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Hello everyone my name is Ruth Delaney, I am a shoulder Surgeon at SSC and I’m going to talk about sports injuries and conditions that can affect the shoulder at various stages of life. A little bit about my background I spent 6 years in Boston doing my orthopedic training and most of that time was spent at this institution as a shoulder fellow so in my last year of training I got to spend some time in France before coming back to Dublin in 2014 and my practice is exclusively focused on the shoulder.

Shoulder pain is quite common the majority of us are going to experience shoulder pain during our lives at some stage and a quarter of people who have shoulder pain report that they have had it before as well so t can be a recurring thing. It can be quite debilitating in terms of sleep disturbance, in terms of affecting daily life and work and it can come from a variety of different sources it can be a little bit hard sometimes to figure out exactly where it is coming from.

That is where the specialist comes in, I suppose talking about the shoulder and sports, the sport that I know the most about is tennis and you can see wh, for example, tennis serve the shoulder is doing a lot of work there are different phases of the service and one of the important things about sort of keeping the shoulder healthy when you’re playing a sport like a tennis, is to remember that the shoulder isn’t working in isolation and so what’s important is from the ground up, so everything is connected and everything is part of what the physiotherapists and the S&C coaches will talk about as a kinetic chain so if you have good solid core strength, a stable base from your legs and core, then your shoulder is going to be that bit more protected when you’re doing things like playing tennis or swinging a golf club. The shoulder blade is also really important that’s a stable platform for the shoulder to function and if you think about the shoulder as a ball and socket with the socket relatively small and the ball having a lot of freedom of movement, its got to have a stable platform to work off and the socket of the shoulder joint is apart of the shoulder blade and that’s why I said when we send you to physoitherapy for your shoulder, the physio will often spend a lot of time working on your shoulder blader control and getting all those smaller muscles around the shoulder blade to work because they often go to sleep particularly when the shoulder is sore and a lot of the times when we go to the gym we train the bigger muscles and we forget about those small really important muscles around the shoulder blade, when the shoulder blade isnt really working well with the rest of the shoulder, its something we call scapular dyskinesis which is a broad term that just means kind of that the shoulder blade is out of rhythm and that in people who play overhead sports can increase the risk of shoulder pain, so again going back to for example a tennis serve so things that are going on with the foot position or with the knee bend can affect how the shoulder ends up having to compensate and lead to problems with shoulder pain the same thing with hip flexibility with trunk and the core strength and as we talked about the shoulder blade or scapula so that scapular position, all can feed into what happens when you try to go through the motion of a serve and a lot of us are stiff through for example the htoracic spine or that part of your spine between your shoulder blades and again that can have an affect on how your shoulder works so when you’re playing a sport that involves a shoulder having to do something there’s a lot more going that often needs to be addressed when your shoulder is sore playing golf not strictly considered an overhead sport but when your at the extreme peak positions of a golf swing those positions can provoke shoulder pain so abduction is bringing your arm away from your body, adducton is the opposite bringing it across your body and you can imagine that there are parts of a golf swing at times that will be in the maximal extremes of those positions and when you bring your arm away from your body sometimes you can end up with something called impingement or when the ball and socket is up like this the ball is up like this we’ve got the roof of the shoulder over top here what we call the chromium you can get some pain from inflammation under there when your arm is across your body or in adduction that can particulary in younger golfers and we see it in hurlers as well with a similar positionsa of the shoulder, that can sometimes leave the shoulder vunerable to a less common type of instability which is out the back or posterior instablity, the biceps is an interesting muscle it has two tendons at the top end and one of those longer one goes right through the shoulder joint and repetive motions like a golf swing can irritate that tendon leading to tendonitis in there and that’s something we see commonly in people involved in many different sports the nice thing about a sport like golf while it can place demands on the shoulder we usually see that people are very well able to get back to playing golf and pretty much at the same level as they played before even when we do pretty complex shoulder surgeries for example repairing rotator cuff tendons or replacing the whole joint.

