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Why does Ireland have such a high rate of ACL injuries?

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Why does Ireland have such a high rate of ACL injuries?

Professor Brian Devitt is a Consultant Orthopaedic Surgeon at the UPMC Sports Surgery Clinic in Santry and a Professor of Orthopaedics and Surgical Biomechanics at Dublin City University.

This interview with Professor Brian M. Devitt was published on RTE’s Drivetime on 20th February 2023.

Professor Brian M Devitt SSC

For further information on ACL Injuries and Reconstruction or to make an appointment with an Orthopaedic Surgeon, please email info@sportssurgeryclinic.com

What is the Anterior Cruciate Ligament ?

The rate of Cruciate Ligament injuries in Ireland is among the highest in the world, which could be down to the types of sports commonly practised here. Brian Devitt is a Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic in Santry and also a Professor of Orthopaedics at DCU. He’s been researching this area, and he joins us now, you are very welcome Brian (BD)

Just for those who don’t know what is the cruciate ligament and why is it so important?

BD: We have two Cruciate Ligaments, one is the anterior one at the front of the knee, and we also have the posterior one at the back of the knee.

The Anterior Cruciate Ligament (ACL) is the most commonly injured of the two, and it is only a 3.7cm ligament, but it is very important in sports because it controls rotation and stops our shin bone from moving forward in relation to our femur, side bone, so potentially it is a career-ending injury or at least it used to be anyway, but it certainly can cause a lot of damage in the knee when injured.

Is it easy to Injure your ACL?

BD: It is surprisingly easy, and that’s the problem; it tends to happen with non-contact injuries. So it is not when someone is being tackled, for instance, or trying to evade an opponent but more as ‘pivoting’, which means moving quickly in one direction.

Seven out of ten times, it occurs as a non-contact mechanism.

It isn’t usually an injury that you would associate with athletics or racing where you are just running in a straight line it is more where you are stopping, starting, turning and twisting types of sports?

BD: Yes, that is exactly right, a lot of those sports tend to involve a ball and particularly in the sports that we play in Ireland, the ball tends to be above the eye line so you tend to be focusing on the ball and catching it and then an opponent is tackling you, or you try to evade them so your eye line and your ability to move quickly can change.

Q: So what are we talking about here GAA, Hurling, Rugby and maybe Soccer as well?

BD: Yes Soccer actually has a very high basis of ACL injury, so all these kinds of ‘pivoting’ sports as we referred to already and really they make up the majority of team sports we play in Ireland.

As a result of that our rates in terms of cruciate injuries are amongst the highest in the world that’s directly related to the fact that we have this love for GAA, soccer and rugby too?

BD: Yes, and it is hard to get a really good number on the injuries. A lot of countries, particularly in Europe and New Zealand, have registries where we can look and get a good idea of the number of people who are injured.

So we have different sports that run data surveillance like GAA and rugby, so we can get a picture of how common the injury is. Certainly, our levels would be equivalent to the likes of Australia, where they play similar types of sport.

You mentioned it used to be career ending, less so now - what happens now if you get a cruciate ligament injury?

BD: So it all depends on the age of the patient, really, people that are slightly older, maybe in their forties perhaps, we can treat these injuries non-operatively.

But for young patients, we tend to recommend ACL Reconstruction, particularly if they have any other damage within their knee.

The idea is you need to control the rotation in the knee and give that patient a stable knee. So we can’t repair them; they tried doing that in the past with very dubious results.

So now we have to reconstruct the ligament by tacking a graph typically from the patient themselves.

Q: That sounds like quite an involved treatment, quite a serious surgery?

BD: It is a serious surgery, we have refined the surgery over the years, so it is not the career-threatening injury it used to be.

Our techniques and our ability to diagnose ACL injuries have certainly improved and nowadays, it is a pretty routine surgery for us.

The prognosis for the patient or how they are going to do in the future is not just based on their injury of the ACL but also to the other important structures that are in the knee, such as the cartilage or shock absorbers which we refer to as the meniscus. This really determines how a patient does in the long term.

There is also an increase in women being diagnosed with ACL injuries?

Q: There is also an increase in women being diagnosed with ACL injuries, I know we were doing a programme a couple of months ago on this and it is partly linked to the footwear women have been wearing, because the footwear woman wears in sports is designed for men and doesn’t take into account the different weight of women. etc., and the different ways they move.

