and it’s very different for everyone. It depends on how much it impacts your quality of life, sleep, and mobility; these all play a role in it and, obviously, the condition of the joints themselves. That’s a conversation you tend to have with the Orthopaedic surgeon to see when they think the ideal timing is. It’s very individual, and everyone’s kind of perception of how it impacts them is different. Again, it is hard to be very specific.

If someone said they had a Knee Replacement in January two years ago, and they’re still getting pain.  On the good leg, on the upper thigh, they also have a bit of wear and tear in that good leg as well. They’re now 52. What should they be doing now?

I’d see a physio. Just to try to understand what’s going on. If it’s in the thigh close to the knee, then you think it’s a little bit more to do with the muscles of the tendons, which is good news because that response tends to respond very well to exercise and to do physiotherapy.  I’d explore that; it might just be that there’s still a little difference between legs, and they’re using that leg a little more. It might simply be an overload issue, but a couple of physiotherapy sessions should help them get on top of that.

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Rehabilitation of Common Ankle Injuries – David McCrea

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Foot and Ankle Surgical Treatment Update – Mr James Walsh

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Republic of Ireland Reimbursement Scheme 2022

Are you currently living in Northern Ireland and on a waiting list for Orthopaedic Surgery?

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

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

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

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

Good evening and welcome to our webinar on the ROI Reimbursement Scheme which some of you will know as the Cross-Border scheme. I’m Fiona Roche, I’m the business development manager here at the Sports Surgery Clinic. I have been looking after the ROI Reimbursement scheme with my team for the last 8 years, so we have a lot of knowledge and hopefully we can help you.

SSC is a leading private orthopaedic hospital in Ireland. We look after all joints, all sports medicine injuries, we do replacements of knees, hips, and shoulders, we also do all foot and ankle work, wrist and hand surgery, and spinal surgery. We are situated around ten minutes from Dublin airport and we do have parking here as well. We have 7 theaters and 4 wards. We also have 3 MRI scanners and a dedicated sports medicine department.

How to apply for the ROI Reimbursement Scheme?

To apply for the scheme you need to contact the Health and Social Care Board or it’s called the National Contact Point, you can see here we have all the contact details. You can download the application form on our website and all the details are there as well to apply. The first thing you need to apply is you have to must on an NHS waiting list in Northern Ireland for surgery, so you must have seen a surgeon and they have put you on the NHS waiting list. There are ways around doing this as you could be waiting around a year to see a surgeon, so you could see someone privately as long as they have a waiting list and I am happy to take any calls on that. Once you have your application form filled in, you must have proof that you are on a waiting list for surgery in Northern Ireland (you can get a letter from your GP or the hospital where you are on the waiting list), you need proof of who you are like a passport, you need proof of address like a utility bill and another thing you will need is proof of your bank statement as they want to know where you can fund the money.

On the application form, it will ask you if the hospital is private or public? SSC is in the private sector, They will also ask you the name of the surgeon doing the surgery? If you don’t have anyone in mind you can put down that you haven’t decided yet, it will also ask you how many nights you will be admitted? For hip and knee’s it’s 2-,3 nights, for other things it may be 2 nights, and in some cases, it can be a day case. They will ask you about the diagnosis and tests you might need? Just put down that will all be done at your appointment and it is part of your pre-assessment. The form will also ask if you will need any follow-up care, which will be mostly physiotherapy. They will ask for an estimated price? I will give you the contact details that you can call and we will give you the price. We have set prices for hip and knee surgery. For other procedures, we will need a letter stating the procedure you need so we can ask our surgeons to give us a procedure code to price it for you.

Once the application is submitted it can take 4-6 weeks to get approval. The full amount for surgery is paid a week before admission and refunds take around 3 weeks, it can take longer so just be aware of that.

Approval & Finance

Once you have submitted your application form and you have got approval you can then contact me on Roche, Glenda Thorne, or Janice Molloy to discuss the application process and what to do once you receive approval. Glenda Thorne is who you can contact for finance information and she can then pass your call on to me. I and Janice can help you and can direct you to Glenda for pricing.

What is included in the surgery price? The hospital stay in semi-private accommodation (it’s not a private room on its own), your first appointment, pre-assessment, and a cardio echo if required, surgeon and anesthetist fee, pre and post-op x-ray for joints, The surgery, two post-operative appointments, and your covid swab.

What is not included?

Any additional consultations with other specialists, so for example if you go to pre-assessment and they find you may have a cardiac issue or issues with your kidney or liver, etc. something that was unexpected and you now need clearance for surgery, you may have to go see a consultant here to give you clearance and you will have to pay that fee. You can do phone consultations which can cost between 60-100 euros and a face-to-face consultation would cost 250 euros. Another thing that would not be included would be any additional investigations not part of the normal pre-assessment appointment for example if you might need an MRI. A private room is not included it is semi-private if you do want a private room Glenda can give you a price for that. It is not guaranteed that we have a private room available.


When you are deciding that you want to come to SSC for surgery, some of you may have already decided on a surgeon and some of you won’t. If you have a preference for a surgeon we can pass on your details to that office. At the moment appointments and surgery can be complete in 4-6 weeks. This can vary between surgeons. We do try and book all appointments as the same day as pre-assessment to avoid numerous journeys. Appointments can be made on receipt of approval.


