I will be presenting this evening on menopause HRT and other treatment options. So a quick overview of what I will be discussing this evening, we will go through some definitions, we will go through the symptoms of menopause and perimenopause and ill be looking at HRT and HRT alternatives.

Just to start with some definitions so we are all on the same page, I thought I would start with hormone because it’s a word that gets thrown a lot, women tend to feel like we are ruled by our hormones and its important to know what it is.

A hormone is essentially a chemical messenger that’s released from one part of the body and sends a message to another part of the body and an effect is created, for example FSH which is follicle stimulating hormone is released by the brain and sends a signal to the ovary to release an egg and ovulation happens. Now perimenopause/menopause/post menopause are words we hear a lot and especially at the moment we are hearing a lot of, its helpful to know exactly what all these different terms mean, so I will start with menopause. Menopause is essentially the end of a women’s reproductive life cycle, when she stops her periods, she stops ovulating and because she is no longer ovulating, her oestrogen levels drop quite significantly and its really the drop in oestrogen which causes symptoms of menopause.

For most women menopause happens at around 51 and the average duration of symptoms depending on various factors is around 7 years. Now perimenopause is the leadup to menopause, women tend to still be having periods at this time but they start to become erratic. We see a lot of hormonal fluctuations and the changes in these hormones account for symptoms. For most women perimenopause starts at around 45.

Then post menopause is the period of time where you have then gone through your perimenopause, you have gone through your menopause and you go through a phase where you are no longer symptomatic, so you are still not having periods, you are still not having oestrogen but you are no longer symptomatic because of the low oestrogen.

Then HRT or MHT the terms are used interchangeably, so HRT is hormone replacement therapy, MHT is menopause hormone therapy and really the mainstay of hormone replacement therapy is oestrogen as I said earlier it is the loss of oestrogen in menopause which causes symptoms. So by replacing the oestrogen that helps to improve the symptoms and then depending on whether or not a woman’s has a uterus a progestogen is added alongside that.

What are some of the symptoms of perimenopause and menopause, I think many of us know or associate menopause with hot flushes and night sweats, and while those are definitely the kind of classic symptoms there are over 40 different symptoms of perimenopause and menopause.

I tend to break them up into physical, mental/emotional and genitourinary symptoms I just helps to make it a bit easier to go through everything. Physical symptoms as I mentioned earlier those include your hot flushes and night sweats then around the perimenopause we see irregular period so your cycle could become shorter or longer.

Its often a time when a women experience heavier periods as well it has to do with the fact that if you are not having a cycle where you have ovulated it means that the lining of the uterus builds up over one or more cycles and so we start to see these really heavy periods and that can be very bothersome for women.

Around this time we start to see a change in sleep as well, sleep can be disturbed by night sweats or in women who are not having night sweats they could still have poor sleep. The kind of typical pattern that patients would describe to me is that they are exhausted, they get into bed and fall asleep straight away but come 2 or 3 in the morning they are wide awake, mind is racing, tossing and turning, cant go back to sleep until half an hour before the alarm goes off and they wake up feeling exhausted, so again fatigue a really common symptom, it could be due to lack of sleep, it could simply be due to the changes or loss of oestrogen as well.

Joint aches and stiffness is a really common symptom as well and various muscular skeletal complaints, dry eyes and changes in hair skin and nails we have lots of oestrogen receptors all over the body including in places where we produce fluids, our mucosa of our eyes, our mouth, vagina, bladder so we often see things like dry eyes and dry mouth around this time, along with as I said dry skin, hair and nails. Bloating and wait gain really common as well, the weight gain is very multifactorial, it could be due to the fact that you are tired and not sleeping as you well, you are achy, your sore and not exercising as much you might be reaching for different kind of comforting foods but there are hormonal aspects as well which would make women more prone to gaining weight and kind of changing body shape at this time, we see women tend to gain weight around the middle and lose the waist, that’s quite typical of changes in oestrogen.

Breast tenderness is more of a perimenopausal symptom and that’s to do with the fluctuating hormones. Now not to be overlooked by the mental and emotional symptoms these can be quite significant for a lot of women, women who have pre-existing history of anxiety or depression are prone to this getting worse around perimenopause and menopause but we also know that women can experience new onset changes around this time as well and that can range from feeling anything from low/flat or depressed to having mood swings especially before period, a lot of irritability, rage, anxiety, feeling overwhelmed, loss of confidence and brain fog this is a really common symptom and one which is very concerning for a lot of women.

As the brain has so many oestrogen receptors when we are having all these fluctuating hormone levels or the oestrogen drops off the brain needs to work a bit harder and one of the things we typically see around this time around the kind of brain fog is issues with verbal memories, so women will struggle to remember the names of people even though they know exactly what it is they can’t get the word out or they might forget what people have told them and as I said this can be very concerning a lot of women will come to me and say could I have early Alzheimer’s or dementia and brain fog is not a precursor for that it is concerning and like I said not a risk factor for Alzheimer’s or dementia.

Then lastly the genitourinary symptoms as I mentioned earlier because we have so many oestrogen receptors along mucosa including the vagina, vaginal dryness is a very common symptom and this can lead to pain during intercourse as well we see a lot of bladder issues so urgency, frequency, incontinence and leaking and recurrent UTI’s as well and low libido.

The genitourinary symptoms are often symptoms women don’t want to talk about but it is important as they can be very bothersome and uncomfortable and so you know if you are having those issues they need to be addressed alongside the physical and emotional issues.

This lead onto if you are having symptoms how do we treat them and this is where HRT starts to come in and we start to have a conversation about it, as I mentioned earlier is the end of a women’s reproductive life cycle, it’s a very natural phase of a women’s life, its not a disease to be treated but because these symptoms for many women are really distressing and significantly impact all areas of her life she is looking for some sort of treatment and we know that HRT is the most effective way to treat these symptoms.

HRT has come quite a long way, it has been very good, very bad, and now somewhere in between, looking at the heyday of HRT, HRT was actually first released to market in the 1940s and that was Premarin which is the conjugated equine oestrogen, it was oestrogen which came from pregnant maze urine, that’s where the name Premarin comes from.

It was really in the 1960s where it really picked up steam, there was a book published by a man and supported by big pharma and there was a lot of messages around the benefits of HRT in keeping women kind of young, sexy and healthy it make women more pleasant and husbands were very grateful for this and there was very much the narrative that menopause was a hormone deficiency disease and should be treated with HRT and so between the 1960s and 2000s there was a massive uptake in prescriptions of HRT many women were on it and it was only around the early 2000s when a study which had been going on for a few years, the results of which were published called The Women’s Health Initiative.

The results of that study were quite alarming in that they noticed a significant increase in breast cancer, clot, heart disease, stroke things like that. There are a lot of issues with that study we know now that the patient population that the study was done on was probably not reflective of women who are actually in menopause, the type of menopause they used, and the doses were quite different, and the way that the data was interpreted and released to the public were incorrect, so there was a lot of issues with that study but with that messaging we started saying don’t take HRT, a lot of doctors stopped prescribing it, a lot of women stopped taking it and so having seen this big rise of the use of HRT in 1960s up until the early 2000s we then saw a big drop off.

If women were prescribed that they were told you can only take it for a short time, you have to stop it at 60, there was a lot of fear around HRT. Now going into 2020 and above there is a lot more conversation around menopause and HRT a lot more women are understanding if they have symptoms they should be offered something to treat those symptoms.

We have you know more data and information about HRT and know that it’s a lot safer than it was published in the early 2000s, we have different types of HRT and we have different doses, a lot more patient prescribing guidelines, so we feel very comfortable prescribing HRT now but myths still exist, women still worry that you can only take HRT if you have severe symptoms, if you have a family history of breast cancer you cant take it, HRT might cause dementia might prevent dementia, there is still a lot of conversation and a lot of uncertainties for women around HRT, and I think the role of your healthcare provider should be to reassure you around HRT and to prescribe it if you are having symptoms so that you can feel better.

As I mentioned earlier we have a lot more safety data, more treatment options, better guidelines, better access to information, I think this is really important, women now feel a lot more empowered to you know go to their doctor armed with information and symptoms and discuss HRT and menopause and so we have more patient advocacy and autonomy as well.

If you google what is HRT? It can be a bit of a mind field because there are all different types and subcategories of HRT. As I mentioned earlier HRT is hormone replacement therapy, giving you exogenous hormones, so external hormones to replace internal hormones and treat symptoms. HRT can be broken down into various different categories as I have outlined here, so the first category which ill go through is synthetic versus bioidentical.

So bioidentical is a term you might have heard of, its kind of a big term in HRT at the moment a bioidentical hormone essentially means a hormone which looks almost identical to our own natural hormones and in theory its then better tolerated from a scientific perspective and possibly lower risk.

A synthetic hormone is one which is made in a laboratory it has a similar structure but not an identical structure. Synthetic doesn’t mean bad you know the oral contraceptive many of them are synthetic hormones and women have relied on oral contraceptive for many years and its you know been a great medication for a lot of women, but we do see with synthetic versus bioidenticals, bioidenticals are often better tolerated but it certainly doesn’t mean they are better, it very much depends on the woman and what her aims of treatment are. In terms of bioidentical there is a bit of a overlap in that there are also something called compounded bioidentical HRT so this means HRT which is made in private pharmaceutical kind of laboratories the doses are made up according to the patients blood results, it is not something which is endorsed by the menopause society’s they would very much recommend going with pharmaceutical grade bioidentical hormones rather than the compounded hormones.

Now oral versus transdermal, again something that has come to market fairly recently are these transdermal hormones, that means hormones oestrogen specifically which it gets absorbed through the skin as opposed to oral which is taken by the mouth. The big difference between that is oral oestrogen is metabolized through the liver whereas transdermal is not and when oestrogen is metabolized through the liver it kicks off some clotting factors in the liver as well and that can potentially increase the risk of a clot, again it doesn’t mean that oral HRT is bad, it doesn’t mean if you take it you will get a clot, it just means for patients who are at a higher risk of a clot for example if they were a smoker or if they had a family history of clots we might choose transdermal as a safer alternative.

Then oestrogen versus oestrogen plus progesterone or progestogen this depends on whether or not a woman has a uterus, so oestrogen is the hormone we need to use to treat the symptoms but oestrogen given by itself cause the lining of the uterus to grow and if this happens continuously of a period of time it increases the risk of endometrial cancer.

If we combine oestrogen plus progesterone in a woman with a uterus stops that from happening. Then lastly systemic vs local HRT, so systemic HRT is HRT given through the skin or orally, it has an effect over the whole body, local oestrogen is given for vaginal and bladder symptoms only so that would be a cream which is inserted vaginally, its very effective at treating the genitor urinary symptoms nut it will have no impact on the other physical or emotional symptoms. Local oestrogen is extremely low dose, its extremely safe and almost all women who are in menopause and have gentry urinary symptoms can take it.

Its all well and good knowing what HRT is but also important to know who could take it. HRT is indicated for the treatment of symptomatic women in perimenopause and menopause, so if you are having symptoms that are bothering you, a lot of people say to me well how many symptoms should I be having? How bad should the symptoms be? Really it depends on you, every woman is different, every woman will experience menopause differently, you might have one or two issues and that’s a big issue for you, you might have ten and they are not a big issue for you, but if you are having symptoms which are impacting you in any way those symptoms could be treated with HRT.

We also know HRT should be prescribed for women who go into early menopause or who have premature ovarian insufficiency, early menopause is defined as going into menopause before the age of 45 and premature ovarian insufficiency is before the age of 40. These patients are at a higher risk of developing osteoporosis and cardiovascular disease as of a result of the oestrogen deficiency and so in these women we offer HRT to replace the hormones they would have naturally had up until the age of natural menopause which is around 51. Surgical menopause is when a woman’s ovaries are removed this might be part of a hysterectomy or it might be done as a separate procedure for things like in women who are a high risk of getting ovarian cancer.

Again, if this happens in women who are below the age of menopause we want to replace the oestrogen that those ovaries would have been producing to prevent the risk of osteoporosis and then it actually can be considered as treatment for osteoporosis in symptomatic women, so women symptomatic of menopause under the age of 60.

The big kind of NO’s for HRT, so who cant get HRT, this is women who have had a personal history of breast cancer and some types of ovarian cancer, look this is a bit nuanced, we do have patients who have had breast cancer before and that you know, and they are having a lot of symptoms they come and see us and we have a discussion around it but its very much weighing up risks versus benefit and you know when we are looking at this category, the yes category we know that the benefits significantly outweigh the risks so we know that it is very safe for women to take. In this category the benefits are likely outweighed by significant risk for a woman with history of breast cancer there is a much higher risk of recurrence of breast cancer if she goes on HRT.

The maybe category is where we need to decide what is the benefit, what is the risk and does that benefit outweigh the risk and can we use HRT. So, these categories include women who are over 60 or more than 10 years after there last menstrual period, if they have had a previous clot if they have had a previous stroke or heart attack and if there is a significant family history of breast cancer again its not to say these women can’t get HRT, its very much a decision to be made between the patient and her doctor and looking at all the various factors.

The main benefits of HRT is symptom relief, that’s the primary reason to use it and it’s the best thing you will do to improve you symptoms, and the symptoms are really what we went through earlier so in terms of your mood symptoms, vasomotor symptoms, the genitourinary symptoms, those will improve with HRT, musculosketal and sexual functions, we know we have good evidence, if you take HRT and you are in menopause those symptoms will be improved.

As I mentioned earlier it should also be considered first line for prevention and treatment of osteoporosis that would be in our kind of younger patients who go into early menopause or have been diagnosed with osteoporosis. They talk about a critical window for HRT and this is really about when should we be using HRT to ensure that there’s benefit from a kind of cardiovascular perspective because we do have good evidence HRT reduces the risk of cardiovascular disease but it must be started within that critical window which seems to be within 10 years of the last menstrual period or before the age of 60.