Is that something you will be seeing as well, women are playing more sports also and women are being diagnosed with more ACL injuries?

BD: Yes, I think it is a multifactorial reason as to why women tend to create quite a risk in certain sports, but what we are certainly seeing is a greater level of participation of women, so therefore, we are seeing the rates increase in terms of the number of women presenting to us for reconstruction, definitely increases.

I think there was a very worrying trend in Australia, where I was working for the last eight years, where they have seen a huge epidemic of ACL injuries, particularly in the young female population, from the ages of twelve right up until eighteen.

I think similarly in Ireland we have more organised sports at a young age, particularly for girls and young women. Therefore our rates are increasing

If you’re listening and you have children involved in sports, like the sports you have mentioned. What do you do to try reduce the chances of them getting an ACL injury?

BD: Well, the great thing is a lot of the sporting bodies that I have mentioned have fantastic initiatives in place to try to reduce the rates of injuries. I think initially they are referred to as injury prevention strategies, but really, we can’t prevent injuries but just reduce the risk.

These warm-up exercises have been shown to reduce the rate of injuries by up to fifty per cent, and they are included as part of a warm-up in GAA fifteen, FIFA Eleven and Rugby have an equivalent warm-up technique.

If you’re to do anything, it is to encourage your children and also their coaches to get involved in this warm-up because they are really very effective.

Q: Ok, so the warm-up really matters then? It’s really important?

BD: Absolutely, it matters.

Q: Is it something that children have a bit more resilience against? they are a bit more bouncy to use a non-medical term.

BD: They can be bouncy at younger ages, but what we typically see is when they become less bouncy as they get to the adolescent stage, they are probably at increased risk.

Also, once they have had  ACL surgery, there is quite a risk of re-injuring the same ACL even though they have been reconstructed but also injuring the contralateral or opposite leg.

This is a group we really focus on. We refer to them as high-risk groups, so whereas we can try to mitigate and reduce the rates of injury when we have patients that have sustained these injuries, we have to think quite clearly in terms of how we reconstruct them and if it is efficient alone to do an ACL reconstruction or do we have to do something else to try to reduce the rates after surgery.

Alright, it was great speaking to you that was Brian Devitt, Consultant Orthopaedic Surgeon at the UPMC Sports Surgery Clinic in Santry.

‘Ireland’s rate of ACL injuries among highest in the world because of GAA and rugby’ Professor Brian M Devitt

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Leading surgeon points to alarming number of injuries here as competitors push their bodies further

This article was published in the Irish Independent on 20th February 2023.

 

Professor Brian M Devitt Consultant Orthopaedic Surgeon at SSC in Santry.

A leading surgeon has said the incidence of anterior cruciate ligament (ACL) injuries in Ireland is among the highest in the world, as sports popular here have a high risk for the injury.

Brian Devitt, a consultant orthopaedic surgeon at the UPMC Sports Surgery Clinic in Santry and Professor of Orthopaedics and Surgical Biomechanics at Dublin City University, said he is also seeing more ACL injuries as the number of women taking part in sport is on the rise.

“In GAA, hurling and rugby, the ball is often played overhead, above a player’s eye-line,” Prof Devitt said.

“When a player is fielding a high ball, landing, and trying to avoid an opponent by pivoting, there is a lot going on which requires huge co-ordination. Unfortunately, when this co-ordination fails, even momentarily, it can put the knee at risk of giving way, and that’s why there’s a high rate of ACL injuries here.

“There are lots of times during a match when players aren’t aware of how they are landing when trying to catch the ball. An injury can happen in a microsecond, and that’s especially true for the sports we love in Ireland,” he added.

When the ligament pops or snaps, it may require surgical reconstruction as it has a limited capacity to heal.

“The ACL controls the forward motion of the knee and also, most importantly, rotation. If you are changing direction, such as side-stepping, then your ACL is working. In the majority of cases – roughly 70pc – ACL injuries occur without contact with an opponent.

“A rupture typically happens when a player is pivoting, or changing direction at speed.

“The other reason we are seeing such a high incidence of ACL injuries in Ireland is because the level of female participation in sports is surging, which means we are seeing comparable ACL numbers now in women.”

