How do I get fit for skiing in two weeks?

Watch this video of Dr Neil Welch, Head of Lab Services and Research at UPMC Sports Surgery clinic, presenting on ‘How do I get fit for skiing in 2 weeks’.

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on preventing and managing skiing injuries.

 

Dr. Neil Welch is Head of Lab Services and Research at UPMC Sports Surgery Clinic

I’m going to show you a clip here of what the very highest level of skiing looks like and what I want you to do is get a bit of a sense of forces that are involved during skiing and the movements that we have to undertake and often times people perceive skiing as a leisurely activity but the harder you ski the higher the intensity of the exercise becomes so you can see the amount of strength that is required by putting weight onto the ski in order to create turns. We can see here in slow motion the body positions that are required and the flexibility that is needed in order to make a turn. None of us will be skiing this fast on our holiday but I think the aim of it is to give you a bit of a sense that it is a relatively tough and physical activity that we are undertaking.

How do I get fit for skiing in 2 weeks? The answer is you don’t and what I am going to do is give you a few tips on how you can get a bit fitter and a bit more prepared if you have left it to last minute but hopefully also help you to build some behaviours that you can add to your weekly lifestyle and prepare you for any future endeavours.

The aims I want to highlight ae the physical demands of skiing and snowboarding and when I’m talking about skiing I am actually talking about both sports. I am going to give you some specific guidance to get you fitter prior to your holiday and then I am also going to help you plan to get a bit fitter before you go away and also stay fitter throughout your day to day life.

Why can I talk about this stuff? It seems like an awful long time ago and it has been 15 years since I was working as a strength and conditioning coach with England’s development ski team and my role there was to help prepare the skiers for the physical demand for their sport so I have a couple of photos here from some training camps. The English ski team isn’t the best funded which might not surprise you. The facilities they had available were homemade so what you see on the left is a gym that we built in the garage of the accommodation that we were staying in and it also served as a kit room and a ski prep area. On the right-hand side this is an early year ski camp which is a little bit different in terms of the snow demand and they actually like that hard pack and icier conditions. This is a ski resort in Italy where we get used to the dry land conditions along side some of the conditions for the technical training. I’ve got a good understanding of the physical demands of the sport from that work.

With that said there were some very specific challenges that we have to negotiate when we are going on a ski holiday. The first is that we only do it for mainly 1-2 weeks of the year and what that means is that it is very difficult to get used to the conditions of skiing when you are only doing it 5-6 days per year and that offers its own demands. I like to see the back of patients who come through the clinic and often there is very little physical preparation some of us very much see skiing as a holiday we don’t necessarily change our behaviours so we are moving into an activity that you do a lot less physical activity prior. The make up of the holiday itself, you know you buy a lift ticket for 5-6 days and we don’t like to see that money go to waste so we ski back to back days. Essentially you are doing the equivalent of putting your running shoes on and trying to run a 10km for 5-6 days on the bounce and we all know we find that incredibly challenging. We then often times do get reduced sleep and that is self-induced by enjoyment on the holiday or children not settling into a different routine. Also, inadequate recovery so a bucket of melted cheese, a few pints or glasses of red wine isn’t always the best recovery from a day of physical activity and these are some of the challenges that we have when we go away.

What do you need to be able to ski? This is relatively straight forward and I am not going to go into too much depth here but we saw on the video there we need to be able to create pressure on the boots in order to be able to initiate the turn and that requires some force and some strength. Then in order to be able to hold an edge during a turn and we have to undergo what we call eccentric contraptions to be able to tolerate those forces so the strength demand particularly on the bottom ski on each turn. Then we have some demands of the holiday itself so being able to tolerate multiple runs and often times some of us want to ski as many vertical metres as we can, we have tracking apps for that. We want to do multiple runs each day and we want to do that on consecutive days and the stronger you are the more capable you will be.

On the other side of the coin we have fitness. There is an aerobic demand to skiing and we know that because when we get to the bottom of a run we can feel out of breath and again the faster we ski, the more intense we ski then the more out of breath we do get. Aerobic capacity also helps us to recover between runs. Skiing isn’t purely aerobic, there is an anaerobic element to it which is why people talk about building up metabolites and they talk about building up lactates and muscle. The aerobic system helps us to recover between runs so being fit is important to be able to tolerate that. Then depending on the resort, we select some may be at higher altitudes some may have less snow and if you are operating at higher levels of altitude then fitness will certainly help us.

When I talk about fitness or aerobic fitness, this is the ability of the body to be able to transport and use oxygen during physical activity. Again, in order to be able to access some of the energy that we have stored basically that requires oxygen and that reaction is relatively slow which is why we use aerobic pathways during lower intensity activities when there is not a high-speed demand on us. Aerobic conditioning usually relates to activity that you can do for a relatively long period of time so essentially over a minute to anything over a couple of hours so that’s what we are talking about when we talk about aerobic fitness.

In terms of actual measurement of fitness and V02 max, this is the maximum amount of oxygen you can use during intense physical activity we measure it here in the clinic and it is available here across a few of our UPMC sites. We measure it using a gas analyser on a treadmill or bike and it gives an accurate measure of how fit you are. The reason I put a picture of a biathlete here and this is someone who cross country skis and shoots at a target. These athletes are really fit, they grow up in high altitudes and train with very intense endurance activities so they have very high V02 maxes but having some sort of measure of your aerobic fitness is a good way to understand what sort of level you are at at the moment prior to your holiday or even just for general health.

There is a good reason why you should be trying to understand your own aerobic fitness and these changes happen throughout our lives so as we age we tend to use fitness levels and this is often dependant on the type of activity levels we partake in. If we play a lot of field sports during our teens, 20’s and early 30’s and we stop then we should take up another activity in order to keep up our aerobic fitness levels. We would be more conditioning focused say we are a runner, cyclist or triathlete often times we will maintain high levels of V02 maxes until late 30’s early 40’s but we lose fitness basically based on the amount of training we do so if our activity levels change and we have different lifestyle changes like we take on a new study or there are busy period at work or children get in the way then we lose fitness, if we have a period of illness for example you are in hospital for a couple of weeks or COVID-19 would have had a big impact on this. Your body gets used to what you give it and you need to be able to train in order to be able to possess those fitness qualities. There are some elements of our fitness that are genetically determined like our size which contributes to our lung size and heart size but we can all improve it and I imagine there are some of you who engaged in the talk tonight that have reached our peak so we can definitely all improve.

Why should we worry about our fitness levels? Maintaining high levels of aerobic fitness is important we know it reduces the risk of cardiac arrest and stroke. It is incredibly important for weight management and exercise is often perceived as important for weight loss but I is actually the other way around it has little bearing on the amount of weight you lose that is all diet based but it is really important for not putting weight on when we stop aerobic conditioning we tend to pile on the pounds. We know there are mental health benefits to aerobic training as well. We feel better, we have increased energy levels and the r4eason we are here for the talk today we have more enjoyment in our skiing.

How do I get fit? First of all, you have to pick an activity and we don’t get fit by sitting down watching the TV. There are plenty to pick from here is a small list for example running, cycling or rowing. Then we have to pick an intensity so we want to figure out how hard we want to exercise and often times I think this is driven by what we are comfortable doing. Some people like to go for the high intensity interval training and that is known as HIIT and this is because they prefer to get out of breath and hot and sweaty quickly. Some people don’t enjoy that and they prefer steady state low intensity exercise by going for a longer time period but it is personal preference and both of these will improve your aerobic fitness. In terms of frequency, 1-2 times a week and up to 3 hours is enough in order to be able to reduce the risk of cardiac episode and stroke. Obviously, you can exercise more than that but if you are looking for a baseline and trying to become a little bit fitter then the actual requirement isn’t that high.

