Dr Éanna Falvey evaluates neuromuscular training programmes for ACL injuries.


Research on all the studies carried out on neuromuscular training to prevent ACL injuries was broken down into three groups; those that had no training, that university-trained and those screened for high-risk injury, and then trained.

The aim of the research was to determine if it might be less expensive to identify high-risk athletes and treat them rather than treating the population as a whole.

A correlation of all the studies showed that it is probably more cost-efficient to introduce a neuromuscular training programme to the general population rather than spending the money identifying those at a higher risk.

The research also showed that the more input and interaction that occurs in an athlete’s coaching, the better they will perform.

In a situation where there is live feedback and the programme is explained properly, the athlete will see more benefit.

A meta-analysis of the data out there showed there is a dose-response between neuromuscular training and reduction in the risk factors for ACL injuries, so much so that over a 12-week course in neuro-muscular training, a significant decrease in risk factors for an ACL injury can be attained.

However when the training stops the risk factors creep back in ensuring that not only is there a need to perform the work, but also a requirement to stay at it.

One solution to these is ensuring that coaches, strength and conditioning coaches, physiotherapists, trainers or doctors can all deliver the programme.

All groups involved in programmes saw an improvement, or a decrease, in their risk of ACL while it was noted that the harder an athlete worked or the more compliant they were the better they did.

‘The Young Arthritic Knee’


Osteoarthritis (OA) is the most common form of arthritis and the third-leading cause of life-years lost to disability.
By the age of 65 years, 50% of the population has OA and, as the population ages in demographic terms, the prevalence of OA is expected to rise. 90% of people over the age of 40 years complaining of knee pain have OA even if their X-rays are normal.
The ageing of the Baby Boom generation, who started reaching 65 years old in 2011, is a factor in the increased future demand for knee replacement surgery in the western world. Knee OA is diagnosed about 13 years earlier, from 69 years in the 1990s to 53 years in 2010. In the US forecasts show an increase in demand for Total
Knee Replacement (TKR) surgery by 673% by 2030. Recent literature reports tripling of TKR use in 45 to 65 years olds in the US. Currently, in the US about 40% of all knee replacements are done in people under the age of 65. Similar data is emerging from Finland showing increased use of TKR in the young.
To make an appointment with Mr. Vioreanu  please call +353 1 5262340 or email gwenjackson@sportssurgeryclinic.com
CLINICAL DIAGNOSIS.
Patients with knee OA complain of discomfort or pain in their knee, which could be consistent or intermittent. The pain is usually worse with activity such as climbing stairs or walking for long distances and relieved by rest. Stiffness of the knee often occurs. This is usually because of fluid accumulating inside the knee joint. The patient finds it difficult to fully straighten the knee and often there is a fixed flexion deformity at the knee joint. Crepitus or grinding is felt in more advanced stages of OA. In the young adult population (patients in their 40’s to 60’s) those signs and symptoms can be subtle and intermittent and always precipitated by a “loading event” such as for example: sudden increase in exercise, putting on weight, a recent holiday and long distance walking, moving house or increase or domestic duties around the house etc Many people with arthritis note increase in their knee pain with rainy weather.

