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.

ACL reconstruction

New study finds high level of satisfaction and return to sports after ACL reconstruction

ACL reconstructionA report issued last month from New York’s Hospital for Special Surgery merely confirms what we all knew: that ACL reconstructive surgery has reached an optimum level of patient satisfaction. The study involved over 230 patients – all of whom are active athletes – who underwent ACL reconstructive surgery and the results were a resounding endorsement of the treatment, with 98% of patients claiming that they were ‘highly satisfied’ with the procedure and they would happily undergo it again if they needed to.

The study set out to investigate rates and predictors of return to play, evaluate patient satisfaction after ACL reconstruction surgery, and analyse the relationship between the ability to return to their chosen sport – basketball, football, lacrosse, skiing, American football and tennis – and overall patient satisfaction. The 232 patients involved were on average in their mid-twenties, and an attempt was made to create an even gender split, with 52% of the study group being male.

ACL reconstruction – it needn’t be hell

All study participants had a minimum two-year follow-up after surgery, and were invited to partake in a questionnaire that asked about return to play, sport performance, repeat injury, factors influencing ability or inability to resume a sport, and overall patient satisfaction. The results were fascinating: 201 of the participants surveyed claimed that they had returned to playing their chosen sport at a mean time of ten months and 89% of those claimed that they had returned to their previous level of competition.

Obviously, results varied from sport to sport. The tennis players recorded the highest level of success, with a 100% return to participation: meanwhile, the football and lacrosse players recorded the lowest levels of success. Among those who didn’t make it back to peak performance, the most common reasons appeared to be more psychological than physical: fears about re-injuring the knee or being unable to ‘trust’ the reconstructed knee were a constant factor.

How the ACL works

Located from the back of the femur and running diagonally through the centre of the knee to the front of the tibia, the anterior cruciate ligament is a crucial component in maintaining joint stability. Simply put, the ACL stops your knee from rotating too much and helps keep the shin in place. It can be torn over time by repetitive turning and changing direction: it can also be instantly damaged by any violent impact on the knee.

The symptoms of an ACL tear include mild to severe instability, painful swelling and a long layoff from playing and exercising. Surgery isn’t always a given: ACL tears tend to be treated on a case-by-case basis, and there’s a school of thought that claims that a period of highly structured rehabilitation can repair the damage without surgery. However, in the world of professional sport, those rules don’t necessarily apply: ACL reconstruction surgery (using a strip of the patella tendon as a replacement graft) can get an injured participant back to full fitness in less than six months, if all goes well.

As the study bears out, ACL reconstructive surgery has come on in leaps and bounds: far from being a career-ending situation, the procedure has become an enforced time-out for athletes that could even prolong their careers in the long run – and it seems that the next step is to educate and reassure certain athletes to put greater trust in the procedure.

meniscal tear

Running repairs: when to mend a meniscal tear and when not

meniscal tearThere’s been a fascinating debate in Orthopedics Today about the thorny problem of how to treat a meniscal tear, and the conversation – conducted by a five experts in the field – is something worth commentating on.

Before we get into it, a brief overview. The meniscus is a rubbery, crescent-shaped disc, and their job is to cushion the stress that your knees endure as you walk or run, and help steady the knee by balancing the weight you put on it. Each knee has two of them: one at the outer edge of the knee, and one at the inner edge.

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, or during the rigours or sports participation. Sometimes, amongst older people, it happens while you’re going about your day-to-day routine, as your menisci start to wear over time.

Meniscal tear: one ailment, many symptoms

The symptoms of a meniscus tear can vary depending on the severity of the ailment. A minor tear results in slight pain and swelling, which lasts for a couple of weeks. A moderate tear causes worse pain and swelling, along with knee stiffness and difficulty in bending, but the symptoms will go away and reoccur if the knee is left untreated. A severe tear can result in pieces of the meniscus getting caught in the joint space, leading to the knee locking and catching. Furthermore, the knee can give way without warning on occasion.

To sum up, then, it’s a particularly problematic ailment for a very important part of the knee. As the debate points out, however, making a diagnosis is tricky. Unless it’s a severe tear, the typical symptoms – locking, catching and giving way – aren’t happening. It’s also difficult to pin down what the patient actually did in order to cause the tear, especially when that patient is over 40, overweight, or both.

Meniscal tear: to treat or not to treat?

