Archives: Recorded Events

Hi, my name is Neil Welch. I am the head of the Sports Surgery Clinic lab services and research within the sports medicine Department. Thanks for taking the time to listen and watch this presentation. I’m going to cover a topic and hopefully convince you a little bit about the importance of Fitness, but I’m going to talk about how fit is fit enough for golf?

The sports medicine department is kind of adjacent to the main Sports Surgery Clinic site. For those of you who’ve been out here, we see between 600 and 700 patients a week, the majority of whom have had some musculoskeletal issue, either back pain or knee pain, but we also see a portion of patients who are just looking to improve their health and fitness, and it’s the experience of these type of services that we’re going to draw upon today to talk about the role of aerobic conditioning and aerobic fitness for golf, but first of all I think it’s worth exploring and going through what aerobic fitness is? Now I’m not going to go into a lot of physiological detail with you; we’ll just do a high-level overview. Essentially aerobic fitness and changes in that is an improvement in the ability of the heart and lungs to move oxygen around the body. When your muscles work, they use oxygen to help burn fuel in order to be able to continue to deliver force and keep you moving, and so any improvements in the ability to move oxygen around the body lead to an increase in aerobic fitness and an improvement in your efficiency during tasks that require that.

Now golf is a sport that’s changed quite a lot over the last couple of decades, and the answer is on Fitness; it certainly has grown, and that is filtering down towards the amateur levels and the social levels within the game as well to some extent, I guess! Most of the emphasis has been placed on the role of strength and power, with figures like Bryce de Jambo highlighting the importance of lengthening his driving game, and Club head speeds and ball velocities are figures that are talked about a lot. We have even covered this in presentations here at the Sports Surgery Clinic before. But what I’m going to do is lean a little bit away from the strength and power side of things, the importance of the relevance of that and talk more about the aerobic elements within the game and the aerobic demands. So first of all, we talk about aerobic fitness for golf, you know why we need it? What’s the point? The two broad areas where it can have some benefit, one is around improved endurance and the second is around better mental focus and concentration. We’re going to talk about each one of those.

So the need or requirement for some kind of endurance comes from essentially the length of the game, and depending on the course that you play and how well you are playing, you can cover anywhere between six and twelve kilometres during the round okay, which is a decent Difference by anyone’s yardstick and in order to be able to support the strength and power demands within the game having a good aerobic base is important for that. What you will actually see during a round is your heart rate will vary, so the aerobic demands will vary depending on, I guess, whereabouts on the golf course you are and the mental demands of the mental strain, but anywhere from sort of 52 and 78 percent of your maximum heart rate is where you can jump around so it’s quite a significant Range or change in Aerobic demands within the sports and oftentimes this can be down just to the track that you’re playing.

So here is a lovely image of Enniscrone; I’m sure there are a few of you on tonight who have played there even if the courses don’t have a lot of vertical, but there’s a lot of undulation there’s a lot of challenges in that up and down movements, and that’s where a lot of the aerobic demands come from so just making sure you have

Fitness to get around the golf course regardless of the shots you are playing is a bit easier; this is where the endurance and the aerobic demands and improvement start to have an impact. When we talk about concentration, studies talk about aerobic fitness being related to higher executive functioning and so your ability to start making decisions through sustained attention; you know, for those of us who start to fade throughout the back nine, oftentimes we can talk about the role of an attentional focus being an issue the fitter we are the more able we are to sustain high levels of attention to whatever it needs to be would be that a club selection, shot selection or even just the task demands and being able to execute our golf swing the way we want to. Selective attention, so for those of us who are looking to maybe improve our golf swing and are focusing on certain cues or certain elements within the swing, maybe you have been working on it with a coach, being able to stay on the message, I guess with our attention is aided by aerobic fitness that falls under this higher executive function and the technical side of the game is something that is impacted massively by the level of aerobic conditioning and obviously a potential Focus so any improvements there are obviously going to be beneficial and then resistance to interference so the idea that you know potentially and some of our old habits and old thoughts around our golf swing start to slip back in or even some jibes with the people that we are playing with our ability to resist those kind of and not let them become part of our golf game is also improved by better aerobic fitness so there’s a few areas there where we can start to develop our game just simply by being a little bit fitter.

There’s some relatively interesting cases where we can kind of see that the role of this particularly among the elite game so what I’m showing you here is a graph of heart rate information from Justin Thomas a couple of years ago and this was around him making an eagle putting when he was playing in the tall grass and what we’ll look at is the first part of this graph here highlighted on the left is as he’s starting to get ready for his for his putts and his pre-putt routine we can see obviously the importance of the shots his heart rate starts to climb from below 100 up to 110 beats per minute the next patch of this graph just demonstrates the effectiveness of his pre-shot routine so aerobic fitness is going to impart support your ability to lower your heart rate is going to be dictated by the efficiency and the Improvement in your heart that you gain from aerobic fitness so we can see that heart rate dropped to below 105 before he takes the putts and then what we see after this is success and celebration so obviously he goes a bit bananas at sings in Portuguese. He is putting himself in a much better position within the tournament there, but some interesting information around maybe how the role of aerobic fitness can benefit our golf game and give you a little bit of better control. Right, who’s to say that if Justin Thomas’s Fitness levels weren’t as good and he wasn’t able to bring his heart rate down that he might not have made that shot, and then obviously, that’s going to impact his earnings, you know we can imagine the same thing happening for us in our golf games.

So is getting a little bit fitter worthy of devoting that much time to improving the game? You know I’m not going to stand here and say that you know you should take time away from you’re your practice in order to be able to get fitter, and that’s going to have the magic input into your game to have you reaching the handicap that you’re looking to, but it can have some benefits probably I think the wider benefit of aerobic fitness is something that might swing you towards making a bit of a change you know because there are lots of other benefits to aerobic fitness and again I’m not suggesting we all need to be looking like this in our later years, but certainly we start thinking about the longevity effects of being more aerobically fit.

There are a number of areas where we can see improvements, and a healthier cardiovascular system is one of them. What we’ll see is a reduced gain in weight as we go year on year; aerobic fitness is vitally important for that, we see reduced inflammation within the body, and anyone who’s had issues with joint pain in the past is probably going to understand the rules of information there, and we’ll talk about that in a second and then reducing the risk of developing chronic diseases so just staying healthier throughout our life and making sure we’re living as long a life as possible.

When we’re talking about cardiovascular health, essentially, we’re looking at the improvement within the heart itself, the circulatory system behind that and then also the lungs, and there were certain adaptations that we get with our fitness work and our aerobic training, Increases in our heart stroke volume this is essentially the amount of blood that the heart can pump in each heartbeat so as you get fitter the heart itself changes certain elements within it get bigger it’s able to bring more blood into it and to pump more blood around the heart this is what contributes to reduced stressing heart rate so effectively the heart is more efficient and like as your aerobic demands increase your heart just doesn’t have to work as hard. We also get an improvement in the way we move oxygen around the body, so actually, within muscles themselves increase the number of capillaries, they are the smallest blood vessels that we have, and we get a large number of capillaries around the muscles to deliver blood around the muscles and therefore oxygen to help us become more efficient at burning fuel and using the muscles.

Let’s talk about these most common injuries, as we as we discussed the MCL or the medial collateral ligament this is the most common injury so a sprain or a tear in this ligament. The Anterior Cruciate Ligament is the next most common and again we can have sprains which is a more minor injury or a tear, complete rupture and then we also have meniscal injuries which are the shock absorbers in the knee that can be injured from skiing related falls.

Medial collateral ligament injury, as discussed earlier this is the most common injured ligament in the knee while skiing. A typical injury from this can result from a blow from upslope on the outside of the knee. We can see here in the diagram there’s a direction of force coming from the outside of the knee which is pushing the knee inwards. In turn, this will stress the ligament or strap-like ligament along the inside of the knee which can cause either a sprain which is a stretch or a tear, complete rupture which is when the ligament is severed. Following an injury like this we can have some perhaps delayed swelling, immediate pain depending on the severity of the injury and a sense that the knee is unstable or inability to weight bear through the knee.

The second ligamentous injury then is the Anterior Cruciate Ligament. This injury typically is a more forceful injury when we have some rotation of the knee with ski getting caught perhaps landing awkwardly from a jump. Typically, with a complete tear of the Anterior Cruciate Ligament we will hear either a pop or a snap and we will have some immediate pain and immediate swelling with this. Again, inability to weight bear can be a sign of a higher-grade injury.

Finally, we have our meniscal tear injury, in this diagram we can see a picture of the meniscus from a frontal view of the knee. We can see this is the shock absorber that’s sandwiched between the big bones in the knee and on the right-hand side of the screen we can see a tear in the meniscus. These injuries can typically occur from some sort of rotational based injury so this can be an awkward fall, it can be a ski getting caught or it can be from a trauma from an upslope collision. Some of the tell-tale signs of these type of injuries are symptoms that disappear as we straighten out the knee and that reappear as we bend the knee. This is as we compress that shock absorber when the two bones come together.

Now we’ll move on to factors that lead to knee injuries. Level of ability, skiing at a level that is too fast or too steep for our ability can inevitably cause injuries. Another point is incorrect ill-fitting or damaged ski equipment perhaps boots that are too loose, ski bindings that are not adjusted to our weight and come off while we’re skiing at speed can all cause injuries. Our fitness levels and strength levels and we will touch on our strength levels as we move on through this presentation. As with any sport taking too many risks and ski conditions can have a big part to play when we talk about skiing injuries.

Now we’ll move on to reducing the risk of sustaining a potential injury. We touched on strength in a previous slide and now we’re going to look at some targets and some things that perhaps you at home can aim for to see how strong is strong enough. For our front squat we’re looking for 50 to 75 percent of our body weight and we can see that the bottom corner of our picture here. Wall sits, again we will see them later on in the presentation we’re looking for four sets of a one-minute hold and leg press we’re looking for 1.2 to twice our body weight. For our posterior chain then for our big bum muscles and hamstrings we’re looking at our deadlift which we’re looking for at least a body weight lift on this. Our hip thrusts, again this should be our strongest exercise so we should be aiming for one to 1.5 times body weight on this exercise. Then if we talk about our upper body so a consecutive round of 10 to 12 push-ups can be a measure used here. One to three pull-ups or a single arm row, where we’re pulling at least 30 to 40 percent of our body weight. Now these are quite general targets which can be used in the general population as we progress into maybe more athletic or more elite. Key themes, we’re looking for higher levels of strength.

Now we move on to our initial injury management. If we’re unlucky enough to pick up an injury like this what should we do? In the first instance we need to stop skiing, we need to use the police method for swelling management. Some of you at home may be familiar with this method previously known as the rice method. We’ll talk through it now so protection is the first thing so again we want to remove ourselves and rest ourselves up so let’s take a break from the slopes. Optimal loading, so this is more our rehab-based stuff which we’ll talk about later in the presentation. Ice, compression and elevation. These are going to be our big three to try and manage that swelling and manage that pain early on. Again, we reassess this after 24 hours initial swelling and pain should start to subside pretty significantly if we’re using this method after 24 hours. However, if we’re struggling to get the pain and swelling under control it’s a good idea to seek some medical professional in the locality of the ski resort.

What are the urgent signs and what are the non-urgent signs that we need to see our physiotherapists?