IMAGING.
Weight-bearing Knee X-rays are best for screening for OA in the knee joint. When taking the X-rays the patient should be standing so reduction of the joint space will become evident under the body weight. Often sub-chondral bone sclerosis and formation of osteophytes is present on the X-ray. In the presence of a normal weight-bearing X-ray an MRI of the knee can be performed to determine the condition of the soft tissues around the knee. In reality, nowadays a lot of patients present to their GP or Specialist with a MRI report. The majority of the MRI reports performed in patients of that age group (40’s – 60’s) will read a ‘meniscal tear’. There is published research showing that patients have an emotional reaction to the word ‘tear’ and associate it with something that would have to be ‘trimmed’, ‘cut’, ‘removed’ or ‘repaired’.
The majority of patients when reading the MRI report themselves will have a desire to improve the situation and are looking favorably towards surgery, such as ‘clean-out’ or ‘wash-out’ arthroscopic knee surgery. In reality ‘degenerative meniscal tears’ are normal for that age group. I call them ‘wrinkles and grey-hair’ as collagen degeneration happens naturally with aging. The large majority of the ‘degenerative meniscal tears’ do not require surgery and are best treated with non-operative treatment. That is why the MRI films should be reviewed by an Orthopaedic Specialist and interpreted in the patient’s clinical context before recommending surgery.
There is increasing evidence (prospective randomised controlled trials) published in recent years, showing no benefit of surgical treatment for degenerative meniscal tears (arthroscopic partial meniscectomy) over physiotherapy. I make the analogy of removing degenerative menisci with ‘removing the shock absorbers from an old car, just because they squeak’.
Like the old car, that side of the knee joint will further collapse after meniscectomy and the cartilage deterioration will be exacerbated. Often the symptoms are getting worse as it is the subchondral bone edema after partial meniscectomy in early OA. I call this ‘post-meniscectomy syndrome’.
x ray of young arthritic knee sports surgery clinic
(Left) In this x-ray of a normal knee, the space between the bones indicates healthy cartilage (arrows).

(Right) This x-ray of an arthritic knee shows severe loss of joint space.

The ultimate goal of knee OA treatment focuses on the reduction of symptoms, especially pain, in addition to optimisation of joint function to support activities of daily living.
There are three major categories of treatment in osteoarthritis: pharmacological, non-pharmacological, and surgical. The most effective OA management is multidisciplinary and staged, using combinations of approaches and prioritising the most conservative treatments over those which are move invasive or have more severe complications.  Each of the three treatment categories is summarized below.
Pharmacological Treatments: A mainstay in OA management, drug therapy combines a variety of agents that are mostly analgesic or both pain-reducing and anti-inflammatory.
Non-Pharmacological Treatments:  include a range of treatments such as physiotherapy; weight loss; nutritional supplements; exercise; and joint protection.  Clinical guidelines indicate that non-pharmacological treatments should be a “cornerstone” of treatment, though more research is needed to produce evidence-based rationales for these conservative approaches to OA.
Surgical Treatments:  Surgical intervention (such as re-alignment surgery or arthroplasty surgery) is warranted if conservative modalities have not sufficiently relieved pain or disability, with the choice of procedure being guided by the stage of disease, the type of symptoms and co-morbidities and patient expectations.
Patients with knee OA may move through all three levels of treatment and experience the full continuum of care. When the disease cannot be managed in the general practice setting, then a referral may be made to a physiotherapist or occupational therapist, rheumatologist or orthopaedic surgeon. Sometimes specialised education clinics may be appropriate.  Education is not always a discrete treatment per se, but rather an adjunct to all the interventions requiring active involvement of the patient, and adherence to a treatment plan. In some instances patient education takes the form of a package of self-management approaches.  In other instances it involves specific instruction and follow-up, or trouble-shooting and advice.
The American Academy of Orthopaedic Surgeons (AAOS) recently (2013) released a summary of recommendations for the non-operative treatment of knee OA based on the existing evidence from medical research studies. The report is a 1,200 page document including over 10,000 studies from around the world. The presented evidence is controlled for bias, transparent and reproducible. The guidelines have been written by orthopaedic surgeons and scientists and are continuously revisited and updated.
The recommendations presented are classified as strong, moderate and inconclusive.
A Strong recommendation means that the quality of the supporting evidence is high. Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
A Moderate recommendation means that the benefits exceed the potential harm, but the quality/applicability of the supporting evidence is not as strong. Practitioners should generally follow a Moderate recommendation but remain alert to new information and be sensitive to patient preferences.
An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
After taking a detailed history and performing a thorough clinical knee examination, I spend the necessary time with my patient explaining the diagnosis of knee osteoarthritis. I find using a knee model and looking at the available images (Xray & MRI) together with the patient an easy way to give some insight into his/her condition.
I then discuss in depth the natural course of knee osteoarthritis and the expected results with all treatments, including surgical and non-surgical interventions. This will allow the patient to be actively involved in the decision-making process and make an informed decision on what is the best treatment option for him/her.
In the majority of cases I recommend initial non-operative treatment for knee osteoarthritis in the young patient in order to reduce the symptoms and improve the quality of life. I discuss in detail with each patient the available evidence and the AAOS recommendations for non-operative treatment of knee OA.
I do not recommend arthroscopic knee surgery for treatment of knee osteoarthritis.
If, despite aggressive and persistent non-operative treatment, the symptoms continue to affect patient’s quality of life or are getting worse, then I discuss alternative surgical treatment (such as High Tibial Osteotomy or Total Knee Replacement) at subsequent visits. Proceeding with surgery in such situations is always an informed and joint decision with the patient.
This ensures patients have sound expectations from their treatment and ultimately it will ensure the greatest satisfaction and best possible outcome form their treatment.

