Mihai Vioreanu SSC

Is it time for Total Knee Replacement (TKR) surgery?

Knee Replacement Surgery at UPMC Sports Surgery Clinic

KNEE OSTEOARTHRITIS

Osteoarthritis (OA) is the third-leading cause of life-years lost to disability worldwide. By the age of 65 years half of the population have OA, and this prevalence is expecting to rise as the population ages in demographic terms.

Nearly 1 million knee replacements (TKR) are performed annually in United States. Rates of TKR surgery tripled in the last 20 years and projections in US show further increase in demand by 6 fold (673%) by 2030.(1,2) A similar rise in TKR surgery is also expected in Ireland.

Since the 1970’s, when first performed, TKR surgery has been a successful procedure that gives mobility and independence back to people suffering from knee arthritis.  However, TKR surgery comes with risks. The risks of clot formation, pulmonary embolus, infection, and fracture range from 0.1 to 1.0%, with higher risks among older persons and those with a higher number of coexisting conditions.(3,4) Also, the procedure is not always successful; approximately 20% of patients after TKR have residual pain 6 or more months after surgery.(5)

There are other non-operative alternatives for treatment of moderate knee arthritis and I have written about those in a previous article – “The Young Arthritic Knee”. Clinical trials have shown that physical therapy (including exercises and manual therapies) can reduce pain and improve function in patients with moderate and advanced knee osteoarthritis.(6-8)

Until now, we have lacked rigorously controlled comparisons between TKR surgery and its non-operative alternatives.

THE SCIENTIFIC EVIDENCE

A prospective randomized control study is the gold standard for a clinical trial and provides the most credible evidence when assessing different treatment effects on patients. These are carefully designed and executed studies to eliminate bias and establish the best available treatment.

Recently (October 2015), New England Journal of Medicine, a highly esteemed medical journal, published a study entitled “A Randomized, Controlled Trial of Knee Replacement”. Interestingly, prior to this publication NEJM published only 4 original articles on arthroscopic knee surgery and all with ‘negative’ results. I have made reference to those articles in one of my previous article (“The Young Arthritic Knee”).

The recent study was performed by a Danish group of researchers over a number of years and involved 100 patients with symptomatic moderate and severe knee osteoarthritis.  Patients were split in two different groups and assigned to undergo either total knee replacement followed by a rigorous 12-week nonsurgical-treatment regimen (TKR group) or to receive only the nonsurgical treatment (Nonsurgical-treatment group), which consisted of supervised exercise, education, dietary advice, use of insoles, and pain medication. Improvement in pain and function was assessed at 1 year after initiating treatment to see the effect on both treatments on a similar group of patients.

IS TKR SURGERY BETTER THAN NON-OPERATIVE TREATMENT FOR MODERATE KNEE ARTHRITIS?

TKR surgery proved markedly superior to non-surgical treatment alone in terms of pain relief and functional improvement. The percentage of patients who had a significant improvement in pain after 1 year was 85% in the total-knee-replacement group and 68% in the nonsurgical-treatment group. In fact, one in four patients in the nonsurgical-treatment group elected to have TKR before in the first year, and more patients are likely to cross over as follow-up extends further.

It is noteworthy that more than two-thirds of the patients in the nonsurgical-treatment group had clinically meaningful improvements in pain and that this group had a lower risk of complications compared with the TKR surgery-treatment group.

When discussing treatment options for moderate and severe knee OA patients face choices that are associated with different levels of symptomatic improvement and risk

TAKE HOME MESSAGE

When compared with non-operative treatment, TKR surgery gives better pain control and better function despite the inherent higher risk of adverse events.

The right time to have knee replacement surgery is when the patient is having symptoms that are affecting his or her quality of life and they want something done about it. This is a personal and very subjective decision. I always advise patients to take their time, really think it over and have surgery when it suits them.

I certainly stress to my patients that surgery of any kind carries risks and it is important for them to fully understand what they are. However, in the hands of a good surgeon, experienced nursing staff and in an excellent hospital facility, complications are unlikely.

With modern technology, implant design, materials and surgical techniques, knee replacement surgery has become one of the most successful operations available to patients with moderate or severe knee arthritis. Successful knee replacement surgery reduces or eliminates knee pain and improves joint function, enabling patients to get back to a normal active lifestyle.

Read more from Mr Mihai Vioreanu at www.mrmv.ie
Colin Griffin, Lead Running Coach at SSC discussing 'Couch to 5K and beyond'

Fuelling ‘on the run’ during a marathon race – by Colin Griffin

UPMC Sports Surgery Clinic
Race day nutrition is a topic of interest among many marathon runners. Questions such as ‘should I take a gel’ or ‘how many gels should I take during a marathon’ or ‘what type of gel is best’ are commonly asked.
There are a number of factors to consider when planning a race-day fuel strategy. These include:
·         Sources of energy
·         Amount of carbohydrate you need to (or can) consume
·         Your ability to digest products on the move
·         How often should you consume carbohydrate
·         Pre-race fuelling

Sources of energy

The sources of energy can have a small but significant impact on absorption and performance. Mixing sugar-based carbohydrate sources such as glucose, fructose, dextrose and starch-based sources such as maltodextrine and maize; can enhance carbohydrate absorption into the blood. It can be useful to look at the ingredients label on a particular gel or energy drink powder formula. You can analyse carbohydrate sources and also the sugar content under the nutritional value label. Most products have a one third sugar content of carbohydrate. For example a product containing 30g carbohydrates of which 10g is sugar-based.