On my slide earlier about the kind of changes in HRT and the views to it, there was something about dementia, there appears to be a reduction in dementia risk when we use HRT but we need more evidence and it is certainly no reason to be prescribing HRT we shouldn’t be using it you know giving it to asymptomatic women to reduce the risk of dementia because we don’t have good enough evidence to say that and then as I mentioned earlier benefits for early menopause and premature ovarian sufficiency.

Now what are the potential side effects and risks? Its these risks which have been overstated over the years and that’s what many women are afraid of. The side effects are you know the most common ones would be breast tenderness, irregular bleeding, some fluid retention, certainly not weight gain but fluid retention, headaches and GIT symptoms, these are often temporary and can often be alleviated by changing the type of HRT that we use.

Now the big kind of risks around HRT be the increased risk of breast cancer and then potentially endometrial cancer, clot and stroke, the endometrial risks comes into play if we are not using progesterone alongside oestrogen or enough progesterone alongside oestrogen but if you are on a regimen and if you have a uterus and you are on oestrogen plus progesterone that risk is very insignificant and the clot and stroke risk again depends on the type of HRT that we use, if we are using transdermal its very low.

The breast cancer risk overall is very low as well this is a graphic from the British menopause society and it shows that 23 per 1000 cases of breast cancer diagnosed in the UK an additional 4 cases occurred in women who were on HRT, so yes there is a risk but its significant and certainly not as dramatic as what was stated in the past. However, for some women this risk might be unacceptable and she may decide so doesn’t want to take HRT.

In that case for women either can’t take HRT, that are in that no category of the slide I showed earlier or they don’t want to take HRT, they might still have symptoms though that they want to treat and that are bothersome and that’s when we need to look at non-hormonal therapy.

Sometimes I say this to patients and they so oh but you know I don’t want to go on supplements, I want medication, and I want to make it clear that there are medical treatments available that are not hormonal but can still very effectively treat your symptoms. So, the first class of medication would be anti-depressant medications these are your SSRI/SNRI we are certainly not using these medications for women who are depressed in their menopause we are using it because it treats the symptoms of menopause like hot flushes and night sweats. Its very effective at treating symptoms, it can obviously help with positive mood benefit, it may help with sleep and we typically use much lower doses in menopause or menopausal symptoms compared to the doses which are used in clinical depression. Clonidine and oxybutynin are medications which help with hot flushes and night sweats, they don’t have any other benefits and they tend to have side effects that are quite unpleasant including dry mouth and headaches so a lot of patients will stop taking them as they find it quite difficult medication to take.

Gabapentin is an interesting medication, its an anti-epileptic its also used for chronic pain, it can also be used as a mood stabilizer and again has good benefit for alleviating hot flushes and night sweats, it can have a sedative effect so good for sleep and may help with mood as well. Then veoza is a brand new medication which has just been released, it’s a really exciting development because it is the first medication which has been designed specifically to treat hot flushes and night sweats, so these other medications have other indications and they also have the benefit of treating hot flushes and night sweats, whereas veoza is designed to work in the brain to stop hot flushes and night sweats from originating and it’s a great option for women who are not able to take HRT.

Under medical therapies I have put psychotherapy and CBT as well, CBT is cognitive behavioural therapy we have really good evidence for this in terms of helping with hot flushes and night sweats and help with mood and sleep as well. CBT is a specific form of psychotherapy, kind of helping with reframing thoughts about events and a lot of women find it very useful either by itself or in addition to these other medications.

Looking at the non-medical alternatives these are things that probably all women should be doing anyway to support their health during this time but for women who didn’t want to take HRT or they felt that their symptoms were mild and they wanted to manage it from a lifestyle perspective these are things that we should be looking at.

I must say a lot of women struggle to implement these changes when they are not feeling great, sleep hygiene is very important but when your sleep is being constantly disrupted because of night sweats its quite difficult to make those changes but sleep hygiene is really around things that we all know should be doing, don’t be on your phone late at night, going to be at the same time, don’t drink coffee too late in the day, just optimizing things to make sure you have a better sleep quality.

Weight management and diet, it is important to maintain a healthy BMI, during this time a women’s risk of cardiovascular disease increases when she goes into menopause and so we want to try and reduce that by managing lifestyle factors. The best kind of diet is probably a Mediterranean type diet that’s a lot of brightly coloured fruits and vegetables, lean protein, healthy wholegrain carbohydrates, good fats and a reduction in really processed and refined carbohydrates and sugars.

Then stress management is something much easier said than done, they talk about doing things like yoga, meditation, breathing exercises, all things to help reduce stress in the moment, like I said easier said than done. Supplements are a big one if you are going into any health food store and you ask for something to help with menopause there are almost hundreds of options available, a lot of them at best wont work or at worst could have some harmful side effects, so I would be cautious of the wide range of supplements that are available. I always recommend my patients to take vitamin D especially during the winter, we just don’t get enough sunshine unfortunately and omega 3’s are quite helpful as well if you are not getting kind of two portions of fatty fish a week, otherwise you don’t need to be buying hundreds of expensive supplements. Acupuncture, a lot of women will anecdotally report that it helps their symptoms, it is unlikely to do harm, so you know if this is something that makes you feel better there is no issue with using it although the actual data in terms of efficacy is quite sparse.

Cold exposure, this is you know when I moved to Ireland, I’m from South Africa, I was quite amazed at how many people were swimming in the freezing cold see and I have noticed a lot of women as well, interesting they have recently released a study in the UK which showed that women who regularly sea swam had a reduction in menopausal symptoms or perceived reduction so there is definitely something to it, I think it’s a big social thing as well which is really important as well from a lifestyle perspective but again as long as you are dressing warmly afterwards, you have got your tea and your dry robe its probably unlikely to do harm and could be a nice thing to add.

In summary menopause is not a disease it is a natural phase of life but if this phase is accompanied by bothersome symptoms they should be treated. HRT is the most effective treatment and while HRT has been thought of as very good and then very bad it is kind of somewhere in the middle now and we know that it’s a safe effective option to be used although it’s certainly shouldn’t be used solely for the prevention of disease. There are good alternatives for women who can’t or choose not to take HRT.

Cholesterol levels can definitely increase postmenopausal but statins are still the preferred way to treat them, HRT is not indicated to treat high cholesterol.

In theory you can be on HRT for the rest of your life, previously there was this cut off you could be on it for five years or up to the age of 60, and that’s changed, women can be on it for as long as they are getting benefit from the HRT and there are no side effects or major health issues that arise. If you come off HRT your not going to go into menopause again, really the principle of HRT is to treat the symptoms during menopause but once you go into post menopause and those symptoms significantly reduce at that point we could take you off HRT and those symptoms shouldn’t come back because you are now in post menopause.

Patient dependant really around symptoms, so if you are getting symptoms in your mid 40s and they are bothersome consider it, if you are only starting to get symptoms in your early 50s consider it, but its really around rather than age go by symptoms and how bothersome they are.

Your fertility declines as you through perimenopause because your egg numbers reduce, ovulation becomes sporadic, pregnancy is not impossible in perimenopause, its about a 1% chance of falling pregnant and then menopause can’t fall pregnant for they say that you should consider using contraception up until one year post your last period. So, contraception is still advised and the best options would be condoms, the progesterone only pill which can be used up until the age 55, the marina coil or vasectomy if your partner is open to that.

So that’s really important as I mentioned with in the symptoms there are a lot of genitor urinary symptoms that occur during perimenopause and menopause, and a lot of changes in the vagina, the vulva, the bladder, the pelvic floor and women might start to experience bladder issues but also bowl issues as well including things like faecal incontinence so any bladder issues that are bothersome around that time a pelvic floor therapist can be incredibly helpful and help you to know which muscles to engage and which muscles to relax and how to manage those symptoms, rather than just relying on medication.

When talking about Menopause we can talk about Perimenopause which is ages 45-55. We can find post-menopausal which is the time after menopause so really fitness and exercise in menopause we are talking about a large part of a woman’s life. If the average age of a woman is 84 then menopause will be about 1/3 of your life. If we are talking about perimenopausal age 45 that would be considered as mid-life and this is an opportunity at this stage in our life when you look at the choices you make in terms of activity and how that will help your ability to do things and move on into the future.

First of all, defining what is exercise and what is activity? They can be easily interchanged but physical activity is any activity you do in daily life and that could be gardening, housework, or playing with children, whereas exercise is a planned physical activity that keeps you fit or makes you fitter.

Exercise has always been a part of life right through to older ages. The Grandparent Hypothesis looks into how societies that flourish rely on the older members of society to be active and healthy and have the ability to help out in physical activity in order to keep the community going. We are genetically programmed to be able to keep fit and strong right into later life.

Exercise has been strongly proven through epidemiological studies to reduce the risk of getting seven of the most common cancers including breast, colon and endometrial cancer and this is in the realm of about a 20% reduction when comparing people who are physically active to people who aren’t.

There is a pretty big change in terms of a womens cardiovascular risk and that’s the risk of heart disease and that’s comparing before menopause and after. Oestrogen has quite a protective effect on the heart and so in the absence of oestrogen then for a number of reasons the risk of getting cardiovascular disease goes up by a factor of 2.6 between pre-menopause and post-menopause. On the left are the main contributors to this such as worsening insulin resistance, higher blood pressure, higher cholesterol, reduced sleep quality, and mood changes can also have an effect.

Exercise can improve every single one of the risk factors. Exercise can also help improve your mental health with strong evidence from studies that follow women through menopause such as the Swan study in the United States, following a group of women for 20 years through menopause with clear evidence showing women who were physically active reporting better mental health and better quality of life, while reducing symptoms of depression anxiety and stress.

Something quite topical at the moment is whether exercise can improve symptoms of the perimenopause transition? The classic symptom being hot flushes but there are many other symptoms associated with perimenopause which is a period that can negatively impact a woman’s health and well-being.

There have been studies done on how exercise can potentially help some of these symptoms. One of the interesting studies looks into the relationship between musculoskeletal pain and menopause. Musculoskeletal pain has been proven to be one of the most common menopausal symptoms causing pains and aches in muscles or joints causing about 1.6 times the amount of aches and pains to premenopausal which is a big increase. There has also been good evidence from these studies that people who are active and take regular exercise reported less headaches, less joint pain, and less heart palpitations. This evidence that symptoms such as difficulty sleeping, mood changes, low energy, heart palpitations, headaches or migraines, and joint/muscle aches can be positively affected by exercise. The jury is still out on whether exercise has a significant effect on hot flushes. There is a theory that as we know that exercise increases your parasympathetic tone is upregulated so this may help with hot flushes although we don’t have strong evidence for this.  There is good evidence from studies that keeping physically active will also help maintain a healthy body composition, maintain your muscle mass, and reduce the amount of central adiposity or visceral fat which is the weight you carry around your middle. This increases after menopause so maintaining good activity and exercise can help offset this and has health benefits as carrying weight around the middle has effects on cardiovascular health, and insulin resistance.

The main musculoskeletal effect that we see in menopause such as the decline of oestrogen. Oestrogen is not just a reproductive hormone it has effects on lots of body symptoms and has a really strong effect on our muscular system and on our bones, this can have a big knock-on effect on a woman’s health. Oestrogen helps to maintain muscle mass, it helps with muscle’s response to exercise and also helps with making new muscle fibres. There is an increased risk of sarcopenia in menopause but really that comes about when you combine inactivity with a lack of oestrogen. Osteoporosis then is when you get a decrease in bone density which causes an increased risk of fractures which later in life can have a devastating effect on a person’s independence. This drawing in the top right is what is meant by sarcopenia, where you have muscle in the dark red over the years if you have a lack of oestrogen and a lack of exercise have the combined effect and cause the muscle to get smaller and the fat mass to get bigger. In the absence of oestrogen and bone breakdown starts to exceed bone formation so our bones get thinner and a lack of mechanical stress can breakdown bone. This is why exercise is so important to maintain bone health.

When talking about sarcopenia and the loss of muscle it is something you definitely want to avoid and it is because muscles are so much more to our bodies than a piece that just moves us. Muscles can send messages to other parts of the body and it is an endocrine organ. Substances released from muscles are called myokines which can have effects on the brain, the gut, the kidney, the pancreas and bones. When you have muscle and maintain muscle it sends all these positive messages out to the body which decreases inflammation, decreases immunity and this is where the decrease 9in cancer risk comes from. It helps you metabolise your food better, makes you happier, makes your bones stronger so muscles really are such an important organ in your body rather than just being something that moves us

Is menopause a one-way ticket to sarcopenia and osteoporosis? The answer is no and the reason is that it is possible to maintain your muscle mass and function to keep your bones strong with the magic pill and that magic pill is exercise.

Exercise, a combination of aerobic and resistance exercise in other words getting out of breath and lifting heavy things will keep your muscle mass and muscle function. In terms of osteoporosis, menopause is not a one-way ticket to osteoporosis. If you are maintaining and currently doing impact activity or taking up impact activity now then that loading effect on the bone will maintain bone density and perhaps even improve it. The impact is basically jumping, landing and things like running and in fact it actually does not take a lot to get a good stimulus of the bone and 50 jumps a day would be enough to maintain your bone and that is something that all of us can do right up to the elderly ages with the right advice and modifying what sort of impact they do.

In terms of what exercise to do, there are plenty of science-backed recommendations on what’s the best mix to do. Interestingly, I came across this in the paper and in certain states in Germany it has been mandated that people who own dogs must walk them twice a day for at least half an hour so an hour exercise for dogs because if not then it would be considered as cruel.

There are bodies such as the World Health Organisation (WHO) who come up with recommendations that are all pretty similar and this is for adults in general not specifically women in peri-menopause or menopause because the same advice would be true for a man or any healthy adult and there is importance on the bone loading part of this for menopausal women. The advice is 3-5 days a week of moderate to vigorous aerobic exercise at 30-60 minutes each time. To make sure that some of those are bone-loading or impact-type work and then a really strong recommendation is to do two days a week of resistance training. It is also worth doing some flexibility and balance work.