Again, that pain and swelling that persistent high levels of pain and swelling which hasn’t subsided, inability to weight bear particularly a day or two after the injury and a knee locked in a certain position. We discussed earlier with the meniscal tears when we’re straightening and bending our knee sometimes those symptoms can reappear and then sometimes they can subside so particularly with our meniscal injury sometimes the knee can get locked in a certain position and we can struggle to straighten or bend this. Some of the non-urgent signs if we’re struggling to get back to full function, so we just feel like this injury is lingering we’re able to manage on a daily basis but perhaps we can’t get back to more higher-level tasks. Unable to regain full movement in the knee so perhaps we’re struggling to fully straighten out the knee or fully bend the knee, and a decrease in strength and endurance.

Let’s move on to some rehabilitation or rehab ideas for some of these most more common injuries. Here in the Sports Surgery Clinic we use a six-step approach so we move from our diagnosis and assessment so if you come in first from from a ski injury or from a ski holiday first of all we want to get a diagnosis and get a good assessment and then we can build our program on top of that. Step two then we want to get our mobility back, we want to be able to bend and straighten our knee fully, get full control in our quad and optimize our strength back to normal levels. Thirdly, then once we have our strength in order we want to build on top of our power and our reactive strength particularly some people who are maybe going back to high level sport or back to high level skiing. Then we bring in our linear running and our multi-directional running and then we’re back into sports specific and fatigue ability and this is the end stage before we go back to performance.

Now we’re going to move on to some rehab ideas and some rehab exercises for the more common knee injuries. Here you can see my colleague Vanessa who’s performing a wall sit exercise so we’re going to start off with a double leg wall sit, 90-degree position at our knees back flat against the wall or even to hold this position for 20 seconds by four sets. Progression of this can be moving on to one leg and holding for the same amount of time. Next, we have a leg extension exercise. We can see Vanessa here doing a single leg, leg extension which could be completed in a normal gym. We’re straightening out the leg keeping the toe pulled up towards the sky. All the way up and slowly back down, so slow and controlled with this motion again aiming for somewhere between three sets of eight and three sets of ten. Here we have our pistol squat exercise so we can do this in a gym or using a banister at home something that we can hold on to having a chair behind us around knee height. We’re going to slowly lower ourselves down on to the chair and then come slowly back up the key to this is that our knee doesn’t drive out over our toes or we’re trying to maintain our knee in the same position and finally we’re going to move on to our crab band exercise so the previous three exercises we focused on the quad muscle along the front of the leg. Again, after knee injuries our quad muscle is the most affected muscle so inevitably we’re going to be decreasing our strength in this muscle so it’s vitally important that we work hard to build that strength up to the same strength as the other side. Another important muscle following an injury like this is our lateral hip muscle along the side of our bone. Here we can see Vanessa performing a crab band exercise so we have our feet hip distance apart we have a black band just above the knees we’re going to sit back into this. We’re trying to keep our feet flat along the floor and we’re going to push our knees apart hold for three seconds and come back to the start position. Again, this can be done in a gym or it can be done at home using a banister or a door frame so. These are the main exercises that I would focus on post injury after skiing but also these can be used as prehabilitation or before we go skiing to build up the muscles around the side and hip and the muscles around the leg.

That concludes today’s presentation on knee injuries and skiing, feel free to ask any questions.

 I have osteoarthritis in both knees would that prevent me from taking up skiing and are there exercises I can do to prepare for that? Are there things that can help you?

Yeah, some of the videos that we touched on in the presentation focused around quad strength of lateral hip strengthening the stronger we are in these areas the more pressure we’ll take off the knee and the easier skiing is going to be for us. I suppose age will come into this, the age of the of the patient who’s skiing or the person who’s skiing and the level that they want to get back to so obviously the more intense or the higher level skiing the harder it’s going to be if there’s a high level of arthritis, if there’s a lot of arthritis in the knee. As an off the bat answer. I’d say absolutely not you can certainly ski with arthritis in the knee.

Should you avoid skiing totally with arthritis?

No, I think you know within moderation as well I think you have to look at the period of time you are going to ski for. It’s a fairly active exercise puts a lot of pressure on the front of the knee so one would try to be a bit judicious how long you spend on the slopes and perhaps have a few anti-inflammatories ready with you on your trip just in case you do get a bit sore. I went skiing a couple of weeks ago my mother who has some arthritis in her knees and I was chasing her down the slope so I don’t think it’s a contraindication whatsoever.

Due to wear and tear I had a full knee replacement 12 months ago should I be expected to be able to ski?

I think it depends on what level you’re skiing at and how much you want to ski and the degree of difficulty with the slopes but certainly there’s no reason why someone can’t go back to skiing following a knee replacement. I think once again you want to maintain your level of fitness and the same muscle groups the quadriceps, your gluteal muscles, you need to be fit and active to be able to do so and I would suggest if one is going back that they don’t go on a black slope to begin with and start relatively easily and just have reasonable expectations but Andrew might want to offer some other advice from a physiotherapy perspective.

I think a lot of that comes down you know we see a lot of patients post-operatively here from a rehab point of view having had a knee replacement with Brian or some of his colleagues and I think it comes down to the level of rehab and what they want to get back to so what the patient puts into it they  get out of it. The higher the level they want to get into it the more intense rehab is going to be involved but as Brian says, I think it’s certainly achievable but just having your goals and ambitions in line.

What is the usual time for returning to sport after an ACL injury or tear, and skiing as well?

I think we’ve probably changed our outlook on that over the last number of years because we recognise that the most vulnerable time for someone to re-injure is within the first year after ACL reconstruction, so we tended to push back the time a little bit in terms of they’re looking at anywhere between nine months and twelve months typically now. We’re a little bit more objective about that as well I think that the advantage within the sports medicine department is we do ACL testing so we look at an individual’s strengths compared to their other leg and also look at their ability to perform tasks. Andrew or his colleagues would do a full battery of tests to see how someone is coping after an ACL reconstruction but typically it’s in the region of around 9 to 12 months. We love to return to sport all going well.

Someone had ACL surgery actually just in October. They started a hematoma at the time as well, which is bleeding into the leg and the consultant has given them the all clear but they wanted to know would they be fit to go by the end of March?

I don’t know, I think that’s a little bit too soon from my perspective but you’d have to assess the individual but I’d be a little bit concerned to go in March I think perhaps next year or go to the southern hemisphere to ski in late June or July elsewhere but I think that’s a little bit premature personally.

Someone fully tore their ACL almost fully to her MCL she has bone bruising and a small fracture. How soon should you see a consultant? She’s in a brace and it happened on the 2nd of January.

From my perspective, I think a reasonably accused consultation, so within the next couple of weeks I think would be appropriate but more importantly as well I think that you need to get to see a physiotherapist to get moving that leg. I think one of the fears we have once someone’s had an injury of that nature is that they don’t move and get stiff and that’s a really important. Maybe Andrew could give his opinion regarding the effective rate of the importance of range of motion pre-operatively.

We see a lot of these what we call pre-op ACLS and the first thing they come in is crutches. Perhaps in a brace you know very fearful of moving, very fearful of putting weight through their knee. If a patient moving like that was to go straight for surgery I think that they’d be in a little bit of trouble so what we want to do is reassure the patient that we want to get the knee moving, bending and straightening within normal ranges. We want to get the the quad muscle on the front of the leg working adequately and then get them into surgery so it’s kind of a case of the better condition they are going into the surgery with yourself Brian the better condition they are going to be coming out of it. I think that’s quite an important factor as well particularly with the ACLS and the younger athletes who are more fearful.

Hoping to ski regularly twice a year but have ACL damage in both knees not ski related. One has been repaired with a graft and the other one hasn’t had surgery to it just rehab about five years ago. Any advice, this is for Andrew, on strengthening exercises or preventative measures example supports to help prep while skiing.

I think as a general answer to this question there absolutely is and when we’re talking about general strengthening advice for ACLS a lot of it is going to come centered around the gluteal muscles and the quadricep muscles. It’s going to come from a strength point of view and also from a control point of view so how well can we control that muscle as we’re moving. Perhaps in a single leg squat motion something of that nature but for something like that it’s very hard to give individual advice on a query like that. Ideally we’d like to perform some sort of testing so we can have some kind of objective data to fall back on and then give them more of a concrete answer on that.

Someone’s just said I think probably from watching your videos, would the band crab exercise irritate the meniscus or the menisci?

No, it depends on what the degree of meniscal injury is. If it’s what we call a displaced meniscal tear, maybe where a piece of the meniscus has come out and is causing irritation in the knee something where the knee is perhaps locking that may be something that might have to be surgically excised or just removed but other than that the exercise can be adapted so that we wouldn’t irritate the meniscus.

Someone’s asking us does skiing increase their like likelihood of developing osteoarthritis?

I’m not aware of any studies that have shown it. I think if you rupture your ACL unfortunately the risk of developing arthritis is greater and skiing is a high risk sport for ACL injury. Typically skiing you’re downhill you know you’re just a bending motion within your knee normally if you ski well. Unless you get injured I wouldn’t think it would increase it significantly but if you’re injured perhaps it does.

I sustained a tibials fracture in my left knee no displacement on Christmas Day in France home last week and have been referred to a local hospital for the Fracture Clinic that hasn’t been seen yet. I’m still in a knee brace and on crutches when should I start Physio and be fit to return to skiing?

The important part of that last question is when they should start physio and I would say immediately. I think that the likelihood is this brace may not be a brace that moves and that can be problematic given that it’s almost four weeks now and since the injury so I’d certainly see a physiotherapist and likely get to see an orthopaedic surgeon reasonably soon to get moving. I would hesitate to answer the last part of that question without assessing the patients.

I tore my ACL skiing two weeks ago but waiting on an MRI result before seeing a consultant do you recommend the physio demonstrated in the video to do at this stage?

This is what fall into the category of a pre-operative physiotherapy for ACL. The exercises and the muscle groups that were working in the videos would absolutely be appropriate but it’s just the dosage is really important and that’s why it’s kind of important to see a physio maybe to get a tailored program to make sure that the exercise is at the correct level for the patient so some of those exercises particularly a single leg wall sit would be at too high of a level for a patient who’s perhaps just rupturing ratio today might be a little bit more advanced for for for someone who just ruptured their ACL.

I currently have no knee problems but I am over 50 is it wise to wear knee braces or straps to prevent injury?

I don’t think there are any proven knee straps that will prevent injuries while skiing I think that sometimes you know if someone has a sense of instability that they can get some feedback from straps Etc but my advice would be to follow a good prehab or prehabilitation program prior to going skiing so you know that your muscles are activating well and you have a general level of fitness I think that’ll be more important than any brace personally.

Someone is 15 months post total hip replacement they worked hard on fitness but still strength deficit is skiing safe even on blue slopes?

I would be a little bit concerned with the strength deficit. If an individual can’t walk properly and it’s noticeable that they have a limp or some type of altered gaze then I would be cautious about skiing in that scenario. If if they improve on their strength or they adjust their strength deficits you know there’s no reason that person couldn’t ski and they’d want to be able to kind of move or perform you know reasonably good twisting exercises prior to considering it and blue slopes are probably one of the more dangerous slopes, they tend to run into the village and where lots of people are coming so it might not be the easiest one to go for.

Good evening ladies and gentlemen. I’m going to speak this evening on common knee problems when skiing.  The title of my presentation is ‘Beware the slippery slope’ My name is Brian Devitt. I’m a Professor of Orthopaedics at Dublin City University and I’m a consultant Orthopaedic surgeon at the Sports Surgery Clinic.