Amount of carbohydrate

A carbohydrate intake of between 30-60g carbohydrate per hour is generally recommended for optimal gastric emptying and intestinal absorption. There appears to be an upper limit of 75g per hour, above which will have no additional benefits and may in fact inhibit absorption and cause stomach issues. Most gels contain 25-35g carbohydrates. Most self-prepared sports drinks with a 6% carbohydrate concentration will contain close to 30g carbohydrate per 500ml, which can be diluted accordingly. You can calculate this by looking at the label and knowing what 1 scoop or 100g contain.
Nutritional content of a typical sports drink
Nutrition UPMC Sports Surgery Clinic
Nutritional content of a typical gel product  

Your ability to digest carbohydrates on the move

The key objective is to keep blood glucose levels topped up during a race by consuming carbohydrate-based fuel. Whether that carbohydrate comes from a gel, solid food or drinks powder mix, is a matter of individual preference for the athlete. You will see from the above referenced labels, that a 500m energy drink mix with 30g carbohydrate content or one gel with close to 30g carbohydrate content; still provides the same amount of energy. It depends on how well the athlete can digest the product. Some athletes prefer to take a solid fuel such as a gel, a piece of energy bar or some jelly sweets; while others can only tolerate liquids. It is something that should be trialled and practiced on a few training runs well in advance of race day.

How often should you consume carbohydrate?

It is recommended that an athlete consume between 30-60g of carbohydrates per hour of activity if their event last longer than 1 hour. There are usually personal drink stations every 3 miles or so during a marathon race. A 2 hour 30 minute marathon runner, who consumes 250mls energy drink containing 10-20g CHO every 3 miles; should achieve sufficient fuelling throughout the race.  The athlete could substitute a gel for an energy drink every third or fourth 3 mile segment. For an athlete who may not be in a position to consume prepared drinks on the course and relying solely on water stations, could carry some gels with them and consume with water. It is best to begin fuel intake early on in the race, perhaps from the first drink station.

Pre-race fuelling

Many athletes ‘carbo-load’ in the days leading up to a race by increasing their carbohydrate intake. There is little evidence of any additional benefits of carbo-loading longer than 24 hours pre-race. When you taper your training but still consume the same amount of carbohydrates in meals and snacks, you will be increasing glycogen stores regardless. Some athletes don’t like the lethargic and often bloated feeling of being carbo-loaded.
The best advice is to maintain normal meal portions and carbohydrate intake the week of a race, with perhaps a little extra intake in the meal the evening before the race. Have a pre-race breakfast meal that has worked well in training and previous races. Carbohydrates consumed in the 60 minutes before the race should be liquid-based, but only in small amounts. One must also factor in race day anxiety and nerves, which can affect digestion and absorption. Sometimes ‘less is more’ in terms of food intake and perhaps allow for an increased pre-race digestion window than you would usually in training.

Conclusion

The most important fuel the athlete has available on race day is the glycogen stored in the muscles. Between 10-30% of carbohydrates consumed during a race is actually utilised. Most well trained athletes will have sufficient muscle glycogen stores to sustain a 2-hour effort. It is a good idea to include some occasional steady state runs in a low glycogen state to promote fat utilisation for energy. It is also good to complete other workouts in an adequately fuelled state to as to have that metabolic flexibility so that our bodies are trained for both fat utilisation and carbohydrate utilisation. Our bodies our smart at self-regulating! With a good aerobic engine and some fine-tuning, along with adequate fuelling; our bodies will find the most efficient way of fuelling performance early on and keeping energy reserves for the latter stages.
Click here for further information on Running Services offered at UPMC Sports Surgery Clinic, or to make an appointment call +353 1 5262030.

‘The growth of hip surgery in Ireland’ Dr Éanna Falvey

An article on the ‘Growth of Hip Surgery in Ireland’ by Dr Eanna Falvey, Director of Sports & Exercise Medicine in SSC.
This article was published by the Gaelic Players Association (GPA) as part of their ‘Body of Evidence’ Blog.

How common a problem is this?

Hip and groin pain are common time-loss injuries in sport. This is particularly common in Gaelic sports, especially football. Our clinic has seen large numbers of GAA players over the years with hip and groin injury and footballers outnumber hurlers nearly 4:1. It is often argued that kicking is the main reason why football causes more groin injury but this is probably a little simplistic. Football by its nature requires more running and contemporary ‘transitional’ defensive systems require even higher fitness levels combined with sharper twisting and turning. Ball retention is a focus meaning a short hand-pass is often favoured over a kick-pass or longer kick. The old adage of ‘let the ball do the work’ doesn’t hold in this system – meaning players work harder. Players at all levels around the country are now also undertaking varying levels of conditioning. From unsupervised to one-on-one sessions, most teams perform gym-based conditioning over the winter months and pre-season. The combination of torsion forces (twisting the upper body relative to legs) higher load (how many metres you run a week) and less recovery time (more training sessions plus work/school/college = less time to recover) all add up to an overload pattern which is at the root of many of the hip and groin problems we see.

Why is it such an issue?