So first of all you have some moderate aerobic exercise which is exercise which feels somewhat hard the best way to think about is as exercise where you can talk but you can’t sing a song so something like brisk walking where you are a little out of breath, swimming, jogging, cycling or also team sports or racket sports can all be considered moderate aerobic exercisers.

What is bone loading/ impact? Not all moderate aerobic exercises can be considered bone loading, walking doesn’t have enough impact to consider it bone loading neither does swimming or cycling. You need something in which you are jumping or hitting the ground a little harder for example tennis would be an excellent bone-loading activity It is multi-directional, your running forward and back all those things give novel stresses, so changing messages to the bones and that’s what really stimulates them to get strong. Dance is a really good form impact exercise, the picture on the left is Zumba which has been shown to be really good in terms of bone loading because of the jumping and sideways movements. Team sports are great, the picture there is Gaelic football but really any sport where you are changing directions, and the other benefit for this is that they can be really fun and social. As mentioned just simply jumping, jumping off a box hitting the ground that’s the impact. Needs to be a little thought around the safety of that for an older person or a person with osteoporosis but they can all be modified. Getting impact loading in two/three times a week so not just walking, cycling or swimming.

Strength or resistance training is basically where your making your muscles work hard and get tired, so again there is lots of different ways to do this, certainly gyms, gym classes, anything with lifting weights is good. Things like Pilates are also a form of resistance exercise, your body weight Is a from of resistance. Things that work your big muscle groups like your glutes and your quads like squats or lunges are really excellent.  Lots of different ways to achieve two days of strength work, it could be through something like a class or going to the gym or it could be in your own living room with some weights and there is some pretty good YouTube workouts if you are looking for inspiration. Obviously going to see a professional to develop a program for you would be optimal, some good online things and some good apps as well. Big benefits by doing resistance training twice a week in terms of strength function and maintaining that muscle mass, which is so important for your overall health.

The best exercise is one which you enjoy and you keep doing so if you can find something you can enjoy that’s always going to be the best.

Menopause and Tendons are really quite complex, we are kind of a bit unsure on how the decline in oestrogen effects tendons, well we know it reduces collagen formation, increases the stiffness but again if you keep your tendons strong through exercise that’s the best way of keeping them strong and avoiding injury.

Quick word on MHT (menopausal and hormonal therapy. In terms of taking HRT or MHT that’s going to replace the oestrogen that you would otherwise be losing through menopause. It’s been shown pretty clearly to help maintain muscle mass and function and it also has a positive effect on bone. This coupled with exercise is going to give the best results in terms of maintaining muscle and bone mass.

If there are any elite athletes or anyone who competes as opposed to just keeping fit, there are a few studies which show that the MHT or HRT can help with performance more so the adaptation to training, it’s not like it makes you run faster on the day you take it, its more in terms of being able to maintain muscle mass. There is also a bit of evidence around recovery from exercise sessions so probably something worth thinking about for elite athletes but that’s not necessarily promoting it to so people can keep winning races but there is some science there.

In terms of training and the effect on muscles and bones it’s pretty clear that it is a positive influence, it’s a little less clear in terms of oestrogen supplementation or oestrogen replacement on tendons. So the best advice that through good strength training that you maintain your tendons in good condition.

The final thing is some conditions which commonly occur in postmenopausal and perimenopausal women, the first being Knee osteoarthritis which is really common in the general population but it is twice as common for women as it Is for men. The advice for managing Knee Osteoarthritis is really clear from all the major medical bodies that deal with it, both the medical rheumatological surgical and this little graph here is good from the Osteoarthritis research Society International and that’s that everybody who has Knee arthritis should receive education about activity, exercise and weight management, because this is what makes the biggest impact on the osteoarthritis so maintaining a healthy weight as best a possible, keeping good strength in the muscles around the knee and keeping the knee moving. Exercise is good for Knee Osteoarthritis, in the old days people might have thought that rest was the answer but that’s been shown to actually make things deteriorate because of some of the metabolic effects, the negative metabolic effects that being inactive have, so again exercise therapy is really the mainstay of managing osteoarthritis. Some people may benefit from medications or injections and very few need surgery but in our clinic we manage the vast majority of people with exercise and it works well.

Another common and really annoying and painful issue is a pain at the side of the hip, it’s mainly the gluteus Medius and Minimus tendons which come down the side of the hip and attach onto the Bony part of the outside of the hip called the greater trochanter, that’s the bit that kind of sticks out when you lie down and so it can often be quite uncomfortable to lie on, it can be really debilitating, stopping people from running or walking even so that’s something we would see a good bit of, again the management of that there has been some really good interest into it, and specific exercise and strength along with some simple advice on some postures to avoid can be quite effective for this. That doesn’t mean it’s a quick fix it takes a while but it’s been shown that exercise and education beats injections for improving gluteal tendinopathy. Sometimes we would use injections or shock wave therapy but good strength work is the way to both prevent and treat Gluteal Tendinopathy.

A few of my patients have mentioned to me whether HRT might help their Gluteal Tendinopathy and there has only been one study on it so not a lot of evidence, but that did show a combination menopausal hormonal therapy in the form of oestrogen combined with an exercise program was better than an exercise program alone. Only one study but potentially promising.

Finally, exercise can bring its own problems in terms of picking up injuries so simple advice to try and minimise that risk. So Festina Lente is latin for make haste slowly, that’s the single best piece of advice, whatever your doing, if your starting from a low base just build up slowly, if you’re already doing a lot don’t add a lot suddenly just build up slowly and let your body adapt to it. Before you do impact work like running make sure that your muscles are strong, and make sure that you get good recovery. It takes a little longer to recover once you go past the age of 40 that goes for men and women, so a day off in between hard sessions, make sure you eat well, and get some expert advice if you are embarking on a training program.

Bursitis doesn’t burn itself out in the same way that frozen shoulder does over a long time maybe 2 years. Eventually, frozen shoulder burns out but bursitis doesn’t particularly do that in the same way so something has to change to relieve that bursitis whether that is better movement patterns in the shoulder or treating the inflammation that goes with the bursitis. The other thing to say is that with night time pain that is often an inflammatory issue and the other thing to think about there is that although it may be bursitis on the MRI it is not necessarily the bursitis causing the pain it could be something else. Although there may be fluid in the bursa on the MRI that still may not be the thing causing the pain. The rotator cuff tendons may be causing the pain or the Acromioclavicular joint (AC). You may even have pain coming from the neck and I know you said the person in question has had a steroid injection if that has not worked then maybe they should look into getting it checked again to see if it would be re-diagnosed as it may be something else. Sometimes, if it does look like bursitis a second injection would help even if it is under ultrasound as it can target a small area.

If it is gluteal tendinopathy which is pain on the outside of the hip then there is a high likelihood that it is gluteal tendinopathy. The tendons are the bit that is sore but the muscles that are attached to the tendons are on the side of the hip and they can feel it and be really tight and sore and this can work it’s way up to the buttock area and it feels as though you should stretch it but it actually does not help it. It might be detrimental by pulling the tendon across the outside of the hip. Gluteal tendinopathy is something where stretching should be avoided.

I am a shoulder surgeon and certainly not an expert on menopause but there is a shoulder condition that we tend to see more commonly in women and often around the time of the menopause and that’s Frozen Shoulder. The other name for it being Adhesive Capsulitis. So, in terms of shoulder pain around the time of the menopause there is good evidence to show that the most common diagnosis both premenopausal and perimenopausal by far is adhesive capsulitis or frozen shoulder. So almost a third in both cases whether its before the menopause or around the time during the menopause, the diagnosis behind shoulder pain is frozen shoulder.

The second most common diagnosis is shoulder synovitis which often goes hand in hand with frozen shoulders inflammation of the lining of the joint more common that was found in the actual perimenopausal group rather than the premenopausal, but the point is shoulder pain around menopause is far more commonly due to frozen shoulder than in the general population where there is a lifetime prevalence of frozen shoulder of 2-5% yet In the perimenopausal or premenopausal population you are looking at 35% and 32% of all shoulder pain is due to frozen shoulder.

So, what is Frozen Shoulder? Who tends to get it? What is not frozen shoulder? How do we go about figuring it out and diagnosing it? And then how do we treat frozen shoulder once we have arrived at that diagnosis? These are the things that I will go through this evening.

So, the terminology that is often used medically is Adhesive Capsulitis, the capsule of the shoulder joint is the lining around the ball and socket, so the shoulder joint is a ball and socket, the capsule is around the joint and the capsule gets inflamed and that’s the capsulitis. The adhesive part is I suppose reflective of the fact that it tends to be almost like adhesions where the capsule gets really tight and thick and scarred as that’s how its become to be known as adhesive capsulitis.

We don’t really know why this happens, there are some theories out there, but there is often no real cause for it. Its important when somebody has a painful and stiff shoulder that we don’t just call all of those things frozen shoulder, there are other things that can present like that and those need to be ruled out before we make a diagnosis of frozen shoulder.

One of the other things that can present with a painful/stiff shoulder is Arthritis of the shoulder joint, the very simple way to make that diagnosis is with a x-ray and you will see as on the x-ray here in the picture where instead of there being a nice ball and socket and some space between the ball and socket, that space on the x-ray is no longer really visible, the space reflects the cartilage being worn away and there is in that picture what you would call bone on bone arthritis. Whereas in frozen shoulder the capsule is inflamed and x-ray should look pretty normal.

There are other situations where it is difficult to move the shoulder for example, with sever weakness it can be difficult to raise the arm and that can happen with a massive tear of the rotator cuff and sometimes people will make the mistake of calling that frozen shoulder because it seems as though the patient can’t move the shoulder at all but in fact if you take the other hand and move the arm up or if I move the persons arm, there is movement there they just don’t have the strength and so we are just differentiating the passive from the active movement and frozen shoulder both will be very stiff whereas in a case of severe weakness the passive motion will often still be there.

Sometimes a shoulder is just simply too painful to move but again if we move it passively its possible to move through the pain, whereas with frozen shoulder its not actually possible to move beyond a certain limited range or what we call a capsular end field, physiotherapists will often refer to that and so basically with frozen shoulder the shoulder must be stiff actively and passively but have a normal x-ray.

People find it quite frustrating when we cant explain why they got a frozen shoulder, what caused it, did they do anything, usually no. There is no real consensus on what causes it, it is inflammation of the capsule, so usually its idiopathic for no good reason. It can happen after trauma so sometimes you will see somebody who falls or has some trauma to the shoulder doesn’t actually do any structural damage to the shoulder but the shoulder responds by getting really inflamed and that can result in a frozen shoulder.

One theory is that if there is a minor injury to the shoulder, then the first response is inflammation which is normal, the first stage of any healing is inflammation and if the shoulder somehow gets stuck in that inflammatory phase or overdo the inflammation that can result in frozen shoulder.

There are some theories about it maybe being autoimmune and then sometimes we see it if somebody has sort of had less movement of their arm for an unrelated reason, for example if they have been put in a sling for something else, so that’s often why we don’t put say hand and wrist injuries or elbow injuries into a sling very much because the shoulder ends up getting stiff. Sometimes we see it after something like a pacemaker insertion, so on the left side and maybe there is a bit of soreness there for a little while afterwards as the person doesn’t move their shoulder as much and they can develop a frozen shoulder or after breast surgery or IR radiation to that area, but there is no definitive cause known for frozen shoulder.

It was interesting during Covid we saw there was an increase the presentation of frozen shoulder to us at the clinic and we wondered were we imagining it or was there actually a pattern to it, so we analysed that time period to an equal time period before hand and we found that yes there were a lot more frozen shoulders, it had increased by more than a third.

In terms of presentations it wasn’t any different in terms of the severity or how responsive to treatment or what proportion needed surgery and other centres have found similar phenomenon as well, we don’t have an explanation but the theories were perhaps its related to a low grade pro-inflammatory state so either if people had subclinical or even clinical Covid  was that somehow related to frozen shoulder or perhaps stress, everybody was some mental distress at the time during the pandemic for various reasons and that is a pro-inflammatory state and whether that has translated into an increased risk of frozen shoulder is unclear. However, we were able to see that there was a spike of frozen shoulder during Covid for whatever reason.

There are classic associations with frozen shoulder, diabetic is probably the most well known one, Thyroid disorder is usually underactive but can be overactive thyroid as well and the one that we are discussing tonight around the time of the menopause, so those are all hormonal disorders, so there does seem to be some interplay between the endocrine or hormone system and frozen shoulder, its yet to be explained fully.  The associations are not causes, they are sort of seen as patterns. Typically frozen shoulder effects females in their 40s or 50s but we do see men with it and we do see people outside of those age groups.

The way we go about making a diagnosis, the history can give us a clue, so many people with frozen shoulder will have those typical associated factors that we have just mentioned not always. The classic pattern is that there has been this gradual onset of pain which is worsening over time and it can be very severe pain especially with any sudden movements which is a sign of capsular irritation or having to reach or overstretch beyond the range that’s available as the shoulder starts to get a bit stiff and irritable, a lot of people will find getting dressed or undressed or reaching out to get a ticket out of a machine in a car park can be really painful.

Usually the pain starts first and then the stiffness comes in a little bit later, the capsule is becoming thicker and tight as it becomes more inflamed and that’s making it physically impossible to move the shoulder and that’s why its limited both passively and actively. In fact if we were to put someone asleep who has frozen shoulder, we give them a general anaesthetic muscles are completely relaxed they are not feeling any pain and fully asleep the range of motion is still the same because its physical block that this thickened tight capsule is creating, physical block in movement.  Typically, frozen shoulder will get better on its own if nothing is done but the reason to think about doing something is that can take a long time.