In terms of exercise intensity, generally, this is measured using heart rate now a lot of devices can give you a heart rate measure and it should give you a decent ballpark. If you do have access to a chest1 heartrate monitor with your watch then that is a much more accurate version and essentially, we are looking at different training zones based on your max heart rate. In terms of building aerobic conditioning/fitness then zone 1 and zone 2 is really all you need so relatively low intensities so 50-60% and 60-70% of your maximum then we are going to get a little bit fitter. You don’t always have to exercise until you are very out of breath and fatigue in order to improve your fitness.

This now leads to the different types of sessions that we can do and you are looking at a cascade in terms of intensity so 30 minutes of a low intensity exercise like going out for a fast jog or bike ride is zone 1 and that will get you fitter by doing that for multiple sessions over a long period of time helps you to stay fit. If we are a little bit tighter on time or we prefer to be working at a slightly higher intensity then the middle row there 4 lots of 4-minute work with 2 minutes rest between repetitions and a short warm up will have you done in about the same time about 30 minutes but working at a slightly higher intensity, zone 3. The final one, this is the one with big blow outs so we are doing 10 reps of 45 second work at zone 4/5 with 90 seconds rest between reps and again with a short warm up. All of those sessions will take a short period of time but doing this a couple times a week will help to build your aerobic fitness and this is all do able a couple times a week in the run in to your ski holiday.

We have got some idea on the sessions but what is the secret to getting and staying fit? It is simple, the answer is consistency and I am sure a lot of the things I have spoke about today in the session is not new to you. Building consistency is essentially forming habit and there are certain things you can do in order to be to do that. Firstly, you should create a schedule and find a window where you can do your exercise so work around your job, study and picking the kids up. Then you want to set up a group rewards structure and by doing a habit it is about creating positivity around the activity you are doing and if you are rewarded for doing it then that helps to build habit. If you are looking to do two sessions a week and complete them then you might reward yourself at the end of the month with maybe a takeaway or a trip to the cinema. Accountability is often very effective so this can be a training programme or a training routine with somebody whether it is a partner, sibling or a friend but accountability is important because it helps keep people on a high. Setting targets is a good way to build consistency and drive motivation so it might be that you are trying to get a certain 5km time and achieve that and that can be very rewarding. Some people’s sociability is very important so that is why sports like CrossFit have become really popular because it is not just about the exercise but it is about friendship too. Some of us are not some of us are happy to go off on a bike by ourselves with some headphones to get in the right headspace. Measurement apps are really good for seeing progress but at the same time they do mix in to targets. The final one that I will talk about then is assessment so if for example you come in and have your V02 max measured then you can go away and train for it and you have some accountability and targets and you can see in black and white that you have made some progress and again that helps to drive some consistency.

Final tips for enjoying your holiday and reducing injury risk. You should do some aerobic fitness work in the lead up to your holiday. You should also try to use mixed methods for example, fitness and strength work. Taking regular breaks especially if the skiing is high intensity. I think sticking with the recommended DIN settings on binding will reduce the risk of injury. Eating breakfast, and hydrating throughout the day will help with your energy levels which is really important while skiing. Be wary of fatigue and change of snow conditions throughout the day. Finally, ski at your own pace and level.

Après knee prevention and management of knee injuries on the ski slope

Watch this video of Prof Brian Devitt, Consultant Orthopaedic Surgeon specialising in hip and knee surgery at UPMC Sports Surgery Clinic, presenting on ‘Après knee prevention and management of knee injuries on the ski slope’.

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on preventing and managing skiing injuries.

Prof Brian Devitt is a Consultant Orthopaedic Surgeon specialising in hip and knee surgery

I am going to start off my talk by showing you a video and this is a classic example of what happens on a ski slope so you have friends laughing at you for falling but often times there is an injury. I just want you to hear what happens now as the skier comes down the slope. Do you hear that snap? If you look at the person that snap is not the skis coming off that snap is the ACL rupturing and you see that the individual is coming down the slope probably at too high a speed and leaning back onto his skis and that is what is causing the injury and this is a classic example of how an ACL ruptures on a ski.

I was lucky enough as part of my fellowship training that I worked in a ski resort in Colorado and one of the fore fathers of treatment of ski injuries is this man Dr. Dick Steadman and unfortunately he passed away last year and he described the ski as the ideal device to rupture an ACL so really you have to be cautious when you are using skis because there are a high rate of ski injuries related to skiing.

In terms of skiing it is good for our business because people go away and injure themselves. It is a hugely popular sport and nowadays you see many people heading away to the slopes as holidays are becoming a little more accessible and it is a very enjoyable pursuit for the whole family but it is a risky sport and you see here the idea of the type of knee injuries that we get and 35% of the injuries occur in the knee and that relates to what Dick Steadman said about skiing because it is a high torque object that can twist at your knee because your boots are held in place there are also other injuries related to skiing.

The equipment has changed remarkably over the last 100 years or so that people have been skiing and what you see here the old fashion skis have much less binding and the boots are not as high on the ankle as they are nowadays.

The modern boot goes 2/3’s the way up your shin and your ankles are essentially fixed that it just allows a bit of flexion and extension at the ankle with very little rotation and the rotation does not occur at the ski but the rotation tends to occur at the knee and that is what happens in terms of getting ACL injuries.

You often hear about people getting skis and then getting bindings and the bindings are tightened up so when you go to an instructor or a person who is giving you your skis they will often talk about the din and the din relates to how tight the boot is fixed to the ski so when you are a very aggressive skier you want the boots to be really tightly fixed to your ski but when you are a more novice skier you want your boots to be able to come away from your ski so if you have any suspicion then you should probably get your din low so your ski comes away from your boot so you don’t turn your boot and your knee to cause an ACL injury.

The terrain and conditions are also very important and you notice here there is very deep and foul snow but equally if you have icy snow or very slushy snow they can grab your ski and increase the risk of injury.

Unpredictable behaviour from people that are on holiday for example they could be drinking too much or they could cause a collision and increase the risk of injury. If we look at the example here this is from Deerpark in Utah where they gave an example of how people cause injuries and they tend to be novice skiers or they are leaning backwards as they are going down the mountain as they were instructed and that creates the skier to be off balance, have their hips below their knees, uphill ski un-weighted, you tend to fall on the inside edge of the ski and this causes the injuries because it has your knee in a vulnerable position as the ski twists. As I said there is unpredictable behaviour and the après ski but it is also when you are coming downhill with a few pints on board and you don’t have that neuromuscular control that you might have had in the morning or perhaps in the morning you are a bit hungover and that too may increase the risk of injury.

On the mountain what can you do? First of all primum non nocere is the saying in medicine to cause no harm so you want to be skiing within your area of expertise so you don’t want to go out of your lane that you might get stuck in or if you go down a slope that you are not able to then you are much more likely to get injured or worse even get lost, die or fall off a cliff. Avoid hazardous conditions like snowing if you are not a very good skier or you have very low light then it’s very hard to see the undulations in the ground and that can make you far more likely to fall over so even on the flat slope it is more likely for you to have a white out and also be well able to stop before your start and this is another example of another collision type injury of someone out of control.