Hip and groin pain is the third biggest time-loss injury in field sports like GAA, rugby and soccer. Long before a player begins to miss games their performance tends to drop – sprinting, direction change and cutting all see decrements in performance. Worse still, because athletes often continue to play and train and there are no stitches or crutches to be seen, it can be hard for other athletes and coaches to understand why the athlete is not better. Similarly, the medical team often struggle to manage the symptoms and a pretty classic tactic is to move the ‘blame’ for this onto the athlete- you would be amazed how many athletes are relived to ‘have a diagnosis’ that things are not in their head. Worse again is the lack of an endpoint to when the problem will be resolved.
This is an emotive issue where a player, their manager and medical team will try anything to get them back training and playing. To be told hip surgery will sort this problem will make this better is “great news” for all involved. We all love to have an endpoint- “you will be back playing in 4 months”. Often this is delivered in tandem with them the news that if the surgery is not performed you will have arthritis aged 40. This makes surgery almost mandatory.
These are pretty emotive areas with some pretty scary outcomes. When fear, loss and anxiety are mixed into the decision process making a clear choice can be difficult. This article is aimed at taking the emotion out so some of the questions and answering it with the scientific information that is out there.

How much hip surgery are we seeing?

There has been an 18-fold increase in the number of hip arthroscopies in the USA between 1999 and 2009. The FAI-surgery rate has increased by over 600% among newly trained surgeons from 2006 to 2010. In Ireland GAA insurance figures show 314 hip surgeries in 2014 compared to 80 in 2007- a rise of 392%.
I remember the first time I encountered a hip labral tear. I was consulting on an intercounty hurler in 2005. He had a history of tight groins and intermittent flares of groin pain. An MRI confirmed a labral tear. An intra-articular injection of his hip helped to settle his pain, but it returned a few months later. At the time hip arthroscopy was not readily available in this country and was not an option for this player. With modification of training and rehabilitation input the player continued to train and play at an elite level until 2012. So what has changed since to see such an exponential rise in surgery?

Morphology Vs Pathology

It is a worthwhile exercise to discuss some of the terms that are commonly mentioned in this area.

Morphology

This is a difference in shape from the norm (Figure 1) with either the ball (femoral head) or the socket (acetabulum) of your hip. It does not mean that there is a problem. This is commonly referred to as femoro-acetabular impingement (FAI). It means that you are at a biomechanical disadvantage compared to “normal” shaped hips. This does not guarantee that you will have a problem but does increase the chances of one developing. Its means there is a “possibility” of a problem developing. It is felt that morphology changes are far more common than we imagine and we know FAI morphology doesn’t guarantee you will have either pain or poor performance.
In ‘A’ the small solid arrow indicated the area of ‘extra’ bone seen in cam-type FAI. In ‘B’ the long interrupted arrow shows the head/neck offset we would label ‘normal’. It is worth noting that though the patient in ‘A’ had similar x-ray findings on both sides he was symptomatic on the right side only.

Pathology

Pathology is where morphology combines with other factors to cause pain and dysfunction. Pathology implies that there is a “probability” there will be longer term damage. Much has been written on this in scientific literature.
To develop pathology you have to have 5 things:
(1) Abnormal morphology of the femur and/or acetabulum- the abnormal shape is present.
(2) Abnormal contact between these two structures- this shape increases impact between the structures.
(3) Especially vigorous supraphysiological (high-level/high-intensity) motion that results in such abnormal contact and collision- the athlete trains or plays at a high level with poor ‘control’ worsening this impact.
(4) Repetitive inefficient motion resulting in the continuous insult- the athlete does this a lot ie trains/plays a lot.
(5) The presence of soft-tissue damage- labral tear or ligamentum teres tear, the biggest risk factor for injury is previous injury, so soft tissue injury can cause further issues.
So it is worth bearing in mind that even if you have 1 and 2 or even 5 if you alter 3 and 4 you may manage very well.
A prospective study in professional ice-hockey showed this very well. Twenty-one players were followed for 5 years- 15 had labral tears in one or both hips. At 5 years 19 of the 21 were still playing professional hockey. The development of any hip and/or pelvis symptoms occurred in only 3 players (14%) within 4 years. Only 1 of the 3 players missed any games because of hip and/or pelvis symptoms (this was ITB pain which is most likely unrelated).1
Figure 2 A: FAI of both hips, B: focused x-ray of left hip, C: MRI of left hip showing bone change and labral tear (Arrow)

This is a training phenomenon

A number of recent studies from the Netherlands have confirmed what many clinicians in the field have believed for many years- in your adolescent years the more you train and the higher the intensity of that training the more likely you are to develop FAI morphology. The study looked at elite soccer players in Holland and compared the rates of development of FAI morphology. Basically the more often you trained and played at a higher level the more likely you were to develop FAI morphology.2
That’s why so many players who present with hip and groin pain on one side are often shocked to see the MRI findings of FAI are seen on both sides on imaging. This is a developmental issue, which may or may not cause an issue. It will only cause a real issue when the other factors outlined above are present.

But I have a tear in the labrum!

