Archives: Recorded Events

This is a topic that poses a lot of challenges to the patients themselves, to the families but also to the clinicians who look after these young athletes who would like to return to sport.

So, I hope that by the end of this lecture you will be able to suspect if not diagnose an ACL rupture in someone. I hope you’ll have a better understanding about the increased frequency of this injury and what is causing this increased epidemic and injuries. I also hope that you will be able to understand the treatment and the progress in the treatment that has been done in the last few years and what are the challenges with the reoccurrence of reinjury. Most importantly, I think that it is important to know how to prevent those injuries and the psychological aspects that impact those athletes beside the somatic ones which we are able to treat.

I’d like to present you a case, a patient of mine from 2021, this is Sarah who’s a 15-year-old transition year student who presented with an ACL rupture after playing a GAA match. She had surgery with me, we performed a primary ACL reconstruction with an lateral extra-articular tenodesis. She had a whole year of rehabilitation and after returning to playing GAA in the she suffered an injury to the other knee. When she returned to us we operated on the other knee and this time it was a huge disappointment for Sarah. I had to ask for psychologist, Dr Jessie to work with her in the second year of rehabilitation consecutively.

I had seen Sarah’s parents recently because they came in with her younger brother who also ruptured his ACL while playing GAA. So, this is a video of the injury that Sarah suffered, you can see her left knee that is forcefully stepping trying to change direction and decelerate and the left knee gave way. It’s almost classical that the patients hog their knees and they go to the ground, it’s sharp pain immediately they are often helped off the pitch but after a few minutes, although, the knee gets quite swollen it’s not that painful. This is a classical ACL injury, Sarah had surgery with us unfortunately after returning after a year she suffered another ACL injury.

So, how do we rupture the ACL? well generally the vast majority of injuries happen with a non-contact injury and as we saw in that video clip Sarah’s foot is stuck to the ground, there is an element of rotation to the knee and the lateral side literally comes out of the joint for a fraction of a second and pops back in. When that happens the ACL, which is a small ligament inside the knee, gets snapped. A small minority of injuries happen through contact when another player falls onto the patient’s leg or indeed from a hit from the side contact, as we can see in this picture. Those injuries are generally more severe and are associated with other ligament injuries.

This is a very interesting statistic that comes from our neighbours in UK and the study concluded that for every ACL reconstruction surgery from the 1990s we are doing 29 ACL surgeries now, there is a huge 300% increase in ACL injuries that we can see, possibly because is way more awareness among the general population also because at that time we didn’t recognise those injuries and therefore we didn’t treat them. I think everybody in the audience know a guy of my age who had a dodgy knee and was strapping the knee while playing football, these guys generally tend to get arthritis in their 50s and 60s requiring other forms of knee surgery.

So, just to expand on worldwide view in US due to their large number of sports people there are about 100,000 to 200,000 ACL’s per year. There is an increase in adolescence and juvenile ACL about 2.5% each year and females are four to six times higher in cutting pivoting sports in terms of ACL injuries. Australia has the highest rate of ACL reconstruction in the world, when a study looked at under 25-year old’s ACL rupture increased by 74% over the last 15 years. In Norway they have a very strong ACL registry in Northern European countries and a similar increase by 40 and 55%, respectively, in males and females in terms of ACL in adolescents and juveniles.

When we look at our own registry here at the Sport Surgery Clinic which we started in 2015 I just took the last five years and you could see at the bottom the grand total of ACL injuries in the under 20s has increased dramatically, in fact in the last three years we almost doubled the number of ACL injuries in young people.

Why is this epidemic? As I said, it’s a pure numbers game, increased participation in younger ages who play for longer periods of time, they play a number of sports and they play throughout the year, winter and summer. As they get better they tend to specialise in one sport and that actually is shown to be a risk factor in itself. We also have increased awareness regarding the injury, so it’s like everything else when you have such injury it seems like a new world opens up there with everybody around you having had the injury or knowing someone who had the injury themselves. Also, another factor is that we have more MRI availability and that increases an early diagnosis. In the past as, I said possibly people weren’t diagnosed or just diagnosed with an MCL injury and therefore weren’t treated accordingly.

There are some risk factors which are better recognised in more recent times. When I was training about 15 years ago in Australia family history was suspected but since then there have been various genes discovered as family history is a very significant risk factor for an ACL injury and when I say family history is brothers’ sisters’ parents. That also leads to type of collagen and that leads to hypermobility so often those patients are double jointed. If you ask around they often have injured their shoulders before due to type of collagen and also hyper mobility.

As I mentioned before, the girls are more susceptible to the injury than the boys and that is for a number of reasons. Firstly, girls will have a wider pelvis to accommodate childbirth and therefore they have knock knees more often than boys. When you have a knock knee it is more likely that you twist, particularly if the hip muscles are not strong enough and the core muscles are not strong enough and induce that rotation movement to the knee that snaps the ACL. There is also some hormonal variation that is suspected for an increased risk of ACL injury, an increase of oestrogen in girls sometimes and the variation through the menstrual cycle has been observed. Other factors would be the anatomy of the knee, some people have a narrow notch which is the place where the ACL lives and when you have a narrow notch it is more likely that you rupture your ACL.

Some people have increased slope and these are all anatomical factors that really, we cannot control but it’s important to be aware of them as treating clinicians. Of course, there are other factors, extrinsic factors, which we can control and that is the type of sport. So, we consider the riskier sport level one sport in terms of twisting, pivoting and cutting sports such as Gaelic football, hurling, soccer, rugby and basketball or net ball in other countries. Playing surface plays a role for ACL rupture so it’s been suspected, although it’s difficult to prove, that the AstroTurf due to increasing friction between the foot and the playing surface that rotational force is being transferred to the knee where it ruptures the ACL. The footwear, through the same mechanism, if you don’t have correct footwear for AstroTurf and if you increase that friction even more one can induce more rotation to the knee.

It’s been a myth that kids don’t need to warm up, they definitely do and I will show you some warm-ups that really are designed to prevent rupturing the ACL. Another myth that I want to dispel today and that is kids don’t need to go to the gym, they certainly do. Going to the gym is part of athletic skill development and athletic education. In fact, the American academy of paediatrics has recommended that resistant training in children and adolescence even prepubescent is really useful for their development. I don’t mean going to the gym and doing CrossFit or lifting up weights but weight resistance, could be your own body weight it could be elastic bands it could be chin-ups, pull-ups, agility proprioceptive exercises that should be done in the gym under supervision and learning how to do correct jumps hops and step-ups.

Now when it happens how do we fix it? We generally take a graft from a different part of the knee and some techniques take a graft of the patella, where you take a piece of bone of the patella and a piece of bone of the tibia with a tendon in between and the patella tendon is being rooted into the knee to become your ACL and being fixed with two screws. Another technique will be to take the hamstring tendons from the back of the leg and similarly that’s being rooted in the knee to become the new ACL and to control rotation. So various surgeons have various preferences but in this age group when the physis and the growth plates in the kids are closing or still open in particularly the prepubescent one’s hamstring is preferred due to the fact that putting a bone block through the physis is not really indicated.

So, what is the challenge with these injuries obviously the same as primary ACL’s happen more often also the re-rupture rate is quite high so when you think about it why did it happen in the first place? Obviously, what we reconstruct it’s not as strong, as solid as what we were born with and therefore we encounter a re-rupture, rate a reinjury rate and that has been reported around the world irrespective of who does it, where it’s being done or what graph they use between as little as 8% at two years and as high as 30% at three years so it’s been widely accepted in the literature that in this age group one in four athletes younger than 25 who return to sport after ACL surgery will go on to have a secondary ACL injury and what I mean by secondary ACL injury is either rupture of the graft or injuring to the other knee.  If you think about it again why did it happen in the first place, if you go back to the same risk factor particularly level one sport there is a huge chance that that will happen again particularly to the other knee. That led to around the world for people to try to reduce this reinjury rate and re-rupture rate and on this background the extra articular procedure has been explored as another surgical innovation in order to reduce the re-rupture rate, so what does it mean as shown in the picture beside doing the ACL graft we also take a strip of the iliotibial band which is a strong fibrous layer at the side of the knee on the outside and wrap it around one of the ligaments to stop it rotating, I describe it as being like a seat belt and that took vogue about 10 years ago and the research that has been conducted since shows that the re-rupture rate has been reduced to less than 4%.

I would like to share with you our experience here in our practice in UPMC Sport Surgery Clinic when we used the extra articular procedure, I looked at all my patients over a period of six years, we had about 192 patients we lost a few to follow up, but about 160 were followed up for a minimum of two years all these patients were operated with hamstring graft and lateral extra-articular tenodesis and they were followed up for a minimum of two years. So, this graph shows the distribution of females and males, there were more males in the younger adult group and there were a few prepubescent about 10 patients before their puberty and they require a special surgical technique.

I grouped the sports that they were doing, the vast majority being GAA both hurling and Gaelic football at about 75% of patients were in GAA. A few patients played soccer and a few played rugby while the rest played basketball or gymnastics. So, what did we find after following these people from between two and eight years [post-surgery]? We found everybody and we asked them if they had any other surgery, we found out that the re-rupture rate, in other words injury to the same knee, only four patients suffered this and they were representing about 2.5% significantly lower to the rates worldwide. A significant number about 20 patients suffered an injury, like Sarah, to the other knee representing about 12.6%.

What have we learned by looking at our work and data in the last eight years? So, we demonstrated that the hamstring graft and with the lateral extra-articular tenodesis. significantly reduces the rupture rate to 2.5%. There is still a high rate of contra-lateral injuries, about 13%. I insist that the patients will have a minimum nine months of rehabilitation and may return to sport one year after their surgery. We do that after we test them clinically in our 3D biomechanical lab. I stress to everybody at nine months when I see them the importance of injury prevention and we look at psychological readiness after such traumatic event and after such a long period of rehabilitation if they’re ready to return to sport.

If you remember nothing from my talk maybe you will remember this GAA 15 warm-up which is excellent work done by our GAA community of physio and coaches essentially what this is an activate program it’s a warm-up that is about 15-20 minutes and includes a series of shutter runs strengthening agility and proprioceptive exercises. There are similar programs around the world such as the FIFA 11 plus or PEP program in the states and there’s been a lot of research done in collegiate athletes showing that if we do these warm-ups at least three times per week we reduce the risk of knee injuries by 40 to 60%. This is really important, if we invest time in becoming agile strong reactive as players and our kids follow this warm-up, it is like brushing your teeth, you half the reinjury rate.

In terms of performance psychology, I was fortunate to meet Jessie about two years ago in Aspire Orthopaedics our office along with Professor Brian Devitt and Mr Gavin McHugh, we work in close relationship with Jessie and she sees all our patients that require psychology intervention. Jessie is a former athlete and understands very well the trauma that those kids go through and helps them psychologically to get over the injury, plan their rehabilitation, plan their return to sport and also to deal with a possible reinjury as well.

That’s a really insightful question, normally we operate on what we call a cool knee so a knee that is pain free and has full range of motion. There is a very short window that you could operate it straight away but generally, when patients get the injury by the time they get the MRI and get referred to us they will be passing that window which is the first few days, so it’s almost never that urgent. The ideal time to operate is when the patients swelling has gone down and they are moving the knee freely, that takes about between four and six weeks. If the patient is stiff and swollen before surgery it will be very stiff and very swollen after the surgery so there is that concept of pre-habilitation when we ask the patient to get on the bike, get all the braces off. This is another misconception that kids and general patients get put in braces by various health care professionals, so the idea is if it happened once it will not happen again until they play sports. It’s good for the patient to get on the bike, ice the knee, fully weight bear, walk properly on it and then once we see them we continue this pre-habilitation program until we get to surgery generally between four and 6 weeks.

That is a relatively new indication as I presented in the talk, it’s been sort of promoted and researched in the last 10 years I’ve been doing it for the last eight years. I started with doing only the revision ACLs, they’re done second time.  I’m trying to select the high-risk patients and what I mean by that is patients and teenagers who have either a family history, are, double-jointed, have increased laxity and also want to return to level one sport and I mean by that GAA, hurling, rugby, soccer. They have a higher risk as shown in the talk of reinjury and those patients I do extra articular procedure like a seat belt to protect the ACL graft.

It’s not really a treatment, we don’t use it, stem cells really are bleeding and when we do the surgery we create a lot of bleeding from the bone. Stem cells is a word that’s being maybe used in marketing and promotion of various clinics. There is no evidence that the stem cells are helping in degenerative conditions but not at all in youngsters who have a lot of proliferative cells, we don’t use that at all.

That’s a very rare situation, there is no such thing as an overstretch ACL, I think it’s a partial torn ACL. If you remember the mechanism of injury that half of the knee dislocates and it’s like tearing a rope, you put tension on it and it gets stretched to a certain point and it fails catastrophically and that’s why the ACL ruptures, it’s a catastrophic failure of the ACL. It is not like an elastic that gets stretched, it’s extremely rare. Maybe in a low energy situation like skiing or jiujitsu that you slowly stretch the knee, I’ve seen it maybe once or twice. Generally, we treat those conservatively but if the patient has instability with such stretch we tend to reconstruct it but that’s a very rare situation.

Hi everyone I’m Jesse Bar, I’m the performance psychologist within the Aspire Orthopaedics team at the UPMC Sports Surgery Clinic this evening I’m going to give you a little insight into the work that I’m doing within the Aspire team around using performance psychology strategies to enhance recovery from ACL reconstruction.

What is the state of play in ACL recovery according to the research at the moment? So according to the results of two systematic reviews and meta analyses conducted on seven and a half thousand patients it was found that to 85-90% of ACL reconstruction patients returned to a fully normal or an almost fully normal knee function after their operation. However, these studies also found that the rates of return performance among these patients was not reaching those same high levels of 85-90%, what they were finding was that 81% were returning to general physical activity or general low levels of sport participation, 63-65% were returning to their pre-injury levels of sport so only ¾ of those who had an ACL reconstruction were actually returning to their pre-injury and pre-surgery levels and up to half were returning to competitive levels of sport. So, what the surgeons were finding in Aspire is actually reflective of the current state of play within the research, that while many will return successfully to normal knee functioning not many were actually making a full return to competitive sport and that’s where I’ve come in to give some support from that psychological point of view.