The length of stay depends on the surgery you require. It is usually 2-3 nights for joint replacements. There are local hotels that SSC has corporate rates with if you have relatives who need to stay, we use the Carlton Hotel Dublin Airport. If convalescence or any is care required at home on discharge you are still entitled to this and it can be organised. You are also entitled to physiotherapy on discharge but if there are delays in starting you may need to start with some privately.

Another thing on discharge from the hospital is that the Cross Border does not pay for your medication t take home and the GP’s aren’t always able to write you a prescription when you go back so it has been suggested that you get your medication here and then when you go back home you have your prescription and you have all your medication with you. We recommend you don’t leave Dublin without your medication just in case you go home and you can get it from your GP. We will give you a form to visit a local pharmacy. If you have any problems afterward at home please contact the surgeon’s rooms or discharge nurse or wards if you are concerned re your wound or have any other issues. We will bring you back down to see us, don’t worry about contacting us.

Covid Restrictions

You are not to have one person accompany you for appointments. There are still no visitors at this time for inpatients. You require a PCR test 72-48 hours before surgery. You can have your PCR test in Northern Ireland (you don’t have to travel l down) as long as you have a copy of the results on the day of admission. A charge of 150 euros will be deducted from the overall cost.

Frequently asked questions

Do I need insurance?

You don’t need insurance, there is no insurance that can cover you. There is no travel insurance or medical insurance that will cover you coming down here to have your surgery.

What happens if there are complications?

If you have a complication that is not related to the surgery for example your heart or bowl problem, we can admit you into the local hospital here which is normally Beaumont Hospital or the Mater Hospital, they will look after you. EC1 card make sure you have applied for that and you have that as well, that will cover you here if you have any complications, it is very rare that these things happen, it only happens once or twice a year but if it does happen it is good that you are prepared.

If re-admission is within 30 days is there a charge?

There is no charge.

Where to find us?

We are very close to Dublin Airport as you can see on the map.

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 replacementsknee replacementspartial 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 is having both joints done at the same time, as in both hips together or both knees together. This can sound daunting to patients, but obviously, the huge advantage of this is getting everything over with one operation both operations and one recovery progress. It offers huge advantages to people that may be in a bad or painful way to get back on track again. Its not going to be something for everyone but pretty much every week Ill do one or two patients with both knees or both hips.

Back to do partial knee, it is obviously 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 combine your pre-assessment and consultation on the same day to make it straightforward for you. It is as seamless as we can make it. I am happy to see everyone and give my opinion. I often laugh when people say when doctors differ, 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.

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:

The scheme was supposed to finish on the 30th of June and then they extended it by 5 million. Once that is gone they then re-access, we will have to then see what they will do about funding. If you have an application form ready to go I would suggest you put it in as quickly as possible because we are not sure how long that 5 million is going to last.

We did chat with the national contact point about this, what we do suggest, is we normally give 4-5 days’ worth of medication but you do have to purchase that from a chemist on the way home from SSC, we don’t have a dispensing pharmacy here, we have a number of local chemists. We do give you a form to hand in to the chemist so they will know you are a cross-border patient and what to give you. If you need to go back and get another prescription from your GP, a lot of the GP’s cant see you for about a week so now they are suggesting you get your medication down here for longer before you go home, defiantly get the 5 days before you go. Some ones the medication down here inst available up the North and the GP may have to change that, that is okay and we are aware of that it doesn’t not be exactly the same sometimes. You can call me or Janice to discuss if needed.

You will be on crutches for 6 weeks following surgery and then you see the surgeon again, they may put you on one crutch and then gradually you come off that. You can discuss your return to work with your surgeon. Be prepared to be on crutches for 6 weeks after surgery.

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 00 353 1 5262117

For more information please email or call  00 353 1 5262117

Republic of Ireland Reimbursement Scheme September 2021

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

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

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

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

How to apply for the Republic of Ireland Reimbursement Scheme

by Fiona Roche, Business Development Manager at SSC.

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

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

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

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

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

The  Republic of Ireland Reimbursement Scheme Application Process

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

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

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

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

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

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

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

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


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

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

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

What’s included in the price you pay SSC?

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

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

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

What is not included?

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

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

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

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

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


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

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


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

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

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

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

Hospital Stay 

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

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

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

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

Frequently Asked Questions

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

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

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

Thank you for listening tonight.

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

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

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

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

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

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

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

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

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

Q&A Session – Republic of Ireland Reimbursement Scheme

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

How long do you stay in hospital after hip surgery?

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

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

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

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

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

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

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

How soon can you pay before surgery?

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

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

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

How can you pay?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is 100% of the cost covered by NHS?

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

Are Cheilectomy performed at Clinic, please?

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

Do you have to self-isolate before surgery?

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

Do all the surgeons vary in a package price?

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

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

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

Can you get two knee replacements at the same time?

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

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

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

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

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

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

Do you do laminectomy for Spinal canal stenosis?


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

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

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

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

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

What is the cost of a private room, please?

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

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

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

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

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

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

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

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

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

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