return to play and re-injury risk

Footballers could reduce risk of re-injury with extra training before return to play

It doesn’t matter what sport you play, or at what level – the temptation to pull on the boots (or spikes, or cleats, or skis) after an injury is overwhelming. You’ve been put on a course of treatment, and you’ve been given a recovery schedule, but you feel that no-one knows your body better than you do. Big mistake, according to recent return to play research from the Football Research Group at Linkoping University in Sweden.

According to the study, injured footballers who skip a course of practice sessions before returning to full competition are more likely to aggravate their injuries – or even develop new ones – than those who are eased in gradually. And when it comes to the highest level of the game, professional matches have a seven-fold greater risk than practice ones for the returning player.

The research team went right to the top for their study: they examined data on 303,637 matches involving Champions League teams, and that data included 4,805 matches involving players returning to the field after moderate-to-severe injuries kept them in the treatment room at least eight days.

Their conclusions? Injury rates were 87% higher during players’ first match after an injury than they were for typical matches during the season. However, the study also discovered that with each practice session prior to the first match after an injury, players’ risk of another injury dropped by 7%.

So, what entails a proper practice session?

That’s not something the study was concerned with. “While we can’t say anything about the content of those training sessions, our data suggests that if they complete six training sessions after they have been cleared by the medical team to fully participate in all team activities but before they play a game, the risk of injury in that game is only marginally higher than the average risk in matches,” said Hakan Bengtsson, physiotherapist with the Football Research Group and lead author of the study.

[external link: https://bjsm.bmj.com/content/early/2019/08/28/bjsports-2019-100655.abstract]

According to Bengtsson, the biggest risk for repeat injury occurred with four practices prior to the first match, and made clear that he and the study team were aware that some players might not be able to wait for six training sessions due to various factors – but the results clearly demonstrate that rehabilitation alone may not be sufficient to prevent repeat injuries, due to the fact that most rehab procedures are conducted alone, away from the healthier members of the squad, and are no substitute for what they go through at the top of their game.

Let your team ease you back in

“When the player returns to full team training, it will be more similar to actual game play” he added. “And thus, full team training offers a better environment for the athlete to build tolerance to what he will be exposed to in matches.”

There’s a lot of truth in what the study team say, from my experience. All professional athletes who suffer an injury and go through rehab are champing at the bit to get back in the game as soon as any sign of progress happens. And even the most prudent coaches and managers don’t like to see their talent on the bench for too long. But in cases such as this, a gradual easing-in process is essential.

For more advice about returning to play after injury, contact sport injury specialist Mr Jonathan Webb. He offers clinics in Bristol (08450 60 44 99) and London (0203 195 2443).

World Rugby injury prevention programme

World Rugby launches new exercise programme developed to reduce rugby injuries

We’re all enjoying the Rugby World Cup, but it’s also good to see that the powers-that-be haven’t given themselves a month off and are addressing some major issues in the sport. And the biggest one of all is injury prevention.

We’ve already discussed the new trials introduced by World Rugby last month, and now – in conjunction with England Rugby and the University of Bath – they’ve launched a new injury prevention programme called Activate, which is designed to put the code at the forefront of injury prevention in contact sports – and according to research already conducted by the University, the programme can reduce the risk of soft-tissue injuries by 26 to 40% and concussion risk for youth players and by 29 to 60% for adults.

Activate, in a nutshell

The Activate programme consists of simple, user-friendly exercises designed to improve general movement control, muscle activation, strength and power. Interestingly, there are several exercises geared towards developing stability and mobility of the head and neck region, with a view to reducing the potential ‘whiplash’ effects that can occur with concussion.

The objective is to encourage coaches and players to regularly integrate Activate exercises into their training sessions and pre-match routines. There are four different versions of the exercise programme: an adult version, and three age-graded versions. Each programme consists of a number of progressive phases, which should be undertaken for a set time before moving onto the next.

