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Good evening everyone, my name is Neil Welch – Head of SSC Lab Services at the Sports Medicine Department in the UPMC Sports Surgery Clinic in Santry. I would like to spend some time talking to you about your health, your fitness, and rehabilitation. In particular, the journey we may take throughout our lives, how that journey can change depending on our circumstances, and hopefully give you an understanding of how important it is to try and adopt some activities whether it is fitness, personal training, or organized activities to help maintain your fitness throughout your lifetime.

The first thing I want to start by saying is everybody’s journey is different we all have our path that we follow throughout our lifetime. I don’t want to come across as judging anyone for the number of activities they do or don’t do. The aim today is simply to help you understand the impacts of the paths that we do follow and to give a little bit of guidance hopefully to paths that guide each of us to better health.

When I talk about fitness and health, I am going to split it into 3 categories. The first is Musculoskeletal, this is the health of the muscles and the bones and joints within the body. The second subject we are going to touch on is our cardiovascular fitness, the health of your heart, lungs, and pulmonary system. Then as a general health element, we will discuss your BMI and body fat percentage. To help us through this journey, I want us to try and imagine that we are either a twin or we have some twins and we are going to step through a fitness journey with this pair here. We are going to call them Jack and Sarah. Being the good parents that we are, we guided them through their early years and into some activities so like GAA, camogie, hurling, soccer, rugby, athletics, some organized sports for our children that we are always keen to do as parents I think, to promote physical activity.

By doing this we cover several positive developments in their physical developments. The first is around optimizing skeletal Health. So we stepped forward a bit into our 50/60s osteoporosis and osteopenia the elements we want to try and avoid. We avoid these by having healthier bones essentially and higher bone density and bone mass. Physical activity in childhood could be a way to protect ourselves in that going forward. So what this study demonstrated were the activities that we may undertake have a massive difference in the challenge that they offer the body. We can see from this graph at the very bottom is the amount of force that the body has to cope with while standing still, that dotted line while walking and then the spikes and ground reaction force, that the body has to cope with while running and during a landing task which we might also equate to decelerating change direction during field sport are all very different and very often the impact loads that are sustained during running and field sports are castigated being a negative thing, and they can be if we do too much of them, so if we have children who are very active and are training every single day and sometimes a couple of times a day, we can give them too much and we can get bony stress responses but for the most part these kind of impact loads are health and the body changes itself to be able to cope with so the bones become denser and they become stronger. By asking Jack and Sarah to pop down to their training sessions we are helping to strengthen their bones and limit the chances of these issues later on in life.

We often adopt physical activity and promote it amongst our children, to promote healthy body weight. We know that obesity particularly well throughout the whole population icon the rise and pediatric obesity is no different. This systematic review looked at studies around obesity in children and whether youth sports do anything to prevent it okay and then the results of this study are inconclusive, so we can’t say certainly that exercise is going to prevent obesity in childhood it seems like it’s a much broader topic and nutrition plays a much bigger role or as big a role as an exercise in preventing it. So moving away from junk foods and high sugar foods seem to be as or if not more important than exercise for saving off weight as youngsters. We also know as well that physical activity reduces cardiovascular risk factors in children, so a healthier heart and lungs, and circulatory system leads to fewer complications in children and this then carries forward into later life in part because we take on healthy lifestyle choices and habits so we maintain a lot more physical activity when were more active were young, so when we think back to jack and Sarah there’s a whole heap of benefits were given to both of them just simply by bringing them down to sport and helping them to participate inactivity.

Now we are going to step up upon a scenario, so we imagine jack who’s active and enjoys his football, come across some tricky times with injury, he’s unable to rebuild rehabilitate himself to a position where he can get back, he didn’t rehabilitate here but that ends his sporting journey, he gets to a stage where it is not worth him picking up the niggles and he stops playing sports and that’s probably a fork in the road that a number of us watching tonight have stumbled upon. Sarah on the other hand stays fit healthy, enjoys a sport, stays engaged with it, and continues playing sport throughout her adult life. So we end up with this little fork in the road, so what happens there. We think first of all around our musculoskeletal system so muscular strength is really important for reducing all-cause mortality which might come as a surprise to you but this is a large review study so there are over two million or approximately two million participants worth of data over 38 studies essentially the strong you are in the lower and upper body the lower risk of all-cause mortality in the adult population so essentially you live longer and this association was higher among females. So again if we think back to Sarah and Jack and by removing some of the strong stimuli that we might get with exercise we maybe predispose them to further issues in adulthood, similarly we remain active ourselves again maybe we are doing ourselves a disservice in terms of our longer-term health and we know that as we age we lose muscle mass anyway this is a process called sarcopenia and the example here is an MRI of the thigh and we can see on the left-hand side the muscle mass so that’s the grey elements around the white bone at the center now the white ring around the outside is subcutaneous fat, so it’s the fact that you have just sat below the skin. In the second image, we can see how that changes so the muscles mass reduces and the amount of the percentage fat we have increased and then graph on the right-hand side is it just indicates how the number of muscle fibers reduces throughout our lifetime so that’s the battle was trying to have as we go through the aging process. Activity can influence this, here we have an MRI slice of the thigh with a 40-year-old triathlete again the white thigh bone in the middle and the grey muscle around it, and a very thin layer and a tiny layer of fat around the outside. Then we have our 74-year-old sedentary man as an example so again we can see how the size and the quadriceps are reduced and the amount of adipose or fat tissue that can exist around the quads then. We can also see an example of a 70-year-old triathlete and we can see the difference in condition.

There are also cardiovascular effects and exercise benefits without going into too much detail, we reduce our risk of cardiovascular disease and cardiovascular mortality. The elements on there you will recognize are our reduced resting blood pressure and reduced blood pressure as well also reduce resting heart rate. So again lots of positives to remaining physically active. The dotted lines are those who didn’t do exercise and the black lines are those who did exercise throughout the 12-week intervention. The lines going down indicate that they lost weight. It doesn’t matter what diet you take as long as you run a deficit you will lose weight. In the future those who did not exercise gained weight. So we see these graphs here, they have split this up into an a and b, one for smoking and non-smoking. I think it’s worth noting from the data that we have and the changes in risk when we adopt certain lifestyles. So broadly speaking this is the world health organization, we know that maintaining a healthy weight and maintaining physical activity, reduce our chances of type two diabetes, cardiovascular disease, We reduce falls in depression, dementia and there’s a certain healthy body healthy mind element to that joint and back pain and cancers reduce just by simply being more physically active. We talk about being more physically active, so what does that mean, essentially we look at the bright green on the left-hand side and we think of this as being our cardiovascular fitness, so exercise that gets us out of breath, a bit sweaty. 75 minutes of vigorous-intensity exercise or 150 minutes of moderate exercise is going to lower those risk factors. Reducing our sedentary lifestyle so sitting less and getting up and moving around more and then some form of strength exercises like the gym or yoga to build strength at least two days a week.

That brings us to what we do here at the UPMC Sports Surgery Clinic to try and help individuals with their health and fitness. My job as the Head of Lab Services is to try to introduce testing and rehabilitation or training interventions for everyone and wherever they are on their fitness journey. We think that offering information and education is important for shaping your rehabilitation from surgery and injury. Within the fitness realm offering testing services to ensure that your exercise strategies are doing what they need for you. It is simply to give you an understanding of where your current fitness and strength levels are currently and to give you guidance on what you need to work on. Our rehab lab testing is what we do for our injured patients for example if you were jack and injured your ankle you would come in for some isokinetic testing, so we measure the strength of his joints to hip knee, and ankle to try and understand where he was weak and we might need to work on. As well as getting some biomechanical information, to understand anything in the individual’s movement that they might need to change. Fitness lab, we can do vo2 max test to measure cardiovascular fitness, we measure body composition, upper and lower body strength measures, and explosive strength measures and we also give you an individualized strength and conditioning program to target your needs. We are starting our Health lab service which is more tailored to weight loss, we measure your resting metabolic rate, blood glucose monitoring, blood inflammatory monitoring, and body composition. Thank you for taking the time out to watch this and I hope it has been informative.

If you start thinking of your exercises divided into two categories, one of them is around cardiovascular health, exercises where you get out of breath and sweaty, these exercises look after the heart and lung function. That becomes more biased as we age. The other categories to maintain muscle mass would be resistance exercises, these would be elements if you were a member of a gym where you might simply use some of the machines in the gym for the lower body exercises like the leg press and the leg extension are excellent for maintaining muscle mass.

In the upper body, especially in females, we see more of a loss in muscles mass and strength in females. Pushing and pulling exercises again there are machines. The exercises should be tough enough so they feel a bit sore. If you do strength exercises twice a week you can maintain and even gain more muscle mass. It is also very healthy for the joints and tendons as well, there is good evidence emerging of this.

Similar to what I was saying and without being an expert on the hormonal changes and systematic changes that join them during menopause. I’d say first of all if you have any severe symptoms then chat to your GP first before engaging in physical activity, but as a general rule doing stuff where you feel comfortable doing it would be a good guideline initially.

Then to just do what you can, if you go through periods where it is a real struggle through symptoms and pain then you just do what you’re able to and you’ll find there’s very often a certain psychological benefit to doing some exercises as well that might even give a little bit of a lift during periods where there’s more pain or symptom.

My first taught there is about the range of motion in the hip. If you are sitting in a kayak you would need 90 degrees plus of hip flexion, so if you can get your full range of hip flexion back then it shouldn’t be a challenge. Then there is a cardiovascular component to kayaking and a bit of strength loss with the upper body so I would be thinking from a cardiovascular perspective, you might be reliant on the bike, to begin with, to maintain their fitness and upper limb strength you can maintain again relatively straightforwardly in the gym, to limit the strength loss you will have from just not doing kayaking anymore. The main limiting factor would be I would expect a hip range of motion

Getting advice and finding a physiotherapist that you trust to give you some guidance on that and some things you will be surprised by how much you can do relatively early on the following surgery, the area that takes the longest period regaining the loss of muscle through that will have occurred following a long period of pain preceding the surgery and then also the surgery itself that’s what we find its re-gaining the size and strength of the muscles around the knee joint that is always the slowest.

