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Hello, my name is Dr Owen Gallagher, and this talk is called ‘Live Well Longer – Metrics That Matter For Longevity.’

Right now, I’d say everyone watching knows three important numbers. Probably their phone number, their bank balance, and maybe even some people know their Wi-Fi password. But how many of us know our Ferritin Level, our Testosterone Level, our Cholesterol Profile?

These are numbers that have a far greater impact on how we feel and how we age.

And so today, I want to talk about why those numbers matter, why symptoms often appear later than we think, and how better insight into our health can help us stay healthier for longer.

Most of the time, people think about longevity in terms of lifespan, i.e. how long we live. And in general, Ireland is doing very well. Our average life expectancy is 82 years according to the CSO, and that’s about eighth in Europe.

We’re still behind countries like Spain and Italy, but they have better weather, more olive oil, and they take an afternoon nap. So, we’re doing better without any of that.

But I want to bring our attention to another number, health span. The number of years you’re genuinely healthy, active, and independent

This is an important topic that Dr Farrell will put into more context later, but in Ireland, our healthy life expectancy is probably closer to 65. That means on average, people spend the last 17 to 18 years of their life living with illness, pain, or limitation.

That gap between when we stop being well and when we die is not inevitable. It’s largely determined by the choices we make and from my perspective, the signals we catch or miss along the way.

Everything we’re going to talk about today is about closing that gap. Not just living longer but living well for longer.

So, some inspiration for this talk came from research done here in Ireland by Professor Rose Anne Kenny at Trinity College Dublin. She leads a TILDA study, Ireland’s landmark study on ageing, which has tracked 8,000 Irish adults for 14 years. And she determined that only 20% of how you age is written in your genes. The other 80% is down to how you live.

But to have an honest conversation about health, we have to look at what actually threatens it. The four biggest causes of death in Ireland are Cancer at 30%. Cardiovascular Disease, which includes Heart Attacks, Strokes, and Heart Failure, at 28%. Lung Disease at 12% and rising, is dementia at 6%.

Together, these four account for the vast majority of deaths in this country and what they share almost without exception is that they develop quietly over years and decades with no symptoms at all. A person can have very high blood pressure for a decade and feel completely fine.

Arteries can be narrowing for years before we feel anything, and that’s both the challenge and the opportunity because protecting your heart, protecting your brain, reducing your risk of cancer, they’re not separate conversations.

The metrics that matter for one matter for all.

And so, when you look behind all those conditions, you find the same underlying drivers.

High Cholesterol, High Blood Pressure, High Blood Sugar, Obesity, Physical Inactivity, smoking, poor sleep, and chronic stress.

Of interest, the TILDA study also found that 45% of older adults have high cholesterol and don’t know it. 36% have high blood pressure and don’t know it. And it’s generally because nobody checks. There’s a gap in how we do healthcare in Ireland, and it’s exactly that gap that a service like UPMC’s health Screening aims to close.

So, let’s get on to the metrics themselves, and we’ll start with metabolic health, as it is the foundation on which everything else is built.

Your metabolism shapes your energy, your weight, your hormones, your mood, and your long-term disease risk of almost every chronic disease.

Weight

I’ll start with something that I’m genuinely excited about because it changes the conversation about weight.

Two people can weigh exactly the same but have completely different metabolic profiles, the same number on the scale but completely different health pictures. And that’s why we’ve invested in a new device called the Bod Pod. And it gives us three things that actually matter. Body fat percentage. And crucially, we can use this number to help determine where fat is stored in your body. For example, fat around the abdomen is a far stronger predictor of cardiovascular and metabolic risk than overall weight.

Lean Mass

And resting metabolic rate, how many calories your body burns just keeping you alive, which is an incredibly useful number for nutrition and recovery planning. The Bod Pod is also radiation-free, takes about 5 minutes, and really gives us a picture that the scales can’t.

Blood

From a blood-testing perspective, there are four metabolic markers I think we should know about.

First is your Liver Function. Your liver quietly performs over 500 jobs in your body, and it’s often the first place where metabolic dysfunction shows up. But a simple blood test can tell us a lot about how it’s coping, as liver stress is seen in the blood long before you feel anything.

Second, your Sugars. First, a snapshot of your sugar right now, called your fasting glucose and your HBA1C, your blood sugar report card for the last 3 months. Together, these catch pre-diabetes, which can be reversed if you catch it early enough.

Third is Insulin, which you can think of as the body’s metabolic smoke alarm. It rises before blood sugar does, which means that elevated insulin can flag insulin resistance and pre-diabetes long before a standard test would show anything.

And fourth is Cortisol, your primary stress hormone. We need it, it gets us out of bed in the morning, but when it’s chronically elevated because of work pressure, poor sleep, never switching off, it drives weight gain, disrupts metabolism and accelerates ageing.

Heart Health 

Next is heart health, and as I said, cardiovascular disease is the second leading cause of death in Ireland overall. But once we reach 65, it becomes number one. Your cardiovascular risk is highly measurable and, in most cases, highly manageable if you know your numbers.

And I would start by checking your blood pressure, of course, with the target around 120 over 80. High blood pressure is one of the most common and most silent conditions in Ireland, and you can have it for years and feel absolutely fine. Resting heart rate, if you have a smartwatch or a wearable, you probably already have this number, and we’re aiming for around 60 beats per minute. A nice way to think about it is a heart that beats 10 fewer times a minute beats 5.2 million fewer times per year.

So that’s 5.2 million fewer beats of wear on your body’s most important muscle. A 12-lead ECG which checks the electrical rhythm of your heart and can detect conditions like atrial fibrillation and irregular heartbeat that significantly increases stroke risk and a full cholesterol panel that includes your LDL the kind of cholesterol that builds up in arteries and HDL the good cholesterol that clears it away but for those that want to go further particularly if your cholesterol is normal or you have a family history of heart disease, four advanced tests can reveal risk that the standard tests often miss.

So, the first one there is Apolipoprotein B (Apo B). So standard cholesterol measures the volume of cholesterol, and that’s like measuring how many passengers are in all of the cars on a motorway. But Apo B instead counts the total number of cars. And on the motorway of your arteries, the number of cars determines the risk of a pile-up, and so it gives us a much more precise picture of your cardiovascular risk.

Lipoprotein(a) or LPA is largely genetic, but about one in five people have elevated levels. High LPA is one of the most significant inherited risk factors for heart attack and stroke, and it does not appear on a routine blood panel, but you only need to test it once in your life to assess your risk. Homocysteine is a marker of inflammation that directly stresses our blood vessel walls, and high-sensitivity CRP (hsCRP) is a marker of chronic inflammation. Low-grade inflammation persisting silently in the body over years is now understood to be a major driver of heart disease, diabetes and dementia. So, hsCRP gives us a window into that process.

Next, I’m going to talk about your general health and vitality, and this section tends to resonate with many people because it touches on something almost everyone has experienced at some point: feeling tired all the time.

And in the clinic the first thing I want to establish is this tiredness a true deficiency or is it lifestyle related because the answer changes what we do about it and screening is how we find out.

So, the first is Vitamin D, which is almost universally low in Ireland. Our latitude and our weather mean we simply don’t get enough sunlight and so, the HSE recommends 15 micrograms daily for everyone from Halloween to St. Patrick’s Day, and some of us need it all year round.

Low Vitamin D can affect energy, mood, immunity, and bone health.

Vitamin B12, which is also essential for energy and how our nervous system functions. Low B12 causes fatigue, brain fog, low mood, and in time can lead to nerve problems and it’s more common than people think, particularly in older adults or those who eat a plant-based diet.

Ferritin is your iron storage marker. Standard blood tests check haemoglobin, which can often look normal even when your Ferritin is low and low Ferritin causes exhaustion, poor concentration, hair loss, and sometimes low mood.

Thyroid function, which includes your TSH, your T3, and your T4, regulates your entire metabolism, and when it’s underactive, everything slows. Your energy, digestion, mood, and weight. It is common but treatable. But it can go undetected if not checked.

Of course, closely linked to fatigue and vitality are hormones. And for men, testosterone is central to energy, motivation, strength, libido, and mood.

But it starts to decline from our mid-30s onwards. FSH molecule, a key hormone that tracks transitions as a woman goes through peri-menopause and menopause. And these hormonal transitions have a profound effect on overall well-being, metabolism, sleep, and our mood.

Something that’s not tested often in our routine health checks is your functional fitness. So that’s how your body actually performs, and it’s one of the strongest predictors of how long and how well you’ll live.

The first test I’m going to talk about is VO2 Max. That’s the maximum amount of oxygen your body can use during exercise. It’s the gold standard of cardiovascular fitness. Until recently, only athletes had it tested, but we now have a sensor in our clinic that measures it quickly and comfortably, so everybody can find that number. Research has shown that low cardiovascular fitness can predict early death as effectively as obesity, smoking, or diabetes in some studies.

Without training, our VO2 max declines by up to 10% per decade after the age of 30. But it is trainable at any age with zone 2 cardio. That’s exercise at a conversational pace. The most effective way to improve that number.

We test it in the clinic with a small handheld device that takes about 30 seconds and tells us a lot. There was a landmark study published in The Lancet in 2015 that found that for every 5-kilogram reduction in grip strength, there was a 16% increase in all-cause mortality.

This is something that you can test yourself at home. So, the next time you’re in the gym, or you pass a pull-up bar in the park, if you hang from the bar, arms relaxed, feet off the ground, and see how long you can hold on comfortably, because in this simple test, you’re measuring your grip strength, your shoulder mobility, your upper body endurance, and your overall physical reserves. If you last under 10 seconds, it’s probably worth more practice, but if you’re getting into the 60- to 90-second range, that’s very good.

How effectively we breathe can be assessed in the clinic using lung spirometry. And we have two numbers here that we look at. your FEV1, which measures how open your airways are, and FVC, which measures how much air your lungs can fully hold and empty. And spirometry can help us detect lung conditions like COPD, asthma, smoking-related disease, often before you have any symptoms.

And so to wrap up, the metrics that we’ve covered today span metabolic health, heart health, vitality, fitness, and lung function. None of them requires you to be sick to be tested. They’re about understanding your baseline and catching silent risks early so you can make informed decisions about your health.

At UPMC Sports Surgery Clinic, our new health screening service brings all this together in one place and more.

We offer guidance on what your results mean and what to do next because that’s often the harder part. So, if you’re interested, please see our email address on the screen. If you have a question or you’d like to book in and maybe to finish this week, if you pick one metric you don’t know, whether it’s your blood pressure, your resting heart rate, or your hang test time, and see how you can improve it, and that will start you off on your journey to living well longer.

Number one, if they have symptoms, they should go to their GP and get checked. But if they’ve no symptoms and they’re high-risk family history, I’d probably do a blood test in your 40s just to get a baseline level. With the number if it’s less than 1.5, you’re probably good then screening every two or three years again if you don’t have any symptoms. And then I think maybe as you reach your 50s, you probably should get it more routinely again based on a number every two or three years.

Okay. What were the symptoms then as well? probably just to recap on symptoms as well, that yes for prostate I suppose the common one is getting up at night to pee kind of one was in the realm of normal but if you’re getting up two three times a night it’s bothering your sleep it can be an early sign then when you’re trying to go to the bathroom maybe some difficulty starting or difficulty in the flow of urine or again any pelvic pain that’s new it’s worth getting checked okay thank you someone else here is asking do you offer MRIs as part of health screening, but the MRIs aren’t part of the standard screen, but on the day of your visit, you get a full head to toe exam,

So, if there is any abnormalities or you know when we’re talking, if you have any particular worries, we can refer you for MRIs, but also any imaging like chest X-ray, CT, cardiac echo, and we can refer them as a priority to the Sport Surgery Clinic where they do the imaging.

Yeah. Again, it might depend on the level, any mild changes.

You probably could do it every 12 months, but if it was particularly high and you’re trying to, you know, change your diet, increase your exercise, it’s probably going to be 3months before you see any changes. And of course, cholesterol is only one part of it. At the clinic, we do your blood pressure, we do your ECG, we gointo your family history, and that’s probably more of a comprehensive risk assessment of your cardiac risk.

My name is Dr. Aisling Farrell. I’m a GP with a specialist interest in lifestyle medicine and the service lead for the Lifestyle Medicine clinic in UPMC Swords. Today I’m going to present Move, Nourish, Recover, Lifestyle Medicine for better healthspan and lifespan.

So today we’re going to explore what exactly lifestyle medicine is, how everyday habits can have a profound impact on our health, and I’m going to give you some simple practical steps that you can begin applying in your own daily life.