The source of the trouble, the ACL, is a 3.5cm piece of connective tissue which links the shin bone to the thigh bone, located in the middle of the knee.

When the ligament pops or snaps, it may require surgical reconstruction as it has a limited capacity to heal. This is especially recommended in young, active individuals returning to a pivoting sport.
ACL reconstruction surgery is reasonably routine, but it can be complex if there is additional cartilage damage.

There is no guarantee of success, particularly in young patients, who are high-risk.
“It is tragic when an ACL reconstruction fails, and, unfortunately, we do have higher failure rates than we would like in our younger population,” Prof Devitt said.

‘In GAA, hurling and rugby, the ball is often played overhead, above a player’s eye-line,’ Prof Devitt said.

“We understand some of the reasons for this, but not all. This is one of the questions I would like to address in my clinical research.”

Prof Devitt went to school at Belvedere in Dublin’s north inner city, where he excelled academically and in sport, playing rugby for the school team. He studied medicine at UCD, and continued to play rugby.

“Given how much I was involved with sport, it seemed like a natural progression to head for a career that would involve sport, and orthopaedic surgery was the ideal speciality for me,” he said.
After UCD, he completed his orthopaedic training at the Royal College of Surgeons in Ireland, before heading overseas on a fellowship in the US, Canada and Australia.

My research is looking outside the knee for new solutions – not simply doing a reconstruction of the ACL, but a procedure outside the knee.

He also found time to raise a family with his wife Marina, with whom he has three children, aged 10, eight and six.

“We have the unique distinction of having three children, all born on different continents. As such, our children all have at least three passports,” he said.
He decided to return home last year, when he accepted a role where his time would be divided between clinical work at the Santry clinic and research at DCU.

Since returning he has been staggered by the number of ACL injuries coming through his clinic door.

“I worked at a hospital in Melbourne for a number of years, and saw a lot of ACL injuries – which was not a surprise given how devoted the Aussies are to sport,” he said.

“Ireland though is totally bonkers about sport, and the volume of ACL injuries I’m seeing in Santry certainly surpasses the numbers I experience in Melbourne.”

He sees injury reduction as a big part of his new role, and he does not want to be a surgeon interested only in treating injuries.

“An ACL injury is traumatic for the person who suffers it, and it can increase the risk of earlier onset of arthritis,” he said. “A successful reconstruction of the ligament can get someone back playing sports and perhaps delay the onset of arthritis later in life, though we can’t prevent it.

“A big research question for me is how we can reduce ACL injuries as we will never be able to totally prevent them from happening.

“My research is looking outside the knee for new solutions – not simply doing a reconstruction of the ACL, but a procedure outside the knee. We want to improve our surgical techniques, and also to use biomarkers, which can hopefully inform us about who is at great risk for arthritis.”

For further information on ACL injuries or to make an appointment with an Orthopaedic Surgeon specialising in knee Injuries, contact info@sportssurgeryclinic.com
UPMC Sports Surgery Clinic Orthopaedic Hospital

UPMC to Acquire UPMC Sports Surgery Clinic

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UPMC Sports Surgery Clinic in Santry to become part of renowned global care network.

DUBLIN, 16th January 2023 – In a move that will dramatically expand UPMC’s ability to provide world-class orthopaedic and sports medicine care in Ireland, the health system today announced that it is acquiring the renowned UPMC Sports Surgery Clinic (SSC), a leading independent hospital located in the northern Dublin suburb of Santry.

Well-known for its care of patients and athletes across Ireland and Europe, SSC will become part of UPMC’s network of orthopaedic, sports medicine and rehabilitation facilities, and will also become UPMC’s fourth hospital in Ireland, joining UPMC Whitfield in Waterford, UPMC Kildare in Clane and UPMC Aut Even in Kilkenny, along with sports medicine and outreach facilities across Ireland.

“With the acquisition of the UPMC Sports Surgery Clinic, we will have the ability to expand our already trusted and high-quality care to more patients across Ireland and beyond,” said Charles Bogosta, president of UPMC International. “SSC will complement our existing network of orthopaedic care in the U.S. and Europe and ensures that we can provide access to care to more patients, close to home.”

