patellar instability

Managing patellar instability

patellar instabilityThe American Orthopaedic Society for Sports Medicine has just concluded its annual meeting in Toronto and one research project stood out among the rest, suggesting that younger patients who suffer patellar dislocations are at a higher risk of recurring dislocations, especially in the long term.

The research project, which was conducted by The Mayo Clinic in Rochester, Minnesota, won the Herodicus Award for the best resident paper featured at the meeting, examined a study group of 232 patients who were deemed as ‘skeletally immature’ at the time they suffered ipsilateral recurrent patellar dislocation (in other words, their proximal tibia and distal femoral physes were open at the time of dislocation), who had suffered their injury between 1990 and 2010.

The study concluded that over 20% of those recurrent cases happened in the first two years after the initial injury, and by the 15 and 20-year mark, cases of reoccurrence had shot up to 54% of the study group patients.

Patellar instability: the facts

When we talk of ‘patellar instability’, we’re essentially referring to a welter of conditions which affect movement of the patella or knee cap, including patellar dislocation and patellar subluxation. The patella is a very important part of the knee joint: it forms part of the extensor mechanism, a chain of structures that give the knee the ability to straighten. The patella rests in a groove at the lower end of the femur called the trochlear groove, or trochlea, which centres it during knee flexion and extension, with ligaments on either side of the patella adding further support in keeping it central.

Patellar instability can happen at any time, and complete dislocation of the patella causes sudden, intense pain in the front and side of the knee and a sensation of the knee giving way or popping out. There may be a visible deformity of the knee, due to the patella moving out of position, accompanied with a rapid onset of swelling within the first couple of hours after injury.

Some sufferers of patella dislocation can experience a reoccurrence, where patella moves out of position rather more easily, but it can return to its original position with certain knee movements, usually involving straightening the knee. When this happens, pain and swelling may occur, albeit on a minor basis.

Clicking, crunching, popping and locking

Obviously, for professional athletes and dedicated amateurs, patella dislocation can seriously impact a sporting career, with an ongoing discomfort that may increase on activity, and reoccurrence of pain during knee flexion activities including hill work, squatting or lunging (and going up and down stairs, or course). There can often be tenderness on the lateral side of the patella, as well as clicking or crunching within the joint during flexion and extension, due to articular damage sustained during the dislocation. And of course, the fear of the knee giving way at any point can weigh heavily on your mind.

The study adds weight to previous research, which typically shows that 40% of adolescent patients go on to experience a recurring patellar dislocation. However, the news was not all bad. “Despite high numbers of recurrence, our research showed that these young patients did not develop significant patellofemoral arthritis,” said Thomas L. Sanders, MD, corresponding author of the study. “We hope to use our research to help educate both physicians and parents on the risks young athletes face after these injuries in their early years, and hopefully take steps to prevent them.”

Does patella instability require surgery?

Patella instability typically requires physiotherapy to strengthen the supporting structures of the knee. If there has been damage to the patello-femoral ligament or if the patella is failing to align properly, then surgical repair to the ligament may be an effective option. In severe or recurrent cases, a partial knee replacement may be the preferred option. London knee specialist Mr Jonathan Webb will discuss your options in full during your consultation.

knee replacement surgery

Study finds that knee arthritis rates have doubled in just a few generations

knee replacement surgeryA recent study from Harvard University resulted in a mass of media attention: people born after World War Two are twice as likely to develop knee arthritis as those born in generations beforehand.

The study, which involved an examination of more than 2,000 ancient skeletons dating as far back as 6,000 years and cross-referencing the data with information on human knee health from the mid-nineteenth century right up to the modern day. And the results concluded that knee arthritis is clearly on the rise. As Professor Daniel Lieberman of Harvard University pointed out, “The most important comparison is between the early industrial (1800s) and modern samples. Because we had data on each individual’s age, sex, body weight, ethnicity and, in many cases, their occupation and cause of death, we were able to correct for a number of factors that we considered important co-variants.”

It’s not necessarily a weight problem

So, what’s the cause for this? The obvious answer would be a comparable rise in lifespans and obesity – after all, pronounced weight gain clearly puts extra pressure on the knees, and by simply being around longer, one runs a greater risk of contracting any particular ailment – but according to the experts, this isn’t necessarily the case.