So, if you’ll indulge me, I’d like to begin with a very short experiment. Now, don’t worry. This isn’t any mind tricks. This is just a fun short experiment to start us off. So if you’re comfortable,
I’d like you to gently close your eyes. Picture yourself standing in your kitchen. In front of you on the table, there’s a wooden chopping board. Resting on it is a fresh, bright yellow lemon alongside a small knife. Now, in your mind, reach out with your right hand and pick up that lemon. Feel the slightly uneven textured skin. And as you hold it up, you can catch a faint, sharp citrus scent beginning to rise. Now, I want you to place it back on the chopping board. Imagine taking the knife and carefully slicing through the lemon. You hear the soft resistance of the skin giving way. The moment it’s cut open, the smell becomes stronger. It’s sharp. It’s zesty and instantly refreshing. You can see the yellow flesh glistening inside with tiny drops forming along the edges. Now, I want you to bring one half of the lemon up towards your mouth. Just imagine taking a big bite into it and taste that burst of intense sourness across your tongue. Now open your eyes. Did you notice that your mouth started to water?

What’s fascinating here is that the lemon isn’t real. Yet many people still have a physical response. That’s because the connection between our brain and body is remarkably powerful. Our thoughts can shape our physical reactions, influence emotions, and ultimately guide our behaviours. And that’s where lifestyle medicine begins.

If a single thought can trigger a measurable bodily response within a couple of seconds, consider the impact of the thoughts, the habits, and behaviours we repeat every single day over months, years, and decades. These patterns shape our health far more than any single event ever could. Lifestyle medicine recognises that many of the key drivers for long-term health, like how we eat, move, and sleep, are rooted in our daily thoughts and choices. So, by understanding and intentionally shaping these patterns, we can harness that same mind-body connection that made us salivate at an imaginary lemon to create lasting improvements in health and well-being.

So, now I’d like to introduce you to my patient, Mark. Mark is a 42-y old man. He works in finance and is married with two small children. His day starts early, but he’s usually rushing to get everyone out the door, so his breakfast is often skipped. He faces an hour commute each way and spends most of his working day sitting at a desk or in meetings. Work is very demanding with tight deadlines and constant emails. So, to keep going, Mark relies on five or six coffees throughout the day. By the time he gets home, he is exhausted and has very little energy left for exercise. His evenings are busy with family responsibilities. So once the children are in bed, Mark likes to unwind with a couple of cans of beer while watching Netflix.
Mark came to see me in clinic. He said, “I’m exhausted all of the time.” He said he had constant fatigue and low energy. He felt overwhelmed by all of the conflicting health advice that he found online. He had quite a strong family history of heart disease and was quite concerned about his future health. He was unsure where to start or what was going to actually work.

So, in the clinic we did a number of investigations. Firstly, during his questionnaire we identified that he had quite low levels of physical activity. He had a high consumption of red meat, minimal fibre intake, and quite high saturated fat intake in his diet. His alcohol intake was above the HSE low-risk alcohol guidelines. And his questionnaire found that he had quite a high stress load. He also was noted to have a significant family history of cardiovascular disease and diabetes.

On his clinical examination, we noted that his blood pressure was elevated. And when we measured around his waist, we noticed his circumference was elevated. His bloods identified high cholesterol levels, particularly his LDL cholesterol, and his blood showed markers that were concerning for pre-diabetes.

On his functional assessment, then we noted that he had low VO2 max or reduced cardiovascular fitness and his grip strength was also reduced. I asked Mark what his goal was and he said, “I just want the energy to be able to play football with my kids and be around for them as they grow up.”

Mark said that he had tried multiple approaches over the years. He had done walking programs, running plans, diet changes, but always had this fresh start every single Monday. He could never maintain the changes long term, and he felt really frustrated, guilty, and like he was failing. And it wasn’t as if Mark didn’t know what to do.

He already did know what to do. The question here is why is it so hard to actually do these changes consistently? So why does all of this matter now? Well, as you saw in Dr. Gallagher’s presentation, the leading causes of illness and death are chronic conditions like heart disease, respiratory diseases, cancer, and dementia. And the important point is that many of these conditions are strongly influenced by our lifestyle. In medicine, we have become really good at extending our lifespan or how long people are living. But I think today’s biggest health challenge is actually our healthspan.

This is the number of years we actually are living in good health with energy, independence, and quality of life. The goal here simply isn’t to add years to our life. rather it’s about adding life to those years. So, this is where lifestyle medicine comes in. This is an evidence-based approach that uses healthy daily behaviours to prevent, treat, and in some cases even reverse chronic disease. This is not about adding more information. Rather, it’s about turning evidence into consistent real world behaviour change.

It focuses on six pillars that influence almost every chronic disease pathway, including healthy eating, physical activity, sleep, stress management, social connections, and avoiding risky substances.

Now, we already see this working in the real world. Researchers have studied regions of the world where people live longer and healthier lives, and these are known as the blue zones. They include regions all over the world from Italy to Japan and Costa Rica. And what’s striking is that these populations are very different culturally, but they share remarkably similar habits. They tend to move naturally throughout the day. They eat mostly whole foods. They maintain strong family and social connections. And many have a very clear sense of purpose.
These communities don’t just live longer, they tend to live better for longer. And in many ways, lifestyle medicine is the clinical translation of these patterns. So, when we look at the six pillars of lifestyle medicine, I like to simplify it into three main themes. Move, nourish, and recover.

Movement

And movement comes in many different forms. Aerobic activity supports our heart health and our lung health. Strength training protects our muscles and bone and balance and mobility help maintain independence as we age. The benefits from being physically active are almost immediately present. Even a single bout of exercise can improve our mood, reduce our stress, and boost our energy levels. And over time, movement can improve things from our blood sugar control. It reduces our cancer risk and supports cardiovascular health.

VO2 max is a measure of aerobic fitness or how efficiently our body uses oxygen during activity. It’s also one of the strongest predictor of long-term health and longevity.

One of the very earliest examples of this importance comes from the London bus study in the 1950s. This compared bus drivers who spent most of their day sitting with bus conductors who regularly climbed stairs while working. And despite sharing the same environment, the conductors have a significantly lower rate of heart disease than the bus drivers. The message is clear here. Movement matters. Both structured exercise and everyday activity like walking or gardening.

I think a common misconception here is that exercise only counts though if it’s very long or intense. However, small bursts of movement throughout the day can have some real health benefits and these are sometimes called exercise snacks. So, this can be something like a few squats waiting for the kettle to boil or walking during phone calls or even taking the stairs. The key here is consistency and making movement a regular part of your daily life.

When people think about exercise or being physically active, they often think of these cardiovascular areas. But maintaining strength is just as important. As we age, we naturally lose muscle mass and strength. And without intervention, this can affect our balance, our mobility, confidence, and even our independence.

Strength training helps preserve our muscle, maintain our bone health, and reduce fall risk, supporting our quality of life as we get older. The image above illustrates this clearly. This study showed that researchers compared older adults who stayed physically active throughout their life with those who are more sedentary. In the MRI scans that you can see here, muscle appears darker grey while fat tissue appears white. The active 70-year-olds retained muscle mass similar to someone in their 40s. Whereas those who were sedentary by contrast showed mark muscle loss and significantly more fat infiltration within the muscle.

I think the encouraging news here is that strength training does not have to mean lifting heavy weights in the gym all the time. This can include resistance band exercises, body weight movements, things like Pilates, gardening, any activity really that challenges your muscles regularly.

Strength is about much more than building muscle. It helps us to continue doing the everyday activities that matter. Whether that’s climbing stairs, carrying groceries, or playing with our grandchildren as we age.

So, a simple test that we can try at home right now is the sit-to-stand test. So, what I’d like you to do in your chairs is cross your arms and put your hands on your shoulders. I want you now to stand up from your chair without using your hands. Were you able to do it? This may seem very straightforward, but it provides a very useful indication of lower body strength, balance, and functional fitness.

So, knowing movement is important is not the same as having a plan that actually fits into your life. Exercise is important for Mark, my patient, to reach his goals, but it was also important to improve his health markers.

As a reminder, his goal was to have energy to play football with his children and be around for them as they grow up. For Mark, we agreed on two priorities in regards to activity.

Number one was to increase his daily steps to 5,000 a day and to track this on his phone. And number two was to add two at home body weight workouts of 30 minutes each.

Nutrition

The next scene we’re going to move on to is nourish. Every day we make dozens of food choices and over time those choices become patterns and those patterns shape our health. Food influences everything from our energy levels, our mood, blood sugar control, our gut health and cardiovascular risk.

One of the most researched eating patterns in the world is the Mediterranean diet. This pattern has been consistently linked with lower risk of heart disease, stroke, diabetes, and cognitive decline. It’s rich in plant-based foods, whole grains, healthy fats like extra virgin olive oil. It’s moderate in fish, eggs, and poultry, and low in foods like red meat or ultra processed foods high in sugar. Importantly, this is not about strict rules or perfect eating. Rather, it’s about a long-term pattern of mostly whole plant-based foods.

I think so much dietary advice nowadays focuses on what we should cut out. And that really creates a mindset of restriction and that some foods are bad.

In my opinion, I think one of the simplest and most effective nutrition strategies is to switch the focus to foods that you can add. So, examples would be maybe adding chia seeds to our breakfast or maybe adding beans, vegetables or fish more regularly. I think these small additions gradually improve the overall quality of the diet without feeling restrictive.

So, we’re going to go back to Mark and what did we do for him? He often skipped breakfast and reached for coffee and sugary snacks around 11:00. He felt time starved in the morning and meal prepping had worked for him in the past. So, we agreed to perhaps prepare overnight oats in the evening for a source of complex carbs and including chia seeds and flax seeds for fibre, omega-3s, and Greek yogurt for protein. We also agreed to include more oily fish like salmon twice a week.

The final theme is recovery. In today’s modern world, we often focus on activity, productivity, and doing more. But health is also built during recovery. This theme includes everything from stress management, sleep, avoiding harmful substances, and social connection.

So, I’m going to bring you back to the lemon from earlier. We saw how our thoughts alone can create physical responses. The same is true for stress.

The body doesn’t only respond to actual threats. It also re reacts to perceived ones. So, notifications, work pressures, or even imagining a difficult conversation can be enough to activate that stress response, increasing our heart rate, causing muscle tension and issues with sleep. And in the longer term, this can have significant negative implications for our mental and our physical health.

Mark had very high stress scores. We discussed a very simple tool that he could use during the day, anytime that he felt like he was becoming stressed, and I’d like to share it with you now.
It’s called the Physiological Sigh, and it’s quite simple. What we’re going to do is firstly take a deep inhale through your nose. Once you’re almost completely there, take a second short inhale through the nose on top. Then slowly and fully exhale through the mouth. Did you notice your shoulders start to drop?

Many people will feel their body relax almost immediately. You can repeat this a few times anytime you need it. It’s one of the fastest ways we have to control the nervous system and it’s a tool that is always available to you whenever you need it.

Sleep

The second area we’ll look at in recovery is sleep. This is one of the most powerful recovery tools we have.

During sleep, it’s actually a highly active state in which the body repairs tissues, supports memory formation, and strengthens the immune system. Poor sleep, on the other hand, is linked with things like diabetes, mood-related disorders, and an increased risk of cognitive diseases. Yet, for many people, switching off at night can be really difficult. Mark reported issues with his sleep, particularly when he was stressed. He told me that he just felt his mind was busy all the time.

This is a really common issue, and it can just feel like having a dozen browser tabs open at once. A tab for tasks, for worries, for ideas or different conversations. And a simple strategy is to close those tabs before bed. Take out a pen and paper and write everything down for five minutes before bed.

Everything that’s going on in those tabs, what needs to be done, what you’re worried about, anything that’s on your mind. This helps signal to the brain that it doesn’t need to keep holding on to it overnight. It can make it much easier to switch off. And I’d ask you now, what is keeping your tabs open at night?

Another part of recovery here is reducing harmful exposures. Smoking remains one of the strongest risk factors for cancer, heart disease, and lung disease. Alcohol increases our risk of liver disease, cancers, and mood disorders. And I think even reviewing nowadays our time spent on the internet or even scrolling social media as this can have a detrimental effect on our mental health. I think the encouraging message here is that even small reductions can improve our health.

We decided to look at Mark’s alcohol consumption. He liked to unwind with a can of beer watching Netflix. When we looked at his average consumption over the course of the week, it was approximately 14 cans of beer. We decided to look at the calorie content of beer he was drinking and the units it contained. On average, he was consuming approximately 160 calories per can of beer, which equated to just over 2,200 calories per week. Each can of beer had approximately 1.5 units, which equated to about 21 units per week.

Mark was unaware that this was over the HSE low alcohol intake guidance and this is 17 standard drinks per week for a man and 11 for a woman. We decided to look at the zero-alcohol version and the difference in calorie content over the course of the week.

If he switched to a zero or alcohol-free can of beer, this was 70 calories per can or 980 calories over the course of the week with no units of alcohol. This led to a over 1,200 calories reduction over the course of the week. Mark decided that he was going to switch to zero alcohol on weeknights while still enjoying an alcoholic beer at the weekend.

Social Connection

And the final theme or area in our recovery theme is social connection. This is one of the most overlooked aspects of health. Long-term studies have shown that strong relationships are associated with better physical health, better mental health, and a longer life. So, having looked at those three themes, why is change much harder than it looks?

I think behaviour change is hard, not just because people don’t know what to do, but often because they feel overwhelmed when it comes to change, competing priorities, and a significant lack of support.