Not recommended

Arthroscopy
Strong Recommendation:   No benefit over physical therapy and medical treatment in 3 of 3 studies
Glucosamine, Chondroitin, Fish Oil
Strong Recommendation:   No evidence of clinically important improvements over a placebo in 2 studies
Acupuncture
Strong Recommendation:   No benefit over placebo in 8 studies
Hyaluronic Acid
Strong Recommendation:  No benefit is demonstrated over placebo. 14 studies
Lateral wedge insoles
Moderate Recommendation:  No improvement in 4 of 5 studies
Needle Lavage
Moderate Recommendation:  No improvement in 2 of 2 studies
Electrotherapeutic modalities (electrical stimulation)
Inconclusive Recommendation
Medial compartment unloader braces
Inconclusive Recommendation
Corticosteriods
Inconclusive Recommendation
Growth factor injections or Platelet Rich Plasma
Inconclusive Recommendation

Recommended

Low impact aerobic exercise (e.g. cycling, swimming, walking, yoga)
Strong Recommendation:   Significant benefit in 5 of 7 high strength studies
Weight Loss for those with BMI >25
Strong Recommendation:   Beneficial in 3 of 3 studies
Non Steroidal Anti-inflammatory drugs (NSAIDs)
Strong Recommendation:   quality of evidence demonstrating effectiveness is high.
Mobic, Naprosyn, Arcoxia, Mobic, Celebrex, Voltaren, Nurofen.
Supervised Physiotherapy aimed at improving strength, balance and, flexibility.
Strong Recommendation

Professor Julian Feller on LARS and how psychological barriers impact ACL recovery.


There is a common assumption that if you tear the Anterior Cruciate Ligament (ACL) you must have surgery, however, according to Professor Julian Feller, a Melbourne based Orthopaedic Surgeon there is a group of patients that will cope without surgery.
 Prof. Feller believes there are patients for whom a trial of non-operative management can determine if they can get by or need surgery.
The number of factors determine if an operation is required, however, the initial main ones are how the knee feels and what the future activity, goals and needs of the athlete are.
Giving the athlete time to make this decision is also important. A lack of urgency on the part of the consultancy can in some instances help the patient get their head around the procedure.
With professional players, especially in Feller’s experience Australian Rules Football (AFL), there is a lot of support leading up to the moment of surgery however when they wake up the full impact of what happens to their season really hits them.
That realisation leads to, in some instance, the athlete having less tolerance for pain and the rehabilitation process. Some literally “fall in a heap” as they come to terms with the post-operative process.
There are two trains of thought here. One is that the athlete’s tissues are firmer, harder and tighter, maybe they have harder bone however a lot of it is the psychological impact of the injury that influences their ability to cope with pain and swelling.
The post-op support structure for the player is not the same before they go under the surgeon’s knife, and this makes it difficult for the player to accept.
While the surgery itself is unlikely to undergo a major transformation and will remain a very predictable procedure, the pre and post-operative process will change, something that will help with individual athlete’s needs.
Recovering and the decreases in re-injury are just as much down to the rehabilitation as it is the surgery. Going forward it would appear that graft targeting on an individual basis will form a key part of the process while there is still research ongoing to determine if extra particular procedures will have a role.