What you are trying to do before surgery is minimize the muscle loss or gain as much muscle as you can beforehand but also there is a challenge there in that depending on symptoms, you don’t want any of your exercises to flare up lots of pain or symptoms around the hip as you want to preserve as much range of motion before surgery as possible.

Oftentimes when you exercise into pain you kind of speed the loss of strength anyways, so exercises in particular for your bum, the back of your bum so exercises like a glute bridge, for example, banded clam exercises for the side of the hip and then basic hip flexor exercises as well, anything that doesn’t cause pain but makes the muscle work hard is going to give you as much benefit as possible. You might find you can do more than this before your surgery, you might speak to someone before to get a more challenging strength program, which puts you in a better place before the surgery.

This can be quite dependent on and Gavin might expand on this, depending on what the knee is like before surgery and the period that there’s been a loss of flexion for. So if its been 5 years and you have only had 90-degree knee bend, then it’s unlikely that you are going to restore full flexion compared to the other side, so unfortunately I think it’s a how long is a piece of string kind of scenario there but you would expect whatever range of motion is going to come back, you should have that restored certainly within 9 months following surgery.

My name is David McCrea and I am a Senior Physiotherapist working at the UPMC Sports Surgery Clinic. I’m here to talk to you about injury prevention strategies for golf with a particular focus today on low back pain in golf. I taught I would start by reviewing the physical activity guidelines published by the American College of Sports Medicine. The American College of Sports Medicine recommends 30 minutes of moderate-intensity exercise 5 days a week, which can also be referred to as well as 150 minutes of total exercise per week. On my next slide, you will see golf is considered a low-intensity exercise, so gold can help contribute to us achieving our physical activity guidelines in healthy adults. It doesn’t quite fit the category of vigorous-intensity exercise but definitely, it fits the category of moderate-intensity exercising can contribute to our health in that sense, at the bottom of the slide you can see they recommend resistance training 2-3 days per week, this can often be the forgotten piece for Golfers, the resistance training is going to be a particular point of focus for us today as this is often the piece that allows us to stay healthy and to improve performance in our golf.

I taught we would also start by looking at the demands of the sports of golf. Golf is often perceived as maybe a leisurely activity for many of us it’s a hobby and it’s a pastime we don’t often see it as a sport or a way of us achieving our physical activity goals. There have been some nice studies done where they analyzed golfers physiological data and you can see the top here so, in terms of the cardiorespiratory toll, the average heart rate during an 18-hole round of golf is approximately 60% of peoples max heart rates, so for someone like myself that might be averaging kind of 120 beats per minute for nearly 3 hours. Below you can see the average walking distance over an 18-hole round of golf is anywhere between 9.5-10.5 kilometer’s and obviously, that can be halved if you’re playing 9 holes, the average standing duration can be close to four hours so 3 hours 45 minutes.

Injuries in gold. Is it an issue? In the world of sports medicine and research, injuries are reported per 1000 hours of participation. If you were to participate in golf for 1000 hours the current injury rates are 0.28 to 0.6 injuries, seeing as golf is an individual sport a well, you can see here 1000 hours equates to nearly 250 rounds of golf and that’s not to say that if you play 250 rounds you’re going to get injured but at the moment among amateur golfers that’s the current injury rate being seen.

How does this compare to other sports? Golf reported injury rates are low to moderate when compared to other popular sports. Football reports up to 8 injuries per 1000 hours and running reports up to 2.5-12 injuries per 1000 hours. Overall golf can be considered very safe to participate in with a lower injury rate in comparison to other sports.

Low back in golf is consistently cited as the most common golf injury. Between 18-54% of all golf injuries are related to the lower back. Research shows it equally affects both young and old golfers and it also affects both high and low handicap golfers. How to prevent low back pain in golf, is worth having a look at some of the most common causes for back pain in golf. There has been research done in this area that showed consistent themes that emerge are displayed on the screen as you can see repetitive strain, trunk strength & control, and hip strength & control. We must look at the key physical qualities that underpin the golf swing. You can see here there are 3 pieces of the pie. I have prepared a video here of Rory McElroy swinging in slow motion.

We have trunk hip rotation, the mobility to allow us to access and get into these positions to generate some good speed and power, we have trunk muscle to be able to control that motion of decelerating the club and then re-accelerating the club and hip strength, to be able to decelerate the club and accelerate the club. For the next portion of the presentation what we will on is exercise strategies to try and maintain each segment from the pie. These can be incorporated into your pre golf warm-up or could be incorporated into your weekly routine.

We will start with trunk rotation, which is going to allow you to reach the top of your back-swing comfortably and follow through on your downswing comfortably. You can see that time has himself set up in a lunge position, he has a football squeezed between his knee and the wall and he is set up with his hands in front as if he is holding a gun, his goal here is to keep his knee squeezed against his football, not to let the football drop away from the wall. If you have a football you can use a cushion or a foam-roller, whatever suits. He is then trying to maintain good contact with his knee to rotate and open up his chest.

The video Tim is lying on his side in a similar position and again his knee is squeezing down the football down onto the floor and that is going to fix his hips in one position. Then from here he is trying to wrap his hand all the way around the floor to the other side, then bring it back until his hand is on top of the other hand. He is working on his trunk rotation here. The few videos show other examples of exercises for trunk rotation or pre golf warm up. Tim here is again is lying on his back, he is pinning his upper body and arms to the floor, he is then rocking his knees side to side like a windscreen wiper to create good rotation through the lower back. In this video Tim is using a speed stick, you could be using your driver or broomstick at home for example, Tim is setting himself in a almost golf position, he has a slight bend in his knees and slightly bent forward as he is standing over a ball, from there he has his speed-stick crossed across his chest and what hes really focusing on doing is pinning his hips in one position but trying to encourage as much trunk rotation as possible.

The faster clubhead speed you have, the lower handicap you’ll have. We see long game performance improves and your distance will improve both your carry and your run as well. It is important once we get you strong to do a little bit of transfer work and I’m going to show you videos of that tonight, different ways you can transfer this once you have strength, you can transfer this onto your swing. When we strike the board with the driver there are massively high forces its similar to that of throwing a javelin actually believe it or not and so having that level of strength protects you against injuries when you’re using the driver and this young man on the right-hand side he’s got about 133 miles per hour clubhead speed can probably strike the ball into the mid to low 300 yard kind of range.

We have a continuum that we use here at the clinic and it goes from the high force on the left-hand side to higher velocity on the right-hand side. I have got a few videos here to show you. These are clips of our training. So then it brings us on to our swing speed progressions, once we have the prerequisite strength and we want to try to improve the actual speed of our swing. There is a couple of different progressions that we use that you can do down the range as well, In this video, we are using a swing speed stick that helps us, gives us a little bit more speed not swinging but using different clubs so you can use your lighter clubs such as your pitching wedge or heavier clubs as well such as your fire burn to do this with. We’re not focusing on hitting the ball here, we’re just focusing on swinging as fast as we can so it’s far removed from actually hitting practice on the range.

That concludes today’s talk, hopefully, you have learned something a little bit about back pain in golf, in terms of how it happens and maybe some simple strategies to try and address it from happening in the first place or if you are struggling with back pain in terms of trying to resolve it as well using exercise as a tool to do so and if you’re unsure where to start, I’m more than happy for you to ask a question during a Q&A session. I or Luke Hart will be hopefully able to answer that for you. If you want to book in with a physio, please feel free to book in. Thank you for having me today.

Golf Lab is a testing service that we can then provide a personalized strength and conditioning program for to help your injury risk and your performance on the course, it involves strength testing for your gluteal muscles essentially the big muscles at the back of the body that is going to produce all the power for your swing, we look at how well you can rotate, we look at the amount of force you can produce into the ground which is really important for your clubhead speed but also protecting your lower back as well.

We look at how much power you can produce in both double and single-leg, then we go into a personalized program. Off the back of that, we can write a personalized program for you to suit where you are at. It really is for everyone, all kinds of levels, and every age demographic because we individualize the tests to whatever level you feel comfortable with and your injury history.

Firstly, these conditions can be quite painful, these can lead to some protbehaviorsaviours setting in, if they linger for a period of time, it can lead to a loss of mobility and range of motion which then can impede your swing, particularly the backswing. The golf swing is broken down into different components.

I think probably an important step for you, would be to break the golf swing down into different components and try to target each area to ensure that he is staying mobile in the right areas, that he can swing pain-free. If he is struggling and doesn’t know exactly where to start, I would probably recommend getting an assessment with a physiotherapist or S&C coach to give him some advice.

Yes, this is a common issue that physios encounter all the time, especially if a patient has spent time immobilizing a boot or in a cast or on crutches, they often lose a lot of strength and often lose a lot of muscle size so by working with the physio, we definitely can rebuild that muscle size and strength, it’s important that the exercises you’re selecting are appropriate and that the stimulus you’re getting from those exercises are sufficient to strength, difficult enough to build your strength back up again.

The first step would be to get an assessment to ensure this is si joint problem. Your back pain can be caused by all sorts of reasons but first and foremost you would look to rule out some of the more serious causes for the pain, an assessment with the physio can do that. You may or may not need a scan based on the findings or a rehabilitation program can be made for you.

Osteoporosis is a condition with reduced bone density and it’s a long-term condition that has to be managed I’m kind of an ongoing basis and the cornerstones for managing osteoporosis, one of them is weight-bearing exercise so if you see in my presentation and also my colleagues Luke’s presentation, there are lots of examples of good weight-bearing and resistance based exercises, a physio or an S&C coach can help you with that. While a doctor would help with the medication and diet aspect of managing osteoporosis.

Low back pain is often associated with sort of the repeated stress of the swing throughout the round so this might suggest that as the round progresses that he’s fatiguing, the fatigue is then causing him maybe a mechanical overstrain of his lower back so by improving your strength and control around your lower back, hips and pelvis area later in the range you might find the mechanical strain on your lower back is reduced and that sensation of pain or tightness is reducing as you go.