People do much better when they have clear priorities, personalised guidance, and they’re accountable. This involves a proper interpretation of their health results and a realistic plan that fits into their life.

I want to bring you back to Mark and his three-month progress.

When we looked at his behaviour changes, he had incorporated the step count into his day and it was now on an average of 6,000 steps per day. He was also starting to play football with his children at the weekend and was attending his children’s football matches. He had reduced his alcohol intake by 50% and had introduced breakfast every single day. He had a 3kg weight loss. His waist circumference had reduced. His blood pressure markers had improved and significantly improvements in his cholesterol and blood sugar control over that 3-month period. He himself felt better. He reported that he had improved energy levels and felt quite motivated and encouraged by the objective improvements. and he remains engaged in ongoing behavioural change. His goals now are to complete a 5K run and increase up his grip strength by incorporating more strength-based workouts. I think the most common mistake we see is trying to change everything at once.

We’ve all had New Year’s resolutions that faded quickly, and Mark is an example of this. Big changes often lead to overwhelm and inconsistency. Small habits on the other hand are much more likely to stick. I want you to think small, achievable, and repeatable.

And as we finish, I want you to choose just one thing. Not 10, not a full life overhaul. Just one small habit. Maybe it’s a 10-minute walk. Maybe adding a protein source to your breakfast or writing down your thoughts before bed. The goal here is a habit that you can repeat for years.

So, as you leave today, I want you to remember three words. move, nourish, and recover. It’s never too late to make healthier changes to improve our lives.

If you’d like support in making lifestyle changes to improve your health, our Lifestyle Medicine Clinic in UPMC Swords is now accepting new patients. You can contact us using the email below or visit our website to learn more. I’d like to thank you all very much for your time today.

That’s a great question. Thank you so much. So yeah, high blood pressure is quite a common condition in Ireland and knowing how to manage it is really important. I think, from a dietary perspective, one of the most effective approaches for managing high blood pressure is a Mediterranean-style diet.

So, when we’re looking at that, we’re mostly looking at whole-based foods. So, that would be like plenty of fruit and vegetables, lots of whole grains. So, like brown rice, brown pasta, that kind of thing. And our healthy fats. So, that would be looking at options.

So, for example, our extra-virgin olive oil, avocados, nuts, and seeds. And particularly for people who are living with hypertension or high blood pressure, having a look at our salt intake is important here.

So, making sure we’re not adding salt to food and being mindful of how much salt we’re taking as well.

All right, that’s again quite a common question, really. So, menopause and bone health is a really important topic to look at. Oestrogen has a protective effect on our bones and our cardiovascular system. And during the perimenopausal and menopausal stages of life, our oestrogen levels start to decline. And that can mean our bone mineral density starts to decline, increasing our risk of developing conditions such as osteopenia and osteoporosis. Also, during that time, our muscle mass can decline by about 5 to 10% each decade. So, exercise can help look at both of those areas.

From a bone health and a muscular point of view, we want to focus on strength training. So, the aim here would be maybe two to three sessions of strength training per week. Now it doesn’t have to be in the gym.

And I think this is my big point this evening that strength training can be, for example, done at home with body weight exercise, resistance band, Pilates, it doesn’t really matter, but as long as you are consistent with it and trying to do it regularly during the week, it will be my big take-home point tonight.

The other area, then, I think, from an exercise point of view, is cardiovascular health. It’s important that we don’t forget that as well. So, that would be things like the aerobic exercise I talk about.

So, running, swimming, cycling and aiming for about 30 minutes five times a week, and that doesn’t need to be a full 30-minute session. We could break that into like our exercise snack. So doing five-minute walking, you know, during the day, some cycling in the evening time, but we’re trying to hit that overall mark over the course of the week.

That’s an important question. Particularly, lifestyle medicine, this whole concept is quite new in Ireland. I compare it to the analogy of a banker and a financial adviser. So, going for a health screening is like going to the bank; you’re getting a snapshot of exactly where your health is right now. So, like going in and getting a bank statement, you know exactly what is in the pot, which gives the snapshot of what our blood pressure is, our cholesterol levels are, etc. And those markers come in to do a lifestyle medicine consultation; it’s kind of like going to your financial advisor. We’re looking at where you’re at right now and what your goals are for the future, and helping you put together a plan for the short and long term to help achieve those goals. So, I hope that analogy made sense.

The resting heart rate is the heart rate, or your resting heart rate, which is the number of times your heart beats every single minute when you’re at rest. And in general, a lower resting heart rate reflects better cardiovascular fitness and a more efficient heart rate.

When we’re looking at that and ways to reduce or improve resting heart rate, we’re looking at all the basics here. So, sleep is really important here and making sure that we’re adequately recovered. So, high-quality sleep of about seven to eight hours per night, if we can.

Managing our stress, and that’s a really important one here, that you know a very high resting heart rate can indicate that the body is under not just physical stress, but also mental stress as well.

So, keeping an eye on our stress and regular physical activity.

So not always just that really high intensity exercise but even just some gentle cardiovascular exercise like walking can be helpful.

So we can definitely see improvements in your bone mineral density. And that would be a lot of things that we’ve spoken about already, like your strength training is really important here.

Having a look at some dietary changes here. So, making sure your calcium intake is nice and high and looking at your Vitamin D consumption and all of those things together can help improve your bone mineral density.

However, if you have been diagnosed with Osteopenia or Osteoporosis, it is really important to talk to your doctor about any medications that may be required to help.

Good evening. Andrew Hughes is my name, hip and knee surgeon from UPMC Sports Surgery Clinic, many thanks for the opportunity to speak to you this evening on hip and knee pain in hill walking and hiking. Hikers get hip and knee pain from mechanical overload of their hip and knee structures due to repetitive loading stresses of the tendons, the cartilage, and the joints in the hip and the knee. Uneven terrain demands stability from the hip and knee muscles. Unfortunately, something as small as an inadequate warm-up or an unlucky step can put a hiker or a hill walker at risk of injury. Forces walking uphill versus downhill differ. Walking uphill, there’s a particular pinch on the structures at the front of the hip joint, there’s friction between the iliotibial band, the large fascia on the outside of your thigh, and the bursa on the side of your hip joint and the load goes through the knee quite extensively from a flexed or bent position as you bring yourself up the hill. Going downhill, four to eight times your body weight can go through your kneecap or your patellofemoral joint. These forces peak as your heel touches the ground or the heel strike component of your gate cycle and the quadriceps muscles are lengthening but also contracting at the same time. We call it an eccentric contraction, and this controls your descent. Unfortunately, eccentric loading of a muscle or a tendon puts it at risk of injury. The tendons and cartilage around the hip and knee joints can succumb to overuse injury mechanisms whereby the load exceeds the tissue’s capacity to heal from repetitive micro traumas. These micro traumas can accumulate particularly if there’s insufficient recovery between a hike between hikes or a particularly long hike. Weak muscles can also transfer stress to otherwise passive structures and put these areas of succumbing to these micro traumatic episodes.

It’s important when you have pain around the hip or the knee to understand what we as physicians or surgeons look at to determine what the cause of the pain is. So, some of the terminology we use is lateral which means the outside of the hip, the thigh, the knee, medial which would be along the inside or kind of radiating from the groin, anterior is at the front, posterior is at the back. And then often times to distinguish to distinguish between particular pathologies or injuries, we want to know is the is the pain focal, is it pinpoint or is it diffuse? Is it over a wider area? And this can help us distinguish particularly from bursitis versus an Iliotibial band syndrome which I’ll come to shortly. So, pain in the groin could be Femoroacetabular impingement or arthritis in the hip joint, pain in the lateral hip could be gluteal tendinopathy or inflammation of the tendons in the outside of the hip or it could be bursitis which is inflammation of the shock absorber. Pain radiating down the lateral thigh into the lateral knee could be iliotibial band syndrome which is often associated with gluteal tendinopathy and or bursitis, pain at the front of the knee could be patellofemoral pain syndrome or an issue with the back of the kneecap. Pain below the kneecap can be patellar tendinitis where there’s an inflammation of the tendon where it attaches to the underside of the patella. Medial or inside the knee or kind of diffuse knee pain could be related to knee arthritis that’s come on over time.

So, the common hip problems that affect hikers most notably could be femoroacetabular impingement which arises from abnormal contact between the ball and the socket within the hip joint. So, you might hear terms like a pincer lesion or a calm lesion or mixed impingement, and these can be seen in the diagram on the right-hand side. This can cause groin pain especially on inclines or after prolonged activity that involve hip flexion. So, bringing your knee up over your hip, you can be stiff after rest or stiff in the mornings, you can have discomfort with prolonged sitting as you sits in a seated position with your knees up. This imping bone can lie in contact with each other either on the ball side of the socket side of the joint and cause a deep-seated groin discomfort and there can be clicking or catching within the hip or the hip joint or the groin particularly if the liberum is torn which is the shock absorber within the hip. Diagnosing an FAI really involves a clinical examination with a physician or a surgeon or your GP. X-rays are the gold standard of investigation to see are there abnormal bone and an MRI to look at the cartilage in the liberum in the hip. I would advise seeking  help if you have sharp pain in your groin that persists despite rest and the treatment involves activity modification, avoiding hip flexion, physiotherapy to strengthen your hip and your core, improving the strength of the rotators deep within your hip, working on improving the lateral control of the hip or the gluteal tendon strength around your hip. A hip injection of either corticosteroid or platelet rich plasma can reduce inflammation, improve the ability of micro tears to heal, and allow you to engage your rehabilitation pain free. If all conservative options fail, then you may benefit from hip arthroscopic surgery or a camera surgery where we go into the joint with long fine instruments, shave down the abnormal bone that’s causing issues and repair the labium.

Glutaeal tendinopathy or gluteal tendinitis is inflammation or irritation or degeneration of the hip tendons on the outer or lateral aspect of the femur. The pain is on the lateral side of your hip. It can worsen on stairs or hills and if you have coexisting bursitis, you can have pain lying on that side at night. Weakness or discomfort can also be noticed when standing on one leg and you can feel unstable or as if you’re about to fall when you are walking, particularly coming downhill if you have gluteal tendinopathy. Again, it’s a clinical diagnosis, but that would need to be confirmed with either an ultrasound or usually an MRI of the affected hip. I would advise seeking help if walking or climbing stairs is particularly difficult and if the pain progresses such that it it’s affecting your sleep quality, particularly when lying on that affected side treatment, physiotherapy is highly effective. I would advise avoiding crossing your legs or sidelining on the affected hip to reduce the amount of pain that you’re experiencing. A graduated strengthening program with a physiotherapist, progressive hip strengthening particularly sidelining leg lifts and single leg stance progression as per the guidance of a chartered physiotherapist.

Greater trochanteric bursitis then can be inflammation of the fluid fil cushion or the shock absorber on the outer side of the hipbone which lies in close proximity to the gluteal tendons. So this really gives you that point tenderness on the outside or lateral aspect of your hip. It can be a constant dull ache. It can really affect when affect your pain levels and increase if you lie on that affected side. And it often coexists with tendonitis of the gluteal or abductor tendons plus or minus iliotibial band tightness because that can push the greater tricentric bursa in against the bone as you walk. Diagnosis for greater trochanteric bursitis is clinical examination. It’s your point tender over that particular spot. And again, that can be that can be diagnosed further or confirmed with ultrasound or more commonly an MRI in these days. Again, I would recommend seeking help if climbing stairs is particularly difficult and if you’re having trouble sleeping as you cannot lie on the affected side. I would rest, ice, and take anti-inflammatories for greater trochanteric bursitis. Physiotherapy to progressively start loading the gluteal tendons which will take the pressure off the greater trochanteric bursitis and a corticosteroid injection or a steroid injection into that site of maximal tenderness can be very helpful if the pain is severe.

If gluteal tendinopathy and GT bursitis coexist, a progressive load-based physiotherapies rehabilitation program can be very effective, and platelet rich plasma injections have been shown to encourage healing of the micro tears within the tendon and encourage all of this to settle down. Iliotibial band syndrome then is tightness of this big fascia band that runs down the lateral side of your knee, and this can push the greater trochanteric bursa against the bone and really inflame your bursa as you’re walking. You can get sharp lateral hip thigh knee pain during repetitive hip flexion or bending of the hip. The pain typically starts after a consistent distance every time, but again that can start to worsen as that distance comes down with progression. You would be worse on hilly sections due to repetitive hip flexion. It’s particularly common in trail runners and you can feel a click or a clunk of your iliotibial band as it moves over the side of your hip. This is a clinical diagnosis. There are provocative tests that can prove that iliotibial band syndrome exists within your anatomy and stretching this or foam rolling the iliotibial band can be very effective. Then progressing to hip abductor or gluteal strengthening with clamshells or side planks. Retain retraining the gate so that your gluteal tendons are more fired and more turned on during the gate cycle. Modifying your activities until you really regain this strength and then gradual return to hiking particularly a hiking distance.