Founded in 2007 by orthopaedic surgeon, Mr. Ray Moran, and accredited by The Joint Commission International, the 101-bed SSC has become a centre of excellence for joint replacement and surgery for sports soft tissue injuries in Ireland. The SSC currently has more than 40 consultants in orthopaedic surgery and allied specialties, supported by a team of more than 400 nurses, physiotherapists and other health care professionals.

Commenting on the agreement, Mr. Ray Moran, said: “This is an exciting development for all of us involved with UPMC Sports Surgery Clinic and we are delighted to be joining forces with UPMC. It brings together like-minded and innovative teams whose combined experience and expertise will benefit the patients that we serve.” He continued: “We look forward to working with UPMC to build on the legacy of excellence and innovation that the UPMC Sports Surgery Clinic has established as we expand the scope and location of our services for the benefit of patients.”

“The addition of SSC will position UPMC as an all-Ireland network of care and builds upon our commitment to clinical excellence since establishing our first cancer center here in 2006,” said David Beirne, senior vice president of UPMC International. He continued, “This pending acquisition is just the latest expansion of UPMC’s clinical care in Ireland. In addition to the current three hospitals and concussion network, UPMC operates two advanced radiotherapy centres, three sports medicine clinics and several outpatient facilities across the country.”

UPMC’s acquisition of SSC is subject to approval by Ireland’s Competition and Consumer Protection Commission. Terms of the purchase are not being disclosed.

Dazed and contused: Tackling concussion in women head on – Colm Fuller SSC

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UPMC Sports Surgery Clinic’s head of Physiotherapy, Colm Fuller, contributed to this article by Sharon Ni Chonchuir which was published in the Irish Examiner in December 2022.

A growing number of women are togging out to participate in team sports. The Football Association of Ireland’s 2019 review found that there were more than 19,000 female youth and 4,800 adult soccer players in Ireland. The Ladies Gaelic Football Association has more than 1,000 clubs nationwide. And as of 2018, there were 2,500 girls and 1,341 women playing rugby union.

While this level of women’s involvement in sport is to be celebrated, it is concerning that their injury rates are increasing in tandem with their participation rates. A 2019 study [exa.mn/women-rugby-injuries] reported that St Vincent’s Hospital in Dublin had experienced a 243% surge in injured female rugby players presenting at the hospital in the previous ten-year period and its authors warned of an increasing number being treated for concussion.

It’s happening in ladies’ Gaelic football too. A recent DCU survey of 657 players found that 10% had been diagnosed with concussion in 2020 and a further 8% thought they had been concussed but hadn’t reported it.

Experts point out that delaying seeking medical attention for concussion can lead to persistent symptoms.

International research warns that women may be more vulnerable to concussion than men. A 2021 study [exa.mn/soccer-concussion] led by Abigail Bretzin, a research investigator at the University of Michigan’s Injury Prevention Centre, looked at data from 43,000 male soccer players and 39,000 female soccer players over three years. It concluded that girls’ chances of concussion were 1.88 times higher than boys’ and that they were more likely to require longer recovery times.

“It proves something we’ve suspected for a while,” says Bretzin. “When comparing sports that men and women participate in, women have a higher rate of concussion.”

Bretzin is one of many academics working to uncover the reasons for this gender bias.

“Some studies suggest there are differences in axonal structures in male and female brains,” she says. “Axons are tiny fibres that form a network within the brain, transporting information from neuron to neuron. A 2017 study [exa.mn/axonal-structure] found that female axons were predisposed to greater mechanical damage and physiological dysfunction compared to male axons receiving the same injury. However, this is limited to animal studies and more research is needed.”

Other research points towards the difference in neck strength, girth and circumference as a factor that may reduce females’ ability to resist a head impact compared to males. “Using neck strengthening and muscle activation is now being studied as a way to protect athletes, and military personnel, from concussions,” says Bretzin.

Dazed and contused

Colm Fuller is the head of physiotherapy at the UPMC Sports Surgery Clinic in Santry and has worked with the London Irish, Munster and Ireland Rugby teams. He explains that concussion is a “mild traumatic brain injury that results from a transfer of mechanical energy to the brain from external forces”.

This can happen in all sorts of ways. Players can sustain a direct knock to the head by bashing against another player or hitting a ball or a goalpost. Concussion can also be indirect, resulting from the brain absorbing some of the impact from a fall on another part of the body.

“Sports – particularly contact and collision sports – account for approximately 20% of concussion injuries, but concussion can happen in many other circumstances,” says Fuller.

