‘Menopause and Muscles (and bones, and tendons): Maintaining fitness during Menopause.’

Watch this video of Dr Colm McCarthy, Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic, presenting on ‘Menopause and Muscles (and bones, and tendons): Maintaining fitness during Menopause.’

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on shoulder pain and fitness during menopause.

Dr McCarthy is a Sports & Exercise Medicine Physician at UPMC Sports Surgery Clinic.

For further information, please contact info@sportssurgeryclinic.com

‘Frozen Shoulder – Adhesive Capsulitis.’

Watch this video of Ms Ruth Delaney, Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic, presenting on ‘Frozen Shoulder – Adhesive Capsulitis’.

This video was recorded as part of UPMC Sports Surgery Clinic’s Online Public Information Meeting, focusing on shoulder pain and fitness during menopause.

Ms Ruth Delaney is a Consultant Orthopaedic Surgeon specialising in Shoulder Surgery at UPMC Sports Surgery Clinic.

For further information on shoulder Surgery, please contact info@sportssurgeryclinic.com

Fit for Life – How to maintain strength, fitness and a healthy lifestyle as we age

Watch this video of Tommy Mooney,  Senior Strength & Conditioning Coach at UPMC Sports Surgery Clinic’s Sports Medicine Department., presenting on ‘Fit for Life – How to maintain strength, fitness and a healthy lifestyle as we age’.

Tommy Mooney is a Senior Strength & Conditioning Coach at UPMC Sports Surgery Clinic’s Sports Medicine Department.

I’m Tommy Mooney Lead Strength & Conditioning Coach at UPMC Sports Surgery Clinic. I will be talking about Fit for Life: How to maintain strength, fitness and a healthy lifestyle as we age. I will plan to summarise some of the evidence regarding healthy aging, particularly as it pertains to golf performance and offer some practical examples of what you can do to help improve your fitness and golf performance.

It is well understood the importance of being fit for an array of lifestyle factors such as benefits like general health, longevity and weight management.

What do we mean by being fit?

Fit means many things to many people, whether in group or individual activities, indoors or outdoors. Whether it be cardiovascular-based, flexibility-based or strength-based.


Tonight, we are more interested in fitness as it pertains to golf we can all likely agree that Rory McIlroy is a fitter golfer than John Daly. We will talk about some of the physical factors and what we will do to change them to help improve our golf performance.

Firstly, I am going to talk about the importance of muscular strength. Anyone who has watched the Netflix ‘Full Swing’ documentary has seen this custom-built gym that the PGA Tour brings with them around the country to all the major events to allow all elite golfers to maintain their strength and conditioning work whilst on tour.

Strength is also important for the ageing golfer. Ageing is associated with the loss of muscle mass and strength and can often result in falls, functional decline, feelings of subjective weakness or on the golf course that may look like a loss of distance and fatigue.

Typically, as we age, we can see a loss of muscle mass. This is shown here in this study with the two MRI images. One of a 60-year-old woman vs an 80-year-old woman and basically what we are looking at here is the muscle mass or the darker material vs the white material being more fatty infiltration.

As you can see as we age typically the number and size of that muscle mass in this instance is your quadricep muscle. We see that decrease while we see the fatty infiltration increase. However, this does not have to be the case.

This particular study looked at 40 master athletes aged between 40-80 years old who trained 4-5 times a week during this study they underwent tests of body composition, quadricep strength, and bilateral MRIs. What we can see here is a 40-year-old master athlete relative to a sedentary vs an active population and basically, what we can see here is the muscle mass, size and the number of muscle fibres maintained really well in our active population vs in our sedentary population we see an increase in adipose or fatty infiltration into the muscle.

Ultimately, this study contradicts the common belief that as we age, we lose muscle mass and strength, and that suggests that the loss of muscle mass and strength is a factor of disuse rather than ageing alone. This has important benefits for our ability on and off the golf course and will help us to maintain that muscle mass and strength and eliminate some of those risks we mentioned earlier around a loss of independence and falls.