Collision sports are a little different the most common injury we see in people who play things like GAA, rugby, or hling is instability or dislocating the shoulder and the more common type of that is the shoulder dislocating at the front so the ball and socket joint ball come out the front of the socket and the reason that the shoulder is susceptible to that is that the socket is relatively shallow as well as being small that’s what allows us to have so much movement of the shoulder but in certain positions, particularly for example with the arms overhead the shoulder can be vulnerable to install, it and if you dislocate your shoulder for the first time at an age under 25 there is a very high risk of it happening again as you get a little bit older than 25 so peoples in their 30s, 40s who dislocate their shoulder for the first time those people have a much lower risk of it becoming a recurring problem. Sometimes you can have other injuries that happen with it and which are more common in people over 40 for example tearing rotator cuff tendons but the likelyhoof of the instability having to be addressed is much lower in these younger players often we end up looking at surgery to stabilize the shoulder and there csn be broadly speaking two types of surgery, one is a soft tissue surgery where we fix the soft tissue surgeries or the cartlidge bumper around the shoulder socket call the labrum and the other one is where theres more severe damage to the shoulder often in cases of multiple  dislocations where we have to actually put a bone block on the front of the socket to stablise it and after those surgeries the rehabilitation time varies, it depens on the type of surgery, it depends on the type of sport that the player wants to get back to but the quickest would be typically about 3 months and it can often particulary the soft tissue surgeries take 6 months for the shoulder to be ready for the high demands of collision sport because those are probally the riskiest sports for the shoulder joint.

If we think about the type of symptoms that people typically get in the shoulder, the shoulder can be sore it can be weak, it can be unstable like we’ve just spoken about or it can be stiff. These are not mutually exclusive a shoulder can be sore and weak at the same time. The other thing that we often think about as well and it’s important not to forget is that a problem in the thneckco in the cervical spine can present as shoulder pain or weakness around the shoulder and equally a problem in the shoulder can give you some neck pain and a lot of people have both going on at the same time so it can sometimes take a while between the spine specialist and the shoulder surgeon to figure out between us okay wheres most of the pain coming from which should we tackle firstor often we tackle the two things in parallel sometimes injections might be part of that because as well as helping the inflammation and hopefully making your pain or symptoms better they also give us good diagnostic information if an injection into the neck does nothing for your shoulder symptoms but sn injection into your shoulder helps your shoulder a lot then obviously the pain is coming more so from the shoulder and we prioritize taking care of the shoulder so the kind of diagnostic work up of shoulder symptoms can often be complex and so the history that yiu as the patient give us is something that we learn a lot from because there a typical patterns of symptoms for some things and typical sotries and that’s why where the questions come from that we often ask people presenting with shoulder problems. We get a lot of information from actually examining the shoulder and during the height of the COVID pandemic when we were doing video consultations and trying to figure things out without being able to hands-on examine people, I think that made a difference with shoulders it was a little harder to figure things out sometimes and then imaging will often play a part too, plain x-rays are very good for certain shoulder conditions and sometimes are better than MRI’s for example if you have tendonitis in your rotator cuff and there’s some calcium in it or what we call calcific tendinitis we can see that much better on an x-ray than an MRI, we can see the bones much better on an x-ray than on an MRI so if you have a shoulder fracture or if you have shoulder arthritis where you want yo see the bones and the shape of them an x-ray will often help us more so than an MRI. The MRI helps us a lot for soft tissues so if you have a weak shoulder and we’re not sure if there’s a torn tendon that’s when we might look for an MRI or if there’s an unstable shoulder we might get a special type of MRI with dye in the shoulder which will outline the structures that get injured or instability. Sometimes we need other studies too, for example, a CT scan is sometimes useful for certain situations as well so which imaging is best depends on what we’re thinking the problem is and sometimes we need more than one type of image.

