arthritis and ageing

Arthritis and ageing

We are fast becoming an ageing population and, according to Arthritis Research, we’re getting even older than we think, as the average lifespan of the world’s population goes up by five whole hours every day, meaning a child born a year from today will statistically live 76 days longer than one born today. Good news if you’re planning on having a long life – not so good news if you’re planning to live that life free of arthritis, one of the most common ailments that afflict us as we age.

While it’s true that arthritis is not an age-specific malady – research proves that the average ages that people develop it is between 30 and 60, and many babies are born with it – the fact remains that arthritis and ageing go hand-in-hand, and will have a profound effect on the society of tomorrow – after all, in a world where people are already starting to retire later in life, arthritis is going to have a major effect on our ability to keep going.

FoxO on the run

So why does the risk of arthritis increase as we get older? A recent study conducted by the Scripps Institute in California investigated that very dilemma. And according to their findings, the key to delaying and even avoiding arthritis is all down to a certain protein.

FoxO proteins get their name from the term ‘forkhead box’, which describes the shape of the motif formed by scores of amino acids which bind to a DNA structure. Also known as the Winged Helix, they play a very important role in the regulation of genes that perform a range of tasks – including cell growth, proliferation, differentiation, and longevity.

Previous research conducted at the Scripps Institute determined that a lack of FoxO develops in cartilage as our joints age and that people with osteoarthritis have a marked decrease in the genes our cells needed for autophagy, which is the process that allows our cells to remove and recycle damaged elements in order to stay healthy.

No FoxO, no lubricin

For the new study, researchers used mice with FoxO deficiency in cartilage and a control group of mice with no FoxO deficiency, in order to monitor how FoxO proteins affect maintenance of cartilage throughout adulthood. They noticed a severe difference in the mice with FoxO deficiency: their cartilage degenerated at much younger age than in the control mice. The FoxO-deficient mice also had more severe forms of post-traumatic osteoarthritis induced by meniscus damage and were more vulnerable to cartilage damage during treadmill running.

Researchers deduced that the FoxO-deficient mice not only had autophagy defects, but they also were unable to produce enough lubricin – a lubricating protein that normally protects the cartilage from friction and wear. This deficiency was associated with a loss of healthy cells in a cartilage layer of the knee joint called the superficial zone.

In other words, if you’re lacking in FoxO proteins, the problems start – and the cells in the cartilage can’t do the necessary repair jobs. Hopefully, the next step will be to discover why FoxO proteins drop off as we age, and how we can keep them there for as long as possible.

While we wait to discover why these proteins deplete as we age and how the process can be reversed, there are certain steps you can take to minimise the development of osteoarthritis.

  • Manage occupations risks – certain occupations involve repetitive movements which can increase wear and tear on your joints
  • Maintain a healthy weight – extra weight means extra stress on your joints. Controlling our blood sugar levels is also important as diabetes can trigger inflammation. It also makes a regular exercise harder which leads us to our next preventative measure
  • Keep moving – low impact exercise, whether aerobic or strength training can help you maintain healthy joints and strengthen the supporting structures of the knee or hip
  • Rest – regular exercise is important but do not overdo it and if an activity is causing discomfort then you should discontinue it until you’ve received advice from an expert

For more advice, call us on 0203 195 2443.

Bristol Joint Replacement Centre

Mr Jonathan Webb heads up new joint replacement service in Bristol

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Bristol patients in need of hip or knee surgery now have a new joint replacement service dedicated to getting you moving as quickly as possible.

Knee specialist Mr Jonathan Webb has brought together a team of experienced and expert joint surgeons to form the Joint Replacement Centre at Nuffield Health Bristol Hospital, The Chesterfield. The surgical team have all performed a high volume of hip and knee replacement procedures over the years and offer the highest levels of clinical care and expertise, backed by Nuffield’s unrivalled commitment to patient care.

Mr Webb, who was instrumental in bringing together the consultant team, explains: “We have chosen to join together as an expert clinical team, following many years of working alongside each other in Bristol, to provide the best possible care for patients requiring hip and knee replacements.

“The Joint Replacement Centre programme is based on the latest clinical evidence and best practice, delivered by highly specialist, carefully selected orthopaedic surgeons. We are there to support patients all along the way; from assessment, diagnosis and treatment through to recovery and beyond.”