Another thing that can often hamper our golf performance is injury, time away from the golf course due to injury is going to have a knock-on effect not only on our general health and fitness but also on our handicap so injury can often be the start of that misuse that we mentioned. Post-injury, resistance training is really important. It has been shown here in several studies and we see it daily around the clinic that it improves function, reduces playing scores, and helps improve strength. Strength plays a fairly key role in keeping us on the course as well as benefiting performance, as we mentioned.

If all of that doesn’t sway your opinion on the necessity of strength as a part of our exercise routine this particular meta-analysis looked at nearly 2 million participants over 38 studies and what they found with this was adults with higher levels of strength had a lower risk of death when compared with those of lower levels of muscular strength.

As a general guideline, in 2015, the World Health Organisation (WHO) changed its guidance to include strength training twice per week, and basically, those guidelines look like this. Trying to incentivise 150 minutes of light activity a week, again if we are playing golf we are already ticking this box quite easily.

75 minutes of vigorous activity that is increasing our heart rate and getting out of breath a little bit more.

Strength training as we mentioned at least twice per week. Some form of balance training and minimise sedentary time.

Again, if we are on the golf course a couple of times a week we will tick most of these boxes but strength training is not a box that we will tick once. Again, it is important to know that these are generalised guidelines and do need to be adapted to the individual, but they do show the importance of strength.

How does a golfer lifting weights in the gym contribute to a pro playing well on the golf course or hitting long drives. This study shows strength training and healthy non-injured golfers. The study analysed the relationship between muscle strength and swing performance, such as club head speed, driving distance, ball speed, and skill (handicap/score).

The results seemed to implicate that there is a positive relationship between handicap and swing performance. Although relatively few studies have been investigated in this area. There is a positive correlation between handicap and muscle strength and also a distinct relationship between driving distance, swing speed, ball speed and muscle strength. The results go on to show that training of the lower leg, hip extensors, trunk power as well as grip strength are relative for improved golf performance.

This slide shows a sample training program or strength plan for a golfer. It is important that these programs are individualised so it is best to consult a professional when looking to begin any new strength plan. Ideally, we want to try and meet the individual where they are at for example someone who has a history of training regularly vs someone who is coming from a more sedentary base. This example is a 6-week program for a relatively trained individual with a good experience of strength training.

To show you some of these exercises. Again, these are advanced exercises for someone who has not done strength training before. In the top left we have a racked deadlift exercise looking to build up posterior chain strength. Here, we have a hip thrust exercise looking to develop gluteal and hip extensor strength. These are going to be important exercises when we think about our follow-through in our drives.

We have some upper-body exercises here in our push-ups, our single arm pull down and our single arm press. We have some lower limb, working on balance here with our split squat, a single leg squat working on our single leg strength as well as our T-spine rotation working on rotation, mobility and flexibility.

Here are some general guidelines for strength training as we start as a beginner we want to focus more on lower/lighter resistance utilising bodyweight exercises we might start with higher repetitions and lower sets and that can progress into heavier weights with lower volume. Again, the sessions per week may be reduced at the start like 1 or 2 and that can gradually progress as we become more advanced.

In terms of exercises again here are some sample exercises these are not all of the exercises that we use but just give you an example of some that might be used across a couple of different types of movements. It is not necessarily the case that we move linearly from one and these are an example of some exercises that can be used.

It would be remised not to outline the importance of cardiovascular exercise although I think everyone understands the benefits of cardiovascular exercise in terms of gain, reducing inflammation and reducing the risk of chronic disease. To quickly talk through it this meta-analysis looked at 33 studies with over 100,000 participants and what they found here was people that who had better cardiovascular fitness had a lower mortality rate or incidents of coronary heart disease, cardiovascular disease and essentially working on our fitness, whatever form of fitness that may be is beneficial towards all calls of mortality.