In the clinic what do we do? One of the articles I often quote in my talks is a very eminent professor and he talks about kneemanship and doing an appropriate examination is very important and one of the key factors of doing that is taking a look at history so if someone injures their knee going down a slope, has a fall, tends to hear a snap like the one in the video and it is difficult to put the ski back on and ski down the slope may lead to a more serious injury then someone is taken away by ski patrol but what typically happens is they go to the clinic at the end of the mountain, they get an x-ray and they get a very overpriced knee brace and then they are sent on their way. In terms of taking history you can really tell what’s going on that’s very indicative. When your doing a clinical examination, we look for a number of features to compare to the normal knee because it gives you a good idea of what’s going on but we are looking for the presence of swelling following an injury particularly bleeding because the presence of blood generally means you have torn something. Commonly it is your ACL and that is why it is very important to look at the other knee and you will see yourself when you take off your ski pants that you should probably get assessed. In terms of the clinical examination we go through it in a very systematic manner as we can assess all the ligaments around the knee like the side of the knee so you can often damage the Medial ligament, the ACL is very commonly injured so you will see a very swollen knee as you see in this picture and often in the ski medical facilities they are often very limited, they are quite primitive so what I would typically do is simply do an x-ray to out rule a fracture and that is very important but the clinical examination determines whether you have a severe injury which may be more than one ligament injured or whether it is a more routine injury with just a solitary ligament and that has big implications, a lot of times they will try to sell you a brace and often times the brace is not needed but then they will say lets get an MRI scan and lets have surgery early and this often happens in the US and I would advise against this. I think in the cold light of day you can get further investigations when you come home and get appropriate treatment that is not under pressure by people trying to make money so it is very important to consider that. The x-ray as exampled here can show you what a little flake of bone coming off the side of the tibia and that is an example of what we call a segond fracture and that is indicative of an ACL injury. The MRI’s can be done and often in the mountains they can be poor quality but, in this situation, you can see some bruising at the mid portion of the femur and the back portion of the tibia then you have an injury that causes an ACL rupture. You can do an ultrasound scan and these are cheap scans to get and they often are effective at looking for ligament injury on the side of the knee. Then referrals the referral is very important so getting back to your home countries by packing and getting back to your home country safely and that is very important.

As I said in the cold light of day this when we should see people by assessing them appropriately, we take away the drama we take them back where they are comfortable and they have less anxiety and we can explain things and have the appropriate investigation. Early diagnosis is important we need to know what we are dealing with but also with knee injuries we don’t have to rush into surgery and sometimes there is a decreased range of motion or your muscles are not working properly then pain management is much more appropriate to discuss the treatment, not all knee injuries require surgery and I often tell people to try and avoid surgery if they can but certain situations will warrant surgery and we will go through all the options with you in the cold light of day. We remove the splints as quick as possible and often these splints are unnecessary particularly when knees are meant to bend. We don’t like keeping them straight unless it is a really serious fracture that has to be stabilised but most ligament injuries if the knee is not very unstable then you can move them but that’s not important and being ready for surgery is dependant on motion and that is really the first thing we do. We also get people to weight bare as tolerated as cartilage doesn’t take a joke and cartilage doesn’t like to not be loaded and it is really important that we get you back weight bearing as soon as possible because if you are to have any knee surgery we like to get you weight bearing very quickly afterwards and it is important that you ae bale to do this before surgery and these are some of the things that people do they get assessed and get back to their normal activities.

I am going to go through some of the common scenarios that I see in my clinic and much more frequently at this time of year when they come home from holidays. You see in this picture the type of referral I get and the history is a contact injury turning, he didn’t feel a pop, he fell to the ground, he was unable to weight bear and there was no immediate swelling but there was within 12 hours so we know that something serious has happened. With the clinical examination then he was able to keep his knee in a flexed position, he was unable to activate the muscles at the front of the knee, he is walking a mild length and some swelling within the knee is what we diagnosed he was unable to straighten his knee by 10 degrees but had good flexion then had a one degree laxity or instability of his medial ligament and he had a negative Lachman test so that means that his ACL felt in tact so if we look at the x-rays here we see that this is a juvenile because he still has growth and there was no evidence of any fractures on these x-rays so that’s very reasonable and then the MRI was performed and this is what we see in MRI we look for the presence of whiteness in MRI so that indicates fluid in these sequences as you see on the inside of the knee the fluid is in this region of the medial ligament on the inside of the knee and we see that the ACL is this ribbon like structure in the middle it does have a little bit of fluid in the knee so we know that there has been some damage with the ACL but in this situation it looks in tact which would be keeping with the clinical examination findings.

This individual was just treated non-operatively and allowed get on their way so they escaped a major injury which is good so that is a very common scenario we would see and a lot of times we just give people reassurance but we assess them thoroughly with a proper investigation and this is the second scenario and it was an experienced skier. They had a history of a high-speed fall turning on a steep slope, they heard a loud pop, they tried to stand but the knee buckled, they had to be removed from the mountain by ski patrol and they had immediate swelling. On clinical examination once again when you have ruptured your MCL you are typically unable to straighten your knee and people will see that they couldn’t weight bear, couldn’t stand, big effusion and echymosis which is bruising, they had a grade 3 laxity and they were Lachman positive which meant we suspect that this was a multi ligamentous injury. If you look at the x-ray’s here we didn’t say what side but I presume it is the right knee because the x-ray shows a little bit of bone here and that will indicate that this person has sustained an ACL injury and possibly a higher grade injury and they will go on then to have further investigations so this is the MRI we see and we see lots of fluid within the knee so this whiteness is blood we also can see some bruising so the colour of this knee we see a lot of light grey which indicates fluid within the bone or what we call bone bruising and you can see the meniscus which is this black structure is hanging o0ff the back of the knee so we know that this knee is far further forward so there is something that has been ruptured in this case and as we look into the middle of the knee we see the ribbon like structure that we saw previously has been ruptured so this is the ACL which is torn and this person has got the appropriate imaging and we can now identify that there is a definite tear of the ACL. Then we look at the image of the knee from the front and we see that here we like to see a nice black ligament and that is just this grey colour so we know that the MCL has torn off as well and that would explain the feeling of looseness on the inside ligament. That is a more serious condition and that is a condition that would require ACL reconstruction and MCL repair or reconstruction.

Finally, we have a recreational skier and his history has a twisted knee removing his boot from the bindings, he felt a crunch in the knee and skied on and said “it was fine after a while”, he then said it was very painful that night and he also said he “lasted the week through gritted teeth”. From the clinical examination the alignment was normal, there was small evidence of any fluid or effusion, full range of motion but pain at the end range when they are fully extending the knee or flexing their knee was painful. Pain on the inside of the knee and then a normal ligamentous examination so we are not suspicious of any ligament injury here but we might be suspicious of soft tissue damage within the knee and this is the side view we see of this persons knee and what we are looking at is the meniscus so the crunching sensation with twisting is a very common meniscal injury so what we see here is the meniscus and it should be like a black triangle but you see this white line going through the black triangle and what they have done is they have torn the meniscus. Often times people describe this as being fine at rest when they walk down stairs or twist in and out of a car however they do find some pain. I often tell people it is similar to having a stone in your shoe and if the toe is sitting under your toes it doesn’t cause any problem but when it moves under the ball of the foot that is when it really hurts you like the meniscus when that flap moves it can often give a lot of pain so we try to treat this non operatively to begin with but if the pain or symptoms are persisting beyond 3 months or there are obvious signs of displacement on the MRI scan then we would often have to do an arthroscopy and just remove that torn portion of the meniscus. This is another example of that where you see that the meniscus is just pushed out to the side there and there is some displacement.

Hamstring Injuries in Sport

Watch this video of Dr. Ronan Kearney, Consultant Sports and Exercise Medicine Physician at UPMC Sports Surgery Clinic, presenting on Hamstring Injuries in Sport

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

Dr. Ronan Kearney is a Consultant Sports and Exercise Medicine Physician at UPMC Sports Surgery Clinic.