This draws many parallels to knee meniscal surgery (shock absorber often called ‘cartilage’ in lay terms). Efforts to improve meniscal repair and minimally invasive surgery are the hallmarks of the efforts we make to preserve the meniscus- this is a shock absorber which protects the rest of the joint and the articular cartilage. In the past the surgical approach was very aggressive and much more tissue was removed than is now the norm. Over time it became obvious that this strategy caused considerable joint damage in later years- hastening the onset of osteoarthritis.
Nowadays even when a meniscal tear of the knee is confirmed, unless there are mechanical symptoms such as the joint locking or recurrent joint effusion (joint swelling) we try to avoid operating on the joint.
A good lesson to learn from previous findings is that case series for other surgeries (eg, meniscus tear, shoulder impingement) are often favourable, but subsequent randomised controlled trials (best evidence level) show no additional benefit over non-surgical or sham therapy.
We are making the same mistakes with hip surgery. Studies have shown that labral tears are, more often than not, asymptomatic even in an athletic population.3 Studies have also shown that tears in the labrum as large as 3cm may be present while the labrum still does its job.4 Unfortunately it has also shown that removing the labrum increases the force across the acetabulum- which may, in fact, predispose the patient to arthritis.5

Movement patterning

Studies have shown that a number of movement patterns may predispose the athlete to develop pain in the presence of FAI- the athletes may develop one of the 5 issues outlined above.6 This is a factor of colliding variables. In the absence of a symptomatic labral tear, it is a little simplistic to think surgery to the area will fix this. It is often proposed that if the athlete does not gain significant relief or in fact abolition of their pain on an intra-articular injection it is unlikely they will benefit from surgery. This is not supported by any research but is based on some sensible thinking- if we neutralise any pain source within the joint and the pain persists this suggests there are a number of soft tissue structures around the joint which are causing some pain- these should be cleared first.

Will I get arthritis 

I regularly hear from patients that they are going to develop arthritis of their hip if they don’t have surgery to correct their FAI. Although some information exists on osteoarthritis secondary to grossly visible deformities (severely abnormal ball or socket shapes), there is almost no information on the natural course of more subtle femoral or acetabular deformities as present in FAI.7 There is an association between symptomatic FAI and development of OA.8 We don’t know who will develop OA but we do know the risk tends to be less as we get older. If we are to be scientific in our approach to the medical management of this issue we must respect this information.
This has been highlighted in the work of one of the most respected hip surgeons in the UK, his 2009 work followed a group of patients (90) with FAI and found “mild to moderate osteoarthritis in hips with a pistol-grip deformity will not progress rapidly in all patients. In one-third, progression will take more than ten years to manifest, if ever. The individual geometry of the proximal femur and acetabulum partly influences this phenomenon. A hip with cam impingement is not always destined for end-stage arthritic degeneration.”9
Even more worrying, no study to date has supported that arthroscopic surgery of the hip actually changes the outcome of whether arthritis will develop or not.8 The timing of surgery poses other real questions, as the severity of joint cartilage damage is associated with worse outcomes following surgery and more rapid progression to total hip replacement.10 A sobering thought.

Evidence-based approach

Most scientists in the area of sports medicine agree that an evidence-based approach is in the patient’s best interests. They also agree that performing high-level research in sports medicine is difficult because athletes are in a hurry and want to ‘get the job done’. We need to take a moment here however to consider what we are trying to achieve. Taking the model of 5 colliding variables is a useful one to keep things sensible. Even though x-ray or MRI findings support bone shape changes or cartilage damage doesn’t mean surgery must happen. Of course there are situations where surgery is required, but it is imperative for those doctors and physiotherapists looking after teams to ensure 3 & 4 above (especially vigorous supraphysiological (high-level/high-intensity) motion that results in such abnormal contact and collision, repetitive motion resulting in the continuous insult and) are altered first.
I have listed references here in a manner similar to a scientific article as these facts are bound to irritate a number of people. I have tried to take some of the emotion and fear out of this topic and instead look at this from a scientific perspective. There are rarely black and white answers in sports medicine- the best option often being quite grey.
Those trying to help and guide athletes must be prepared to look beyond what appears to be a quick fix and use the information out there to guide their decision-making process.
For further information on this subject please contact sportsmedicine@sportssurgeryclinic.com or phone 015262030

De-Mystifying Hamstring Injuries


Hamstring Injury UPMC Sports Surgery Clinic Santry Dublin 9


We have all seen it: the sniper picking off your club’s best player 15 minutes into a championship game. One hand reaches for the back of the thigh while the other hand goes up signalling his/her game is finished.

Commonly what you may not see is in the weeks prior to injury where many of the signs were there – the increased training load, the missed sessions due to hamstring tightness and the decreased hip range of movement. Recovery between sessions may not have been as good as it could be due to increased driving, studying or working hours. There is often a history of recurring hamstring injuries that just won’t alleviate despite all the hamstring strengthening work.
Hamstring injuries account for a significant portion of overall injuries in the GAA, with injury rates reported at 29.1% and 23.6% of overall injuries in Gaelic football and Hurling respectively. A hamstring injury can result in significant lost playing time, anxiety to the player involved and significant cost. Re-injury rates currently reported in the literature are high (up to 33%). This would indicate that our rehabilitation strategies are either incomplete or athletes return to play too early. In reality, it is probably a mixture of both.