It is important to understand that PRP injections are done to help reduce inflammation and it might offer you a window of opportunity to engage in rehab more comfortably or less painfully. The exercises shouldn’t be painful to do but they should be reasonably hard to do as this is what is going to help you improve and strengthen the area.

My name is Luke Hart, I am head of Strength & Conditioning here at SSC. I also run our fitness services and our gold lab services. Tonight what I’m going to talk about is how S&C can really impact your health but also your golf performance as well and linking the two together and linking in with what David is talking about in terms of how we can use strength and conditioning to minimize your injury history and the amount of that you get. What we’re going to go through tonight is why you should include some S&C in your plan and how they can hopefully minimize your injuries and keep you on the course for longer but also touch on how that can improve your golf performance as well improving your distance and your clubhead speed as well and the way you can go about doing that.

The first bit I want to go through is the misconception that this is just for young people and this is just for people who want to hit the ball far, more and more we’re seeing everybody of all demographics and all walks of life are being able to hit the ball a little bit further but more importantly S&C is for everybody, it is a massively healthy activity and helps you maintain that muscle mass and maintain what you love for longer so that was the first bit I just wanted to put that out there because often people look at some of the videos that we pop up today and I think I could never do that and sometimes actually a lot of the clients that we have with inside 6 months even are doing some of what you’ll see on the videos today and we’ve had people, male/female aged 60-70 all doing some of the videos that you’re going to see tonight. Hopefully, then I’m also going to talk about why being strong is so good for you in the long term.

We know that the World Health Association really thinks this is something that we should be doing, they advocate for everybody to be doing two S&C sessions a week and on top of that they also say that we should be doing about 150 minutes flow-intensity activity, well the good thing for everyone who plays gold is pretty much all of us should get that at least once in a week but when the night are like they are at the moment and it’s a little bit dark out you might want to think about adding a second session and that might be your S&C session, it could also be a bike, it could also be a long walk but just something maybe in the middle of the week you know Tuesday, Wednesday away from the weekend when generally we have out competitions and were out on the golf course that you could do just to keep up your physical activity up or maybe you know keep that strength up and you know minimize the chances of joint pain, back pain and especially any kind of bone stress issues as well, so it’s a massively healthy activity that we want to do.

Why is it important well, David’s going to talk about this as well in terms of the fact that with golfers up to 50% of people will experience some form of lower back pain within the season you know, each year about 25% will experience some form of the elbow and wrist pain and up to 20% will have some form of knee pain and generally with golf most people don’t stop golf because they don’t enjoy it anymore, it’s generally a lifelong sport we love it for as long as we can play and so it is generally injuries that stop us playing its not any other reason and so if we can minimize the risk of injury then hopefully we can keep you playing golf for as long as you want to play golf and playing to the level and the performance you want to as best as possible.

Why is strength important and I get this question all of the time, what we can see here on the left hand side we can see the muscle in the dark colour and then we can see the kind of fat mass around that on the top left there of your screens, on the right we can see an 80 year woman and we can see that the fat mass is increased and the quality of that muscle that the white running through the muscle has increased as well, If we look at the graph below we can see the ages of 40-50, we see that steep drop off in our muscle strength and muscle quality and so the big thing here is this is completely preventable and generally what we see is without us doing any work we see about 3% decline in our muscled strength year on year after the age of 50 but as you can see on the right hand side we can absolutely do something about this, so we can see in the top picture on the right hand side a 40 year old triathlete has that brilliant muscle quality you can see that dark colour there, in the muscle with very thin amount of fat around the outside and if we don’t do anything we can see what it might look like when were 74 so we can see that the fat is increased and the white running through the muscle has increased as well.

The good news is as we can see on the bottom is that as a 70-year-old we can see that it’s completely preventable and by doing some S&C and some aerobic work we can maintain a lovely amount of muscle as you can see in that bottom picture with a very small amount of fat mass there and that is what all us what to try and achieve okay and if we can do that we see some massive improvements in our life expectancy but also the amount of support that we can play and the amount of physical activity and how long we can be self-serving ourselves as well so it’s brilliant to be able to maintain those muscle mass levels. Strength and endurance together gave the best results. The first things we lose as we get older are strength and power, so it makes sense that there are two qualities that you try to keep.

Strength is really important for our health, what we find is generally if you are strong you have a better life expectancy, and if you are slightly weaker and studies have shown that if you are strong and you have a slightly higher BMI, you still actually have a slightly better life expectancy than maybe someone who’s weaker but has a lower BMI. When all things are equal being strong is very healthy for you even if you have a slightly higher BMI, versus maybe someone who has a slightly lower BMI but isn’t as weak, so for everything else being equal, being stronger is going to have a better life expectancy but also it is going to have a big impact on how active you can be throughout your year. We found in the studies the stronger you are, the better clubhead speed.

The faster clubhead speed you have, the lower handicap you’ll have. We see long game performance improves and your distance will improve both your carry and your run as well. It is important once we get you strong to do a little bit of transfer work and I’m going to show you videos of that tonight, different ways you can transfer this once you have strength, you can transfer this onto your swing. When we strike the board with the driver there are massively high forces its similar to that of throwing a javelin actually believe it or not and so having that level of strength protects you against injuries when you’re using the driver and this young man on the right-hand side he’s got about 133 miles per hour clubhead speed can probably strike the ball into the mid to low 300 yard kind of range.

We have a continuum that we use here at the clinic and it goes from the high force on the left-hand side to higher velocity on the right-hand side. I have got a few videos here to show you. These are clips of our training. So then it brings us on to our swing speed progressions, once we have the prerequisite strength and we want to try to improve the actual speed of our swing. There is a couple of different progressions that we use that you can do down the range as well, In this video, we are using a swing speed stick that helps us, gives us a little bit more speed not swinging but using different clubs so you can use your lighter clubs such as your pitching wedge or heavier clubs as well such as your fire burn to do this with. We’re not focusing on hitting the ball here, we’re just focusing on swinging as fast as we can so it’s far removed from actually hitting practice on the range.

That then brings us on to our Golf Lab, over the years we have done a lot with a lot of our golfers in and around Ireland, we wanted to make a specific service for people who want to try and improve their golf and to minimize their risk of injury, so we have created the Golf Lab. Within the Golf Lab, we have several different tests to help you. We have some total body strength and power testing, where we test your total body strength, similar to what we saw in the video earlier my colleague lifted the bar into an immovable weight, very safe. We also do some jump testing to see how powerful we have both double leg and single leg and that’s interesting as we know both your dominant and your non-dominant leg both have a really big impact on how fast you can swing your club. Then we have what’s called some Isokinetic strength testing, now what we do on this day is w test the strength on your glutes your backside muscles because the stronger you are through them, the better we can protect your lower back but the more powerful we can be. We also have some swing speed testing. Then we have a personalized strength and conditioning program based on the results and what you want to achieve. That’s important because you might want to achieve maximum speed where others may have had injuries come from knee surgery or back surgery and want to make sure they can stay playing golf for as long as possible. Everything is individualised to you and all of the tests are individualised to you. The price is €150, we have contact details available at the end.

We also have our Total Tee Box Warm-up, we’ll have a link to this afterward. It is really important as you can get up to an extra 20 distances and prevent that double bogey by just warming up. We also have a sample S&C program available on our website. It is an excellent 6-week program. You can then see a qualified professional get a program tailored to your strength. A few takeaways taught from this evening. Take it slow by gradually introducing exercises. Then increase wither weight, reps, or sets when it gets too easy. Consistency is Key, doing well over one year is going to give you better results in terms of your muscles, in terms of your swing speed, and terms of your injury prevention, than doing 3 perfect months, so doing a little bit over one-to-three years we know it’s healthy for our whole lives is much better than you know is perfect for six or eight-week program. Strong = Healthy, as we have a longer life expectancy and important for us and our general health as well as our swing speed.

Lastly for those of you who have health insurance with Irish Life, VHI, or Laya, we also have the Fitness Lab and the Fitness Lab is included in a lot of the health plans and within the Fitness Lab we can make it specified to you, so if you wanted Golf Lab and you wanted some of those assessments that easily done and included in the Fitness Lab.  A lot of it is covered for you by your health insurance and sometimes it’s partially covered and sometimes it’s fully covered, just to have a little look at your policy document and see whether you have that available for you. I’d be more than happy to take any questions or email any questions to us, hopefully, that helps you.

Absolutely, some of the exercises we went through on the video there would be excellent, the wall holds especially because there is not much movement associated with it you get a brilliant strengthening of the muscles around the knee so that probably my first go-to exercise because it’s unlikely to cause you any discomfort. A lot of the exercises in the video would be perfect.

Yeah, there is some fascia underneath the foot that can get swollen if you load it too much, so it would kind of be a telltale sign that it’s happening when walking, that could be plantar fascia. There is some fat padding some bursts underneath that could be getting inflamed. You would want to look at an assessment and see why that is happening, it might be you need to strengthen around the foot, to try to provide that with a little bit of support or you may need some physio.

No you don’t need a GP referral for the Sports Medicine section, to see a physio, a sports medicine physician, or S&C you don’t need a referral but if you are going to see one of our consultants and our surgeons you would need a GP referral.

The big thing after a total knee replacement is you get the strength back into the leg so what tends to happen is after total knee replacement we do see a lot of muscle wastage around the knee and we have to try and get that back before heading back out onto the golf course.

You want to do all of the normal rehab exercises that you do for total knee replacement but make sure those muscles around the knee are as strong as possible before heading back to golf. There are lots of exercise options available to you, it’s just what suits you best.

That is a brilliant question, it is vital not only from an injury perspective but from a performance perspective. The evidence is you can get up to 1- or 15 power improvements if you do a good warm-up but also just in terms of your scoring over the first four holes, you will do better if you do a warm-up.

Getting your rotation and doing some swings is the most important but if you have some time do some squats or total tee warm-up which we have online. I think it’s important to do At least 5 minutes.