The programme has already been (for want of a better word) activated at Skerries Rugby Club in Ireland – a team which just happens to have Mark Harrington, World Rugby’s Head of Technical Services, as its Director of Rugby. “We introduced the youth and adult versions of the Activate programme across several teams at the club during the 2017/18 season. Led by our coaches, the programme has grown to become an accepted part of training sessions and pre-match warm-ups for the players,” said Harrington.

“We have also taken the opportunity to adapt some parts of the programme to better suit our needs and keep things fresh, such as breaking the programme up into parts to be completed during training sessions instead of as a warm-up. Although based on only a few teams, we have noticed that fewer players are turning up to training with knocks while player availability for matches has been better than in recent years. Because of this, we have decided to continue using the Activate programme.”

Minimal set-up, maximum injury prevention benefit

The Activate programme has been designed to take up minimal space – essentially, a third of a rugby pitch, split into four separate zones – and use nothing but cones to mark out zones, and it runs for 15 to 20 minutes for youth programmes and 20 to 25 minutes for the adult version. Many of the exercises are performed individually or in pairs, and it’s up to the coach to decide if balls should be used.

While one coach can manage the Activate session, it is advised that assistants are also deployed to keep the exercises moving, so the coach can focus on the players’ technique. It’s recommended that players should be put through the Activate programme three times a week for optimal results, and it can also be deployed as part of a player’s rehabilitation after injury. And if you haven’t seen it already, it’s worth downloading the manual, which is available on the World Rugby website.

To arrange an appointment with knee injury specialist Mr Jonathan Webb, call 08450 60 44 99.

ACL rehab

Why your quads matter in ACL rehab

We’re all aware that knee injuries are far and away the most common serious injury in the Union code, especially ACL tears. It’s the price we pay for the sport we play: unlike other codes, Union is a succession of grind-it-out, stop-and-start plays which put huge amount of stress on the knees.

Consider the way we tackle – much lower on the body compared to other contact sports – and it’s clear to see why the knees cop the most damage. They can be taken out in an instant, by a player landing on your leg in a ruck, or an opponent shoulder-tackling from the side. Or they can be worn down over the years, especially in the scrum.

Factor in the indisputable fact that the game is getting faster, the players are getting more athletic and the seasons are getting longer, and it’s fair to say that the risk of knee injury looms large over everyone who plays the game, regardless of age, level and ability. And one of the most common injuries is the ACL tear, so let’s talk about it.

The basics of an ACL injury

Located deep within the knee joint, the Anterior Cruciate Ligament is a very important thing indeed. In a nutshell, it stops your knee from rotating too much, helps keep the shin in place, and is a crucial component in maintaining joint stability. But it can be torn over time by repetitive turning and changing direction, and it can also be instantly damaged by any violent impact on the knee during a game.

However, it happens, an ACL tear – from minor to major – is not fun. Symptoms include mild to severe instability, painful swelling and a long layoff from playing and exercising. And there isn’t a one-size-fits-all cure – solutions depend upon the severity of the tear. In extreme cases (or in the case of high-level players who need to recover ASAP) ACL reconstruction surgery will be recommended.

However, in less extreme cases, a period of highly structured rehabilitation is recommended. And while it goes without saying that a complete recovery programme will be designed to strengthen all the muscles in the affected area, it’s the quadriceps which really come into their own.

Why quads matter in ACL rehab

The primary function of the quads is to bend and straighten your knee, but they’re involved in almost every movement your legs go through.  They work in harmony with other leg muscles in order to promote effective movement, running, squatting, cycling and balance. When an ACL injury occurs, all the work the quads put in are cast to the wind – no matter how severe the injury. When you’re out of action, the quads are the muscles which suffer from lack of exercise the most.

A recent study from America spelt out the bare facts recently: according to the study, young athletes who have returned to competition after ACL reconstruction with lower quadriceps strength than before running an increased risk of a second – and more damaging ACL injury.