This is a common scenario when we’re skiing if your friends are like those who need enemies! I’m just going to replay this video clip in slow motion and you just see how a common Knee injury can occur, so he’s going through it in very deep snow, and he has slipped back, and that crack you here is not a ski coming off but his ACL rupturing. Unfortunately, knees and skis injuries are very common. I did one of my fellowships in Vale Colorado which is a ski resort and it’s essentially a conveyor belt for knee injuries and one of the forefathers of ski treatments in terms of knee injuries is this gentleman called Dr Richard Stedman and he told me when I was there that ‘if you were to design a device to rupture the ACL you couldn’t get much better than a ski’, now skiing is good for business in ACL surgery and that’s why they have a big hospital at the foot of the ski hills and the reason it’s good is that skiing has become hugely popular it used to be just a sport for the wealthy but now most people have access at least can go skiing once in their lives but many people go a couple of times a season but it’s a risky sport we look here at some of the statistics of which joints get injured you see that the upper limb happens in seventeen percent of cases you get forearm and hand injury in seven percent of cases you can get some neck or back pain less commonly but then you get an awful lot of knee injuries which represents up to 35 percent of injuries and these relate to the ski and the devices that the equipment you use for skis.

If you think back to the olden days when people used to strap themselves in their boots to two wooden flanks and go down a mountain, things have advanced quite a lot with respect to knee injuries and equipment and skiing equipment. We have boots that are fixed and the boot allows a little movement at the ankle but it’s fixed to the ski, and unfortunately, when the ankle is fixed that all the rotation occurs around the knee, and that’s where you get a lot of injuries the skis themselves have improved and you look at the binding of the ski and this allows the boot to come out so when you’re going to a ski shop to get fitted for skis they’ll often ask you your level of expertise being novice, advanced or expert and really what they’re doing in this scenario is they’re tightening your boot or the dim they call it to the extent to which you have to move or pivot for your boots to come out of your skis. So expert skiers have their boots fixed into the skis, and therefore, if there’s any twisting, it goes through the knee and the boot doesn’t come out, so if you’re any way apprehensive when you’re going to get your skis fitted ask them to keep the din low so your boots can come out of the skis and not your ACL rupturing in your knee.

We also recognize that terrain and the conditions are very important for knee injuries, and obviously, steeper slopes or heavier snow or slushier snow can develop injuries we also know that the après ski is quite popular, and it’s when you can combine alcohol with risky behaviour that you can get unpredictable behaviour and this is often very common in ski resorts and is a major source of ski injuries so when we look at the specific type of mechanisms and these are often Involuntary and particularly when you’re starting you can’t stop it well you very much see that the person leaning back under skis the skis off balance your hips are below your knees or your uphill ski is on weighted and these put an increased torque or twist through your knee which can cause some injuries so the key issue in terms of avoiding injuries is getting lessons and sticking to your ability level so that you can decrease the risk of twisting your knee if you’re on a slope that you’re not experienced or able to manage.

We also know the unpredictable behaviour with drinking and that can be a huge factor, as I’ve previously mentioned and we also realize there’s no legislation for stupidity, so you can’t prevent those types of injuries, unfortunately, so when you’re on the mountain what can you do well we use the phrase in medicine ‘primum non nocere’ first do no harm so be careful don’t try to hurt yourself stay in your lane don’t ski beyond your level of expertise which is really critical and oftentimes it’s a husband or a boyfriend bringing their partner up on the slope that they’re not able for so do stick to your level of ability because it’s really important.

Beware of the hazards when you’re on a slope. There are lots of people on the slope you need to slow down the uphill skier is responsible for avoiding the downhill skier, so it’s really important that you are aware of your surroundings and those people who are surrounding you, and sometimes, it’s not just on the slopes, it’s getting to the bottom of the slopes where injuries can occur and I think that was more of a head injury rather than a knee injury but equally someone is going too fast and not being aware of their the hazards in their environment so return to your comfort zone it’s often best when you’re starting off, particularly in a week’s worth of skiing that you start easier get your ‘ski legs’ as we refer to it as opposed to going right up the top of the mountain on the black slopes.

When we’re in the clinic, unfortunately, when people injure themselves, they may need to be taken down from the mountain by the ski rescue and they’re often reviewed in one of the ski clinics at the bottom but when you’re in the clinic as we assess people we normally aren’t doing it on the mountain that we have the cold light of day which allows us to assess things more appropriately so this is an article I really feel is very effective in terms of how to manage someone with a knee but it was written in 1964 by a gentleman called Professor Appley and it’s referred to ‘Intelligent Kneemanship’ so I’m going to give you some of the hints and tips that we as surgeons utilise when we’re assessing someone who’s injured their knee following an injury. First, We Take a History, so “To listen is to learn… we all pay lip service to a careful history, but how many of us are patient enough to elicit one?” so this is the real key when you’re taking a history you want to figure out what happened to the person on the slopes so typically they involve a twisting injury where they may hear a pop as we saw in the video earlier on we ask for the patient or could the individuals ski down the mountain typically if you can ski down the mountain the injury may not be too severe but if you’re taking off the mountain it likely is we also want to recognize did the knee swell up within 12 hours of the injury and that would give us a good idea that normally if you have swelling, it relates to bleeding and if you have a knee that’s bleeding it typically indicates an ACL injury or something and quite severe within the knee.

We perform a clinical examination so this is really important you do this appropriately and this is another quote from this article “to look at one at only one knee is absurd man is biped – and how considerate of nature to provide a normal for comparison. But nature did not provide trousers and these must be removed.” so you often come to a clinic and I insist the patients to wear shorts so I can see both legs we can compare the good side with the bad side it makes for a much more accurate clinical examination we then have to recognize the surface anatomy around the knee so we go on a systematic approach to assess the ligaments at the side of the knee and also the ligands in the middle of the knee through our clinical examination you can see very clearly looking at this lady’s knee that she has an injury to the right knee which is extremely swollen but if you look more careful you’ll see that she also had a previous injury to the left knee but this is typically what you see following an injury you see a big swollen knee which is difficult to bend and quite stiff in terms of further investigations when someone comes to the clinic we would always get an x-ray the x-rays can be very helpful I’m going to show you on this x-ray where you see there’s a little flake of bone just on the outside of the knee which indicates that person has torn their ACL more commonly however we get MRI scans and these are hugely important in terms of looking for knee injuries we see this area of whiteness within the bone and this indicates a bone bruise so there’s two areas of bone bruising one on the femur here in the middle and another one at the back on the outside so if you imagine at the time of that injury this part of the bone and the femur was in touch with that part of the bone on the tibia so for that to happen something has to give and that’s typically the ACL.

You can use ultrasound; however, with the Advent of MRI, it’s not as effective and it’s best for superficial injuries. The most important thing is to get a referral, and once you suspect having a knee injury get a referral to an orthopaedic surgeon or a sports medicine physician who can assess your knee and determine whether you require any further treatment and at least come to a diagnosis which is very important so in the cold light of day that’s the time that we should manage these injuries I’ve often heard stories of people getting operations the following day following a knee injury and having a knee reconstruction and it’s not really best advisable I think you’re best off returning to your country of origin having things assessed and dealing with the injury in the cold light out of day with all the information available.

So early diagnosis is important, but often delayed treatment is necessary; the reason we do this is that the knee may not be ready for surgery following an acute injury, and the reason for that is it does become swollen and it’s not a good environment to operate in a knee that doesn’t move fully so it’s really important we get people’s legs moving immediately after the injury to ensure that we can operate on when it is appropriate. We also look at non-operative versus operative intervention I’ll give you some case examples later on to define when we would treat something non-operatively versus when we require an operation and not all knee injuries require operations that’s really important we try to remove splints as soon as possible to get motion so the only reason we would leave a splint on is if we’re very concerned that a ligament is lacks and therefore is going to not heal in the right position but typically we take the splints that keep the legs straight off so we can get the knee moving as soon as we can as I said range of motion is critical weight bearing is tolerated it’s important so a lot of times people try to offload their knee by not putting the weight through the knee but weight bearing is very important to load the cartilage and it allows the cartilage to be nourished but also improves your range of motion and where appropriate and in most cases it is appropriate we encourage patients to start weight bearing again.

I’m going to go through some common scenarios that I would see in my clinic on a regular basis and hopefully, these will be helpful for you to understand the common knee injuries. I saw a novice snowboarder so this is the letter I received ‘Dear Brian thank you for seeing Ben age 14 years with a snowboarding injury one week ago the mechanism of injury wasn’t clear so he didn’t appreciate what happened but they were swelling within 12 hours and he was able to toe touch weight bearing on his toes only so he’s obviously very sore he couldn’t fully extend his knees I couldn’t straighten it out and he had an x-ray which was unremarkable showed a little bit of fluid and MRI was performed and revealed a small medial condyle fractured so that’s a small fracture at the outside of his knee with the grade two MCL which is the medial ligament or the ligament inside of the knee so he’s currently in a brace i’ve advised him to be non-weight-bearing’ and so the mother will bring on the images this is a very common injury so it’s a contact injury while turning there was no pop when I took his history he didn’t hear or feel anything pop he fell to the ground but he couldn’t wait there it had to be taken off the hill no immediate swelling and but swelling within 12 hours which is very common so when I looked at this young man I saw his knee was flexed he had a limp, he had swelling within his knee, he couldn’t fully straighten his knee but he could bend it pretty well and he had a laxity on his medial ligament was somewhat loose but he had a negative Lachman that’s the test we used to assess for an ACL so that wasn’t and I wasn’t concerned about that when we look at his X-ray he sees a young man so these areas are his growth plates but there’s no evidence of any significant injury within his knee on x-ray we then looked at his MRI and you can see in the MRI there’s increased signals so that’s increased fluid on the inside of the knee so this indicates that he had a medial class of ligament injury so for this young man it doesn’t require any surgical intervention we need to get his knee moving and we need to allow that ligament to heal and thankfully he avoided any surgery and was able to return to snowboarding the following season. This is just an example of his ACL being intact, and it’s this nice ribbon-like structure going from the tibia all the way to the femur, so that was absolutely fine.

Our second scenario is an experienced skier so the history of this individual is he at a high speed fall while turning on a steep slope he heard a loud pop just like the guy in the video at the start, he couldn’t stand, his knee buckled and he had to be taken off the mountain with immediate swelling so on examination his knee was bent unable to weight bare there was a big effusion or lots of fluid within his knee and he had lots of bleeding or bruising on the inside of his knee so when I examined him his knee was opening up hugely on the inside so he had a big medial sided or inside knee injury and the Lachman test his ACL was positive so looking at this guy’s x-rays he doesn’t show any significant injury on x-ray on the left which was the uninjured side but you look in the right he has this flake of bone on the right side which indicates that he has torn his ACL so we look at his MRI scan first of all you see the whiteness within the knee so this is his femur here this is the tibia and you see all this fluid within his knee which indicates he has bleeding within his knee and if you look at this structure here which looks a bit like a bow tie that’s its meniscus that’s sitting off the back of his knees so that indicates that his tibia is too far forward so he’s torn his ACL and you can see that here this is the ACL so we saw the previous image with a nice ribbon and you can see that there’s no continuity of that structure so unfortunately he’s torn his ACL and he also has a big site medial sided injury or inside injury where this should be like a black line but it’s grey and there’s lots of fluid around that area suggestive of a big injury so unfortunately this gentleman required an ACL reconstruction and medial class ligament reconstruction to get him going again.