Hello, my name is Dan Withers, I am one of the knee surgeons here at the UPMC Sports Surgery Clinic. Thanks for watching my talk here on ‘Common Knee Problems and Golf’. To put a disclaimer out there, if anyone is watching this and is hoping to reduce their handicap, there is no money-back guarantee, I won’t be able to help you with that, but hopefully, I will be able to teach you a few things about the common issues with the knee and golf’

Just to talk about the background, as a knee surgeon most of the operations that I would perform are things like knee replacements – that includes partial knee replacements and total knee replacements. Then the other half of what I do is a lot of sports knee injuries, mostly the famous ACL ligament reconstructions, surgery on meniscus injuries and various other ligaments, and also doing some operations on knee cap patella instability. When you talk about the knee, the anatomy of the knee, what the knee is made up of its bones, ligaments, and meniscus. The bones that make up the knee include the Femur or thigh bone, the Tibia or shin bone, and the Patella or knee cap at the front of the knee, that’s are the 3 main parts of the knee. In between the main hinge parts of the joints of the thigh and shin bone, we have C shape cushions, on the inside of the Medial Meniscus and one on the outside of the Lateral Meniscus, essentially they act as little shock absorbers and distribute the forces that go through the knee joints. Then the other part of the knee is the ligaments, there are four main ligaments, you can see two green ones on either side there, that’s the medial collateral ligament, towards the inside part of the knee and then the lateral collateral ligament, that goes towards the outside part of the knee. The blue ligament there is the Anterior Cruciate Ligament and then the yellow one there is the Posterior Cruciate Ligament. The Anterior Cruciate Ligament is the main sort of stabilizer for the rotary and stability of the knee and then the Posterior Cruciate Ligament stops the backward motion of the shin bone or the thigh bone.

The most common issues that would relate to golf, now there js a lot of different knee issues, but two main ones that I would see would be related to Osteoarthritis of the knee joint and Meniscal Tears. They are defiantly two of the most common things. Funny enough, two of the most high-profile golfers, have those injuries, Brook Koepka had a dislocated knee cap, whenever he had his injuries, then Tiger Woods, he had a torn ACL, which he had reconstructed, but subsidence to the reconstruction, I think he had some ongoing issues because of the instability and he had a couple of other operations, they did a proper job on it last year.

The Articular Cartlidge of the knee joint, basically what happens in osteoarthritis is the ‘wear and tear’ thing, the main issue of Anterior Cartlidge, it’s normally that nice shiny tissue on the end of the bone that allows the joint to glide on top of each other. The main issue really with it is that it has no nerve or blood supply, so whenever it is damaged it doesn’t have the acute ability to regenerate itself. It affects pretty much every joint of the body, but very commonly it affects the knee and the hip, and also the neck and back, which would be other common areas that would be affected.

Sometimes you hear various people talking about different stages of Osteoarthritis (OA) and really what that means, these pictures here are from arthroscopic pictures of the knee, you can see the cartridge. In picture A there, you see the little probe pressing into the cartridge, it’s a little soft and you see the indentation there, this is very, very early stages of wear and tear of the cartilage and that’s stage one. Stage 2 is pictures B and C, at that stage, you start to get a little bit of fraying and fibration of the cartridge itself. In picture D there, you see some partial thickness loss of the cartilage and then in pictures E and F, it actually wears right down to the bone and sometimes you might hear people saying they have stage 4 OA or bone on bone, which is another common phrase people may use.

The risk factors for OA include age – everyone, as you start to get older develop some sort of wear or tear, and around about 50% of people, of adults over their lifetime, will develop symptoms at some stage or another of OA with around aboutb25% having symptoms related to the hip over their lifetime. Obesity causes more forces to go through the knee. The more pressure and the more wear and tear can develop, history of the previous injury, family history, overuse, and also muscles weakness and imbalance.  They can all be risk factors in developing OA.

However, there is a large proportion of people who are a-symptomatic of OA, as I say if you scan a lot of peoples knees, to some degree you might see a little bit of wear and tear, there have been studies performed before where people have had MRI’s of their knee and around about 40% of adults over 40 years old show signs of Osteoarthritic change on the scan, some may have been fairly minor ranging up to the more severe stage 4. Reasons, why you may not develop symptoms, could be to do a lot with the strength of the muscles around the joint itself and the biomechanics have an important role themselves in keeping the symptoms of OA. This is actually an interesting little study as well, sometimes people may get a little bit worried that they might need to go through some form of knee replacement or something like that, but actually, this study here that is from Spain and involved around 50,000 people and they looked at around 50,000 people, and everyone who was diagnosed with a GP with having OA change, only 30% of those people who had a diagnosis had to go through a knee replacement. As mentioned before obesity/increased weight was a risk factor that increased your risk of requiring some sort of knee replacement. As mentioned this is what OA looks like, you get wearing away of the cartilage and that wears down to the bone. You also may develop little bits of extra bone called Osteophytes as your bone tries to regenerate but does it abnormally.

The symptoms, well the main symptom is pain and the pain can be quite severe, some patients may have a limited range of motions/stiffness, swelling, pain after standing for long periods and walking around the golf and some people may develop night pain, that can be an indication of its getting quite bad where you may need to consider some form of knee replacement or some form of treatment. How do you diagnose it? A clean x-ray or MRI scan will show it up, as you can see here in the picture of the knee on the left of the screen where you can see very severe arthritic change here there is no gap between the joint, where the other knee here you can see a gap between the joint there.

Treatment – I would start with conservative management, taking simple painkillers, starting with a simple thing like paracetamol or anti-inflammatory, sometimes it’s not a bad idea to say if you’re going for a round of golf to take a few anti-inflammatory 1 or 2 hours before you go out to play and that may prevent a build-up of pain that may develop during the round or after. Weight loss – as we said would help and it is well known that around 7 times your body weight through the knee on certain activities, so even if you lost one kilo that’s 7 kilos of force less through the knee joint. Sometimes people ask about supplements – if you look at the evidence for supplements, there is no clear evidence that any supplement prevents osteoarthritis. There is some evidence to suggest things like glucosamine and chondroitin may have a small role in pain relief of symptomatic OA. It’s all about breaking the pain cycle, you will develop pain and because you have pain will start to become less active because you don’t want to be injured more, your muscles become deconditioned and less strong and more forced on the joint. It then turns into a vicious cycle, it becomes more painful and weaker.

This is something interesting here, everyone, as they get older, will have decreased muscle strength and this is an MRI scan showing quite clearly of someone who had an MRI scan of their thigh at age 25 on the left there and then at age 63, the same person who can see the muscle there is a lot smaller. The main muscle groups you want to strengthen up when you have issues with the knee are the quadriceps muscles and the glute muscles which are your bum muscles. You can do that by starting with some simples things like a bit of conditioning on an exercise stationary bike, there is good evidence that aquatic therapy is good for OA and reduces symptoms, Then there are some simple exercises that you could do like some straight leg raises and then you can do that with some resistance bands. You can do single-leg hip raise, hip bridge and wall sit, goblet squats. They can help a lot in terms of symptoms.

If you are still in a lot of pain, you might consider injections to help, there any many different types of injections – there is a standard Corticosteroid, Hyaluronic Acid, and Platelet Rich Plasma. If you have tried all these options and are still having pf pain, this is something you may end up having, this is a total knee replacement. This is an x-ray of that afterward, then this is something called a partial knee replacement which is also quite a good option, this is used on people who have very specific wear and tear and has slightly easier recovery and slightly quicker.

That’s OA, the other thing I mentioned is Meniscal Tears. Meniscal Tears are very common they occur frequently. If you scanned everyone over 40 years old you would see probably 30% of people would have a meniscal tear, not everyone will have symptoms, and the most common type of tear would probably be a degenerative tear. Normally the symptoms of Meniscal Tears would be a short history and it develops quite quickly, people tend to have sharp pain, sometimes people may have some catching and locking.

Diagnosis- Is done through an MRI scan as you can see here this is looking at the knee from the side, the blue arrow is posting to the posterior or the back part of the meniscus itself and on that scan, there is a distinct black triangle, you can see the white line at the back of the triangle in the back and that signifies a tear.

The treatment for it – initially should be conservative management, I would normally recommend people to try some physiotherapy for at least 6-8 weeks, if it’s very painful we would try an injection to dampen down that pain and then if it is not settling then an arthroscopy can be done to debride the tear.

At some rates, knee problems are extremely common and the most common for golfers would be OA and Meniscal Tears. Conservative management is feasible in most knee conditions.  I would always recommend trying this as first-line management. Physiotherapy strength and conditioning are extremely important. That is all I have, if you have any questions id be more than happy to answer except any on golf as I’m defiantly not going to be any help to any of you, thank you very much once again.

Yes, parameniscal cysts are very common and there quite commonly found on MRI’s, basically they occur from some degeneration of the meniscus tissue itself and then you get a little bit of a fluid collection around the meniscus. If it’s pain-free I would leave it alone, unless it started causing problems.

This is a very common finding, even people with normal knees can find that it can crack, pop, and do all sorts of things. It’s generally never anything to worry about and a lot of the time what it can be is a little bit of roughness of the joint surface underneath the knee cap, and if it is not causing any pain at all, it’s generally fine, and it’s not to worry about that there doing any damage. I would just carry on as normal.

Knee replacement is a quality of life operation, so really it depends how bad the pain is and how much that is impacting on your quality of life and restricting all your daily activities, so if it gets to the point where you are on painkillers every day, you might not be able to walk more then 5-10 minutes before you’re getting paid, you’re having a lot of swelling, maybe you can’t even sleep at night with the pain, those are all sort of factors that you might start saying would indicate it’s time to get a knee replacement.

For me, age doesn’t matter as much, it’s about the symptoms and how much that’s impacting your quality of life. With regards to getting back to say something like golf, it would probably take I would say at least 3 months before you get back to any type of golf.

it’s much like the knee, I always say to everyone to some degree all of us will have a little bit of wear and tear in our joints, in our knee and your hip and some people may be affected with symptoms of it and others may not.

It depends on your symptoms and there was a slide there that I mentioned that around 30 % people of people in their lifetime would need a knee replacement and haven’t had a diagnosis of OA, so there is a large majority of people I would say of people who have wear and tear and don’t have the symptoms that would fit to need something like a hip replacement.