Injury Mechanism & Prognosis

The importance of establishing the mechanism of injury is important in terms of guiding the rehabilitation process and advising the time that will be lost to sport. Adopting a one size fits all approach to rehabilitation can lead to slower rehabilitation and poorer outcomes.
Studies suggest that more proximal (higher) hamstring injuries will result in a prolonged rehabilitation period. Acute tendon damage can also significantly increase recovery times. An injury to the proximal tendon of the long head of biceps femoris is particularly significant in prolonging the rehabilitation process. Other studies have suggested that high speed running injuries will result in quicker recovery times in comparison to stretch type injuries. With sprinting type strains, the high eccentric forces during both the stance and swing phase of running increases an athlete’s injury risk during maximal sprinting. Stretching type injuries generally occur much closer to the ischial tuberosity (where the hamstring attaches to the pelvis) and commonly involve the semimembranosis tendon. These injuries should be treated with caution as the symptoms often appear much milder and heavy loading and stretching provoke the injury further. Other factors that will negatively influence progress include avulsion fractures, a grade III hamstring rupture, recurrent hamstring injuries and a large and deep haematoma on examination. This demonstrates that there are many factors that will determine how severe the injury is and how long it will take to rehabilitate.

Recurring injuries – What are we missing?

This is a tough question to answer as there are a lot of rehabilitation strategies being used. Sometimes ‘why’ injury occurred is not fully identified and focus is on the ‘where’ injury has occurred i.e. hamstring. Identifying the root cause is often the difference between fully rehabilitating and the athlete who has ongoing tightness and re-injury.

Strength

Post injury strength deficits and any neuromuscular inhibition must be addressed in order to return an athlete to performance. Progressively loading the injured muscle to maximise strength gains and enhance collagen fibre formation in the tissue remodelling process is key. Ideally hamstring strength on return to play should be symmetrical and also proportionate (roughly 66%) of the strength of the ipsilateral quadriceps muscle. However the number of athletes that present with quite “strong” hamstrings is high. These are the athletes who are most confused; ‘I have done all the strengthening’, ‘I have done all the nordics’, ‘I have done all the hamstring curling’, ‘why do I keep getting these injuries?’.  These are normally people who have rehabilitated the ‘where’ injury has occurred.
Strengthening agonist muscles during rehabilitation will also help off load the injured muscle on return to sport (i.e. gluteals). Tight hamstrings have also been attributed to an inability of the gluteal maximus to act as the primary muscle to extend the hip during running. Failure to address factors such as these explains why athletes continue to experience hamstring and hip tightness despite a lot of stretching and foam rolling. The underlying reasons for the tightness is not addressed through stretching or foam rolling, hence why the hamstring reverts to tightness soon after again. This leads to overload of the hamstrings and increases the risk of hamstring strain. Both speed of loading and direction of load need to be considered. At SSC we use multi-joint strengthening strategies such as squatting and deadlifting to achieve these aims (both single and double leg).
We also use exercises such as Nordics and isometric hip extension holds in the latter stages of rehabilitation to enhance muscular strength and as maintainance work on return to play.
So if this part is generally done quite well, where do athletes fall down? At the SSC, we are lucky enough to have access to 3D biomechanical analysis in our motion analysis lab. This gives us invaluable data on how an athlete moves and aids our rehabilitation strategies.
Rehabilitation can then be guided based on both examination findings and identifying the biomechanical deficits with each individual athlete. Often the hamstring is the victim of inefficient mechanics at the trunk, pelvis, hip and ankle. Identifying the reasons behind an acute or recurring injury will lead to more successful outcomes.
Lumbopelvic control
The ability to control the pelvis effectively represents one of the most important aspects to successfully rehabilitating and preventing 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. This is due to the change in position of the hamstring origin at the ischial tuberosity. Addressing this issue also allows the gluteus maximus muscle to more efficiently contribute to hip extension. Poor trunk control can also lead to further compensatory mechanisms in the lower limb which can increase the risk of hamstring injury and influence running effiency.

Running Mechanics

Running is the principal form of transport during field sport and the most common mechanism of injury for the vast majority of hamstring injuries. Failure to address asymmetries or poor techniques can increase injury risk and reduce athletic performance.
There are a number of common technical issues when running that lead to overload of the hamstring muscle group. Athletes often struggle to bring their swing (recovery) leg through far enough while running both pre and post hamstring injury. This results in an athlete overstriding, increasing loads through the hamstrings over a prolonged ground contact time. When an athlete exhibits an excessive anterior pelvic tilt, this exposes the athlete to a greater injury risk as the load is increased even further. Studies have demonstrated a reduction in peak hip flexion post hamstring injury. This could be a compensatory subconscious response to reduce hamstring stretch in the late swing phase which could reduce risk of injury. It has also been suggested that for every degree of decreased hip flexor flexibility increases hamstring injury by 15%.
Delivering optimal multi-factorial rehabilitation strategies represents the most effective method of reducing this risk of re-injury, and the fastest return to competition. It also provides the athlete with a progressive programme that not only returns them to sport post injury, but by addressing biomechanical and movement pattern dysfunction it is also possible to enhance athletic performance and reduce future injury risk.