It can also result in a wide range of symptoms. “Some people experience a change in mental status and become dazed and confused,” says Fuller. “Others have physical symptoms such as headache, dizziness or increased sensitivity to light and noise. There can be cognitive symptoms like difficulty concentrating. There can also be emotional symptoms with people experiencing emotions that are uncharacteristic or heightened for them.”

Losing consciousness only happens in about 10% of cases. “The brain has three main parts: the left and right hemispheres and the brain stem,” says Fuller.

“A loss of consciousness may only occur when the brainstem itself is or both hemispheres are disrupted at once. If only one side is disrupted, the other side can usually compensate and help it out.”

Because concussion is a mild form of brain injury, it affects how the brain works but doesn’t cause structural damage that is visible on current standard imaging such as MRI. This means it’s typically diagnosed by analysing the symptoms that follow a head injury.
“It could be a cognitive test such as asking the patient their name, where they are and what time of day it is,” says Fuller. “Or maybe a balance test or seeing how their eyes move and react to vision tasks.”

While symptoms can be serious, Fuller reassures us that they are usually temporary. “Most of the time, they resolve and people recover,” he says. “Adults are typically symptom-free within two to four weeks of their injury.”

“Early intervention promotes better recovery,” says Fuller. “Up to 30% of concussions may have persistent symptoms lasting longer than normal recovery times and, unfortunately, these are the cases that tend to present for medical attention. Therefore, it is recommended to at least check in with a health professional in the event of a concussion to help guide your recovery.”

Governing bodies have introduced guidelines to protect their male and female players from concussions. These guidelines are similar across GAA, soccer and rugby.

As soon as someone sustains a suspected or confirmed concussion, they must immediately be removed from play and subjected to a medical examination before following a graduated return to play.

This phased return consists of five steps. The first is two days of complete physical and cognitive rest. The second involves building up to normal activities and light exercises. Then aerobic exercises are introduced, followed by sports-specific and non-contact exercises before players finally return to full contact practice. Players can only progress from one step to the next if they remain symptom-free during the various exercises and for 24 hours afterwards.

Different guidelines

The Irish Rugby Football Union and the Football Association of Ireland apply the same guidelines to male and female players but the GAA distinguishes between the sexes. In recognition of the evidence that females may require more time to recover, they are advised to take at least two weeks before returning to full contact training and matches, while men are advised to take at least one week.

Increasing medical personnel at women’s sports could help redress the concussion gender imbalance.

“We have seen that the quality of medical personnel available at the time of injury may not always be equal for women and men,” says Bretzin. “Equal access to trained medical providers could help in early concussion management.”

Fuller agrees. “Women’s sports tend to have less financial support than men’s, which means that they’re less likely to have medical personnel at games,” he says. “This has to be addressed and, in the meantime, players, referees and coaches should be educated about the risk of concussion.”

His advice to all players is never to ignore a head injury. “If in doubt, sit them out,” he says. “Take them off the pitch and seek medical attention.”

Regardless of the risk, Fuller doesn’t want to deter women from playing sports. “Sports participation is to be encouraged and promoted for all the benefits it brings from a physical, mental, emotional and social point of view,” he says.

“There is a varying risk of concussion in a lot of sports, and this needs to be addressed with education of participants, parents, coaches and administrators/referees. The better informed we are about it, the better decisions we can make to keep the game safe while ensuring high levels of participation.”

Concussion checklist

Concussion is defined as a mild traumatic injury to the brain and most people are symptom-free within four weeks. However, this depends on you and those around you recognising the signs and symptoms of concussion and getting the treatment you need in time.

The range of symptoms varies from person to person and case to case, and they may develop over minutes, hours or even days. If you think you might be concussed, the Ladies Gaelic Football Association has compiled a checklist of critical symptoms.