I suppose the short answer is yes, some people get relief off it, others don’t, it probably would help in the more mild-moderate cases of OA. It is as I mentioned one of the first-line treatments either hyaluronic acid or steroid injection or a platelet-rich plasma injection, it would be the initial treatment for me to try conservative management, so you inject it and get some physiotherapy.

Then give it a period of around 4-6months and see what type of benefit that would have and then you know to base your decision on whether or not you need to do something further based on how long relief that they’ve had from it.

If you look at a lot of the evidence on this, there’s not t great deal of evidence to say that any brace is actually going to do anything physically but what I normally say to people is if they feel as if it’s given some sort of symptomatic relief then I would say you can try it, normally I would say not too spend too much on any sort of fancy braces but yeah if it is given some type of relief, I would say go ahead yeah.

That’s very, very common and what it is normally, maybe as I mentioned in the talk there are two main parts of the knee, there Is the main hinge part between the thigh bone and the shin bone and then the other part is between the knee cap and the thigh bone, your patella, so it’s extremely common to get a little bit of wear and tear underneath the patella and when you have patellar wear when you’re coming downstairs or inclines, that’s the moment that part of the joint is being loaded more, so roughly about seven times your body weight that goes through the knee on these activities and that’s why it’s probably more sore doing these activities.

I have to say but whenever people do have patellofemoral degenerative changes it can be very well managed conservatively and generally doesn’t end up needing any knee replacement as such because it’s only really on activities such as going downhill or going downstairs.

If you have a meniscus tear and you’re pain-free I would say, yeah you should play on, it doesn’t mean you’re not going to cause any more damage to it, and if you are completely pain-free then sometimes you may not even need the surgery for it because as I mentioned before meniscal tears they can be a-symptomatic as well so if your managing fairly well and you’ve got the tear it doesn’t necessarily mean that you need to go and have the operation.

It depends on what type of tear it is, the orientation of the tear but generally the most common type of tear is degenerative meniscus tear and those types of tears don’t heal as such but what I normally say is they can become a-symptomatic whereby yes you have a tear but it does cause any symptoms but it doesn’t necessarily heal itself.

Luke Hart, Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine.

“How to stay healthy & injury free – From youth sport to the ageing athlete.”

Hello, my name is Luke Hart, and today I am going to present how to maintain strength, fitness and how to keep a healthy lifestyle after competitive sport. My presentation will also cover any injury you may have had, applicable to many different situations you might find yourself in. We are going to talk about being fit for sport is being fit for life. If you’re fit for sport and have the health, the fitness and the strength and we can continue to play sports for as long as possible, that is the same as what we need to be fit for life and health.

So when we look at the difference between an elite athlete and those who have retired, it is very interesting to see that the bit we struggle to maintain after sports is the skill component of the sport. This is the so it’s the agility, the speed may be the throwing or the specific qualities of when you’re playing that sport, that is what we lose. We can see from the studies that the retired athlete and the elite athlete have the same physical test numbers, even though they have been retired from sports for several years. So what we see is that upper body strength, maximal strength in the upper body and running tests are the same in those who have retired to those who are still elite athletes. That is really positive because there are the key areas for us, people who don’t play sports anymore, there the factors we want to know about, the ones that will influence us on our health and our lifestyle. We need to know what to do after sport, whether it’s sports or GAA, soccer, football, or cricket. We need to maintain a healthy lifestyle and maintain as much of our physical fitness as possible and how that relates to our health.

The World Health Organisation about four years ago changed its recommendations. They added a couple of new recommendations that didn’t use to be there. We still have the usual 150 minutes of light activity, but often we would already get this in our sport. When we leave sports, we need to find something that will replace that, 75 minutes of vigorous activity, strength sessions at least twice per week, and minimising our sedentary time. Sedentary time is really the problem at the moment with COVID lockdowns and people working from home. People now have a much higher increased sedentary time than what they had even just a year and a half/ two years ago. This is also a problem after we finish sports if we were playing team-based sports. In Ireland it is very popular such as GAA, we could be out of the house 6 hours a week, 2-hour sessions three times a week. When we stop playing, we start to get a huge increase in our sedentary time if we don’t find something to replace that with. If we put working from home on top of that, we are looking at a bit of an issue, and we will discuss that later.

So what I would like to talk about today is three key areas: Strength & Power, Cardiovascular Fitness, and we will touch on BMI & Body Fat. I am going to start with Strength & Power. I am going to start with this that this fundamentally underpins all the other qualities we will talk about, and I am going to show you why. So when we look into strength, Muscular Strength is a predictor of all-cause mortality. A study was done on two million men, and women found stronger had significantly decreased risk of all-cause mortality, essentially decreased risk of death by any kind of disease. So it was the biggest factor that played a role in reducing people’s risk. We want to know how we can maintain our strength as we age and why it is that important. We can see here on the left is a 60-year-old woman, has muscle mass there, the black part is the muscle mass, and the white part is the fat mass. On the right-hand side, we have an 80-year-old woman again, and we can see the dark muscle mass and the white being the fat mass. What we want to do is, we want to try to maintain as much of that darker mass as possible. If you look at the graph underneath, you can see that the line’s slope is the drop of the number of muscles people have as they age. What we want to do is try to minimise that drop as much as possible. We want to try and get that line as flat as we can. It is okay if it’s ever-increasing. If you haven’t done much strength training before or fitness work before, you might see an increasing line as you age. The flatter we can get that line, the healthier and lower our risk will be as we age. You don’t have to lose that muscle, so what we can see here in a brilliant study by Wroblewski, they found that a 40-year-old tri-athlete had a great muscle mass with small fat mass in comparison to the 74-year-old sedentary man the fat mass has begun to invade the muscle mass, you can see that increased white mass around the muscle. We can see on the image below a 70-year-old triathlete had the same muscle mass as the 40-year-old tri-athlete. The best way for us to do this is through muscle training.

What is the best way of doing this? You can see in this study here the difference between doing maximal isometric leg press and maximal isometric bench press over a 21 week period. The strength and endurance group circled in blue had the best results. This shows while strength is important, it also shows the importance of strength and endurance. The combination of the two is the way to get the best results for yourself or anyone after sports.

I also wanted to touch on why strength and conditioning are important for other conditions as well. Mark will talk about this later on as well. ACL’s are a key kind of risk in field-based sports. We see them a lot in GAA, soccer, rugby and other sports as well. I’m sure many of you have had an operation on the knee or have had muscular issues or ACL issues. What we really want to know is how I prevent any issues down the line and for my knee. What we found is those with osteoarthritis, which is a common complaint after knee surgery or having any knee issues down the line, is that the people who increased their strength had a 22.5% reduction in pain and a 17.5% increase in their function when they’ve already had knee osteoarthritis. This will only be better if we start sooner. We also found those who had improved quadriceps strength, who already had knee OA, they had significantly improved gait and movement afterwards.

That brings me on, how strong is strong enough? What do you need to do? And how can you quickly and efficiently see whether you are strong or not? This test looked at a leg extension vs a sit-to-stand. There is a really good test that you guys can do at home. If you have a seat where your knee aligns with your hip, so a kitchen chair would be perfect. You have to see how many sit-to-stand you can do in 30 seconds. If you can achieve more than 11, that means you are above that low. If you can do less than 11, you need to do a bit more work. 15 would be the hitting average, and 22 would be in a good position. The younger we are, we would want to push that a bit forward if you are getting 27 plus. That is excellent. It is a really good test see to see where you are at. We can test this in more detail in our Fitness lab here.

Although that is a really good test at home, what do we suggest here at the clinic? For those of you that go to the gym, we suggest doing a front squat with 0.5-0.75 times the body weight. Let’s you are an average 80kg male, and you would want to be doing a 40-60kg front squat. This is the same across all genders and their body weight. A leg press of 1.5-2 times the bodyweight would also be a good alternative. For our posterior, the muscles at the back of our body so our lower back, sides and hamstrings, a deadlift of 1-1.5 times the bodyweight would be brilliant, hip trust of 1-1.5 times our body weight is also equally as good. Then lastly, for our upper body, which is important for females for osteoporosis as we age. 8-10 good quality push-ups would be absolutely fantastic. 1-3 pull-ups would be a great aim and target.

We are moving on to aerobics, fitness & physical activity and the role that they play in your health and fitness. Why is it so important? VO2 Max is something we use to test your fitness, so we use it here in all our health and fitness tests. We find it to be one of the most important tests to see how fit and how healthy you are. A Finnish study that followed 2226 males with no history of cancer for 16 years found that if you have a VO2 Max of 33.2 ml resulted in a 27% less chance of getting cancer and a 37% reduction in cancer mortality. Those that did 2 hours of moderate exercise reduced cancer mortality by 26%. An improved VO2 Max decreased the risk of lung, gastrointestinal and prostate cancer. Moving on to dementia risk, which is a big topic at the moment, those who have moderate to high fitness demonstrated significant reductions in dementia risk. So we say for every 3.5 ml. kg of oxygen improves, there is a 14& reduction in the likelihood of dementia mortality. Then for those that already have a moderate and high cardiovascular fitness group had a greater than 50% reduction in dementia Mortality. There is a lot of health benefits and significant reductions by having a higher fitness level.

Lastly, if we have increased fitness, we have significantly reduced the risk of cardiovascular disease. So if we have a moderate to high fitness level, we have a 53% reduction in risk of heart failure if we have a high VO2 max. An increase of just 9% in VO2 Max results in significantly decreased BP and Cholesterol levels.

We want to improve our fitness, so how do we do that? The first rule I have is to take care of the basics. That’s what we do without patients. What I mean by that is to take care of your daily steps. Anything after 6000 steps is a reduction in mortality rate. Every 1000 increase in steps reduces mortality risk by 23%. Rule 2 just start now, and yesterday would have been even better to start. People who do lifelong exercise see significantly improved data. Whether it is hard or easy, you will still see benefits. As we live for longer, we want to do the things we love longer. Continuing exercise throughout your life improves the condition of your life. Rule 3 intensity over the duration, so what previous studies have found is that if you do some high-intensity training, even just 60 seconds work with 75 seconds rest and ten times and three times a week in 5 weeks, you can have almost 10% improvement in your VO2 max. 10% improvement decreases many health risks. Secondly, what was found in the rating of perceived pleasure during HIT running than continuous running. This is really important because if we want to do this for the long term or as a habit, we need to make it official and enjoyable—a short amount of exercise with higher intensity. Continuous training also has lots of benefits, including mindfulness; you should stop this but maybe consider adding high-intensity training.