It can take up to 2-3 years with some people and It tends to go through phases where its painful and intensely painful, then it becomes stiff and painful. The pain gradually fades away and your just left with stiffness and then eventually the range of motion comes back and the shoulder does tend to go back to normal, there is nothing wrong with the shoulder joint, the underlying joint itself, its this inflammatory process involving the joint capsule that does burn itself out eventually. As it is so miserable when people have it its not entirely reasonable to just wait two or three years to get better.

The other way we diagnose it is by doing clinical examination and unfortunately for whatever reason this part is often skipped and everyone with shoulder pain is just sent for an MRI and that’s where things can get confusing, what we are looking at in the clinical exam is the shoulder being irritable with range of motion and that obviously is non-specific a lot of other shoulder problems can show that as well. Often we find pain towards the end range of motion and then if its very early in frozen shoulder that might be the only thing that we find, if it is a little bit later then stiffness will have developed and the stiffness should be both the active and the passive range of motion.

All we usually need is an x-ray and many people will already come having a MRI but if we examine the shoulder and there is no weakness we can establish that the rotator cuff muscles and tendons are all working well and we have a stiff painful shoulder. We take an x-ray to make sure it is not arthritic and if the x-ray shows a normal joint then we know it’s the capsule and that’s our diagnosis. It’s a combination of history in a typical patient, the clinical exam and an x-ray being normal.

The thing about the MRI’s and we have I suppose learned this and gotten this message out there that not every back pain gets an MRI but for some reason in Ireland every shoulder pain seems to get an MRI and the reality is, that nobody of the age around the time of menopause in fact nobody over above 30 is going to have a normal shoulder MRI, there is age related changes that happen within the tendons, little bits of wear they are not necessarily significant but the radiologist has to describe everything they see, so when you get an MRI of your shoulder you will have a big long report and what we often see that things get inappropriately emphasized on that report and people get sent down the wrong road. The reality is often if you had a MRI on the asymptomatic shoulder it would generate a report very similar.

We don’t encourage getting MRI’s without a good clinical exam and often we don’t need it in cases of frozen shoulder where we have a good exam, we don’t need the MRI to make the diagnosis, it can be quiet uncomfortable to lie inside a scanner for 20-30 minutes if you have capsulitis of the shoulder, a lot of patients with frozen shoulder find that there pain is quite bad at night time and its quite uncomfortable when they lie down and the same thing inside a scanner.

The times when we will ask for an MRI is if we cant establish in the clinical exam whether the strength of the rotator cuff is normal because sometimes the shoulder is so sore when you have a frozen shoulder that it’s really hard to cooperate with the exam and do all the tests, sort of push and pull against the examiners hand because its just too painful, so a lot of times we will check an MRI for that reason, but the vast majority of people we can exam and understand what’s going on without necessarily having to put them through having a scan. Sometimes you can have a rotator cuffed hair that gets secondarily stiff and that’s kind of a secondary frozen shoulder which is a bit of a different scenario.

Then if you have a frozen shoulder what to do with it? How to treat it? The first thing is pain management, if you are still in that painful phase we need to decrease the pain to give back quality of life, to get back sleep, and to then allow you to start doing some gentle stretching of the shoulder. As it is an inflammatory problem we use anti-inflammatory as the first line, usually start with the non-steroidal anti-inflammatories’ simple things like ibuprofen or maybe some of the prescription non-steroidal anti-inflammatories. Its also reasonable to do a short course of oral steroids, yes that’s giving steroid to the whole system but in a very short burst for maybe a week to 10 days of a decreasing dose. Many times GP’s will be happy to give that and that can give a really intense burst of anti-inflammatory treatment which helps the frozen shoulder.

Other simple things like using heat to try and loosen it out, using ice to settle it down before you go to bed at night, those are kind of the basic pain management strategies. We also then suggest very gentle stretching, maximum five out of ten discomfort when stretching. Getting into a pool can be very helpful people often say well I like to swim in the sea, well its not quite the same, I think you need the warm temperature of the water to help you stretch. O

ften people with frozen shoulder have been sent to physiotherapy and they have found that it has aggravated it and they actually feel that physio made them feel worse and I think that is probably because the instinct on the part of the physiotherapist is to try and push and get the range of motion back and not let the shoulder get stiff but when there is a capsulitis that often just actually makes it worse and it tends to get more painful, more inflamed and then stiffer. So usually we have people just stretch by themselves and do some self-directed stretching rather than have anyone else go at the shoulder particularly when its in that irritated phase.

Sometimes if the shoulder is really sore you might want to give it a rest and put it in a sling but that’s probably the worst thing to do because it will just get more and more stiff with that, so no slings for frozen shoulder try to gently keep it moving. With the pain management sometimes we will add an injection of steroids so usually if somebody has come to me they have normally tried some of the simple things already and we will be thinking about injecting cortisone.

The diagnosis needs to obviously be made first, we need to make sure the injection is going to the right place that it needs to be and I wouldn’t advise having anymore than three steroid injections because if you keep having indefinite amounts of steroid it can have a negative effect on other structures in the shoulder such as the tendons. The vast majority of cases of frozen shoulder absolute vast majority will resolve with anti-inflammatory treatment, injections and gentle stretching most don’t end up needing further treatment.

We use just very simple stretches for frozen shoulder which anybody can find on our website, under services and then stiff shoulder stretches and you will see some videos on how to do the stretches for different directions of movement and with frozen shoulder again we do not advise pushing the stretches really hard as to not aggravate that inflamed capsule. Getting in the pool and do some very simple things can be helpful as well, just walking in the water and some stretches in addition to dry land stretches and that’s what we prescribe our patients.

In terms of cortisone injections, a lot of times people will come to us and may have had an injection already but found that it didn’t help a lot and I think a lot of the time that’s probably because it was in a different space of where the frozen shoulder is. The subacromial space is the space above the rotator cuff tendons underneath the point of the shoulder, its not actually in the main joint but a lot of time people who are not shoulder specialists will inject there because that’s kind of the easiest space to inject in the shoulder and it is where a lot of shoulder pain comes from.

So often if you go to a non-shoulder specialist and have an injection, the injection will be put into that space, that can be done from the side or from the back, so if somebody tells me they had an injection done from the side I know it was into the subacromial space. If it was done from the back it could be into the main joint or it could be into this subacromial space. With frozen shoulder the capsule and the main joint is actually what we call the glenohumeral space, the humorous being the arm bone and the glenoid being the socket, and that’s where the frozen shoulder is happening.

There is often some secondary inflammation in the subacromial space or what we call bronchitis, so you might find you get a bit of relief from a subacromial injection, but unless injection is into the main glenohumeral joint its not treating the capsulitis directly. A lot of times when people have come they have had an injection and that hasn’t helped, I still like to inject them myself so I know the location is exactly where it needs to be. It depends on the exam whether we inject both spaces or whether we only inject the glenohumeral space.

Then further treatments, a small minority of patients with frozen shoulder end up having surgery, usually that is if it is not resolving with those conservative measures, or if it dragging on a really long time, 6/7 months. The best candidates for surgery are the ones that are no longer so painful but may have gotten stuck in that stiff phase, it’s a small minority of people but they find they can’t really get any range of motion back. If we do any surgical intervention on a shoulder that’s still painful it can take a little bit longer to settle down afterwards compared to a shoulder that is no longer so painful but is stiff and problematic in terms of stiffness.

What we do is a keyhole surgery called an arthroscopic capsule release, so we have a thick inflamed tight capsule and we release it all the way around front and back, using a radio frequency wand as you can see in the picture. Its done under general anaesthesia but we also like to have the anises do a regional nerve block, so we put a long acting local anaesthetic around the nerves that come from the neck, the roots which cross over in the network called the brachial plexus and we block that brachial plexus with local anaesthetic, so that when the patient wakes up after the capsule release they don’t have any feeling from the shoulder and the muscles are also asleep, so the arm is basically floppy and that allows us to get stretching straight away because after surgery to release the capsule the thing we want to avoid is the capsule scaring back in and that’s what tissue will tend to do when you operate on it or when you cut it.

So unlike the non-operative treatment if we operate we are really aggressive with physiotherapy straight away. The nerve block will typically last 18-24 hours, so we keep the patient in the hospital, not because it’s a big surgery but because we want physiotherapy to start immediately and take advantage of that nerve block and actually get some stretching done passively while the arm is still asleep. The key and the challenging part is to maintain that stretching once the nerve block wears off the next day and that’s why we have people start their physiotherapy straight away after a capsular release.

This is what it looks like on the inside if we have a camera inside the shoulder and the humorous is on the picture that you see on the left, on the right-hand picture the humorous is on the right, so the camera is looking from the front and this is all the same shoulder. We have got in he back at the beginning, were releasing the front then we switch the camera to the front and release the back, but you can see just how thick that tissue is and how red and angry and inflamed it is.

This is one of the most painful conditions in the shoulder and people are often frustrated because they have been told there is often nothing much on their MRI or they have been told something completely inappropriate based on an MRI and nobody’s actually put the picture together of the typical history and the exam.

There are some other things you may hear about in terms of treating frozen shoulder, Hydrodilatation is something that is sometimes done. The idea is to dilate the joint capsule by injecting fluid, by injecting saline and then a steroid injection is done at the end. Its probably the steroid injection that actually helps as because the capsule is so thick as you just saw in those surgical pictures that to actually distend it or to actually stretch it you would need a really high volume of pressure under quite a bit of pressure. If that is done awake as it often is in a radiology department there is no way your going to be able to do that to somebody because it would be so painful, the volumes that tend to be put in are pretty small, so I think probably what’s helping there is the steroid that’s been put in.

The other thing you may here of is an old-fashioned technique called manipulation under anaesthesia and I would strongly advise against that, what that involves is simply putting someone under general anaesthetic and then manipulating the shoulder very forcefully to rip the capsule and there is a few reasons why this could be problematic. Its what used to be done before we had arthroscopy and keyhole surgery and it would work in a lot of cases but there are some potential problems. One is your basically tearing the capsule instead of cutting it in a controlled fashion so it is more likely to scar back in but the bigger issues are that the amount of force it takes to actually rip that capsule and regain movement in the shoulder can also damage things around the shoulder including brachial plexus, that network of nerves going along just under the shoulder joint.

I have seen patients with damage to the nerves from manipulation under anaesthesia and I have actually seen cases where the humorous actually broke so they got a fracture from being manipulated, so I would strongly advise against blind manipulation under anaesthesia. If you have done a controlled capsular release sometimes you will stretch the shoulder gently at the end to make sure there is no last little adhesions but that doesn’t take much force whereas the amount of force involved in blindly manipulating is quite significant and I think in this day and age its probably not reasonable as its not very safe.

So the take home messages about frozen shoulder which we do see more commonly around the time of the menopause. The underlying joint itself is normal and even though it feels really terrible and its hard to believe at the time when you are going through it, most cases it will go back to normal in the end without needing any surgery. You need to have a normal x-ray otherwise you cant call it frozen shoulder, and most of the time you don’t actually have to go to the bother of an MRI.

The treatment is basically aimed at decreasing that time to recovery, the natural history is that it should recover anyway but if we can shorten the amount of time that it is miserable, then I think that makes a big difference to peoples quality of life. So pain control, gently restoring range of motion and in a very small number of cases maybe a arthroscopic capsular release.

I suppose if you can stop the process early on then you may not develop the full blown frozen shoulder, if you have shoulder pain and its keeping you awake at night or making you struggle with you normal day to day activities that’s something that you should go and get evaluated and so the key is having someone examine it and decide what the diagnosis is and that’s the tricky part with frozen shoulder it gets missed or misunderstood a lot of the time.

There are no hard and fast rules about it the reason why we say it that way round is typically that the heat will kind of loosen any muscular stiffness and help people do stretches better. The ice will tend to help with pain relief particularly at night and help with sleep. How it does that well you could argue well its probably not going to get as deep as the capsule to reduce the capsular inflammation directly, is it sort of providing a different stimulus kind of like the gate theory of pain control or is it actually having an anti-inflammatory effect, hard to know as the capsule is quite deep the muscle and tendon between the skin and the capsule so the ice may not get all the way into the capsule but I think it tends to decrease the pain sensation that people are having from their shoulder.

Its very successful in the long term now you could argue well its frozen shoulder its going to get better anyway overtime, the people who would tend to run into trouble again which is very rare tend to be the diabetics. The diabetic frozen shoulder tends to be a bit more difficult to shift, I have only very rarely seen it where they have gotten stiff again after capsular release, I have never seen it in a non-diabetic. So a peri menopausal frozen shoulder I have never seen after frozen shoulder.

You don’t jump then with the surgery straight away and you would rather not jump in when the shoulder is still in the painful phase, so typically most patients before considering surgery would be at least 6 or 7 months in and if they are caught early enough and started the anti-inflammatory therapy and had injections early enough they may be better by 6 or 7 months so certainly the non-invasive and less invasive treatments are first line.

I’m Tommy Mooney Lead Strength & Conditioning Coach at UPMC Sports Surgery Clinic. I will be talking about Fit for Life: How to maintain strength, fitness and a healthy lifestyle as we age. I will plan to summarise some of the evidence regarding healthy aging, particularly as it pertains to golf performance and offer some practical examples of what you can do to help improve your fitness and golf performance.

It is well understood the importance of being fit for an array of lifestyle factors such as benefits like general health, longevity and weight management.

What do we mean by being fit?

Tonight, we are more interested in fitness as it pertains to golf we can all likely agree that Rory McIlroy is a fitter golfer than John Daly. We will talk about some of the physical factors and what we will do to change them to help improve our golf performance.

Firstly, I am going to talk about the importance of muscular strength. Anyone who has watched the Netflix ‘Full Swing’ documentary has seen this custom-built gym that the PGA Tour brings with them around the country to all the major events to allow all elite golfers to maintain their strength and conditioning work whilst on tour.