How I’m going to illustrate that is through a case study of one of the athletes that I came across quite early on when I started within the team. With this case study we’re going to look at a female GAA player who was in her early 30s. She was presenting with her second ACL reconstruction in three years and it was on the same knee so she was back into Santry to get her knee redone. She was referred to me by her physio at about seven months which would be considered that kind of return to play phase this stage, she should have been running, turning, jumping and being involved with general football related activity. At this stage she was hitting all of her physical targets and key performance indicators in her rehabilitation program so physically she was ticking all the boxes that were indicating she was on track to make a full successful recovery. But her progress had stalled she was stuck at the straight-line running phase which you would typically be in much earlier in a rehab program probably at the four to five months mark, this athlete was seven months in and still hadn’t got past straight line running. Why was this? What were some of the issues that she was presenting with? One of the main issues that I could see from my early work, my initial consultation with this athlete, was that she was experiencing significant reinjury anxiety or fear of reinjury.

Reinjury anxiety and fear of reinjury are consistently cited as the most significant reasons for an unsuccessful return to performance or a lack of return to performance so maybe a longer return a more stunted return or someone who doesn’t return at all to their pre-injury levels of competition. So, these are really important factors that I will see a lot of ACL patients experience. What is reinjury anxiety? Reinjury anxiety is cognitive and emotional reactions so it’s thoughts and emotions in response to the anticipation of negative consequences of reinjury so it’s quite future focused. It’s focused on what may happen if the patient has an injury again so this could be thoughts around having to do a surgery again, having to go back to the start with rehab, or what that might mean in terms of their season in terms of their progress so far and what it might mean for example their place on the team. It can manifest in lots of different ways with negative emotions like frustration, hopelessness, anger even and it can just be just a persistent worry and just general uncertainty that the athletes presenting with and as a result the athlete may want to avoid certain movements or activities. What I was seeing with this athlete, in the initial consultation, was significant reinjury anxiety she was terrified essentially of injuring the knee a third time or even injuring her other knee and requiring surgery on the other knee that hadn’t yet had a surgery.

Fear of reinjury on the other hand is more of a response to a perceived threat of a reinjury in the moment and the challenge of this is it doesn’t always show when an athlete presents to the physio, the surgeon or their clinical specialists on check-up. Fear of reinjury usually only manifests when they are actually in the place where they do sport so, on the pitch, on the track wherever they are. It is that immediate emotional response, that immediate fear and stress response and behavioural responses which could lead to avoidance behaviours as well. The fear of reinjury presents in the moment when a person is presented with the opportunity to do something that they fear could cause a reinjury. Where this athlete was experiencing this was on change of direction, so as I mentioned she was stuck in straight line running the change of direction on the pitch was causing a huge fear of reinjury. She was having a strong emotional reaction on the pitch, she had a strong fear of movement and the fear of the pain which is caused by the movement. This was leading to these fear avoidance beliefs which are the thoughts and emotions that were driving the fear that she was experiencing about this change of direction, these turns, causing further injury.

So, just to understand reinjury fear and anxiety it’s a really important factor for me to understand and to understand the sources of it because these fears and anxieties can create some quite strong long-lasting beliefs so I needed to understand the patient’s story. I must understand what was going on up until now where I’m meeting her at seven months, what has created this fear and anxiety and why is it presenting so strong and why now.

Back to the case study of my female GAA player, her first ACL surgery that she had three years prior was very successful, there was a smooth rehabilitation and recovery and she had a full return to performance within 10 months. However, her second ACL she was already significantly behind on her timelines by the time I met her and according to her physio had been quite behind on her timelines all the way along had experienced more setbacks. She had family members who had ACL reconstructions as well with various levels of success so brother and two cousins all male and some had made full successful returns while one had not returned to sport at all, so her experience of those around her had been quite mixed so it wasn’t instilling her with confidence either.

She was working full-time as a teacher so she was quite conscious of spending a lot of time on her feet, she wasn’t getting to recover and you know rest the injured knee as much as she wanted and didn’t have as much time as others to maybe dedicate to her rehab and her recovery. She was one of the most senior members of her club and her county team which was really important to know because there was maybe an element of pressure, an expectation and whether that was external or that was self-imposed she was quite a senior member and had you know aspirations of returning. Finally, what was another really interesting factor to understand in her story she was nearing the end of her playing career and why is this important. Well when we talk about reinjury anxiety and the anxiety related to the future outcomes of an injury she thought she was too old to have to go through the whole process again so if she was to reinjure the knee or injure the other one she thought that was probably going to be the end of her career she didn’t have that much time left in her in her playing career, so that was something that was really important and probably driving a lot of that anxiety was that she really just felt the that her clock was against her.

So, just to take a step back and understand what some of the potential psychological responses to sports injury can be and what maybe creates those response I’m going to introduce the integrated model of response to sports injury. This model indicates what could create the psychological and emotional responses to a sport injury and also to the rehabilitation process, that response is actually created before the injury even happens. It can be linked to personality factors, history of stressors, coping resources interventions, so what does that person already have access to what type of person are they, are they someone whose tendency to be quite anxious so even before the injury happens there are some factors that can create the response. Then once the injury happens once the ACL has been torn there is a number of factors that will impact and contribute to the emotional and psychological responses that the athlete will present with both at the time of injury and throughout the rehabilitation process. The athlete will take into account their personal factors, things like their injury history, have they experienced injury previously for example their individual differences so their motivation their athletic identity, which I’ll speak about in a little bit more detail in a while, that idea of how much they identify with being an athlete what age and gender, they are all of those personal factors can contribute. Those factors are then combined with things like the situational factors, so the sport, when in the season is it right coming into the start of the season versus the end could change the psychological response, who are the people around them those social support networks, is there a lack of social support or is there good availability of support to the athlete, those are some situational factors that can create positive or negative responses. So, as you can see its quite complex, there is no way to really predict how any athlete is going to react so getting that understanding of the person and understanding their story, understanding the beliefs they’re taking with them as well can give an indication of where I can offer my help and support.

So, what does her player tell me about that, why was she experiencing it? Thinking back over the story that I shared she had a very strong belief that if she was having slower progress, which she was in comparison to her first knee, that it meant there was going to be poorer outcomes. She had this belief that because she was not hitting timelines she was not going to make a success or return and had nearly made that decision just by maybe speaking to other people and coming to her own conclusions. She had less opportunities to build trust and confidence in the knee because, she was avoiding a lot of opportunities to build that trust so she was avoiding drills she was avoiding some activities at training which would be opportunities to build confidence and trust in the knee at that later stage of her rehab. She had what we call perceived susceptibility and a lack of control, so this athlete was presenting with the belief that you know my brother has had an ACL reconstruction two of my cousins I’m on my second maybe we just have bad knees or bad ACLs in the family. Suddenly she was kind of accepting that she didn’t have as much control over this injury as she maybe had once thought and there was a perceived susceptibility she’s just someone who’s going to get ACL   injuries and there’s nothing I can do about that. This almost learned helplessness was starting to kick in that no matter what I do I’m probably going to get injured again because look I’m here again my family has been there too.

Because of her full-time job as I mentioned she did have less time to dedicate to her rehab and recovery. As I mentioned earlier the idea of athletic identity is one of those personal factors, so she was a club and county player one of her most one of the most senior members and a really valued member of both teams. She was someone who herself identified very strongly with being a footballer she’d identified first and foremost, as footballer before she identified as teacher or as anything else so it was a big part of her self-concept who she was, in research will say that someone with a very strong athletic identity may struggle with being away from their sport and not being able to I suppose fulfil that identity. There didn’t appear to be as much external pressure from teammates or managers on either team but she was definitely self-imposing pressure on her return to play and returning to the pitch due to her age, she really felt that time was running out and the clock was against her. Understanding those beliefs, so understanding those contributing factors was starting to paint a picture of where these reinjury fears and anxieties were coming from and what I could do next where could we go with this.

My plan and interventions started with confidence building as I just gave a little indication of I needed. I recognised that the athlete was presenting with a high level of anxiety but very little confidence and one way to counteract the anxiety she was feeling was to build that confidence in her knee and in her body and at that time it was very low so we needed to go back and reflect on the work she had done up until this point on the rehabilitation process that she had done until seven months reflect on that think back through it, reflect on training logs go back her training logs from her first ACL and make some comparisons as well. We needed to cog do some cognitive restructuring through self-talk which is that internal dialogue because when we spoke about what it was she was telling herself, where was her head when she was at training what was she telling herself throughout the day where was her attention throughout the day every little niggle or every little you know awareness in her knee was creating or confirming the belief that her knee was weak wasn’t going to be able to take the demands of change of direction and further match play scenarios. We needed to challenge those beliefs through self-talk interventions, identify those negative unhelpful self-talk that she was engaging in at training and throughout the day make note of it and then create a more helpful script to counteract it. This was so that she has something to respond and challenge and let stop those unhelpful thoughts from spiralling and going unchecked. That was something that was a constant theme throughout, one big part of the work we did was actually just going back and doing some goal setting, seems simple but there were some real glaring gaps in the goal setting that she had been doing up until that point. We looked back at doing some smaller goal setting and I’m going to go into a little bit more detail on that in a second.

Then we did an imagery intervention which is also known as visualization, to try and build confidence in the activity she was going to be putting herself forward, that she had been avoiding up until now, so that was change of direction. Some match play scenarios were causing a huge amount of stress and that stress was leading to her avoiding those movements and avoiding those activities altogether, so imagery was a way of practicing doing some mental rehearsal of being in those scenarios of feeling confident in those scenarios or feeling nervous and still doing it without having to put herself in those physical scenarios. It was a way of training her brain to feel comfortable and confident with those activities before she actually put her body in the situation to do them. Finally, I just taught her some relaxation exercises because what was quite clear was when she was at training and when she’d moved past the easy drills that she was confident with straight line running and they were moving into more complex drills, change of direction, and more Matchplay scenarios her stress was shooting up and as a result, she was creating a lot of tension physically and mentally as well so that tension physically was linked then with some unhelpful self-talk so we had some self-talk interventions but we needed to make sure her body wasn’t tensing up and creating unnecessary barriers through just that physical tension. So, just some simple breathing activities when she noticed those little triggers of those unhelpful thoughts or that tension that was maybe in her jaw or in her shoulders, we just did some breathing activities to just relax and centre herself and then be able to maybe attempt the start of what she was hoping to put herself forward for. So, they’re just some examples of the plans and interventions.

In terms of the outcome and I said I will talk about the goal setting in a second but in terms of what the outcome looked like now this athlete I must preface was very engaged from the start really bought in after about 20 minutes of our discussion I could see that she really wanted the help she really wanted to be involved in this process and it made the work I did much easier. The athlete did present with this reinjure anxiety and fear of reinjury, we had three consultations which looked at those four or five interventions after those three consultations she felt confident enough to return to performance and played just 10 minutes and she was delighted with those 10 minutes. Following that we had one or two more consultations throughout the season and after those she felt confident and ready to return to full match participation, so for the first time in her rehab for that second ACL she felt psychologically ready to return to match participation to match play and was able to overcome those barriers, again, a lot was to do with the athlete, how engaged she was and how willing she was to give everything a go.

I mentioned goal setting, and this was a big part of our intervention and probably bigger than I anticipated it being because it always seems like one of the simplest interventions, but it can be so effective if done right. What I recognise and in my early discussions with athletes, I always want to identify what their goals are for the rehabilitation, the recovery and what they’re hoping to return to and where she was at seven months this was an athlete who could only run in a straight line her overall goal, was the top of that set of stairs, was to play a match and I said, “Okay well we need to bring it back a bit we’re a really long way away from playing a match if you can’t do anything bar running in a straight line.”  So, we discussed what would be the next step from where she is and she said, “Okay well, the big goal then taking it back a number of steps was change of direction and speed with the ball.” So that became our main focus, we parked the match we said, “We’ll come back to that but let’s just make a smaller more achievable target that is not doesn’t seem so daunting.” And what I realised with talking to her and something I’ve recognised with a lot of the athletes that I’ve been working with it with after an ACL reconstruction is there aren’t enough of those kind of smaller incremental goals between those large milestones and this is probably most evident in the latter part of the rehab because obviously early on in the rehab it’s very controlled, its gym based and there’s a lot of small goals to hit but once the athlete moves out onto the pitch or out into the field to play and they’re back in training suddenly the jump becomes much bigger with less small goals to kind of build that confidence up slowly in the way that we’re being done in the gym ,so, really that was where that lack of opportunity to build the confidence and the trust in the knee was presenting because she hadn’t had the opportunities to actually do that she was just trying to jump too far forward.

So, what we did is we revised the patients goal setting so instead of it being match play we parked that completely and we said okay your performance goal one is that change of direction and speed with the ball, we set that at the top of that set of stairs for where she was at now and again, we brought it back. So that’s the performance goal that’s a performance indicator that she can move on to the next once she was able to change direction and speed with the ball. She knew she was ready to move on to the next step, which was one step closer to match play, but she wasn’t there yet she was still at straight line running so I brought her back again and said “Okay we’re at straight line running what do we need to add next what’s the next process what’s the next step?” . The next process was just change of direction, being able to participate in change of direction drills at a steady pace then she was ready to progress to the next step that next process goal which was a change of direction drills at a steady pace adding in a ball.  Adding in another small demand once she was ready to do that move on to change of direction at speed and finally then she could move on to that performance goal, so we broke it right back down it seemed like it was baby steps but that’s what it was in the gym so we needed to apply that thinking to the pitch work as well. That’s what we wanted to do is to add in those extra steps, to build trust and confidence in the knee so rather than going from running in a straight line to fast change of direction with the ball we needed to add in some steps to build that confidence and make her feel that she was able to do it, and we didn’t move on until she was ready.

We’ve come together and recognised the best approach is getting in as soon as possible and offering that support as soon as possible. My approach now looks like again still understanding the backstory. I offer athletes a discovery call so a free 30-minute call to just give me a bit of background of who they are before they ever commit to initial consultation because I know it can be quite daunting and even in that initial consultation there will be a lot of opportunity to understand their story and their background understanding the injury, what happened, what was their experience, what are the potential repercussions of this injury and their season, their timeline, just to kind of get a sense of what their emotional response looks like and how they’re feeling in that immediate in that initial period, in that early stage of rehab. I want to understand their previous experience of injury because that can really shape how they can apply their skills and apply their knowledge to this new injury, if it’s their first it can be very different to someone who’s had an injury before. Someone who’s had an injury before may feel competent and know what’s to come or maybe having had a previous injury feel dread because they are aware of how taxing rehab can be so knowing if there’s a previous experience of injury can be a really valuable understanding of the level of athletic identity. So how much does that athlete identify with their athlete role, is their identity shaped by being an athlete, are all their friends’ athletes, is their social life centred around their sport, are all their friendships centred around their sport and is all their spare time centred around their sport, that’s important to know to kind of direct towards different strategies. So, identifying how an athlete can manage their time depending on their level of athletic identity, they identify quite strongly we want to find ways to maintain that identity in a different way while they’re injured and just understanding what other interests’ pursuits and what else is going on in their life are they working, are they in school, are they in college or are they a full-time athlete.