General guidelines for cardiovascular training are to get out of breath regularly. We get that lower-intensity exercise ticked off as we mentioned earlier from the WHO recommendations and we can try to challenge ourselves a little bit more with slightly more intensive exercises during the week. Again, that starting point is going to be based on your current level of fitness examples might include some fast walking, walk to run, cycling and swimming can all be effective methods.

Naturally, with golf, we all enjoy the social aspect and that’s no different when exercise training. Trying to make measures of progress, we track our handicaps, we track our scores on the golf course which should be no different to our training off the golf course as well. As I mentioned, if you are unsure of something that is where getting advice from a professional is key. These are general guidelines and not targeted at anyone and will naturally depending on your levels of fitness but aiming for 3 days a week. Some of that may be made up from golf but outside of golf then what are we doing? Is there other activities we could include there.

Again, we mentioned looking to utilise some higher intensity exercises where we are going to push that heart rate into higher ranges or higher levels. Our steady-state things are going to be largely ticked off the golf course especially if we are playing a couple rounds a week but then the interval training option might offer a good alternative to a challenge that is more intensive cardiovascular sessions and see those benefits as we mentioned.

At UPMC SSC we offer some bespoke fitness testing. It is covered by various health insurers, VHI in particular cover some amount of the cost of our fitness testing here. The fitness testing covers a variety of different elements so we will look at body composition, upper body strength, lower body strength. We can also look at swing speed assessment as well as a cardiovascular fitness test or a V02 max that can be done on a treadmill or an exercise bike.

Testing is one part of the equation but then it is implementing those testing results into a bespoke programme based on the individual and based on what their goals are as well and that is all included in the VHI package that I mentioned earlier.

If you have any questions you can email fitnesslab@upmc.ie

For further information on this subject or to make an appointment, please contact sportsmedicinessc@upmc.ie

The Forever Fairway: Strategies for life long golf without pain or injury

Watch this video of Dr Ronan Kearney, Consultant Sports and Exercise Medicine Physician at UPMC Sports Surgery Clinic, presenting on ‘The Forever Fairway: Strategies for lifelong golf without pain or injury.’

Dr Ronan Kearney SSC

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

I am a Consultant Sports and Exercise Medicine Physician primarily based at the UPMC Sports Surgery Clinic in Santry. I also work across several different sports, but at the moment, I am in the high-performance centre in Sport Ireland and looking after athletics, preparing for the Paris Olympics. I have also worked for DP World Tour Golf and Legends Tour events. I also do a bit of work in the GAA and am a senior clinical lecturer at Trinity College.

I spend most of my time in the UPMC Sports Surgery Clinic, which is made up of the main hospital and the Sports Medicine Department. The Sports Medicine Department is made up of a team of Sports Medicine Consultants alongside a full MBT of specialists, physiotherapists, and strength and conditioning coaches. We work in tandem with our rheumatology and radiology colleagues in the main hospital.

Working in golf is very rewarding and I hope that some of the things I have learned in elite golf I can share with the recreational golfer also. Worldwide 60 million people play golf in 206 countries so huge participation sport. As you age previously accessible activities can be more challenging. Golf, however, is a more popular sport for the older adult and it is a really important form of exercise as we age. Golf in itself is a recipe for lifelong health.

These are some nice infographics that the DP World Tour has published and they did a lot of work in terms of public health and the benefits of golf overall so physical inactivity causes over 3 million deaths worldwide per year and golf is a phenomenal form of activity in its own right.

Typically, golf is a form of moderate exercise for most people. When walking the course, you will get 11,000 – 17,000 steps. If you are unable to walk the course you can still achieve approximately 6,000 steps while having a buggy and that in itself still gives great benefits.

Research has long proven that the more physically active we are the greater we live in terms of time. More specifically the health benefits of golf reduce your risk of multiple medical issues like cardiovascular disease, diabetes, stroke, colon cancer, breast cancer and dementia can be reduced by up to 33%. There is a reduction of 65% in hip fractures in golfers as well so huge benefits to be gaining. A Swedish study found that golfers have a 40% lower mortality rate than non-golfers.