“Before this study it was assumed without having been tested that the prevalence of knee osteoarthritis hadn’t changed over time. We were able to show – for the first time – this pervasive cause of pain is actually twice as common today than even in the recent past,” said Dr Ian Wallace, also of Harvard University. “But the even bigger surprise is it’s not just because people are living longer or getting fatter, but for other reasons likely related to our modern environments.”

Everything from refined sugar in our diet or the fact that we are pounding pavements could be a potential factor.

Counting the cost of arthritis

What dangers these ‘modern environments’ harbour, however, is the bone of contention – and the race is on to pinpoint the causes. And the stakes are high, as a study from Arthritis Research UK pointed out last month. According to their figures, arthritis will cause 25.9 million lost working days from this year to 2030, costing the country £3.43 billion.

As their report – dubbed The Nation’s Joint Problem – points out, one in six people in the UK suffer from arthritis – a figure that is predicted to rise to one in five by 2050 – and treatment and care of arthritis sufferers is expected to soak up an estimated £118.6 billion over the 2020s.

A more positive conclusion drawn from the study is that the researchers are pointing the way towards the finding of ways to prevent the onset on knee osteoarthritis, going so far as to draw comparisons between it and heart disease. “Knee osteoarthritis is not a necessary consequence of old age. We should think of this as a partly preventable disease,” claimed Professor Lieberman. “Understanding the origins of knee osteoarthritis is an urgent challenge because the disease is almost entirely untreatable apart from knee replacement surgery – and once someone has knee osteoarthritis it creates a vicious circle.

“People become less active which can lead to a host of other problems – and their health ends up declining at a more rapid rate. Right now, our society is barely focusing on prevention in any way, shape or form, so we need to redirect more interest toward preventing this and other so-called diseases of ageing,” concluded Professor Lieberman.

Until a plan of action has been mapped out, it makes sense to give yourself the best shot at avoiding knee arthritis by going for what we currently know: keeping tabs on weight gain, strengthening the quads through exercise, avoiding unnecessary injury by warming up and cooling down properly, and maintaining a healthy diet. However, if you’re suffering from the aches and pains associated with knee arthritis, arrange a consultation with a knee specialist to discuss your options.

return to running

Return to running after a knee injury

It goes without saying that we’re always keeping an ear to the ground for new developments in the field of knee injury rehabilitation, so a new report from the University of Kent has piqued our interest – especially as it could be a breakthrough for athletes who have recovered from a knee injury, but are struggling to get over psychological barriers that stand between them and getting back on the field.return to running

In a report published in Physical Therapy in Sport titled ‘Return to running following knee osteochondral repair using an anti-gravity treadmill’, Dr Karen Hambly – a knee rehab expert who specialises in helping athletes who have been given the all-clear to resume sporting activities but may have concerns about moving from being a patient with a knee injury to being an athlete again – has explained how a graduated return to running using an anti-gravity treadmill can help to reduce fears about re-injury, and increase the athlete’s self-belief in being able to run on the injured knee.

How does walking on the Moon help return to running?

The case report focuses upon a 39-year-old female endurance runner and spells out the regime she undertook from the end of her post-knee surgery rehabilitation to taking part in her sport again, which involved an eight-week programme designed by Dr Hambly which incorporated the use of an anti-gravity treadmill.

The treadmill – which can be adjusted to reduce the body weight of the client from 100 per cent to a mere 20 per cent, which is a precise simulation of what it would be like to walk on the moon – is designed to reduce the load on the joints in the lower limbs. This means that not only is the client given the opportunity to ease their joints back into the swing of running with no chance of re-injury, but it also offers a vital psychological boost as the pressure is reduced over time.

While this is a potential breakthrough in the field of sports rehab, it goes without saying that anti-gravity treadmills are still thin on the ground – and walking holidays on the Moon aren’t an option. But there are still plenty of options available for the post-rehab athlete who still isn’t ready to trust putting their full weight on their joints.

Post-injury rehab: have a plan, and stick to it

You may not know it, but by being leery of returning to your sport, you’ve already won half the battle for a successful rehab – because you already know that it’s going to take a while before you’re back to peak fitness. The key here is to maximise what you can do during this period – and ensure you get the support system you need.

What you’re looking to achieve here is a graded return, by finding a level that you can manage at the moment and creating a manageable route map that will allow you to progress back to full fitness at your own pace without risking setbacks.