By just understanding what else is going to be there to distract them during this rehabilitation process understanding their current knowledge so what do they know about ACL reconstructions what they know about the rehabilitation and the recovery do they have any experience with other people, does any of their teammates family members friends and what was their experience and are there any beliefs or fears they hold about the rehab process or that return to play, are they someone coming in saying understanding that only half of people return to full sport and full competitive levels or are they someone coming in believing that the harder I work in my rehab the more likely I am to return so understanding where they are at the moment and what their beliefs and knowledge is identifying those goals that they have of the rehab and recovery and of the psychological support I support I can offer or is there a certain timeline they want to get back for or are they willing to just see it out and return when their knee is ready, just identifying what those goals are is really important early on to help manage expectations. As I said expectation management is a really important one. If we understand their goals we can then start to put in those strategies to manage expectation, helping them understand that setbacks will happen, when they may happen, how they may react if they do kind of nearly pre-empting it.

I use the self-determination theory as a framework for initial interventions and I’m going to talk about that what is a self-determination theory and how am I using that to shape those early stages of interventions with new patients. What is the self-determination theory? The self-determination theory encompasses three concepts, the concept of competence which is where a person is motivated to gain mastery to feel capable and effective in their own actions, so an athlete wants to feel competent even when they’re injured or when they’re rehabbing, we want to encourage autonomy with the athlete. We want the athlete to feel in control of their choices and in their day-to-day life one thing a lot of athletes will say is they don’t feel that they’re in control of their decision-making in their life or their day-to-day when they are rehabbing because someone else tells them what they should do, when they should do it, when they can do more, if they have to pull back and do less so there can be a feeling of a lack of autonomy during the rehab process. What we want to do is create opportunities for autonomy and finally the self-determination theory of motivation, the last factor is relatedness so it’s that idea of feeling connected and belonging to others. It’s a way of recognising that they feel cared for and supported. This self-determination theory and the theory of motivation and it’s all three of these factors can combine to create a motivated athlete who will see out their rehab, who will stay engaged in the process and hopefully feel more in control of that throughout.

So, what can that look like, what are some of the strategies that I do to try and create a self-determined athlete. If I want to encourage an athlete to be more competent something very simple at the early stages I suggest athletes keep a recovery journal to record their progress record any signs of improvement or any upskilling that might happen. With an athlete we want them to take back that bit of control, have a bit of more autonomy but also see that competence grow because that competence is what creates that confidence that we see later on and that trust in the knee so if they’re witnessing their recovery they’re recording their progress and they’re not waiting for the physio or the surgeon to give them the green light they’re also seeing it with their own eyes and they’re recording it they’re creating that confidence throughout the rehab process and feeling more competent in the rehab and in their knee. We want an athlete to be more autonomous so while they feel a lot of controls been taken away they can’t engage in their sport we want them to identify opportunities to develop other skills during the rehab period, so while the injury initially could have brought on all of these really negative and unhelpful responses we want them to see that an injury can be a time of opportunity, it can be time to develop a more rounded athlete that you may not have time to do when you’re training full-time. Encouraging the athlete to seek out those opportunities maybe it’s developing other physical skills like fitness on the bike or upper body for example maybe getting involved in the sport in other ways so still staying involved in the sport and taking back the control of maybe their tactical awareness by doing some video analysis or the strategic awareness by doing some stats work for the team or just even offering a little bit of coaching and just feeling they have something to give back and they have control over their choices. Finally, a self-determined athlete is someone who has that relatedness they feel related to others so helping that athlete at that early stage, identifying who the sources of social support are going to be and what the types are at different times, so, how can they use them, who are the people who have been through it before and can they seek guidance from them about their experience of surgery and injury and learn from them and who are the people that they want to be around when they need a break from all things sport and injury. So, at that early stage now that I’m getting athletes much earlier on through the referral processes this is the type of work I’m doing with them and then as we move through the rehab process we go back to things like goal setting, cognitive restructuring, expectation management those kinds of strategies but at the moment that’s where I keep my focus create those self-determined athletes.

I became aware of the struggle these kids have when they get such a significant injury to their knee over time and in my head that’s a psychosomatic injury so we deal with a somatic aspect where we get the patients to have a stable knee and to get fit but the psychological aspect is significant, I realised this through having adolescents of my own who play sport, fortunately, they haven’t had such a big injury but I could see whenever they had a small injury how important it was for them to be part of the team and to go training. Literally in the office the entire team is crying the patients, the kids themselves, the parents, its often those kids are the best in their sport because they play full on they get injured and then I got the feeling that we need to do something about that to work with a psychologist. I was talking to my colleagues for months trying to liaise with a psychologist and my colleague Gavin McHugh at the time worked with Jesse’s husband now and who was an orthopaedic register and Gavin facilitated the connection and I rang Jesse and I explained to her that we are in a position to carve a new field and she took up the challenge and here we are.

I suppose I used the example of a 30-year-old case study and the reason I chose her was she was someone who I had seen from right through to return to play and I haven’t had as many yet because a lot of my referrals have been more recent. Would I deal with an adolescent differently? yes and no, I suppose the challenge with an adolescent is often they haven’t had an injury before, so a 30-something year old athlete has probably had a lot of experience or has some experience of an injury. A lot of the adolescence that have presented it would probably be their first, some of them this is their very first injury ever, for many it’s their first major injury and that presents its own challenge. There is a lack of knowledge of what to expect, a lack of I suppose understanding of the value of rehab and sometimes my work is not just from the psychological side but also nearly a coaching side, a coaching of what the importance of what this means to do a full rehab cycle and what that’s actually going to look like. Even making suggestions around really simple strategies like suggesting to join a gym, this was something that was completely out of the norm for that age group that a lot of them had never been in a gym before so I suppose the challenge is what their experience level is, where they’re at in their career compared to an older athlete who probably has that range of experience and you’re dealing with an athlete who has a full career ahead of them so you are really bringing home the importance of following the rehab program staying motivated throughout, seeing the positives, looking for the opportunities because they potentially have 10 or 15 years ahead of them so we want them to try and stay as injury free going back so that’s definitely a way of approaching it is understanding the age and what are the different dynamics, how that looks depending on what their experience is in the sport and as Mihai said they usually are the best in their sport and probably haven’t had many setbacks so far so a lot of it is around coping strategies for dealing with what is probably their first major set and maybe even first major injury.

I do unlike Mihai I’m not a specialist in the knee, you know the skills that I use for ACL patients can be applied to the shoulder, to the hip, to muscular skeletal it’s not necessarily just ACL specifically. Obviously, ACL is one of the you know the longer of the rehabs but I have you know I have a skill set in other areas as well none of the strategies I would use would just be moulded to suit the injury and the demands of that recovery process.

Yes, I suppose to refer back to that earlier question the challenge is often to do with the lack of education and understanding, they maybe don’t know what is ahead of them they maybe don’t know many people who’ve had it maybe they don’t really understand the impact this could have on their career so a year seems like such a long time for these athletes they don’t really have an understanding of what that year might look like and I mean this in the best way possible but parents involvement can be a positive because mostly most of the adolescence who have been in front of me are there on the on the basis that their parents see the value in the psychological support but on the flip side if parent and teen aren’t aligned or there’s a feeling of pressure coming from parent it can it can send a teen digging heels in and wanting to do the opposite so that can sometimes be a challenge, its nearly me being a middle ground for the parent who’s giving the good advice and following what you know Mihai and the clinical specialists have suggested but at the same time the teenager doesn’t want to follow the rehab program then the parent is tearing their hair out so that’s actually been quite a challenge as well is finding where that middle ground is and where I sit without being a nag but also trying to help them understand the value of what suggestions everyone around them is making that. Yeah, just a lot of it is around psycho education, just educating what is to come what the benefits of engaging with my services, with the rehab, will look like long term and why maybe people at home are seeming like they’re being quite pushy. That’s definitely been a unique challenge that I haven’t maybe hadn’t thought of how I’d have to encounter that until I had more parents and teenagers sitting in front of me.

When someone refers into me, if a referral hasn’t been made directly through Mihai my best answer is just to emai, l so my email is just [email protected] just send me an email directly and we can set up an appointment from there. I offer a 30-minute free discovery call because I know psychology for a lot of people especially adolescence is quite daunting, there can be a feeling that if you’re being referred to a psychologist it’s a sign there’s something wrong with mentally and it’s just to maybe break down that stigma and just put someone at ease, it’s a Zoom call they don’t have to come in and commit to a full consultation with me it’s just break the barrier so they understand that this is who you’d be talking to and this is what we might speak about. I kind of just introduce what the work is, how I can help them and just put a face to the name because I know it is very daunting to come into UPMC and walk through those lovely marble corridors and see a psychologist for the first time ever. As Mihai mentioned my own background, was as an athlete, I spent a lot of time injured as an athlete so I kind of have nearly a common ground that I can meet with the athlete as well. I’d never say that someone has to commit to an initial full one-hour consultation, have a chat, introduce their teenager if it is a parent setting it up or if it’s a person looking to make the referral themselves, avail of that call and just get an idea of what the expectations are.

Good evening and welcome to my presentation on the management of low back pain. So let’s just start off with some, statistics around low back pain. Low back pain is the leading cause of disability worldwide and rising, and it’s estimated that over 80% of people will experience an episode of back pain at some point in their lifetime. In 2020, a staggering 619 million people suffered from low back pain. So if you have low back pain tonight, you’re definitely not alone. Tonight, as part of my talk I’d like to bring you through some historical low back pain treatments. What an evidence-based care looks like and tips on how to manage a flare up of your back pain

So historical treatments – low back pain is nothing new and it’s been documented that potions and spells have been used by ancient civilisations. Hippocrates, the father of medicine and Greek philosopher and physician, even documented exercise and manipulation. So, I hear you ask the question, what has changed? In truth, not much there’s multiple non-surgical treatments out there, and these kind of range from core strengthening exercises, dry needling, manipulation and wearing back braces, taking even painkillers and having a you know a spinal injection. The list is endless and we can’t forget our conflicting advice between colleagues and friends and a good old Google, but in essence, a lot of these treatments are actually quite costly and when used in isolation often ineffective. A really good example I have is, I had a young patient coming to me, last week, and she’s been having weekly treatments for the last few months and her back pain is still there, it’s actually getting worse and she comes in, and she tells me that everyone’s quite puzzled as it’s why she still has back pain. So she went on to have an MRI scan. This is where a picture isn’t a thousand words. Her MRI scan came back completely normal, and we know from the evidence that having some age-related changes in an MRI scan is quite normal and these changes increase with age and I typically describe them as, it’s like having wrinkles and grey hairs, and it doesn’t necessarily correlate to a person’s back pain. Another issue I suppose an MRI scan is it’s a static picture. It doesn’t tell me how you move. It doesn’t tell me about muscle imbalances between your core muscles and your leg muscles. But more importantly, it doesn’t tell me about your thoughts and your feelings.

So this particular patient came into me, and because she wasn’t getting better, she really felt that something seriously was wrong. She was scared to move her back, and she really felt that she was going to do more damage if she was going to move into a pain. So she was protecting her back, having really good posture and not lifting anything heavy and I’m going to talk about these thoughts tiny bit later on in my presentation.

So if we move on to current day, what is evidence-based care look like? So there’s guidelines out there to help guide physicians as into how to manage back pain. These guidelines recommend that we kind of have a combined care, tailored to each person’s needs and this may consist of education around some about your back and your dos and your don’ts, exercise prescription, manual therapy and for some people, psychological therapy. Again, for us as physicians, we want to use some tools to help manage your back pain.

So when we go on, what does recovery look like? So when we adopt a kind of an evidence-based care approach what does recovery look like. While most people would love to see the graph on the left-hand side. In essence, back pain, the recovery can be quite complex. I always describe in the beginning, it’s like an annoying squiggle. This is where having for us as clinicians having a deep understanding about what’s going on is really important. So we want to take a kind of an in-depth history about what’s going on in your life, but also about some fears that you have around your back pain. So many people are quite fearful of moving their back and causing the current pain, and I want to know about your expectations. Do you think it’s going to get better? Because it’s really important that for all of you out there who suffer from back pain that you have this hope and hope that it will get better. But as I said, kind of listening to your story is so important because it helps us to tailor that exercise program to your needs. Once we kind of get on track, you know, recovery is still going to have its peaks and troughs. A good example of where I really want to figure out what’s going on in your life is, a patient a few weeks ago who came into me and he had three weeks of really disabling low back pain, and he’d seen three other physicians prior to coming to see myself and throughout the assessment we were able to change his pain through exercise, and I was like this is great. Brought him back a week later, and he was kind of over 70% better. I was really curious about, why, what got you better? He actually said to me that it was a phone call with his boss and his boss had given him some reassurance, go and look at it don’t worry about work, come back whenever you’re better, I pay you for while you’re off and he came back and he told me it was that reassurance that helped him to kind of not panic about getting better. In essence that social stress that was removed from him that allowed him to progress with his rehab.

So after kind of getting a history from you, what do I want to see? I want to know, are you breathing? How do you bend? How are you standing up from a chair? What is your posture like? For me, these four key questions are really important because unless we get the basics right it’s very hard to make improvements within an exercise program.

So let’s talk about breath. So many patients come in to me, and I’m like going, are you breathing? And when they go, no, and I’m going, are you protecting your back? They’re going, yeah. They’re all protecting their back because they’re so fearful of causing damage. That’s really important to know that your back is strong, over 90% of people have back pain. There’s no one specific cause for it. Most people say it’s non-specific or it’s benign in nature, but it’s not serious and it’s not harmful, but it’s really impacting your life and causing you distress. It’s not harmful. When people come into me and I see that they’re bracing and they’re protecting, I kind of go to kind of a clenched fist. I use this analogy and I get my patients to make a clenched fist. If you can all make a clenched fist now for me, and you need to really squeeze your fist as hard as you can. Now I want you to try to move that fist up and down. It doesn’t feel that nice. I hear a bit of clicking and cracking, and I feel my knuckles are beginning to get a bit sore. Your knuckles and your wrist are actually the same as the joints in your back. So if you’re bracing or holding your breath you’re probably increasing the amount of stress and strain going through those joints, and also if I’m holding my fist all day long, I’m beginning to feel my forearm muscles get a bit sore. I’m sure you are too there and now I want you to move it. Now I want you to relax your fingers and just move your wrist up and down. It feels so much nicer. That’s the same with your back. So you need to breathe, you need to relax, that’s what really is the key. This most probably comes natural to you, so it’s important that you’re telling yourself, ok breathe, relax feel your tummy, Does it feel soft?