So, building up slowly once again. Hip osteoarthritis is cartilage wear causing bone on bone contact which can result in morning stiffness which improves at movement, pain in the groin after prolonged activity particularly walking similar to FAI or femoroacetabular impingement, difficulty getting down to do your own shoes and socks and needing to back into a low car seat because the actual movement in your hip is affected. This is a clinical diagnosis with X-rays. Treatment is weight optimisation in the first instance to reduce the amount of force going through your hips, gluteal strengthening with a physiotherapist and anti-inflammatory medications, injections or a hip replacement for advanced disease. And these have been shown to have excellent success. A total hip replacement would have you 90% recovered at 90 days. And we would hope to have you returning to hill walking or hiking with no restrictions after about three or four months of recovery and rehabilitation with a physiotherapist. With regards to the knee, patellofemoral pain syndrome is pain around the kneecap and it’s due to how the knee tracks within its groove. So, the kneecap or the patella moves within the trochlear groove at the bottom of the femur and how it always wants to go on the outside of the lateral side. And if this is the case, you can get pain at the front of the knee particularly when walking downhill as four to eight times your body weight can go through your kneecap when you are walking downhill. You can have pain with prolonged sitting or as the Americans call it the cinema sign or the movie theatre sign. So, after a prolonged period of sitting you feel like you have to shift in the seat in order to relieve yourself of this discomfort at the front of your knee. You can feel a grinding or a clicking sensation in the knee as it bends and straightens. My action plan would be to avoid steep descents when hill walking. If you have patellofemoral pain syndrome, consider trekking poles to reduce the load going through your knee. Warm up. Focus on your quadricep strength and ice the knee after activity. This is a clinical diagnosis. MRI can be considered if persistent, the treatment would be to improve how the kneecap tracks within the groove. So, strengthening the quadriceps on the inside of your knee.

The VMO is the quarter of the quadriceps that’s on the inside of the knee. And this can improve how your patella moves within the groove, improve its tracking, and hopefully reduce the patellofemoral pain that you’re experiencing. You can tape the patella or brace it to encourage it to track more immediately or more towards the inside of the knee. And if you’re having persistent problems, I would recommend a biomechanical assessment and a footwear review as the as there are multiple factors that can contribute to how your kneecap tracks. A corticosteroid injection can be very beneficial to reduce the inflammation and allow you to re reintroduce rehabilitation and strengthening exercises when the knee is calmed down.

Patellar tendinitis is inflammation on the underside of the tendon where the patellar tendon attaches to the kneecap or the at the top of the tendon. So, this is pain on the very underside of the kneecap worse with activity. You can be stiff or uncomfortable first thing in the morning in particular. You can get a sharp pain at the start of a hike on the underside of the kneecap where the tendon attaches. However, this eases as you warm up and then return slowly. Tenderness is also reproducible when your doctor presses on the underside of your kneecap or you or your physiotherapist press on the underside of the kneecap and really hit that that sore spot where the micro tears of the tendons are. It’s a clinical diagnosis which can be confirmed again using ultrasound or more commonly MRI these days. Treatment I would recommend rest and applying ice to allow the inflammation to come down, an eccentric strengthening program. So, it’s a strength and stretch program combined. So it’s very important to link in with the physiotherapist and patellar tendon strapping can reduce the amount of force going through the tendon particularly during hill walking and hiking activities. The exercises that a physiotherapist would probably introduce would be wall sits at 60° and progressing to 90 degrees with an increasing number on seconds per set. Progressive loading with single leg declining squats and gradual returning to your impact activities.

Knee osteoarthritis again like hip osteoarthritis is cartilage wear causing bone on bone friction morning stiffness pain within the knee globally after prolonged activity particularly walking and also swelling and reduced range of motion that can come on slowly. Knee arthritis is a clinical assessment which will be proved or confirmed using x-rays and the treatment again will be weight optimisation to reduce the force going through your knee. Physiotherapy to strengthen your quadriceps, non-steroidal anti-inflammatories, corticosteroid injections or platelet rich plasma injections or a knee replacement if the disease is advanced like in this x-ray. Again, similar to a total hip replacement, I would expect somebody to be 90% recovered at 90 days after a total knee replacement and after three or four months of rehabilitation, return it to hill walking or returning to hiking with no restrictions. There are essential habits that can protect your joint and function as prevention strategies.

I suppose the key principles are to progress your mileage roughly 10% weekly increase as you take uphill walking or hiking or returning from injury. Trekking poles particularly in the knee can reduce the load going through your knee joint by 25%. Proper footwear with adequate support can reduce the stresses going through the inside of your knee or the outside of the hip. And maintaining a healthy body weight again can reduce the amount of force going through your hip or your knee joints. I would recommend incorporating a warm-up routine into your hill walking or hiking. 5 to 10 minutes at the start. Roughly 5 minutes of level walking or light jogging in the car park before starting on the hill walk or the incline. Ankle circles, knee pull-ups, and hip rotations. So, 15 ankle circles in each direction to wake up the ligaments in the ankle on both sides. Knee pull-ups to work your hip flexors, your knee flexors, and your knee extensors, your quadriceps. And then hip rotations to wake up your gluteal tendons and your deep hip rotations, your deep hip rotators, doing 10 in each direction. So, 10 external rotation and 10 internal rotations. I would then do some dynamic stretches, some walking lunges, some high knees, some leg swings forward and back, and some calf raises, calf raises. And again, this is to increase the blood flow going through your gluteal tendons, going through your quadriceps, going through your calf, and just improving the vascularity of your soft tissues before you start on a hill walk or a hike.

Cooling down then afterwards for 10 minutes is very important. So, slowing down your walking to bring down your heart rate slowly. Standing and stretching your quadriceps for 30 minutes each. Stretching your hamstrings. So, bending forward and touching your toes for 30 seconds on each leg, calf stretching against a tree or a rock again for 30 seconds each. So, strengthen your quads, stretch your hamstrings, and stretch your calves. With regards to your hip and your iliotibial band, if you are engaged in a in a rehabilitation program for these specifically, I recommend stretching your hip flexor, which is a kneeling lunge and pushing your knee forward, stretching your iliotibial band, where you bring your affected knee over your the knee on the other side, and you feel a deep stretch going down the outside of your thigh. And a figure four glute stretch, particularly if you need to stretch the deep hip external rotators at the back of the hip. But these are more specialised or niche stretches. If these have been prescribed to you by a physiotherapist, I would seek medical attention for any of the above if the pain persists beyond about four weeks of rest or activity modification.

It takes about four to six weeks for soft tissues to settle down. So I would recommend rest and activity modification if you do have a flare of tendonitis or bursitis. If you cannot wake bear due to the pain, if the swelling comes on quite rapidly, if you feel like your joint is unstable or you’re at risk of falling, and if you’ve persistent pain at night or difficulty sleeping. One thing I did want to say with regards to joint replacement surgery is that it is a reliably successful option for bone-on-bone arthritis, which unfortunately is becoming more common as we live longer, and the capabilities of the medical services continue to improve internationally. You can return to hill walking, hiking or any sport after roughly four to six months depending on the level of impact. There is novel techniques and technologies to aid in surgical accuracy and improve recovery. Implant longevity or how long implants are lasting improves year on year. It was initially thought that knee replacements or hip replacements lasted between 15 or 20 years depending on how much activity you put through them. However, the newer generations of implants are really exceeding our expectations and the implants that have gone in between 2005 and 2010 are not coming back loose.

So, the honest answer is we don’t know how long the newer generation of implants are lasting. We’re doing hip replacements through the direct anterior approach where we go in through the front of the hip. It’s muscle sparing, It passes between two nerves. We can do X-rays within the actual surgery itself and ensure that the hip replacement goes in at 100% of an accurate position. We’re now using robotic assistance to do our total knee replacements. Again, ensuring that these are more accurate. We’re using cementless or no cement in knee replacement so that your bone grows onto the implant and this becomes one with your bone and as a result hopefully would never need to be revised. Physiotherapy is always a great first line treatment and there’s an increasing menu of injections available, platelet rich plasma, hyaluronic acid, corticosteroids. I would not recommend exploring stem cell injections just because the evidence is still quite limited and they can be quite expensive, but physiotherapy and injections are fantastic. And there’s no need to be afraid or apprehensive about your function after a total knee replacement or a total hip replacement because these are improving year on year. So, thank you very much for your time this evening and I’ll be delighted to take any questions.

It really depends on your joint, on your knee or on your hip. In the hip what the what the poles do it stops your pelvis from tilting. So it helps your gluteal tendons or the tendons on the side of the pelvis so that they have to do less work to keep your pelvis stable as you’re walking down the hill. So they’re very beneficial in the in the in the hip setting. In the knee setting it’s about reducing the amount of force going through the kneecap. I said it was four to eight times your body weight that can go through your kneecap as you’re descending a hill or stairs. So the poles will just reduce the amount of weight or the amount of force going through your kneecap. In terms of using them versus not using them if you have good strength and dynamic stability in your knee, the recommendation will be to, you know, not use the poles because you want to keep your knees nice and strong. But if you do have some changes on your X-rays or any inflammation on your MRI, then the purpose of the poles will be to offload those tendons and muscles that are affected. So, it’s kind of hard to say is there an age cut off, it really just depends on the status of your knee or of your hip. And but if you have any discomfort or any issues or any instability episodes, I would strongly recommend them. In terms of where to get them, I’m not entirely sure of if there’s a brand specifically that that would be recommended, but going into a shop like one of the hiking shops 53 degrees north or Decathlon and just speaking to somebody, feeling what feels good in your hands, feeling what what’s nice and ergonomic, what’s a good height for you, get them appropriately sized. It’s more having the support rather than a particular type of brand or a particular type of material.

Very good question. So, the older generations of hip and knee replacements we thought lasted kind of 15 to 20 years. However the newer generation of hip and knee replacements, we don’t entirely know how long they’re lasting because they’ve kind of gone in in the late noughties around 2005 to 2010. And they haven’t come back loose or worn to the same degree that we’ve seen the older generation of implants. This is because how the ceramic is engineered, how the plastic is engineered, how the titanium implants grow onto the bone. We’re not using cement as often. So there’s multiple factors and multiple developments that have contributed to hip and knee replacements lasting a lot longer. The technology and techniques we’re using going in through the front x-raying hips using robotic assistance for knees that all contributes to hopefully the longevity of the implants as well to the best of our knowledge. In terms of getting back to general exercise, it’s usually the kind of first four weeks or so is getting back on your feet. So, coming off your crutches, the second four weeks kind of getting your range of motion back and the third four weeks kind of focusing on your strength and your power. So anywhere between three and four months, you should really feel that you turn that corner and hopefully you can get back to some general exercise.

Ober’s test OB or test, so, if you bring your knee across your other knee and you get that tightness down the outside of your thigh that really is diagnostic that your iliotibial band is tight and that pushes your greater trochanteric bursa against the bone and that that bursa is really interconnected quite closely with where your tendon attaches. So that entire lateral hip complex can be inflamed. So, strengthening your glutes, stretching your iliotibial band, that’ll really help your gluteal tendons, help your iliotibial band and take the pressure off your bursa. So whilst a gluteal tendon based program is very beneficial, stretching the iliotibial band will really take the pressure off the burst as well.

Yes. And yes, unfortunately it really when you when you do see a physiotherapist and really make kind of strides or progress in the right direction, it’s about maintaining that progress. And I always tell people in the clinic that the most important time to stay on top of your rehabilitation and stay on top of your physiotherapy exercises is when you’re strong and when you’re relatively pain free to prevent a flare. That goes for back pain. That goes for gluteal tendinopathy. That goes for knee arthritis. It’s really about working these exercises into your daily into your daily routine. So first thing in the morning or lasting at night.

Hello everybody. My name is Matt Cosgrave; I am a consultant in sport and exercise medicine at the sports medicine department in UPMC SSC. I am delighted to join you this evening to talk to you about foot and ankle issues that affect walking and hiking. Just as a bit of an overview of what we are going to cover today, there is a saying in medicine that common things are common, there are lots of injuries and lots of problems that can happen to the feet and ankle associated with walking and hiking. We are going to look at the main families of injuries, and we will cover some of the common treatment options and the pathophysiology that might be associated with these injuries. We are going to have a look at why we get injured and then we are going to talk in a bit more detail then about how we can prevent these injuries happening rather than focusing on just treating and curing them.

So, what is common? If we think about studies around walking and hiking and the epidemiology of injury one of the biggest studies is from the Appalachian Trails and it looks at respondents from over 1300 hikers over a six-month period. They found that of all hikers who responded 42% of them did not complete their hike with the primary reason being cited as injury. of the of those who got injured, 40% reported foot and ankle injuries as the as the primary issue and this was by far the highest area of injury associated with hiking,13% reported pain in the Achilles tendon specifically and a smaller percentage of only about four reported issues such as stress fractures which we’ll look at in a little bit of detail later. Then there were also walkers and hikers who suffered traumatic injuries such as ankle sprains, and these might have made up about   14% of presentations.  Today however our primary focus is going to be looking at some of the overuse injuries that patients get.