Lastly, I would like to talk about Body Mass Index and Body Fat % and the role that it plays in your health and fitness. This is the one that is spoken about in the newsletter the most and all over social media. There are some interesting studies; what we do find is that those wither a higher BMI and higher body fat percentage do have a significantly higher risk of all-cause mortality. There are some other factors that we need to account for. I would like to talk about those with Knee Osteoarthritis, which can be higher risk if we have had any operation or anterior cruciate ligament injury. We do find that body mass is important for those people. If you have had an operation on your knee or osteoarthritis, you should be trying to keep a lean body mass. So as social media and the newspaper say that BMI is the be all end, it really isn’t. Recent studies have found powerful older people exhibited an improved life expectancy of 9 years regardless of BMI.

What should we be targeting? The World Health Organisation is spot on. One hundred fifty minutes of low-intensity exercise golf is a great example of doing this. If we can include vigorous exercise every single week, about 1-2 sessions a week if we’re getting our low-intensity exercise if not 2-3 times a week. 2 strength sessions a week is vital as it helps to keep doing what we love for longer and is the key factor. A little bit of balance and mobility. We are maintaining a good diet of 80% /20% and hitting 7000 steps a day.

We offer a fitness lab here that is covered by VHI, Laya and Irish Life. We can give you all the information that we spoke about tonight and a personalised program and suggestions. VO2 Max Testing is a vital test as it gives you a great insight into your fitness. Contact us at 01 526 2050 to book in. Thank you very much for your time.

Q&A with Luke Hart.

Fiona Roche, Business Development Manager here at SSC, asked Luke Hart, Senior Strength & Conditioning Coach and Fitness Lead at SSC Sports Medicine questions sent in by the viewers live during the event.

Q. I only have a limited time to train. Should I prioritise strength or some form of cardio?

A. As you saw in the talk there, strength underpins everything we do, so if we can stay strong, it allows us to do all the things we love to do, whether that is football, golf or tennis etc. Some part of the week should be dedicated to strength. The use the rest of the week can be prioritised to cardiovascular as that is also very important so like 60% and 40% in strength. We only really need one session a week to stay strong. We definitely need some strength in there because if we don’t use it, we lose it.

Q. What pace of running is needed over 60 seconds?

A. It depends on the individual. For over 60 seconds, you want to be working quite hard. We use a concept called the rating of the exceed excursion so how hard you work. You can track it by ten, being it being preseason, which is really hard, and one being like you getting out of bed. You should keep it at 6-7. It is individualised.

Q. Should I be using weights at age 50+?

A. Yes, absolutely, it provides great benefits for bone mineral density and tendon health or any who is prone to osteoporosis. An individualised program would be important if you haven’t used weights before.

Q. Do all health insurance cover the fitness lab?

A. It depends on your policy. VHI, Laya and Irish life all cover the fitness lab, but it depends on your policy. Check your policy; usually, the benefits are down the bottom of the policy. You can ring us here at sports medicine, and we can check for you or else you can ring your insurance company to find out.

Q. Would you recommend a 45 minute Pilate class as a strengthening method, or would this be more balancing and conditioning?

A. It depends on the type of class you do. We want to see something that is over and above our body weight to influence bone mineral decadency and other areas improvements. Pilates alone might not be enough to influence the bone mineral and provide all the benefits. You would need to add some exercise for strength. It depends on the Pilates class, whether it is more of a relaxing class or a harder class.

Q. 11 days post-surgery, how can I prevent significant muscle wastage?

A. This can be hard to prevent post-surgery as post-surgery you are going to get some level of muscle wastage. The most important thing is to get that muscle back activated as soon as possible to prevent that waste. There will always be some, but by doing some exercises, especially ones that are specific to the surgery and the injury, then we can maximise the amount of muscle mass we can retain. That is really important. All those early-stage exercises are there to maintain muscle mass. Try to do exercises to encourage that muscle in that area.

 Q. Can you overdue your sessions in a week?

A. If we do too many sessions in a week and don’t allow enough recovery time, that’s when we can experience burnout. We need at least two dedicated rest days per week. When we train, we break down muscle, and when we recover, we build and heal that muscle.

Q. Do you recommend protein shakes for recovery?

A. Protein shakes are good and available quite easy. I see them supplement your nutrition, not replace good nutrition. Immediately After or up to 30 minutes are training would be a good time to take protein. There is high protein chocolate milk or Avon milk that you can buy on the shelf, which is just as good. It doesn’t have to be used, but it is something that can be and supplement.

As you saw in the talk there, strength underpins everything we do, so if we can stay strong, it allows us to do all the things we love to do, whether that is football, golf or tennis etc. Some part of the week should be dedicated to strength. The use the rest of the week can be prioritised to cardiovascular as that is also very important so like 60% and 40% in strength. We only really need one session a week to stay strong. We definitely need some strength in there because if we don’t use it, we lose it.

Yes, absolutely, it provides great benefits for bone mineral density and tendon health or any who is prone to osteoporosis. An individualised program would be important if you haven’t used weights before.

It depends on the individual. For over 60 seconds, you want to be working quite hard. We use a concept called the rating of the exceed excursion so how hard you work. You can track it by ten, being it being preseason, which is really hard, and one being like you getting out of bed. You should keep it at 6-7. It is individualised.

It depends on your policy. VHI, Laya and Irish life all cover the fitness lab, but it depends on your policy. Check your policy; usually, the benefits are down the bottom of the policy. You can ring us here at sports medicine, and we can check for you or else you can ring your insurance company to find out.

It depends on the type of class you do. We want to see something that is over and above our body weight to influence bone mineral decadency and other areas improvements. Pilates alone might not be enough to influence the bone mineral and provide all the benefits. You would need to add some exercise for strength. It depends on the Pilates class, whether it is more of a relaxing class or a harder class.

This can be hard to prevent post-surgery as post-surgery you are going to get some level of muscle wastage. The most important thing is to get that muscle back activated as soon as possible to prevent that waste. There will always be some, but by doing some exercises, especially ones that are specific to the surgery and the injury, then we can maximise the amount of muscle mass we can retain. That is really important. All those early-stage exercises are there to maintain muscle mass. Try to do exercises to encourage that muscle in that area.

If we do too many sessions in a week and don’t allow enough recovery time, that’s when we can experience burnout. We need at least two dedicated rest days per week. When we train, we break down muscle, and when we recover, we build and heal that muscle.

Protein shakes are good and available quite easy. I see them supplement your nutrition, not replace good nutrition. Immediately After or up to 30 minutes are training would be a good time to take protein. There is high protein chocolate milk or Avon milk that you can buy on the shelf, which is just as good. It doesn’t have to be used, but it is something that can be and supplement.

Tommy Mooney, Senior Strength & Conditioning Coach at SSC Sports Medicine.

“How to protect our young athletes in modern sport”

Thank you for taking the time out of your evening to watch this SSC series. My name is Tommy Mooney, and I am a Senior Strength and Conditioning Coach at Sports Medicine. Alongside my role here at the clinic, I work with a host of different athletes of all different ages from a multitude of different sports, including team sports, individual sports and tracking field etc., ranging in ages from 6 years old to 80 years young.

My presentation today is going to be about how we can protect our young athletes in modern sport. I am going to suggest a three prone model for optimum health and development. First and foremost, we are going to talk about the importance of multi-sport and using different sports to enhance our movement vocabulary. The more movements we learn, the more skills we can accomplish and showcase in our sport. I am then going to talk about training load and finding the balance between rest and training, and then thirdly, we will talk about strength and conditioning.

First, I would like to present a story to you. On the screen, we have two kids here, both 7-8 years old. Jack on the right here is a tennis player, adamant he is going to become the next big thing in tennis as well as his parents believe he is going to be a tennis player. Jacks life revolves around training tennis and getting as good training as possible. Jill, here on the left-hand side, plays a multitude of sports such as GAA, gymnastics, tennis and athletics outside of her busy social schedule. Jill wants to become a gymnast or an influencer when she is older. My question for you is, which child do you think will have a longer and more successful sporting career? Ultimately we can’t pick one, and we never know as many childhood progeny’s like Tiger Woods and Lionel Messi has gone on to grow from their childhood success, but despite that, we often would suggest that having a multitude of sport and playing many different sports is typically the optimum way to develop a broad range of skills and capabilities that can then lead on to your final sport at the end of your career or as you age.

Another benefit of multiple sports is that children are going to learn multiple different skills that are going to help burnout and increase participation for longer. It can also reduce the risk of injury, improve cognitive skills and decision making, is typically more enjoyable, offers breaks different in-between sports. We also know sports diversification leads to a long sporting career.

Forgetting about sport for a minute, we know that children nowadays are typically slower compared to children 30 years ago. They are weaker when compared they are less physically literate and less physically active. Introducing children who may not be playing sport to physical activities like strength and conditioning is going to be really important to know that less than 5 hours a week of physical activity can increase the risk of injury. Obviously, there is a bell-shaped curve that we know if we do too much training, that can also be a risk factor; I think this became much more clear of the back of covid where we saw an extended period of not training followed by a spike or increase of training in our training load, this is something we associate with an increased risk on injury.

What are strength and conditioning? The bottom left is an example of what it doesn’t look like as it is obviously too heavy and too young. Moving on then to the other pictures, we have multiple different movements such as crawling, jumping, landing, moving, lifting and squatting in an environment that is safe and fun, but also challenging and then as they get older, you can see the exercise progress and increase in load and make it more challenging.