My name is Dr. Ronan Kearney I’m a Consultant Sports & Exercise Medicine Physician. I mainly work at UPMC Sports Surgery Clinic in Santry. However, I also work across a number of different sports predominantly at the high-performance centre in Sport Ireland looking after mostly athletes preparing for the Paris Olympics. I have also done some work in the past with European Tour Golf, International teams in the FAI and also club level rugby. I am from Louth and I have been involved with Louth GAA’s Men’s Football Senior Team. I am also Chairman of The Gaelic Athletic Medical Association. Addressing Hamstring injuries has formed a large part of my job both in the clinic and the sports I am involved in.

Just a quick overview of today’s talk, it Is important to understand the context and background of these injuries and to know the anatomy in order to assess, manage and prevent hamstring injuries.

This was Usain Bolt the fastest man in history entering his las race as part of the 4×400 metre relay. At the World Championships in 2017. It was a very unfortunate end to such an incredible career of sprinting. Sprinting is the typical mechanism of injury of hamstrings. I will now discuss how we assess manage such injuries in this presentation.

With the focus on team sport, hamstring injuries make up for 25% of all team sporting injuries. They make up 33% of all time lost to injuries also. A study carried out within the GAA saw that 26 days was the average loss per injury. If we consider a full intercounty GAA team how might this look for the season? On an average for each team 9 players suffer a hamstring injury per season. This will take a tole on not only the player health but also the team’s performance. As well as that re-injury rates are also reported to be often quite high. Some hamstring injuries involving the tendon can have an injury rate of over 60%. This would either indicate an assessment of the management strategies are incomplete or an athlete has potentially returned to play too early but in reality, it is probably a mixture of both.

How might the toll of injuries affect the team’s performance overall? This was an interesting study of the estimated league performance and financial cost of injuries for premier league teams. It showed that the more total days out injured corresponded to a drop-in league position and the authors calculated that 271 days out injured would cause a drop in final league position by 1 place. In premier league terms this corresponds to about 37 million pounds. Being a Liverpool fan, I will highlight Manchester United in 2016/17. Man Utd had a high injury toll compared to the other top 6 clubs and it had an associated correlation with their total league points lost. They had the most valuable team in the league but not even their manager Jose ‘The Special One’ Mourinho could counteract the impact of the injury toll. Obviously, there are many other factors affecting a league position but it gives us context on the impact of hamstring injuries within elite sport.

This is a busy slide and it in no means covers all the risk factors for hamstring injuries there are some factors that we just can’t control such as age and previous injury. However, it is essential to understand that those who have had a previous hamstring injury or even a lower limb injury are 3 times as likely to suffer a hamstring injury. It is obvious that it would be sensible to try and reduce the risk where possible on factors that are modifiable such as strength, biomechanics and training load. Wen know that reduced hamstring strength is a risk factor for hamstring injury as is a number of key biomechanical measures such as ankle and hip range of movement. We also know that a sudden spike in training load going from doing very little to a lot is increasing that risk. We also know that athletes that have gradually increased running at high speed exposure over time have a lower risk of hamstring injury. Other factors such as a new manager with the team, as well as poor communication between coaching departments within a team increases the risk of injury. Really think outside the box when trying to reduce the risk of injury

How do injuries happen? Sprinting is the most common cause of injury as we have just seen Usain Bolt’s video. However, there are a number of other reasons, this was an interesting study done at Leinster Rugby. Where we can see that both decelerating in the orange and rucking in the lighter blue colour both sit at 19%. I suppose this comes back to management and from a rehabilitation perspective its important to review the mechanism that caused the injury. This might involve a discussion amongst coaches regarding the rucking technique to see if there is any ways of reducing the risk a mechanism for causing another injury.

Understanding the anatomy of the hamstring is the key to be able to understand and assess the injury itself. The hamstring is made up of muscle and tendon but lets just focus on the muscle first that we have circles here. Muscle is made up of long muscle fibres both fast and slow twitch and when they become active they allow the limiting move, with strength training these fibres enlarge. If the muscle is injured a number of healing steps happen which we see on the right-hand side of the screen. The top of the screen we see the inflammatory cells fill the muscle defect and a blood clot or a haematoma form. The next very important step is the regrowth cells and they are called satellite cells and they stimulate the injured muscle tissue to repair with a scar. The final step is the muscle scars return to normal. If rehabilitation is not correct there is an incomplete healing and a chronic scar can form. This chronic scar generally is not as robust as normal muscle and can lead to an increase risk of injury.

Now we will focus on tendon, tendon is very different to muscle and tendon is made up of stiff collagen fibres which have a high tensile strength that have elastic property. They respond and adapt to mechanical loading the junction between the muscle and the tendon is often the weaker link in the connection of movement. Tendon healing takes a lot longer in muscle for numerous reasons including the lack of a regrowth cell that we spoke of, the satellite cell. It is slower to heal and requires a cell scaffold alongside a number of other gradual mechanical loading in order for it to adapt and regain its tensile strength. For this reason, a number of weeks rest which is not an uncommon management strategy often is the worst thing for hamstring tendon injuries. When we look on the right-hand side of the screen here it is the stages of healing. The first stage of hamstring tendon healing is similar to that of muscle where a blood clot or haematoma develops and inflammatory cells fill the defect. Platelets increase and release growth factors to kickstart healing. By week 5 a tendon scar has generally formed and it may take up to 8 weeks before it is stronger and robust. With appropriate loading, rehabilitation and exercise it gradually returns back to normal healed tendon tissue. We often see patients at Sports Surgery Clinic that have reinjured their tendon in this phase before it has fully bridged the defect of a knee injury. When a tendon that is reinjured becomes a trickier injury to manage.

We will just go through some of the hamstring anatomy itself. The video on the left, we see there is 3 main hamstring muscles, the semi tendinosis, the biceps femoris which has 2 different heads, this is the long head biceps femoris and it is the most commonly injured hamstring muscle. If we rotate around we can see there is the short head of the muscle that inserts further down. If we rotate back to the inside part of the leg we see that below the other two hamstring muscles lies the semimembranosus which is an uncommonly injured hamstring muscle. The picture on the right illustrates that the tendons of the hamstring muscles are not just insertion points onto bone, each of the hamstring muscles have long tendons that span most of the length of the thigh. This makes the diagnosis of the tendon or muscle injury difficult by just location of the pain.

Are we hamstrung by anatomy? We might be if we don’t fully appreciate a few key concepts. Mechanically, the hamstrings cross both the knee and hip joints this means that they have greater contraction velocity, greater capacity to change length and unfortunately, they have less capacity to withstand tension. We already know that tendons heal differently to muscle and this tendons healing phase also takes longer. If we don’t respect this we are most definitely hamstrung from the onset.

Can we tell if a hamstring injury is either a muscle injury, muscle tendon injury or a tendon injury? It is often difficult to tell just by taking a history and examining someone, some clues that may suggest a tendon injury can include a popping sensation, a severe loss of function or strength, bruising in the area or there may be some more subtle signs such as a higher up injury near the pelvis, or a lower down injury near the knee sometimes mean a tendon injury. More recently we know that rotational mechanisms seem to be at a higher risk of distal or closer to the knee tendon injuries or a recurrent injury that just does not feel right may be a tendon injury.

This was a study from the GAA, often the initial suspected grade of hamstring injury and the projected return to play time is very wrong. The initial projected time loss for over 4 weeks was only 2% of the actual time loss time was a quarter.