The final case is a recreational skier so the history of this individual is that he twisted his knee trying to remove his boots from the bindings so we’ve often seen this scenario where you’re tired at the end of a long day and you get lazy and you twist your boot to get out and he felt a crunch at this time he used a different form of analgesia however to what we recommend and he said it was fine after a wine so he managed to persevere, but the knee became very painful that night but he did manage to ski on he said he lasted the week through Gritted teeth so the examination showed a normal alignment of the knee but he did have a limp while walking there was some fluid within the knee but the range of motion was excellent however, once I flexed his knee to the maximum extent he did have some tenderness over the inside and all the ligaments examination was normal so we look at this MRI scan here and we see the inside meniscus so the shock absorber and this should be like a black triangle like we saw previously but you see that this white line through the meniscus and based on this individual symptoms if they had a lot of displacement at that meniscus and what’s causing some issue so unfortunately they had to undergo an arthroscopy and just remove the torn portion of the meniscus to get them back on the mountain the following season this is just a view from the side where you see that that meniscus has flipped and it’s stuck down the outside of the tibia here which causes quite a bit of discomfort, unfortunately, these type of injuries aren’t going to heal with just rest as you have a displaced fragment which is the key factor so thank you very much I would urge you to be cautious on the slopes and ski within your level of expertise and if you are injured however we’re very happy to see you and we’ll hopefully get you back on the slopes as quickly as we can okay thank you very much.

 On average, how many weeks of pre-operation Physio are required?

A- yeah, that’s an interesting one, so a lot of things that come down to this is kind of objective testing and how the patient is performing themselves, so rather than a definite timeline if you need six weeks, it’s more so how long does it take to get what we call a quiet week where we can maintain full extension getting the knee fully straight maintain an amount the same as the other side and have good quad muscle activation in that we can lift our leg straighten that leg straight up off the bed and we can tick all those along what walking normally that we have no limp I think that’s a suitable time then that we can suggest they can go in for surgery.

I’ve had an ACL reconstruction and several cartilage tears from soccer and rugby during skiing this season, struggling with a lot of swelling; the baker cyst was painful at age 62. How do I know when it’s time to think about the replacements?

B- well, I think it’s similar to the last question again when it affects your quality of life, so it’s yes, you’d expect someone who’s skiing that you know more low is going through the knee they may have more swelling but it’s in their day-to-day activities and you know remember we only ski at best a couple of weeks a year or more if you’re lucky so it’s more in your day-to-day how much it’s affecting you and particularly night pain as I mentioned and you know I ended up having an assessment with someone who’s going to you know look do some weight-bearing x-rays to see how bad the arthritis is and they’ll be able to give you advice on that.

Andrew, would those rehab exercises be beneficial for a patellar injury?

A-I suppose we need to be a bit more specific in the injury, so there are a couple of Patella based injuries; there could be a patellar fracture, or it could be a patellar dislocation. I suppose the key to those injuries is they’re General exercises for, you know, the injuries that we talked about in skiing which were predominantly ACL MCL and meniscal injuries, but if we want to tailor them to a patient outside of those iron injuries, it’d be pretty important just to get a tailored program by a physiotherapist on that because it’s very hard to give general advice when we haven’t assessed them.

We’ve spoken about how going to go back after an ACL surgery but they’re saying if they don’t opt for surgery and it’s non-operative ACL management, how long then should they return to Skiing?

A- yeah, again, that’s an interesting one and it comes back to how the patient is doing themselves; so if a patient was going back to skiing and they were conservatively managing the ACL, which we see a lot of in here, again I would advise doing the testing so that we have some measures under quad strength some measures under their hamstring strength have a look at their jumping and Landing to see are they going to be able to tolerate the forces of skiing and if they can tolerate those forces there would be no problem with skiing.

B-I also add that I think it’s important that you check the symptoms and whether someone feels unstable, and I think that you know if you might be fine in a straight line, but then if someone twists and that can cause a sense of instability to the knee, so I think you’d want to be symptom-free from an instability perspective as well.

Dislocated in the knee 18 months ago since having patellar stabilization surgery with ten months recovery, returned to playing Gaelic football at the start of the season in 2022 without any recurring injuries; what precautions should I take for skiing?

B-That person seems to have done it very well following surgery which is successful, and be able to return to sports, so if there’s a good level of fitness and they, you know, a good deal and quad strength, I think that they should be able to return to skiing and I wouldn’t advise any precautions if they’re fit and healthy.

Do you see an increase in ACLS in females compared to males?

B-From skiing or from other sports? Yeah, we certainly have seen an increase in female patients and I think one of that is it’s been a big epidemic in Australia where I was recently working, and we see a huge increase as more when we’re paying ladies AFL and so yeah, we see it a lot and we see in younger patients as well quite a lot and with skiing it’s like a conveyor belt for ACL injuries whatever the gender so it’s a very common injury for both genders.

What is the importance of flexibility in comparison to strength training for Skiing?

A-I suppose the two of them go hand in hand, you know, the stronger we are in our muscles, the more range or, the more flexibility we tend to have, so both of that kind of go hand in hand. I wouldn’t pick one over the other and I certainly wouldn’t work on a stretching program when strengthening is what we want; you know, strength is what would outweigh the flexibility arm for knee injuries and skiing anyway.

I’m sure some of you who are listening might be frequent flyers into physio and know what it’s all about; others might be listening to this thinking, I have no idea what to expect when I have back pain and attend a physiotherapist.

Firstly, your Physiotherapist will ask you to provide them with a history of your back pain. When did it start, how long has it been ongoing, and are there movements that make it worse or better?

Then a physical exam will examine how your back and hips move, and some strength measurements will be taken.

At the end of the session, there will be a conversation where you can ask questions, and we will go through some advice on treatments.

So physiotherapy sessions are usually divided into three sections, the history, the exam, and the treatment.

As healthcare professionals, physios are obliged to work within evidence-based treatment guidelines. This means that we have to offer and be up to date with all the evidence and research coming in through our field. If you’re going to see a physio, you should ensure that they are CORU registered to ensure they are keeping up with evidence and standards.

So the first thing is back pain can be really scary, but it doesn’t need to be. I hope this presentation will help alleviate some of the fears associated with low back pain.

I find with patients that their fear often comes from not understanding the source of their pain.

If you find yourself in this situation, I recommend you tell your Physiotherapist what is worrying you at the beginning of your consultation.

Now we will keep returning to this notion of the fingerprint. While back pain can be very straightforward to treat, it can also be complex. Think about your back pain as you would think of your fingerprint.

It is very specific to you as an individual. We will develop this idea later in the presentation but remember that your treatment needs to be tailored to your specific needs.

Looking at the background of low back pain, the picture at the top is from a paper published in the Lancer, a very well-respected Journal. In 2018, they did a vast series of documents highlighting how common and prevalent low back pain is.

It is the leading cause of disability globally, and at any point in time, about 550 million people are experiencing it at any one time, which is vast. Most people will experience it during their lifetime at some point.

I hope talks like this will help put the correct information out there and that people learn that low back pain isn’t necessarily something to be frightened of.  It is unpleasant, but it is very treatable, and people should know what to do and not do when they suffer back pain.

The biggest thing to take from this slide is that if you’re playing a numbers game, most cases of back pain must settle within six weeks. Somewhere between 80% and 90% of episodes will settle within six weeks if you do nothing without any treatment from your GP or Physio. That’s an empowering statistic because your back is always working behind the scenes to settle that pain.

Another thing to remember is that serious causes of back pain are extremely rare. Less than 1% of patients have something that is serious or requires ongoing management or investigations or has a serious underlying cause. So it is very rare.

But why do so many people feel there’s something seriously wrong?

When I talk to my patients, they believe something is seriously wrong with their backs, as their pain is excruciating. Back pain can be really sore. In the best cases, you are uncomfortable, unable to do the things you want to do. In worst-case scenarios, people experience excruciating pain so naturally, believe something to be seriously wrong.

I would like to reassure you that the pain and damage aren’t the same and that you can be sore but safe.

We break back pain into two categories. Specific and non-specific.

Specific back pain relates to 5% to 10%  of cases depending on which research you read. Specific means you can point to something or know the cause of your pain. It might be an infection because say you’ve had surgery. If there’s an infection in the back that’s a specific cause, or you’ve had a fracture in your back that’s a specific cause, we know exactly what’s causing it.

Everything else is called non-specific. So 80% to 90% of people fall into this category, and it’s unsatisfactory. It’s extensive, and I will explain why it’s so broad, but most people are in that non-specific low back pain category.

Timeline is another way to categorise back pain. Acute backpain refers to the first six weeks and persistent back pain for six weeks and onwards.

Why are so many people in that non-specific low back pain category and why can’t we tell exactly what’s causing their back pain?

Part of the reason is due to the anatomy of the lower back.

if you look at my finger here you can localise my anatomy around my finger, But if you look at the picture on the left the yellow bits are the spinal nerves and in between are joints. Two joints might be a centimetre apart on the left and a centimetre apart on the right and there’s a lot of anatomy within the same area. All of these body parts have a nerve supply so your skin, your muscles, your ligaments even the nerves of your discs have a nerve supply and they’re all very close together.

So if you’re lifting, carrying, moving or bending forward you’re going to be moving all of them so it’s very hard to say well look it’s absolutely one or the other causing the pain.

If you look at the picture on the right in terms of your lower back you will see the anatomy is very complex. There are a lot of muscles covering this area so we used to think we were able to diagnose precisely the cause of it every time – it’s just that the anatomy is too complicated to let us do that.

Discs have a nerve supply, so some problems can be very painful, and some discs can have degenerative changes. It’s just like getting arthritis in our knees, arthritis of our hips or growing hair and wrinkles. It’s part of our ageing process and doesn’t necessarily cause any pain.

Think about how your body adapts to that. If your discs change slowly over time, your body doesn’t see that as a problem. But if somebody has a sudden injury,  they fell down the stairs, and there was too much pressure or force, causing a sudden change, that disc can be painful.

Ten years ago, a significant study was conducted on 3000 people on this subject. A cohort of people between the ages of 20 to 80 who were not suffering from back pain was given an MRI.

MRI showed that 30 % of people in their 20s had disc bulges but no back pain. The figure was 50% for those aged 50 and over which is a significant amount of disc bulge with no symptoms of back pain.

So the MRI findings need to fit in with your own personal history and with your clinical patterns. You are subjective, and I think getting advice from your Physio or Healthcare practitioner around that is essential in order to interpret them correctly.

I spend a lot of time with people who are just given reports and understandably have a long list of things that come up from an MRI, and a lot of it is like grey hair and wrinkles; it’s part of how the body ages and not something to be worried about.

I like to focus on evidence-based exercises and treatments for low back pain. You may have heard of NICE or The  National Institute for Health and Care Excellence.

They are a huge research body that provides guidelines for rehabilitating things like low back pain or obesity, and smoking.  The same applies to Cochrane.

The following guidelines have been approved by these two bodies.

They are divided into Acute Low Back Pain and Persistent Low Back Pain.  As a reminder, Acute Low Back Pain is what we have from zero to six weeks, and this table is taken from the paper I referenced earlier on, and I have the reference for you at the very end of this presentation.

What is the evidence advising during the first six weeks?

The first advice is to remain active, but look at and pacing yourself, and manage what you need to do.  For example, if you have an irritated back in the first six weeks, this is not the time to try and run a personal best or do a big clear out in the house or swing the grandchildren around. It’s about doing what you can, pacing yourself, and maybe keeping yourself moving without overdoing it.

The interesting part here is exercise therapy has limited use in selected patients, so from a physio point of view, I tell people to do the movement things that they enjoy. I try to give them some basic exercises if needed. It’s more like telling people they’re sore but still safe, and I try to get them back into things they need to do.