So, the first thing we’re going to talk about is plantar fasciitis which is one of the most common presentations of walkers and hikers that attend the clinic here. The plantar fascia is a thick semi elastic band that runs from the heel to the forefoot, its primary job is to help maintain the arch of the foot so when we stand or when we walk gravity and the force of our body wants to push down on that midfoot and it wants to make the arch of the foot collapse, the elastic band then of the planter fascia stretches in a horizontal direction to try and prevent that collapse of the arch. At the heel it is attached at two parts whereas at the forefoot it is attached at five parts at the five heads of the toes and so, for the vast majority of patients the problem tends to occur right at the attachment on the heel. What happens over time is that you get a little bit of micro tearing or micro trauma, if we have the opportunity to rest this then it’ll usually heal. If we do not and we continue to load it continue to walk on it then we tend to develop scarring and a little bit of thickening and stiffening of the tissue. Then what happens is we get a little bit more traction force on the heel and we get a little bit of bruising at the attachment side on the heel. Eventually what can happen is some of those fibres can fail and we can develop some micro tearing at the attachment site, and we call this intra substance tearing. These can be very stubborn and quite difficult to treat.

The main way we look at treating these is we look at rehabbing the foot and ankle complex. This is just a bit of a diagram or a schematic of all the muscles and tendons that surround the foot and ankle. I mean if we think about the foot arch itself as it scrolls back round to the inside part of the foot you can see there are a number of muscles within the foot on the under surface that help support that arch. There are also a number of muscles high up in the calf that run down both sides of the ankle and wrap underneath the foot to try and give the foot a side-to-side stability but also help to prop that arch up on the inside. So, when we talk about physiotherapy and rehab for this type of injury really what we’re trying to do is optimise the strength in the muscles within the foot and optimise the strength in the muscles particularly that wrap around the inside part of the ankle and help to support that arch thereby taking away some of the work that the planter fascia has to do. When we struggle with that, we then start to use some other treatment modalities.

This is shockwave therapy, the way shockwave therapy works is it delivers sound waves to the area at a very high frequency. Those sound waves cause the cells to vibrate very quickly. That does two things, one is it stimulates a healing response by mimicking trauma, and the body starts to send growth factors to that area to try and heal. The other thing it does is it desensitises the area, so it can actually function as a little bit of a pain-relieving agent. When we do shock wave treatment we normally recommend starting with three sessions. We would do one session at a one-week interval and after that 3 weeks you should already be starting to see some improvement. I mentioned earlier that some one of the problems with plantar fasciitis is that the connection of the plantar fascia to the heelbone sometimes you are developing a bit of bruising within the heelbone and this is the kind of scenario where shock wave can be very helpful.

In in some other scenarios, we might use injections. The two main injection options that we have are steroid or PRP. We use steroid injections if there’s a lot of inflammation in and around the planter fascia and that’s because steroid acts as an anti-inflammatory it usually has a very quick onset of action and quite often patients feel very comfortable within the first one to two weeks. The downside to it is that it only is a temporary treatment in that it suppresses the inflammation but if we don’t do the other treatment modalities such as the shock wave or the rehab for the foot and ankle to build up the strength around the muscles to support the arch then eventually what will happen is if you go back to walking  back to walking a high mileage you’ll be back in the clinic usually somewhere in the region of three to six months later with a recurrence of pain and sometimes even worse because you’ve been walking on under the effects of the steroid and probably causing to some degree a little bit more trauma to the to the planter fascia.

The other option that we have for injection is PRP and that stands for platelet rich plasma. That’s when we take a sample of your own blood from the arm, we spin it in a centrifuge, and we take the platelets from the blood sample, and we inject those directly into the planter fascia. The reason we do this is the platelets have a healing property. They stimulate a healing response and so for all of us we have our planter fascia and our tendons in general they have poor blood supplies. So, what we’re trying to do is take these healing properties that our blood has and put them in a high concentration into the planter fascia to try and stimulate that repair and recovery process. It also has a natural anti-inflammatory effect. The downside to the injection is it can be painful it is also much slower onset of action than the steroid injection and so it may be about six to twelve weeks until you’re really feeling the benefits of it because what it’s doing is it’s stimulating a biological process and we still need to wait for that to happen. The other thing with the PRP injection is because we’re injecting into the planter fascia we’re temporarily causing a little bit of trauma and weakening it and so, we normally recommend that you wear a walking boot for about ten to fourteen days after the injection of PRP which is a little bit more restrictive than some of the other treatment modalities that we have.

If we move on then we’ll look at tendinopathies, the main tendinopathies involve the Achilles tendon which is at the back of the heel. It is the thick rubbery substance that attaches onto the heel, and it attaches the calf down onto the heelbone. We have your   tendons that run around the inside of the ankle and support the medial arch. There are three main tendons there is your Tibialis Posterior, your Flexor Halilis longus and your Flexor Doctor and of those three the one that tends to give us the most trouble is your tibialis posterior because it’s the one that hooks around the inside of the ankle and attaches on the midfoot and has the main responsibility of propping up the arch. Then if we go to the outside of the ankle, you have two paranal muscles which stop the ankle from rolling out. So, stop you inverting the ankle or rolling the ankle as an injury and they wrap around the outside of the ankle and attach onto the outside of the foot and then one runs underneath the foot.

What is tendinopathy? I suppose there’s two analogies that we commonly use for this.   If we think of a tendon like an elastic its job is to transfer the contractile force of the muscle to the joint and make the joint move. So, if we think about the Achilles or calf muscle contracts it pulls on the elastic that starts to lift the heel off the ground and then the recoil of the elastic is actually what gives you your spring in your step. It’s the same principle for the tendons that run around the inside and the outside of the ankle. The Achilles would just be much more of a power-based tendon, and it would help drive you forwards and drive you uphill. The tendons around the inside and the outside of the ankle, they’re more involved in the control of the side-to-side movement of the foot and ankle. So, if we’re you doing a lot of trail walking where the ground is uneven the tendons around the inside and outside of the ankle are going to have a lot more work to do than if we’re just walking on a on a smooth flat ground.

If we stick to the elastic analogy, what happens with tendons are the same that happens with elastic. If we stretch them nice and gently, they tend to work very well but if we stretch them too much or stretch them too often what happens is they lose some of that elastic property. I suppose that’s to some degree what’s happening within the tendon. Similarly, if we don’t use the elastic or the tendon for a long time what happens is it stiffens up. And then if we go from not using it to so suddenly trying to basket it or try to put a lot of demand on it and we try and stretch it what we tend to find is it’s a little bit resistant to movement and that can often present with pain and inflammation around the tendon if we’ve gone from a period of inactivity to quite a lot of walking or hiking in a short period of time.

What can sometimes happen with tendons as well is if we continue to strain or stress and ignore the signals that the tendon is giving us, we can also develop this intra substance tearing that we talked about within the within the planter fascia. What tends to happen is if we now move to the kind of analogy of spaghetti the tendon is made up of very thin fibres of collagen that are nice and tightly packed together. When we have tendinopathy some of those spaghetti fibres become cooked. Now again the tendon is designed to tolerate tensile force so, if we have dried spaghetti and we pull it from side to side it tends to tolerate that very well. Whereas if we have some cooked spaghetti that’s a bit soft and we pull it from side to side we can split that fibre. So, when we get into a substance tearing of the tendon it’s not torn like a piece of paper, it’s not torn off the bone, what we tend to find is that there’s a little bit of failure of some of the fibres within the tendon and what we’re trying to do in treating it then is either directly treat those torn fibres or we’re trying to treat the fibres around the injured area. So, we’re trying to treat the healthy tendon so that it becomes stronger and it can deal with more of the added burden that’s being placed on.

That takes us then into the treatment modalities and it’s very similar for the Achilles for the for the inside of the ankle tendons and for the outside of the ankle tendons. There’s just a little bit of nuance and specificity in the exercise selection that we use. So some of this might be heel raise activity some of it might involve resisted banded exercises  but ultimately it’s a strength-based program that tries to improve the strength in the muscles that are predominantly based up in the calf area and that wrap down around the back of the ankle or the inside or the outside of the ankle. When we’re struggling to get headway with the rehab program we may use shockwave therapy to the tendon or to the tendon attachment site or we may use an injection. Again, if our primary aim is to just suppress the pain so that we can get a good block of rehab we’ll often use steroids. If there’s any damage to the tendon such as intra substance herring, we’ll favour the PRP or platelet rich plasma injection.

So, if we move from the kind of back of the foot and ankle forward to the forefoot there are three main issues that we tend to find with the forefoot. One falls under this umbrella term of metatarsalgia. Now this may involve just some pain and inflammation of the fat pad at the head of our toes, or it may involve something called sesamoiditis   which is a very small bone that sits immediately underneath the big toe. Its job is to act as a little bit of a pulley for the for the tendon that runs underneath the foot, and it helps to strengthen the strength and the flexion of the big toe. But what can happen is you can develop some bruising and inflammation both within the bone and around the bone. Similarly, often patients who walk and hike a lot will come in and complain of pain in the big toe itself and that’s because there’s often a lot of movement at the big toe and that movement over time can translate into some arthritis change in the toe. If we move over to the second image what we’re looking at here is what we call a Morton’s neuroma. So, pain in between the toes either presents with pain that we feel in the forefoot or sometimes a numbness and tingling and that numbness and tingling is because a neuroma is essentially a thickening of the nerve that runs between the heads of the toes. Sometimes if we walk a lot or if we wear tight fitting shoes, we can get a bit of compression of that nerve, and it starts to swell and it develops something called a neuroma.  That neuroma can simply give us pain, or it can give us some sensory change in disturbance in the food as well.

Moving on to the third image then on the right. What we’re looking at here is essentially what we would see on an MRI of a patient who has a stress fracture or what we call a bone stress injury. When we’re loading the bone, we expect the bone to heal. If we don’t give it the opportunity to heal then what happens is the bone structure starts to break down a little bit. You develop some bruising in the bone structure which is what we see in the image here in the second toe that bright white colour. The beauty of an MRI over something like an X-ray is that often X-rays will miss stress fractures especially in the early stage. And so, MRIs are much more useful and much more sensitive for picking up   bone stress injuries and stress fractures.

When we think about treating these types of injuries again they similar they all fall into a fairly similar pattern. If we park stress fractures for a second, I’ll come back to that in a minute, but if we look at metatarsalgia sesamoiditis Morton’s neuroma or something like an intermetatarsal bursitis where we get pain that almost mimics a neuroma but there’s no neuroma present. What we want to do is we want to try and provide as much support around the foot as possible, that’s the first step, something with a stiff forefoot. So, a shoe modification is where we usually start, and a stiff forefoot is something that’s going to give us minimal toe flex. That’s going to allow the force that we translate on the step to almost rock through the bottom of our foot and let us spring off the toes rather than getting a lot of bend or flex in the toe area. If we’re unsuccessful here, we might use some custom fit orthotics. When we think of custom fit orthotics, we can break these into two. We have the lower spec which might be off the shelf that we can mould and there’s a service that we offer here in the clinic where we can look at your foot shape. We can look at the issue that you’re dealing with and then we can mould and fashion what’s effectively an off-the-shelf orthotic to provide a bit more support around your foot that’s specific to you. The higher tech version of this is where you would go in somewhere and you would get something like a 3D scan of your foot and then you would get a bespoke hard orthotic that’s moulded perfectly to your foot size and requirements. The difference between the two is the off-the-shelf version is a little bit more malleable so you can make changes to it more readily. The second benefit is in terms of cost, if you’re thinking about getting something like a custom for fit orthotic you could be paying somewhere from €300 upwards. Whereas something like an off the shelf orthotic can range from €30 to €100. The benefit of getting something like a custom fit or an off the-shelf orthotic with us in the clinic here is that we can tailor the needs specific to you and we can also look at some of the rehab needs of your foot and ankle at the same time as fitting any orthotics.

If we go on, then to look at bone stress injuries in a little bit more detail I just wanted to give you a sense of why bone stress injuries and stress fractures happen. Essentially there’s a constant continue largely between bone healthy bone and bone stress and we know this because there’s been some real great studies done on triathletes who have run for or who have performed in a race and after they’ve raced you’ve scanned them and they’ve had quite prominent bone stress in a number of areas. Now they’re totally asymptomatic of this and after a few days rest and recovery a lot of that bone stress recovers. Now if we know that process is happening when we apply stress to the bone   if we don’t get the signals from the bone and we’re not allowing the bone periods of time to rest then eventually what happens is we start to develop a bone stress injury where we start to get pain with it. When you reach that bone stress injury phase the recovery time just takes longer. If we ignore the pain and continue to work, we’ll eventually develop a stress fracture which is a small crack in the bone. It doesn’t necessarily break which is what go which is what happens when we have complete fracture, but it cracks. And again, the implication of that crack is that it just takes much longer to heal. The only way really to treat these is to take away the insult. So, take away the stress that is causing the problem. And for most people that will involve either going into a walking boot for a period of time or depending on the site of the injury it may involve going no weightbearing which might involve using crutches for a period of four to eight weeks depending on the issue.