So, while you’re focusing on the state of your ACL and contemplating a return to play, it’s vital that you take care of your quads.

knee rugby injuries

World Rugby introduce six trials aimed at reducing rugby injury rates

We’re all getting ready for the Rugby World Cup at the end of the month, obviously – but while us fans are working out how to reorganise our sleep patterns right through to the beginning of November, the game has its eye firmly on the future.

After a comprehensive evaluation of the sport and its injury rate by the World Rugby Law Review Group, six new trials have been announced in an attempt to bring the rugby injuries rate down. Depending on their success – or otherwise – we could see certain changes happening to the sport as recently as the 2023 World Cup in France, and the findings could even set the course of the Union code for the rest of the century.

Here are the trials which most concern the sports medical community;

Rugby injuries trial: the reduction of tackle height to the waist

Obviously, this is the big one, and the reasons for it are clear as day: it’s a bid to reduce injuries, and head injuries in particular. According to the Law Review Group’s findings, 50% of all rugby injuries – and a whopping 76% of concussions – occur in tackles.

The concussion rate is particularly alarming: anyone who takes the slightest interest in American football will be aware of the spate of problems retired NFL players are dealing with, and although the Union code isn’t as blatant when it comes to head-to-head contact, the speeding-up of the game and improved physical condition of its players mean that the knocks are getting harder.

Ruby injuries trial: the high tackle technique warning

Simply put, if you put in an upright tackle (i.e., you’re not bent at the waist as you go in), and there is clear and obvious head contact, you’re issued with a warning. If you get a second warning, you automatically serve a one-game suspension.

This rule has been trialled at the World Rugby U20 Championship for the last two years, and it appears to have worked. Over the course of 300 matches, the LRG worked out that an average of 2.5 high tackle technique warnings were issued, and the incidence of concussion in games dropped by more than 50%.

While the other trials are more concerned with sin bins, encouraging players to drop back from the defensive line and reducing defensive line speed, these two trials have attracted the most attention, and for good reasons. As Bill Beaumont, the chairman of World Rugby’s executive committee, pointed out; “World Rugby is unwavering in its commitment to ensuring rugby is as simple and safe to play as possible for all. While injury incidence in the sport is not increasing and concussion incidence is decreasing, we can and must do more to reduce injuries at all levels. This is an important milestone on that journey.

“The next step is to identify in partnership with our unions’ appropriate competitions to run the trials.”

Several unions, particularly those Australia, France and South Africa, are interested in operating one or more of the trials in domestic or cross-border competition, meaning that the possibilities of a safer sport could be in reach over the next few decades. Which can only be a good thing.

For advice, diagnosis or treatment of rugby injuries, call 0203 195 2443 to arrange a consultation with Mr Jonathan Webb

robotic-assisted knee replacement in Bristol

Robotic-assisted knee replacement now available for Mr Webb’s Bristol patients

Knee replacement techniques and instrumentation have undergone constant improvement since this type of orthopaedic surgery was first performed. The introduction of robotic-arm assisted technology is the latest development in this field and Mr Jonathan Webb is delighted to be able to offer this innovative technology to his patients.

He has been performing this surgery since January 2018 in his London practice and now Bristol patients are able to experience the many benefits of the Mako Robotic-Arm Assisted Technology, including greater accuracy, shorter hospital stays, quicker recovery and increased patient satisfaction.

The technology can be used for both partial and full knee replacements. Prior to your operation, a 3D CT scan is taken on your body and the data fed into the Mako software.

How robotic-assisted knee replacement works

At the start of the surgical procedure, Mr Webb can utilise the additional information provided by the MAKO in planning exactly where to place the components of your knee replacement so as to make the ‘fit’ as comfortable as possible.

Having established what he feels is the ideal placement for each individual patient, Mr Webb uses the robotic-arm assisted technology to guide surgical tools to shape the knee to accept the new replacement. During the surgery itself, Jonathan is always in control of the robotic-arm but guiding it to within millimetre accuracy.  Clinical data points to a shorter stay in hospital being required and a speedier recovery process when you return home. There also is evidence that patients feel less pain in the early phase of recovery.