  • Are you displaying cognitive symptoms such as difficulty concentrating, difficulty remembering, fatigue or a feeling of brain fog? Are there any physical symptoms like headache and pressure in the head to neck pain, nausea, dizziness, vision problem or sensitivity to noise and light?
  • Concussion can have an emotional impact. Are you feeling more irritable, nervous or more intense emotions than usual?
  • Concussion can have a wide-ranging impact on sleep. Some people feel drowsy, while others have difficulty falling asleep. Some sleep more than usual, and others sleep far less.
  • If you suspect someone else of sustaining a concussion, they may be unable to tell you their symptoms. You will have to rely on the signs you can see. These include poor balance and loss of coordination, slurred speech, vomiting, constant clutching of the head, a vacant facial expression or a loss of consciousness.
  • If you’re in doubt, err on the side of caution and seek medical attention. Then rest for 48 hours, avoiding screens, alcohol, recreational and prescription drugs, and driving.
For further information on this topic or to make an appointment with Colm Fuller, please email sportsmedicine@sportssurgeryclinic.com

 

An Interview with Colin Griffin : Masters of Running Podcast

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Listen to this interview with Colin Griffin, Head of Running Services at UPMC Sports Surgery Clinic’s Sports & Exercise Medicine Department.

This was recorded as part of The Masters of Running Podcast in October 2022.

Colin Griffin has over 15 years experience in high-performance sports having represented Ireland at the 2008 and 2012 Olympic Games in the 50km walk which he holds the Irish record of 3.51.

He has also coached other Irish athletes to Olympic level

In 2013 he joined UPMC Sports Surgery Clinic in Santry, where he now manages Running Services at the Clinic. Colin is undertaking a PhD on the biomechanics of muscle-tendon interaction at the Achilles during exercise and gives great tips here on avoiding and helping such an injury.

He’s continuing to race as a masters athlete at 040, recently running a 1.11 half-marathon as a build-up to The Dublin Marathon.

For more information on Running Services at SSC or to make an appointment with Colin, please contact sportsmedicine@sportssurgeryclinic.com

Interview with Professor Brian M. Devitt: The FiftyFaces Podcast

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Listen to this Podcast with Professor Brian Devitt,  Consultant Orthopaedic Surgeon at UPMC Sports Surgery Clinic and Professor of Orthopaedics and Surgical Biomechanics at Dublin City University.

This interview was recorded by Aoifinn Devitt for The FiftyFaces Podcast as part of their “Inspiring People in Medicine and Science” series, which is being released later this year.

For more information on how to make an appointment with Professor Brian Devitt, please contact devittadmin@sportssurgeryclinic.com

Limerick’s Mike Casey conquers ‘dark moments’ on long road to recovery from injury blows

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This article was published on the Independent and written by Donnchadh Boyle.

Earlier this year, when Limerick were still searching for their first win in the National League, Mike Casey had his own little milestone success.

Limerick hadn’t managed a win in four attempts in the league at that point but after a most unfortunate series of events, Casey was about to start his first game for Limerick in two years.

Back in 2020, the All-Ireland-winning full-back was motoring well, playing four of the first five games in that year’s league. However, Covid hit and set in chain setback after setback that would see him out of action.

“In October 2020 we played a challenge against Galway and I did the cruciate then,” Casey explains, picking up the story.

“I had surgery in mid-November, and around July, after my nine months, I came back and played a club game and got through that okay – then the next training session I had a cartilage issue. I felt a pop in the knee and unfortunately my cartilage had given way.

“In July 2021, I got that surgery done by Ray Moran up in Santry; they were excellent.”

 

“Thankfully, I haven’t looked back since.”

Back in the thick of it, it’s easy to forget that the road back was a grind.

“There were definitely dark moments – my girlfriend, Jessica, I’ve been with her five or six years and she was excellent through it all. Any time I had a setback and needed someone to talk to she was there for me. And with the group, a lot of the lads have been through a lot of things, knee surgeries and things like that. And I never left the group.

“I was asked to come in and help with stats and that so I was part of everything that was going on, there was some small bit to contribute to the team.”

He missed plenty in his time out with Limerick sweeping the boards. And while he could help out with the analysis, he also found himself in the unwanted position of being able to advise his brother Peter on his own recovery. He damaged his ACL in last year’s All-Ireland final while in the midst of a tour de force and has just recently returned to full training.

“It was really unfortunate but he’s been able to bounce ideas off me and ask me questions. With an ACL they’re all different but Barry Murphy did his the week after in a club game but they’ve rehabbed unbelievably well under our medical team.”

In the wake of the Munster final win over Clare, a photo featuring Casey and a few of his team-mates celebrating shirtless emerged.