You’ll know they’re at the very bottom for things like manual therapy, spinal manipulation massage, and Hands-On work should be in conjunction with the education and remaining active, so it shouldn’t be done by itself it’s if you’re seeing a Physio and they’re doing some Hands-On that’s fine. However, it still needs to come with advice and education as well.

To recap, here are the dos and don’ts for low back pain. If you want to take a picture of this slide, I don’t mind.

So do keep moving. You could talk to your pharmacist about pain relief; you can use hot water bottles and gentle mobility exercises to encourage normal movement. It is really important to stay at work where possible and don’t panic. Back Pain can be very sore but we want to try to get the body out of this fight or flight mode and back into a more relaxed state.

The advice 20-30 years ago was to stay in bed. Try not to stay in bed. Get up and move around every 20 minutes to half an hour. If you’re sitting, resting, standing up, sitting down, walking to the kitchen and back, and just trying to keep yourself moving.

I would say to patients at this time that they are sore, but they are safe.

Can pain be a good thing?

I’m sure everyone thinks that there’s no way pain can be a good thing and that I am actually like Pinocchio and that I’m telling lies, but I promise you I’m not especially in the acute phase of back pain.

Imagine your pain is your body trying to talk to you asking you to change your behaviour. There are a group of people with this genetic mutation who cannot feel pain. This sounds wonderful but their bodies don’t have a way to tell them if they have an infection or have broken a bone.

Their mortality rate is relatively high, so we need our pain system to work, and tell us what we need to pay attention to. It’s you’re body letting you know that we’re not going to go to the gym today and that we will do more gentle exercise. So our pain system must be there because it keeps that warning system in place, which is good.

Persistent Back Pain.

Persistent low back pain is when the pain is there longer than six to twelve weeks. If you are suffering for this amount of time I would recommend you visit your GP or Physiotherapist because you’ve suffered for long enough and there are lots of treatments available so there is no need to suffer.

The advice or evidence here is slightly different, so the advice is still to remain active and educated is still essential.  However, exercise therapy now becomes the first treatment. It’s as crucial that its used in conjunction with manual therapy, and actual hands-on treatment which is secondary. Exercise advice and education are all the first things that need to be part of your physio program, and some hands-on work can be used, but it needs to be done in conjunction with the above.

What are the challenges in treating persistent low back pain?

We are going to remember that this is like your fingerprint and pain has a context so the best example I can give for that is imagine that you’re having a really good day that you fall up the stairs at work and it’s really funny you think oh my gosh look I’ve landed on my knee and I’ve hurt myself. Imagine you’re late for work and you’ve got soaked going in from the car you fall off the chair land on your knee and everything is the worst you’re really sore.

The same thing has happened but the context is different so our thoughts, our feelings and our beliefs can shape the way we shape our pain experience remember that if we have an irritated or grumpy back that back is attached to a person in their lived experience so and all of our lived experiences are completely different. I will expand on this in a minute.

The paper I referenced earlier shows different factors can be at play in terms of feeding into low back pain. Things like genetic factors and biophysical factors. So there is strong evidence that people with low back pain have some changes in their strength and coordination. There are other comorbidities like anxiety, depression, social factors and things like stress that can add to the causes of low back pain while not necessarily being the root cause.

Remember that our pain and why low back pain has been persistent and more complex to treat is because everybody is going to have a different interplay or some people might have absolutely no stresses in life and none of that going on, and really all we need to focus on is the muscles and strengthening. For other people, the strengthening is not a big factor we need to focus on pacing and management so it really just depends.

Why is exercise important for treating back pain, and why is it recommended?

The American College of Sports Medicine has published guidelines on physical activity for adults. This is what we all should be doing anyway as healthy adults. Ideally, everybody needs 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity a week. In addition, we should be building our strength on two days or episodes a week.

This is quite a high amount of exercise, but it’s what we should be doing not just to be fit but to maintain a baseline level of health. So sometimes, patients with low back pain can miss out on the benefits of general exercise because they’re sore.

Why do we recommend our patients undergo strength or resistance training at SSC?

We encourage our patients to do some strength or resistance training here in Sports Medicine for several reasons.  In this slide, the bottom left is a picture of a cross-section of the human back.

The two dark circles at the very bottom are the back muscles. Resistance training can improve the amount of fat within a muscle. Another reason for promoting resistance training is it is very good for maintaining joint range of motion in our spine, inner hips and all over the body. It is excellent for building bone strength as well as building muscle strength.

Our lives require us to have a level of strength so if you think of pushing a shopping trolley, opening a heavy door, lifting grandchildren or walking to work, all of those things require us to have a certain level of strength, so it’s being able to meet the demands of your day-to-day tasks as well as the positive impact it has on our mental health.

Our Physiotherapy Department at UPMC Sports Surgery Clinic takes self-referrals. You can phone us on 01 5262040 or email [email protected] for further inf

Do you have any recommendations for exercise that a person can do to help relieve pain from spinal arthritis in all three parts of the spine?

yeah I think so there’s some um there’s lots of great questions coming in and we’ll try to answer as many as we can but certainly with marks in terms of exercises like we spoke about in in the Talk looking at things that you enjoy so try to sometimes pay people with spinal arthritis they find that extremes of movement so it might be do yoga but maybe avoid an extreme back bend or stream front Bend if that doesn’t feel right to you so what I’d say in terms of guidelines and pain from spinal arthritis is that the odds nip or pinch with pain is okay if an exercise feels like you know you really don’t feel good afterwards it’s really making that pain worse that one isn’t for you so examples of things with spine arthritis there’s no limits you could run you can do yoga you can swim really looking at what trying to meet those recommended guidelines that I spoke about earlier try to get your enjoyment in but there’s no Bible or gold standard of the thing you absolutely have to have to do and that links in with Maureen’s question which that she spoke about having um some fusion due to arthritis so what that will mean if somebody has lots of arthritis down at the bottom of their spine some of the movement around that region isn’t going to be as good which we’d expect but what if you what you want to try to do is maximize the movement that you do have and maximize the areas above where the fusion is or where the arthritis is and below so it might be making sure you’re getting good hip range of motion and making sure you get good Lumbar and thoracic range of motion so from a treatment an excise point of view Mobility work, yoga will be nice and resistance training would be nice, medical questions I’ll leave I’ll leave for Matt, for that but it really is like our guidelines from earlier on is trying to meet recommended guidelines, do something that you enjoy and if something doesn’t feel right or is painful or if you want more specific advice I think I would chat to your own physio or GP.

A patient has been diagnosed with scoliosis-like species in the past year with grade one slippage of the vertebrae onto the L5 S1 nerve, causing severe back pain and groin weakness. He has been going to Physio and a chiropractor with limited results.

okay so I think my guess is follow-up questions to this patient, and we’re trying not to answer this more broadly because I haven’t assessed them myself. Still, certainly, it depends if you’ve been giving us a good go with a physio or a chiropractor treatment. Indeed, if it’s been going on for a while, I think Hands-On work from a physio or a chiropractor probably sounds like it’s not working, so I think a different approach might be worth there going back to the GP and looking for a second opinion.  So what all those terms mean for anybody who’s not familiar with them is just that there’s a little bit of movement of one of the vertebrae, which is putting pressure on a nerve. Some injection options and others depend on how severely you’re impacted from a particular exercise point of view, so certainly, I think if it’s not working with a physio or chiropractor, my first question is, what type of things are they doing with you? If it is more Hands-On, I would put a pin in that go back to the GP looking for an opinion and move from there.

I was wondering how long it takes the muscle condition to deteriorate within an activity, especially in the lumber area, okay?

That’s a great question, so I wonder whether that came from seeing the cross-section of the spine in the presentation earlier. I showed pictures of where there were lots of fatty infiltrates that can level of infiltrate for years, so that’s not something that would happen over weeks or a month, so that level of infiltration when someone is very sedentary takes years, so in terms of deconditioning so you can lose some muscle strength within two to three weeks. Still, you can get it back again really quickly, so I don’t want people to worry or necessarily that if they’ve been on holiday or if you’ve been, you know, unwell for a period that you know your muscle strength completely goes it doesn’t and what you want to try to do is to get your muscles in good condition as best you can. So you’ve noticed the difference in, say, if you were in the gym and what you would lift if that’s a good level of muscle strength. It might be well you know I lifted my grandchild before I went to my six week holiday and have come back to I feel they are bit heavier you might notice some impact in your function after several weeks a very significant deterioration where there’s a tremendous amount of fatty infiltrates that takes years. Still, you can notice lower grade changes within a couple of months. I hope that answers that.

Hello everybody, good evening; I hope you’re enjoying the evening. I’m delighted to be able to join you and discuss the sports medicine doctor’s role in managing low back pain. My name is Dr Matt Cosgrave or Matthew, and by introducing a little bit of my background, I studied in Belfast at Queens University. I originally trained as a GP, working through various Specialties in the NHS. Then I moved down to Dublin to pursue a career in sport and exercise medicine and did my speciality training in Dublin outside of working in the clinic here at Santry. I work with a number of sports teams, but over the last three or four years, I’ve had the pleasure of mainly working with the Irish Women’s National Rugby team and, over the last couple of years, with Connacht rugby men’s senior team. From the point of view, what I hope for you to get out of my talk today is to answer these three questions do I need to see a sports medicine physician? Do I need an MRI, and do I need an injection? Before we get into things, I’d like to reassure you all that when we talk to patients, these are the three most common emotions that they present with in relation to low back pain worry over some underlying disease process or pathology that maybe they’re missing, confusion over often why their pain isn’t getting better or why their pain comes and goes unpredictably or apathy which is really a down to a lack of motivation around managing their pain and that no matter what they seem to do they’re always suffering. Interestingly enough, these three CM emotions are often what positions physiotherapists or General Practitioners experience with low back pain because it can be tricky. Still, hopefully, I will try and uncover some of the Hidden Truths Behind that today.

I don’t think we help ourselves by calling ourselves Sports Medicine Physicians; this is a common misconception that the only people that we treat are people who do sports or athletes; we are musculoskeletal Physicians, so yes, we do look out for teams, yes we do look after athletes, but we look after any active individual which from the point of view of day to day that’s the general public and the vast majority of the patients that we see in care are general public and are not high-flying athletes in any shape or form. About eighty percent of people at some stage in their life will experience low back pain. Interestingly, about eighty percent of these cases will improve on their own or with very little treatment within about six weeks. My rule comes into it whenever we have this huge chunk of 20 percent who are not improving over the three to six weeks or the three-month to six-month period, which can be a substantial number when you cross when you break it all down.

Really what the sports medicine physician does is considers do we need to order other investigations now this may be a scan of some description a CT an MRI or it may be some blood tests really the main role for us is to confirm a diagnosis often once we have the diagnosis actually managing the problem can be quite straightforward sometimes when we’re in the dark about the diagnosis we try and we almost have a trial and error process but if we can confirm a diagnosis it’s often fairly straightforward to get on a plan to recovery excluding severe pathology is a big part of this and this falls into the worry side of things for patients a big concern that patients often have is there some sort of underlying disease process such as cancer and that is extremely rare when it comes to low back pain but nonetheless when back pain has been going on for a long time it’s always something that we have in the back of our mind and it’s always something that we make sure we exclude we’ll also review the treatment plan that the physiotherapist or the GP has already put in place and we’ll see can we add to that we rarely change things significantly but we’ll make small adjustments and then finally we think about treatment adjuncts so rehab is a huge part of what we do here in the clinic but there’s always options for some additional help and often for us that falls in the way of injection therapy which I’ll discuss for you in a little bit further detail later.