The Chesterfield Hospital in Bristol is the latest Nuffield Hospital in the UK to take delivery of the Mako technology. To find out more about the potential benefits of this technology and whether you’re suitable for a robotic-assisted knee replacement, call 08450 60 44 99 or email laura.claremont@nuffieldhealth.com to arrange a consultation with Mr Jonathan Webb.

knee injury diagnosis

New mini MRI scanner could improve knee injury diagnosis

Magnetic Resonance Imaging: it’s a thing of medical brilliance. A large tube packed with strong magnets that shoot out radio waves, its ability to safely and effectively visualise tissue has transformed the field of medical diagnosis since its development in the 1970s. An MRI scan can get to almost any part of our bodies, particularly the brain, the spinal cord, breasts and other internal organs.

One part of the body where the MRI scanner can fall short, however, is the knee. Due to the size of the scanner, certain key components of the knee are tricky to pick out on current MRI technology. And due to the effectiveness of MRI scans in other, more life-threatening conditions, people in need of a knee scan are being put at the end of a long waiting list.

However, that wait could be getting shorter in future, if a research study recently conducted by scientists at Imperial College London bears fruit. They’ve produced a prototype of a miniature MRI scanner designed to be fitted around the knee. And not only does it work better on the knee than its larger counterpart, but it’s also small enough to be based or rented out to your local clinic or even your GP surgery.

Why do standard MRI scanners find it hard to examine knees?

While an MRI scan can easily pick out the components of other parts of the body, it’s a lot trickier with the knee. And that’s because of the way water molecules are arranged in our tendons, ligaments and meniscus. Those structures are mainly made from collagen, a protein which knits itself into fibres.

As those fibres cling onto water molecules extremely tightly, they show up as blocks of black on a standard MRI scan, giving off the impression that there is more fluid around the knee than there actually is, which makes it tough for medical staff to make a call on the actual state of the area.

Introducing the Magic Angle

Due to the reduced size of the prototype scanner, however, the research team claim it can deploy what they call a ‘magic angle’ – the ability to come at the joint from a whole new perspective which produces a sharper, brighter image. This is achieved by a specially-designed magnet, which can whizz around the knee area and help build up a fuller picture – something that a standard scanner simply can’t do.

The prototype scanner has already been tested out on goats and dogs (as both animals can suffer knee injuries similar to those found in humans), and the results were extremely positive. Now the research team are looking forward to trying it out on humans within the year – and if all goes well, potential knee problems could well be picked up on without a trip to the hospital, which could take a lot of work and expense out of the NHS and help doctors come to a swifter and more accurate knee injury diagnosis.

knee replacement checklist

Now you can predict if your knee replacement will last

Out of the many factors that can determine whether a knee replacement surgery procedure will work, one of the most important issues is the timing of the operation. While other considerations also have an impact – such as age, weight, health, mobility and levels of pain – the stage of your life that you’re in when you have the op can be the most critical factor of all.

Why is this? Well, if you have a knee replacement too early, it can be a real psychological blow: you may feel that the new joint is a huge downgrade when compared to the knee you had before, and totally unsuitable for your day-to-day lifestyle.

But if you leave it too late, progressively worsening knee pain and lack of mobility can have a significant impact on quality of life. Furthermore, you may find the muscles around the knee area start to deteriorate or become deformed as they overcompensate, making the recovery period when you finally undergo surgery more challenging than it needs to be.

Put your joints to the test

A recent development announced by scientists at the Universities of Bristol and Sheffield may help practitioners and prospective patients get the timing right, thanks to an online test called the Patient Decision Support Tool for Joint Replacement – which could prove to be an absolute boon in the field of joint replacement.

At present, the current system in place offers patients general information about the risks and benefits of the procedure, but there’s absolutely nothing resembling a bespoke service when it comes to taking into account the wide range of factors that determine the need for a joint replacement.

This new test – which is based on data collected from more than a million UK patients that have had knee or hip replacement surgery – will predict how successful the new knee or hip will be, and whether the chances of pain can be reduced and day-to-day function will be improved.