Stiffness after knee replacement surgery

How to treat a stiff knee after replacement surgery

After going through the challenges of knee replacement surgery, there’s nothing more demoralising than becoming afflicted with knee stiffness and often patients can experience a similar lack of mobility to their pre-surgery state. Although it’s not a complication that Mr Jonathan Webb’s knee replacement patients commonly experience, it’s worth addressing.

There are two main options for the practitioner when it comes to knee stiffness after knee replacement surgery: the first is to accept that the patient still has a way to go before the new knee ‘beds in’, and to recommend a regime of exercise and manual therapy whilst being overseen by a trained physical therapist, to gradually ease the knee into its workload. As a matter of fact, most practitioners will try this route as a matter of course.

If that doesn’t work – or in cases where it’s clear that the replacement knee procedure hasn’t ‘knitted’ effectively – then further surgery is advised and there are a number of options to explore:

MUA procedure

‘MUA’ stands for Manipulation Under Anaesthesia, and it does what it says on the tin: the patient is anesthetised, then the surgeon moves the joint through a full range of motion in an attempt to break through areas of fibrosis and scar tissue.

An arthroscopic exam and debridement

This involves examining the joint with an arthroscope (a camera fitted into the head of a needle) to see what’s preventing the knee joint from working, and then removing any dead, infected or damaged tissue therein, in order to give the living tissue the room it needs to do its business.

An open incision with revision

Simply put, the practitioner deduces that the new implant has been improperly positioned or has moved since it was fitted – or has malfunctioned – and goes in for a remove-and-replace procedure.

But which works best? A systematic review recently conducted by the Department of Orthopedics at New York’s Mount Sinai Hospital in New York City attempted to answer that question, by reviewing all of the articles on the three surgical techniques over a 42-year period. Although the bulk of the information over the years was sketchy at best, they managed to break down what they discovered by age, sex, time lapse between the replacement and adjustment procedure, and which technique was deployed.

The study concluded that the majority of procedures were conducted between two weeks and three months after the initial replacement surgery,

Results of each treatment approach were measured using change in knee motion and total motion. Any complications that affected the patients’ recovery or outcomes were also analysed.

The findings included:

  • Manipulation under anaesthesia (MUA) and arthroscopy are more effective in removing adhesions and other tissue debris than open surgery
  • MUA alone (without arthroscopy) appears to give the treated knee the most motion
  • Using an open incision to gain access to the joint had the worst results overall
  • The earlier the MUA, the better the results – but later MUA treatment is still effective

The moral of the story is that if you’ve had knee replacement treatment and you’re still struggling to get up the stairs, don’t assume that it’s something that will correct itself – get in touch with your practitioner as soon as possible so they can effectively eliminate any stiffness after knee replacement surgery.

arthritis therapies

New therapies being developed to treat arthritis in the future

Osteoarthritis continues to be one of the most common physical ailments to affect an already-ageing population, but an array of new treatments and potential arthritis therapies have been unveiled already this year. Some are still at the trial stage, while others are already being used around the world. Here are three ventures which could be worth keeping an eye on…

Stem cell research to the rescue?

The University of Liverpool’s Institute of Integrative Biology has announced a three-year collaboration with the American global medical technology company Anika Therapeutics, in an attempt to develop an injectable mesenchymal stem cell (MSC) therapy for osteoarthritis treatment.

The idea that stem cell treatment could alleviate the symptoms of – and even cure – arthritis isn’t new: a 2014 trial run by the Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust (RJAH) in Oswestry, Shropshire and funded by Arthritis Research UK and a 2015 study conducted in Ireland produced encouraging signs in the possibility of patients’ own stem cells being able to generate joint tissue: now the medical companies are sensing a commercial breakthrough, we could see a sizeable advance in the near future.

Could a protein injection alleviate arthritis pain?

Interesting news from the Keck School of Medicine at the University of Southern California: the development of an injection designed to combat the pain of osteoarthritis.

Deploying a protein called RGGD 423 – which regenerates cartilage and reduces inflammation by communicating with a molecule, called glycoprotein 130, which is responsible for promoting cartilage development when we are mere embryos, the injectable therapy is aimed at people who are suffering from an early to a moderate level of arthritis, and experts are already speculating that if the project comes to fruition it could save the NHS up to £1 billion per year.