‘Strength Training for Runners’

Strength Training for Runners
Overuse injuries are common for runners due to high volume or high intensity running with poor posture and poor running mechanics.  Weaknesses or poor muscle activation in the trunk, hips and ankles can cause problems elsewhere as these areas assume greater load than they are able to tolerate.
More energy is consumed to fuel poor running mechanics. Athletes often find they cannot go faster or in fact fatigue prematurely in a race no matter how hard they train. Every time they hit the ground they leak energy from the body due to poor strength and control. This can be worth several minutes over a marathon distance.
At the UPMC Sports Surgery Clinic, we prescribe strength exercises to runners whether they are recovering from injury or seeking to improve their performance. Strength training has been shown to improve neuromuscular function, increase the percentage of fast-twitch fibres and improve tendon stiffness – all of which contribute to faster and more economical running, as well as reduced injury risk.
Many runners are fearful of doing strength training mainly due to lack of available knowledge to them. We address some myths surrounding strength training below:
It will slow me down
Strength training under heavy loads or explosive movements increases the recruitment of fast-twitch muscle fibres.  You need more of these fibres to run fast! Being able to utilise these fast twitch muscle fibres in conjunction with good cardiovascular fitness with improving an athlete’s speed and efficiency particularly at faster paces and longer distances.
I will get too big
This is a common fear, particularly among female athletes. A properly designed strength-training programme should not allow this to happen. Whole-body exercises appropriate to the athlete and using the right repetition ranges will ensure that strength is achieved without increased muscle size. The key aim of a strength programme should be to train the movement, not just the muscle!
I’m in my 50’s and too old to start strength training
It is never too late to start some form of strength training. Strength training can help to maintain muscle and bone mass and improve metabolic function, which is important for long-term health. For the middle to late age runner, strength training can help them reduce injury risk, improve coordination and performance.
I’m only new to running
This is the perfect time to begin strength training. Many beginner runners develop lower limb injuries in their first 3 months as they place stress on muscles, tendons and bones that are not accustomed to that stress. By adding some strength training in conjunction to a graduated running programme, they will develop the motor skills necessary to run with good biomechanics and reduce the risk of injury.
The athlete is only a teenager and it will stunt their growth
A young adolescent or pre-adolescent athlete doesn’t necessarily have to lift weights to improve strength. They can develop strength and co-ordination through whole-body, multi-joint exercises at their own body-weight. Once a good movement base has been developed then some load can be added using a medicine ball, dumbbells or an Olympic bar.
Designing a Strength training programme
A strength-training programme should be appropriate to the athlete and the level they are at. A typical programme should begin with a warm-up consisting of:
·         Mobility exercises including foam rolling and dynamic stretching
·         Muscle activation to ‘switch on’ hip muscles, core and ankles
·         Movement preparation exercises to prepare the neuromuscular system
The strength exercises should cater to your individual needs at a weight that you are challenged but able to maintain good technique at. The repetitions can be between 4-8 with 3-4 sets and 1-2 minutes rest between sets.  As a rule of thumb, it is best to sequence the exercises so that the biggest whole body movements at the beginning when you are fresh. Two strength-training sessions per week is sufficient and must fit appropriately into the overall training programme.
For the more advanced runner with a good strength base developed, they can include some explosive power exercises such as Olympic lifts or a variation of one, box jumps, bounding and single leg hops. These exercises place high stress on the central nervous system and should be done at the beginning of the session and allow longer rest recovery periods between sets.
Check out our RUN Sport and The Edge for Runners programmes at SSC where runners can benefit from one-to-one or group sessions with an individually designed strength training programme, as well as improving running technique.
For more information or to book an appointment with Colin Griffin Phone +353 1 526 2030 or Email sportsmedicine@sportssurgeryclinic.com

‘Extrinsic and Intrinsic factors affect ACL injuries’


This early research shows that due to variations in some of the genes that code for proteins that make up soft tissues such as the ligaments some athletes could be more prone to ACL injuries than others.