Strength is also important for the ageing golfer. Ageing is associated with the loss of muscle mass and strength and can often result in falls, functional decline, feelings of subjective weakness or on the golf course that may look like a loss of distance and fatigue.

Typically, as we age, we can see a loss of muscle mass. This is shown here in this study with the two MRI images. One of a 60-year-old woman vs an 80-year-old woman and basically what we are looking at here is the muscle mass or the darker material vs the white material being more fatty infiltration.

As you can see as we age typically the number and size of that muscle mass in this instance is your quadricep muscle. We see that decrease while we see the fatty infiltration increase. However, this does not have to be the case.

This particular study looked at 40 master athletes aged between 40-80 years old who trained 4-5 times a week during this study they underwent tests of body composition, quadricep strength, and bilateral MRIs. What we can see here is a 40-year-old master athlete relative to a sedentary vs an active population and basically, what we can see here is the muscle mass, size and the number of muscle fibres maintained really well in our active population vs in our sedentary population we see an increase in adipose or fatty infiltration into the muscle.

Ultimately, this study contradicts the common belief that as we age, we lose muscle mass and strength, and that suggests that the loss of muscle mass and strength is a factor of disuse rather than ageing alone. This has important benefits for our ability on and off the golf course and will help us to maintain that muscle mass and strength and eliminate some of those risks we mentioned earlier around a loss of independence and falls.

Another thing that can often hamper our golf performance is injury, time away from the golf course due to injury is going to have a knock-on effect not only on our general health and fitness but also on our handicap so injury can often be the start of that misuse that we mentioned. Post-injury, resistance training is really important. It has been shown here in several studies and we see it daily around the clinic that it improves function, reduces playing scores, and helps improve strength. Strength plays a fairly key role in keeping us on the course as well as benefiting performance, as we mentioned.

If all of that doesn’t sway your opinion on the necessity of strength as a part of our exercise routine this particular meta-analysis looked at nearly 2 million participants over 38 studies and what they found with this was adults with higher levels of strength had a lower risk of death when compared with those of lower levels of muscular strength.

As a general guideline, in 2015, the World Health Organisation (WHO) changed its guidance to include strength training twice per week, and basically, those guidelines look like this. Trying to incentivise 150 minutes of light activity a week, again if we are playing golf we are already ticking this box quite easily.

75 minutes of vigorous activity that is increasing our heart rate and getting out of breath a little bit more.

Strength training as we mentioned at least twice per week. Some form of balance training and minimise sedentary time.

Again, if we are on the golf course a couple of times a week we will tick most of these boxes but strength training is not a box that we will tick once. Again, it is important to know that these are generalised guidelines and do need to be adapted to the individual, but they do show the importance of strength.

How does a golfer lifting weights in the gym contribute to a pro playing well on the golf course or hitting long drives. This study shows strength training and healthy non-injured golfers. The study analysed the relationship between muscle strength and swing performance, such as club head speed, driving distance, ball speed, and skill (handicap/score).

The results seemed to implicate that there is a positive relationship between handicap and swing performance. Although relatively few studies have been investigated in this area. There is a positive correlation between handicap and muscle strength and also a distinct relationship between driving distance, swing speed, ball speed and muscle strength. The results go on to show that training of the lower leg, hip extensors, trunk power as well as grip strength are relative for improved golf performance.

This slide shows a sample training program or strength plan for a golfer. It is important that these programs are individualised so it is best to consult a professional when looking to begin any new strength plan. Ideally, we want to try and meet the individual where they are at for example someone who has a history of training regularly vs someone who is coming from a more sedentary base. This example is a 6-week program for a relatively trained individual with a good experience of strength training.

To show you some of these exercises. Again, these are advanced exercises for someone who has not done strength training before. In the top left we have a racked deadlift exercise looking to build up posterior chain strength. Here, we have a hip thrust exercise looking to develop gluteal and hip extensor strength. These are going to be important exercises when we think about our follow-through in our drives.

We have some upper-body exercises here in our push-ups, our single arm pull down and our single arm press. We have some lower limb, working on balance here with our split squat, a single leg squat working on our single leg strength as well as our T-spine rotation working on rotation, mobility and flexibility.

Here are some general guidelines for strength training as we start as a beginner we want to focus more on lower/lighter resistance utilising bodyweight exercises we might start with higher repetitions and lower sets and that can progress into heavier weights with lower volume. Again, the sessions per week may be reduced at the start like 1 or 2 and that can gradually progress as we become more advanced.

In terms of exercises again here are some sample exercises these are not all of the exercises that we use but just give you an example of some that might be used across a couple of different types of movements. It is not necessarily the case that we move linearly from one and these are an example of some exercises that can be used.

It would be remised not to outline the importance of cardiovascular exercise although I think everyone understands the benefits of cardiovascular exercise in terms of gain, reducing inflammation and reducing the risk of chronic disease. To quickly talk through it this meta-analysis looked at 33 studies with over 100,000 participants and what they found here was people that who had better cardiovascular fitness had a lower mortality rate or incidents of coronary heart disease, cardiovascular disease and essentially working on our fitness, whatever form of fitness that may be is beneficial towards all calls of mortality.

General guidelines for cardiovascular training are to get out of breath regularly. We get that lower-intensity exercise ticked off as we mentioned earlier from the WHO recommendations and we can try to challenge ourselves a little bit more with slightly more intensive exercises during the week. Again, that starting point is going to be based on your current level of fitness examples might include some fast walking, walk to run, cycling and swimming can all be effective methods.

Naturally, with golf, we all enjoy the social aspect and that’s no different when exercise training. Trying to make measures of progress, we track our handicaps, we track our scores on the golf course which should be no different to our training off the golf course as well. As I mentioned, if you are unsure of something that is where getting advice from a professional is key. These are general guidelines and not targeted at anyone and will naturally depending on your levels of fitness but aiming for 3 days a week. Some of that may be made up from golf but outside of golf then what are we doing? Is there other activities we could include there.

Again, we mentioned looking to utilise some higher intensity exercises where we are going to push that heart rate into higher ranges or higher levels. Our steady-state things are going to be largely ticked off the golf course especially if we are playing a couple rounds a week but then the interval training option might offer a good alternative to a challenge that is more intensive cardiovascular sessions and see those benefits as we mentioned.

At UPMC SSC we offer some bespoke fitness testing. It is covered by various health insurers, VHI in particular cover some amount of the cost of our fitness testing here. The fitness testing covers a variety of different elements so we will look at body composition, upper body strength, lower body strength. We can also look at swing speed assessment as well as a cardiovascular fitness test or a V02 max that can be done on a treadmill or an exercise bike.

Testing is one part of the equation but then it is implementing those testing results into a bespoke programme based on the individual and based on what their goals are as well and that is all included in the VHI package that I mentioned earlier.

If you have any questions you can email [email protected]

I am a Consultant Sports and Exercise Medicine Physician primarily based at the UPMC Sports Surgery Clinic in Santry. I also work across several different sports, but at the moment, I am in the high-performance centre in Sport Ireland and looking after athletics, preparing for the Paris Olympics. I have also worked for DP World Tour Golf and Legends Tour events. I also do a bit of work in the GAA and am a senior clinical lecturer at Trinity College.

I spend most of my time in the UPMC Sports Surgery Clinic, which is made up of the main hospital and the Sports Medicine Department. The Sports Medicine Department is made up of a team of Sports Medicine Consultants alongside a full MBT of specialists, physiotherapists, and strength and conditioning coaches. We work in tandem with our rheumatology and radiology colleagues in the main hospital.

Working in golf is very rewarding and I hope that some of the things I have learned in elite golf I can share with the recreational golfer also. Worldwide 60 million people play golf in 206 countries so huge participation sport. As you age previously accessible activities can be more challenging. Golf, however, is a more popular sport for the older adult and it is a really important form of exercise as we age. Golf in itself is a recipe for lifelong health.

These are some nice infographics that the DP World Tour has published and they did a lot of work in terms of public health and the benefits of golf overall so physical inactivity causes over 3 million deaths worldwide per year and golf is a phenomenal form of activity in its own right.

Research has long proven that the more physically active we are the greater we live in terms of time. More specifically the health benefits of golf reduce your risk of multiple medical issues like cardiovascular disease, diabetes, stroke, colon cancer, breast cancer and dementia can be reduced by up to 33%. There is a reduction of 65% in hip fractures in golfers as well so huge benefits to be gaining. A Swedish study found that golfers have a 40% lower mortality rate than non-golfers.

Anyone who plays golf also understands that the physical and mental health factors are so beneficial. It is proven that there is a boost in self-esteem and a reduction in depression.

Golf is associated with a higher risk of skin cancer, so anyone who golfs should make sure to get their skin checked on a regular basis and use sun cream. We share this with professionals on the DP World Tour to remind them, but it also applies to recreational golfers in terms of skin care.

Golfers can develop a number of musculoskeletal issues that may or may not be related to the sport itself, and that is where we, sports and exercise medicine physicians, can help. We have to keep you as active as possible and on the course for as long as possible so that you achieve all those health and social benefits that we all know golf brings.

What are the common issues that we might be able to help with?

A recent study looked at the injuries in both amateur and professional golfers and as you can see the most common injuries in golf are elbow, lower back, hand/wrist, and shoulder. Life-long golf can most definitely be cut short by injury so appropriate management of such injuries is essential to getting you back on the course. The purpose of today’s talk we will focus on the amateur’s two most common injuries lower back and elbow.

Lower back pain makes up 16% of amateur golfers injuries and about 41% of professional golfers injuries more likely to be in professional golf due to the larger forces in it and the larger repetitive load placed on the lumbar spine with professional golfers hitting 100’s of golf balls a week generally.

Several modifiable factors can reduce your risk of lower back pain while playing golf. These are a reduction in BMI, poor strength, flexibility, and coordination. Certain swing biomechanics lead to lower back pain, and we also know that carrying a bag can increase your risk of having lower back pain while playing golf.

The golf swing is considered one of the most difficult movements in sports and to perform a golf swing a powerful movement is required with rapid rotational forces being transferred to the golf ball with lots of compressive load placed on the lumbar spine, calculated to be about 7 to 8 times body weight.

Recreational golfers have different variations in swing and muscle activation during the golf swing itself. We know that older golfers age related muscle changes their swing and 3 typical swings have been associated with lower back pain. The early extension is where our hips come forward to the hand space during the swing. A reverse-C finish puts a greater load on the lower back structures. The reverse spine angle is an over-extension of the lumbar spine during the backswing.

I’m not going to get too mechanical but certain swing mechanics are more common in those with backpain so it is really important for those mechanics to be identified and to work closely with your golf professional to address these issues in your swing as part of the management of your injury. Other potential modifiable factors include flexibility.

It is obvious that strength plays a large part in both the prevention and management of golfing injuries and the professional game itself has transformed over the last decade with most top professional golfers putting a large emphasis on strength and conditioning as it reduces the risk of injury and improves performance, this can also be applied to the recreational golfer.

To get to the root of the problem in lower back pain you need to have a full assessment so a clinical assessment, strength assessment, flexibility assessment and biomechanics assessment and sometimes imaging if it is necessary.

To manage lower back pain in golf, really if we take a general approach here education will form a huge part of that so in terms of making sure that you are aware of what you need to do to improve your symptoms.

Weight loss can form part of the management we spoke about muscle strengthening and muscle exercises as well as flexibility exercises which can also be helpful. Looking at your swing biomechanics can be helpful also to have your golf professional assess that as well.

We are lucky enough at the UPMC Sports Surgery Clinic to have options to secondary management which is not always needed but is helpful at times to create a window opportunity where pain doesn’t progress into exercise rehabilitation.

The second most common injury in golf is the elbow and it is often an overuse injury more common in females. Unfortunately, the term tennis elbow is associated with tennis but it is more common in golf.

Risk factors for developing elbow pain in golf can be due to hitting too many balls in too short a time. The grip may be too tight or, you may be hitting the ground before the ball or if you try to change your swing very gradually without increasing the load. Often, we will see wrist flexion changes at the impact of the golf ball that can lead to different loads placed on the elbow.

The wrist flexor burst at impact is to try and increase clubhead speed but can lead to some additional forces placed on both the outside the lateral and the medial lead and trail elbows. The problem with golfers who have wrist pain is the wrist position and impact is assessed. There can be several different causes for elbow pain in golfers that would need to be assessed as we said inside a golfer’s elbow is a medial epicondylopathy and outside elbow pain is often lateral epicondylopathy.

To truly determine the issue, you will need a full clinical, strength, flexibility, biomechanics, and, at times, imaging assessment.

Management for elbow pain depends on the diagnosis itself but generally consists of education about your problem, strength-based rehabilitation, biomechanics, and, again, coming back to that golf-specific rehabilitation. Some aids can be a support brace or maybe even increasing your grip size. Again, all of this will depend on the injury itself.

Management options that can be helpful for elbow-related pain in golfers include ultrasound-guided injections, platelet-rich plasma, corticosteroid, and, at times, extracorporeal shock wave therapy.

What is Extracorporeal Shockwave Therapy (ECSWT)? It is a shockwave that works by acoustic shockwaves which carry energy to different tissues. These shockwaves can trigger tissue responses which have many beneficial effects such as pain relief, and increased blood flow and when needed can disrupt calcium deposits in tissues. The combination of these effects can lead to improved muscle recovery.

What is Platelet Rich Plasma (PRP)? It is a form of regenerative medicine that harnesses the body’s ability to try and increase natural growth and has healing factors to try and improve injury recovery. The blood is taken as it would during a simple blood test spun in a centrifuge and then the PRP portion which contains concentrated healing cells is injected into the targeted tissue. PRP has less side effect profile than traditional corticosteroid injections and some cases show they are proven to beat steroids in the long-term musculoskeletal conditions.