Some of the most common diafnosediagnoses see are rotacuff problems, frozen shoulder which ill explain in a few minutes, arthritis of the shoulder and instability, and course many other shoulder injuries can also present particularly in the context of sports things like broken collar bones, ac joint or the joint at the end of your collarbone getting injured during sports or fall but I think there four are probably the most common that we see. So if you have an injury and you end up getting to the point where it’s an injury that’s appropriate for surgery and you’re considering shoulder surgery, I think it’s important to get advice from a shoulder specialist. There is a lot of misinformation out there of course there is google snd all of that but even sometimes within the medical community because the field of shoulder surgery and shoulder care is evolving so fast that unless it’s a shoulder specialist that you are talking to you may not be getting the most up-to-date advice or the appropriate advice specific to your condition. Anytime we talk about surgery, its always a risk-benefit balance, any surgery will have risks even the smallest surgeries do even the minor keyhole surgeries there will be a small risk of infection, a small risk of stiffness, and a small risk of pain not resolving. While those problems are very uncommon, if they happen to you then that’s something you know is a real problem and can mean your recovery takes longer. The potential benefits of the surgery have to be bigger than the risk. If we offer someone surgery it means we think their particular problem will benefit a lot from the surgery and far outweighs any of the potential risks. The other thing about the surgery that is important to think about is the recovery and rehabilitation time, some shoulder surgeries take quite a while to recover from and the rehabilitation is quite intense. Preparation is important, that is our job to help you prepare and what to expect. The website also helps with providing information. I explain this information and you can read it back at home as well.

Going back to the main diagnosesgoingnd go through each of these sorts of broad groups. You hear a lot about the rotator cuff, it is a group of four muscles that are deep inside the shoulder attached to the shoulder blade and then they sort of coalesce and form a cuff if you like of tendons which is the white part you can see in the picture around the humerus, the right-hand side is the front view and on the left is the back view. They can be involved in various processes in the shoulder that cause pain, they don’t have a great blood supply so they do undergo normal wear over time, and sometimes in the context of that where the tendons can get inflamed, they can get inflamed just from repetitive use and cause some inflammation around them and that space, that is one of the most common things that we see. Other times the tendons can tear at a point where a little bit of the tendon detaches or it can tear from a sudden trauma/fall. There can be many different ways to handle it, you will almost see some sort of abnormality in the rotator cuff and MRI in anybody over the age of 25 or 30 because normal wear over time will show up on the MRIs. The inflammation I spoke about or bursitis or tendinitis will often respond to physiotherapy and working on the shoulder blade control. Sometimes we will add an injection into that space over the tendon and that can be very effective occasionally we will do keyhole surgery depending on how large the tear is as they are at risk of getting bigger and more painful. After rotator cuff surgery you will be in a shoulder immobilizer for 4 weeks, 6 weeks if the tear is larger. You start with gentle exercises initially and no driving during that time. Physiotherapy is key, range of motion or stretching is the most important part of the beginning and we don’t have the physios do any strengthing or weights or resistance bands until about 3 months as the tendon fibers have not healed enough to take any resistance by that stage. So typically it takes about 6 months to get over a rotator cuff repair. It is not a quick fix.

Moving on to something else in the shoulder is frozen shoulder. Frozen shoulder, is something we don’t understand exactly why it happens. Its other name is adhesive capsulitis so it’s an inflammation of the capsule of the shoulder so the lining around the ball and socket of the joint capsule gets inflamed often for no good reason more common in women, the typical age group would be the 40s and 50s. There are associations with hormonal changes like menopause, diabetes, and thyroid but it can affect anyone we see often in people who have none of those risks factors. What happens is the capsgets get inflamed and the shoulder can get quite painful and in the early stages it hant gotten stiff so sometimes the diagnosis is not clear in the beginning as that capsule gets more inflamed and thicker the shoulder gets tight and stiff and it becomes difficult to move and that can be a really difficult problem to have. Thankfully most of these cases resolve without surgery, the capsule is inflamed so if we use anti-inflammatory strategies those are typically very effective so anti-inflammatories that are not steroids things as neurofen or other drugs from that group. Sometimes we do use steroids, so cortisone injections can be very effective but it’s important as to where they are put. Steroid tablets we might use if somebody having a lot of pain just for a short course maybe a week.

To talk about shoulder arthritis it’s worth mentioning, people don’t tend to hear about it as much as hip & knee arthritis so it’s the cartilage wear of the main shoulder joint so again the ball and socket joint, the ac joint which is up at the top between where it says clavicle there and acromion so clavicle being your collar bone and acromion being your collar and the chromium being the pointer shoulder, that little joint up there id not your main shoulder joint and almost every single MRI will show some wear of that joint, so you may see the word arthritis in an MRI report but if it’s talking about the ac joint the that does not shoulder arthritis most of the time that doesn’t even hurt, sometimes that wear can get inflamed if your pain when someone right on that shoulder top.