Professor Schwellnus has also identified a number of extrinsic and intrinsic factors cause ACL injuries.

Extrinsic factors linked to cruciate ligament injuries are based on the type of sport with movement, landing and alteration of the moment key focal points.

The level of exposure, the surface, often altered by weather conditions and indeed footwear can all have a role to play in ACL injuries.

So too do laws and changes in rules and while these have yet to be fully researched, this is an area that is going to get more attention.

Intrinsic factors are those relating to the genetic makeup of the athlete.

Female athletes participating in the same sports as male athletes tend to suffer a higher level of ACL injuries.

Having a wider pelvis in a female and slightly knocked knee configuration to the lower limb would be attributes that could lead to ACL injuries.

Body mass index, age and anatomy of the bones could also be differentials on a general level for both men and women to determine those that suffer injury and those that don’t.

Dynamic risk factors such as landing, cutting and changing direction, where the knee bends in, the foot rotates and hip stability is lost are other very high-risk intrinsic factors.

Martin Schwellnus, Professor of Sports Medicine and Exercise Science, University of Cape Town was speaking at the ACL return to play conference in Melbourne.

Professor Kim Bennell – Surgery is not the only option for ACL Injuries


Speaking at the “Return to Play Conference 2014” in Melbourne, Professor Kim Bennell stated that while more research is needed in the area, initial studies appear to suggest that abstaining from surgery can help avoid osteoarthritis.

Kim’s research at the University of Melbourne, focuses on conservative non-drug management of musculoskeletal conditions including osteoarthritis and osteoporosis, with an emphasis on the role of exercise in both prevention and management. However, it is worth noting that surgery is not at fault here. A return to fully-loaded competitive action is. Once an athlete or elite sportsperson has recovered from surgery they resume their high impact participation in sport. Those that don’t undergo surgery tend to modify their sporting activity and take on lower impact sports such as swimming, walking and cycling.  This could help protect you from osteoarthritis however more study is required in this area.

However, if you want to play elite sport than surgery is your best option. Electing to undergo surgery and a return to action are the only factors that influence osteoarthritis though, there are a number of different reasons why people are at risk when they have had ACL. Damage at the time of the injury, not just to the ligament, but to the bone and cartilage, can have an impact.

This can lead to structural damage, leading to a change in the way the ligament works. It can lead to changes in the contact area and in some instances, the muscular support is not the same as it was prior to the ACL injury.

Mihai Vioreanu

Why I try to preserve the Meniscus – Meniscal Injury concepts by Mr. Mihai Vioreanu