High Speed running

As well as the mechanics of running it is essential to have exposed your hamstrings to high speed running and sprinting on a regular basis. Sprinting conditions your muscles to high levels of load. This is very important during pre-season but also while returning from injury. The majority of hamstring injuries can run at relatively high speeds in the first two weeks but get into trouble when at maximum speed in straight lines and changing direction. We are currently undertaking a reliability and validity study on a return to play test (the VU test) designed specifically for hamstring injuries that we use with our athletes. On return to play, rehabilitation exercises should continue and form part of gym and warm up routines. Fatigue is also a massive issue on return to play and cross training should take place throughout the rehabilitation process to maintain/build aerobic conditioning and fatigue resistance.
The most important take home point for an athlete is to flag issues early with your team physiotherapist. If there is hamstring tightness evident or hip/ hamstring range issues, address them early through appropriate rehabilitation strategies, adjust your training load and increase your focus on recovery methods. This way it reduces the chance of you being the guy/girl with their hand up in the air 15 minutes into a championship match.
For further information or to book an appointment please contact physio@sportssurgeryclinic.com
Mr Ray Moran UPMC Sports Surgery Clinic

Understanding the Anterior Cruciate Ligament (ACL) Injury


For those of us that are involved in sport, either through participation or from the comfort of our sofas, the term ACL will be a very familiar phrase. One that no doubt conjures up images of discomfort.
We hear about it, we read about it, but what exactly is the ACL?
ACL is an abbreviation of Anterior Cruciate Ligament. It is a 38mm long band of fibrous tissue that connects the femur (thigh bone) to the tibia (shin bone). Its job is to control stability when performing twisting actions.  The cruciate ligament is usually not required for normal daily living activities, however, it is essential in controlling the rotation forces developed during side stepping, pivoting and landing from a jump.
The ACL is commonly injured whilst playing ball sports or skiing when attempting any of the above actions.
When the ACL is stretched beyond its stabilising function, it snaps. Swelling commonly occurs within the hour. Frequently pain is felt on the outer aspect of the knee. The medial ligament of the knee joint may also be disrupted resulting in severe pain and swelling about the inner side of the joint.
Historically this snap would have meant end of the career for an athlete. Thankfully medical and technological advancements mean that diagnosis is made quicker, increasing the chances of full recovery. Improvements in MRI, magnetic resonance imaging, have also helped with the identification of issues with the ACL.
However, while medical improvements have led to better treatments becoming available, the increased weight training and conditioning programmes aimed at making modern day athletes bigger, stronger and faster have increased the risk of ACL injuries.
Prevention is always better than the cure and sometimes making small changes to warm up routines can have a very measurable impact.
Studies have discovered that different use of the quadriceps and hamstrings when landing means that women are 4 to 6 times more likely to suffer an ACL injury. A simple warm up routine centred on jumping and landing has shown significant results in preventing ACL injuries in women’s sports
Prevention, however, is not always possible and there are times when surgery is required. A repair of the ACL is one way of getting the athlete back on track however the most effective way is often a replacement, known more commonly as anterior reconstruction.
For a reconstruction, the surgeon will use a portion of a tendon, typically from the Hamstring areas as a direct replacement for the ACL.
This has the same effect as it is good, strong and very stable, ensuring that the athlete, especially younger ones, return to peak condition. Strength, balance and physiotherapy play a large part in the recovery process.  The modern day recovery times for ACL injuries range from six to 12 months.

‘Warm up for Runners’ by Colin Griffin

UPMC Sports Surgery Clinic Importance of a good warm up for runners
A good warm-up should prepare the body for the movements and the intensity required in the sport. A warm-up does not need to be time consuming or complicated, but it is an opportunity to address any movement deficits an athlete may have.

Activate and Potentiate

We must take into account that running requires good interaction between the body and the ground. The body applies force to the ground, absorbs it and generates force to propel itself off the ground again. When the foot is in contact with the ground the limb needs to stiffen to load up and store elastic energy and then release it at the right time and in the right direction.
A compliant limb where the joints continue to bend and muscles stretch, as load is being absorbed can waste energy and can lead to lower limb injury. Try riding a bike with flat tyres – a lot of effort goes into the pedals with so little in return and a risk of further structural damage!

RAMP sequence

A desirable warm-up should follow the RAMP principles – Raise, Activate & Mobilise and Potentiate, but not necessarily in that order if you are an endurance athlete.
The athlete should begin with some mobility exercises targeting the hips, thoracic spine and ankles with dynamic movements to achieve an optimal range of movement. Key muscle groups should then be activated.
The muscles around the hips have big jobs to do and need to be prepared for that. These include the gluteal muscles and hip flexors, and for some athletes with internal hip rotation tendencies – the external hip rotators. Some ankle activation work is also useful particularly the ankle plantar flexors.
When running it is desirable to have hip extensors and ankle plantar flexors pre-activated before initial contact with the ground to achieve optimal ankle and knee ‘stiffness’ during mid stance phase. This can be achieved by actively striking the ground with a vertical shin as opposed to just passively striking the ground.
Some athletes may choose to begin with some Raise activity such as a jog, but it can be more beneficial, to begin with Mobility and Activation exercises first before you run. It may be more effective to train good muscle recruitment and movement patterns first and then look to ‘activate’ the aerobic or anaerobic energy systems a little closer to the activity depending on race distance and individual needs. A Marathon runner may not need an intense warm-up, but a middle-distance runner would benefit from priming their anaerobic energy system before a race with some sustained run efforts at race pace.
Potentiation movement drills activate the neural patterns required for running. These are usually fast movement patterns that include low-level plyometric exercises, sprinting and short foot contacts with the ground. Some hopping, skipping and ground reaction exercises and drills are ideal, followed by some short sprints at close to maximum speed. Just one or two sets of low volume duration are required to help prime the system for the task in hand

To stretch or not to stretch?