The next thing I want to look at is how do you bend? So your spine is made up of segments stacked upon each other. Within each kind of bony segment, you have a disc, and it’s designed to twist and turn. So when you are keeping your back very straight, you’re not allowing your back to do its function. Hence it kind of may feel a bit stiff, a little bit tight. These are some videos that I’m just going to show you. All how some people typically move when they come in to see me. So, the first video is someone kind of hinging forward.

You can see here he’s keeping his back really straight, and he’s just hinging from his hips. Another movement pattern that I typically see is actually bend from your legs and your knees, and you’re trying to keep that back really straight, but what I want to see when you come in to see me is that we’re flexing, we’re bending from your upper back, your mid back, your lower back from your hips and this movement is quite nice. Again, when you’re bending I want to make sure that you’re breathing and when you’re bending, it’s okay to feel pain and discomfort. You’re not going to do any harm, but if you can on a daily basis throughout your tasks think about every time you’re bending to pick up your socks or you do the laundry, you know that you’re actively going, let’s breathe, let’s move through my back normally, that would really help in your recovery.

So next we go on to posture, everyone comes into me thinking that you should have this real upright posture and when we have back pain, I typically see that people probably try to overcorrect their posture. If we can go back to that clenched fist analogy, if you are holding yourself upright and squeezing your shoulder blades and trying to have that nice straight posture, in essence, your kind of going around with that clenched fist all day long. So you kind of have that increased activation of your back muscles. So what I generally like to see is that perhaps you’re a bit more slumped, you’re relaxed. When rising from sitting we’ll go on to kind of looking at how people typically come in, when they’ve back pain and how they stand up. Most people come in to me, they’re keeping their backs straight. You’re using your hands to come up. This is like a co-contraction, you know, so people pushing down through their arms, increasing that intrabdominal pressure within your tummy, and increasing activation of your trunk muscles. If you can see in this video, you know, Steven here is going right upright he’s not flexing through the back, he’s pushing through the arms, trying to keep his back straight. When we look at the function of your arms, your arms are for reaching and for pulling, not for standing. Your legs are for standing. So it’s really important that when you’re rising from your chair that your using your legs. So this is an example of where we get Steven trying to keep his arms relaxed and you can see his nose is coming over his knees. He’s not using his hands and he’s kind of really send those hips backwards when he wants to come down so he’s utilizing his legs. This is a lot nicer, on your lower back and it’s actually a lot easier to do. So next time at home when you’re rising from a chair and you have back pain, think about bringing your nose over your knees, think about really trying to use those legs instead of pushing through your arms.

So next, what I want to look at, once we kind of have those functional movements done, I did an in-depth analysis of how your muscles are functioning and, it’s been shown that a lot of people who have back pain and even who’ve recovered from back pain have this kind of altered muscle activation. What I typically see is that patient’s back muscles and core muscles are actually quite strong and it’s the leg muscles that are weak. From a retraining point of view, what I want to do is kind of try to get those leg muscles and those core muscles stronger and I want to be really specific when, we’re exercising.

So the next slide will show kind of some examples of some specific exercises, and any exercise that we did at this stage can be tailored to your needs. But what I’m looking for is that when you’re exercising it, you’re feeling it is that right muscle improves. So, when I give you kind of a bum strengthening exercise, I want to know that, yes, it’s your bum that’s working, and not maybe the muscles in the front of your thigh or the muscles in the back of your thigh. The first exercise here is, you can see Ciaran using what we call a hip thrust and this can be modified into a lower level by perhaps doing what’s called a bridge, or can be made slightly harder by going into single leg hip thrust or adding on a weight. The next one you see, we think that what we call a kind of side line hip abduction and you’ll see that this green band, this is called the TheraBand and it’s a resistance band. So he’s pulling up against a bit of resistance, and this resistance is really important because what we’re looking for is that we’re looking for that we’re developing some changes in those muscle fibres so that you’re getting kind of like those strength changes that you need in order to help with your recovery. When we’re bringing you through an exercise program, it’s really important that you’re kind of working at a level where those changes will happen. So I generally say an effort of seven out of ten is what we’re aiming for, and when we’re looking at repetitions, do eight reps, seven out of ten should be sufficient to kind of allow me to get the changes that we need, but it is all about being specific within that muscle group.

So next we kind of go on to what we call, strength training. So we’re kind of looking at the whole body. There’s guidelines from the World Health Organization, they say that all adults should be doing at least two days of training, per week. In order to see changes kind of in your pain levels and in your function, it has to be a progressive strengthening exercise program. This can take 3 to 4 months, so this is where what I typically see in clinic is some patients come back to me and they go, I’m doing the exercises, I’m not seeing any changes in my pain levels, but what I’m actually seeing is I’m seeing changes in your strength, and it takes time for some of these strength changes to kind of correlate to a reduction in your pain level. This is where you’re not giving up on your exercise program and keeping that hope is still really, really important. You can see to the right of my screen, I have some cross-sectional pictures of an MRI scan. What I’m looking at here, I’m looking kind of after the two kind of black circles at the back of it, and they’re called your paraspinal muscles and your multifidus. The, picture to the top, left hand, side, kind of is normal, good muscle fibre and then as you go down through the other three pictures, you can see there’s a lot more white within these back muscles and that’s what we call, fatty muscle infiltration. That gives us some idea that those back muscles just are not working and that may be contributing to your pain. A study that was done here in Sports Surgery Clinic back in 2015 found that patients who did a kind of a progressive loading free weight exercise program, actually, had a reduction in their pain and improved quality of life, improved function, and this correlated to an increase in muscle fibre architecture on these MRI scans. So, strength training does work. But you just need to give it time, you need to put in the effort and you need to be consistent.

So what else kind of is evidence-based care? We need to look at cardiovascular exercise and the research will tell us there’s no right and wrong and my recommendation for you tonight is to really pick something that you enjoy. It’s about that consistency, so again, the guideline is recommending that we’re doing between 150 and 300 minutes, of moderate cardiovascular exercise, per week. Now, obviously, you’re going to say to me, I have pain, I’m not able to do that, and that’s okay. I suppose my tip is to start small, and to gradually build it up, and there is a ton of research to show that actually walking is such a great exercise for people who have back pain and this was a study that was on the Guardian newspaper, and it was it was published in The Lancet journal and it was done in Australia. They looked at people who had recovered from lower back pain and they put them on a walking program and what they found, all the people who engaged in a consistent walking program actually had a reduction in their flare up and the severity of that flare, so a simple exercise you can go outside, it doesn’t cost you anything, and again, you can just start small. Even walking around house with an amount of back pain, building it up and, and then gradually trying to progress it.

So the next – managing a flare-up. So what do we do? Flare-ups can be very distressing. Again, it can be quite disheartening, especially if you’re improving in this journey of managing your back pain, and once you have an episode of back pain, you have had an increased risk of developing another episode of back pain. The first thing I would suggest is don’t panic. You haven’t done anything serious and it will get better and if you’ve had previous flare-ups and back pain, you know that it will get better. Again, what we want to kind of see that you’re trying to still keep those normal and functional movements going. So, you’re still using your breath work, you’re not trying to protect your back. Trying to do some simple exercises while you’re in this flare-up will actually help you recover quicker. So it’s all about keeping moving or pacing yourself. So if you typically would have gone for half an hour a walk, perhaps during a flare-up, you’re going for two, five minutes each walks, spaced throughout the day.

On my next slide, we have an example of some exercises. One of my favourite exercises is what I call child’s pose. This is again a really nice, safe exercise. Your kind of getting a nice stretch to those muscles, along your back. Again, you’re using your breath and you can hold this stretch for anywhere between 10 to 30 seconds. You can do simple knee-ups, even just bringing one knee up to your chest at a time, if able you can bring two knees up. This is Ciaran here doing some breathing and I generally kind of recommend patients during a flare-up, if you might go on to YouTube, find a nice meditation video and just focus on that belly breath trying to relax through those back muscles.

Then what do we do after a flare-up? We actually want to get back exercising. Again, you may not be able to get back to the load that you were lifting prior to the flare-up, but as soon as you feel able to you’re getting back into the gym, you’re getting back down onto your exercise mat. This is kind of a picture of Stephen doing some of this strength work. So here is kind of a nice goblet squat and the muscles in front of the leg going, you might be able to go into my split squat, and all of these exercises again really safe for people who have back pain. You’re targeting the leg muscles and the main thing is, after a flare-up were really striving for function. I suppose that’s one thing that I really try to encourage my patients to do is to set goals for yourself, try not to be chasing your pain, but chase your function.

So look, in conclusion, there’s no one magic solution. I suppose everyone’s journey of back pain management is quite different. Consistency is key and it does take time And flare-ups will happen, but what counts is really how you manage them and you get back on track, and you have that kind of end goal in sight.

That’s a really good question and it’s suppose I typically would hear that sometimes people come into me and they’re doing exercise and it’s causing their back pain and it’s not that the Pilates or the exercise is bad sometimes it’s down to your technique so you know I typically say that if you’re feeling it in your back it’s a sign that you’re using your back muscles and not necessarily your core. So a lot of the times it’s just down to your technique of how you doing some of your palates exercises and if you remember my talk I was talking about a lot of diametric breathing and using that breath control and that is really important to help relax some of those back muscles so it might be worthwhile that if you’re finding in a class setting that that’s flaring up your back pain that perhaps you’re kind of going for a one to one session and that you’re kind of really trying to work on you know your technique and how you’re performing you know the exercises so that you can get a lot more specific with how you’re activating your core.

Yeah there is and I suppose you know a lot of the times it’s about if you’re kind of stiff in one segment you’re going to have to gain that movement through moving another segment so a lot of the times if we see patients in our clinic if they’re really stiff in their hips they generally tend to overuse their backs. If you can kind of free up your hips and allow them to move a lot more effectively a lot of the times that can help improve your back pain and some of that stiffness within the hip can be freed up not only through stretches but also through strength training as well so trying to get those kind of like hip muscles working a tiny bit better. So yeah there definitely kind of is that correlation between the lower back and your hips.

Yeah again I suppose you know what we always do is treat the person in front of us and again it’s trying to you know get that flexibility back into your spine and there’s various ways of how you may do that and it’s kind of really that exercise program you know per person so you kind of want to know well maybe what’s driving that stiffness. Is it that there’s that kind of like tension in your trunk muscles and do you need kind of a bit more relaxation techniques. Is it that your back muscles are just not allowing you to move because they’re compensating for weak hips and weak legs and that actually your treatment program needs to be more targeted towards your leg muscles and then you have you know the classic stretching program that some people you know can do kind of on a daily basis to help with that but a lot of the times you’re kind of trying to bring it back to function you know how is that stiff back affecting you day to day and you’re kind of trying to maybe drive your exercise program to your function as opposed to just maybe trying to get a really flexible back.

It’s horrible when you suffer from Sciatica there’s nothing worse than nerve pain so I definitely feel for you but driving I suppose a lot of times with sciatica your nerve just doesn’t like being stretched and when you are driving unfortunately that can put extra stretch on that nerve and cause irritation on it. Best tips I generally say is you know take regular breaks kind of avoid long journeys so if you know that you’re going to be traveling two and a half hours maybe every half an hour 40 minutes get out of the car do a little walk around also maybe try not to have your car seat you know bolt upright so change you know the angle of your car seat and you can kind of variate back and forwards throughout your car journey as well and they’re probably my two main tips of how to limit irritation of that nerve when you’re driving.

The second part maybe you know swimming again it’s I generally kind of again really patient specific if you have a lot of pain on that like backward bending you know through your Lumber spine then you know trying to maybe going into your breath stroke or your back stroke can be quite good and again you’re kind of looking at that whole spine you know if your neck is really stiff you want to avoid the amount of times that you’re rotating it from side to side so sometimes spending as much time in the water with your head and neutral can be better as well.

Yeah I think improvements can be kind of multifactorial and from the talk that like you know different factors can feed into you know patients improvements and one of them is making sure that people are doing it consistently but regards to ages I think once you get kind of over the age of 65 and you’re getting some changes within those muscle fibres and muscle bulk called sarcopenia sometimes it can take a bit longer to build up the strength. That’s where probably adding on resistance and weights is even more you know important so sometimes the older you get the harder it is to build that muscle bulk. Regards to gender again like that postmenopausal woman with the hormonal changes that can influence your ability to put on muscle bulk as well. So yeah there can be that changes kind of in the gender as well.

I suppose as a physiotherapist you I mean we’re not going to I suppose change a structural change within your spine so what Spondylolisthesis  is kind of a forward slip of one bone on top of the other and this can kind of vary to you know different degrees and while it’s nice to know kind of a specific diagnosis we still treat what we see with regards to your movement and your strength deficits so physiotherapy can definitely help improve that  because a lot of the times the first line of treatment is nonsurgical.

We can of use an outcome measure it’s called a start back screening tool and that even helps us guide what’s the best form of treatment for you and we just use it as a guide like everyone has their bespoke treatment program but some people actually just need advice on how to self-manage and they can go and do their own exercise program another kind of cohort might just kind of need kind of you know an exercise you know program and then you have that other cohort which need a bit more for an MDT approach having some you know psychological approach. At work we tend to use that to help guide us but we’re also really listening to you, what’s your preference with regards to your exercise and you know what type of exercise training do you like and we really try to kind of like fit it into your schedule as well so while it’s recommended that you might be doing strength training two to three times a week if you have a really busy life and you can only fit it in once a week then we’ll work around that or you know we’ll give you tips on how to incorporate it into your schedule so there’s various tools that we use to really create that bespoke training program just for you.

Yeah no I love cycling, I think cycling is one you know like it’s suppose there’s no one exercise that’s better than the other but I really like cycling, I think it’s really safe, I think the back is in nice relaxed position, you’re getting the legs working hard and you’re getting a bit of cardiovascular you know fitness as well so I’m a big advocate for cycling.