You have managed your golfer’s elbow and you are trying to ensure you have lifelong golf like we initially spoke about. Performing a warm-up means you are less likely to get injured playing golf. Injury is 3 times more likely in recreational golfers without a warm-up, here are some of the pre-round warm-ups recommended by the UPMC Sports Surgery Clinic. I recommend you take a copy of this and bring it into your pre-round routine.

You will often see professionals preparing for a round hours in advance when most of the time we are rushing out of the car to get to the first tee. How many times has it taken you 2 or 3 holes before your body is ready to swing a golf club. Try and go earlier to the golf club and spend 10-15 minutes warming up.

There have been a few questions ahead of today’s talk regarding osteoporosis and golf. I suppose osteoporosis is a condition that means your bones are below bone mineral density and are at an increased level of fracture. We can make a diagnosis with the help of DEXA scanning. It is in approximately 20% of females and 6% of males over 50 years of age in Ireland. It is vital that those with osteoporosis manage it properly often with the help of your doctor and rheumatologist.

Resistance exercise plays a huge role in the treatment of osteoporosis and really should be guided by your professionals. While golf is considered low impact, individuals with osteoporosis should discuss with professionals if they should participate. It is crucial to understand the persons overall health status, bone density, pain levels and functioning strength abilities before having that decision.

I look after a number of golfers with osteoporosis and there is a number of different tips in terms of the golf swing that can reduce their chance of further injury.

Firstly, working closely with their golf professional to ensure that their golf swing is a good technique. At times rotating your lead foot to improve movement through the hip externally. Shortening the backswing can reduce that bending stress in the lower back. Even something as simple as standing closer to the ball can reduce that forward bending and reduce the bending of the lower back. There is a number of different mechanical tips and tricks that can reduce your lower back stress especially if you have lower back stress, osteoporosis can allow you to continue to golf in the future.

In summary, strategies to improve lifelong golf among recreational golfers include really a holistic approach that includes appropriate management of medical issues and injuries.

Exercises to improve strength and flexibility that act as both health and performance boosters as well as injury prevention.

Working alongside a knowledgeable golf professional to help identify any swing biomechanics that may lead to future injury. Ensure an appropriate warmup prior to playing and most importantly have fun golfing.

I’m going to show you a clip here of what the very highest level of skiing looks like and what I want you to do is get a bit of a sense of forces that are involved during skiing and the movements that we have to undertake and often times people perceive skiing as a leisurely activity but the harder you ski the higher the intensity of the exercise becomes so you can see the amount of strength that is required by putting weight onto the ski in order to create turns. We can see here in slow motion the body positions that are required and the flexibility that is needed in order to make a turn. None of us will be skiing this fast on our holiday but I think the aim of it is to give you a bit of a sense that it is a relatively tough and physical activity that we are undertaking.

How do I get fit for skiing in 2 weeks? The answer is you don’t and what I am going to do is give you a few tips on how you can get a bit fitter and a bit more prepared if you have left it to last minute but hopefully also help you to build some behaviours that you can add to your weekly lifestyle and prepare you for any future endeavours.

The aims I want to highlight ae the physical demands of skiing and snowboarding and when I’m talking about skiing I am actually talking about both sports. I am going to give you some specific guidance to get you fitter prior to your holiday and then I am also going to help you plan to get a bit fitter before you go away and also stay fitter throughout your day to day life.

Why can I talk about this stuff? It seems like an awful long time ago and it has been 15 years since I was working as a strength and conditioning coach with England’s development ski team and my role there was to help prepare the skiers for the physical demand for their sport so I have a couple of photos here from some training camps. The English ski team isn’t the best funded which might not surprise you. The facilities they had available were homemade so what you see on the left is a gym that we built in the garage of the accommodation that we were staying in and it also served as a kit room and a ski prep area. On the right-hand side this is an early year ski camp which is a little bit different in terms of the snow demand and they actually like that hard pack and icier conditions. This is a ski resort in Italy where we get used to the dry land conditions along side some of the conditions for the technical training. I’ve got a good understanding of the physical demands of the sport from that work.

With that said there were some very specific challenges that we have to negotiate when we are going on a ski holiday. The first is that we only do it for mainly 1-2 weeks of the year and what that means is that it is very difficult to get used to the conditions of skiing when you are only doing it 5-6 days per year and that offers its own demands. I like to see the back of patients who come through the clinic and often there is very little physical preparation some of us very much see skiing as a holiday we don’t necessarily change our behaviours so we are moving into an activity that you do a lot less physical activity prior. The make up of the holiday itself, you know you buy a lift ticket for 5-6 days and we don’t like to see that money go to waste so we ski back to back days. Essentially you are doing the equivalent of putting your running shoes on and trying to run a 10km for 5-6 days on the bounce and we all know we find that incredibly challenging. We then often times do get reduced sleep and that is self-induced by enjoyment on the holiday or children not settling into a different routine. Also, inadequate recovery so a bucket of melted cheese, a few pints or glasses of red wine isn’t always the best recovery from a day of physical activity and these are some of the challenges that we have when we go away.

What do you need to be able to ski? This is relatively straight forward and I am not going to go into too much depth here but we saw on the video there we need to be able to create pressure on the boots in order to be able to initiate the turn and that requires some force and some strength. Then in order to be able to hold an edge during a turn and we have to undergo what we call eccentric contraptions to be able to tolerate those forces so the strength demand particularly on the bottom ski on each turn. Then we have some demands of the holiday itself so being able to tolerate multiple runs and often times some of us want to ski as many vertical metres as we can, we have tracking apps for that. We want to do multiple runs each day and we want to do that on consecutive days and the stronger you are the more capable you will be.

On the other side of the coin we have fitness. There is an aerobic demand to skiing and we know that because when we get to the bottom of a run we can feel out of breath and again the faster we ski, the more intense we ski then the more out of breath we do get. Aerobic capacity also helps us to recover between runs. Skiing isn’t purely aerobic, there is an anaerobic element to it which is why people talk about building up metabolites and they talk about building up lactates and muscle. The aerobic system helps us to recover between runs so being fit is important to be able to tolerate that. Then depending on the resort, we select some may be at higher altitudes some may have less snow and if you are operating at higher levels of altitude then fitness will certainly help us.

When I talk about fitness or aerobic fitness, this is the ability of the body to be able to transport and use oxygen during physical activity. Again, in order to be able to access some of the energy that we have stored basically that requires oxygen and that reaction is relatively slow which is why we use aerobic pathways during lower intensity activities when there is not a high-speed demand on us. Aerobic conditioning usually relates to activity that you can do for a relatively long period of time so essentially over a minute to anything over a couple of hours so that’s what we are talking about when we talk about aerobic fitness.

In terms of actual measurement of fitness and V02 max, this is the maximum amount of oxygen you can use during intense physical activity we measure it here in the clinic and it is available here across a few of our UPMC sites. We measure it using a gas analyser on a treadmill or bike and it gives an accurate measure of how fit you are. The reason I put a picture of a biathlete here and this is someone who cross country skis and shoots at a target. These athletes are really fit, they grow up in high altitudes and train with very intense endurance activities so they have very high V02 maxes but having some sort of measure of your aerobic fitness is a good way to understand what sort of level you are at at the moment prior to your holiday or even just for general health.

There is a good reason why you should be trying to understand your own aerobic fitness and these changes happen throughout our lives so as we age we tend to use fitness levels and this is often dependant on the type of activity levels we partake in. If we play a lot of field sports during our teens, 20’s and early 30’s and we stop then we should take up another activity in order to keep up our aerobic fitness levels. We would be more conditioning focused say we are a runner, cyclist or triathlete often times we will maintain high levels of V02 maxes until late 30’s early 40’s but we lose fitness basically based on the amount of training we do so if our activity levels change and we have different lifestyle changes like we take on a new study or there are busy period at work or children get in the way then we lose fitness, if we have a period of illness for example you are in hospital for a couple of weeks or COVID-19 would have had a big impact on this. Your body gets used to what you give it and you need to be able to train in order to be able to possess those fitness qualities. There are some elements of our fitness that are genetically determined like our size which contributes to our lung size and heart size but we can all improve it and I imagine there are some of you who engaged in the talk tonight that have reached our peak so we can definitely all improve.

Why should we worry about our fitness levels? Maintaining high levels of aerobic fitness is important we know it reduces the risk of cardiac arrest and stroke. It is incredibly important for weight management and exercise is often perceived as important for weight loss but I is actually the other way around it has little bearing on the amount of weight you lose that is all diet based but it is really important for not putting weight on when we stop aerobic conditioning we tend to pile on the pounds. We know there are mental health benefits to aerobic training as well. We feel better, we have increased energy levels and the r4eason we are here for the talk today we have more enjoyment in our skiing.

How do I get fit? First of all, you have to pick an activity and we don’t get fit by sitting down watching the TV. There are plenty to pick from here is a small list for example running, cycling or rowing. Then we have to pick an intensity so we want to figure out how hard we want to exercise and often times I think this is driven by what we are comfortable doing. Some people like to go for the high intensity interval training and that is known as HIIT and this is because they prefer to get out of breath and hot and sweaty quickly. Some people don’t enjoy that and they prefer steady state low intensity exercise by going for a longer time period but it is personal preference and both of these will improve your aerobic fitness. In terms of frequency, 1-2 times a week and up to 3 hours is enough in order to be able to reduce the risk of cardiac episode and stroke. Obviously, you can exercise more than that but if you are looking for a baseline and trying to become a little bit fitter then the actual requirement isn’t that high.

In terms of exercise intensity, generally, this is measured using heart rate now a lot of devices can give you a heart rate measure and it should give you a decent ballpark. If you do have access to a chest1 heartrate monitor with your watch then that is a much more accurate version and essentially, we are looking at different training zones based on your max heart rate. In terms of building aerobic conditioning/fitness then zone 1 and zone 2 is really all you need so relatively low intensities so 50-60% and 60-70% of your maximum then we are going to get a little bit fitter. You don’t always have to exercise until you are very out of breath and fatigue in order to improve your fitness.

This now leads to the different types of sessions that we can do and you are looking at a cascade in terms of intensity so 30 minutes of a low intensity exercise like going out for a fast jog or bike ride is zone 1 and that will get you fitter by doing that for multiple sessions over a long period of time helps you to stay fit. If we are a little bit tighter on time or we prefer to be working at a slightly higher intensity then the middle row there 4 lots of 4-minute work with 2 minutes rest between repetitions and a short warm up will have you done in about the same time about 30 minutes but working at a slightly higher intensity, zone 3. The final one, this is the one with big blow outs so we are doing 10 reps of 45 second work at zone 4/5 with 90 seconds rest between reps and again with a short warm up. All of those sessions will take a short period of time but doing this a couple times a week will help to build your aerobic fitness and this is all do able a couple times a week in the run in to your ski holiday.

We have got some idea on the sessions but what is the secret to getting and staying fit? It is simple, the answer is consistency and I am sure a lot of the things I have spoke about today in the session is not new to you. Building consistency is essentially forming habit and there are certain things you can do in order to be to do that. Firstly, you should create a schedule and find a window where you can do your exercise so work around your job, study and picking the kids up. Then you want to set up a group rewards structure and by doing a habit it is about creating positivity around the activity you are doing and if you are rewarded for doing it then that helps to build habit. If you are looking to do two sessions a week and complete them then you might reward yourself at the end of the month with maybe a takeaway or a trip to the cinema. Accountability is often very effective so this can be a training programme or a training routine with somebody whether it is a partner, sibling or a friend but accountability is important because it helps keep people on a high. Setting targets is a good way to build consistency and drive motivation so it might be that you are trying to get a certain 5km time and achieve that and that can be very rewarding. Some people’s sociability is very important so that is why sports like CrossFit have become really popular because it is not just about the exercise but it is about friendship too. Some of us are not some of us are happy to go off on a bike by ourselves with some headphones to get in the right headspace. Measurement apps are really good for seeing progress but at the same time they do mix in to targets. The final one that I will talk about then is assessment so if for example you come in and have your V02 max measured then you can go away and train for it and you have some accountability and targets and you can see in black and white that you have made some progress and again that helps to drive some consistency.

Final tips for enjoying your holiday and reducing injury risk. You should do some aerobic fitness work in the lead up to your holiday. You should also try to use mixed methods for example, fitness and strength work. Taking regular breaks especially if the skiing is high intensity. I think sticking with the recommended DIN settings on binding will reduce the risk of injury. Eating breakfast, and hydrating throughout the day will help with your energy levels which is really important while skiing. Be wary of fatigue and change of snow conditions throughout the day. Finally, ski at your own pace and level.

I am going to start off my talk by showing you a video and this is a classic example of what happens on a ski slope so you have friends laughing at you for falling but often times there is an injury. I just want you to hear what happens now as the skier comes down the slope. Do you hear that snap? If you look at the person that snap is not the skis coming off that snap is the ACL rupturing and you see that the individual is coming down the slope probably at too high a speed and leaning back onto his skis and that is what is causing the injury and this is a classic example of how an ACL ruptures on a ski.

I was lucky enough as part of my fellowship training that I worked in a ski resort in Colorado and one of the fore fathers of treatment of ski injuries is this man Dr. Dick Steadman and unfortunately he passed away last year and he described the ski as the ideal device to rupture an ACL so really you have to be cautious when you are using skis because there are a high rate of ski injuries related to skiing.

In terms of skiing it is good for our business because people go away and injure themselves. It is a hugely popular sport and nowadays you see many people heading away to the slopes as holidays are becoming a little more accessible and it is a very enjoyable pursuit for the whole family but it is a risky sport and you see here the idea of the type of knee injuries that we get and 35% of the injuries occur in the knee and that relates to what Dick Steadman said about skiing because it is a high torque object that can twist at your knee because your boots are held in place there are also other injuries related to skiing.