The simple answer is no, not everybody needs an MRI, and most patients with low back pain don’t require an MRI. This great graphic explains why we don’t all need MRI. These are findings on individuals who are asymptomatic so people with no back pain have a variety of changes, and the percentage of patients who have changes increases with age; just for one example, this degeneration in this top area which is often reported on scans and often causes concern for patients nearly 100 percent of patients in their 80’s will have this degeneration but even more interesting at the age of 30 one in every two patients will have some degree of disc degeneration on their scan even if they are asymptomatic. Hence, a scan is not always necessary.

So when is the scan necessary?

We use scans; this is what the sports medicine position is looking for if we go clockwise from the top left; this is a condition called sacroiliitis. This is an inflammatory process where you get some inflammation in the base of the lumbar spine where the sacrum, a little triangular bone, fits into the pelvis; we look for sacroiliitis because it doesn’t normally respond to Conventional treatment. Usually, it’s caused by some inflammatory process in the Blood, and therefore we often need to give medication to reduce that inflammation in the blood, which will then reduce the inflammation in the joint; this is not very common and but when it does present it tends to be in the younger person. If we move over to the right, then we have this condition called facet irritation; this is a lumber spine from the side; the square blocks on the left are the vertical bodies, and they sit on top of intervertebral discs the vertebrae then communicate with each other and the back through something called a Facet Joint now this Facet Joint like any joint in the body a knee, a hip they can become irritated and inflamed so when we look at MRI scans of backs or patients who are not improving we’re often looking to see are there any individual joints that are irritated or inflamed that could be contributing the symptoms and therefore is there a Target for some injection therapy. In the bottom left, this is the view of a spine in cross-section, so this is like I’ve taken you lying down and then chopped you along, and I’m looking down the body; this pointy bit at the back is called a spinous process, and this is the area that we feel when we feel down in the back. In patients, again usually young patients who are very active and who do sports that involve a lot of bending off the back, so gymnastics or tennis, there is a risk of developing something called a porous fracture or a stress fracture, so in the younger patient especially this is always something that we want to exclude. Finally, which you’re probably most familiar with when it comes to low back pain is this condition in the bottom right called disc degeneration; the black circle in the center is the spinal cord the yellow marks to either side are the nerve Roots. When you get a disc bulge or a disc protrusion, the center of the disc, a jelly-like material, pushes out a little bit, and it causes the disc to bulge the disc itself doesn’t move. It creates a little bit of a bulging on the outside edge; now, this bulge can do a few things; one is it can create irritation around the nerve. The other is if it’s bad enough, it can put some pressure on the nerve, and then if we think about treating this often, what we think about doing is delivering some injection therapy, usually a steroid in and around this area to reduce inflammation and irritation and to reduce any pressure that’s on the nerve itself. Hence, these are the four main reasons why we do MRI scans, but we know specifically what we’re looking for; we’re not doing the scan and hoping that it gives us the answer we’re doing the scan because we think that we already know the answer and we’re trying to confirm or exclude that. From a disk point of view, I just wanted to give you a little bit more detail so from a disc bulge point of view, the reason this is important this is a spine on the left from the side this is the spine on the right from the front these grey areas that are running down the side and then are coming out on either side on the image on the right these are nerve roots your nerve Roots Supply your sensation and your part to different levels along your lower legs so when you come into us with symptoms what we do is we try to correlate whereabouts on the leg front, or back your symptoms are and then when we do your MRI scan we try to look at the disc at that level to see if it’s causing some pressure around the nerve root.

In many cases you will have disc bulging it doesn’t relate to your symptoms so you may have disc bulging at this L1 L2 level but your symptoms may be coming from L5 or L4 for that reason MRI’s are not useful in that they can create confusion for patients and sometimes for Physicians as well because we see disc bulging but it doesn’t marry up with what’s going on in the history .finally sorry I want to make a quick note on something which Katie has probably already discussed which is a degree of fatty  infiltration in the low back when we are less active we see a change from the left hand side where the muscles are nice and grey kind of like a fillet steak to on the far right hand side when the muscles are not being used because other areas of the back are having to work harder for example the facet joints then the back becomes weaker and we see this fatty infiltration if we see this on a scan it’s a very good indicator to us that you’ll respond well to rehab so in summary from an MRI point of view we’re looking to exclude significant disease we’re trying to correlate what we see and what you tell us with what we find on the image or on the MRI scan it’s really not guesswork and we’re not asking for the MRI to give us the answer.

Finally, we’re looking essentially if there is an area for injection. Hence, if we see a disc bulge or a Facet Joint, that’s irritated. If it fits with where you’re sure and where we examine you, then that’s usually a good Target for us to inject the injection is only part of the treatment plan, which I’ll discuss and that brings us on nicely. Do I need the injection? Injections are not always straightforward, and often patients are a bit apprehensive about them.  injection treatments are put into two major areas; one is for nerve root impingement, so if we have this disc pathology or there are other causes of nerve management, but if we have nerve root impingement, we’ve got two options, we’ve got a coral epidural injection, or we’ve got a more sophisticated CT guided nerve root injection again we’re correlating our MRI findings based on where your symptoms are. We are deciding on what level you need the injection.

Sometimes it’s not always clear exactly which level sometimes you might have a disc bulge at a couple of levels and sometimes you might have symptoms that correlate with a couple of levels when that’s the case we’ll often do a call to epidural injection this injection is done right down at the base of the spine we inject some steroid and it flows up along and around the nerve roots and it beads the nerve Roots at those lower levels in steroid and it reduces any inflammatory or Earth and change around there it’s a little bit of a broad brush stroke and we’re hoping to tackle a number of different areas in one go the CT guided nerve right injection however is much more selective we do that when we are very confident that the image that we see on MRI fits perfectly with the way the patient comes in now this is not always the case but when we have this sort of scenario you get much more relief from us a selective nerve root injection than by doing the broad brush stroke of what we describe as I called epidural injection technically we call the epidural is slightly easier than the CT guided nerve root we perform the seat they call epidural injections in the clinic here as Sports Medicine Physicians we do this under ultrasound scan the selective nerve roots however we have to refer to our Radiology colleagues in the main hospital for this because it’s slightly more sophisticated and we want to be exactly precise about where were placing that steroid.

The next group of injections then is for the joints I mentioned to you earlier about this condition, sacroiliitis or inflammation around your sacrum again, normally the way that we treat this is with some medication to reduce inflammation in the Bloods, but on occasion, if you have it on one side it can be because the joint is irritated without inflammation in the blood, in that case, a steroid injection over that area can be very helpful again we do this in the clinic here. We use an ultrasound scanner to guide where we place the needle.

Finally, then is the facet joint injection, the Joint between the different levels of vertebrae same principle as a knee joint, like a hip joint. If it gets inflamed, they often respond very well to cortisone steroids; it is not the main way of treatment; it’s an adjunct, so we try to improve your symptoms a little so that you can then progress on and do whatever rehab is necessary.

Are injections necessary?

Not always, but we use them when patients are not improving or deteriorating in some shape or form. We only do them if the symptoms that you’re telling us or the findings that we have on examination match up with what we see on the MRI scan; if they don’t match, there’s something else happening, and that’s rarely the case. Finally, we do them if your symptoms stop you from doing good rehab. Suppose you’re too sore to rehab, and we have a focus on injection. In that case, these can be extremely helpful in trying to get you some pain relief so that you can do the strength work it helps to take the pressure off the back it helps to get you moving more naturally, get you feeling more comfortable and then get you back to living a healthy and happy life.

Very straightforward self-referral, GP referral or physio referral, and you can forward an email or a referral to [email protected], or you can call us at this number 015262030. You can have a discussion with one of the staff at the desk, and they’ll give you more direction about how to get in contact with us. I hope you found that helpful there’s a lot of information in there. You don’t need to take it all away. It’s really to give you a flavour of what we do here in the clinic and why our role as Sports Medicine Physicians helps to supplement the work that are very successful and very proficient strength and conditioning and Physiotherapy and Rehab teams do here in the field. Thank you very much.

what advice can you give  the L4,5 disc care with lumbar spondylosis other than pain management?

I suppose it to a degree it depends on what the symptoms are if they are what we describe as radicular symptoms so symptoms that are not in the low back traveling down the leg then we have the option for some injections and if we have a good idea where the pain is traveling to and it correlates well with the MRI findings then we could do a selective nerve root block if it’s a little bit broader or a little bit more difficult the ascertain and exactly where the pain is radiating to or if there is a little bit of discrepancy between what we’re seeing in the patient and what we’re seeing on the scan then something like a cold epidural would be a good option and so that might give some symptom relief and then we would always do some follow-up rehab work and that would be along the lines of the stuff that Katie discussed uh strengthening of the low back strengthening of what we described as the posterior chain which is the bone muscles the hamstrings the calf and just you’re trying to get the patient to move more comfortably and confidently.

Is Botox successful in managing muscular spasms caused primarily by spinal fractures?

Botox we would use on in a very select group of patients and usually patients who have some form of muscular spasm or contracture so these tend to be limited to patients who have an underlying neurological condition like cerebral palsy or somebody who has maybe a long-term contracture following a stroke it’s not something that we use in the clinic to treat back spasm and Botox is a it has a very broad effect on the system so we can’t target it to any specific muscle and for that reason we’re very selective about the patient group that we use and we don’t use it for back spasm treatment.

Can a protruding discs in the lumbar region be the cause of constant knee pain?

It certainly can and if the lumber disc prolapses pressing on the nerve root that supplies the sensation over the knee then yes it can be the cause and often that is a case of patients who we see who have maybe had a long-term knee complaint for a number of years when we see them we assess their need we scan their knee we maybe don’t find much and we get a little bit more in depth into the history we find that actually they have some underlying back condition or back complaint when we scan their back and we’ll find a disk or a nerve root compression that’s actually the main source of their knee pain so in in short yes that can be the case yeah.

How could you get sciatica pain to improve?

It’s a multi factorial approach I suppose again it comes back to what are the exact symptoms of the sciatica what does the patient look like what are the Imaging findings do we have an option for injection therapy if we do have an option for injection therapy is it a selective nerve root injection or is it a call for an epidural injection and then following that can we get the patient comfortable enough to start to do some Rehabilitation and quite often this sciatica pain will resolve on its own if it’s very refractive then we do have oral medication options we have injection options and then we have some of the rehabilitation stuff that again Katie discussed that is often the next step to get patients over the line and back to full fitness.

what treatment exercise do you recommend for multi-level lateral stenosis?

Multi-level lateral stenosis again is quite a complex but broad diagnosis a lot of it really depends on what the symptoms are so the main aim is going to be getting the patient strong and getting the patient comfortable and confident moving again if they have some specific pain target or pain level in you know from that when we when we describe multi-level spinal stenosis we’re wondering is there an individual level in the spinal column that’s causing one problem more than the other if there is we have an option for a selective nerve root block again if the pain is coming from multiple levels and we’ve tried oral analgesia we’ve given it time and it’s not settling then a  coral epidural might be an option to give a little bit of a broad cover of a number of nerve roots in a number of different levels.

For five years someone is suffering from severe chronic like joint pain after twisting her back badly misaligned pelvis which she tried to rehab with exercise and a joint dysfunction steroid injection it did not work and what do we do with the joint Fusion at the clinic in the in SSC Sports Medicine?