How do we get around this? MRI is vital at identifying the exact location of the hamstring injury. It shows us what structure is involved and it takes a lot of the guess work out of injury grade prediction. The MRI above shows the injury site in the tendon and as the tendon loses tension it becomes wavier further down. We also see tear into the muscle junction with a feather like appearance at the arrows. This would be classified as a very high-grade hamstring injury, a grade 4 C and depending on the clinical picture may want surgical repair.

We grade hamstring injuries with the help of MRI now, we no longer use the historic grading system of 1, 2 and 3. This has been replaced by the (BAMIC) criteria the British Athletic Muscle Injury Classification. This ranges from 0-4 and A-C. This is a busy slide so lets just simplify it a little bit.

Really to simplify the (BAMIC) classification, if it is a muscle only injury the it is a grade A. If it is an injury at the junction between a muscle and tendon then it is a grade B. If it is a tear to part of the tendon or all of the tendon it is a grade C.

Is this really relevant? Yes, it helps us to stratify the risk of re-injury, we know that grade C injuries where the tendon is involved will take a lot longer to heal and also has an increased rate of re-injury. Also, knowing the tissues involved in the injury with the help of the (BAMIC) plays an important part in rehabilitation. When a track and field athletics group follow the (BAMIC) graded rehabilitation protocol. The re-injury rate was dramatically reduced to 2.9% over a 4-year period which is very impressive when we look at the re-injury rates overall.

As well as that, not only has it helped to stratify the risk of re-injury and help guide rehabilitation principles. The (BAMIC) grade gives a good predictor of a return to play time. When working with athletes often the first question an athlete will as you is ‘When can I return to play?’ The grading system allows for an estimated return to play prediction. It is not a crystal ball, however, there are many other factors that will influence return to play time but it is as good a tool as we have currently to guide the prediction of the return to play. Often times, a re-scan with MRI at the 6-8 week mark can be helpful to assess structural healing and this often comes in helpful when dealing with a target of a short timeframe with return to play. It can give the athlete an objective marker of structure of injury at that time point and forms part of the evidence for which the risk/reward decision making comes in to play.

As a Sports & Exercise Management Consultant our assessment of hamstring injuries always start with a detailed history and clinical exam. We then find the mechanism and the clinical queues as well as prior history is upmost important. Knowledge in the context of the injury along side when the target of return to play from the athlete’s perspective is also important. We review MRI images to help grade the injury according to the (BAMIC) criteria and for some hamstring injuries we may carry out a point of care ultrasound assessment. That can be helpful at times for decision making around the higher risk injuries. Generally, we like to have objective, physical and functional parameters to help guide the stages of rehabilitation. A process which we call the hamstring rehab lab with the help of our SSC and physiotherapy colleagues we will assess strength, biometric and biomechanical measures to give the individual objective targets.

At the Sports Surgery Clinic we use multi-joint strengthening strategies to achieve the aims of rehab. Lumbopelvic control basically means we need to control the pelvis effectively during movement and it does represent an important aspect to successful rehab and prevent hamstring injuries, an individual with an excessively anteriorly tilted pelvis or pelvic drop is already at a biomechanical disadvantage with increased tension placed on the hamstring muscles. Assessment and optimising running mechanics with each individual athlete are also important. Often, the hamstring is the victim of inefficient mechanics at the trunk, pelvis, hip and ankle. Then to find the reasons behind the recurring injury will lead to a more successful outcome. High speed running has always been the most common mechanism for injury and therefore forms a key stage at the end of rehabilitation. Delivering optimal rehab strategies represents the most effective element of a faster return to play by addressing these biomechanical movement pattern disfunctions it is also possible to enhance athletic performance and reduce the risk of future injury. The use of plate rich plasma has gained a lot of attention in tendon injuries. It is common practice among elite sport in other countries to have regular PRP injections after hamstring injuries. Evidence of effect is mixed with some studies suggesting a shorter return to play time when PRP was used. It does not form part of our standard management process at SSC for such injuries but we have an available guidance on a case by case basis. We are also lucky to work alongside orthopaedic surgeons some of whom have expertise in hamstring tendon repair. Surgical repair is limited for the very high-grade tendon injuries and thankfully such injuries are uncommon but it is great to be able to have a team to deal with them when they do occur. We have spoken about many of these prevention strategies and the management of hamstring injuries. Prevention of occurrence forms vital part of management of the actual injury itself. Just to highlight a few from the list, the FIFA 11+ warmup protocol has reduced hamstring and ACL injuries by about 60% in competitive soccer. The Nordic hamstring exercise protocol has helped reduce hamstring injuries by 51%. We know that clear lines of communication between medical and coaching teams have shown to reduce injury, so if you are working with a team consider your systems of communication for injury risk. I suppose, of upmost importance, prevention of the next injury starts with an appropriate management of the initial injury.

Just to run through a quick case discussion of an athlete that I recently managed. This was an intercounty GAA player and he was injured during a game. The injury occurred while running and rotating with a hand pass, initially the player thought it was a low-grade injury but he just did not feel quite right and was worried as he had been through recurrent hamstring injuries the previous season. His physio asked me for an opinion, so as we previously discussed it can be very difficult to clinically tell just by examining someone without imagine if there is tendon or muscle involvement. In this players case he didn’t feel a pop. However, he was more tender closer to the knee over the T-junction, there was a small amount of bruising noted also. His strength was good when I saw him at 2 weeks but he felt his hamstring was vulnerable while trying to increase his speed especially when trying to run on the turn. This apprehension was reduced with an Aisling H test in the clinic room when I saw him.

This is his MRI and I will just run through the slides. We can see on the right-hand side of the picture a white high signal which shows an injury at the tendon of the T-junction. With these injuries they have a very high and large rate of recurrence up to 60%. It can often present very subtly and not very obviously. The player himself wasn’t too surprised but often times we can be shocked at the high grade of injury with subtle clinical signs.

We help guide the player alongside his physio through the phases of rehab, given it was a tendon injury and a high-risk injury we delayed high speed running and high eccentric load of rehab to a little later in the rehab phases. We repeated an MRI at 4 weeks which gave the player and us confidence of good tendon healing there still remained a little amount of inflammation around the muscle tendon junction so all was not clear yet but in as good a situation as we could have hoped for. On ultrasound there was no dynamic gapping which also increased our confidence. With the help of our hamstring rehab lab here at Sports Surgery Clinic we assisted the player and his physio with objective markers he had regained concentric and eccentric strength of his hamstring muscles both left and right and his running mechanics had improved also with some coaching. He returned to a phase which was pitch-based training following then a discussion with the players coaching team you were aware that there were certain movements that had a higher chance of re-injury. He managed to return to an adapted role during the match in week 7. He then subsequently returned to full play and performance at week 8 and thankfully didn’t have any further injuries in his hamstring for the rest of the season. Overall, we are very lucky at the Sports Surgery Clinic to have access to all facets and management of such injuries. If you have a hamstring injury that you feel needs attention from us please let us know.

There is not a one size fits all approach for hamstrings and it does depend on the individual but generally there are a few different ones that have been shown to reduce the risk of hamstring injuries.

Some physiotherapists in the room might be familiar with the Aslings L protocol and it really involves 3 exercises to increase the hamstring length, that would be one thing.

Prehab can mean preventing injury but also including injury treatment it is all the one so strength through the hamstring.

The Nordic hamstring protocol is another programme to improve hamstring strength overtime and that has been shown to significantly reduce hamstring injuries overtime.

These are the two programmes I would generally direct people towards.