There are different ways we can treat this similar to arthritarthritis hip or the knee, pain relief, physiotherapy can sometimes help, some people find it doesn’t help their arthritis so we tend to just try it out, if it’s not helping we don’t push it, injections can help they won’t change underlying arthritis but they can take down the inflammation associated with it which sometimes helps with the pain so cortisone can do that, there are other injections that are sort like a gel that mimics the joint fluid we call them viscosupplementation injections, sometimes they work for some people. There are various things we can try before surgery. In people with milder stages of arthritis, PRP can sometimes give pain relief, in some cases a younger patient with milder arthritis e might consider a keyhole surgery to clean it out but again were not going to affect underlying arthritis but we are may buy some time and get some pain relief. Ultimately the most definitive way to treat shoulder arthritis is to replace the joint. The implants where we replace the joint with metal and plastic just like in a hip. The longevity of those implants can be affected by heavy use of the shoulders or high-impact activities but a lot of sporting and recreation activities are just fine things like golf, swimming, tennis, and yoga all of those are well tolerated by the shoulder replacement. This is one of the situations where we get a CT scan because we see the bones much better on action than on any other type of scan and that allows us to plan your shoulder replacement in a very individualized way where we can figure out exactly what shape your socket is and which implants are going to fit you best. It is possible to return to recreational activities and often it’s easier to go back as you don’t have the pain from your shoulder arthritis. This is what a total shoulder replacement looks like. There is also something called the reverse shoulder replacement, you can see if we go back in the anatomic or primary total shoulder, the ball and socket are right where they used to be in the native shoulder, but we can also put the ball and socket the other way around and the reasons we might do this are if the rotator cuff was torn as well as having shoulder arthritis, the regular or anatomic shoulder replacement will not work unless they are intact rotator cuff tendons around it and this was a real problem up until a french man named paul Grammont discovered that reversing the geometry of the shoulder allowed the shoulder replacement to work without rotator cuff tendons so now if you have shoulder arthritis and a rotator cuff tear that isn’t fixable you can still have a shoulder replacement it’s just going to be reverse shoulder replacement. Similarly, if there’s an awful lot of wear on the socket of the shoulder from arthritis we can’t use the regular socket, the plastic socket that goes in anatomic replacement but the reverse shoulder replacement can handle that problem. Sometimes we even end up doing a reverse shoulder replacement for a very large rotator cuff tear where the shoulder is not functioning anymore even if there isn’t arthritis so if the rotator cuff tears the tendon tear is too big to fix and the patient has trouble raising their arm, if we reverse the ball and socket by doing this we can allow the big deltoid muscle on the outside of the arm to take over the job of raising the arm, obviously this isn’t meant for younger people we know it lasts pretty well for probably about 15 to 20 years so we don’t want to be putting it in a 40-year-old, but that’s what I mean we say that you probably have more options when you have a bigger rotator cuff tear at age 60 or 70 than you do when you’re younger. There are many things we can do to help those problems.

What’s involved in a shoulder replacement? They’re done under general anesthetic most people would spend about two nights in the hospital, four weeks in that same shoulder immobilizer so again you can’t drive after that first four weeks. People with shoulder arthritis often find the pain relief is dramatic even in the first few days, despite the fact we’ve just done a very significant surgery, the surgery pain is nothing compared to the arthritis pain has been for all those years. Physiotherapy works on regaining motion and then strengthening, it usually takes about 6 months to work through the rehab program. In terms of returning to recreational, it depends on what the activity is but golf is probably four or five months, swimming maybe a little bit earlier and tennis is probably closer to six months.

This is what we do we the ct scan that we have you go get before your shoulder replacement. It shows us in great detail the measurements and the angles, particularly about the socket of your shoulder and we can even order a model of the socket of your shoulder and a guide that helps us in surgery position the implants exactly where we planned on the software so it’s a way of doing the surgery on the computer before we do it in you its trial without error its sort  of like a flight plan for a pilot, it’s the same so pre-op planning is really important and something we have been able to introduce within the past year is using mixed reality which is where you overlay a virtual reality hologram of that patients individual shoulder and the shape of their socket and the guide over the real environment when you’re operating by wearing this Microsoft hololens which is what I am doing in the picture on the right and that improves our accuracy in implanting the shoulder replacement  so there are a lot of exciting things happening around the field of the shoulder surgery particularly replacements.