However, as the project enters the trial stage, side effects – including high blood pressure, stomach ulcers and even strokes – have been detected. So, don’t expect to see this on the market in the very near future.

Could South Korea lead the way on OA?

Meanwhile, in South Korea, the single-shot treatment is already a reality. The cell gene therapy treatment Invossa was approved last summer, after undergoing clinical trials over there and in the US, where it was developed by TissueGene, a subsidiary of South Korea’s Kolon Group.

Invossa is a cell-meditated gene therapy – only the fourth of its kind to have been approved anywhere around the world – and according to trials conducted in the US, 88% of patients who were treated with it reported improved symptoms for up to two years. While Invossa is entering phase 3 trials in the US, the Koreans are already planning to produce and sell it in their domestic market in the near future, before exporting it to Japan. So, while it might take a while for Invossa to reach our shores, it’ll have gone through the most rigorous trials before it does.

Currently, none of these therapies is available in the UK market but if you like to discuss your treatment options, call 0203 195 2443 to arrange a consultation with Mr Jonathan Webb.

ACL reconstruction long-term success

Looking at the ACL reconstruction long-term success

Arthroscopic anterior cruciate ligament surgery is considered the gold standard treatment for ruptures of the ACL. Without this intervention, it is commonly thought that this injury can lead to functional knee problems such as instability, pain, associated meniscal injuries and, eventually, develop into osteoarthritis that can greatly impact on quality of life.

Among all the wealth of clinical data on ACL reconstruction, there are not many studies into the long-term outcome of ACL reconstruction. Often the injury is compounded by other trauma to the structures of the knee – the meniscus, collateral ligaments and damage to the chondral surface – and these related injuries impact on any evaluation.

One study that has evaluated the long-term outcome of ACL reconstruction surgery was recently published in the American Journal of Sports Medicine.  It was authored by the North Sydney Orthopaedic and Sports Medicine Centre, where I undertook a Fellowship in 1996, training under world-renowned knee specialists Leo Pinczewski and Merv Cross.

The first step was to select patients to review; initially 333 patients were identified who had been diagnosed with an ACL rupture. All wanted to return to sports that involved sudden changing of direction or pivoting or were experiencing periods of instability that wasn’t responding to rehab.

The next step was to eliminate any patients that had associated trauma to the knee; other ligament injury, chondral damage or meniscal injury. The clinic then had 90 patients remaining in the study. A standardised operative technique was used as the surgeons performed an isolated reconstruction using patellar tendon autografts. Following on, a standardised post-operative recovery protocol and rehabilitation programme was also prescribed for all patients, including a prohibition on returning to competitive sports that involve pivoting or sidestepping for six to nine months after surgery.

Evaluating long-term outcome of ACL reconstruction surgery

The experts at the North Sydney Orthopaedic and Sports Medicine Centre evaluated the patients first at yearly intervals and then at 10, 15 and 20 years after surgery, offering a really fascinating insight into the longevity of this surgical option. In fact, I was one of the authors of the paper that first reported on these 90 patients, at two years post-surgery.

At 20 years, 36 per cent of patients had sustained another anterior cruciate ligament injury. Interestingly, only 9 per cent re-injured the same knee whereas 30 per cent suffered a ligament rupture in the other knee, with three developing an injury in both.

The highest rate of reinjury was in patients under the age of 18 when the initial procedure was performed – something to bear in mind when treating younger patients with a ruptured ACL.

Another insight that the study gave was the gender differential; women were much less likely to reinjure the reconstructed ACL, possibly because they were far less likely to participate in strenuous activity post-surgery, but they reported worse knee function scores. Kneeling pain was present in the majority of patients and was persistent over 20 years.

ACL reconstruction and prevention of osteoarthritis

The study also evaluated the development of osteoarthritis (OA) in these ACL reconstruction patients as other studies have suggested it can play an important prevention role. Degenerative change was identified using radiography in 27 per cent of patients at five years, 51 per cent at 15 years and had risen to 61 per cent at 20 years. However, only a very low proportion of patients reported moderate to severe symptoms. The suggestion is that ALC reconstruction surgery may not prevent OA but can reduce premature degeneration.

football knee injuries

The importance of the warm-up: new study has shown football knee injuries in children cut in half

They might be smaller, but don’t be fooled: children’s sports injuries are deadly serious, particularly in team sports. For example, did you know that underage footballers are more likely to contract bone fractures and injuries of the upper extremities than their adult counterparts?