The equipment has changed remarkably over the last 100 years or so that people have been skiing and what you see here the old fashion skis have much less binding and the boots are not as high on the ankle as they are nowadays.

The modern boot goes 2/3’s the way up your shin and your ankles are essentially fixed that it just allows a bit of flexion and extension at the ankle with very little rotation and the rotation does not occur at the ski but the rotation tends to occur at the knee and that is what happens in terms of getting ACL injuries.

You often hear about people getting skis and then getting bindings and the bindings are tightened up so when you go to an instructor or a person who is giving you your skis they will often talk about the din and the din relates to how tight the boot is fixed to the ski so when you are a very aggressive skier you want the boots to be really tightly fixed to your ski but when you are a more novice skier you want your boots to be able to come away from your ski so if you have any suspicion then you should probably get your din low so your ski comes away from your boot so you don’t turn your boot and your knee to cause an ACL injury.

The terrain and conditions are also very important and you notice here there is very deep and foul snow but equally if you have icy snow or very slushy snow they can grab your ski and increase the risk of injury.

Unpredictable behaviour from people that are on holiday for example they could be drinking too much or they could cause a collision and increase the risk of injury. If we look at the example here this is from Deerpark in Utah where they gave an example of how people cause injuries and they tend to be novice skiers or they are leaning backwards as they are going down the mountain as they were instructed and that creates the skier to be off balance, have their hips below their knees, uphill ski un-weighted, you tend to fall on the inside edge of the ski and this causes the injuries because it has your knee in a vulnerable position as the ski twists. As I said there is unpredictable behaviour and the après ski but it is also when you are coming downhill with a few pints on board and you don’t have that neuromuscular control that you might have had in the morning or perhaps in the morning you are a bit hungover and that too may increase the risk of injury.

On the mountain what can you do? First of all primum non nocere is the saying in medicine to cause no harm so you want to be skiing within your area of expertise so you don’t want to go out of your lane that you might get stuck in or if you go down a slope that you are not able to then you are much more likely to get injured or worse even get lost, die or fall off a cliff. Avoid hazardous conditions like snowing if you are not a very good skier or you have very low light then it’s very hard to see the undulations in the ground and that can make you far more likely to fall over so even on the flat slope it is more likely for you to have a white out and also be well able to stop before your start and this is another example of another collision type injury of someone out of control.

In the clinic what do we do? One of the articles I often quote in my talks is a very eminent professor and he talks about kneemanship and doing an appropriate examination is very important and one of the key factors of doing that is taking a look at history so if someone injures their knee going down a slope, has a fall, tends to hear a snap like the one in the video and it is difficult to put the ski back on and ski down the slope may lead to a more serious injury then someone is taken away by ski patrol but what typically happens is they go to the clinic at the end of the mountain, they get an x-ray and they get a very overpriced knee brace and then they are sent on their way. In terms of taking history you can really tell what’s going on that’s very indicative. When your doing a clinical examination, we look for a number of features to compare to the normal knee because it gives you a good idea of what’s going on but we are looking for the presence of swelling following an injury particularly bleeding because the presence of blood generally means you have torn something. Commonly it is your ACL and that is why it is very important to look at the other knee and you will see yourself when you take off your ski pants that you should probably get assessed. In terms of the clinical examination we go through it in a very systematic manner as we can assess all the ligaments around the knee like the side of the knee so you can often damage the Medial ligament, the ACL is very commonly injured so you will see a very swollen knee as you see in this picture and often in the ski medical facilities they are often very limited, they are quite primitive so what I would typically do is simply do an x-ray to out rule a fracture and that is very important but the clinical examination determines whether you have a severe injury which may be more than one ligament injured or whether it is a more routine injury with just a solitary ligament and that has big implications, a lot of times they will try to sell you a brace and often times the brace is not needed but then they will say lets get an MRI scan and lets have surgery early and this often happens in the US and I would advise against this. I think in the cold light of day you can get further investigations when you come home and get appropriate treatment that is not under pressure by people trying to make money so it is very important to consider that. The x-ray as exampled here can show you what a little flake of bone coming off the side of the tibia and that is an example of what we call a segond fracture and that is indicative of an ACL injury. The MRI’s can be done and often in the mountains they can be poor quality but, in this situation, you can see some bruising at the mid portion of the femur and the back portion of the tibia then you have an injury that causes an ACL rupture. You can do an ultrasound scan and these are cheap scans to get and they often are effective at looking for ligament injury on the side of the knee. Then referrals the referral is very important so getting back to your home countries by packing and getting back to your home country safely and that is very important.

As I said in the cold light of day this when we should see people by assessing them appropriately, we take away the drama we take them back where they are comfortable and they have less anxiety and we can explain things and have the appropriate investigation. Early diagnosis is important we need to know what we are dealing with but also with knee injuries we don’t have to rush into surgery and sometimes there is a decreased range of motion or your muscles are not working properly then pain management is much more appropriate to discuss the treatment, not all knee injuries require surgery and I often tell people to try and avoid surgery if they can but certain situations will warrant surgery and we will go through all the options with you in the cold light of day. We remove the splints as quick as possible and often these splints are unnecessary particularly when knees are meant to bend. We don’t like keeping them straight unless it is a really serious fracture that has to be stabilised but most ligament injuries if the knee is not very unstable then you can move them but that’s not important and being ready for surgery is dependant on motion and that is really the first thing we do. We also get people to weight bare as tolerated as cartilage doesn’t take a joke and cartilage doesn’t like to not be loaded and it is really important that we get you back weight bearing as soon as possible because if you are to have any knee surgery we like to get you weight bearing very quickly afterwards and it is important that you ae bale to do this before surgery and these are some of the things that people do they get assessed and get back to their normal activities.

I am going to go through some of the common scenarios that I see in my clinic and much more frequently at this time of year when they come home from holidays. You see in this picture the type of referral I get and the history is a contact injury turning, he didn’t feel a pop, he fell to the ground, he was unable to weight bear and there was no immediate swelling but there was within 12 hours so we know that something serious has happened. With the clinical examination then he was able to keep his knee in a flexed position, he was unable to activate the muscles at the front of the knee, he is walking a mild length and some swelling within the knee is what we diagnosed he was unable to straighten his knee by 10 degrees but had good flexion then had a one degree laxity or instability of his medial ligament and he had a negative Lachman test so that means that his ACL felt in tact so if we look at the x-rays here we see that this is a juvenile because he still has growth and there was no evidence of any fractures on these x-rays so that’s very reasonable and then the MRI was performed and this is what we see in MRI we look for the presence of whiteness in MRI so that indicates fluid in these sequences as you see on the inside of the knee the fluid is in this region of the medial ligament on the inside of the knee and we see that the ACL is this ribbon like structure in the middle it does have a little bit of fluid in the knee so we know that there has been some damage with the ACL but in this situation it looks in tact which would be keeping with the clinical examination findings.

This individual was just treated non-operatively and allowed get on their way so they escaped a major injury which is good so that is a very common scenario we would see and a lot of times we just give people reassurance but we assess them thoroughly with a proper investigation and this is the second scenario and it was an experienced skier. They had a history of a high-speed fall turning on a steep slope, they heard a loud pop, they tried to stand but the knee buckled, they had to be removed from the mountain by ski patrol and they had immediate swelling. On clinical examination once again when you have ruptured your MCL you are typically unable to straighten your knee and people will see that they couldn’t weight bear, couldn’t stand, big effusion and echymosis which is bruising, they had a grade 3 laxity and they were Lachman positive which meant we suspect that this was a multi ligamentous injury. If you look at the x-ray’s here we didn’t say what side but I presume it is the right knee because the x-ray shows a little bit of bone here and that will indicate that this person has sustained an ACL injury and possibly a higher grade injury and they will go on then to have further investigations so this is the MRI we see and we see lots of fluid within the knee so this whiteness is blood we also can see some bruising so the colour of this knee we see a lot of light grey which indicates fluid within the bone or what we call bone bruising and you can see the meniscus which is this black structure is hanging o0ff the back of the knee so we know that this knee is far further forward so there is something that has been ruptured in this case and as we look into the middle of the knee we see the ribbon like structure that we saw previously has been ruptured so this is the ACL which is torn and this person has got the appropriate imaging and we can now identify that there is a definite tear of the ACL. Then we look at the image of the knee from the front and we see that here we like to see a nice black ligament and that is just this grey colour so we know that the MCL has torn off as well and that would explain the feeling of looseness on the inside ligament. That is a more serious condition and that is a condition that would require ACL reconstruction and MCL repair or reconstruction.

Finally, we have a recreational skier and his history has a twisted knee removing his boot from the bindings, he felt a crunch in the knee and skied on and said “it was fine after a while”, he then said it was very painful that night and he also said he “lasted the week through gritted teeth”. From the clinical examination the alignment was normal, there was small evidence of any fluid or effusion, full range of motion but pain at the end range when they are fully extending the knee or flexing their knee was painful. Pain on the inside of the knee and then a normal ligamentous examination so we are not suspicious of any ligament injury here but we might be suspicious of soft tissue damage within the knee and this is the side view we see of this persons knee and what we are looking at is the meniscus so the crunching sensation with twisting is a very common meniscal injury so what we see here is the meniscus and it should be like a black triangle but you see this white line going through the black triangle and what they have done is they have torn the meniscus. Often times people describe this as being fine at rest when they walk down stairs or twist in and out of a car however they do find some pain. I often tell people it is similar to having a stone in your shoe and if the toe is sitting under your toes it doesn’t cause any problem but when it moves under the ball of the foot that is when it really hurts you like the meniscus when that flap moves it can often give a lot of pain so we try to treat this non operatively to begin with but if the pain or symptoms are persisting beyond 3 months or there are obvious signs of displacement on the MRI scan then we would often have to do an arthroscopy and just remove that torn portion of the meniscus. This is another example of that where you see that the meniscus is just pushed out to the side there and there is some displacement.

I suppose I would stop you there in using the word necessary as quite often when it comes to a joint replacement strictly speaking it is not necessary it is whether somebody would benefit from it and I think it is important to make that little bit of distinction as ultimately it is up to the person and it is whether or not they decide to go ahead.

It is not like a broken leg that absolutely needs to be fixed. In general, you can look at these things in terms of pain and disability. The overriding factor that drives someone to have a joint replacement is pain. The vast majority of people has pain. Disability can come into it but it is generally a secondary thing and I will talk about that again.

In terms of the pain, again, we can go into as much detail as you want. For me one of the deal breakers is night pain especially with the hip you will find that people get to the point where they are wakening from sleep 1-6 times every night or most nights. Ultimately, that is when you would benefit from having something done.

In terms of pain throughout the day or with activities if they are holding someone back from doing the activities that they want to do or indeed affecting their quality of life and it is not controlled then that is often a time to start thinking about having something done.

We are often taught to see if the conservative measures have been exhausted and that is just a way of saying yeah, we have dealt with all that and it is now time to talk surgery. That is something that is really important to all of us as well. Ultimately, not only can you potentially gain months and even years without having to have surgery, you can potentially set yourself up much better off in the event that you do require surgery. Things like weight loss that we will speak about again can be very important and pure strengthening activities so anything that works again particularly from the hip and knee point of view like your quads and glutes in particular can benefit.

Strictly around the hip I find a lot of stretching activities can actually precipitate more symptoms rather than improve things but within reason keeping active tends to do good and not bad.

From an analgesia point of view simple analgise such as paracetamol which everyone turns their noses up at initially but I mean it comes with a very low side effect profile and it is often worth while trying to just take the age off of things and as you move up you can then mind that with anti-inflammatories.

Opiate type of medications for the vast majority of people tend to avoid it. They tend to come with a lot of side effects and they don’t really work particularly well for musculoskeletal type pain. They work better for other types of pain like cancer pain and in that they have a hugely important role but for us for joint pain they are no great at relieving it and even if they do with time you tend to become tolerant to it so you don’t get the effects with time so for me just paracetamol and anti-inflammatories.

Again, that is when you have to weigh up how it is affecting you day to day and you have more to gain than you do to lose anyway and when somebody’s quality of life is disrupted to an extent where they have more to gain than they do to lose then that is when it is worth while considering. I see people who get a little bit of groin pain for example on the 16^th or 17^th hole of a golf course and they play once a month and that’s it.

I also see people who would wake 6 or 7 times every night and I’ve seen someone who has slept in an armchair for two years because they have not been able to lie down flat in bed and who could take 20 minutes to get to the bathroom.

They are the two different ends of the spectrum; the vast majority of people are somewhere in between and again you have to see if you are leaning more towards the severe side of the spectrum or are you leaning more towards the conservative side of the spectrum where your paracetamol helps. This is something that I always try to say and it is that you don’t have to be as bad as people make it out to get a joint replacement and we know from loads of systems by scoring patients and if you divide them up in terms of severity the group that would benefit the most from a hip or knee replacement are the ones with moderate symptoms and it is very subjective as to what is classed as mild or moderate symptoms but the moderate group are the people who are still just about able to do their job and normal day to day activity and in many ways they are ready to hit the ground running after they get the joint done and they will rehab quite quickly.

Whereas the really severe group the people I spoke about that have slept on an arm chair for 2 years well they have a huge amount of work to do following the surgery in terms of getting back to their morbid level. There is a happy medium, it is often not as bad as you think and with hips especially I find that people come in and they almost feel like a fraud and they think they are not bad enough. This is what a hip does to people, a hip slowly drags someone down along with everyone around them who is aware like their husbands, wives and children. Everyone around them will be saying “would you ever go and get that fixed, your always complaining” and the response usually is I’m not that bad as it is in our human nature to adapt and cope with things and we manage to get on with it and generally it is not that they are in denial, they don’t actually realise they are as bad and I often put it as a background noise that until you turn off that noise then you realise. It is only after people get their joints replaced that they then realise how bad they were prior to the surgery.