The first thing to do before starting on this road is to get the injured knee checked out. There should be full range of movement in the joints surrounding the affected area with no risk of instability, no swelling, and – ideally – you should be pain-free. From there, you can start the rehab process. This article from Running Physio is a great overview of what you should be doing – and what you need to avoid.

knee damage sports

Study reviews the worst sports for knee damage

Osteoarthritis – the condition that causes joints to stiffen and cause pain – has long been seen as an inevitable consequence of the ageing process, but it’s also a distinct hazard for athletes. We’re already seeing incidences of osteoarthritis in middle-aged and even young adults with athletic backgrounds, as a consequence of the sports they play. But which are the worst knee damage sports that risk players developing knee osteoarthritis at a later date?

A recent study conducted by assorted universities in America looked into this question and the results are very interesting. A team of researchers from US universities carried out a review of six databases to analyse the link between different sports and osteoarthritis among nearly 3,800 athletes.

The results? Around 45 per cent of the athletes ended up with knee osteoarthritis – and the risk increased to 57 per cent among those who had suffered knee injuries, and rose to 61 per cent among former athletes who become obese. And when they dug deeper into the actual sports the athletes participated in, a pattern of sorts began to form.

Football, weightlifting, wrestling… and knee damage

knee damage sportsThe least surprising sport which cropped up in the study results was long-distance running but, according to the data, football, weightlifting and wrestling are the prime culprits – raising the chances of developing osteoarthritis in the knees by three to seven times when compared to low-risk sports, such as basketball, boxing and track and field events.

Why would one sport be more damaging to the knee joints than another? Well, the dangers of long-distance running are obvious: repetitive shock and stress on a targeted area over time. The shock and stress that can be brought on by weightlifting and wrestling target the same area, albeit with massive and concentrated amounts of pressure on the joints.

Football’s hazards are brought on by extended periods of running combined with instantly stopping (or twisting and turning) – not to mention the sharp impact of making a tackle, or receiving one. But why would basketball be seen as the safer sport, in that case? Well, it’s a matter of endurance – while the average NBA player covers a distance of 2.72 miles in an average game, his Premier League counterpart can cover anything up to 9.5 miles in a game.

…and don’t forget tennis

Although it wasn’t mentioned in the study, tennis is another sport where the threat of knee injuries hangs over its participants. Although the repetitive pounding of the turf (or clay, or asphalt, or concrete) isn’t as relentless as other sports, the stopping, starting and twisting is even more of a requirement. And such stress can cause torn cartilages, knee swelling, and general wear and tear.

Another factor unique to tennis is that it is one of the few athletic pursuits where the participants are unable to pace themselves to a set time or distance. Runners have a rough idea of how long they’ll be required to perform, footballers know how long they’ll be required to play, but the nature of tennis means that a game can last anything from an average of an hour and a half hours (in the case of women’s tennis) or two and a half hours (for men’s), to anything up to five hours – and the Wimbledon record is an incredible eleven hours and five minutes (held over three days, admittedly, but still…).

Whatever sport you play, preparation is essential. Preventative measures – such as an extensive warm-up regime, constant monitoring of the state of the joints, an approved exercise programme and a strong line of communication with training and medical staff – can help you avoid osteoarthritis issues throughout and beyond your sporting career.

ACL & Young Female Athlete

ACL surgery rising fast in young females

ACL & Young Female AthleteIt’s great to see more people taking part in sporting activity, but according to a recent study of the private insurance data of a whopping 148 million US residents, there’s been a marked increase in operations to repair torn knee ligaments – and the highest and fastest rates can be found amongst teenage girls.

According to the study, which focused on surgery for anterior cruciate ligament (ACL) tears, the average annual ACL surgery rate climbed 22 percent from 2002 to 2014, when it reached 75 procedures for every 100,000 people. For girls between 13 and 19, however, the average annual knee surgery rate soared to 59 percent during the study period – to 269 procedures for every 100,000 people.

Why is this happening amongst both sexes?

According to Mackenzie Herzog, the lead author of the study, it’s impossible to pin it down to one particular aspect – but the booming popularity of sporting activity amongst the younger generation is an obvious factor.

“There are likely multiple factors contributing to the increase, including increased participation due to broader promotion of physical activity to improve health and adolescents participating in athletics more frequently and more intensely,” said Herzog. “Two particular trends that concern us are increased trends toward year-round sports participation at a young age and the tendency to specialise in one sport early.”

As far as ACL surgery rates go, women are starting to catch up, even though men are still having more procedures. By the end of the study, 87 men and 61 women out of every 100,000 people had ACL surgery each year.