A common question we are often asked in the clinic is whether static stretching should be included in the warm-up. We tend to avoid static stretching immediately prior to the activity.
Dynamic mobility exercises are much more beneficial in the warm-up as an athlete only needs enough mobility to fulfil the movement requirements of their sporting activity. Such exercises allow for more elastic movements involving a stretch-reflex response that is required for running.
A warm-up should follow some logic and be relevant to the movements required for your sport.
For further information or to book an appointment call +353 1 526 2040 or email physio@sportssurgeryclinic.com

‘It’s not about the shoe’

Shoe selection has become a topic of interest lately particularly among runners. Many sports shops offer a gait analysis service to help with the process of shoe selection with a wide variety of shoe types available. A runner will select a shoe or be advised on their selection based on the theory of extra-cushioning as a protective measure against impact forces, and anti-pronation features to prevent over-pronation or ‘flat feet’. Both influencing factors can be very misleading.

Cushioning

It is not how hard you hit the ground at initial contact or how hard the surface is, that causes overuse injury. It is at mid-stance when the foot is flat under the centre of mass when peak impact forces are absorbed when the risk of injury is at its highest. How the body interacts with the ground as opposed to what’s on the athlete’s feet is most important.
In order to absorb forces effectively and efficiently, certain technique changes can be made so that the leg is stiffer while in contact with the ground. A soft spongy limb will result in greater forces absorbed locally and for longer.

Pronation

Everybody pronates to some degree. Pronation itself is not a problem. It’s the speed of pronation that is the problem for many athletes. This can be influenced by hip strength and running technique.

It is important to look at hip strength first. Weak hip muscles and poor joint stability can reduce the ability to control the speed of pronation. If you can’t control your hip first, how can you then control your foot?

An athlete who runs with a cross-over step can place greater stress on the inside their shin as it attempts to absorb forces with greater degrees of movement within the ankle. This will also make the process of controlling pronation very difficult. Increasing step width can sometimes help reduce the amount of deceleration and stress in the medial shin.

Minimalist shoes and barefoot running

This is another concept that gathered great attention among the running community in recent years as a means of achieving natural mid-foot or forefoot landing based on how our ancestors used to run. Attempting to replicate ancestral practices can be dangerous given that humans nowadays have evolved and adapted to a more sedentary lifestyle.
To completely change from normal running shoes to barefoot or minimalist while replicating the same workloads can be simply too much stress due to gait alterations. Of course, there is nothing wrong with doing some short runs or drills barefoot or minimalist to improve balance (or proprioception) and train foot strength.

Orthotics

There can be a tendency to over-prescribe orthotics. For many athletes, this can be seen as a quick-fix measure. Unless the athlete has properly addressed their strength and movement deficits, it is like bringing your car to a mechanic to fix the wheel tracking without pumping up the flat tyres first.
Of course, if an athlete has improved their strength and running gait and still has injury issues, then there may be a legitimate case for an intervention such as orthotics. It is best to seek advice from a sports medicine physician who can then refer the athlete to a suitable sports podiatrist.

So what type of shoe is best?

This is a question many of our patients at the UPMC Sports Surgery Clinic ask us. The best advice to give an athlete is to select a shoe that is comfortable to run in. We would usually focus on strength and improving running technique first before looking elsewhere.
When assessing a runner’s gait, it is important to look at the body moving as a whole unit. The foot does not work in isolation!
For further information or to book an appointment call +353 1 526 2040 or email physio@sportssurgeryclinic.com

Exercise advice ‘for beginners’ with Osteoarthritis.

Benefits of exercise for Osteoarthritis
Populations of the world are increasing, partly but significantly due to falling mortality rates due to advances in treatments for cancer, cardiovascular disease and infectious diseases. The rheumatic disease has also felt the benefit of modern scientific developments, particularly in rheumatoid arthritis where the ‘biological’ medications offer many a chance of remission and even cure. Unfortunately, and as I have previously written in these pages, there is no single or combination of medications that can treat osteoarthritis (OA), save commonly used pain-killers (‘analgesia’). While analgesia can improve an OA sufferer’s quality of life, used alone it is unable to decelerate or reverse the degeneration of the joint. Many researchers and scientists working in the field of OA believe that treatments that can re-grow or repair damaged cartilage, a feature of OA, might have potential, yet such treatments remain, at best, 5 to 10 years away. What hope, then, is there for someone suffering from hip or knee OA?
Thankfully, there is a treatment for OA, however, patients tend to be less adherent to this prescription, and doctors not so diligent or encouraging when it comes to persisting with the prescribed treatment.

The treatment I am referring to is Exercise, but please don’t turn the page just yet at the thought of another health professional carping on about the benefits of exercise and dietary change! Both doctors and patients want ‘quick fixes’ for illnesses, and patients are accustomed to prompting returns to health after an antibiotic, an anti-inflammatory drug, or surgery. That is one of the reasons a prescription for Exercise in OA is often less than successful at achieving a reduction in pain and an increase in joint function; the fix (Exercise) for OA is not quick.