With acceleration and deceleration with regards to mechanism of injury you really want to recreate that in your rehab to make sure that the player or the athlete has enough robustness to have an increased threshold and really above that mechanism to cause an injury again if the injury was acceleration or deceleration then that will be a really important part of their rehab.

In terms of prevention and strategies of working with teams obviously in SSC strength & conditioning is very important as we all know but absolutely working on high speed running and working on acceleration and deceleration we know that over time if you have increased your exposure or you have maintained your ability to sprint and to highspeed run you do reduce the risk of hamstring injuries

There has been a lot of research done in the last number of years on supplements especially around tendon health. It is really the cherry on top type of stuff as if you miss out on the strength, you miss out on the highspeed running or you miss out on the ability to jump, sprint and rebound biometric type strength then I would say there is no point in taking supplements but if you have ticked all the other boxes and are in a good position then collagen and vitamin C has been shown in some instances to improve your ability and improve tendon health by 5-10%.

There is some evidence especially for let’s say the competitive athlete, many will be taking them anyway but I suppose the conscious thing with athletes is to ensure we batch test the supplements as well to make sure it is from a reputable source.

In relation to this, you want to look from the ground up. What I mean by that is firstly looking at the range of movement in the ankle often times people may have had a couple ankle sprains and they may have lost some of that ankle movement so keeping an eye on how far they can bring their knee over their big toe or ankle.

People that reduce dorsy flexion movement have a higher risk of hamstring injury. Then coming up to the knee with reduced knee extension i.e. the hamstring is tighter and that shortened hamstring muscle has an increased risk of injury as well so working on that hamstring length overtime through stretching and through the protocols like the asling and Nordic.

Then coming up to the hip, if you have reduced hip movement flexion or an extension then you have difficulty bringing you swing leg or follow leg through and that can increase tension on the hamstring and increase the risk of injury so I suppose in essence really improving the range of movement in the joints and improving the strength of the hamstring is key in biomechanics.

If you prevent the recurrence of injury then that is the best way from preventing that chronic scar from forming. Managing the initial injury is the best way to prevent the chronic scar.

Unfortunately, many athletes and players that will come to us after their 2nd, 3rd or 4th hamstring injury in the space of 12 months and it is a really difficult to manage its not like a day 1 injury it is an injury that has just occurred it is a tendon that generally has had to heal 3 or 4 times and has broken down 2 or 3 times so really managing the first injury is the best way to stop the chronic scar from forming.

RED-S is an energy deficiency in sports syndrome and it happens a lot when athletes under fuel and they don’t put enough fuel or calories into their body to exercise and a number of body systems then unfortunately lose out.

For females they will eventually end up losing out on some menstrual cycles and have less periods which is an obvious sign, some people will get stress fractures but there is definitely an increase in soft tissue injuries including hamstring injuries for anyone that is under fuelled.

It is hard to say without having an assessment. You do need to be seen and you should definitely have a scan if you have had a significant injury like that.

There are a couple of different surgical indications for hamstring injuries and thankfully they are rare but without a clinical assessment and a scan it is hard to say.

The ACL & Common Knee Injuries

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

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

Professor Cathal Moran SSC

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For further information on Anterior Cruciate Ligament (ACL) Reconstruction, please contact info@sportssurgeryclinic.com

Knee Osteoarthritis: What You Need To Know

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

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

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

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

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

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

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

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

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

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

Acupuncture hasn’t shown to be very effective.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For further information on Total Knee Replacement (TKR) or Partial Knee Replacement, please contact info@sportssurgeryclinic.com

Surgery & Arthritis with Mr. Gavin McHugh

Mr. Gavin McHugh joins Arthritis Ireland’s Chief Executive Grainne O’Leary to speak about Surgery and Arthritis

Mr Gavin McHugh UPMC Sports Surgery Clinic

 

 

 

 

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

I suppose I would stop you there in using the word necessary as quite often when it comes to a joint replacement strictly speaking it is not necessary it is whether somebody would benefit from it and I think it is important to make that little bit of distinction as ultimately it is up to the person and it is whether or not they decide to go ahead.

It is not like a broken leg that absolutely needs to be fixed. In general, you can look at these things in terms of pain and disability. The overriding factor that drives someone to have a joint replacement is pain. The vast majority of people has pain. Disability can come into it but it is generally a secondary thing and I will talk about that again.

In terms of the pain, again, we can go into as much detail as you want. For me one of the deal breakers is night pain especially with the hip you will find that people get to the point where they are wakening from sleep 1-6 times every night or most nights. Ultimately, that is when you would benefit from having something done.

In terms of pain throughout the day or with activities if they are holding someone back from doing the activities that they want to do or indeed affecting their quality of life and it is not controlled then that is often a time to start thinking about having something done.

We are often taught to see if the conservative measures have been exhausted and that is just a way of saying yeah, we have dealt with all that and it is now time to talk surgery. That is something that is really important to all of us as well. Ultimately, not only can you potentially gain months and even years without having to have surgery, you can potentially set yourself up much better off in the event that you do require surgery. Things like weight loss that we will speak about again can be very important and pure strengthening activities so anything that works again particularly from the hip and knee point of view like your quads and glutes in particular can benefit.

Strictly around the hip I find a lot of stretching activities can actually precipitate more symptoms rather than improve things but within reason keeping active tends to do good and not bad.

From an analgesia point of view simple analgise such as paracetamol which everyone turns their noses up at initially but I mean it comes with a very low side effect profile and it is often worth while trying to just take the age off of things and as you move up you can then mind that with anti-inflammatories.

Opiate type of medications for the vast majority of people tend to avoid it. They tend to come with a lot of side effects and they don’t really work particularly well for musculoskeletal type pain. They work better for other types of pain like cancer pain and in that they have a hugely important role but for us for joint pain they are no great at relieving it and even if they do with time you tend to become tolerant to it so you don’t get the effects with time so for me just paracetamol and anti-inflammatories.

Again, that is when you have to weigh up how it is affecting you day to day and you have more to gain than you do to lose anyway and when somebody’s quality of life is disrupted to an extent where they have more to gain than they do to lose then that is when it is worth while considering. I see people who get a little bit of groin pain for example on the 16th or 17th hole of a golf course and they play once a month and that’s it.

I also see people who would wake 6 or 7 times every night and I’ve seen someone who has slept in an armchair for two years because they have not been able to lie down flat in bed and who could take 20 minutes to get to the bathroom.

They are the two different ends of the spectrum; the vast majority of people are somewhere in between and again you have to see if you are leaning more towards the severe side of the spectrum or are you leaning more towards the conservative side of the spectrum where your paracetamol helps. This is something that I always try to say and it is that you don’t have to be as bad as people make it out to get a joint replacement and we know from loads of systems by scoring patients and if you divide them up in terms of severity the group that would benefit the most from a hip or knee replacement are the ones with moderate symptoms and it is very subjective as to what is classed as mild or moderate symptoms but the moderate group are the people who are still just about able to do their job and normal day to day activity and in many ways they are ready to hit the ground running after they get the joint done and they will rehab quite quickly.

Whereas the really severe group the people I spoke about that have slept on an arm chair for 2 years well they have a huge amount of work to do following the surgery in terms of getting back to their morbid level. There is a happy medium, it is often not as bad as you think and with hips especially I find that people come in and they almost feel like a fraud and they think they are not bad enough. This is what a hip does to people, a hip slowly drags someone down along with everyone around them who is aware like their husbands, wives and children. Everyone around them will be saying “would you ever go and get that fixed, your always complaining” and the response usually is I’m not that bad as it is in our human nature to adapt and cope with things and we manage to get on with it and generally it is not that they are in denial, they don’t actually realise they are as bad and I often put it as a background noise that until you turn off that noise then you realise. It is only after people get their joints replaced that they then realise how bad they were prior to the surgery.