Their remarkable physiques served as a reminder that while they’ve led the way with their hurling, Limerick’s physical conditioning is top drawer too. “It (gym work) is such a fundamental to it. If you’re progressing there, it is definitely going to help you on the field.

“Yes, it’s not the be all and end all of it. You still have to put the ball over the bar. Your bicep curls aren’t going to do that for you.

“But we’re really, really competitive in there, and everyone takes massive pride in it.

“And it’s definitely something that if you are slacking, lads are going to let you know that you need to improve this aspect of where you’re coming at. A lot of lads have really bought in.”

Limerick face Galway this weekend, two wins from yet more silverware for this remarkable team. A third consecutive All-Ireland win would force them deeper into the ‘great teams’ conversation. But for Casey there’s no real secret to their success.

“It’s about getting down to the brass tacks and working and winning that ball. We love doing that.

“It doesn’t matter if we win the game by 20 points or by one point to no score – we love the battle and the intensity and working hard. I think we’ve put that stamp on our play – when people come and play us they know they have to match that.”

From Cavan to Qatar: The physio helping the world’s best athletes recover and improve

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This article was written by Maurice Brosnan and published by The 42.

In the summer of 2018, Tipperary and Sydney Swans flyer Colin O’Riordan came crashing to a halt. He suffered from osteitis pubis as a teenager and in his third year of professional sport it started to flare up again.

O’Riordan persevered until one agonising day at the SCG against the Gold Coast. As he turned to race up the field, the pain became unbearable. At that moment he was convinced his hip was about to explode.

“I couldn’t play the last four games of the season at all,” O’Riordan explained last year.

“I went home and saw Enda King. He had me back running in two weeks. He just sees things differently. Not that he doesn’t believe in surgery but fix the problem before you do that. It was about running mechanics and technique.

“He is honestly incredible. His knowledge of the body. I don’t think he did any work on my groins. It was all hips and glutes. We were doing calf work. I was wondering how this influenced my ability to run. But it does. We’d do a squeeze test and there would be less pain. It is all related.

“He views your body as one. Your upper back is as important as your hips in running. It is all linked. It opened my mind to how the body works. It was like going to college for five weeks.”

This endorsement came to mind recently when reading Chloe Mustaki describe her remarkable recovery from Hodgkin’s lymphoma and an ACL injury. The physical and emotional toll was considerable. During her first visit with King, Mustaki broke down in tears of frustration. It was seven months since her surgery and the pain had not subsided. Fears about never recovering had started to creep in.

Last month she made her Ireland debut.

“This is one of the best parts of my job. It is nice to help good people,” says King.

He has been working as the Head of Performance Rehabilitation at the UPMC Sports Surgery Clinic in Santry, Dublin for the past decade. There he has worked with the likes of Johnny Sexton, Ruby Walsh and Dan Carter as well as a host of professional clubs across sports from the Premier League, NBA and the AFL.

“Going back to my own career and injuries, it can feel like a crater. When you are in it and you’re not sure if anyone can help you get out of it, you cling to any light at the end of the tunnel.

“My goal is to help them understand why they are where they are, but it is also to give them some direction and that they feel empowered to stick to it rather than wait for it to get better. I am not at the level of Chloe or Colin and never was, but any footballer knows what it is like to sit in that chair and wonder will I ever be right.

“Most chronic or recurrent injuries do not go away. You have to get rid of them. People are waiting for it to go away and naturally you become despondent. Whereas a broken bone has a defined recovery and timeline and it gets better. Having been through those experiences, from a research and biomechanics point of view, really opened my eyes.

“Moving attention away from where you are sore and focusing on why you are injured. Then trying to get that across to an athlete. Ultimately, they are doing all the work. I am just trying to show them the direction.”

King’s own playing days influenced his approach now. He still draws on it. He was moulded by it. After success with his club Cavan Gaels, the midfielder went into an intercounty squad with dreams of Ulster glory. Meanwhile, his hip and groins gave him nightmares.

The same thing that hindered him on the field allowed him to prosper professionally.

“At the time, you want it to be fixed rather than standing back and wondering why it is happening. Training load is naturally a massive factor in most overuse injuries. You want to contribute to every team, all the time, rather than focusing attention and saying, developmentally I want to play at this level.

“What can I do this year to achieve that? You try to be a servant to everyone and end up pleasing no one.