Exercise requires motivation, a shift in one’s routine or schedule and sometimes monetary cost. For patients with OA, movement of the affected joint brings pain and discomfort, a significant deterrent in prescription adherence. But the evidence for Exercise as a treatment for OA is overwhelming, directly by strengthening supporting muscles surrounding the OA joints and indirectly by assisting with weight loss. Even for those with severe OA, the medical evidence supports the pursuit of Exercise as it can delay the need for joint replacement and reduce pain.
What is Exercise and how can it benefit my OA?
When I tell patients that Exercise is one of the primary treatments for OA, often eyes will start to glaze over. This is because many people equate Exercise with participation in an elite sport seen on TV like the Tour de France or the Olympic Games. On the contrary, the World Health Organization informs us that, to maintain health, we should all partake in a minimum of 150 minutes per week of ‘moderate physical activity’.
Activities that qualify include housework, brisk walking, gardening and walking domestic animals: not exactly the Olympic Games but undeniably attainable by the vast majority of OA patients. The activity should induce a ‘noticeable increase in heart rate’. Most of us (this author included) do not achieve this recommended weekly minimum of 150 minutes, too often citing work or domestic commitments as barriers to achievement. Yet the scientific evidence has shown that Exercise in OA reduces pain and increases physical function, with weight loss an added benefit. In fact, Exercise-induced pain relief is the equivalent of that achieved with many over-the-counter pain killers.
Where and how do I start an Exercise programme?
For patients who have never pursued any type of regular physical activity, there are a number of options. Walking, cycling (including use of an exercise bike) and/or pool-based Exercise are good starting points. These activities will help strengthen the muscles of the lower limbs, further helping with OA. Even if you can’t swim, ‘pool walking’ (walking up and down the shallow end of a heated swimming pool) allows calories to be burned assisting weight loss, the water’s buoyancy takes some of the body’s weight off the joints and the warmth of the water assists flexibility.
Exercise regimens should ideally include aerobic-type activity (where your heart rate increases and calories are burned) as well as strengthening and flexibility exercises. A physiotherapist has expertise in providing advice on all of these facets of Exercise and an assessment is a good investment.
When starting to Exercise for the first time, it is important to set realistic goals, to be patient regarding your progress and to choose an activity that you will enjoy pursuing. Start off your programme by completing 5 minutes of your chosen Exercise. Aim for small increments in your duration of Exercise (e.g. increase the session duration by 3 to 5 minutes once every fortnight). ‘Start low, go slow’ is a useful motto.
Whether you choose to Exercise on your own, with a partner or in a class is purely a personal preference and your choice should foster long-term adherence to regular physical activity.
Am I causing more joint damage by exercising?
The answer to that question is a resounding ‘No’. While pain in the OA joint can increase upon uptake of an Exercise programme, this should decline pretty quickly over a few weeks. If you are particularly concerned about the onset of pain during your Exercise then, with the consent of your treating doctor, take a painkiller 30 minutes to an hour before your session to allow the joints maximal benefit from your activity.
Indications that your Exercise programme may be too intensive include the presence of severe pain during the activity, failure of the pain to subside within a few hours of the activity and increased pain the following day. If this happens, reduce the intensity of your activity to a level that does not induce these adverse symptoms and slowly escalate the programme from there.
Conclusion
In conclusion, Exercise is a proven treatment in OA but unlike modern medicine, it may not deliver a ‘quick fix’. Patients require motivation and determination to succeed. With the right attitude and support from family and healthcare professionals alike, both pain and physical function can improve when a prescription for OA is followed, as well as one’s mood and sense of wellbeing. Remember: Start low and go slow. Good luck!
NB Please inform your GP before partaking in any new exercise regimen.
For further information please call +353 1 5262371 or email rheumatology@sportssurgeryclinic.com

Concussion – Facts and Figure

What happens when you have a concussion? Symptoms, diagnoses, treatments

A concussion is a traumatic brain injury after a whiplash-type injury that causes your head and brain to shake quickly back and forth. It is a complex process in which forces are transmitted to the brain and result in temporary impairment of brain function. A concussion can have a significant impact on the short and long term health of a player if not managed correctly. There is no such thing as a minor concussion.

Facts and Figures

  •  Up to 10% of athletes will experience a concussion in any given sport season.
  • Horse Racing has the highest rate of concussion followed by boxing, with rugby and Australian football a close third and fourth
  • 78% of concussions occur during games as opposed to training
  • Speed impact – Professional boxers punch 20mph, Soccer ball being headed by a player 70mph
  • Research suggests adolescent brains may be more susceptible to concussion studies have shown that the adolescent brain may recover more slowly following a concussion.
  • Rugby is the first sport to allow removal of players from the field of play for a comprehensive assessment of concussion – this is the HIA (head injury assessment). Baseline testing pre-season increases the efficacy of psychometric testing. Psychometric testing may be computerised or use SCAT 3.

How do I know if I have a concussion? Signs and symptoms

• Loss of consciousness
• Seizure or convulsion
• Balance problems
• Nausea or vomiting
• Drowsiness
• Amnesia
• Fatigue or low energy
• Headache
• Dizziness
• Blurred vision

Why must concussion be taken seriously?

• Ignoring the signs and symptoms of concussion may result in a prolonged recovery period, more serious brain injury or in extreme cases in death.
• The potential for serious and prolonged injury emphasises the need for comprehensive medical assessment and follow up until the concussion has fully resolved.
• Returning to play before complete resolution of the concussion exposes the player to recurrent concussions that might take place with ever-decreasing forces.
• Repeat concussions could shorten a player’s career and may have some potential to result in permanent neurological impairment.

REFERENCES

1. Houses of the Oireachtas Joint Committee on Health and Children “Report on Concussion in Sport” December 2014.
2. Irish Rugby Football Union.

For further information or to book an appointment with one of our Sports Medicine Physicians call +353 1 526 2030 or email sportsmedicine@sportssurgeryclinic.com