Call it a lack of technique, or the fact that their bones are still developing, or a willingness to chase the ball and get stuck into tackles – or, more likely, a combination of all three – but injuries in youth sports are a serious concern. So it was good to hear some heartening news last month from the University of Basel.

According to a study conducted by that university’s Department of Sport, Exercise and Health and published in the academic journal Sports Medicine, a warm-up programme developed specially for children can reduce football knee injuries by around 50 per cent.

The twenty-minute rule

 The study – which involved the monitoring of 3,900 players from 243 teams based in Switzerland, Germany, Holland and the Czech Republic – involved dividing the teams into a control group who went about their normal business, and an intervention group who adopted the ‘11+ Kids’ programme – a twenty-minute regime of seven warm-up exercises which were undertaken before every training session.

After just one season, the results were clear for all to see: the injury rate of intervention group was 48 per cent lower than the control group, while the rate of severe injury fell by as much as 74 per cent. The people behind the study are now recommending that all youth footballers should be adhering to a warm-up programme at least once – and preferably twice – a week.

Why would a selection of simple exercises cause such a change in the football knee injuries rate? There a clue in the name. By keeping the muscles warm, athletes of all sporting disciplines can nip a lot of potential problems in the bud. A warm-up session can prevent acute maladies such as hamstring strains and other overuse injuries, and steadily and safely prepare the body for a session of intense activity. As well as preparing the body, a proper warm-up session also focuses the mind, helping the athlete to get in the zone and concentrate fully.

Rugby got there first

As someone who is very much involved in the RFU, I also have to say that it’s good to see the round-ball game taking note of what the rugby community cottoned onto long ago: our injury prevention programme Activate sought to address the injury problem in our own sport, and came to the same conclusion – that player-conditioning was a key solution to bring down the injury rate in youth and adult rugby.

The programme has proven to be a resounding success: amongst youth players, teams who were highly compliant with the Activate regime achieved a 72 per cent reduction in overall match injuries, while the adult teams achieved a 40 per cent reduction in lower injuries – while both groups achieved a 59 per cent reduction in concussions. So it’s clear that in both codes, it makes sense to take time to warm up.

how to avoid skier's knee

Ski season 2018: how to avoid Skier’s Knee

The good news: ski season is in full swing. The bad news: according to a recent survey conducted by ABTA – the UK’s largest travel association – nearly three in ten Brits who take ski holidays have admitted that they never check that their travel insurance includes ski injuries. And the older you are, the more likely you are to take to the slopes without proper coverage, meaning that thousands of people are taking a colossal risk this winter.

Obviously, it makes sense to get properly covered, but even if you are it makes even more sense to ensure you don’t get injured in the first place, particularly in the knee area. Here are a few tips on that score…

How skiing can do your knee in

Although skiing is seen by the outside world as a dangerous sport, injury rates have decreased dramatically, due to equipment advances. However, as with any pursuit that puts you in an unnatural position for prolonged amounts of time, the risk of knee injury can be high – be it from an accident or from simple overuse or poor technique.

The most common strain skiers can put on themselves is anterior knee pain – at the front of the knee – and the most common incidence is patella-femoral joint dysfunction, which results in pain, clicking and stiffness, particularly when going up hills or stairs due to the inner part of the quads becoming less active, resulting in the kneecap rubbing against the bone.

Here’s our tips on how to avoid Skier’s Knee this ski season

  1. Hone your knee position

Incorrect knee alignment while skiing can put excessive stress on the joints and lead to anterior knee pain, so it’s important to get into good practice. Get into a skiing position, and bend your knees as you would on the slope. The correct position involves placing your kneecap over your middle toe. Once you’re locked into that alignment, do 30 to 40 gentle bends of the knee, and do this three or four times a day until it becomes your natural skiing position.

  1. Don’t ‘sit down’ on the slopes

It’s all too easy to get locked into an over-squatting position while skiing, where you look as if you’re practically sitting down on an invisible stool. This puts massive amounts of strain on the knee joint – and makes it difficult for the quads to absorb the shocks the legs endure while going downhill. To prevent this, start to beef up your glutes with deep squats – but ensure the weight is moving into the front of the feet and not straight down or backwards.