Yeah I suppose again when you look at kind of any of the guidelines you know manual therapy is part of kind of an evidence-based care I suppose the issue is that you just don’t rely on it, it can definitely help with an acute spasm and acute episode of pain where you do manual therapy. I would typically say like while the majority of my treatment sessions are exercise based in certain cohorts you might need 10 to 15% of that treatment session which is manual therapy just to help get them moving, help reduce their pain. So yeah it’s definitely a good option but not in isolation.

Not necessarily I suppose like when you’re listening to that you’re kind of going okay is it a nerve irritation if it’s paraesthesia alone with a small bit of pain and I suppose one of the advantages of seeing a patient face to face is that you’re doing a thorough examination and I suppose part of that examination is out ruling any kind of signs of something serious going on but also another part of your is your neurological examination. So if patients have those symptoms but your neurological examination is completely normal and you’re happy that it’s definitely coming from the spine then kind of that watch and wait approach you know is fine, where you can bring them through kind of a guided exercise program, so not necessarily opting for concern but it’s something that you’re monitoring because I suppose what we do know with like spines and Lumbers spine is that everything’s can be an involving pathology so what presents to you on a Monday may be completely different in two weeks time and that’s the importance of having that baseline neurological examination.

Yeah and it’s hard because sometimes you get into like this kind of like cycle or pain and stiffness and more stiffness can cause more pain and we tend to stop moving because of the pain but actually if you can gradually build up exercise some of that pain you know will reduce and I suppose you’re not going to do more damage by moving into pain and exercising into pain. It sounds like this person has you know a pain in various different areas and it’s going on for quite a long while so potentially this patient could be good from an MDT approach as well that it’s not just kind of you know physio you’re looking kind of at that wider you know picture but it is important that we’re kind of getting some movement into the body. A lot of times patients who are presenting with chronic pain I tend to try to chase function as opposed to pain so you may still have the same pain levels but can your function improve and so I would in that situation chase function as opposed to pain sometimes.

For physio at the moment I would probably say we’ve no waiting list, I suppose we have a large team so we always kind of we’ll slot you in some place and like we work Monday to Friday and you know so I would say no we we’ll get you in you know within you know a week to 10 days.

My name is Sam Lynch I’m a consultant spine surgeon working in the Sports Surgery Clinic in Santry and I have got public appointments at the Mater Hospital in Dublin and the national Orthopaedic Hospital in Cappagh so I’m going to speak to you about innovations in back surgery but the first thing I’m going to do is address some of the myths that surround back surgery.

The reason we’re going to talk about this is because if you don’t understand the right way to treat it and the causes behind it’s very difficult to get to the bottom of it right and I think everybody accepts that it’s a complex issue and it involves more than just surgery or more than just physiotherapy, everybody has to be involved but there’s an awful lot of disinformation out there surrounding back pain both in the causes of it and the treatment of it and I’m going to hope to address some of these for you tonight.

So, the first myth of which there are seven is that if you have a slipped disc you must have surgery, it sounds like I’m trying to talk myself out of a job here now but I’m not. 50% of people with a slip disc regardless of the size of it provided that they don’t have any weakness in their legs or any alterations in their bowel or their bladder, so if they can go to the toilet normally because after the disc prolapse they improve without surgery, and that improvement happens within 12 weeks to six months. Of the 50% that don’t improve provided that they’ve had the proper treatment which would be physiotherapy, movement, non-steroidal anti-inflammatories and in very specific cases injections, if they don’t improve within 3 to six months it’s reasonable to consider surgery. The reason we consider surgery to take the pressure off the nerves the disc is like but I like to describe it as in the clinic is like a cod liver oil tablet it has a hard shell and a soft centre. When the disc bursts the hard shell around it splits and the contents of the disc spill out into the canal. You can see it up here in the diagram on the right, you can see that blue part of the diagram is pressing on the yellow bit which is the nerves, so you can see that that’s what causes your pain, most of the time and 50% of the time your body will resorb that disc it’ll just dissolve it away over time. If that doesn’t happen it’s reasonable to consider surgery for it because you can develop a chronic pain syndrome which is very debilitating. So, the first myth around surgery is that if you have a slip disc you must have surgery that’s not true you may need surgery but there are other things we can do first.

The second myth that we often encounter is that when you have back pain an MRI scan or an x-ray is going to give you a cause for that pain, in the main that’s not true and this is my worst nightmare and any medic’s worst nightmare in the clinic is you’ve got someone with real and debilitating back pain and absolutely normal scans that doesn’t mean that they don’t have pain or that their pain is in their head or it’s not a real entity it’s a very real entity it just means that from a spine surgery point of view there isn’t a surgical target for their pain and oftentimes the patients history what they tell us when their pain comes on what makes it worse what makes it better and how they examine so when we examine people and ask them to move to bend, to examine the power and tone in their legs that will often give us more information than imaging. So just because you have a normal MRI scan and a normal x-ray doesn’t mean that you don’t have a real problem it just means that it’s a more difficult problem to fix.

The third myth and this is one we hear all the time and it’s one that you your mother would have told you back in the day, is if you’re back hurts you should rest until the pain goes away. That’s the worst thing you can do, when you’ve got an acute flare up of back pain you need to take some painkillers to try and get you over that pain and then you need to start moving gradually as quickly as you can, the more movement you can tolerate the better and the quicker you get back moving the more likely you are to recover. This is especially true in an elderly population because the older you are the less likely you are to regain movement once you’ve stopped moving and that’s the same for anything, it’s the same for back pain, it’s the same for hip pain, it’s the same for knee pain, once people stop moving as they get older it’s very difficult for them to start moving again so the take away from this is that back pain is helped by movement after the initial day or so of acute pain.

The fourth one we have is that most back pain is caused by injury or heavy lifting, right that’s also not true. Back pain is so common that we’re starting to consider it as normal, if you don’t have back pain in the in the course of your life you are in the minority not the majority and this lady on the right she’s an Olympic champion weightlifter and I’m quite certain that she doesn’t suffer from debilitating back pain so the fitter you are, the healthier you are, the more active you are the less likely you are to have back pain. If you obviously go into the gym and lift weights with bad technique you’ll injure yourself but it’s not a direct relationship between activity and lifting and back pain.

The fifth myth around back pain is that it’s usually disabling, we often see people in the clinic and they’re coming to you and they’ve been in pain for an awfully long time and pain is an absolute leveller for everybody. If you’re suffering from chronic pain for a long period of time it wears you down right and people get to a point of desperation where they feel that there’s nothing that can be done to help them, whereas the reality is that if you have a more holistic approach to the management of your back pain, treat it like it’s a chronic condition using a kind of a multi-disciplinary team approach so you involve spine surgeons, you involve Sports Medicine Physicians, you involve physiotherapists, you involve psychologists, all of these people combined can help you overcome your back pain. There is no one person that can do it but if you’re given the right tools by multiple people back pain can be conquered but it’s very difficult but it certainly isn’t a life sentence which is often what people feel by the time they get to see me.

The six myth is that everyone with back pain should have an MRI scan or an x-ray and the reality of it is that there’s only very specific reasons to get an MRI scan and that is back pain that causes leg pain or leg numbness or heaviness in the legs or weakness there’s normally no real need for imaging of any kind x-rays or MRI scans unless you have some of those symptoms or unless you’ve tried other treatments like your physical therapy, your physiotherapy, your pain regimes and your lifestyle modifications and you’re still having ongoing pain then it’s reasonable to start thinking about an MRI scan but because they’re so easy to get now and they’re not too expensive anymore we’re very liberal in their use and oftentimes I think they confuse people because they don’t highlight anything that we can target.

The seventh myth and it’s the worst one is that bed rest is the best therapy for back pain it really is the worst thing you can tell someone to do when they start getting back pain is to lie in bed for days at a time because your back needs to be in a curved position it assumes that position when you’re standing upright when you’re lying flat your back gets straight which straightens the muscles even further, it alters your posture into one that generates pain so it’s actually makes your acute pain worse. So people with acute back pain should stand as best they can and start gradually moving right a period of bed rest never helps anybody and it’s associated with increased and prolonged duration of your back pain, an increased risk of blood clots, depression and it just doesn’t help so bed rest is not the best therapy for back pain it’s one of the worst things you could possibly do. Although some people do say that it’s the only thing they could do, so I do understand that in the real world sometimes people have to take the bed for an hour or two but spending days in bed is not what you need to do when you’ve a bad back.

We’ve seen it now the epidemic of back pain it’s more prevalent in the States but there’s a huge issue now with opioid addictions as a consequence of indiscriminate prescribing of opioid medications and the treatment of back pain because and oftentimes not to vilify people but oftentimes that’s just because it was all that was available to people to manage their pain, but we know that it’s more than just Opioid medications, morphine based medications that’s not what people need people need a multidisciplinary team approach that are paying to help them manage every facet of their life because everything about your life impacts on your ability to cope with back pain.

You can see that and these are American numbers is well we don’t have the numbers Ireland right but there’s like MRI scans they’re over ordered by 300% that means that like one in four MRI scans, give us information that we can actually use in the opioid prescriptions I think they’re much less regulated where this data is coming from but opioid medications are dirty medications they’re really good for pain but they’re really bad for everything else, they cause addiction, drowsiness they cause problems with your digestion, they cause constitutional problems, they alter people’s mood so they really should be avoided and they’re a medication of Last Resort that should only be prescribed for short periods of time. Spinal injections these are really powerful when used properly they’re really effective and I do them in very specific instances in my clinic and I know some of my pain colleagues also use them to great effect but you have to be very discerning about their use there has to be a surgical target that you can see on the MRI scan and that is directly linked to the patient symptoms. So it it’s very important that you take a good history that you do a good physical examination, that you look at the x-rays and that everything matches up together before you start injecting because while they’re very low risk there’s still risks associated with them and there’s no point in doing any intervention on someone unless it works. Then spinal fusions again in America because their health services is very financially driven and so fusion procedures pay more over there so they do them an awful lot more and it’s almost a purely private system so their degree of fusions is much higher than it would be in Europe.

So what we’ve established here in the Sports Surgery Clinic in Santry is what we call an MDT a multi-disciplinary team and the reason we do that is that it is a complex problem all be it a very common problem it’s still a complex problem and the source of each individual’s back pain is different, the causes that are driving it are different the modalities that we use to treat it will be different and unless we give people long-term tools to cope with their back pain as well as the therapeutic interventions that will help get rid of it people aren’t going to get better.

So the MDT that we’ve set up here in the Sports Surgery Clinic in Santry consists of spinal surgeons of which I’m one, I’m really the last resort in the treatment of back pain and the skill set that I bring to it are only applicable to a small minority of patients. Most of the patients will be dealt with by the other members of the team these include the pain Physicians who have great expertise in targeted injections, non-opioid pain medications other pain strategies then we’ve got the physiotherapists who are the main stay of the treatment for most people with back pain. They tailor the exercise based rehabilitation programs to the patient needs and the pain generators that the patient has, psychology is very important in the management of back pain because especially if it’s been going on for a long time it can come to dominate your thoughts and people often come to us in a desperate state because their pain has been ongoing for an awfully long time and they feel disempowered by the by it just controls their life they don’t have any control over it. So CBT or cognitive behavioural therapy is a very powerful tool for people to learn to manage their pain it gives people back power and control over their own lives and it’s one of the fundamental tenants of what we’re trying to achieve and then the sports medicine physicians are very good for devising return to lifestyle programs for people they get people back to where they want to be back to where they started from be that playing sport, going for a walk, just living a normal pain-free life. So you can kind of see that the management of back pain is really complex it takes more than just a spine surgeon to do it and really a spine surgeon while they have an important role at the thin end of the wedge they’re not central to it they’re part of a team.

So the MDT will begin with a comprehensive physical and psychological evaluation of each patient, we look at the physical shape that they’re in how their exercise tolerance, their cardiovascular fitness but you’ll also look at the psychological stresses that they’re facing in their lives, we know that people who are going through any kind of psychological stress be it a bereavement, marital problems, general life stresses, job changes, moving house anything that diminishes people’s capacity to cope with any kind of pain and it also increases the likelihood that they will develop back pain so all of this is important and it needs to be factored into their treatment algorithms. Then based on this you get a treatment plan that involves either the spine surgeons if there’s a mechanical cause to their back pain are the physiotherapists, the psychologists, the nutritionists and the sports physicians, pain management is really important but we really need to not use opioid medications if we can because while they’re very good for pain as we said earlier they’re very bad for everything else. Over time then we try to give people back the power to get rid of their back pain but it takes time it takes buy in from everybody involved but the patients the GPS who are referring them to us and the members of the multidisciplinary team and once we get people back up and moving that’s what we consider a success.

So it sounds like I’ve spent the last 20 minutes talking myself out of a job right but like most of the spine surgeons across the city are very busy and for good reason because even though most cases of back pain don’t require surgery, surgery is a very powerful tool and it’s essential in some instances and they’re very specific instances so the first one is if there’s nerve compression so the nerves come off the spinal cord at the base of the spine and go down into your arms, go down into your legs, supply the power, the sensation and the movement to those limbs. If they’re being compressed by anything be that a slipped disc an infection a tumour any kind of injury then spine surgery is essential to take that compressing element off the nerve before it completely obliterates it permanently. The second indication for spine surgery is if when there’s any structural spinal instability, and this this sounds very fancy right but there’s a couple of instances where this is relevant. The first is scoliosis this is a progressive condition that gets worse when people are growing quickly which is why we see it in young adolescents during their growth spurt, we measure the absolute size of the curves and curves over 50° when we measure it on the X-ray they tend to progress into adulthood, curves under 40° they tend to stop when you stop growing and curves between 40 and 50 can go either way. So, we know that over time large curves in scoliosis get worse and it’s better to fuse them to fix them. The third indication for surgery would be serious conditions like fractures, infections or tumours we deal with a lot of these in the Mater spinal injuries unit which is one of my public appointments but and it’s not really relevant in an elective setting because these conditions they tend to require surgery immediately so we’ll often see these and we’ll operate them on the same day or the next day depending on when they’re referred to us but so spine surgery is important and it has a huge role but people have to be discerning about when they use it.