This Girl Can (get injured too)

While the study wasn’t as comprehensive as we would have liked – there’s a lack of data on what sports people played, how often they participated in practices and competitions and any individual characteristics or medical conditions that might influence the odds of ACL injuries, for example – there’s enough info in there to indicate that there’s a distinct rise.

The obvious factor that we can point at is the undeniable rise of female participation in across-the-board sporting activity in such a short space of time. The female versions of team sports such as football and rugby have been legitimised over the past decade and previously male-only sports have been opened up to women; now the idea of sport as a lucrative career for women is becoming even more evident.

At the time of writing, it’s the flagship event of the tennis season – Wimbledon – and we’ll be seeing a textbook instance of a sport where the women are just as prominent as the men, if not more so. It’s also a sport that can really damage the ACL, as it forces the participant into movement patterns that can create tears.

So, what can be done to nip the potential epidemic of female ACL injuries in the bud? ‘The same things that male athletes should be doing’ is the painfully obvious answer. Cross-training programmes that include exercises to improve strength, balance, coordination and muscle control can help prevent ACL tears, along with the right footwear.

diagnose ACL tear

How we diagnose ACL tears

diagnose ACL tearIt’s always important to be aware of new trends in Anterior Cruciate Ligament detection, so a recent study conducted by Houston Methodist Hospital caught my eye. The study, conducted over the course of a year which involved 91 patients aged 16 to 60 who had experienced a knee injury with subjective swelling or an objective effusion – and they were all examined for ACL tears by a method called the lever test.

What is the lever test?

Otherwise known as the Lelli’s Test, after the person who devised it, the lever test involves getting the patient in a prone position and then placing a fist a third of the way down the underside of the calf, whilst applying moderate downward pressure on the distal third of the quads, whilst the heel of the leg remains in contact with the surface. If the patient’s foot rises while pressure is being applied, it is to be assumed that there is no ACL tear. If the heel remains resting on the table and the foot doesn’t rise, there is a distinct possibility of a partial or full ACL tear. A video demonstration of this can be found below.

As you may have already deduced, this method is a little less high tech than other ACL tests, but the results showed that 78% of patients had MRI-confirmed complete ACL tears. Moreover, the study found that the lever test had a sensitivity of 83%, a specificity of 80% and an accuracy of 82% – which was statistically similar to results from other, more established tests, such as the Lachman, anterior drawer and pivot shift tests.

A challenge to the Lachman test?

The study points out that, like the Lachman test, which has been the industry standard in hands-on ACL tear detection, the presence of a meniscus tear leads to a decrease in the accuracy of the lever test, which doesn’t affect the accuracy of the pivot shift test. But the simplicity of the lever test, the painless nature of the procedure and the fact that no grading is involved (in other words, either the heel lifts off the surface, or it doesn’t) makes it a perfect exploratory method for practitioners who don’t specialise in ACL examinations. It’s certainly easier to perform than the Lachman test.

The presence of a complete, chronic tear of the ACL is possible to detect with all manual tests but diagnosing a partial tear can be more challenging. All tests are important to help make a clinical diagnosis for patients.

excess weight and knee damage

Lose weight to slow down degeneration of the knee joint

excess weight and knee damageYou don’t have to be a medical expert to make the assumption that overloading the weight on a knee joint is a bad idea, but a recent report published by the University of California has demonstrated just how much stress overweight and obese people are putting on their knees.

The research team spent four years monitoring the link between weight loss and the progression of cartilage changes in 640 overweight and obese patients who were either in the risk area for future osteoarthritis or had already been diagnosed with mild to moderate osteoarthritis and were keen to lose weight. The sample group were divided into three: those who lost more than 10% of their body weight by the end of the study, those who lost 5% to 10%, and those whose weight remained stable.

The results? The people in the 5% to 10% group had lower rates of cartilage degeneration when compared to those who didn’t lose weight – and even less cartilage degeneration was reported in the 10% weight-loss group. And not only did the MRI scans on those that had lost weight showed a slower degeneration in the articular cartilage, but there was also a similar result in the menisci – the half-moon-shaped cartilage pads that act as shock-absorbers for the knee joint.