The benefits of staying active overall in terms of the shoulder and the body, in general, will usually outweigh any wear and tear issues that may come along and the shoulder is susceptible to ear and tear for all the reasons that we’ve spoken about before. I think doing simple things to receive your shoulder joint longevity when you play sports are worthwhile, ao thinking about that kinetic chain if you have some weakness in your core or your hips that may affect your shoulder especially playing things like golf or tennis, also play collision sports the kinetic chain is equally important and that’s why the strength and conditioning training all feeds in. Footwork is important especially in sports like tennis so you’re not overextending your shoulder, your tennis coach can help. Then having the right gear and be that for the weather, the footwear all of those things protect your body.

That is all in terms of my slides, id is more than happy to answer some questions afterward, thank you.

I suppose rather than the age as a number we look at the whole picture and so if somebody is of a certain age but in pretty good condition medically its often possible to go ahead, I would always defer to the genesis and our pre-op assessment clinic, so you know that particular person has a pacemaker, is on warfarin those things don’t prevent us from doing surgery there are some challenges in terms of warfarin being a blood thinner, making sure we talk to their cardiologists or whoever is in charge of that, that we have an alternative way around that to prevent too much bleeding and surgery but also keep them you know the way their blood the way it needs to be.

I don’t think we would write someone off and say they can’t have it, they’re having an awful lot of pain and other things aren’t working like medication injections sometimes the pain specialists can do nerve blocks so there are other ways if someone truly id medically unfit for the operation and the anesthetic but we don’t have a specific age cut off, I have certainly done people in their 90s.

It’s unusual with a frozen shoulder for the movement to get better and the pain still to be there so I would wonder if there is something else going on that maybe there was a frozen shoulder and that’s now sort of settled down that capsular inflammation is gone but there is still a pain for a different reason because the usual progression is for frozen shoulders is the pain settles first and the movement takes a bit longer so normally its only kind of when the pain has settled that the movement is possible to increase. Normally what you see is someone is left stiff but isn’t as painful anymore. If you are not stiff anymore but you are still painful I would say go back and re-evaluate with either your physio or a shoulder specialist.

It is certainly treatable, one of the big challenges in shoulder care is arthritis, now true arthritis of the actual ball and socket joint in a young patient because its rare but when it does present, it is treatable snd there are a lot of things we can do in terms of pain management.

You can have a shoulder replacement at a young age and certainly, we’ve done it in some situations, people with aggressive rheumatoid arthritis type things but the problem with it is that the shoulder replacement we know last pretty well for 15 years many years so if you have a shoulder replacement in your 30s you’re going to be looking at a revision and also younger patients will tend to be that bit more active and be a bit harder on it because you’ve got such bad pain from arthritis and then you feel great when we do a replacement and you sort of overdoing it so somebody that age we would try and hold of as long off as long as possible from doing a replacement or we might do another type of surgery if the arthritis was mild to moderate where we do keyhole surgery. The options are varied to your age and the severity of your arthritis.

They kind of fall into the same category, where a labral repair is one type of shoulder stabilization surgery so the labrum is a cartilage bumper around the socket of the shoulder that contributes to the stability of the shoulder when you dislocate the shoulder, the labral almost always tears. If you have done no other damage to the shoulder and it’s pure just a labral tear, you may just be able to have keyhole surgery to repair the labrum and stabilize your shoulder that way.

If you play a collision sport or if there is a bit more damage to the shoulder in addition to your labral tear, if you’ve got some boney damage so the front of the stock that the bone can get worn down or the back of the ball as the shoulder sort of comes out the back of the ball hits the front of the socket and can have it sometimes repairing the labrum won’t be enough on its on to make that shoulder stable so then we do other types of stabilization surgeries that are often are open sometimes using a bone block at the front of the socket, so a labral repair is one type of shoulder stabilization surgery but there are a few different types depending on the situation.

I think if you have had 3 dislocations, then it is very likely that there is damage to the inside of the shoulder the labrum that we were just talking about, and possibly some of the boney structures that are leading to it being more likely to dislocate and easier to dislocate as it goes on and I think in that situation it would be a good idea to see a shoulder specialist and have a special type of scan called an MRI Arthrogram or a CT Arthrogram which is a scan where they put dye in your shoulder, where we can see those structure better.