Just going to briefly touch on each of the indications we’ve discussed right so surgery for severe nerve compression comes with severe leg pain what most people would know as sciatica, which isn’t improving so if you’ve got a herniated disc it’s pressing on your nerve, it’s causing you severe unremitting leg pain that hasn’t gotten better in the first 12 to 24 weeks despite your best efforts at physiotherapy and pain medications then it’s probably reasonable to see a spine surgeon to get that disc removed before you develop a chronic pain syndromes. The surgeries that we would do would be a micro discectomy which is where we make a small window into the spinal canal to remove that bit of herniated disc that bit of disc protrusion that’s pressing on the nerves, in very big discs or discs that are in the centre of the spinal cord we’ll do a slightly bigger procedure called a laminectomy where we take the bony ach off the back of the spine to relieve the pressure. We tend to do that for what people will know as Cauda Equina syndrome and that’s when the disc is so big that it compresses the nerves that control your bowel and your bladder function, that’s a surgical emergency and we would do that overnight if I was referred a patient during the day I would do that operation the minute that patient arrived in my hospital, it’s very rare and it’s on the same spectrum as a herniated disc but it’s at the extreme end of it but in that in those scenarios you do the larger laminectomy.

Then the surgery for structural instability and trauma so that would be severe scoliosis as we’ve discussed Spondylolisthesis is a big word for one vertebrae slipping on top of the other right so there’s just a little bit of a step there and that can sometimes cause pain especially when people are standing so that can sometimes need surgery and again fractures for trauma which is you know most often times you fracture your spine if it’s a road traffic accident or in elderly people with osteoporosis or soft bones they can get they commonly get spinal fractures from minor falls. The common fusion surgeries that we would do would be spinal fusions which removes all movement between the bones in the back using rods and screws or artificial disc replacements. The artificial disc replacements are again very powerful but they’re only relevant in a very specific population you wouldn’t do it in everybody you certainly wouldn’t do it in people who have got arthritis in the small joints of their back or arthritis in the small joints of their neck you tend to do it for younger people who have relatively healthy backs in every other way except for at that specific disc.

We’ve lots of very fancy High-tech tools to make this safer we have robotic surgery which combines your CT scan with your on-table x-rays during theatre to allow us to navigate the screws and the rods into exactly where we want them. So this is really powerful in that it minimizes the risk of any injuries to the nerves or to the spinal cord and allows us to do much more complex surgery much quicker and with much less risk to the spinal cord. Then the other one we the other options we have now are endoscopic surgery this would be for the micro discectomy the shaving the disc off in those in those herniated discs and that allows us to do a nearly Keyhole and this is a new technology that’s come on stream in the last 10 years that has really revolutionized how we can treat these common spinal conditions.

So the conclusions that the talk are that most back pain is not serious and it will go away, the key to getting better is to move as much as you can, while surgery is indicated it is the last resort in most cases, if you are having surgery it’s much safer now than it was in the past because we have an awful lot more technology at our disposal to make sure that the implants that we put in go exactly where we want them but really the more you move the better you’ll be when it comes to back pain.

So the GP will just write into to the spine service here at the clinic and then we’ll just triage out the referrals appropriately so you know we’ve got a lot of specialties available to us we’ve got surgery, we got the pain specialist Physiotherapy, the Sports Medicine so between us we kind of appropriately delegate the patients depending on the triage letter of the GP sends in and it’s very quick to be seen then after that.

It’s not long is the answer a lot of it will depend on the complexity of your surgery so if it’s a simple, let’s say the simplest thing I would do from an operative point of view would be a lumber decompression and the most complex would be a fusion procedure with disc replacements etc, so a lot of it will depend on the complexity of what you have done but if you have a simple procedure you’re talking within you know four to six weeks from consultation once we’ve gone through all the relevant planning and stuff it’s not an honours waiting list.

They’re powerful medications in people who are fit and healthy, if you’ve got any problems with your kidneys, if you’ve got any problems with your stomach, any ulcers they do have issues and taken safely like with within the recommended doses they’re fine. If you’re taking them for longer than a week I would always put somebody on a stomach protector just for that I would try to avoid them for longer than two weeks mainly because you get increased risk of ulcers and they can cause kidney injuries, they are a useful tool, they’re not addictive but they have side effects so you just have to manage them appropriately.

I would only use EMG if I couldn’t figure out where the radicular pain was coming from so radiculopathy in the main is relatively straightforward to diagnose, if it’s coming from your back. So the of EMG is to find out if let’s say you have a normal MRI scan but you have symptoms of nerve compression in your legs, normally that’s coming from your lower back but if it’s not in your lower back the nerve can be compressed elsewhere after it’s left the spine so that’s where I would get the EMG’s but I wouldn’t routinely use them unless there was some ambiguity about the source of the problem.

It does go away actually and it I didn’t put it in this presentation like it can be startling the change you can have an MRI scan taken let’s say a year ago and then a repeated interval at a year and it’s in some people it can be almost completely normal so the body does resorb them right like I mentioned it in the talk discs they kind of go one of three ways in the first six months so the pain either goes away, it gets better, or it gets worse. If it goes away you don’t need to do anything if it stays the same or gets worse after you’ve done everything right and you have some kind of a compressive component to it if there’s a disc pressing on a nerve or if there’s some other thing pressing on the nerve it’s probably reasonable to consider surgery at that stage. In the main your symptoms kind of in the first 24 to 36 weeks will dictate how it’s going to be long term.

Yeah so that’s like a type of conditions it’s very complex because and while like there’s loads understood about the connective tissue conditions, there’s a lot of evolving knowledge there so like and oftentimes the pain generators are hard to identify and as well as that person rightly points out a lot of pain medic medications don’t work so it’s it definitely that’s definitely one that requires an awful lot of input from more than one specialty. I don’t have an awful lot of experience like I have in terms of I’m a scoliosis surgeon as well so I have a lot of experience with people with connective tissue problems because they develop scoliosis as well but in terms of management of pain no it’s very complex and you need input from some fairly specialist people for it.

Yeah general advice is do exactly what you’re doing right which is all the right things and it’s very difficult to piece together exactly what’s going on there without seeing that person and their scan you know because if you have leg pain without a significant component of back pain that sounds very much like those nerves are being compressed which is why it’s worse when you’re standing up for example so there are surgical solutions to it injections in that instance do work as a general rule of thumb if you have narrowing at the base of your spine that’s due to just you know age related wearing tear it’s unlikely to get better over time it’s likely to get worse so it’s probably worth seeing somebody about that.

That’s a really good question and it’s one we have to deal with all the time so there’s two components to transferal nerve root blocks, there’s two ingredients in the injection there’s the local anaesthetic which does it’s just pain relief in the first 24 to 48 hours and then there’s a steroid. What the steroid does is it takes down any inflammation around the nerves because when I do a discectomy I’ve just done one and in the last hour or so you when you take the pressure off that nerve that’s been caused by the disc that’s pressing on it you see that the nerve is very hot and red and inflamed it looks swollen and irritated so the steroid takes down that irritation and that gives it a lasting benefit. So injections they’re not about masking the pain they have a therapeutic benefit as well and again it’s nearly like a rule of thirds with injections about 20% of people will get no response which means that you have to look for another source of their pain, if they get no response at all even if they don’t even get an hour’s response from the injection either the injection wasn’t put in the right place or it’s not the cause of their pain. The second group get a response but it’s transient which means that you have to revisit possibly doing a surgery on them and then the third group get a lasting response which means that you know the either avoid surgery or you can repeat the injection at an interval so it’s more than just masking pain it does have an anti-inflammatory effect that can be quite sustained.

Again like back pain in the absence of any leg pain is best treated non-operatively right if you have back pain and leg pain that are equal in measure there are subtleties to it this is these are all generalities you know but if you’ve got back pain and leg pain you can consider surgical intervention in this in the form of a fusion right if you’ve just got leg pain that’s bigger than your back pain tends to just need a decompression.

It’s a surgical emergency so if it’s left untreated like we I work in the Mater spinal injuries unit in Mater University Hospital as well and so we would treat Cauda Equina within hours of getting the referral to avoid long term consequences with their bowel and bladder function is the main problem right you can also have weakness in your legs but the long term consequences of untreated Cauda Equina are sexual dysfunction bowl and bladder problems so it’s a pretty devastating condition if it’s left untreated.

So it depends who you ask now and there’s a couple of ways to answer that question I’ll try be diplomatic about it but yeah so it with the common ground between orthopods and neurosurgeons is the spine right neurosurgeons do brain surgery and they go from the brain and they can go down into the spine, orthopaedic surgeons do surgery on everything else so every other muscular skeletal part of the body and we do spine. What we’re finding though is that for both neurosurgeons and orthopaedic surgeons spine is nearly a separate specialty now so I have an awful lot more in common with an orthopaedic with a neurosurgeon who does spine than I have with an orthopaedic surgeon who does foot and ankle like we very similar practices. So in real terms there’s probably no real difference depending on the level of training. We’re essentially spine surgeons there’s differences within those like a brain surgeon is different to a spine surgeon in the Neurosurgical side and like let’s say a hip and knee surgeon is different to a spine surgeon on the Orthopaedics.

Oh yeah definitely depends who fixed it now right but I’m sure they’ve done a good job yeah, the whole point the T6 to T10 is most of the mobility in your spine comes from your lumber spine so like yes is the short answer to that you should do provided it’s you’ve healed up and everything is good you should be fine.

My name is Ruth Delany I’m a shoulder specialist and I’m going to be talking about some aspects of skiing injuries that have to do with shoulders. Before you even get to the mountains and get to ski there are probably some things you can do that might help in terms of being in the best possible shape for skiing and possibly even preventing injury as well. So before leaving home if you have a reasonable level of fitness that is going to help you enjoy your skiing more and hopefully keep you out of trouble in terms of injuries probably more so for the legs and for the shoulders and arms but I think overall conditioning can play a role and while you’re out there in the mountains there are some things you can think of that we often forget that may help you as well.

Some things that I’ve used and had fun with preparing for skiing can be gym stuff even just going for a run, running hills and some ski specific things there are apps like perfect turns there are ski specific machines lateral trainers, like skiers edge there’s lots of things you can do you can get really into it but I think the bottom line is if you are reasonably prepared then you’ll have a better time skiing.

When you get there remember that you’re probably going to be at a much higher altitude than we’re used to being at here in Ireland our highest mountain is probably only about a thousand meters and many of the ski resorts that we go to you’re sleeping at an altitude that’s higher than that and during the day going up to you know higher than 2,000 meters often and so hydration is relevant especially when we want to maybe go have a good time people like to have some drinks at some point and again just remembering to drink some water you may feel a whole lot better. Warming up is something that we often don’t really think about both you know tumbling out the door in the morning and just making it on time to wherever you want to get going with your day without actually doing any warm-up before you start or warming up your first run or two not going hell for leather immediately. At the other end of the day being careful of fatigue I think a lot of people are probably aware of this you know that last run syndrome where you try and push one more run or you ski down something that’s really difficult at a horrible time of day when everybody else has been on it as well and so finding an easier way home or maybe even taking a gondola down can sometimes save you and leave you in better shape for the next day. We also see injuries that don’t happen necessarily on skis or on snowboard but maybe around a resort where there’s really icy foot paths and so being kind of aware that injuries sometimes happen not necessarily during the activity, slippery foot baths and maybe slippery bar tables too so I definitely have fixed some injuries to do with après run rather than to do with skiing.

So how about if you have a shoulder injury already or a shoulder problem and you’ve got some plans to head out skiing or snowboarding can you go and what sort of things might you want to think about. So I think you know with the shoulder there can be structural injuries or inflammatory and wear and tear problems and sometimes it’s a mixture of both and so what we tend to think about is well what’s the likelihood of your skiing making it worse, most things pretty unlikely because the shoulders aren’t taking that much of a beating when you’re skiing with inflammatory problems like tendonitis, versitis things that maybe have to do a little bit with and tear it’s perfectly reasonable to have taken some anti-inflammatories or even potentially have had an injection if the appropriate specialist has recommended it and carry on with your activity. With structural problems let’s say you’ve got a full thickness rotator cuff tear something like this you know you’ve got to weigh it up you may find that it’s pretty sore and ruins your enjoyment of skiing you may find that it’s manageable, if you fall on it you may make it worse but if you fall on your shoulder you may get a new injury anyway so for a lot of things you can tend to work around them in the shoulder which may be unlike other joints. Obviously it’s a different situation if you’ve had surgery on your shoulder then it depends where you are in your rehab and what the timelines are like and you’ve got to talk to your surgeon and not take any unnecessary risks in terms of trying to push timelines just to squeeze in a trip maybe you’ve got to save it for next season.

Then if something happens what sort of things do we see in the shoulders and how do we take care of them?  The obvious one is fractures the types of fractures that we tend to see from ski injuries would be mostly collar bone and shoulder fractures being the top of the humorous bone, Proximus humorous fractures and there can be a variety of different ways to manage these. Injuries happen in recreational skiers and they can happen in World Cup racers too, so this is a video of Graham Bell a British ski racer having a clavicle fracture in a downhill race in Kitzbuhel a few years ago and you can see exactly how this happened. So that was a clavicle fracture, ski racers being ski racers I think he was back racing a few weeks after that pretty quickly but for most of us it would take a little bit longer. What do we do with these clavicle fractures then many of them don’t need surgery and sometimes we see people coming home from their ski holiday having been told they needed an operation immediately that day, they’ve been taken off the mountain still in their sweaty ski gear taken to the hospital and taken right to theatre and most of the time that’s not necessary but people are scared, they’re hurt, they’re in a foreign country maybe don’t speak the language and a doctor is telling them they must do this and so the only time that it’s probably necessary to have an urgent operation on a broken collar bone is if it’s what we call an open fracture so if the bone is out through the skin then there’s a significant risk of infection and that needs to be taken care of typically within the first 24 hours that needs an operation. Everything else you can pause take a breath unless there’s nerve or blood vessel damage which is rare so if there’s a problem with the blood flow to the hand or something like that that’s another emergency these are really rare the vast majority of clavicle fractures don’t need to be fixed right there and then. Some of them actually don’t need to be fixed at all and sometimes we see people coming home from a ski trip with plate and screws on there that probably didn’t need to be put on at all and that’s all fine as long as everything goes well but if they run into trouble get an infection or something else then it’s really a shame that they’ve been exposed to unnecessary risk so I think just kind of taking a pause and asking you know well do I really need surgery right now or can this wait, can I go home first, is there an option to manage this injury non-operatively those are all totally reasonable questions to ask. Whether or not a clavicle fracture has surgery depends on some factors that we see on the X-ray like shortening displacement comminution which means lots of different pieces, the fractur in pieces and then other things like maybe if it’s your dominant side we might be more likely to consider fixing it and it’s going to be a discussion between you and the surgeon because there’s often no exact right answer there are risks to fixing it there’s a risk if you don’t fix it that it doesn’t heal and has a non-union and ends up need be fixed later anyway so it’s about balancing all of those things but typically that’s not something you have to decide on the spot.