Joint replacement is still ultimately a joint replacement and it has moved on I think an awful lot in terms of how we go about it and the safety profile of it compared to 40 or 50 years ago and as I say it comes with significant risks although they are rare thankfully. The odds are very much in your favour so if you look at satisfaction rates after a hip replacement then you are talking 96/97% which is pretty hard to replicate in many other surgery’s that are performed.

It comes with the standard risks like infection, infection is our nemesis and again if a surgeon has said that they have never had an infection in their practice then it is nonsense and everyone gets them it is just a fact of life and trust me we take the upmost precautions trying to avoid that but when you’re talking about a joint infection your talking 1 in every 300 which is not that common but it is still a risk you take when you are considering rolling that dice.

Things like clots like a pulmonary embolism is a risk factor that you are talking maybe 1 in 500 to 1 in 1000 and that is the sort of rate now a days and how do we get around that we give you foot pumps we give you stockings to increase circulation but most importantly we get people up quickly and we get lots and lots of joints now immobilised in the same day.

The quicker we get people up the lower that risk becomes and some people are usually given some form of blood thinner then after to help prevent it. Nothing can really reduce risk because some people are more prone than others but thankfully now a days it is uncommon.

Then more specific things with regard to the joints with the knee stiffness would be one of our main issues and a knee replacement can end up stiffening the knee because the knee is hard work and as I say its not like you just get a hip for free but with a knee you most certainly earn it in terms of the recovery and it is not a 6 week job but it is a 6 month job in terms of that recovery and I think it is important that people know it is going to be sore.

Then with regard to the hip, the hip popping out of the socket or dislocating again in comparison to say 20/30 years ago when dislocation rates were at 5% it is much less common now it is a 1 in 200 or 300 type of chance we use a bigger head in terms of the prosthesis so essentially it has to jump the radius in order to get out.

Years ago, there was a 22-millimetre head that we used whereas nowadays most surgeons will use a 32- or 36-millimetre head and that comes with a lot more stability.

We always quote things in terms of damage to the bone or the nerves around the area but again it tends to be very rare now and it is unlikely that something like that actually happens during surgery.

Absolutely, the better shape you are in before surgery the better chance you have of doing better afterwards. Again, particularly with regards to the knee and if you look at the quad muscles on the front of your thigh which allow you to straighten your leg they are essentially an engine for the knee and they are often extremely weak and are often the cause of the arthritis process as people get a lot of inhibition, it is like your brain turns off the muscles in order to protect the joint which I think actually makes the joint worse.

Unfortunately, when it comes to recovery and getting the knee to behave like it should then you need strong quads. There often has to be work put in before hand in order to strengthen up and that is the number one thing that will improve their outcome for them. When you think of getting up after a joint replacement and mobilising with crutches the more weight you are carrying then the harder it is going to be especially for the first couple of days.

In terms of joint replacements there is actually not really a lot of difference as such. Lets focus on the hip first of all, broadly speaking you can offer a cement hip replacement as in one that is essentially glued in or grouted into the bone and that has a rough coating over the surface of it and it allows the bone to then grow onto the surface with it with time and that’s when it gets its fix as such but within that then because you have got the ball and socket you have then got two different sides so you can then have it cemented on one side like the cup or vice versa.

In general, it varies hugely some surgeons will use one type or the other for certain cohorts of patients and I tend to use the cementing for most of my patients and again that is just my preference. Ultimately, a lot of it comes down to what you are most experienced using you are most likely to get the best outcome with the prosthesis that you are most familiar with.

Knee replacements come with cemented and cement less options and increasingly now we are seeing a rise in cement less options but the vast majority of knee replacements are still cemented into place.

There are subtle differences in the mechanisms of how two components in the knee fit and interact together, some have a dish but that’s getting into too much detail. Whatever works best for the surgeon is the way to look at it.

Within knees then as well you can replace the whole joint or you can replace part of the joint which is a partial knee replacement and again I often say to people that the first thing I do when I look at someone for surgery is can I get away with a partial knee replacement and quite often you just end up replacing the knuckle on the inside and it is a much smaller operation.

Smaller operations in general come with a lot less risk and come with a quicker recovery with a more natural feeling in the knee after. Ultimately, roughly 40% of the patients that I would see would be suitable for a partial knee replacement and it is something that I need to bear in mind and again the least you can put someone through is the best way to think about it.

This is the problem where it comes to expectations because I sometimes put people on the spot and say prosthesis can last a year which is possible because the bone can fracture around it, it could subside, you could get an infection and it could be out in a years’ time or less even but on average they are going to last very well we have the benefit now of joint registries across the world some of which have been going on for 30/40 years but the UK are coming up to their 20^th year this year and it tends to mirror our practice and we have an Irish joint registry but it is only in its infantry stage at the moment. If you look at the figures 10 years is often a nice length of time for a replacement to last and it is actually very similar in a hip and knee.

The average hip and knee prosthesis have a 10-year survival and I say to people that does not mean you have to come and trade it in after 10 years if it is still going strong. Essentially you have a 1 in 25 chance of it not lasting 10 years or more.

I replaced a lady’s hip their yesterday and she had her other hip replaced 29 years ago a cemented hip and it is going strong not a problem. One way of looking at it although getting figures for it may be hard is what are the chances in your lifetime that its going to be done again and ultimately that brings the whole age spectrum into it and if you are 80 years of age and you are getting a joint replacement then it is almost certainly going to be fine.

If you are 40 years of age and you are getting a joint replacement the implications are a lot more and not only need to be revised but it might need to be done again and the way to think of it is a mechanical set just getting bigger every time and you need to bring in bigger toys to allow you to fix the problems.

It is an important factor to bear in mind and it is not as if we always push conservative measures but in young people but we are going to try our best. If an injection is giving some relief then you are going to try it again but you try your best to just push people out that other couple of years and they may not think that it is a huge thing but it actually if it gets them a couple of years further down the line it is a big deal potentially 20 years down that line and again if we go back to the same factors of quality of life.

If your 40 years of age as far as I am concerned and your looking at a joint replacement, the diagnosis is correct well then so be it. As far as people are aware that yes there is a chance that it could be done again n their lifetime then I don’t see the sense in riding out 20 years of a poor quality of life just to get that joint replacement and that makes no sense to me.

Absolutely, it is amazing to see the difference and I mean chronological ages and physiological age and it is absolutely amazing the difference. I suppose I have the benefit of getting to look in at peoples lives all the time and you see people who come in and they are 50 years of age and they look about 80. You see 80-year olds who would pass for 50 and that is the discrepancy that is there and it literally is plus or minus 30 years how they look, act and feel.

I replaced a 93 year old gentleman’s knee a few months ago and essentially his knee was pointing the wrong direction and he couldn’t do anything and after that surgery he was back playing golf at 8 weeks and again am I going to say that everyone can get to that absolutely not but it shows that it is possible and at the opposite ends of the spectrum we can say your too young and I think that is wrong.

The one thing that younger people need to realise is that there are to aspects to it. Firstly, they have a lot longer to go in terms of their life expectancy and for some people it could be 40-50 years maybe even more.

The second thing is that younger people tend to be a lot more active so potentially they are going to use up a joint sooner so there are two ways to look at that why they may get through getting it done again.

It is funny you say that because some patients are pretty well informed and I’ve had people come and see me and say I read about this and these are the exact symptoms I have but it is a little bit of a dangerous game to play someone coming in saying what they would like you to do. I will go back to what is on the menu is what the surgeon uses routinely. We are living in a different world years ago saying that’s what we needed and if it is a dictatorship for them then so be it. In that regard there is safety of little knowledge and by reading a lot you can actually end up confusing yourself more by going a little bit beyond that especially with internet because what you are relying on is not necessarily a fact and we can talk about things like stem cells and all these different things that come with a huge internet profile but there is very little evidence for it and the leading things in terms of joint replacement.

From a hip and knee point of view all joints are pre-assessed and they have a pre-operative assessment and it is a normal medical check to make sure someone is optimising from surgery, that is probably the best way to look at it.

They are seen by a doctor and a nurse and they get a little bit of history taken of their previous medical problems, their medication is looked into, their bloods get taken as well so we can examine things like your blood count and your kidney profile that type of thing.

They will also get a trace of their heart or an ECG as it is called. If necessary some patients will get something called and echocardiogram which is an ultrasound scan of their heart but again the more information that we have then there is a lot less risk in many ways. If we know that something is there then it is rarely ever a problem and many patients sail through these things without any issue that can cause trouble afterwards or something that was diagnosed.

Based on that pre-assessment, if more detail is needed well then, we can ask a cardiologist or a respiratory physio whoever is required, to give the go ahead. The vast majority of people will just sail through that there is no problem. Obviously, people that comer with more baggage, more problems as such then we need to pause for that little bit longer to make sure they can be done.

The higher risk patients who can only be done in hospital with a backup its actually quite rare now it is a very small minority of patients who are not suitable for whatever hospital they are attending.

What I say to people when they are struggling the first day or two is that they are discharged the same day and truth be told people going home the same day I don’t prescribe it as such but partial knee is often two nights in hospital and a full knee replacement is 3 nights and a hip is 2/3 nights with us and I find that that is just the happy medium and people are going home because their pain is controlled and they are safe, mobile and confident to do things. Some people that day they are flying around but they are a lacking confidence a little bit and just would not trust it so I think a couple of days is absolutely fine.

I think especially with hip some people are pleasantly surprised the first couple of days in how quickly they improve and the first day can be tricky but by the second day they are really starting to get going and then they are usually mobile and independent going up and down to the bathroom.

Not so much occupational therapy but occupational therapy is more changing things in their home and again you don’t really need modifications like that now. A lot of the old precautions and different things that used to be done have changed. We still get people to lie on their back for the first few weeks to help. A lot of these precautions were designed to help stop the hip from popping out of the socket as such and as I say that risk is much lower now a days and you can pull back a bit on that.

In general, in relation to physiotherapy I would say yes and no because I am firmly of the belief that less is more with the hip and I frequently see people over doing it and irritating tendon muscles and other things around that area I believe just need a few weeks to heal and settle down.

The knee as we spoke about needs to be moved and needs to get going and that would take a bit of work with  a physiotherapist afterwards and as much as anything the exercises are easy, they are very simple in terms of what to do but it is about having someone there going to give you a bit of encouragement saying “come on you can do two more” or knows when it is time to push you a little bit harder and some people like a personal trainer and some people don’t and for some people they absolutely love having someone there telling them what to do.

I will often see the people who need the motivation after a joint replacement and then I will see other people who I need to pullback from overworking their joint replacement.

A lot of people who can work from home, particularly if they are self-employed they could be on their laptop doing a bit of work the following day from their discharge. If people can free up a week or two just for their own headspace I think that is very important.

The opposite of that spectrum like manual work for example climbing up ladders and working on roofs then they could be out for ¾ months maybe even more, depending on what they do and when they will be signed off to be considered safe.

Replacements exist for most joints and my area is obviously hip and knee but there is an increase in shoulder replacements, elbow replacements would be a small enough number but again weight bearing joints are much more likely to cause problems and that is why the number of hip and knees outweighs everything by about 6 times and that is always going to be the case because different joints just function differently.

Ankle replacements are becoming more common nowadays also and for other joints you have other options such as fusions. For example, it was very common to fuse the ankle to stiffen it instead of replacing it but I am now aware that people are starting to replace ankles more frequently.

The hip joint in many ways is quite simple with the ball and screws and the mechanics of other joints do not work the same and it has been harder to replicate with replacements and that is part of the reason for that.

In terms of going back to the knee you have to see if there is any other option than replacing the knee and there is a partial knee replacement as well as that knees will be suitable for something called an osteotomy which sounds barbaric but it is essentially cutting through the tibia bone usually but it can be the femur to realign their leg. If all their pain is on the inside of their leg and they are loading the inside of their leg and if you look around you may often see someone with a bow in their leg well that is loading one side of the leg much more and if you potentially unload that area as such by straightening their leg then you can take away the pain in their leg.

For younger people in particular for example, if you are 20 years of age and you have well established arthritis on the inside of your knee well you are not really going to be able to say that a replacement is an option so that is when something like an osteotomy comes in.

I think there is a nice balance between being a little bit informed and knowing what your getting but not reading too far into it and sometimes people stress themselves out too much and whether they like it or not they have to place their trust in me or whoever the surgeon is for some people it is like getting on an airplane you have to trust the plot. You will not have a list of questions for the pilot so there is an inherent trust you have to give to the surgeon. You are reliant on the surgeon to do their part and then afterwards they can worry about doing their part and in that regard, you find out as the journey goes on because lots and lots of questions before hand are going to progress as you move on that journey and it is often a better way to do it knowing a bit but not worrying yourself either. If it is 8 weeks down the line just focus on getting through today. A knee replacement is often really sore afterwards and you have got to be able to trust me. You have to think of it as though today is sore tomorrow will be better and then they know that they can trust you in that regard.

My main tip then is really to just make sure you have yourself fit and strong but there is very much a happy medium there and if you can hardly walk because your hip is so worn then there is only so much prehabilitation you can do by doing your exercises before hand and there is no point in losing any momentum before you even start the journey. I spoke much earlier about the disability and forgot to go back to it and it is something particularly with the hip and knee that we see. You have your pain aspect but then when a joint is worn, from a hip point of view you have trouble getting your shoes and socks on, trouble getting out of the car, getting up and down the stairs.

For the knee the trouble is behind you knee cap and you actually may have trouble even standing and this is something we spoke about as we get older in general the more baggage you carry in terms of that disability is then harder to manage.

I often speak to people about the risk of a fall, if you have got pain every so often and the leg wants to go then you are at a risk of falling and breaking your hip as such so people looking to avoid an operation isn’t the answer and you are here saying what can I do to maximise the chances of getting someone back being fit again in that regard. The last thing you need if you are in your 80’s is something pulling you way down as far as I am concerned you need everything going for you.