  1. Check the snow quality

If it’s too hard-packed or icy, it’ll be harder for your ski edges to grip and result in more painful falls. If it’s too soft, the sticky and/or slushy surface can prevent the bindings from releasing when you need them to, and you run a greater risk of injuries from slow turns. Remember that snow quality can dramatically fluctuate during the course of the day, and ensure you react to those changes as and when they happen.

  1. Check your bindings

Bindings – the device which connect the boot to the ski, which automatically release when you fall or collide – have dramatically reduced ankle and lower leg injuries. But when used incorrectly, usually when they’re set too tight, they’re a ski knee injury waiting to happen, particularly amongst inexperienced skiers who fall when travelling at a speed too low from them to release.

  1. Avoid drinking and skiing

Remember that certain countries always breathalyse injured skiers when they’re admitted to hospital, and a positive result could affect your claim, so be aware of your off-piste intake.

diet and knee osteoarthritis

Diet & Detox: the best approach to dealing with knee osteoarthritis

It’s January; a time of fresh starts and new resolutions and a recent report from the Radiological Society of North America is further proof that adhering to the right diet and taking a prudent approach to healthy living is not just for the first few weeks of the new year.

The study, the results of which were presented at the annual meeting of the Radiological Society of North America (RSNA), was an attempt to discover what role diet and exercise played in reducing the risk of knee osteoarthritis, and which method works best. It involved the tracking of 760 people with an average age of 63 and a body mass index of greater than 25, who either had mild to moderate osteoarthritis or were displaying risk factors for the disease.

The people involved were divided into two groups: those who had lost weight, and those who hadn’t. The weight-loss group were then divided into groups corresponding to how they lost weight: diet and exercise together, diet alone, and exercise alone. The research teams then measured knee osteoarthritis with MRI at the beginning of the study, after 48 months, and finally at 96 months.

Exercise is not enough

The results were interesting, to say the least: unsurprisingly, cartilage degeneration was significantly lower in the group which had lost weight compared to the group who over the 96 months. However, this finding was only present among the patients who lost weight through diet and exercise or diet alone – and although the group who only exercised lost as much weight as those who dieted, they displayed no significant difference in cartilage degeneration when compared to the group who lost no weight.

“The more weight loss the patients achieved, the greater the benefits were, even if they remained obese after losing weight,” said Dr Alexandra Gersing, of the Department of Radiology and Biomedical Imaging at the University of California, in San Francisco and the study leader. “These results add to the hypothesis that solely exercise as a regimen in order to lose weight in overweight and obese adults may not be as beneficial to the knee joint as weight loss regimens involving diet.”

Exercise and diet go hand-in-hand

Why would exercise alone prove to be so ineffective in reducing the risks of developing knee osteoarthritis?  The study doesn’t go that deep, unfortunately – but at a rough guess, weight loss through exercise would involve putting a lot more strain on the joints than shedding pounds through eating more of the right things. And, of course, more exercise means more muscle build, which can load up the strain on the joint areas.

However, no-one is playing down the benefits of regular exercise on the whole of the body, never mind the joints – and as good habits in the gym or on the track naturally lead to equally good habits in your diet, you should not be put off from embarking on an exercise regime this New Year. Naturally, you’re not advised to plunge in at the deep end: if you haven’t been active in the gym for a while, it makes sense to seek advice and work out an exercise plan that best suits your needs and capabilities.

knee osteoarthritis and fear of movement

‘Fear of movement’ limiting activity levels of knee osteoarthritis patients 

We may be aware of the damage that osteoarthritis can impose on the body, but we’re still trying to understand how it affects us mentally – as a new study from the University of North Carolina reveals. According to the study, which was published in the American medical journal Arthritis Care & Research last month, sufferers of knee osteoarthritis are developing a fear of movement associated with the condition, which is leading to a decrease in active lifestyles, a drop in their quality of life, and increasing the risk of their conditions worsening.

The study involved a total of 350 participants, who were invited to take part in a clinical trial where they were asked to evaluate their fear of movement, as well as providing details on their age, sex, race, education, pain levels and general daily activities. Trends such as knee symptom duration, depressive traits, injury history and balance were also assessed.