So why do we get injured? I suppose ultimately it comes down to we are the idea that the demands that we’re placing on the tissue be it the bone the tendon the muscle the planter fascia are exceeding the capacity of the tissue. It can be affected by a number of things; one is just the underlying strength and quality of the bone and tissue. As we age what we tend to find is that the strength and the quality of the tissue reduce. So, age in general, does play a part in this. But these are not all age-related injuries. Despite aging we can often do plenty of work in terms of building up and developing the strength around the tendons the planter fascia the ankle the foot and even the bone that can reduce your risk of injury going forward. Sometimes it can be down to your biomechanics, essentially how you’re moving what way your foot and ankle is shaped and how they move when you plant on the ground and how they move as you walk and hike. Similarly, problems in the foot and ankle can originally stem from issues higher up through the knee or the hip or weaknesses higher up in the knee or the hip because ultimately when we walk there is a kinetic chain that has to do the work to get us from A to B and if we have weaknesses elsewhere in that kinetic chain increased demand and burden can get placed on the foot and ankle.

Training errors is a big issue, I’ll go into that in a little bit more detail, but essentially what training errors refers to is how we approach exercise and activity. How we ramp up that activity or increase it and at what rate we do that and how we approach activity having had a period of downtime. Equipment errors might involve things like footwear old footwear weathered footwear that maybe has lost a bit of its structure and support and then similarly footwear that doesn’t really fit your foot shape or size something with a narrow toe box that’s possibly giving you some metatarsalgia or contributing to Morton neuroma type pain for example. Similarly, we may want to use equipment to help reduce the burden on the feet and ankle and it’s understanding when we need to do that and that might involve something like walking poles or crutches. Under fuelling is a big issue and we see this more and more and it’s something that we’re becoming more and more aware of and essentially what under fuelling refers to is nutrition. So, if we’re going out and exercising especially if we’re going out and doing two to four-to-six-hour hikes or walks are we getting the right nutrition into us to fuel our bodies to fuel our tissues for that walk? And that goes back you know that that’s not just on the day of exercise but how are we approaching it throughout the week in the buildup to that activity? We wouldn’t run a marathon without preparing and often people refer to this as carb loading.  There are different versions of this but essentially what we’re trying to do there is we’re trying to provide enough energy and enough fuel for the body to meet its demands, the same thing applies to any activity we do especially longer walks and hikes. Finally, then we think about things like external stressors. You know how busy is life? How well rested and recovered are we? If things are stressful, we’re not getting enough sleep. If we’ve had recent illness or recent injury elsewhere our likelihood of getting injuries in the foot and ankle significantly increase. So, if we think about why we get injured and specifically training error there’s these terrible twos that people often refer to essentially too much activity too soon and too fast.

So too much activity applies to the overall volume. So how many miles how much time we’re spending on our feet and are we is our body prepared to do that. Too soon often refers to our return to activity after having a period off. So, if we think of the spring as being the highest risk period for foot and ankle injuries and for injuries and walkers and hikers that’s because we’ve usually had a period of inactivity over the winter and then all of a sudden, we’ve rapidly wrapped it up when the good weather starts to return and that’s significant. That’s one of the significant issues that people find is that they haven’t given their body enough time to adapt and so their return to activity has been too soon especially after a period off. That’s similar for the too fast, you know we might come back to activity and feel great early on, but we might increase the intensity or the demand too quickly that it may be a case that we go from walking on the flat to terrain or high incline walks in a very short period of time. But that principle is starting slow and giving the body time to adapt over a longer period of time rather than a short period of time and listening to our body for signals, listening to the foot and ankle for any signs or symptoms of pain or stiffness that tells us that we usually need to taper back on things before we can then build on that again.

How do we approach this then? How do we try and reduce the risk of injury? I mean the first thing we’ve got to ask ourselves is what is our baseline? You know are we a seasoned walker or hiker? Is this something we’ve been doing on year on year? Is this something that we’re just wanting to start off a fresh? The more chronic exposure you’ve had in years past usually the better capacity your tissues have to tolerate the demand but then similarly I mentioned it about the spring being the high-risk period what have you been doing over the winter period if you’ve been very sedentary you’re going to need to take things low and very slow at the start and gradually build it up whereas if you’ve been active in other areas such as the gym using other equipment outside of the walking then the likelihood is that you probably don’t need a very long time to adapt and you can usually pick up where you left off or at least get back there within a reasonably short period of time.

What is it that you want to achieve? Are you walking for a specific event that you’re preparing for? And if you are use that as your end point and gradually build yourself up there. Think about it in terms of how much do you want to achieve in a week? How much do you want to achieve in a single walk? It may be a case that you just want to walk 30 minutes a day five days a week and that’s very achievable. But your approach to that should be something like starting off at 10 to 15 minutes a day initially and usually at the early phases of walking we would suggest that you start with an alternate day basis so that you have that opportunity to recover. And once you’re meeting your milestone on an alternate day basis then if you want you can start to introduce that that activity on the day in between. For most walkers and hikers, the weekend is the is the kind of is the milestone and it’s important that we remember that just because we’re doing that one walk on the weekend doesn’t mean that we should do nothing the rest of the week. Because actually if we provide some stimulus to the tissue throughout the week then we’re much less likely to get an injury from the big load that we’re applying to it on the weekend. Whereas if we do very little on the weekend during the week and a lot of the weekend our body struggles to adapt to that in a very short period of time and that’s actually much higher risk of injury keeping things ticking along during the week and then and then just a small jump at the weekend. So just keep that in mind for those of you who like to do your longer two-to-four-hour walks at the weekend.

Then how do you get there? I suppose one is just gradually increasing the vol e and the mileage and think about it in terms of either the distance, the time on feet or the time of the walk but also use things like a pedometer, a watch that might track your steps, and just keep an eye on what your average step count is throughout the week. You can also break it down into days and you can highlight the days where you walk and the days where you maybe do your longer your longer walks. Similarly think about the surface that you’re walking on, If you’re starting off or if you’re just returning flat surfaces are optimum flat and smooth then we might start to introduce an incline and decline and then we can start to introduce some of the rougher more unsteady terrain that’s going to   that’s going to put more strain and stress onto the tissues.

So, as a little bit of a summary we want to talk about building volume. So alternate days maybe one longer walk at the weekend start flat then hills then build into terrain and then monitor your load and you should be able to track this fairly easily and when you’re able to track it you’ll be able to see okay ‘is there a day of the week or is there a week that has been a significant outlier to the level of activity I’ve been doing elsewhere?’ , and it often gives you a really good indication and it also gives you a very early sign of where you might have a potential of injury long before any of these problems can happen. I’ll talk to you in a about the 10% rule but that’s something that some patients like to apply if you’re keen on numbers and you want a little bit more detail and to quantify your build of load. The other thing that we think of is our general preparation and this is where the likes of physiotherapy strength and conditioning coaches personal trainers can come in handy and even sometimes if your access to those sort of   services is poor there’s lots of options and lots of resources on the likes of YouTube or other social media channels that can help give you a bit of direction around how you should be building up the strength how you should be building up the function and the resilience of your foot and ankle.

At the clinic here our strength and conditioning coaches offer a service that they can look and get some measures of the strength around the foot ankle. They can provide you with an exercise program and they can also provide you with some programming around building up your walking volume especially if you’ve got a targeted goal or event in mind. Nutrition for most people is just a case of making sure that we are getting all our macronutrients a good balance of carbohydrates protein and fat into our diet and making sure that we’ve got good quantities of food that would be enough to fuel our bodies for extended periods of exercise. We do have access to performance and nutritionists, there’s a few that work within the clinic here and if any patients want the direction to those we’d be more than happy to provide that and we can be able to give you a little bit more direction around specific nutritional needs and a bit more education around that. Then finally equipment and that’s thinking about things like footwear  orthotics if necessary and then walking such as walking sticks.

Finally, I’m just going to finish on this idea of the 10% rule, and this is largely adapted from running but patients will often use this for patients who are returning from things like stress fractures or from foot and ankle injuries. The basic concept is that we want to reduce our total weekly volume increases by less than 10% week on week. So, if our usual walking volume is one kilometre a week we would want to try and avoid walking more than 1100 meters the following week. Now that’s a very small number but if you extrapolate that one kilometre a week out over five days and we say that we walked 5 kilometres a week over the course of the week we would really want to be keeping our increase the next week to be less than 500 meters in total. As I say it tends to be better for larger volumes and that’s why it tends to be better for those who run but more recently there’s been a little bit of refinement around that advice and there’s been a study that produced in the last year that has found that actually the highest risk of injury occurs in patients who increase a single session activity of more than 10% than any previous walk or hike that they’ve done in the last 30 days. So, for most patients this is the highest risk period in that first month or that first 30 days that you’ve done. If you can gradually build that activity level up to your baseline, then that means you’ve got much more wiggle room in the months ahead where you don’t have to worry too much about small spikes in activity as long as they’re no more than that 10 % increase on your previous longest walk or hike in the last 30 days.

First MTBJ or first big toe arthritis is something that we would very commonly see here at the clinic. I suppose you would start off with standard treatments which would be oral anti-inflammatories. That would be probably kind of the most obvious which you could buy over the counter. If that’s not controlling things for you then you might think about some injection options. First line option injection wise would usually be a steroid injection. We do use PRP injections for these sometimes as well, but the steroid tends to be the first line. It’s got more evidence behind it and usually more effective.

Yeah, the same principle of thought behind them is that they will improve the venus return. So, in order in other words improve the blood flow back up from the extremities to the central system and therefore improve the recovery of the muscle and improve the muscle’s ability to work for longer thereby being able to walk further and more comfortably. So, the same principle would exist for walking as it would for running or any of those other endurance activities. There’s certainly no harm in trying them, how much benefit you would get is sort of person dependent but it’s definitely worth a try.

Well, a LisFranc injury is pretty significant injury. It’s definitely possible. We will treat lots of athletes who’ll get back to high level international sport having had Lisfranc injury. I suppose it’s a little bit difficult for me to comment on that not knowing the full extent of the injury and what was done for it. I would always recommend if you’ve had treatment for it through say a surgeon that you speak to that surgeon for advice on where they feel your level of activity should be. But we would definitely be aiming for getting back to some level of activity and it’s certainly achievable to get back to higher level function with it.

So, the short answer is yes. I thought about talking about this during the talk I suppose when I started training.  That was the kind of general advice that we were taught, and it does help. It can definitely improve symptoms; it’s massaging the planter fascia and massaging the tissue around it, and it does provide a little bit of loosening to the tissue, and it allows it to be a bit more pliable. It also desensitizes the area a little so it can make it feel more comfortable but really, it’s a short-term treatment option, you’re treating the symptoms rather than the cause and you may get short-term temporary relief from it. If it’s a case where you walk you massage the food it improves things and you’re able to continue on that   on that kind of pathway then that that’s generally fine. But if you’re finding that it’s taking more and more to control the pain or the pain’s not actually going away with it although it’s desensitizing it a little bit then you probably need to be looking at a more definitive treatment option.

So, we rarely tell patients to stop entirely because we do want the foot to continue to work. We want the muscles in the foot and the muscle around the ankle and the calf to work. It really depends on your level of symptoms; we sometimes use a pain score where we say zero is no pain and 10 is agony, can’t put the foot to the floor. We would normally say that something in the region of about 4 out of 10 is a good barometer for where it’s safe to continue. Going above that you’re probably causing more problems than it’s you know than you’re helping. Whereas if you’re below that 4 out of 10 level generally speaking, you’re okay to continue to walk it rather than a kind of walk or not walk. What it’s usually an indicator of is increasing or decreasing the volume or the intensity of your walking. So, as your pain’s reducing you can then start to increase the volume or intensity of your walks. And then the contrary would be as your pain’s increasing you want to be reducing the volume and if you’re getting to a stage where you’re struggling to get out of bed in the morning you’re struggling to put the foot on the floor then really you probably need a period of rest where walking is at a minimum just to allow it to settle down and that it’s that’s not improving things then you need to start thinking about other treatment options.

Hi, my name is Luke Fogerty. I’m a sports medicine physiotherapist here at UPMC SSC and today I’ll be discussing the challenges and some of the common injuries with winter sports. So just a brief overview of what we’ll be going through today. We’ll be completing a quick needs analysis of skiing and other snow sports. We’ll be looking at some of the challenges of these trips, both physical and logistical, we’ll be looking at some of the common injuries and diving into the common lower limb injuries a little bit more. We’ll then look at the pathophysiology; we’ll look at the risk factors and then some tips for prevention and rehabilitation as well.

So, in terms of our needs analysis, skiing is a sport that involves high intensity aerobic bursts coupled with sustained aerobic capacity. So, you will have a low level of energy expenditure consistently throughout the day as well as short bursts of your more high intense activity. Some of the biomechanical stressors involved, so due to the fixation at the ankle, due to the ski boot, this causes immense torque and pressure further up the chain at the hip and knee and so, this is something to be aware of when we’re considering the prevention and rehabilitation side of things as well as some of the common injuries. It also requires a significant amount of core stability and lumbopelvic control and during our I suppose speed regulation and force absorption we require a lot of eccentric quad control as well.