The test – which will be taken online – will be plotted on a sliding scale from zero (where it is worse than before) to 48 (which will indicate a marked improvement).

Plan to succeed

But it doesn’t stop there. Other data that the Patient Decision Support Tool for Joint Replacement is aiming to provide includes an estimate of recovery time, the likelihood of a need for repeat surgery within a decade, and even the chances of dying in the 12 months after the procedure. Armed with this extra information, the research team surmises, patients will be able to make informed decisions about if and when to go ahead with a knee or hip replacement – or at least alter certain lifestyle choices well in advance.

While the test hasn’t been made available to the general public yet, I’m very keen to see what it’s all about – from a personal as well as a medical basis. While there is extremely little difference from one knee to another, it’s the extra circumstances – weight, body shape, age, lifestyle choices, etc – that can really come into play in a successful TKR procedure, and it would be very good to know what a test such as this will flag up.

best UK knee replacements

The best – and the worst – knee replacements have been revealed

Due to an ageing yet active population and a leap in technology, more and more people are being given knee replacements. Patients are understandably more concerned with the skill and experience of their surgeon, but there is also a range of different prosthetic implants that can be used. Now, a large-scale UK study has been carried out in the performance of different prosthetic implant combinations.

Unsurprisingly, what with the range of products, some knee replacements work better than others – and the recent study conducted by researchers at the University of Bristol has looked into the quality and performance of the most commonly used replacements, concluding that certain brands of joint replacement have more than double the benchmark level of failure after ten years, while others are three times more likely to need replacing than their better counterparts.

However, the good news is that the vast majority of knee implants used by the NHS – 89% of them – are deemed to perform better than standard.

The research team compared different brands and models of implants, which were implanted into over 1.7 million British patients between April 2003 and December 2016 and tracked whether follow-up surgery was needed after the procedure. In particular, they were looking for the types of implant that exceeded a failure rate of 5% – the benchmark level set by both the NHS watchdog the National Institutes for Health and Care Excellence (NICE) ODEP – the Orthopaedic Data Evaluation Panel.

The joint last implants

After scouring the data, they found seven models which failed to make the cut – with the worst performer being the Preservation Unicondylar fixed knee replacement, which was used in 398 operations and had a failure rate of 15 per cent. The list in full:

  • Preservation Unicondylar (15%)
  • Oxford Partial Knee Unicondylar (11.54%)
  • MG Uni Unicondylar (10.03%)
  • AGC Uncemented (7.76%)
  • NexGen Cement (7.13%)
  • Rotaglide + Cement (5.61%)
  • Profix Cement (5.03%)

While the research revealed that knee replacements were more prone to failure than their hip counterparts, it also revealed that the majority of knee replacements used in the UK were far more durable.; 51 were below the 5% threshold, and 16 of them had failure rates lower than half the benchmark.

As a patient – or potential patient – what can you do to ensure you get the best shot of a long-lasting and successful knee replacement? After all, it’s not as if you can run your finger down a shelf and pick out the one you like. Your best defence – as with all surgical procedures – is to be fully prepped. Ask your knee surgeon which implant is being used, and definitely ask about its success rate.

female ACL injury

Contraceptive pill could help protect women from ACL knee injuries

Everyone in the sports medicine community is aware that, due to a combination of hormonal and physiological reasons, women are far more prone to female ACL injury, but the truth is far more jaw-dropping:  women are actually eight to ten times more likely to suffer from an ACL injury than men. The knock-on effects are ruinous: recent studies have concluded that nearly half of women sports participants are forced to abandon their athletic careers, and between 20 and 50% of female athletes go on to develop arthritis within ten to twenty years.

So, it goes without saying that the race is on to bridge the gap between the sexes when it comes to an ACL injury, and the latest development comes right out of the left field: the potential benefits of the contraceptive pill.

Could the Pill cure your ACL ills?

According to a study recently published in America’s Physician and Sportsmedicine journal, female athletes are being advised to go on the pill to avoid career-ending injuries – with the apparent protective effect of the drug particularly potent in teenage sportswomen.