Joint replacement is still ultimately a joint replacement and it has moved on I think an awful lot in terms of how we go about it and the safety profile of it compared to 40 or 50 years ago and as I say it comes with significant risks although they are rare thankfully. The odds are very much in your favour so if you look at satisfaction rates after a hip replacement then you are talking 96/97% which is pretty hard to replicate in many other surgery’s that are performed.

It comes with the standard risks like infection, infection is our nemesis and again if a surgeon has said that they have never had an infection in their practice then it is nonsense and everyone gets them it is just a fact of life and trust me we take the upmost precautions trying to avoid that but when you’re talking about a joint infection your talking 1 in every 300 which is not that common but it is still a risk you take when you are considering rolling that dice.

Things like clots like a pulmonary embolism is a risk factor that you are talking maybe 1 in 500 to 1 in 1000 and that is the sort of rate now a days and how do we get around that we give you foot pumps we give you stockings to increase circulation but most importantly we get people up quickly and we get lots and lots of joints now immobilised in the same day.

The quicker we get people up the lower that risk becomes and some people are usually given some form of blood thinner then after to help prevent it. Nothing can really reduce risk because some people are more prone than others but thankfully now a days it is uncommon.

Then more specific things with regard to the joints with the knee stiffness would be one of our main issues and a knee replacement can end up stiffening the knee because the knee is hard work and as I say its not like you just get a hip for free but with a knee you most certainly earn it in terms of the recovery and it is not a 6 week job but it is a 6 month job in terms of that recovery and I think it is important that people know it is going to be sore.

Then with regard to the hip, the hip popping out of the socket or dislocating again in comparison to say 20/30 years ago when dislocation rates were at 5% it is much less common now it is a 1 in 200 or 300 type of chance we use a bigger head in terms of the prosthesis so essentially it has to jump the radius in order to get out.

Years ago, there was a 22-millimetre head that we used whereas nowadays most surgeons will use a 32- or 36-millimetre head and that comes with a lot more stability.

We always quote things in terms of damage to the bone or the nerves around the area but again it tends to be very rare now and it is unlikely that something like that actually happens during surgery.

Absolutely, the better shape you are in before surgery the better chance you have of doing better afterwards. Again, particularly with regards to the knee and if you look at the quad muscles on the front of your thigh which allow you to straighten your leg they are essentially an engine for the knee and they are often extremely weak and are often the cause of the arthritis process as people get a lot of inhibition, it is like your brain turns off the muscles in order to protect the joint which I think actually makes the joint worse.

Unfortunately, when it comes to recovery and getting the knee to behave like it should then you need strong quads. There often has to be work put in before hand in order to strengthen up and that is the number one thing that will improve their outcome for them. When you think of getting up after a joint replacement and mobilising with crutches the more weight you are carrying then the harder it is going to be especially for the first couple of days.

In terms of joint replacements there is actually not really a lot of difference as such. Lets focus on the hip first of all, broadly speaking you can offer a cement hip replacement as in one that is essentially glued in or grouted into the bone and that has a rough coating over the surface of it and it allows the bone to then grow onto the surface with it with time and that’s when it gets its fix as such but within that then because you have got the ball and socket you have then got two different sides so you can then have it cemented on one side like the cup or vice versa.

In general, it varies hugely some surgeons will use one type or the other for certain cohorts of patients and I tend to use the cementing for most of my patients and again that is just my preference. Ultimately, a lot of it comes down to what you are most experienced using you are most likely to get the best outcome with the prosthesis that you are most familiar with.

Knee replacements come with cemented and cement less options and increasingly now we are seeing a rise in cement less options but the vast majority of knee replacements are still cemented into place.

There are subtle differences in the mechanisms of how two components in the knee fit and interact together, some have a dish but that’s getting into too much detail. Whatever works best for the surgeon is the way to look at it.

Within knees then as well you can replace the whole joint or you can replace part of the joint which is a partial knee replacement and again I often say to people that the first thing I do when I look at someone for surgery is can I get away with a partial knee replacement and quite often you just end up replacing the knuckle on the inside and it is a much smaller operation.

Smaller operations in general come with a lot less risk and come with a quicker recovery with a more natural feeling in the knee after. Ultimately, roughly 40% of the patients that I would see would be suitable for a partial knee replacement and it is something that I need to bear in mind and again the least you can put someone through is the best way to think about it.

This is the problem where it comes to expectations because I sometimes put people on the spot and say prosthesis can last a year which is possible because the bone can fracture around it, it could subside, you could get an infection and it could be out in a years’ time or less even but on average they are going to last very well we have the benefit now of joint registries across the world some of which have been going on for 30/40 years but the UK are coming up to their 20th year this year and it tends to mirror our practice and we have an Irish joint registry but it is only in its infantry stage at the moment. If you look at the figures 10 years is often a nice length of time for a replacement to last and it is actually very similar in a hip and knee.

The average hip and knee prosthesis have a 10-year survival and I say to people that does not mean you have to come and trade it in after 10 years if it is still going strong. Essentially you have a 1 in 25 chance of it not lasting 10 years or more.

I replaced a lady’s hip their yesterday and she had her other hip replaced 29 years ago a cemented hip and it is going strong not a problem. One way of looking at it although getting figures for it may be hard is what are the chances in your lifetime that its going to be done again and ultimately that brings the whole age spectrum into it and if you are 80 years of age and you are getting a joint replacement then it is almost certainly going to be fine.

If you are 40 years of age and you are getting a joint replacement the implications are a lot more and not only need to be revised but it might need to be done again and the way to think of it is a mechanical set just getting bigger every time and you need to bring in bigger toys to allow you to fix the problems.

It is an important factor to bear in mind and it is not as if we always push conservative measures but in young people but we are going to try our best. If an injection is giving some relief then you are going to try it again but you try your best to just push people out that other couple of years and they may not think that it is a huge thing but it actually if it gets them a couple of years further down the line it is a big deal potentially 20 years down that line and again if we go back to the same factors of quality of life.

If your 40 years of age as far as I am concerned and your looking at a joint replacement, the diagnosis is correct well then so be it. As far as people are aware that yes there is a chance that it could be done again n their lifetime then I don’t see the sense in riding out 20 years of a poor quality of life just to get that joint replacement and that makes no sense to me.

Absolutely, it is amazing to see the difference and I mean chronological ages and physiological age and it is absolutely amazing the difference. I suppose I have the benefit of getting to look in at peoples lives all the time and you see people who come in and they are 50 years of age and they look about 80. You see 80-year olds who would pass for 50 and that is the discrepancy that is there and it literally is plus or minus 30 years how they look, act and feel.

I replaced a 93 year old gentleman’s knee a few months ago and essentially his knee was pointing the wrong direction and he couldn’t do anything and after that surgery he was back playing golf at 8 weeks and again am I going to say that everyone can get to that absolutely not but it shows that it is possible and at the opposite ends of the spectrum we can say your too young and I think that is wrong.

The one thing that younger people need to realise is that there are to aspects to it. Firstly, they have a lot longer to go in terms of their life expectancy and for some people it could be 40-50 years maybe even more.

The second thing is that younger people tend to be a lot more active so potentially they are going to use up a joint sooner so there are two ways to look at that why they may get through getting it done again.