So, some of the challenges with these trips are generally the high density. So, when we’re away for three to seven days, generally we’ll be skiing back-to-back days. There is a day three phenomenon where day three is statistically the most likely day that you’ll be injured due to the decline in physical and mental performance over the days of the trip. Some of the other challenges are lack of preparation so poor physical preparation for the demands of the trip, poor recovery. So, I suppose après ski is quite popular and a lot of people do like to burn the candle at both ends when they’re away and this can result in poor recovery which limits your capacity for the following days. Then physiologically then we do have to consider the altitude as well as the cold temperatures. This results in reduced VO2 as well as increased peripheral vasoconstriction. What this basically means is we have an increased rate of muscular fatigue so our muscles will tire quicker.

So, if we look at the most common injuries lower limb we can see is the most common and of that knee is the most common. We also have upper limb and head and cervical. So some of the upper limb injuries we might see in recreational orally skiing are our kind of traumatic rotator cuff tears, shoulder and elbow subluxations, glavvicular fractures, AC joint pathologies as well as hand and wrist fractures. Inner head and cervical injuries, these will generally be due to impact so, whether that’s from falls or collisions. and what we’ll see here is fractures, concussion, lacerations, and so on. I suppose diving a little bit deeper into the common lower limb injuries, our most common are our ACL ligamentous and meniscal injuries, so MCL and NCL, we’ve fractures, so our tibial plateau tibial shaft and then we also have ankle injuries which generally tend to be higher in snowboarders. I suppose due to the recent advances in equipment thankfully the rate of fractures has reduced significantly, however, our ligamentous and particularly our multi-ligamentous knee injuries are still quite prevalent.

So if we dive a little bit deeper into our ACL injury, generally I suppose there’s two main mechanisms, we have our contact or non-contact. So our contact injuries are where there’s an external force either making direct or indirect impact with the person. So I suppose to compare our pivot sports which is generally where our most common cause of ACL injury versus skiing in pivot sports will generally see a lot a lot more kind of lateral compartment bony bruising and this kind of, I suppose indicates that the mechanism may be slightly different. So generally, in pivot sports you’ll have that pivot shift mechanism whereas skiing a lot of the time we’ll see that we’ll have our I suppose anterior tibial translation due to our fixed ski boots and that causes the rupture of the ACL. Generally, the mechanism will be actual compression anterior tibial translation and then valgus stress and internal tibial rotation.

So, some of the common mechanisms we’ll see are snowplough mechanism. So, this is where the tips of the skis come together. The tails come apart and then the inside edge of the ski catches causing a valgus force on the knee. We can also see a boot induced anterior drawer. So, this is basically where the person lands kind of in a backseat position or their weight shifts backwards and then due to the rigid boot that shifts the tibia forward causing, I suppose increased pressure on our ACL. We also have our slip catch mechanism. So, this would be more common in our elite skiers. So, this is generally seen in in more high intensity carved turns. It’s basically where the inside edge of the ski temporarily loses grip and then catches again causing the knee to fall inwards while the body continues to rotate. So, they’re kind of our more common mechanisms.

Then if we’re looking at MCL and meniscal injury, so I suppose the most common mechanism is our valgus stress and external rotation and then also in relation to MCL which is less common but can be seen we have direct lateral blow as well. And so with our meniscal injuries we’ll kind of see a similar mechanism and we’ll just get that scraping of the meniscus with the femoral condyle. So a lot of the time we’ll see these injuries in conjunction with our other ligamentous injuries in particular ACL and so it has been identified that a lot of evidence will show that I suppose 50% of ACL injuries will have comorbid either MCL meniscal or condal pathology as well. A lot of these pathcomorbid or multi-ligamentous knee injuries will more often be seen in elite skiers. and generally, it’s hypothesised that’s due to I suppose the higher energy falls that they would be in due to the increased demand of the skiing that they’re potentially doing or the increased I suppose difficulty.

Then if we look at tibial fractures so I suppose the tibial plateau fractures would be our most common and so skiing is actually the most common cause for tibial plateau fracture, so generally this will happen with a valgus and either internal or external rotational force, due to the rigid boot again and the long lever of the ski this will amplify the torque at the knee and then we’ll get that kind of impacted femoral condyle into the tibial plateau causing fracture. Generally, you’ll see this in conjunction with other ligamentous injuries. We can also get tibial shaft fractures as well, so, we may have a spiral fracture where it’s a pure tor torsional force on the tibia. We can also get oblique fractures where we’re getting torsion and bending and then transverse fractures as well where it’s a direct blow to the tibia and so again due to the kind of higher energy falls that you’ll see in the elite population this injury is more common for them and I suppose return to skiing at three year follow-up was estimated at around 46%, so it can be quite low and in the population that did return it was often at a lower level and I suppose the rehabilitation process was often quite difficult in these injuries as well.

Some of the risk factors for these injuries, I suppose skill level does play a huge role. It’s more common I suppose I’ve alluded to the elite population being more likely to have your meniscal and condal pathologies as well as the tibial shaft fractures. However, overall being a novice or beginner is associated with a higher risk of injury. Another risk factor that is controllable is our neuromuscular control and fitness level. So, if we I suppose fail to prepare going on these trips and then we’re asking of these huge demands on our bodies often they can fail us when we need them and then another risk factor is obviously previous injury, females are at a higher risk of knee injury. Also, poor equipment setup and so I suppose during our falls it’s important that there’s adequate release of our boots and our DIN settings are set properly so that we’re not resulting in that kind of rigid fixation causing force to transmit further up the limb. And so, this is why it’s important to be quite honest and modest with your when you’re getting your DIN settings done because it will stand to you then when you’re on the slopes. Another factor then is sloping difficulty and conditions as well. It might be days where conditions are less favourable maybe stepping down in terms of difficulty level and then again, it’s also being honest with yourself about your level not to overestimate it.

In terms of prevention and rehabilitation I suppose the big factors are due to the high density of the trip can we reduce that so that’s taking breaks during our high intensity periods it may mean say adopting a high low model where day one you might have a day where you’re expending yourself a little bit more intensely enjoy your après ski and then you take the following morning off allowing yourself to rest and recover and have a shorter session on the slopes and then the following day you may be a little bit more recovered to go for a longer day. Again, another factor then is fuel and hydration. So, it’s making sure you’re kind of eating well, hydrating, and making sure you’re topped up in terms of that. And that may mean bringing certain snacks and preparing that for when you’re up on the slopes. In terms of physical preparation, completing a block of kind of strength and aerobic fitness work before going. These qualities are things that do take I suppose weeks and even months to build. So, it’s kind of being aware of that coming up to your trip. It doesn’t necessarily need to be anything extreme, but even a low level of strength and aerobic work in the number of in the few months leading up to your ski trip can stand you then. And then, as I mentioned earlier, accurate DIN settings. so that your boot does release when you are folding and being honest in terms of your experience level. So that’s everything in terms of I suppose the challenges of skiing calming injuries as well as some of the prevention and rehabilitation tips.

Definitely, I suppose postoperatively people can get back to high levels of activity after either meniscectomy or meniscal repair. So, I suppose the biggest thing is having a good, planned rehab block, making sure you’re kind of progressing through the stages and gradually getting back to everything. and then it’s kind of managing load as well. It is something that it can become irritated down the line, but by managing kind of how often you’re loading it and the intensity of what you’re doing that can definitely help as well. And I think it becomes more about managing symptoms. So, if you do have a flare up of symptoms, doesn’t necessarily mean you can’t do an activity you might just need to change you’re doing it and then having a good kind of base of strength, making sure the muscles around the knee are kind of supporting you as well when you are getting back to things like skiing or more intense activity.

It’s similar principles that apply. So, it’s really just having a good foundation of building strength and making sure you’re not provoking symptoms. The biggest thing going into surgery is you want your knee to be nice and calm, you want swelling to be in a good position so that after surgery, which there inevitably will be a little bit of pain and swelling, that it’s not already on the back foot going into that. So, that’ll be the big thing.

I suppose like the big thing with knee replacement is generally the joint will be quite irritated, you’ll have a loss of range, a lot of stiffness. So, I think addressing a lot of those things h pre-surgery can help after because I suppose the big issues we see with knee replacements is if someone can’t fully extend their knee or straighten it, so trying to work on that pre-surgery and get that in a good position, that can help after as well as again kind of building your quad strength and other lower limb strength just because that’s generally what tends to I suppose decondition a little bit after surgery. So yeah, if you’re in a good place there it can set you up well.

I suppose it kind of depends on the level of skiing you’re looking to go back to as well as I suppose your kind of base strength beforehand, if it’s one where you had a good base of strength, like definitely within 12 months probably wouldn’t be going any sooner than that but definitely if you have a good base and you’re following a good structured rehab plan, it’s definitely within the realms of possibility.

It can be helpful because I suppose we have a lot of sensors around the skin of the knee that I suppose providing some taper support can give us that little bit of feedback that does give us a little bit of extra comfort. I don’t think it replaces kind of building actual strength around the knee but definitely can help kind of get you through days of maybe more intensive skiing and stuff like that and just kind of reduce symptoms a little bit.

A brace like it’s I suppose it depends on the situation why you’re wearing it, I suppose if the knee is stable enough to go skiing I think definitely it can be a good adjunct to kind of help support that a little bit as well but it is one if it is kind of highly unstable it’ll kind of be considering you know is it a good option but definitely can be helpful yeah.

Good evening, my name is Brian Devitt, I’m speaking this evening about ski related knee injuries. It’s a great pleasure to be able to join you again. So, I just want to share a quote which I heard from one of my mentors when I started off my fellowship in Vail, this quote stated, “If you’re to design a device to rupture an ACL you couldn’t get much better than a ski.” This relates to the fact that with skiing your knees are very vulnerable to turns because you’ve got a long lever which is the ski and you have your ankles held in position on your skis. So, Dr. Richard Steedman was one of the forefathers of sports orthopaedics and he worked in Vale, Colorado which is a good place for ski injuries because it was at the foot of a ski mountain.

I like this particular picture which one of my colleagues sent me and perhaps we should all wear these when we’re starting off, but really ski slopes are the conveyor belt of knee injuries and other injuries which we will deal with in this series of talks. They are so because it has become hugely popular, back in the day it was skiing was for only the mega wealthy but nowadays most people go on a ski holiday or have access to it and they’ve become hugely popular.

They are risky sports’; in this little schematic we see that skiing has great preponderance of knee injuries whereas snowboarding you can get more kind of upper limb wrist related injuries. It’s just due to where the board is attached to the legs and but also the single board with the snowboard is less risky than the isolated skis on each limb.

In terms of the equipment, the equipment has changed remarkably and changes year on year in fact. But back in the day, you can see these guys no helmets, essentially the planks were lashed to the ankles and there was very primitive kind of footwear. But nowadays we have much more sophisticated equipment, you’ll see the boots have got these bindings which hold your foot in this flex position and the ski boots are then bound to the skis. This is one of the critical things is that when we’re starting off the ski, what we really need is a very loose or a loose enough binding so that if you fall over that your boot comes away from the ski and you don’t use your ski as a lever because that’s where you get a lot of knee injuries.

So, a lot of people come to the ski rental place and they’re very full of bravado from the previous year and they say that I’m an expert skier now because I’ve skied for one week. But what happens is the ski technician is tightening what we call the din on your bindings to make it more difficult for your boot to come away from the ski and as a result you’re more prone to knee injuries. So, if I were to offer any advice, I would say go low on the din or just be truthful about your level of expertise because that’s how the binding is set.

We also know that the skis have changed quite a bit and the skis are essentially making it easier for us to ski, you don’t have to lift your foot as much and it’s a lot about how your weight is distributed, but they’ve really improved safety. The terrain and conditions are really important. So, this is an example of you know very deep snow where you have to lean back on your skis but also and the opposite is true when you have very icy snow you have to lean forward more. So really the terrain conditions really determine how frequently people are injured and often when people aren’t familiar with different conditions that’s when they have greater chance of getting injured. So, if you’re not familiar with the terrain or how to ski in a particular terrain, it’s probably best that you speak to an expert or have some lessons. And also, be cautious when you’re finishing a run of the day is when you go down the blue slopes or the green slopes when there’s lots of people around, that’s where you can really run the risk of getting injured because it’s the traffic, but also the snow is very slushy and tends to be more sticky and that’s where people may get injured.

So, this is probably an example of what the ski conditions are like this year, and you have to be cautious where there’s exposed rocks or um where you’ve got grass exposed because it can stop the ski sliding. So, in terms of the mechanism of injuries, previously when I’ve done this talk, I’ve done a diagram, but I thought it was easier to show this video. You see a guy skiing at pace down the mountain and that snap you hear is not the snap of his ski releasing, but the snap of his ACL. So, you watch the person, he’s in deep slow, leaning, leaning back, back, back, back, and his knee is not in control and it’s his lower ski there those twists, and he twists on that knee, and he’s ruptured his right ACL in in this setting. So, if you have friends like those who needs enemies, it’s laughing at his buddy. But you can see very slowly he’s leaning back, back, back, immediately. He’s really put a lot of stress on his medial ligament. And this is the classic injury pattern we see with knee injuries.