Obviously, there are concerns and misconceptions around strength and conditioning. It is important to know that strength and conditioning is not only gym-based. It is speed & agility based, muscular endurance can also be enhanced by this, but we won’t talk about too much of these particular components today. We already talked about how it can have an improvement in our movement skills, balance and flexibility. As mentioned, one of the concerns typically is that it is dangerous, but it is important to know that sports, in general, is more dangerous. This video on the screen is an example of such. So we know sport itself is dangerous, so the better we can condition and prepare our young athletes for this, the safer they may be when they do take the field.

Some other misconceptions are around stunts in growth. This extends from anecdotal data that weight lifters are small and stocky; therefore, weight lifting must stunt their growth. This is similar to people saying that playing basketball will make me taller because all-athlete basketball players are tall; therefore, playing basketball will increase my height, this obviously isn’t the case. We spoke about the danger. Other misconceptions can be that it makes you slower. This isn’t true proper strength and conditioning can help you increase speed rather than slow it down. Building big muscles is highly unlikely in youth athletes as we don’t have the hormonal profile that is going to allow for this; it typically takes years of training to do so. Then lastly, growth plate injuries are more likely to occur in jumping or landing and field sport as opposed to our gym-based sport. There has been a host of research to back this up that weight training in youth is safe, that long term responses to it are positive.

This table here shows the incidence of injury in youth sports, so it’s looking at some popular field sports such as rugby, soccer and GAA, it is looking at injury incidences over 100 hours of match play. What we can see on the table is that incidence of injury in these field sports are considerably greater than our weight lifting activity. By weightlifting, we are referring to the sport of Olympic weightlifting. We see two studies here boys and girls as young as seven had 0 incidences of injury over one and two years. This study here where there was one injury happened with a weight plate falling on the foot, not even the sport itself but rather maybe from not paying attention during the down period within the activity—emphasising the safety of these when done properly. Injuries in these activities are typically a result of poor technique, excessive loading, training whilst fatigued and a lack of qualified supervision. This is an important point to note that we need to make the people who are organising and running these sessions are qualified. I’m sure there are a host of coaches and parents on the call here who work with these young age ranges. I know how difficult It can be to keep them engaged and supervised, so I have a lot of respect for those working with these young athletes and young groups, but it is important that whoever is leading these strength and conditioning sessions is appropriately qualified.

On the screen is another example of time-loss injuries in elite soccer academies, so this is Arsenal; prior to 2013 and Des Ryan and his team taking over, they had quite a high incidence of injury. After 2013 when they implemented a world-class strength and conditioning program, they significantly reduced the number of injuries over the next couple of seasons. Obviously, we can’t completely irradiate injury as we already mentioned; sport itself is already injurious and particularly risky, but we can do with good strength and conditioning, we can decrease those numbers.

When can we start? How young is too young? This study by Myer, Lloyd, Brent & Faigenbaum showcased that those who started in pre-adolescence achieved a greater level of motor capacity in adults in comparison to those who only started in adolescence, who only practised sport and those who did no sports.

I am going to go through the stages of strength training in more detail. Stages one and two are going to be largely based around bodyweight training and mastering the basic exercises and movement patterns, progressing into maybe some soft resistance things like med ball & sandbag the progressing onto your barbell training. This is similar to our power progression, and it is important to note that strength underpins power; although both are important, utilising some power exercises can help ensure that we the maximal transfer across from our strength training. Okay, again, similar here were interested in jumps, hops and throws, then gradually introducing then some light resistance before we consider moving on to more weighted or loaded progression.

When do we progress from bodyweight to barbell training? When we have good control over our own body and limbs. Good position & patterns for the six major bodyweight movements. So, for example, these six movements may look like this. This is an example from a youth scoring table, so when you can achieve 18 points in each of the exercise categories, that’s a sign you have mastered or you are competent with your own body weight and are ready to progress on to loaded variation. So, for example, here we get points relative to the number of repetitions that you do, the points add up over the different tests and that allows us to achieve our 18 points; again, those scores may be different for our male youth athletes.

Advice and summaries for parents, I would encourage everyone to try and get their children engaged in PE; that way they’re going to see a multitude of different sports and skills, to get out and play with their friends, to incorporate at least one rest day a week, try and play different sports in the off-season, communicate across the different sports they do, try to reduce training load during a growth spurt,

Introduce resistance training under supervision and to make sure have fun as the more enjoyable and engaging we make sport the longer we participate and have more benefits in the long term. Thank you for listening.

The consultant will have clear guidelines to give you as it depends on what stage you are in, such as in the early stages of post-op you are probably not going to be doing as much as well as it depends on where they’re taking the graph from. In reality, you want to try and keep the knee as calm and happy as possible, so not doing anything that is going to aggravate the knee. Do what you can. The key thing is not to aggravate the knee in the process.

That’s a tough one; it can be challenging. The most important thing is the player and coaches relationship, make those communications channels as open as possible, look at the link between sports and monitor that. The first important thing is communication, and then the second is asking the athlete how do you feel?

During periods of a growth spurt, that’s maybe when you want to reel in training a little bit and reduce the training load a little bit, that maybe when you can focus on strength and conditioning activities or not as much heavy load on the pitch. There are also other things you can do in terms of monitoring training, such as watching the minutes you spend on the pitch, how many training hours you are doing in a week and just making sure that it isn’t spiking at certain points a year. It is important to make sure there are periods of the week/month where there are low periods of training.

It is hard to say; you need to consider the individual case, how many sports are we talking about, do the two sports cross over, are they quite different etc. At about 18 years is when you’re going to start to specialise in developing special skills in that sport and dedicating as much time as possible to that sport to optimise your performance. It is also important to ensure they’re not doing too much.

Yes, absolutely. We spoke about the importance of seeking professional guidance, and that’s where maybe touching base on it may be a local S&C coach or you can come into the clinic here that is going to be beneficial, rather than getting a generic program you would probably want something a little more specific so it is tailored to the individual, to their training needs, their sport and then to their injury risk if there is one as well.

“ACL injury and reconstruction – an overview”

Hi, my name is Mark Jackson, and this evening I am going to be talking about the Anterior Cruciate Ligament Injury and a brief overview of the reconstruction. I am an Orthopaedic Surgeon here at the UPMC Sports Surgery Clinic. I am a Knee Specialist. I see patients and their injuries from 12 and upwards. Patients come from pretty much the whole country and are referred in by their GP’s, sports therapists, physiotherapists and other surgeons.

My work is split 50% of the work I do in sports and soft tissue injuries that incorporates the anterior cruciate ligament injury. The top three pictures are with a camera in the knee, and that is just looking at cartilage type problems. The bottom right and middle pictures here are actually cruciate ligament tears. Then the other half of the work that I do is more degenerative in nature which means osteoarthritis, and this can be offering patient’s procedures half or partial knee replacements, full knee replacements as you can see in the bottom left, more complex revision, complex primary total knee replacements and other procedures.

Today we are going to cover the Anterior Cruciate Ligament Injury. This is a very big topic. It has been heavily researched over decades. It is till I guess not completely understood, but we are getting better at helping people with this injury. Ì will try to keep it simple and not too surgical. I am going to go through some of the main points, such as what is the Anterior Cruciate Ligament, how the ACL is injured, treatment options and consequences of an ACL injury.

What is the ACL? As you can see in this picture, on the right-hand side, we are looking at the right knee from the front. The anterior cruciate ligament stands here with the joint in the middle. There are actually two cruciate ligaments, cruciate meaning crossing, so the posterior ligament is tucked in behind the ACL here in the front. The other two ligaments are the ones around the sides called the collateral ligament, so the medial or in the picture it is called the Tibial Collateral Ligament, which we often call the NCL and on the outside the LCL.

These next images are from cadaver specimens; the right-hand picture is looking from the front view of a flexed left knee; we can see these two ligaments in the middle of the knee and then the ACL, which is joining the two bones together. In most individuals, there would be a region of about 3 centimetres long and about 8-10 centimetres in diameter. It is shaped a bit like a ribbon.

So what does it actually do? Well, it is an important and primary stabiliser of the knee. It protects other structures. It is like the guardian of meniscal cartilages. It is particularly important in rotation. If it’s torn, this is An ACL deficiency which leads to a lack of confidence in typical movements. It is a fairly small ligament with a big job to do. In humans, it hasn’t evolved to be put through the rigours we demand of it. If we compare it to a mountain goat, they have a much thicker and strong ligament as it has evolved.

How can the ACL be injured? Anybody can injure their cruciate ligament. There are certainly some high-risk groups. It usually occurs in a competitive environment. Frequently it is a rapid pivot movement such as a push-off, a turn, twist, awkward landings, deceleration’s and hyper-extension. Most commonly, it doesn’t involve heavy contact or collision.

The image here in the middle shows the position of the knee when it is torn, the foot flat and twisted out, the knee falls into a position that we call valgus, buckling down and in on itself and often hip is what we call abducted, taken away from the side. This skeletal image shows us it is being damaged.

What does the typical cruciate ligament injury say? Well, usually, the history is of a sensation at that ‘the knee popped’, ‘the knee buckled’ and ‘the knee went in and out of place’. Generally, there is immediate pain, and severe pain and the patient has to be helped off the pitch. Sometimes people feel like they might want to try and continue, they get to the sideline and don’t feel too bad, but then usually, they try to run again and realise this isn’t going to work out. Generally, over 24-48 hours, the knee looks quite swollen, there is pain on weight-bearing, the patient is limping and may even need crutches for a couple of weeks while things settle down. The knee than can actually start to settle and feel ok day to day; by then, the patient is advised to see advice from a physiotherapist, A&E or their GP. The initial examination can sometimes be difficult if the patient is swollen and sore. An MRI is generally indicated. Sometimes patients are told their knee is too swollen to scan or to wait until the swelling has gone down; I don’t think this is necessary; just crack on and get the scan as soon as possible.

What does it look like on a scan? The left-hand picture here shows a very clear black ribbon structure crossing the joint, joining as we saw in the picture earlier the fibia down onto the tibia. The middle picture shows a ligament that is torn. This picture on the right shows a different sequence of the MRI, so the black line, the ligament, is torn and ripped off the bone. An MRI scan is a very accurate way to indicate this injury.