The meniscus is a half moon shaped piece of cartilage that lies between the weight bearing joint surfaces of the thigh and the shin, and is attached to the lining of the knee joint. There are two menisci in a normal knee; the outside – the lateral meniscus and the inner side – the medial meniscus.
Traumatic tears result from a sudden load being applied to the meniscal tissue that is severe enough to cause the meniscal cartilage to fail and let go. These usually occur from a twisting injury or a blow to the side of the knee that causes the meniscus to be pushed against and compressed. These tears typically occur in the young patients and are associated with a “memorable knee injury or twist”. Swelling of the joint may occur although meniscal tears by themselves usually don’t cause a large, tensely swollen knee. Typically, slight swelling sets in the next day after the injury and is associated with stiffness and limping. If the torn portion of the meniscus is large enough, locking may occur.
Degenerative tears are best thought of as a failure of the meniscus over time. With age the meniscus changes its structure and becomes less elastic and more friable. As a result the meniscus may fail with only minimal trauma (such as just getting down into a squat). Sometimes there are no memorable injuries or violent events that can be blamed as the cause of the tear. With such tear the signs and symptoms come more gradually. Stiffness of the knee often occurs. This is usually because of fluid accumulating inside the knee joint.
The most common problem caused by a torn meniscus is pain. The pain may be felt along the joint line where the meniscus is located or may be more vague and involve the whole knee. Any twisting, squatting or impacting activities will pinch the meniscus tear or flap and cause pain. Often the pain may improve with rest after the initial injury, but as soon as aggressive activity is attempted the pain recurs.
Swelling of the joint may occur although meniscal tears by themselves usually don’t cause a large, tensely swollen knee. Typically, slight swelling sets in the next day after the injury and is associated with stiffness and limping.
If the torn portion of the meniscus is large enough, locking may occur. Locking simply refers to the inability to completely straighten out the knee. Locking occurs when the fragment of torn meniscus gets caught in the hinge mechanism of the knee, and will not allow the leg to straighten completely. The torn fragment actually acts like a wedge to prevent the joint surfaces from moving. Stiffness of the knee often occurs. This is usually because of fluid accumulating inside the knee joint.
There are long-term effects of a torn meniscus as well. The constant rubbing of the torn meniscus on the cartilage may cause wear and tear on the surface, leading to degeneration of the joint. Generally the age of the patient along with the type of onset of symptoms is good indicator of the type “traumatic” or “degenerative” tears.
If the patient is young and had a twisting injury more likely that will be a “traumatic” meniscal tear. If the patient is pass middle-age and didn’t have a knee injury more likely that will be a “degenerative” type.
The difficulty lies with the middle-aged patient who had a minor knee twist and had a traumatic tear on the background of a degenerative meniscus.
More commonly the patient will present to the GP with a MRI report where the tear is diagnosed by the reporting Radiologist.
In such instance the GP should make the patient aware of the two different type of tears. A referral to an Orthopaedic Surgeon, Specialist Knee Surgeon is indicated at that stage.
The patient should be advised that not all meniscal tears need surgery.
No not all meniscal tears need surgery.
The treatment of a meniscal tear largely depends on the patient’s age, the type of tear (acute or degenerative), the extend and location of the tear, the general status of the joint and also on the presence of associated knee injuries.  If the knee is locked and cannot be straightened out, surgery may be recommended as soon as reasonably possible to remove the torn portion that is caught in the joint. Once the meniscus is torn it will most likely not heal on its own.
If there is a traumatic meniscal tear and with a flap that could potentially irritate the joint and damage the articular cartilage surgery is indicated to smoothen out the meniscus and the damaged articular cartilage. In young patients with a meniscal tear my preference is to try my best to repair the meniscus and preserve its protective role for the knee joint. This is done with an arthroscopic technique and involves ‘stitching’ the tear back to its native shape.
I do not recommend arthroscopic knee surgery as part of the management of knee osteoarthritis.
Since 2002, six high quality, randomized clinical trials (RCTs) of arthroscopic management of knee osteoarthritis (OA) have been published, two focusing on the efficacy of arthroscopic debridement and lavage on pain and function and four on the efficacy of arthroscopic partial meniscectomy in patients with symptomatic meniscal tear and underlying mild to moderate knee OA.
These studies showed that arthroscopic debridement for OA was no better than a sham procedure in relieving knee pain or improving functional status, and that patients who underwent arthroscopic partial meniscectomy (AMP) for a degenerative meniscal tear generally did not show more improvement than those who underwent sham surgery or an intensive course of physiotherapy.
The latest American Academy of Orthopaedic Surgeons (AAOS) Guidelines (2013) for treatment of knee osteoarthritis does NOT recommend performing arthroscopy with lavage and/or debridement in patients with primary diagnosis of symptomatic osteoarthritis of the knee. The strength of the recommendation, based on the quality of the reviewed evidence is strong.
Aggressive non-operative modalities including physiotherapy, home exercises, non-impact loading exercise, weight reduction, anti-inflammatories and simple analgesics remain the main stay of treatment and avoid the potential complications of operative treatment.
Four RCT’s have been published in the last several years that begin to address the question about the role of surgery in patients with meniscal tear and concomitant OA. Patients across all these studies were randomized to receive either physiotherapy alone focused on strengthening or APM followed by physiotherapy.
The results documented that subjects in both groups improved considerably in the first 6 months with no statistically significant or clinically important differences between randomized groups at 6 and 12 months of follow-up.
Those findings support initial treatment with non-operative therapy in middle-aged individuals with symptomatic meniscal tear and concomitant OA, with subsequent surgery in those who failed to improve.
1. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347(2):81–8.
2. KirkleyA,BirminghamTB,LitchfieldRB,GiffinJR,WillitsKR,WongCJ,etal.Arandomizedtrialofarthroscopicsurgeryfor osteoarthritis of the knee. N Engl J Med 2008;359(11):1097–107.
3. Herrlin S, Hallander M, Wange P, Weidenhielm L, Werner S. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee Surg Sports Traumatol Arthrosc 2007;15(4):393–401.
4. Herrlin SV, Wange PO, Lapidus G, Hallander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating  non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc 2013; 21(2):358–64.
5. Katz JN, Brophy RH, Chaisson CE, de Chaves L, Cole BJ, Dahm DL, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368(18):1675–84.
6.  Yim J-H, Seon J-K, Song E-K, Choi J-I, Kim M-C, Lee K-B, et al. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. Am J Sports Med 2013;41(7):1565–70.