Most frozen shoulders don’t have surgery and are treated without surgery and how long it takes can vary if you do nothing at all with a frozen shoulder theoretically it will burn out itself so the whole process will be that the inflammation in the capsule will eventually die down and without any intervention and that can take two or three years to happen. The idea of treating it with anti-inflammatories or injections or even sometimes steroid tablets is to shorten the time until it goes away, particularly to shorten that painful phase. A lot of times when we do an injection it can shorten that painful phase within 6 weeks the pain starts to decrease, and the movement varies from person to person. Only a small minority of people doubt get better with injections or stretching and end up needing to consider surgery.

Good Evening ladies and gentlemen, Gavin McHugh is my name, I am an orthopaedic surgeon based at the UPMC Sports Surgery Clinic, I also work in Beaumont and Cappagh hospitals as well. I have been invited along this evening to talk about a few problems regarding the hip and knee and hopefully, I can shed some light on these issues, find out simple advice as to what you can do with certain things and we will also have a bit of a chat about what’s involved with going ahead with things like surgery in terms of joint replacements and the recovery process and how to know when and how to go with the problem.

We will start of with the hip and again it’s going to be really quite simple in terms of breaking down the problems that we see and the first problem that I would see, probably about ten times a week is an issue called bursitis off `the hip, so a lot of people think they have arthritis in their hip and they come to me and they point out over the side of almost the buttock area, so its out over right out on the outside and the first thing to say is that hip pain is actually right In the groin area, so often times when people have arthritis in the groin they have arthritis, they think they have a groin strain initially and that’s often that bursitis presents as a pain over the side of the hip so and classically patients come to me and say they’re having trouble sleeping at night, whenever they roll over on to their right side they get a pain out over the outside, generally they don’t have problems with things like moving the hip but going up things like up and down the stairs that involves quite a bit of hip movement can re-create that pain over the outside shall we say off the thigh area as well, sometimes it radiates down to the side of the leg as well, but quite often it’s just a localized pain and you know what straight away clinically is when you over the thigh area, patients generally hop and yell that’s really sore. I say it quite frequently the vast majority of times it can be settled down with some sort of physiotherapy to help strengthen the glutes abductors and posterior chain is generally and quite frequently I’ll also inject it as well and a lot of times GPs will be willing to inject this as well if not sports medicine physicians will often inject it as well. There are plenty of options there in terms of who to go with and who to deal with that. Quite often find it takes a second or even a third injection to knock it for six but generally we’ll be able to get that to settle down without an operation as such.

Straight on to the next problem which is just arthritis in your hip and how do you know when you’re getting arthritis in your hip. I suppose it’s a good question because a lot of the time, arthritis creeps up on people slowly and subtly over years and years and it can start with a little bit of an ache right in the groin area, and sometimes it comes on after say a couple of miles of walk initially, sometimes people notice that they’re having a little bit more trouble getting their shoes and socks on things like that. It’s usually only later in the process that they’ll get a lot of pain at night time and where it’s often waking people from sleep and so as I say it often comes on quite subtly initially. What to do initially, not a lot is the answer, simple allergies just taking paracetamol can often help, anti-inflammatory are usually the most effective painkiller for any musculoskeletal issues in general but obviously, they come with the risk regarding your tummy in terms of potential for ulcers and a small risk of other things like cardiac issues and stuff so, That has to be offset but at the same time you can’t be going around in pain all the time. What I often say to people is if you know you’re going for a long walk or if you know you’re going to be playing a game of tennis or golf or whatever you do, you might just take an anti-inflammatory just before that and quite often people can get through in a couple of years, before moving on to the next level. In terms of physiotherapy for arthritis in your hip, absolutely in terms of strengthening issues but I often find that people who put a lot of into deep stretching to try and improve the movement will frequently exacerbate the problem and I think that’s just where were basically what you’re causing is an actual pinch in the hip itself so part of the arthritis process involves more bone being formed around the ball itself and to try and force that movement as I say frequently just aggravates things rather than improving it. I tend to say to people to work really within their comfort zone in terms of the range and not to push those ends and movements too much.