Anyone who plays golf also understands that the physical and mental health factors are so beneficial. It is proven that there is a boost in self-esteem and a reduction in depression.

Golf is associated with a higher risk of skin cancer, so anyone who golfs should make sure to get their skin checked on a regular basis and use sun cream. We share this with professionals on the DP World Tour to remind them, but it also applies to recreational golfers in terms of skin care.

Golfers can develop a number of musculoskeletal issues that may or may not be related to the sport itself, and that is where we, sports and exercise medicine physicians, can help. We have to keep you as active as possible and on the course for as long as possible so that you achieve all those health and social benefits that we all know golf brings.

What are the common issues that we might be able to help with?

A recent study looked at the injuries in both amateur and professional golfers and as you can see the most common injuries in golf are elbow, lower back, hand/wrist, and shoulder. Life-long golf can most definitely be cut short by injury so appropriate management of such injuries is essential to getting you back on the course. The purpose of today’s talk we will focus on the amateur’s two most common injuries lower back and elbow.

Lower back pain makes up 16% of amateur golfers injuries and about 41% of professional golfers injuries more likely to be in professional golf due to the larger forces in it and the larger repetitive load placed on the lumbar spine with professional golfers hitting 100’s of golf balls a week generally.

Several modifiable factors can reduce your risk of lower back pain while playing golf. These are a reduction in BMI, poor strength, flexibility, and coordination. Certain swing biomechanics lead to lower back pain, and we also know that carrying a bag can increase your risk of having lower back pain while playing golf.

The golf swing is considered one of the most difficult movements in sports and to perform a golf swing a powerful movement is required with rapid rotational forces being transferred to the golf ball with lots of compressive load placed on the lumbar spine, calculated to be about 7 to 8 times body weight.

Recreational golfers have different variations in swing and muscle activation during the golf swing itself. We know that older golfers age related muscle changes their swing and 3 typical swings have been associated with lower back pain. The early extension is where our hips come forward to the hand space during the swing. A reverse-C finish puts a greater load on the lower back structures. The reverse spine angle is an over-extension of the lumbar spine during the backswing.

I’m not going to get too mechanical but certain swing mechanics are more common in those with backpain so it is really important for those mechanics to be identified and to work closely with your golf professional to address these issues in your swing as part of the management of your injury. Other potential modifiable factors include flexibility.

It is obvious that strength plays a large part in both the prevention and management of golfing injuries and the professional game itself has transformed over the last decade with most top professional golfers putting a large emphasis on strength and conditioning as it reduces the risk of injury and improves performance, this can also be applied to the recreational golfer.

To get to the root of the problem in lower back pain you need to have a full assessment so a clinical assessment, strength assessment, flexibility assessment and biomechanics assessment and sometimes imaging if it is necessary.

To manage lower back pain in golf, really if we take a general approach here education will form a huge part of that so in terms of making sure that you are aware of what you need to do to improve your symptoms.

Weight loss can form part of the management we spoke about muscle strengthening and muscle exercises as well as flexibility exercises which can also be helpful. Looking at your swing biomechanics can be helpful also to have your golf professional assess that as well.

We are lucky enough at the UPMC Sports Surgery Clinic to have options to secondary management which is not always needed but is helpful at times to create a window opportunity where pain doesn’t progress into exercise rehabilitation.

The second most common injury in golf is the elbow and it is often an overuse injury more common in females. Unfortunately, the term tennis elbow is associated with tennis but it is more common in golf.

Risk factors for developing elbow pain in golf can be due to hitting too many balls in too short a time. The grip may be too tight or, you may be hitting the ground before the ball or if you try to change your swing very gradually without increasing the load. Often, we will see wrist flexion changes at the impact of the golf ball that can lead to different loads placed on the elbow.