We don’t do joint fusion um that would be a surgical procedure and it’s not something that I can recall having referred a patient for normally we are able to get enough relief of symptoms through injection therapy and Rehabilitation but by all means if there are refractory cases then we may refer them to a surgical colleague for an opinion so that would be either an orthopaedic surgeon or a neurosurgeon.

How big of a factor is ongoing strength and conditioning to prevent a disc bulge l45 for long-term prevention?

long-term prevention I suppose the key here is trying to keep people moving as naturally and as comfortably as possible any strength work is going to reduce the risk of any recurrence of low back pain and disc bulges will happen regardless of whether or not you do any kind of strengthening program or preventative program but if you’re stronger and you have better functional movement patterns then you’re much less likely to get symptoms and long-term symptoms from something like a disc bulge and if they can take you back to the slide that I used in my presentation there’s a huge percentage of people out there who have disc bulges and that’s not the source of their pain and quite often that’s what we find in patients who come into the clinic so it’s not so much that the strengthening or rehab and exercise programs prevent this bulge but they prevent low back pain in general and they’re very good at doing that.

A patient is just asking, he has a pacemaker which is not compatible with MRI what other scans could be used.

– Again it depends on the diagnosis or at least the question that you’re asking and if you’re asking for information in relation to a disc or a nerve root then you would we would have a discussion with our Radiology colleagues as to whether or not there there’s an option to work around to get the patient an MRI and there are some MRI centers available that can do MRI for patients with pacemakers in terms of if the question is not related to a disc or to a nerve root and it’s a bony finding that we’re looking for that a CT scan would be an option and then thirdly we have options for x-ray or bone scan but they would be used much less frequently and I suppose we get much more detail from our CT scans on our MRI scans but really it all comes down to what what’s the question that we’re asking is it a bone related problem or is it a disc and nerve related problem.

How long will pain relief last from injections and how many can you have?

It depends on what the injection it is that you’re using typically we inject steroid with some local anesthetic the local anesthetic is relatively short acting you’ll get a few hours of relief symptoms from that but it’ll wear off over the course of the day a steroid injection builds up over the first few days and usually you get your most benefit at around about seven to fourteen days and then we hope for around about three months on average some patients come to us for a steroid injection or an epidural or a selective nerve root we’ll get they’ll get one injection they’ll get enough pain relief to allow them to do some form of Rehabilitation and their pain will resolve fully so they’ll never need to repeat occasionally we’ll have patients who come and get one injection get a repeat injection three months later and then follow that pathway where they go on the resolution and then unfortunately there are some cases that are much more resistant to treatment and may need an injection on a kind of repeat three to six months basis we would usually only inject about once every three months so maximum usually about four a year but we’re always reassessing the situation and trying the ascertain are we doing the injection for the right reason is it for the same reason have things changed so there’s a lot of thought that goes into the process rather than just looking out three months injections for the foreseeable future.

Is there any downside to steroid injections?

Yeah I mean there are side effects to any procedure that we do and in general anytime we use a needle to pierce the skin there’s a risk of creating infection in the clinic here we quote more than twenty five thousand and we use a lot of stringent infection control procedures to try and reduce that risk but that’s the biggest concern anytime we do an injection is introducing infection to the site and from a steroid itself about a hundred percent of people can get something called a steroid flare where their symptoms can get a little bit worse before they get better and some patients can get pain at the time of injection which can last for a few days after and some patients don’t get any relief whatsoever and so they go through the process they go through the anxiety of getting the injection then they don’t get any relief, but by and large are they are the main the mean side effects steroid can also give you some minor side effects such as facial flushing which might last 24 to 48 hours it can also disturb your sleep for 24 to 48 hours and it can also have an impact on your blood sugar so if you have diabetes we always recommend that after a steroid injection you keep an eye on your blood sugars for a few days.

A woman had an x-ray which showed a fractured disc, had physio just physio for that but 10 months later she’s still in a lot of pain she goes for walks but it’s very painful when sitting any suggestions where she should go next?

It’s difficult  from the amount of information available yeah it’s difficult to sign posts, I mean if she feels that she’s not getting much benefit or she’s had almost a roadblock with a physiotherapist then perhaps it’s time to see a sports medicine physician you know another assessment a second opinion have a look at you know what information is there today and what investigations have been done and then decide on whether any further investigations need to be done and what other treatment options are available to the patient.

Hi there, everyone. My name is Neil Welch. I’m the head of the UPMC Sports Surgery Clinics and Lab Services within the Sports Medicine Department.

I want to start off by saying thank you to everyone taking time out of their day to watch this presentation on a Tuesday evening or watch it later.

I want to talk to you today about enhancing recovery from Knee Replacement surgery.

Why do we need Knee Replacements?

Osteoarthritis is a scourge that affects a large number of people all over the world. As we can see here, around 250 million people worldwide are impacted. Those most susceptible are obese, patients over sixty-five years of age and, in particular, females. About 35% of females over sixty-five suffer from some form of Osteoarthritis.

From a population perspective, given the ageing population that we have in Ireland and the growing sedentary lifestyles and obesity levels within the population, this means it’s a condition that we’ll have to get used to dealing with.

So, in particular, Knee Arthritis. We often hear the term wear and tear used, and this is a point echoed by Brian this evening as well. Knee Osteoarthritis is not just a wear and tear condition.

The important point here is that we tend to treat our body differently if we feel wear and tear is a big driving factor. It conjures up imagery of sandpaper wearing away wood, and that’s not how these conditions work, as a large inflammatory component also sits within osteoarthritis as well.

There are multiple factors that are thought to contribute to the changes in the joints. Trauma is one. So we know that following certain surgical interventions earlier in life increases the risk of knee Osteoarthritis.

Mechanical forces play a role. Simply it is the amount we do, but also the other factors such as inflammation, which is where obesity plays a role and biochemical reactions within the body.

Changes within the joint fluid itself and then also the metabolic changes that we might go through, changes in activity levels and hormonal changes throughout our life.

So there are lots of contributing factors to this condition.

What does knee osteoarthritis look like?

What does it look like? So this is a photo from within the knee. The curved shape at the top of that circle is the end of the cycle, and the bottom is the Cartilage that sits on top of your shin. This is what it looks like in very good condition.

Now, the next image I’m going to show is the other end of the spectrum, and there’s a whole scale of changes that happen within the knee joint between here. I don’t want everyone thinking just because they have a sore knee that their knee looks like this.

But essentially, this is what Osteoarthritis is. It’s a change or a death in the Cartilage cells within the Knee. That can either happen, as I said, because of trauma or the change in the fluid around the knee that causes the cells to die throughout our lifetime. Okay, So not every knee that is sore looks like the ones on the right.

Oftentimes, we can have changes within the knee joint that don’t result in pain. That’s why it’s not as simple as just simply scanning the knee.

We can now start to see what the changes look like within the joints. In order to go from one end to the other and get to a position where we’re considering knee replacements, we have changes in our physiology, and we have changed within our function.

So from a physiological perspective, we will lose the size and strength of the muscle because of pain. These are in the background to what we see change throughout our lifetime as well.

This image is of a thigh. The white banding around the outsides is fat that sits beneath the skin, and the dark grey images are of the muscles within the leg. This is what a strong well-conditioned leg looks like in our 20s’.

This is the same leg 30 years later. What we can see here is how lifestyle changes can impact us. We see that the banding of fat increases as we have a larger layer of fat underneath the skin, and we can see this marbling occur in the darker area of the muscle. That’s called Intramuscular Fat Infiltration.

The muscle becomes deconditioned, and we get layers of fat and fatty deposits within the muscle. This can change the way that we use the muscle – we get weaker essentially, and we can’t send a signal to the muscle as clearly through our nerves, but it’s also a large storage site for inflammatory metabolites, and that’s where the relationship with inflammation starts.

In the background, we have pain and change in function, we also have these lifestyle changes that we get throughout our body throughout a lifetime as well.

In terms of Knee Replacement, 95% of Knee Replacements happen because of Osteoarthritic changes in the joints. However, not everyone who has Knee Osteoarthritis has to have a Knee Replacement.

In the UK, there are 100,000 Knee Replacements completed each year and 700,000 in the US. Obviously, we can extrapolate those numbers down a little bit within Ireland.

In terms of selection criteria, patients would be undergoing moderate and severe pain over a long period of time and then associated loss of function. So we have changes in the quality of life and the ability to use the leg and haven’t responded to non-surgical treatment. Brian covers the conservative treatment elements within his presentation.

We also know from the larger registry papers around these Knee Replacements that 15 to 20% of people are dissatisfied with the outcome. Sometimes that can be a mismatch of perceptions. People expect to be coming out the other side of the surgery like the $6 Million Man and then not quite feeling that way when they have surgery.

It’s something we’re looking to try and get to the bottom of within the UPMC Sports Surgery Clinic is some of the reasons why people might be dissatisfied. Can we improve those outcomes?

At UPMC Sports Surgery Clinic, we completed 1385 knee replacements last year. We’ll be completing more of them throughout this year. We’re a centre that sees a lot of this type of surgery.

The average age of patients is 68 years old, although we have a range from 48 to 86. Those younger cohorts are starting to grow. I think this is partly due to those lifestyle changes or the increase in sedentary lifestyles and growing obesity in populations that we see.

What happens when I have a knee replacement at SSC?

What would happen if you had a Knee Replacement in the clinic? You’d be staying for two or three days following the surgery. This depends partly on your surgeon’s preference and how you respond to the following surgery. It might be a surprise to some of you that you’re out so quickly.

It’s important for a mind-set perspective to understand that you are not a very sick or critically ill patient when you’re undergoing replacements. That kind of mind-set is also important for your rehabilitation so you will be on your feet and out as soon as you are able.

On your first day following surgery, we will be working on your mobility, trying to get some movements into the Knee. The physiotherapist will show you your home exercise plan and how to use your crutches. You will be up on your feet on day one.

On day two, we will talk you through your exercise progressions, we will look at how to improve your use of crutches and then how to improve your gait on crutches and then stair use. Depending on your progression, this will be done on day two or three.

In terms of going home, you are looking for a 90-degree knee bend and moving independently with crutches. You can use stairs and can perform a straight leg raise. Then it’s on for physiotherapy.

Now I said before about changes in muscle mass throughout our lifetime and obviously throughout pain prior to surgery. We also have to take into account the surgery itself. The two pink circles up here, a slice, an MRI slice of a thigh, we have on the left-hand side before surgery and two weeks after surgery.

If you look at the areas specifically highlighted by this oval shape here, we can see the changes in muscle mass even as quickly as two weeks following the surgery, and the images below of the non-operated leg and even then, we can see a reduction in size. That’s simply because of the increase in rest periods due to the surgery and shows the inflammatory response to the surgery itself.

This is asked to play a role when we’re talking about rehabilitation. Over the longer term, in the first couple of days following surgery, we’re looking to restore your range of motion. We’re looking to try and build up the size and strength of the muscles around the quads in particular. While the muscles are affected, the hamstrings and the calf are as well, and we’re looking to restore their function.

We want you to use your leg the same as the opposite side and the same as we did before we started having these issues. I mentioned before about 15 to 20% of people have issues over the long term or are dissatisfied with surgery. One of the possible reasons for this is incomplete rehabilitation as well, and I’ll touch on that shortly. The aim is to get to a stage with a physiotherapist where you’re mobile, you can walk and then be shown the door again. I’ll talk you through those issues. For example, Poor pre-surgery condition, so not being yourself in the best possible way. You need to be in a healthy condition for surgery in order to give you a chance of a positive outcome.