How do you know it’s time to go ahead with something more substantial? In terms of arthritis and the hip the only real option is a hip replacement, Injections for the odd person can give some temporary relief but in comparison to knee problems, I find it’s often quite short-lived, it is not something that I would recommend a lot. Ultimately for me, all it comes down to is it is time or a joint replacement or not. It’s time for a joint replacement when you have pain daily that is significantly interfering with your day to day activities so if you find that you play golf or you play tennis or something and you’re saying no frequently to this because you know you’re going to end up in pain afterward and you pay that price for the rest of the evening or the following day and you’ve stopped and done well that’s when this time as far as I’m concerned to start to consider something more like a joint replacement. It’s not to say that it is still a significant operation and it’s an operation that comes with risks, why am I then so happy to recommend it? Well we know that patients with moderate symptoms shall we say are the group that ends up benefiting the most following the joint replacement surgery so it’s not the most severe group, the most severe group I often Say t people it’s almost nearly like the ship has already sailed whereas if you got moderate symptoms and you’re still just about clinging on to being able to do all the activities you want but that very easily you can get that back again after the surgery.

In the recovery process after hip replacement, in general, most people are back to see me in about six weeks and most are doing very well at that stage either of crutches completely or just using one walking stick or one crutch but it depends and varies from person to person. Overall by three months the vast majority of people are more or less completely recovered at that stage. In terms of hips, is there anything else? What I often get asked about is people who come with both hips and its something I have moved more and more towards over the years in terms of replacing both hips at the same time a few years ago it sort of came as a real shock to people that this could be done and its now something I would be a strong advocate for. If both hips where one is bad as the other, then as far as I’m concerned as long as your fit it, it’s an absolute no-brainer. You get to recover both at the same time. The risks of surgery that risks of having both hips replaced at the same time are lower than if you had one done followed by one done a few months later and there is evidence to show this.

Then if I just move on then to a few issues with regards to the knee. So first of all just in terms, which we see again all the time is meniscal tears or tears in the cartilage that people will talk about. Quite often patients in their 40s and 50s, they’re out walking or sometimes there getting up from a sleeping position and they feel a relatively sudden onset of pain in the knee usually associated with my swelling in the knee and uncomfortable over a localized area, most common in the inside knuckle of the knee. The vast majority of the time this will settle down with painkillers as we talked about, over time if it’s not settling down then it’s time to get the ball rolling in terms of going to see your GP and potentially getting more organized.

The first I usually do is to inject the knee, injections in the hip don’t often give lasting relief. Injections for cartilage in the knee will often give a few months of relief.  Then moving on overtime the knee shock absorber has been damaged and this over time leads to arthritis. From the arthritis point of view, pretty similar to the hip what goes well things like injections can work well to give you some temporary relief and there are plenty of injection options. In terms of more definitive treatment, you’re moving up into the replacement territory. In terms of replacement, I am a fan of partial knee replacement rather than full knee replacements. A full knee replacement is a significant surgery and day out of searching for what’s involved and the recovery. The recovery is 6 months, it’s certainly 3-4 months until you are back on track. A partial knee replacement, you just replace one knuckle on the knee, it’s a much smaller implant, and up to 50% are suitable for partial knee replacement, where the pain is localized to one area. It’s a smaller operation, smaller implant, and a lower risk of clots and injections, heart attacks, and DMTs. Reduced risks of almost a 1/3 in comparison to full knee replacements. It feels more like your old knee compared to a full knee replacement you can feel the replacement. They last almost as full as full knee replacement, almost as the remaining part of the knee can deteriorate over time but it’s only 2% over ten years.

In terms of what’s involved in the recovery, from the knee and hip, well here at the UPMC Sports Surgery Clinic you’re talking a 2-3 night stay after your surgery. When do you go home after a joint replacement? Well, you go home when your pain is controlled and you are safe and mobile. If that’s the following day perfect, if it’s 2-3 days later then that’s fine as well, everyone has their own pace. The partial knee is usually the day after or two. You give crutches when your here and you wean yourself off after a few weeks, some people that are 6 weeks other 2-3 weeks, you can do this by increasing your mobility around the house and then venturing yourself out. You are much better at taking your time instead of limping around. In terms of the recovery in general, Hips tend to find it easier, knees find it every bit as hard as they were expecting even more so. Quite frequently than with the last one that leads me to the point of both knees at the same time.