The wrist flexor burst at impact is to try and increase clubhead speed but can lead to some additional forces placed on both the outside the lateral and the medial lead and trail elbows. The problem with golfers who have wrist pain is the wrist position and impact is assessed. There can be several different causes for elbow pain in golfers that would need to be assessed as we said inside a golfer’s elbow is a medial epicondylopathy and outside elbow pain is often lateral epicondylopathy.

To truly determine the issue, you will need a full clinical, strength, flexibility, biomechanics, and, at times, imaging assessment.

Management for elbow pain depends on the diagnosis itself but generally consists of education about your problem, strength-based rehabilitation, biomechanics, and, again, coming back to that golf-specific rehabilitation. Some aids can be a support brace or maybe even increasing your grip size. Again, all of this will depend on the injury itself.

Management options that can be helpful for elbow-related pain in golfers include ultrasound-guided injections, platelet-rich plasma, corticosteroid, and, at times, extracorporeal shock wave therapy.

What is Extracorporeal Shockwave Therapy (ECSWT)? It is a shockwave that works by acoustic shockwaves which carry energy to different tissues. These shockwaves can trigger tissue responses which have many beneficial effects such as pain relief, and increased blood flow and when needed can disrupt calcium deposits in tissues. The combination of these effects can lead to improved muscle recovery.

What is Platelet Rich Plasma (PRP)? It is a form of regenerative medicine that harnesses the body’s ability to try and increase natural growth and has healing factors to try and improve injury recovery. The blood is taken as it would during a simple blood test spun in a centrifuge and then the PRP portion which contains concentrated healing cells is injected into the targeted tissue. PRP has less side effect profile than traditional corticosteroid injections and some cases show they are proven to beat steroids in the long-term musculoskeletal conditions.

You have managed your golfer’s elbow and you are trying to ensure you have lifelong golf like we initially spoke about. Performing a warm-up means you are less likely to get injured playing golf. Injury is 3 times more likely in recreational golfers without a warm-up, here are some of the pre-round warm-ups recommended by the UPMC Sports Surgery Clinic. I recommend you take a copy of this and bring it into your pre-round routine.

You will often see professionals preparing for a round hours in advance when most of the time we are rushing out of the car to get to the first tee. How many times has it taken you 2 or 3 holes before your body is ready to swing a golf club. Try and go earlier to the golf club and spend 10-15 minutes warming up.

There have been a few questions ahead of today’s talk regarding osteoporosis and golf. I suppose osteoporosis is a condition that means your bones are below bone mineral density and are at an increased level of fracture. We can make a diagnosis with the help of DEXA scanning. It is in approximately 20% of females and 6% of males over 50 years of age in Ireland. It is vital that those with osteoporosis manage it properly often with the help of your doctor and rheumatologist.

Resistance exercise plays a huge role in the treatment of osteoporosis and really should be guided by your professionals. While golf is considered low impact, individuals with osteoporosis should discuss with professionals if they should participate. It is crucial to understand the persons overall health status, bone density, pain levels and functioning strength abilities before having that decision.

I look after a number of golfers with osteoporosis and there is a number of different tips in terms of the golf swing that can reduce their chance of further injury.

Firstly, working closely with their golf professional to ensure that their golf swing is a good technique. At times rotating your lead foot to improve movement through the hip externally. Shortening the backswing can reduce that bending stress in the lower back. Even something as simple as standing closer to the ball can reduce that forward bending and reduce the bending of the lower back. There is a number of different mechanical tips and tricks that can reduce your lower back stress especially if you have lower back stress, osteoporosis can allow you to continue to golf in the future.

In summary, strategies to improve lifelong golf among recreational golfers include really a holistic approach that includes appropriate management of medical issues and injuries.

Exercises to improve strength and flexibility that act as both health and performance boosters as well as injury prevention.

Working alongside a knowledgeable golf professional to help identify any swing biomechanics that may lead to future injury. Ensure an appropriate warmup prior to playing and most importantly have fun golfing.

For further information on this subject or to make an appointment, please contact sportsmedicinessc@upmc.ie

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.

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

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.