Excess weight and knee damage

It’s a bit of a no-brainer – a heavier weight increases the load on the joints, which creates more stress when we move – but it’s a little more complicated than that. For starters, previous studies have estimated that overweight women have four times the risk of knee osteoarthritis than their counterparts who are of a healthy weight, while overweight men have five times the risk. For the morbidly obese, the stakes are even higher: they’re up to ten times more likely to develop knee OA.

Furthermore, it has been established that people with a higher body weight run the risk of having higher blood levels of substances which can cause inflammation of the joints, raising the risk of OA even higher.

Eat less, move more

There are many factors that bring on knee OA that have nothing to do with a sedentary lifestyle – and, as we all know, the most physically active people can be susceptible to developing it.

But if you’ve piled on the pounds and are worried about the link between excess weight and knee damage, it makes sense to address the issue right away. Studies have demonstrated that a sufficient – but not necessarily drastic – loss of weight results in a decrease in knee OA risk of up to 33% in women and 21% in men. Lifestyle changes, such as weight loss, are always the first option we consider when someone presents with knee pain due to wear and tear changes.

steroid injections for knee arthritis treatments

Recent new studies weigh into knee arthritis treatments

steroid injections for knee arthritis treatmentsOur interest was piqued by a couple of studies – one from the US, one here in the UK – which indicate that some traditional methods for knee arthritis treatments may be slipping out of vogue.

The first report comes from the British Medical Journal, where a panel of international experts claim that knee arthroscopy – keyhole surgery which attempts to relieve pain and improve movement – should not be performed in all but a few instances, based on new evidence that it doesn’t result in a lasting improvement in pain relief or function.

Knee arthritis treatments: one slice doesn’t fit all

The panel – made of bone surgeons, physiotherapists, clinicians and patients with a record of degenerative knee disease – came to the conclusion that surgery was no more effective than exercise therapy. To quote one of the panel members; “Knee arthroscopy has been oversold as a cure-all for knee pain.”

We agree with this article’s opinion that keyhole surgery in patients with wear and tear changes is often of no value.  However, in a tailored or individualised approach, there are situations where specific pieces of cartilage or meniscus are causing very specific or mechanical symptoms, and by targeting these with an arthroscopy there can be some benefit obtained.

In other words, this often comes down to understanding the condition and understanding what the arthroscopy is able to achieve.  It can certainly never cure arthritis in a knee, but it can certainly make some other symptoms more bearable.

The drugs don’t work – they just make you worse

The second article – from the Journal of the American Medical Association – addresses the use of steroid injections in order to treat patients with symptomatic knee osteoarthritis. A two-year study conducted by the Tufts Medical Center in Boston tracked the progress of 70 patients suffering from symptomatic knee OA – half of whom received a course of corticosteroid injections, while the other half received a course of placebos.

The results? Compared with the group who received placebos (who experienced an average cartilage thickness loss of 0.1mm), the group on steroids experienced an average thickness loss of 0.21mm – over twice as much degeneration2.

My response to this is very much along the same lines as the keyhole surgery report.  We use steroids from time to time with patients, but we also take great pains to explain that it doesn’t cure the problem: what steroids can do is make a very swollen, painful knee more comfortable for a period of time afterwards.

The long-term future of the knee is much less affected: we certainly wouldn’t give steroids to a patient every three months over a two-year period, because of my concern about the longer-term function of the knee – something that seems supported by their evidence.

What both these studies spell out is that the viewpoint on how best to treat knee arthritis is always shifting, and it’s crucial for practitioners to keep up with and react to these developments. It’s also hugely important that sufferers of knee arthritis are kept in the loop and are under no illusions to the fact that there isn’t a magic solution to their ailment. There are advantages of a more conservative management regime such as exercise therapy over arthroscopic surgery: no need for an operation, no recovery time, no surgical pain and inconvenience. Yet, for the right patient, surgery or steroids can work.

Meniscus repair with 3D printed cartilage

3D printable implants: the future of meniscus repair?

Meniscus repair with 3D printed cartilage

To demonstrate how their 3-D-printable, cartilage-mimicking material might work, the researchers used a $300 3D printer to create custom menisci for a model of a knee. Photo credit: Feichen Yang

Coming soon – print your own knee? Sounds ludicrous, we know, but the worlds of 3D printing and medical science have been skirting around each other for a few years now. There have already been examples of 3D printing being used to create exact moulds of body parts (such as the scalp), but the latest development from Duke University in North Carolina is interesting for those suffering from a common knee injury.