The other fractures that we see would be broken shoulders so Proximus humorous fracture this is a friend and colleague of mine who had a really innocuous fall skiing he was just at one of those sort of junction points in the piece and waiting for one of his kids to catch up sort of turned around awkwardly and just fell over on his shoulder and had a really nasty proximal humorous fracture and so usually we’ll get a CT scan for these. Again, he was told out there in the mountains in another country oh you need an operation right away but you know he sent a few texts, sent a few pictures and he figured that he could get himself home first and then get taken care of by somebody who’s actually going to be available to follow him up. Again you can see on the other view of his CT scan as we’re scrolling through you can see how the top of the humorous bone is pretty smashed and he had his shoulder fixed by one of the trauma guys did a really nice job put that back together there absolutely perfectly but the problem with these injuries is that once you break the shoulder it’s never the same again, so unlike a collar bone which tends to heal without too many consequences for the shoulder because the shoulder joint’s not involved, once you have a fracture of the shoulder joint be at the top of the humorous or more rarely the socket or the glenoid part that can lead to problems later on no matter how well it’s treated to begin with and the issue here was that the blood supply to that head of the humorous that nice round part of the top was damaged in the initial injury and you can tell by certain features of the initial fracture that this is possibly going to happen but there’s nothing you can do about it, so then the head collapsed over time so now those perfectly placed screws are now prominent and potentially damaging the socket of the shoulder and there’s pain and so the next thing to do is then take the hardware out and he’s left with this shoulder so probably headed for a shoulder replacement at some point and unfortunately, that can just be a consequence of certain breaks of the top of the humorous bone not all of the some of them the blood supply doesn’t get damaged some heal pretty well but you’re often left with some stiffness of that shoulder if you’ve had a break into the shoulder joint.

This is another injury that looks maybe a little bit similar this is somebody who was just standing at the bottom kind of in the lift line waiting for her friends and somebody out of control just came flying down and smashed into her. She dislocated and fractured her shoulder was fixed out there in that country and they put plate and screws on got that head of the humorous sort of back and top of the humorous but didn’t really appreciate the extent of the injury so when she turned up in Dublin for follow up and you can see on the X-ray those sorts of diamond shaped things those are skin clips so it’s really soon after surgery her shoulder is dislocated because that’s where the socket of the shoulder is and you can see the humorous is in front of it and below it and so unfortunately, her injury hadn’t really been completely treated so I took it her to theatre and put it back in but it just sort of fell out again because of the extent of the damage the surrounding tendons of the rotator cuff. She was of an age where it was appropriate that she could have this type of replacement a reverse shoulder replacement so that’s what I did for her and it worked pretty well and she got to go back skiing. So we do let people ski again after shoulder replacements what you don’t want is for someone to fall and have a factor around their replacement so maybe a conversation about changing how they ski in terms of how much they push themselves or how aggressively they ski can sometimes be appropriate depending on the person but it’s not necessarily the end of skiing.

Speaking of dislocations, the more common situation where you just have a straight dislocation, where the humorous comes out of the socket. Like you see in this picture and this is another racer who recently dislocated her shoulder during a downhill she’s one of the best speed racers in the world finished the race and sounds like her shoulders come in and out quite a lot of times before there she is in the gym just a couple of days later but people who have these loose shoulders and tend to dislocate may often find that an innocuous force when they’re recreationally skiing can cause a dislocation. So the people that we think about doing surgery for dislocations are the people that either have a first time dislocation at quite a young age especially if they want to go back to a contact sport if they normally play something like rugby, Gaelic football then they’re a high risk for dislocating again or somebody who’s had multiple dislocations, there’ll usually be structural damage to the shoulder unless somebody has very stretchy ligaments so if the labral and the cartilage bumper around the socket of the shoulder is torn that can lead to further dislocation. So we might fix that as you see on the left with a keyhole surgery, if somebody’s got a bit more damage to the bone of the socket or a dent in the back of the humorous we way have to do a bone block or what we call a latarjet procedure so sometimes shoulder dislocations end up having surgery and it just depends on the situation in terms of how many times it’s dislocated and what are the damages. Physiotherapy is often the way that we treat a first-time dislocation when somebody comes back.

This is another ski racing injury this one from last year Alexander Omakilda had a shoulder dislocation in a downhill race going obviously at a lot more speed than most recreational skiers are going to be going at but his dislocation also was complicated by nerve injury and that can happen when you dislocate the shoulder you can stretch one or more of the nerves around the shoulder. Most of the time that will get better on its own and so whether surgery is indicated or not depends more on the dislocation itself and the other factors that we just spoke about but you can see how quickly these things can happen especially with downhill racers and he crashes into the netting has a significant leg injury as well where the ski edge actually cut his leg and injured a nerve there, his shoulder dislocated he did end up having surgery for that dislocation and that was again a decision that probably had multiple factors in it. These types of ski injuries are extreme but we do see recreational skiers dislocate their shoulders in more typical recreational falls as well there’s just usually no videoing them but you can just see the force involved and the collisions with the ground and with the safety netting.

Another type of shoulder injury that we can see sometimes is rotator cuff tear and believe it or not I have seen somebody who fell off a ski lift. The rotator cuff are four muscles that are deep inside the shoulder, the tendons attaching muscles to bone, the tendons of the rotator cuff don’t have a great blood supply so over time they tend to wear and degenerate anyway. So many people will have some wear in their rotator cuff and over the age of 65 about half the population will actually have full thickness tears but not all of them will have symptoms. If you have a fall you may have an acute rotator cuff tear from an intact tendon that suddenly tears or you may have an asymptomatic tear suddenly become symptomatic because it becomes larger and more difficult to compensate for. I’ve also seen a patient who managed to tear both rotator cuffs in one afternoon of skiing, skiing moguls with his teenage daughter, fell on one shoulder pretty hard knew he had hurt it and then didn’t want  to lose face so continued to ski the bumps and next time he fell, didn’t want to fall on the shoulder he had just hurt so then fell on the other shoulder and presented to us with bilateral full thickness acute cuff tears both of which ended up needing surgery, so it can be a tough injury.

Not all rotator cuff tears need surgery typically the rule of thumb is over 70 the healing rates can be variable and a lot of people in that age group will have had the tear a long time anyway so we may try an injection and physiotherapy to get them back to the compensated state they were in before they fell. Obviously there’s not a hard and fast rule and I’ve dealt with 78 year olds, 82 year olds who are in amazing shape so it’s more to do with physiologic age than chronologic age but in acute full thickness tears in younger or very active people we usually would recommend repair and this is a keyhole surgery where we reattach the tendon to bone using anchors and heavy sutures. The tough part of that surgery is that it takes quite a lot of time to recover and rehab we’ve got to protect the repair in the beginning by putting you in a sling, we can’t allow any strengthening until about 12 weeks out from surgery so in real life day-to-day terms that means you can’t lift anything heavier than a cup of coffee for three months and that has implications not just for people’s recreation but for a lot of people’s work as well. It typically takes about 6 months to rehab from a cuff repair and people are often still improving up to a year so even though it’s a keyhole surgery there’s quite a bit involved but that’s something that can happen from any type of a fall including one on the mountain.

To sum up you know skiing is a fantastic sport is a great recreation it’s an amazing holiday, yes there can be an injury risk but I don’t think anybody should let that stop them from getting out there being active, experiencing the mountains. There are some things you can do to prepare and to try to prevent injury and maximize the enjoyment but if the worst happens then take a breath and assess the options this is not me touting for business we’re already incredibly busy it’s more I suppose from having seen some of the messes that we have to clean up sometimes when people come home just take a breath and find out your options before you get rushed into something. Either way if you have something fixed out in the mountains then you’re going to need follow up when you come home as well and we’re always happy to do that but I think the bottom line is getting out being active and enjoying skiing is far more beneficial than worrying about any of the risks of injury it’s about being outdoors having activity and of course it’s the people that you ski with as well.

Yeah I think it often is a situation where we would consider surgery for shoulder dislocation if somebody is under the age of 25  because we know that if you dislocate your shoulder for the first time under the age of 25 is a really high chance that it’s going to keep happening regardless of how much work you do with physio and how much you strengthen up the structures around the shoulder that help with stability things like the rotator cuff because usually you’ll have damaged the labarum or the cartilage bumper that helps stabilized at the socket of the shoulder. As you kind of get a bit older you are less likely to actually have recurrent dislocation whereas under the age of 25 you may have it happen again so we would have at least a conversation with you about surgery versus trying physio and only intervening after a second dislocation. So I think the bottom line is if you’re 20 years old and you’ve dislocated your shoulder it’s worth at least meeting with a shoulder surgeon and going through your options.

The title of my presentation today is ‘don’t let your knees and hips go downhill’ management of ski related injuries. So I’m going to start this presentation off with a video a little bit of a gory video so those who have any sensibilities you may wish to look away now, this is a man skiing and that snap is not his ski binding releasing but his ACL tearing and you’ll see it in slow motion now. He’s a good skier skiing in deep snow but you see he’s leaning back as he goes into the turn and that’s when his knee is in a vulnerable position, his right knee. You can hear the maniacal laugh of his friends so if you have friends like those who need enemies, but I’m sure he did get them off the mountain to a good orthopaedic surgeon.

I was privileged enough to do one of my fellowships in Vale Colorado and while there I worked with this gentleman called Dick Steadman and he used to look out for the US ski team and he had this phrase that if you were design a device to rupture an ACL you couldn’t get much better than a ski and I’ll tell you the reasons for that as we go ahead.

Well working in a ski resort is like a conveyor belt of injuries because it’s a high enough risk sport and a lot of them occur around the knee. It’s become hugely popular within society going away on an annual ski trip and oftentimes there’s alcohol included in these trips so it does make it equally hazardous.

It’s a great fun sport but risky and if you look at this little cartoon here we see that knee injuries are way more common related to skiing but shoulder injuries are more common with snowboarding so I’m sure Ms Delaney is going to speak to you about shoulder injuries and she’ll be able to show you example of those.

Why is it so risky? Well it relates to the equipment so if you’re careering down a hill on these two planks of wood with the poles in your hand there is a large element of risk associated with it. In the past they used to have boots that went up to the mid shin and were fixed to the ski, they were lashed onto the ski with leather.  Nowadays the equipment is a bit different, so initially the injuries used to occur around the tibia where you’d have fractures or ankle fractures but now they typically occur more around the knee. The reason for this is that the boots that we use are incorporate your ankle and go right up to the top of your shin so where rotation can occur is at the ski itself but when the boot doesn’t release from the binding or the ski the rotation typically occurs around the knee hence making it quite vulnerable.

The bindings are very important and these are set by the person who’s putting your skis together when you either buy them or more commonly when you rent them and the reason they ask you your level of expertise is so they can determine how easily or how more difficultly your ski boot comes out of the binding so that’s referred to as the din. So if you’re anyway suspicious or conscious of your knees ask the person to set your din at a low rating so your ski boost comes out a little bit easier.

Then it’s the ski itself so the ski’s have changed a lot since they were they were initially created and now they’re very easy, they’re actually conformed to how beginner skis as well so it makes it a lot easier to actually ski compared to what I would have started out on in the 1980s. It also has a relevance in terms of the terrain and condition, so we saw in the video at the start it was very deep snow and that makes people lean backwards so you’re more likely to lose control when you’re turning but also so in conditions like this where you very little snow and there’s exposed rock and it’s very common for the injuries to happen towards the end of the day when the snow is a bit slushy on the less difficult slopes where people are kind of relaxed but there’s lots of traffic so a lot of the injuries occur at the end of the day on blue slopes or green slopes which are regarded as being easy.

How do injuries occur? So we saw a fast video of how they occur at the start but essentially, it’s when people lose their balance and this example of images here shows when the skier is leaning backwards when their upper body is rotated into the mountain and the one of the knees get hyper flexed and then the ski acts as a lever so they say if you’ve a lever long enough you can move the world but a lever twisting on a fixed knee can tear an ACL pretty quickly and so this is how the injury occurs. Also occurs as result of stupidity so sorry about the volume here but you just can’t legislate for people like that so these people are going to injure themselves no matter where they are in the world or what pursuit they’re doing.

So what do we do when someone gets injured well on the mountain you really need to look for help and get off the mountain but before you get on the moutain the first thing we recognize in medicine is primum non nocere, first do no harm, so you really need to be conscious of where you’re putting yourself on the mountain so you don’t cause harm to yourself. It’s also key that you don’t chase after that person who’s an expert skier if you’re only a beginner and you need to be well aware of where you’re going to before you get yourself in harms way. Skiing is hazardous but it’s hazardous at the end of the mountain as well and you know it’s not so much that you as an individual need to look out for yourself but you have to look out for other lunatics on the mountain as well and typically this person was trying to get a drink pretty quickly but if you get in their way you’re in awful trouble so you do need to look out for yourself and for others around you. It tends to return to your comfort zone particularly when you’re going skiing I would advise that for the first run or two that you don’t go start doing a double black diamond or a black run if you’re inexperienced that you start off at an easy slope get your ski legs as we used to call it in our family and get confident and stay in your comfort zone when you begin, now you can go outside your comfort zone as the as the week progresses but certainly it’s advisable to start easily.

So what do we when someone has a an injury? So typically if it happens on the mountain that you’re taken off the mountain by an expert some people can ski down the mountain but the classic injury we hear about is someone who their ski binding doesn’t release they hear or feel a snap, they fall to the ground, they have difficulty skiing on and then when they get there they go down to the clinic at the bottom of the mountain or the medical centre they get an x-ray and they could put into a very overpriced brace. They’re told to either get an MRI straight away or they’re told to attend a doctor when they return home in some cases people are more avaricious and they try to encourage you to have surgery on the mountain, I would certainly advise against that because I think it’s important that you make the diagnosis first and then we decide upon what treatment is appropriate and have the appropriate resources around you.

What do we do in the clinic? First of all, we take a good history and I refer to this editorial, this is written back in the 1960s by a guy called Professor Appley and it’s still as relevant today as it was when it was written but one of the nice quotes from this editorial is “to listen is to learn we all pay lip service to a careful history but how many of us are patient enough to elicit one?” so I will say that in terms of taking a history it’s really important that you understand the mechanism of injury, whether the person has any previous knee injuries and very much you can make the diagnosis by history alone.