I’m going to side with long-term guided movement patterns, changing how you use your leg to protect the Knee.  This can be quite hard to change. If you are looking to restore movement patterns, you will look to do it if you were exposed to increased hypersensitivity to pain again. When you experience pain over the long term, your body actually gets better at sensing it and reducing that pain.

Sensitivity over the long term can sometimes take a long time. Then the decision-making for surgery, people figure out that it’s much too much work to carry out because of the kind of injury I mentioned before about patients who had incomplete rehabilitation. We’re looking at an image of strength measurements of someone’s thigh throughout the course. This is four and a half months post-surgery. When the patient had been discharged from their physio, they were back playing golf and walking. They were getting some aching in the knee but wanted to come in and just make sure they were in a really good position.

The red line on that graph is the strength of the right leg, the non-operated leg and the grey line is the strength of the operated leg. And if you look at the bar charts on the dates and we will look at the lines next to where it says Peak, that red leg gets a score of 131% bodyweight strength and quite a good score from somebody who is 65, but the operated leg is 73%, so that’s a 45% difference, and this is a patient who’s been discharged from care.

Again, if I’m putting myself in that position and I want to make sure that I have a much smaller difference between legs, my number one goal is to try to return to my day-to-day life. Many people want to be very active in Knee Replacement and what we looked at to try and do in the sports injury clinic is improve outcomes.

Joint Lab is a project we’ve been working on. For one, we’re looking to launch Autumn Winter this year in order to try and help improve patient outcomes and reduce the 15 to 20% dissatisfaction that we see broadly. It’s off the back of our ACL service and ACL surgery, one you have following a traumatic injury playing field sports, and we’ve been conducting research and review services for almost a decade.

We’ve had thousands of patients with the data come through with over 15 scientific publications around us. If you read the literature around an injury, you’ll see this is a 20 to 25% screen upgrade. People go on to be injured for those patients who come through the research program or the review service and have the surgery with the excellent surgeons here at the sports surgery clinic, that re-rupture rate is about 2%. So we’re looking to try and do a joint map to see if we can do the same thing and understand what the important elements related to your rehabilitation for any of those are.

We are going to do that using a number of different tests. We’ve leaned heavily on biomechanical assessments.  In this image here, you can see the mark is attached to this individual. We use that to get measurements of the way you walk, the way you set the stance and the way you step up and over stairs and before and after surgery.

The idea is to try and identify the important factors for you to work on in your rehabilitation. We do this, rather than just looking at you, to get biomechanical information that we can use to identify the important areas.

You can see quite clearly this patient is limping following the testing, but again, we imagine this is somebody four, five, or six months after their surgery, and we haven’t restored full function for them. Similarly, you see this patient getting up and down from the side on the citizen task. It might look normal, but when we spin around and look at the front, we can see this patient is clearly putting more weight through the non-operated leg on the left-hand side.

What we’re looking to try and do is put numbers on there so we can identify whether or not somebody is improving throughout the rehabilitation. This is to be able to look at activity levels and see whether the amounts of steps we have taken immediately following surgery play a role in a positive outcome.  Then next to that is biomechanical testing which would be looking at the quad and hamstring strength, plus inflammatory markers and body composition, again, hoping to identify those who might respond better or worse to surgery so we can improve surgical decision-making to improve pre-surgery strategies for training before going into surgery, and then better guiding rehabilitation following surgery.

I’d like to thank you for your time. Thank you for listening. Hopefully, you found it informative.

Would cycling be beneficial as a non-weight-bearing exercise and good preparation for a Knee Replacement?

 Cycling is excellent preparation for a couple of reasons. One, it keeps the quads very active. As I mentioned in my talk, that’s a sight of muscle loss which is a really good reason for continuing on with the bike. Brian alluded to it in his talk as well. I think it’s a really important point around weight loss. Even just weight gain throughout the preparation phase as well. Performing some form of cardiovascular exercise, something where you get out of breath, is really important for not putting weight on. I think that’s also important and helps maintain your range of motion. So 100% get behind cycling.

Suppose a person has back issues, like a disc. It sounds like they may have a sciatic nerve problem. Is it a good idea to proceed with the Knee Replacement?

I think there are a couple of factors that you need to consider here. One of them is obviously which is a priority, and addressing that first. If you’re having more of an issue with sciatica-related back pain, you really want to get that sorted first and then also the impact it might have on the rehabilitation. Again, if you have a compression of a nerve, sometimes it can impact the way the muscles recruit down the rest of the leg. That might slow down your rehabilitation as well. A few things to consider are definitely getting a back checked out beforehand to see if there’s anything that can be done to put them in a better position before surgery and before maybe going ahead with the Knee Replacement.

When patients have had a  Knee Replacement, is it okay to continue to exercise when the Knee is swollen because it does stay swollen afterwards for a while?

Yes, a lot of exercises are going to be important in order to be able to help mobilize the joints, and Physiotherapists will be able to give good advice on how to improve your range of motion. Ideally, you’re looking for exercise that doesn’t cause more swelling, but anything that you mobilize the joint, you get it moving should make it feel a little bit better afterwards. But certainly, you want to be kind of cautious not to increase the level of inflammation afterwards.

I have been told I have a bit of arthritis is there any vitamins I can take to help?

It’s more the concern around Osteoarthritis, it is a diagnosis we tag on images of the knee on a scan, but everyone has changes in a joint, the vast majority of people who show up as having some form of Osteoarthritis don’t experience pain at all. It is important that she doesn’t overly worry about it. A change within a knee joint is normal. In terms of prevention, maintaining a well-balanced diet, reducing inflammation in the joint by conducting cardiovascular activities, and limiting drinking and smoking also. For normal bone health in the winter months, the Introduction of vitamin D.

How important is Physio after a Knee Arthroscopy?

It is a much quicker rehab, the surgery is much less invasive. A lot of the time, physiotherapy after that surgery is to undo what happened as a result of the injury beforehand; the likelihood would be there would have been a lot of knee soreness before surgery, and you would’ve lost the size and strength of the muscle around the knee. It is not a major concern after the operation because getting the range of motion back is relatively straightforward, but you will need the advice to get the muscle strength and size back up. I would say it is important following surgery, yes.

If both knees require partial replacement, is it a good idea to have them done at the same time?

I think this is a challenging one. It’s kind of something to kind of talk over with your surgeon and the pros and cons of having both done obviously from a recovery perspective; you’re not going down the line of doing rehab on one and then staring down the barrel of another, say, six months of rehab on the other one. So while it might be worse at the beginning, kind of like having twins, I guess, is to make it a little bit easier in the longer run, I’d say.

Can you still experience Arthritic pain in the Knee after a Knee Replacement? If not, what’s constant Arthritic-like pain in an operated Knee indicate?

The pain that you feel isn’t necessarily down to that, and when we talk about Osteoarthritis, it’s the change in the joints because the joints have resurfaced. It’s unlikely to be related to the condition of the joint’s surfaces, but the pain has many inputs, and it comes from many different sources. Sometimes when you’ve had pain in a joint over a long period of time, you just have heightened sensitivity within that joint, and it takes a long time for that sensitivity to reduce, particularly if it’s been something that’s been playing on your mind over a really long period of time. I talked about the guarding movement patterns within my talk. Those are something that can remain over a long period of time. You could continue limping for 12 months after if you know you’ve had the replacement and not simply because it’s sore. A lot of that can be driven by pain. So pain following the surgery is quite common, and it takes quite a while before it reduces fully.

How do you access the Joint lab?

It’s through referral. If you speak to your surgeon, they will refer you in, and the idea is we organise your pre-surgery appointments at the same time as you have your pre-assessment clinic. You then come over to us in Sports Medicine, and then in six months, you have a follow-up.

What role does a scan have in determining the state of a knee joint and muscle condition to perform an intervention?

Scan less for the muscle, a scan would be done routinely before a knee replacement. A lot of this is done by me to see if the muscle size is reduced compared to the non-sore leg and strength testing so you can determine if there is a big difference in strength and condition of muscle you don’t necessarily need the MRI to tell you that. In terms of scans of the joints, in particular joint replacements, the surgeons rely more on the X-ray side of things, but an MRI scan can tell you if there is a degenerative change in the joint as well. It is not something you’d necessarily do unless you had an issue specifically.

How long after having one Knee Replacement, will they have them staged? How long should they wait to get the second one done?

Again, there are lots of factors that kind of contribute to this. Logistics is one. Often, it depends on what time of year, how it fits around people’s lifestyles, work, holidays, and all that sort of stuff become factors in how the recovery goes. You might feel after having the first one done that you might want to kick it down the road a little bit longer just because the recovery takes a while. It’s a good bit of work, too, from a rehab perspective. But if you are staging them, you want to make sure you’re functioning on the other ones. A good few months would pass, and pain would be reduced and just so you can say, when you rehab on the other side, you’re going to put a lot of weight on to the first operated leg. So you want to make sure that it’s in good condition to be able to take on that workload for you.

Stairs are to be avoided when dealing with pain and swelling in the knee. Or does this help to strengthen the leg in general?

Well, not necessarily just because of functionality. You can’t avoid them, particularly in the house. It’s not that they make things worse. It’s, as I said before, like relating to wear and tear. You’re not going to be necessarily creating a bigger problem; although it’s uncomfortable, you might be able to find ways around that. There are techniques where if you come downstairs leaning forward a little bit more to offload the knee joints, well, I wouldn’t necessarily say avoid it. Obviously, it’s easier for me to say when you experience some pain going up and down. So there’s no physical reason to have to.

How long should you continue exercise after Knee Replacement?

You are probably speaking to the wrong person because you should probably continue exercising throughout your lifetime.  Yeah, exactly. There is a point where it’s like maintaining functions of our life, we should be performing some form of cardiovascular exercise regularly. Some sort of exercise to get out of breath three or four times a week. We should be performing some resistance training two times a week where the muscles are challenged. If we do that, we maintain a function, look after our joints, look after the size of the muscles, and slow down many changes that happen throughout our lifetime.  In terms of rehab, to me, it’s getting symmetry, getting the size and strength back in the muscles in terms of looking after yourself over the long term that’s a lifetime commitment to me.

Should you rest after getting a joint injection into the knee, and if so, for how long?

Everyone has different protocols for this and different protocols depending on the type of injection normally, it is a couple of days, but the individual doctor will give you guidance.

When is the time when replacement is necessary?

Normally, you want to be in a really bad way before you have the Knee Replacement because it won’t necessarily bring you back to 100% now. You want to make sure it’s sort of you feel the improvement from it, and it’s very different for everyone. It depends on how much it impacts your quality of life, sleep, and mobility; these all play a role in it and, obviously, the condition of the joints themselves. That’s a conversation you tend to have with the Orthopaedic surgeon to see when they think the ideal timing is. It’s very individual, and everyone’s kind of perception of how it impacts them is different. Again, it is hard to be very specific.

If someone said they had a Knee Replacement in January two years ago, and they’re still getting pain.  On the good leg, on the upper thigh, they also have a bit of wear and tear in that good leg as well. They’re now 52. What should they be doing now?

I’d see a physio. Just to try to understand what’s going on. If it’s in the thigh close to the knee, then you think it’s a little bit more to do with the muscles of the tendons, which is good news because that response tends to respond very well to exercise and to do physiotherapy.  I’d explore that; it might just be that there’s still a little difference between legs, and they’re using that leg a little more. It might simply be an overload issue, but a couple of physiotherapy sessions should help them get on top of that.