According to a report issued last month, a $300 3D printer has been used at the university to create custom-built menisci for a model of a knee – and if things go to plan, it may not be too long before knee surgeons will be able to print replacement, custom-fitted artificial cartilage, cutting the costs and time or certain knee surgeries at a stroke.

The importance of the menisci

The meniscus is a vital part of the knee. A rubbery, crescent-shaped disc, situated between the thigh and shin bones, their main roles are to cushion the stress that the knees endure during the simple mechanics of walking and running, and help steady the knee by balancing the weight you put on it. In other words, it’s a part of the knee that you don’t notice until something goes wrong with it, and that ‘something’ is usually a meniscal tear.

The meniscus is a vital part of the knee. A rubbery, crescent-shaped disc, situated between the thigh and shin bones, their main roles are to cushion the stress that the knees endure during the simple mechanics of walking and running, and help steady the knee by balancing the weight you put on it. In other words, it’s a part of the knee that you don’t notice until something goes wrong with it, and that ‘something’ is usually a meniscal tear.

A meniscal tear can be caused by many factors: it can happen when you twist or turn your knee, usually when the foot is planted while the knee is bent. It can happen when you lift a heavy item. It can happen during the rigours of sports participation. And sometimes, amongst older people, it can even happen while you’re going about your day-to-day routine, menisci tend to wear over time.

The knock-on effect of a meniscus tear depends on the severity of the tear. A minor tear can result in slight pain and swelling for a couple of weeks. A moderate tear can cause a greater intensity of pain and swelling, along with knee stiffness and difficulty in bending. A severe tear can not only result in pieces of the meniscus getting caught in the joint space (causing the knee to lock and catch, but the knee can also give way without warning.

Coming soon: cartilage from a cartridge?

While replacement surgery for meniscus repair is available (and has been for over 20 years), it’s still a very uncommon procedure, mainly because it depends on the use of healthy cartilage tissue taken from a cadaver and an extremely strict criteria that patients must meet before they’re even considered for treatment. So it goes without saying that the possibility of being able to map out and print millimetre-perfect copies of bespoke menisci could revolutionise knee surgery.

But before we all start rushing out for 3D printers, it’s worth pointing out that while the actual models of the menisci can be printed out, the actual printing materials are not yet up to par. The current gels being used in the printing process are currently not as strong or as hard-wearing as natural cartilage, and it’ll be a while before they match the durability and elasticity of the real thing. But this is one development well worth keeping tabs on.

rugby world cup draw

Rugby and cherry blossom

Earlier this month, I had the pleasure of attending the bi-annual World Rugby Council meeting in the beautiful city of Kyoto, Japan, which coincided with the Rugby World Cup 2019 pool draw at the historic State Guest House.

At the draw, the Japanese prime minister Shinzō Abe spoke of his pride for his country and their opportunity to host the 2019 World Cup: “I promise that Japan will provide the very best for the players and that an enthusiasm befitting the name of the Rugby World Cup pervades the entire nation. Amid all the thrills and excitement expected, we intend to make the tournament one that will live on in the memories of people around the world.”

The 2019 competition marks Asia’s first World Cup and illustrates the exciting growth in the game’s popularity across the globe. Participation in Asia has nearly doubled since 2009 and there’s now more than half a million players taking part in the game throughout the region. Later this month, a new project will be launched that aims to further increase rugby participation in Asia in advance of the World Cup.

I travelled out with Ian Ritchie, the RFU CEO, who is the other World Rugby council representative. It was a fantastic opportunity to chat with other council members and at the meeting we made important decisions about the rules and regulations of rugby, particularly increasing the time for players to become eligible to play for a country from three to five years’ residency which will make it harder for players to play for one country and then swap to another.

World Rugby Chairman Bill Beaumont commented: “As rugby grows, we need to ensure that it continues to be relevant and inspiring to the next generation of players and fans. Everyone has a say and everyone has a role to play in our future.”

rugby world cup drawAfter the meetings, attention turned to the pool draw. With eight slots still to be filled, we know half of the draw for definite; hosts Japan drew Ireland and Scotland in Pool A, Pool B sees New Zealand, South Africa and Italy pitted against each other and Pool D pulls Australia, Wales and Georgia.

England’s pool is set to be a challenging one with us facing France and Argentina as well as one of the two top-ranked teams from the Pacific Nations Cup – either Fiji, Samoa or Tonga – and either the USA or Canada. Next month we’ll find out which of these tough teams we are set to face in Japan.