It’s something I do quite often. I have a very low threshold of doing both partial knees at the same, for both full knees and total knee replacement is a significant undertaking for people, but I would describe it as really grabbing the bull by the horn in terms of this is someone who rents to get themselves sorted and get recovered again. I always ask everyone that has both knees replaced was it easy, they say no it was horrendous, Then I ask do they regret having them both done at the same time and they say not as I wouldn’t have come back for the second one. With that sort of semi not so pleasant thought, they do end up coming back but another couple of years later when they have deteriorated, even more, it’s the reason I have come more around to it in fixing the problem as quickly as we can to get people back and the sooner we get people back fit and active, the better it is in so many ways in their overall health and the pain relief they get. If you are struggling every day it is time to get something done about it. Get it fixed back on track because there is no sense in sliding down that slope as such in terms of deteriorating further and further. I hope I raised a few issues today and I hope you found it interesting. Thank you so much for listening today.

It isn’t ideal to go ahead with a joint replacement in your 40’s or even 30’s or 20’s if necessary, but occasionally that is the case we find ourselves in but it just really just comes down to weighing up the potential benefits and the relief what you are potentially setting someone up for in the future all right.

If someone is in their early 40’s are they looking at having a joint replacement revised again in their 60’s or late 70’s. If you are in your 50’s there is a 30% chance roughly that you are going to end up having a revision done at some stage in your lifetime. In your 40’s that may rise to a 50 / 50 chance of having it done again. If you’re in your 30’s you almost certainly going to end up having something again. It just weighs down and boils down to sort of weighing that up with the potential benefits and how bad someone is. If someone is experiencing night pain and it is waking you up every night from sleep multiple times and it is holding you back from the things that you like to do day to day then potentially then you’re shifting towards having something done about it.

I would look at a joint replacement as in general an opportunity to get back doing things and the only sort of reservation that I would place on a hip replacement or even a knee replacement to a lesser extent is not going back for significant road runs and by that I mean it’s fine if you’re in the gym doing a kilometre warm-up or something on a treadmill but if you’re someone that loves going out for 3-10 mile runs per week then you know I would say pick up, cycling something like that.

Aside from that I mean I’m happy for people to go back playing tennis, I’m happy for people to go back playing indoor soccer, I’m happy for them to go back riding a motorbike absolutely and playing with the kids, that’s the whole point of getting a joint that you are able to do that after. In general, the answer is yes rather than no to activities like that for me.

It depends on what you define by out of action. The rehab starts that day quite often and you’re up to taking a few steps the day of the surgery by the time you’re going home which is 2-3 days later, you’re independently mobile right and I’ll often encourage people to get off crutches around the house one to weeks, not everyone is able to do that for a lot of people they might still require even one crutch at six weeks, they might still be using two crutches for 4-5 weeks when out and about.

As a guide it really depends, you’re not going to be lifting big lumps of children around the place, you could be talking around 4 weeks. People going back to office work, a couple of weeks is quite possible if you are self-employed but don’t make the mistake of selling yourself short. The most important thing is your own recovery, you have to say I’m going to be out of action for 6-8 weeks pending review and get it right as this is the most important thing.

It’s not essential by any means but you do certainly see some knees in particularly if people have been quite reliant on anti-inflammatories for a good period of time before surgery, I think they almost need to wean themselves of them and if they get a little bit of rebound inflammation, so yeah not frequently you’ll get someone who might need to take one every other day for a period of time but it’s just modulated by the swelling and in the joint, if it feels good then absolutely not, but if it is a bit inflamed then potentially yes.

Yes is the answer to that but actually, quite marginally so, the way I explain that to people is that you’re leaving 2/3 of the knee behind, so obviously there’s a chance that can deteriorate. If you look at the UK joint registry the figures for the 10-year survival for a total knee, an average for a total knee is 96 percent, for a partial knee which is the zookas that is the phrase that I use but I just have to compare it with something it’s 94 percent. So a 2 percent difference for keeping 2/3 of your knee. I’d often say to people even if that figure was 10 percent, I would take it tonight because the benefits more than outweigh those risks. Marginal but yes is the answer.

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 after training would be a good time to take protein. There is high protein chocolate milk or avonmore 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.