The fear of falling

After the date was processed, it revealed that 77% of the study group agreed with at least one item on the Brief Fear of Movement measurement scale, with 36% endorsing three or more items, suggesting they had a pronounced fear of movement. Furthermore, it was found that patients’ age, daily activity levels, history of depression and capacity for exercise all had a big influence on their mindset in this regard.

Clearly, these results are concerning to say the least. It’s an understandable point of view, though: when a part of your body that you’ve trusted to work throughout your life breaks down, it’s very difficult to get that trust back. And the results suggest that this fear of further damage are holding back OA sufferers from staying active, which can lead to even worse damage in the long term.

Take the first step back to health

As all sports medicine experts know, getting an athlete off the surgery table and back onto the field of play takes so much more than a mere operation: the athlete has to both physically and mentally prepare themselves to relearn the techniques that were natural responses before the injury, and to trust their own bodies not to let them down again.

As this study makes clear, non-athletes need to take that same journey too. And, like the pros, more often than not they’ll need a bit of help to get there. As Devi Rani Sagar – research liaison manager at Arthritis Research UK – pointed out: “We know that the chronic pain caused by arthritis can be a barrier in keeping active. This understandable fear of movement, caused by the pain someone can feel, is a factor in stopping people from including exercise in their daily lives.

“Exercise is incredibly important and we are committed to helping people remain active. We have developed specialised exercises tailored specifically for people with knee osteoarthritis to help people build up the confidence to exercise. We also recommend that a person with their arthritis speak to their GP if they are worried about exercising.”

total knee replacement for pro footballers

Retired pro footballers found to be at higher risk of developing knee osteoarthritis

Recent research from the University of Nottingham has confirmed that retired professional footballers are far more prone to develop knee pain and osteoarthritis and face problems with their knees earlier in life than the average person, with increased rate of total knee replacement surgery performed at some point.

The research was led by Dr Gwen Fernandes and Professor Michael Doherty from the Arthritis Research UK Centre for Sport, Exercise and Osteoarthritis, and was funded by Arthritis Research UK with from FMARC (FIFA’s Medical and Research Centre) the Professional Footballers Association and the SPIRE Healthcare Group. Their conclusion: male ex-pros were two to three times more likely to suffer from knee pain and knee osteoarthritis and require a total knee replacement – even after adjustment for other risk factors including significant knee injury.

The pain of retirement

Furthermore, the study – published in the British Journal of Sports Medicine – reported that ex-footballers reported more knee pain, structural knee osteoarthritis on x-ray and total knee replacement surgery across all age groups in the study – and especially in younger age groups, such as the 40-54 age group. It wasn’t all doom and gloom, however: the research also revealed that although former footballers presented with more musculoskeletal pain, they were less likely to suffer with and report other conditions or diseases such as diabetes, heart attacks and cancer.

The study – one of the largest and most comprehensive of its kind – recruited over 1,200 ex-footballers with an average age of 59 years, recruited via the PFA and from individual league clubs and professional football associations in the UK. Their data was cross-referenced with that of over 4,000 men from the East Midlands with an average age of 62.8 years, and as well as the main findings, the date threw up all manner of strange conclusions, such as;

  • Ex-footballers had more osteoarthritis in the end joints of their fingers (nodal OA)
  • Ex-footballers were more likely to have an index finger shorter than their ring finger — also known as a pattern three-digit ratio, which has been previously linked to osteoarthritis risk
  • Ex-footballers reported significantly more body pain, knee misalignment and use of painkillers than the study group from the general population

‘Repetitive Microtrauma’ singled out for blame

 Why would playing professional football cause such an increased risk of osteoarthritis? The study flags up the ‘repetitive microtrauma’ that the sport imposes on its participants, and has identified it as the most likely main cause. And although the health benefits of professional sport are obvious, so is the concern for the welfare of players after their careers are over.

As the FA, PFA, the Premier League and English Football League announced in a joint statement: “We welcome Arthritis Research UK’s study into cases of ex-professional footballers affected by osteoarthritis and have collectively and collaboratively supported them in this research. Although there are multiple health benefits from playing football, we are also aware of the risks of intensive and prolonged training and playing at professional level.

“We understand that there are far-reaching and wider benefits of playing football, including overall quality of life and physical and mental well-being. However, it is important that we continue to support ex-professional players with the condition and use this new research to form practical guidance for current professional footballers and clubs to help minimise the risk of developing osteoarthritis.”