We then talk about clinical examination and one of the other great quotes from this editorial is “to look at one knee is absurd; man is biped and how considerate of nature to provide a normal for comparison. But nature did not provide trousers and these must be removed.” It’s really important when people are making assessments on the side of the mountain people are generally wearing ski boots they’re wearing Sala pets and it’s really difficult to do a proper examination with those paraphernalia on so when we get to the clinic we get the person to expose appropriately and you can very much see the damage and you see in this side this example here of a very swollen knee on the right side and a previous injury to the knee on the left side which is interesting. In terms of further investigation so clinical assessment we do an anatomical assessment of all the ligaments around the knee and we assess for laxity and we can typically determine how severe the injury is based on that, but we do like to get some further investigations.

A lot of the time patients will come with an x-ray which they got in the clinic the x-ray can be quite helpful and we see in this view that there’s a tiny little fragment of bone just on the outside of the knee and that’s indicative of an ACL injury and it will certainly tell you if there’s any major fracture but for the most part x-rays are more to rule out fracture than actually make a clear diagnosis.

So what else can they do? At the clinics they often can get an ultrasound that’s not that useful for us in that yes you can it’s very much the ability to understand the ultrasound is in the hands of the person doing it, but it’s not as transferable to other people who are looking at that scan. It’s not extremely useful for us, but the gold standard is for to do an MRI scan and this image here we can see the presence of bone bruising on the outside of the knee and at the back of the knee which is indicative of an ACL injury so we use MRI as a very helpful diagnostic tool. Then the next part is referral, so referral appropriately to either an orthopaedic surgeon who’s looking after these injuries but it’s important that we get the diagnosis and we’re able to then move forward with any management appropriately.

To manage these patients we do it in the cold light of day so as I alluded to anyone who’s pushing you to have intervention on a mountain unless it’s life-threatening you’re probably better off just being transferred back to your home country where things are available and we can look after you very well in that scenario. The key for us is to make early diagnosis so get the diagnosis right but often treatment is delayed and it’s delayed when the knee is ready for surgery, to go ahead with urgent surgery when the knee doesn’t move often results in poor outcomes so we try to avoid this as best as we can. We often would go down non-operative routes and I’ll give you an example in the cases below if they’re considered appropriate and sometimes we require operative intervention. One of the things I like to do is part of the assessment is to assess the person’s good side, so you look at their normal alignment and assess whether they require a brace. A lot of times people are putting braces unnecessarily, now it does give you a little bit of support when your knee is swollen but I try to remove braces as soon as possible to get the knee moving to get it ready for rehabilitation or surgery whichever is necessary. The range of motion I said is critical so you don’t operate on a on a knee that doesn’t move because it’s going to result in a knee that’s very difficult to move afterwards, so that’s really important in terms of early management. I try to get people walking as quickly as they can as well and to normalize one’s gaze is to get the muscles working appropriately and that’s very effective in terms of improving their rehabilitation afterwards.

So I’m going to give you a couple of examples of cases I’ve probably seen within the last week or so as to you know what we frequently see following ski injuries and during the ski season. The first case we see today is a novice snowboarder, so the typical letter I’ll get is thank you for seeing Ben who had a snowboarding Injury one week ago, unclear of the mechanism which is very common, he had swelling early doors, had difficulty weight bearing, he couldn’t fully extend his knee and that results from swelling, he did have some an affusion is the phrase we use for swelling in our in our parlons and he’s currently in a brace and I’ve advised him not to weight bear, so thank you for assistance in further management.

So part of the history I took further history, contact injury turning so he did strike someone and or was struck by someone, he didn’t feel or hear a pop which is important, he fell to the ground, difficulty weightbearing, had to be taken off the hill, was high speed contact, no immediate swelling but did get swollen a little bit later. Then on examination his knee was flexed so when your knee is flexed typically means there is flued within the knee, he had difficulty walking, he had an antalgic gait so like a lin, he did a swelling in his knee and he lacked an ability to fully extend his knee but there was no block there so I was able to do it passively and then he had some laxity of what we call a little bit of opening of the inside of his knee. So in in his situation these are X-rays of his knee so one of the things we see on these x-rays is that he’s a young man and his growth plates are still open so he’s a adolescent individual or pre-adolescent so he’s still a lot of growth remaining and this often bodes well for people’s recovery but it’s important that we respect that this is a growing child. There’s no obvious evidence of any fractures in these x-rays, the x-rays we do are from the front and from the side. We then get an MRI scan which is more helpful so an MRI anything that shows up as white indicates fluid and we see on the inside of his knee here that he’s sprained his medial collateral or what people will know as an MCL so he sprained his MCL. This is a view from the Inside of his knee and we see that his ACL is intact so any person who comes off the mountain with the swollen knee in my mind has an ACL injury until proven otherwise so thankfully for this young man he didn’t injure his ACL and he had an MCL injury. So in his situation that he was placed in a brace for a few weeks and was allowed full weight bear and he got his range in motion going and he’s black playing Gaelic football within three months following his injury without any long-term sequelae.

So the next case example is a little bit more serious so I’ve coined this legs akimbo, it was a 42y old female a recreational skier and she had an unsure mechanism injury as usual so she was skiing down the mountain trying to look after her children and she lost concentration and she slipped with her skis going one each way. She told me that the bindings didn’t release, she felt or she heard a tearing sensation within the middle of her knee and she had great difficulty skiing on, she tried to weight bear afterwards but needed to be taken off the mountain and she had immediate swelling in her knee and a really sense of gross instability that she couldn’t put any weight through this leg it felt like it was going to give way. So in terms of her clinical findings then she when I saw her in the clinic so this was probably five to seven days later she had great difficulty standing unassisted, she had gross swelling of her knee so the level of swelling typically indicates the level of injury to the knee because it means the level of bruising and she had large amount of laxity or very much a loose knee particularly on the inside and we do this test called the Lachman test which assesses for the stability of the ACL and she grows instability or increase laxity of her ACL and examination and most importantly she had a lot of bruising on the inside of her knee which would indicate damage to those structures.

I’m going to show you just an example of what we look at with an MRI so this example here we’ve seen the still image but I’m going to show you this MRI here where we look at the knee from the side, so at the front of the knee we have the kneecap, the top of the knee we have the femur and the bottom we have the tibia so I’ll go through it now more slowly. What we’re looking for here is the presence of fluid which shows up as white we then see that she’s an injury to her lateral meniscus, she’s got some bone bruising at the back of her knee and in the middle of her knee unfortunately her ACL is torn and as we go towards the inside of the knee you see this black structure the back is her PCL and the medial side of her knee or inside of her knee from the meniscus perspective looks normal but not from the ligament perspective. So over on the right side then we see there’s a lot of whiteness over the inside of her knee and we see here on the inside that she’s torn her medial collateral ligament so it’s completely torn through its substance so she had a serious injury to her medial collateral in addition to her ACL with a tear to her lateral meniscus.

I’m just going to show you a couple of examples and those for you were a bit squeamish this is looking inside this person’s knee with consent that we could show these images and what we see here is just the inside of the knee and we see that this is the meniscus on the inside but there’s lots of space here between the femur and the tibia so it means that this side of the joint is opening up so we see this is the ACL that is torn in the front here this orangey structure here so we need to reconstruct that and then we also see on the outside of the knee and this is the ACL again that she has a little bit of a tear at the back of her lateral meniscus as we saw on the scan. We clear everything out we repair the meniscus and then what we do is we put back in an ACL in her situation to reconstruct her torn ACL I’ll show you that in just one moment this is just assessing her knee and this is the ACL which we hold in with a screw there. She did very well following her surgery so she was placed in the brace this is her postoperative X-ray and we got her moving gradually with time with a brace for six weeks and she and go back to all her normal activities.

I’m going to go with a different tangent with the next case this is case three so this gentleman was affectionately known as Bandy legs not by me by the way, but by his family and he’s a 62y old male fanatical skier as he describes himself. I just imagine that this is what he looks like on the slopes. He had a obscure injury was quite innocuous that he injured his knee while getting out of his boots so you often experience this it’s probably the best part of skiing is taking your boots off at the end of the day well it wasn’t the case for him, because his bindings were stiff he had difficulty twisting getting into his boots after this and had a lot of pain over the inside of his knee. He did have swelling now this didn’t deter him he was able to ski after a few wines but presented with quite a bit of discomfort in this region. So anyone who comes to my clinic who’s over the age of 45 will get an x-ray because we want to out rule what is common and common things are common and in this situation his arthritis is common at this age. This is his left knee here and we see an x-ray which is performed initially so on the right side you’ll see that there’s nice space between the femur on the top and the tibia below on both sides of the joint but on the left side the inside of the joint is quite worn, so he has not just a meniscal tear but he has arthritis so he’s severe arthritis of the inside of his knee. In this situation the treatment for him is not to stick a camera in to take away some meniscus but ultimately he’s looking at a partial knee replacement so we counselled, we talked about what the surgery entailed and his symptoms really have been going on a lot longer than his ski accident and it’d be more chronic and he’d been suffering for quite a while so we went ahead and we did a uni compartmental or a partially knee replacement on this man here. So you see this on this view you can see the inside of the knee is resurfaced with a partial knee replacement. So the next question he asked is when can I go back skiing so in his situation I had no problem with him skiing, he’s functioning very well he no pain, no swelling after three months so he went back the following season so he took probably anywhere between 9 to 12 months to return but he was able to ski without any problems and it turns out he wasn’t wearing that outfit because he sent me a picture on the slopes. So it’s very possible to get back to the likes of skiing after a partial knee replacement or a total knee replacement, but it really depends on your level of general fitness at the time. This is a view of the knee from the side.

In terms of the final case then I’m just going to show another case of a gentleman who really wanted to get back skiing because he missed it, he said it was the best family holiday ever and the only time his kids wanted to spend time with him which was interesting but he’s probably right. He was getting progressive hip pain so once again struggling even getting his shoes and socks on but certainly couldn’t get his ski boots on without a lot of assistance. He was complaining of a lot of pain at night on his previous ski trip he really found a difficulty going up the inclines and he was waddling and wasn’t very happy on the ski trip. So we assessed him and we carried out some x-rays so he had formerly been quite a good rugby player and had a lot of injury to his hips throughout his rugby career but you see in this x-ray he’s got gross arthritis affecting not just his right hip but also his left hip. So he’s very keen to get back to skiing and asked he didn’t know what he could do after what was necessary for him which was a hip replacement but we did both of his hip replacements at the same time. I did them through an anterior approach the front of the hip which in my mind allows slightly easier recovery earlier but ultimately as the same result as the alternate which is the posterior approach but he was very keen to get back to skiing and his activities and I had no problem with him doing so once he recuperated fully. This is the final results for him so that brings us to the end of some case examples I hope you all stay safe on the slopes and should you have any issues in the cold light of day don’t hesitate to contact us so thank you very much.

Yeah well, I suppose it comes down to the length of the ski will determine the lever arm of the ski so that the torque that is you get from a smaller ski is not as large one thing I would say is the bindings can differ so that if you have shorter skis sometimes they’re fixed binding, so your boot doesn’t come out so depends on how long they are. So typically people who use the short blades are fairly advanced skiers and they go over kind of short like mogul runs and short kind of jump so they’re probably putting themselves in harm’s way a little bit more, but in general the shorter skis are probably a little bit safer but you’d have to be an experienced person to use them.

Yeah so if you look through the literature that they they’ve looked at a number of different sports and the use of braces to reduce the risk of ACL injury and its only in skiing that they’ve ever shown an advantage to using a brace when skiing. Now I will qualify that by saying the numbers were pretty small and in what we’ve looked at in further biomechanical studies is that these braces only really control the movement, the side to side movement so they protect the collateral ligaments, the inside ligament and the outside ligament but they’re not great at controlling rotation so I would say that they may be somewhat protective but they’re not going to be completely protective of sustaining a further ACL injury.

Yeah so as I mentioned at the end of my talk that you certainly can return to skiing I think Lindsey Vaughn is an elite level skier and she had a partial knee replacement and has returned to the ski circuit, so it’s certainly possible. I think that one of the things that we always tell people is you need to have you know good level of general fitness if you’re returning following joint replacement and really you need to give yourself some time to be able to get over that fitness and you need to have a knee that’s not angry or not going to be vulnerable when you ski so definitely possible. Time periods it varies between individuals typically I’d say at the very least I say around six months to ensure that you’re able to do a good level of activity before you get back. I didn’t answer one of the first part of the question that the question regarding when’s the most opportune time to have surgery if you have had an injury and you in in reality that it depends on the state of your knee so if a knee is very swollen and angry then it’s not appropriate to have surgery, we really would look for a knee that’s moving nicely that doesn’t have much swelling and there’s proper activation of the muscles around it that’s the most appropriate time and that can take up to six weeks on occasion sometimes longer to be ready other knees can be ready much quicker.

Yeah so there are a number of tests that we do and through the sports medicine department we subject most of our patient, most of my patients would go through postoperative testing so a lot of these revolve around assessing the strength of both the quadriceps and hamstring muscles. We do some jump tests to look that how your individuals behaving when they land on the leg, when they jump off the leg and we do change of direction tests now these are not specific to skiing but in general if someone has good balance and they’re allowed to take impact on the leg without any major issue then that determines that they’re reasonably ready we also use the kind of time period that typically you know it’s anywhere between kind of 9 to 12 months after you that you’re pretty much ready to go back but you should really have a  kind of sign off assessment from your surgeon or physiotherapist rehabilitation specialist before you go back.

Yeah so the best way as I mentioned is taking a proper history and just really ascertaining what the problem is now you know that doesn’t need to be with a surgeon or specialist your GP or health care professional can be able to look at that history. I think then the diagnosis comes down to clinical examination and the radiological investigations and you know they can be organized locally but we can also organize them for people if they need an appointment. It’s a very vulnerable time when someone gets injured abroad and as I said at the start we’re very happy to help out and very well able to take over that problem so just contact us and we’ll take all the hassle and make it easy for people when they’re in that vulnerable state.

Tendonitis can be tricky it’s a situation we typically involve or most of the time it’s non-operative management so involve you know rehabilitation and some particular stretching. So occasionally if it’s refractory or if it’s not settling with non-operative manager there are surgical procedures that can be done but we try to hold off on them until an individual has tried everything else. There can be injection therapies as well so it can be tricky enough tendonitis is not our favourite condition to manage because it’s tricky it can be hard to settle down.