How common is it? Well, it is actually quite common. It is very difficult to incidence data in Ireland the UK but referring to other big studies and academic studies around the world; we would have approximately about 4000 ACL injuries across Ireland a year. The majority are between the ages of 12 and 35. This next study is interesting looking at high school athletes in America; it gives us again an indication of how common this injury is. They looked at ten studies that accessed high school adolescent’s males and females involved in the sport such as their local clubs and in schools, not in elite sport. They found if you follow an average adolescent sporting female in a year who maybe go from their soccer season into their basketball and lacrosse season, that’s training and playing, and they accumulate an annual risk of 2.5% risk per annum of ACL injury, which is obviously quite high. This figure is higher in females than males by about 1.6%. There are reasons for that, but we won’t go into too much detail today.

There is again, a difference between looking at an adolescent amateur athlete and comparing that to somebody who is involved in very high elite sport, and actually, the relative risk of an elite premiership footballer tearing their anterior cruciate ligament is relatively low, this study looked at 28 teams of Elite European Soccer teams, relatively the risk is quite low, so the standard male elite squad would probably only get one ACL injury every couple of years, so it is quite different to an amateur teenage type individual as these individual are quiet strong and involved in injury prevention type programs.

At the clinic here, we have a registry that we put most of our ACL injuries into so that we can look at the data and follow up results. We found that the mean age, we have about 6000 individuals on that registry now, but we found a mean age of about 25. It is important to look at the red circled groups on the screen that at least a third of our individuals are actually under the age of 20. We do operate and see more males than females, but that just reflects that males are most tensely involved in sport than women generally in terms of numbers than females.

Then talking about the Mechanism of Injury, again, as we already mentioned, the ‘non-contact’ injury is far more common than contact injury, and most of these Injuries occur in competition as opposed to training. The distribution of sports in Ireland is unique compared to some other countries because of the amount of contact in field sports that are played, So about 80% of our injuries occur in a field sport, the highest number being Gaelic football, the second-highest number being soccer, followed on by rugby and hurling. The other ones are minorities such as simple accidents etc.

There is clearly a problem that exists with an ACL tear. It seems to be an issue in very young and physically active individuals with high demands who want to get back into sports. It can be quite debilitating and life-changing with the potential for long term consequences. A lot of high-risk sports in Ireland, and not everyone is the same; we do have vulnerable and differing risk groups.

Maybe you have gone and seen someone myself; an ACL is torn; what happens next? We will discuss the options. There is a responsibility to advise and give the patient a perspective on this injury. In the short term, what we are going to try and do is the knee is the restoration of confidence, return to sports and activities and no symptomatic instability. In the long term, we would need to cancel out potential problems.

There are three main stakeholders here with this injury. Primarily the first one is the patient, and they just want a few things clear in their mind, such as fixing it, when is the surgery, when will I return to normality and how long until I return to sports. Then the physiotherapist, they’re going to very important, they’re going to have to have appropriate rehabilitation pathways in place, they will have to give guidance on what’s appropriate and what’s not appropriate of the various stages of rehabilitation and guide that individual along the way onto hopefully a successful outcome. Then the surgeon clearly needs to make the diagnosis and have a good ability to be able to interpret what we see on the scan. We need to talk about what surgery might suit that individual and to have a good reliable procedure to get the best possible outcome.

The problem with an ACL that is torn is what we talked about; the knee ‘gives way’, it does not have the ability to regenerate itself like some other ligaments might, and it doesn’t have the ability really to heal, so that person usually reports a sensation of instability not necessary any pain or stiffness. The majority of patients that I see are going to want to resume their activities when we start thinking about options, particularly surgery, but some individuals don’t have sporting goals, but they still need a stable knee for their jobs such as a Garda, the military, people with construction type works, manual labours and farmers. So even if they don’t want to go back to the sport, well often they will still about wanting surgery. This video here demonstrates the instability of someone under anaesthetic just before they’re about to have their cruciate ligament surgery. This is a movement called the pivot shift. What we’re doing is trying to reproduce the motion that happens, so the knee is kind of bent and clicking you feel it gliding in and out of place. That is an indication that the knee is unstable.

So is an operation always needed?  No, non-operative treatment can be reasonable to people in certain scenarios, that might be someone with low demands or somebody who is a little bit older, so for example, if I tore my cruciate ligament and I’m in my 40’s, I don’t play contact sport or football anymore, I would probably see how I went with a good rehab program first, strengthening for 3-6 months and only then I would undergo surgery if I have failed that.  If I was in my 20-the 30s or teens, I would just get on and get the surgery done as soon as possible. Some individuals are not in a position where they can commit to the time out and rehabilitation; the procedure then can be safely delayed once they can commit to a bit of gym work and take on board some of the ‘do’s and don’ts’.

If you do go down the route of non-operative treatment, some studies have been done of this and have demonstrated that at five years, even with rehabilitation, at least half of the individuals have crossed over and got their ACL reconstructed, but these are very difficult studies to do as it is very difficult to get a set of thousands of sporty young people who have torn their ligament and separate them in who is getting their ligament done or who isn’t.

For the majority of young people wanting to return to sport, I would talk to them about an ACL reconstruction. The return to sports rates are good, and most individuals will get the outcome that they want. These two pictures here are arthroscopic, showing what a knee first looks like when the camera is put in, there is such a cruciate ligament on the bone, and then this is a picture of where we put the graph in so this is the ACL reconstruction. So how do we do this? We harvest something called a graph, and there are two main options that I would discuss with patients; we prominently only use this graph called the bone patella tendon-bone. We harvest a bit of tendon from the front of the knee to get a new ligament, which we can then feed into the joint. There are hamstring tendons, and we can stick together to make a construct like this that can be fed into the joint, then hopefully become a new ligament.

In a nutshell, I’m not going to get into too much detail. What we then do is clean out the old cruciate, we drill tunnels up into the bone, and that graft we have already harvested we then have to pull out and pass into the joint; what we are then hoping is that the graph takes the mole of the original ACL and heals, but this Is a slow process, and it can’t be sped up, this is a biological healing time, and even in the best-case scenario, the whole thing takes a minimum of 9-12 months to try and get the best results. That’s how long it takes a premier footballer, and that’s how long whoever is going to be out for as well. There is also a lot of hard work to do in the gym as well while all of this healing is going on. This video shows the graft being pulled out.

Our registry is pretty reassuring, and the good news is that most individuals are going to get back into playing a sport, about 85% will, and that would be in key with lots of other studies that have performed around the world. Now re-injury is an important topic as that can be devastating, not just for that individual in the short-term but also can, unfortunately, be the end for some people in terms of their sporting environment. We can do another ACL reconstruction, what’s called a revision. It’s not easy for results or going to be as good. It’s particularly a concern in our younger aged groups, there have many studies on this, and particularly this one, patients under 25 may have a secondary injury rate of at least 23%. If you look at this Australian group results, in particular men under 18 had a very high re-injury rate of 28..3%

Long term consequences are important as what we are given people is not a normal knee, the cruciate we are putting in is not a tendon, it is usually good enough, it gives a good function and outcome, but there still are potential problems down the line. This is down to arthritis. These individuals, even 20 years later, are still experiencing problems. I would have done several knee replacements in the last few months, and men generally in their 50’s may have had a cruciate ligament injury in their 20’s. These back this up; if you look at individuals’ maybe 20 years after having an ACLR and you x-ray them, you will see at least 40% are showing signs of early arthritis and about a ¼ of them are getting symptom’s. Then looking at how common it is to get knee replacements, if you look at 15 years results, about 1% of people have unfortunately already had a knee replacement against an uninjured group.

It would be ideally nice if we could prevent ACL injury. It’s never going to be zero because of the unpredictability of contact sport. There have been studies done and programs instigated that we can actually reduce the injury rate, particularly in younger athletes and female athletes up to 50%, which is clearly very significant.

So finally, just some take-home points, this is a common knee injury, third of our patients are unfortunately young under 21, we tend to offer an ACL reconstruction to these individuals who are demanding to want to get back into sports, we want to try to give them more stability and allow them to return to the sports they love and hopefully be able to reduce further damage, the majority will get the outcome done once and get back into activity. The surgery approach is individually based. There is a need from parents, GP’s, coaches and individuals to appreciate that prevention programs work, that we do underplay a little the prognostic implications of ACL tear because of the increased risk of osteoarthritis; I always tell younger individuals this can be a problem in secondary injury rates. It is a very significant injury that we do have procedures for, but then there are issues that you need to appreciate and understand. Hopefully, that wasn’t too difficult to take on board, and there are a few points that people have taken home. Thank you.

The chance they get back is good, but unfortunately, the chance of re-injury in that age group under 21 years old is quite high. There shouldn’t be any rush; they need to tick all the boxes. I can see someone is saying their child had passed all the tests here at SCC with flying colours but, there are physiological barriers that people have to go through as well if they’ve had sequential injuries at a young age.

There is going to be a risk every day; there is some things you can change and some things you can’t, such as genetics, the shape of your knee, collagen, which is what your ligaments are made of its not unusual to operate on twins or brother and sisters. If it was my kids, I would let them return if they were able to, but if they kept getting re-injured, then you would need to have the talk if it’s worth carrying on in that sport.

That’s often one of the very first questions people ask; generally, it is important for people to understand that it’s not time-dependent. There is a biological healing phase, which everyone has to go through. It doesn’t matter if you’re a premier footballer or not. There is a ligament healing time, but after that, you shouldn’t be time-dependent; in the past, it used to be, you could go back to play after six months, but we have moved away from that because of the realisation that most people are nowhere near ready at six months.

I tend to recommend 9-12 months, a minimum of 9 months. At nine months, there is an assessment from my perspective on how does the knee look, how the knee feels, swelling, pain and movement good. There is also a test that we often arrange for individuals to see how symmetrical they are between legs, seeing how they are for their body weight, strength scores, and also getting them to do simple tests like landing and hopping tests. Very few people are actually ready at nine months, there shouldn’t be a rush in my opinion, particularly in a younger individual they have everything to lose and nothing to gain, trying to go back at nine months instead of 12-18 months. If that’s what a premier football needs, that’s what everyone needs.