The study, conducted by a research team from Brown University in Rhode Island, compared rates of injury among 82,874 sportswomen taking oral contraceptives during the 12 months prior to the injury, and compared it with the same number of women not on the pill. According to the findings, a total of 465 women in the oral contraceptive group required surgical reconstruction of the ACL over the ten-year period of the study, compared to 569 in the control group. Which means that out of the entire study group, the women who were using oral contraceptive were 18% less likely to damage their ACL.

More surprisingly, when the data on female athletes aged 15 to 19 were analysed, the conclusion was that a whopping 63% of women in that group using the pill were less likely to suffer an ACL injury.

So, what’s the reason for this?

The research team at Brown believe that the lower and more stable hormonal levels that are brought on by the pill help to keep the ligaments firmer. “Young athletes use oral contraceptives for a variety of reasons, including regulating their menstrual cycle and/or preventing pregnancy,” said Dr Steven DeFroda, leader of Brown’s research team. “It’s likely that oral contraceptives help maintain lower and more consistent levels of oestrogen and progesterone, which may lead to a periodic increase in laxity and subsequent risk of tear.”

Of course, it needs pointing out that this is an observational study, so no firm conclusions can be drawn about cause and effect – and the authors point to several limitations, such as not assessing participation in particular sports or their activity level which may explain why some women tore their ACLs and others did not.

They also note that the study did not distinguish between athletic, recreational, or accidental ACL injuries, and only looked at women with injuries that were managed with surgery. So, while it’s an interesting potential solution to the rampant levels of ACL injuries in women, a study which tracks athletes over time to see whether those who take oral contraceptives have fewer ACL injuries than others will be needed.

infection after knee replacement

Infection after knee replacement: new research could help identify those most susceptible

Knee replacement surgery has become a common procedure, with over 110,000 of them carried out per year in the UK, and for the vast majority of people, it’s a pretty straightforward operation with nothing but benefits when the recovery period is over. However, the biggest problem for surgeons (and especially patients) is the risk of infection in the treated area, which could lead to serious complications down the line. It must be stressed that the risk is extremely minor, but at present 1% of patients run the risk of deep infection in the knee area, which can have some pretty nasty knock-on effects.

However, new research funded by the National Institute for Health Research (NIHR) has taken steps to identify which groups of people are most likely to develop a severe infection after knee replacement surgery and therefore need the joint replacement redone.

Zoning in on the risk factors

The study – the largest of its kind – was conducted by researchers from the Musculoskeletal Research Unit at the University of Bristol, who combed the records of the 679, 010 people who had undergone knee replacement surgery in England and Wales between 2003 and 2013 and tracked their progress in the year after their procedures, zoning in on the data of those who had suffered a knee infection.

According to their findings, the groups of people most at risk from needing their joint replacement redone due to infection include patients under 60 years of age; males; those with chronic pulmonary disease, diabetes, or liver disease; and people with a higher body mass index.

The research team didn’t stop there: they also deduced that the reason for surgery, the type of procedure performed and the type of prosthesis and its fixation also influenced the risk of needing revision surgery for an infection.

A clearer picture for practitioners

The goal of this research is to arm practitioners with a honed and refined set of guidelines, in order to help them zone in on the patients who will be most at-risk and prepare themselves to nip any future complications in the bud – be they early on in the post-surgery period, or years later.

It goes without saying that these findings could be a boon for the knee surgery community and future patients alike. Knee replacement surgery is a costly and time-consuming procedure, but having to re-do it is even costlier. And with the number of procedures rising year-on-year due to an ageing population, every re-done procedure means a longer wait for those desperate for their own knee procedure. By identifying possible raised risk factors for infection after knee replacement surgery will help practitioners to develop strategies to minimise the risk.

Call 0203 195 2443 to arrange a consultation with Mr Jonathan Webb and he will discuss all potential risks and complications including infection after knee replacement surgery before you make the decision to go ahead.