It is funny you say that because some patients are pretty well informed and I’ve had people come and see me and say I read about this and these are the exact symptoms I have but it is a little bit of a dangerous game to play someone coming in saying what they would like you to do. I will go back to what is on the menu is what the surgeon uses routinely. We are living in a different world years ago saying that’s what we needed and if it is a dictatorship for them then so be it. In that regard there is safety of little knowledge and by reading a lot you can actually end up confusing yourself more by going a little bit beyond that especially with internet because what you are relying on is not necessarily a fact and we can talk about things like stem cells and all these different things that come with a huge internet profile but there is very little evidence for it and the leading things in terms of joint replacement.

What you need is something that has been tried and tested and has been around for a few years because then essentially you are not a part of an experiment it is only with time that we know how well something will work.

From a hip and knee point of view all joints are pre-assessed and they have a pre-operative assessment and it is a normal medical check to make sure someone is optimising from surgery, that is probably the best way to look at it.

They are seen by a doctor and a nurse and they get a little bit of history taken of their previous medical problems, their medication is looked into, their bloods get taken as well so we can examine things like your blood count and your kidney profile that type of thing.

They will also get a trace of their heart or an ECG as it is called. If necessary some patients will get something called and echocardiogram which is an ultrasound scan of their heart but again the more information that we have then there is a lot less risk in many ways. If we know that something is there then it is rarely ever a problem and many patients sail through these things without any issue that can cause trouble afterwards or something that was diagnosed.

Based on that pre-assessment, if more detail is needed well then, we can ask a cardiologist or a respiratory physio whoever is required, to give the go ahead. The vast majority of people will just sail through that there is no problem. Obviously, people that comer with more baggage, more problems as such then we need to pause for that little bit longer to make sure they can be done.

The higher risk patients who can only be done in hospital with a backup its actually quite rare now it is a very small minority of patients who are not suitable for whatever hospital they are attending.

What I say to people when they are struggling the first day or two is that they are discharged the same day and truth be told people going home the same day I don’t prescribe it as such but partial knee is often two nights in hospital and a full knee replacement is 3 nights and a hip is 2/3 nights with us and I find that that is just the happy medium and people are going home because their pain is controlled and they are safe, mobile and confident to do things. Some people that day they are flying around but they are a lacking confidence a little bit and just would not trust it so I think a couple of days is absolutely fine.

I think especially with hip some people are pleasantly surprised the first couple of days in how quickly they improve and the first day can be tricky but by the second day they are really starting to get going and then they are usually mobile and independent going up and down to the bathroom.

Most people with a hip or knee replacement will be using crutches for the first 1 to 4 weeks depending on how they got on and how strong they are and how their pain is as such but they are better off anticipating in many ways.

Not so much occupational therapy but occupational therapy is more changing things in their home and again you don’t really need modifications like that now. A lot of the old precautions and different things that used to be done have changed. We still get people to lie on their back for the first few weeks to help. A lot of these precautions were designed to help stop the hip from popping out of the socket as such and as I say that risk is much lower now a days and you can pull back a bit on that.

In general, in relation to physiotherapy I would say yes and no because I am firmly of the belief that less is more with the hip and I frequently see people over doing it and irritating tendon muscles and other things around that area I believe just need a few weeks to heal and settle down.

The knee as we spoke about needs to be moved and needs to get going and that would take a bit of work with  a physiotherapist afterwards and as much as anything the exercises are easy, they are very simple in terms of what to do but it is about having someone there going to give you a bit of encouragement saying “come on you can do two more” or knows when it is time to push you a little bit harder and some people like a personal trainer and some people don’t and for some people they absolutely love having someone there telling them what to do.

I will often see the people who need the motivation after a joint replacement and then I will see other people who I need to pullback from overworking their joint replacement.

A lot of people who can work from home, particularly if they are self-employed they could be on their laptop doing a bit of work the following day from their discharge. If people can free up a week or two just for their own headspace I think that is very important.

The opposite of that spectrum like manual work for example climbing up ladders and working on roofs then they could be out for ¾ months maybe even more, depending on what they do and when they will be signed off to be considered safe.

Replacements exist for most joints and my area is obviously hip and knee but there is an increase in shoulder replacements, elbow replacements would be a small enough number but again weight bearing joints are much more likely to cause problems and that is why the number of hip and knees outweighs everything by about 6 times and that is always going to be the case because different joints just function differently.

Ankle replacements are becoming more common nowadays also and for other joints you have other options such as fusions. For example, it was very common to fuse the ankle to stiffen it instead of replacing it but I am now aware that people are starting to replace ankles more frequently.

The hip joint in many ways is quite simple with the ball and screws and the mechanics of other joints do not work the same and it has been harder to replicate with replacements and that is part of the reason for that.

In terms of going back to the knee you have to see if there is any other option than replacing the knee and there is a partial knee replacement as well as that knees will be suitable for something called an osteotomy which sounds barbaric but it is essentially cutting through the tibia bone usually but it can be the femur to realign their leg. If all their pain is on the inside of their leg and they are loading the inside of their leg and if you look around you may often see someone with a bow in their leg well that is loading one side of the leg much more and if you potentially unload that area as such by straightening their leg then you can take away the pain in their leg.

For younger people in particular for example, if you are 20 years of age and you have well established arthritis on the inside of your knee well you are not really going to be able to say that a replacement is an option so that is when something like an osteotomy comes in.

I think there is a nice balance between being a little bit informed and knowing what your getting but not reading too far into it and sometimes people stress themselves out too much and whether they like it or not they have to place their trust in me or whoever the surgeon is for some people it is like getting on an airplane you have to trust the plot. You will not have a list of questions for the pilot so there is an inherent trust you have to give to the surgeon. You are reliant on the surgeon to do their part and then afterwards they can worry about doing their part and in that regard, you find out as the journey goes on because lots and lots of questions before hand are going to progress as you move on that journey and it is often a better way to do it knowing a bit but not worrying yourself either. If it is 8 weeks down the line just focus on getting through today. A knee replacement is often really sore afterwards and you have got to be able to trust me. You have to think of it as though today is sore tomorrow will be better and then they know that they can trust you in that regard.

My main tip then is really to just make sure you have yourself fit and strong but there is very much a happy medium there and if you can hardly walk because your hip is so worn then there is only so much prehabilitation you can do by doing your exercises before hand and there is no point in losing any momentum before you even start the journey. I spoke much earlier about the disability and forgot to go back to it and it is something particularly with the hip and knee that we see. You have your pain aspect but then when a joint is worn, from a hip point of view you have trouble getting your shoes and socks on, trouble getting out of the car, getting up and down the stairs.

For the knee the trouble is behind you knee cap and you actually may have trouble even standing and this is something we spoke about as we get older in general the more baggage you carry in terms of that disability is then harder to manage.

I often speak to people about the risk of a fall, if you have got pain every so often and the leg wants to go then you are at a risk of falling and breaking your hip as such so people looking to avoid an operation isn’t the answer and you are here saying what can I do to maximise the chances of getting someone back being fit again in that regard. The last thing you need if you are in your 80’s is something pulling you way down as far as I am concerned you need everything going for you.

For further information on Total Hip and Knee Replacement Surgery at UPMC Sports Surgery Clinic, please contact info@sportssurgeryclinic.com

Common Problems Around The Hip

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

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

Mr Gavin McHugh UPMC Sports Surgery Clinic

 

 

 

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For further information on Total Hip Replacement Surgery at UPMC Sports Surgery Clinic, please contact info@sportssurgeryclinic.com

Common Injuries in Rugby 7’s

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For further information on this subject or to make an appointment, please contact sportsmedicine@sportssurgeryclinic.com