But we can’t legislate for stupidity, this is another source of frequent knee injuries as well is that people just getting a bit carried away, maybe a few schnaps at lunch or a bit more of the red wine, that doesn’t really compute with the cerebellum when you’re skiing.

So, in terms of how do we manage on the mountain? Well, first of all, we do no harm. That’s the tenet of orthopaedics and medicine in general. I always use the phrase stay in your lane. And they put up these signs for a reason because they don’t want people to ski beyond their limits. It’s not so much at the start where it looks nice and flat, but it’s somewhere down the slope where you can really get yourself into a bit of trouble. So, I’d recommend when you’re starting off that you get lessons and you stay in your lane and go with a guide if you’re unfamiliar with the mountain.

Other things can be hazardous, it’s the people around us, it’s the fact that there’s alcohol being consumed and you’ve got people who don’t really have any regard for those around you and I think that’s very important just be aware that it can be a dangerous sport and you just have to be a little bit cautious.

I would suggest return to your comfort zone. So particularly when you’re starting off on the first day we used to have a phrase in our family you get your ski legs, and you really need to just to go up and do something gentle to begin with and not start off on a black or double black diamond unless you’re very familiar with the with the activity.

So, how do we manage then in the clinic? Well, in the clinic is where the dust has settled and that’s really where we have the opportunity to make a very safe and informed decision as to how to manage the patient. It’s the same way we manage any ski injury. But the recommendation I’d give to people is if you are injured on the mountain, what you need to do is get a diagnosis. So, you go down to the local medical tent, very experienced people, they’ll probably do an X-ray or maybe if they have access to an MRI and they’ll take a history of what the injury is. If you hear a pop and your knee twists and you’ve got a swollen knee well the chances are you’ve had an ACL injury to begin with so it’s very important that a thorough history is taken.

In terms of doing a history we just need to take our time and get the right history but if you have that pop and swelling that’s you know effectively, you’re an ACL injury until proven otherwise. The clinical examination is key and afterwards you’ll see the example that when you take your salopettes off, you’ll see a big swollen knee well that’s a bad sign unfortunately. So, the chances are you may have had you know an intraarticular injury which is an ACL rupture or maybe a ligament rupture. So, if that happens you really need to think seriously about getting that assessed.

In terms of management, we have to look at both sides as well and just to isolate one limb you’re going to miss the other side which gives a good example of normal. So be sure that if you’re being examined by someone that they expose both legs properly to have a good look and if you’re they’re not doing that, you probably need to get a different assessment. They typically would do X-rays, X-rays can be somewhat helpful, if you have this little flake of bone here that can diagnose an ACL, but some people use ultrasound, but it nothing compared to an MRI scan at the end of the day for diagnosing ACL injuries. But sometimes be cautious about what the quality of the MRI scan. If you’re shipping up a magnet to through to through the mountain, they’re not going to always have the premium MRIs up in the mountain so sometimes it’s best just to go down to a bigger city or town and have a proper diagnosis or come home and have a diagnosis. We’ve got very good scanners here and you can get it done very easily.

In terms of the next step, then it’s really referral. So, when you get home, if you’re injured, you really need to see an orthopaedic surgeon quickly. We’re very happy to facilitate people who haven’t got scans. We can get scans the same day and then we’re dealing with the issue in the cold light of day. So early diagnosis is much better than early treatment necessary and if the treatment is not appropriate and one of the things we really need to do is we need to make sure that someone is appropriately managed.

A lot of times if people are away, we there’s this pressure to get treated early and really there’s no urgency unless there’s a neurovascular injury to the leg the blood flow is being interrupted or very serious knee dislocation to treat this urgently. Most of these can be treated down the line. So, it’s important just to be calm about this and just get home appropriately and be treated.

In terms of non-operative versus operative intervention, well that’s the first thing we look at is can we avoid surgery in a lot of situations, and I give an example in the cases below where surgery is not always indicated. We want to remove the splints as soon as possible, a lot of people are put into splints, and you know I will be honest in that the medical companies over there they make money from splints. So, you get €200/300 cost for a splint but often times they’re not necessary. Now, if you have a medial ligament injury, a splint may be helpful for pain relief, but really, we need to get those knees moving. So, we try to take the splints off as soon as we can.

You never go into surgery with a person who doesn’t have a full range of motion. So, range of motion is really critical prior to any surgical intervention. We also want to get people weight bearing is tolerated and we get them using crutches. They often have a series of fancy crutches when we see people in this time of the year. But really, we want people to weight bear once they’re able to do so because that’s good for the cartilage. It’s good for restoring their normal biomechanics of their knee and great for the range of motion.

So, I’m going to go through a few little common scenarios. These are several cases which I frequently see at this time of the year. So, CASE ONE is a novice snowboarder. So, I get a letter 14-year-old snowboarder injury a week ago swelling within 12 hours. So immediately I’m thinking this guy’s got a serious injury. He had a plain film which was unremarkable except for that swelling in the knee. An MRI is performed which revealed a small medial condyle fracture and a grade two MCL sprain. So, the MRI will give you a grade but really, we want to examine this person in her own get the knee in her own hands so we can assess it. So, it’s a very common injury they talk about an ACL sprain in the image.

So, in terms of the history, so contact injury turning, didn’t hear a pop. So immediately I’m not thinking ACL here, fell to the ground, couldn’t wait bear, removed from the hill. That’s often a real factor; someone has to be taken off the mountain by the snow patrol. No immediate swelling, that’s good, but that letter did say swelling within 12 hours. Holding the knee in a flex attitude, well, that’s a position of comfort so if you any swelling in your knee, you’re going to hold it in a flex position. Walking with an antalgic gait, so that’s like a limp, mild swelling within the knee 10 to 135 degrees of flexion so that’s holding that knee in a flex position and the grade one injury in terms of my hands it’s differs to the MRI and the Lachman which is assessment of the ACL was negative so these are all good signs.

These are the x-rays so you can see it’s a 14-year-old, the grow plates these are the lines here they’re still open, but no suggestion of any serious ligamentous injury based on any little fragments of bone so that’s a good sign. This is the MRI scan, this is a one-shot MRI and we see over this side of the knee, you’ve got whiteness and that indicates some fluid. But this is a minor grade ACL or medial ligament and this beautiful structure in the middle of the knee, that’s the ACL. I spend most of my life dealing with that and that’s a really nice intact ribbon-like ACL, so that’s normal. So, in this person, you don’t have to do anything. Just get them moving, take them out of the brace and get them going. really focus on getting that knee extension going which is which is fantastic.

So, this is another case, a more serious case and this is a 42-year-old female. So recreational skier had an injury to the right knee following the fall. Unsure of the mechanism but just had a bit of a blur. She felt that both knees kind of went to the side, the ski bindings didn’t release and that was probably what put all the stress through the medial ligament but also the ACL, difficulty weightbearing afterwards, immediate pain and difficulty getting off the mountain with gross swelling in the right knee. So, in terms of the clinical assessment, difficult to stand. So, you know someone’s got a serious injury. On this side when I examined her knee that she had what we call grade three medial ligament laxity and grade three lachman test. So, the knee was very unstable in this situation and what we call ecchymosis or bruising on the inside of the knee. So really had a very loose knee and that was a more significant injury. So that’s one we recognise we’re going to need to treat and probably treat rapidly.

So, this is just the image from the side. So, I’ll draw your attention to the inside of the knee here. And you’ve got lots of whiteness which is fluid and blood and I’m looking for a black structure but it’s all this grey structure here. So, there’s very little in the way of her medial ligament intact which is unfortunate for her but does correspond with what I’m able to assess clinically is that this knee is really at a very serious injury.

I’ll then show you the image from the side. So, what we’re looking at on this image is we start from the outside of the knee, we see there’s lots of fluid here which is the white stuff on the outside. As we go into the knee, we see this black structure which lies between the two bones. That’s the meniscus or shock absorber. She does have a small tear to that. And then we see the middle of the knee, the ACL. So, you can see the absence of a nice ribbon-like ACL. The posterior crucial ligaments intact and the medial meniscus intact but then we see lots of fluid on the inside where she’s injured her medial ligament. So, this is a serious injury in an individual. So, this is one we don’t hang around with that we recognize we need to fix this.

So, these are just some findings from inside the surgery where you can look in the knee and this is what we see, and this is the big gap on the inside of the knee. So this is where the inside ligament has been injured and this is the structure inside the knee. This is where the ACL is torn so I’m able to reconstruct that. This is the end of the ACL, and the outside ligament of the outside had a small tear which was able to repair as well, and you see that there and then I’ll show you the picture of the ACL. This all went very well, but it was appropriate just to get this done at a timely manner. This little screw, we hold the ACL, this our lovely ACL in position here and the knee can get fully straight. This is an example of a more severe injury, and this is what we see on X-ray afterwards. So, the ACL is held in place with two screws. I repaired the medial ligament as well at the time.

So then we’re going to talk about people who present with more kind of chronic injuries. This is a guy came to me in what he called his bandy legs, so, he two what we call various knees, so he’s bow-legged. He’s a 62-year-old male, fanatical skier, skis couple of times every year, had a mechanism injury where he was twisting his knee getting out of the ski boot. So, not a classic kind of dynamic injury, more of a kind of a slower kind of injury with just a twist. He was able to ski and he said it settled after a few winds but did have a bit of swelling afterwards.

So, we see in the knee here, this is the X-ray, which the right leg shows there’s nice space between the two joints here, but on the left knee, there’s very little space and that indicates that this person has arthritis and the injury was just an exacerbation of their arthritis. So effectively what we need to do with this person is do what we call a partial knee replacement. So, the partial knee allows us to replace the arthritis on just one side of the joint which allows that person to get back to good activity very quickly afterwards and it restores the normal biomechanics of the knee without having to remove any of the ligaments which is excellent. So, this person was back skiing the following season h and it did very well.

The next thing I just want to talk about is joint replacement in the setting of skiing. Oftentimes people feel that their skiing days are over if they require a joint replacement and that’s not the case. In fact, one of the American athletes in her 40’s just won the World Cup Slalom Downhill skiing with the partial knee replacement. So, it’s certainly possible.

In terms of this person, a 65 year-old male, recreational skier, he refers as the best family holiday, the time when his teenage children will actually go on holiday with them because he’s footing the bill. In terms of what he was presenting with was progressive pain in his hips, struggled rotating his hip to get his boots on, pain at night, he felt he was waddling particularly difficult going up and down hills and wearing ski boots was uncomfortable and unstable for him. So, this is an example of his x-rays. So, these are both hips. So, you can see on the right side it’s a ball and socket joint with very little clearance between the ball and the socket. The left is a little bit better but still features of arthritis with extra bone here at the femoral head and femoral neck. So, this person had severe arthritis at both hips. He said he didn’t want the downtime of having one hip sequentially after the other. So, we did both hips, and he was very active very quickly back driving after three to four weeks and he was back playing golf after six weeks and was back skiing the following season. So, there’s no restriction in my mind for someone who wants to go back after knee or hip replacement. You must be a little bit cautious in terms of your level of skiing, you don’t want to go down something if you haven’t done it before. So just ski within your level.

Okay, so that’s it. That just gives you a bit of insight into what I deal with ski related injuries. But skiing is a great activity, it’s great for one’s mental health, it’s great fun and I was just teasing people that the muscles that will hurt the most are your stomach muscles from laughing so much. If you do get injured just be cautious, get home as quickly as you can, make a diagnosis, and we’re very happy to deal with you and get you back on the slopes hopefully. All right, thank you very much.

I think the fastest way to diagnose is to take a history, as I mentioned it’s a really you get a very good indication of what someone has done based on just taking the time to speak to them. Most people tend to rely on radiology a lot, but it has limitations and it doesn’t allow us to assess laxity or what we can determine with our hands, but MRIs have really revolutionised how we do diagnose knee injuries. So, it is certainly part of the package. In terms of urgency requests that I know the GP liaison service within Sports Surgery Clinic is very helpful that patients can ring and to see if it’s appropriate that some of the injuries go to our clinics. Obviously, we don’t deal with you know urgent fractures or trauma, but we deal with most other specialties including foot and ankle, shoulder and obviously knee and hip. So, the GP liaison service will put the individual in touch with the right teams and will get them seen very quickly to just take the stress out of the situation. Our practice that we have a lot of clinical specialists are around all the time. So, the person may not get to speak to me directly, but our PAs will put them in touch with a clinical specialist, and we can also organise scans very quickly through the hospital so that we know we’re getting high quality.

Yes. So, this particularly for the likes of ACL which I’ll take an example. So, it all depends on the severity of the injury. Some situations like I mentioned in my talk need to be done urgently because someone’s knee is so unstable or very lax. But the likes of ACL surgery, we are much rather a leg that’s happy and that’s able to move, that’s important for a good outcome after surgery. So, there’s no huge advantage to doing surgery early doors and sometimes there’s a disadvantage that you get more stiffness. So really, we make a determination on that based on how the knee appears to us when we assess it.