“When I look back, rather than looking for a fix or anti-inflammatories or surgery, the first question is why am I sore in this area? How can I optimise my training load and how I move on the field of play to give me the best chance of staying injury-free and optimise my athletic performance.

“Then it is about how do I do it as an athlete? For example, the idea of being in a gym is to make you a better athlete on the field. Not to be only better in the gym.”

Knowing what you want and the best way to attain it. That is his creed and the bedrock of his work. When athletes present with pain, the first step is not targeting the painful area alone but understanding why it is there.

His PhD research focused on the use of 3D biomechanical analysis to better understand how an athlete moves, how that is driving their injury and how to individualise their rehab based on their specific deficits.

Soreness is not just to be dismissed or suppressed with a short-term fix. King rarely uses injections or anti-inflammatory during groin rehab. Pain is a useful marker. A signal providing valuable information. It is about understanding the source rather than temporarily quelling it.

He recently published a research study on hip and groin pain prevalence and prediction in Elite Gaelic Games. It monitored 2703 male athletes across two seasons, the largest study in elite athletes relating to hip and groin pain internationally. The findings were presented at the IOC conference in Monaco last year.

Such research has led to a seismic shift in rehab strategies. Yet the injuries keep happening. How are we improving one crucial aspect while stagnating in the other?

“That paper shows at least 40% of every intercounty team male squad will have athletic hip and groin pain every season, which is a substantial amount,” he explains.

“When you look at why people develop groin pain, it is also about how they move, and the amount of load placed on the body.

“Our understanding of how it manifests in terms of how we move has greatly improved. It has certainly been a game-changer from a rehabilitation point of view.

“But the one thing that has remained constant is the high training loads. The body is meant to train hard. That is not the problem. It is the fact that some things changed tremendously, and some haven’t changed at all. Look at the window from December to March and the demands on young players across several different squads. It is a recipe for groin pain.

“Our ability to rehab these athletes is improving all the time, our understanding and focus on their anatomy, not sending everyone for surgery but fundamentally it is still underpinned by a need to have sufficient periods of recovery within the week and to have sufficient periods of recovery within the season.

“You can’t be a servant to multiple teams at one time.”

Much done, more to do. After 15 years in Santry, the Cavan native is about to bid farewell and take a new role as Head of Performance and Development for the Orthopaedic and Sports Medicine Hospital in Aspetar, Qatar.

The plan is to swap Dublin for Doha while continuing to work with visiting athletes and travel internationally to assist teams. The chance to work at a FIFA-accredited world-renowned centre of excellence was too good to pass up.

“My role is assisting in the rehabilitation of elite athletes. Both in Qatar and with international athletes visiting. Whether that is players from teams they are affiliated with, such as PSG, or injured athletes I work with, or teams coming for warm-weather training and preparation for the World Cup.

“Obviously, they are connected to PSG, so you have Neymar, Messi, Mbappé etc. I am looking forward to working with that type of athlete and bringing my experience from the SSC with me to contribute to clinical practice and research.

“I will also be assisting the development of their multidisciplinary team. As an international centre of excellence, they highly prioritise that clinical consistency. Trying to put structures and ongoing research pathways in place with a continuity of care at the highest level.

“My attraction to working with elite athletes has always been that it is a fantastic environment to develop yourself clinically. To work with one athlete for five or six hours a day, you can really get into a depth of analysis. Get them from A to B as quick as possible.

“It allows you to take that expertise and share it with colleagues. One of the fantastic things about the SSC was providing elite athlete care for all.

“Take the principles you are applying to a high-level athlete and use that to apply a precise but modified version to the general population. You develop clinically and can have the most impact in terms of pushing understanding.”

Mining the smallest details generates the greatest lessons. That is at the heart of everything King does. Small brushstrokes without ever losing sight of the big picture. The goal is to rehab athletes. If implemented correctly that should ensure they improve as athletes.

“That is the starting point. The day one conversation is where are you sore, why are you sore, what are we going to do about it?

“If you run this way and do this, your performance will also improve. Everyone is great at rehab when they are injured and terrible when they are not injured. How can you get the buy-in that athletes are constantly developing?

“Great athletes like Colin keep in touch not just when injured but because they want to get even better. That is the whole point. Giving you what you need to rehabilitate your injury but also make you a better athlete.”