The broader impact of an ACL injury – Dr Andrew Jowett, Director of Olympic Park Sports Medicine Centre, Melbourne, Australia.


Speaking at the Return to Play Conference 2014 in Melbourne, Dr Jowett revealed that ACL injuries do not only affect professional sports stars, they also impact the community level athlete.
This leads to broader impacts on employment and the ability to work in a physical environment and go well beyond the cost of surgery and rehabilitation.
To help study the prevention of ACL injuries and rehabilitation, there is a requirement to understand how often they occur, and not just at the elite level either where there is a lot of data available.
For example, ACL injuries are 4-6 times more common for Australian international women footballers compared to their male counterparts, stats that correlate with data at an international level however according to Dr Jowett there is no data as to what happens on the levels below.
The gaps exist where people do not get ACL injuries treated, or they are simply not recorded.
In general, there appears to be a change in the modern lifestyle, there is less unstructured play. Kids nowadays don’t really climb, they play and train to structured sports programmes.
Physical Education in the school system should be more about unstructured movement rather than competitive sports.
A change in direction is needed at an administration and programme level. A register of injuries at all levels would help the collection of data while a prevention programme at a younger level would help stem the number of ACL injuries.

The role of functional movement in ACL injury prevention with Mike Snelling, Physiotherapist at Geelong Football Club Australia.


Young athletes and amateur sportspeople are not training the same way as they did 30 years ago and as a result kids functional movement, actions based on real-life situational biomechanics, are poor, leading to more ACL injuries.

Teaching and coaching proper talents is key to this. Snelling believes that coaches and trainers have moved away from raw coaching and need to get back to basics.  It is about addressing certain areas and learning how people learn to move.

Some people use vision, while others use feeling. Depending on the situation coaches can help kids and athletes learn through visual feedback or a more hands-on approach.

Modern technology can play its part too. These days almost everyone has access to video, whether is it through smart-phones, iPads or other devices. These can be used to tape amateur and sub-elite sportspeople and allow feedback to be given very quickly.

As well as focusing on prevention, autogenic muscle inhibition, where the receptors in the knee have been damaged, is another key component in the battle against ACL injuries. This inhibition causes a change in the pathway back to the brain leading to a quadriceps weakness. This “weakness” can be present in the knee for up to 2/3 or 4 years while others often never get it back.

Voluntary exercise can help in this instance however neuromuscular exercises can also aid with the recovery to make sure that when the sportsperson is ready to return to the field of play their strength is back.

Research is key to the prevention of ACL injuries. For instance, studies have shown that dancers and ice skater have low incidents of ACL injuries. This is due to a lack of unanticipated movements, everything is pre-planned and choreographed.

However, in the various codes of football, there are a lot of unanticipated movements. The only way you can protect and prevent is by exposing the player to as many of those movements as possible and that feeds into the situation where for an unanticipated they have the right foot placement to minimise injury.