So why the debate over whether to treat the ailment or not? Because, according to the report; “there is no evidence to support that repairing (degenerative) medial meniscal root tears, knee degeneration will be postponed or stopped”. Past the age of 40, the tears in the menisci tend to be a failure of the cartilage – that is to say, a fragmentation of the cartilage due to repeated trauma. In the case of younger people, the tear is essentially healthy cartilage torn by a single trauma episode. These are more likely to be able to repaired, whereas the failed cartilage is only amenable to being trimmed back to healthy tissue.

It’s worth bearing in mind that meniscal root repairs are a relatively uncommon specific type of tear of the cartilage – the main damage in that area will more usually stem from a tear of the body of the meniscus.

As with any injury to the knee, surgery is not always the automatic option. Knee specialist Mr Jonathan Webb will always take into account the nature of your injury and your personal circumstances and expectations and then advise you on whether surgery is the best solution.

smoking and knee replacement

Quit it: new study finds quitting smoking cuts complications after knee replacement surgery

smoking and knee replacementIf you’re a smoker and were looking for a reason – yet another reason – to give up, here it is: according to a preliminary study conducted by the Department of Orthopaedic Surgery at the NYU Langone Medical Center, smokers who needed a hip or knee replacement fared better in surgical outcomes and experienced less adverse events – including hospital readmissions, surgical site infections and blood clots – if they enrolled in a smoking cessation programme beforehand.

Smoking and knee replacement: the nub of the matter

The study, which included over 500 smokers who had undergone total knee or hip replacement surgery, featured 100 smokers who had gone through a smoking-cessation programme which consisted of four counselling sessions over the phone and the option to receive nicotine replacement therapy if required. The key findings of the study include:

  • Smokers who had undergone the cessation programme prior to surgery had better surgical outcomes
  • The new non-smokers had lower rates of problems post-surgery
  • During total joint replacement surgery, the smokers were 50% more likely to develop complications during surgery
  • The people in the study who continued to smoke within a month of surgery were more than twice as likely to develop a deep surgical infection compared to those who didn’t smoke

The people behind the study are the first to admit the limitations of their study – chiefly, the absence of chemical testing to determine that the ‘non-smokers’ were actually tobacco-free and not just saying they’d given up – but a larger study of 900 people is already underway, and we’ll be following it with interest.

Weight is an issue, too

However, there are other lifestyle factors that need to be adopted by people, especially as they get older, if they want to give themselves the best possible chance of a successful outcome of a joint replacement surgical procedure. In fact, a study presented at the same time in the Journal of Bone and Joint Surgery recommended a procedure of bariatric surgery – either through gastric band surgery or partial stomach removal – for morbidly obese patients who suffered from end-stage osteoarthritis.

Using a computer model to analyse past data on obesity, bariatric surgery and total knee replacement procedures, the study compared the costs and results on morbidly obese people who underwent bariatric surgery before total knee replacement surgery, and those who didn’t. The results? The patients who went through bariatric surgery two years before total knee replacement were more likely to enjoy an improved quality of life post-surgery.

Obviously, this is a no-brainer of a conclusion for a number of reasons, but it adds weight to the theory that if you’re in need of joint replacement surgery, it makes sense to ensure that the rest of your body is in as good a shape as possible to give you a fighting chance of recovery from the procedure – and also delay the need for such surgery in the first place.

runners-knee-prevention

How to beat Runner’s Knee this marathon season

runners-knee-preventionFinally, winter is on the way out and thoughts are turning to the start of long-distance running season. With the London and Boston marathons taking place this month, it is also likely to be a brand-new season of Runner’s Knee.

Patellofemoral pain syndrome, to give it its proper name, is the most common injury amongst the running community – accounting for 16.5% of all running injuries. Essentially, it’s a dull pain that manifests itself behind or around the top of the kneecap and it can flare up whenever the sufferer squats, runs (particularly downhill), walks downstairs and even while sitting. The cause of the problem is the kneecap rubbing against the groove in the femur whenever you flex and extend the knee.

Not surprisingly, developing patellofemoral pain syndrome (PFPS) is one of the most effective ways of throwing a spanner into the works of your season’s training schedule, and has shortened – or ended – many a running career. If you’re female, you’re more likely to experience this particular complaint than men. It’s also possible to confuse it with patellar tendonitis, which is an entirely different complaint with its own specific treatment.

What causes Runner’s Knee?

The general assumption would be to automatically point towards the repeated pressure runners put on the knee, but the development of PFPS is often an indication of a problem occurring either above or below the knee joint.

Above the knee, core strength, ITB tightness and, in particular, glute strength, are all factors in the possible development of PFPS. In a systematic review, published in 2013 in the British Journal of Sports Medicine, growing evidence was found to support the link between gluteal muscle strength and patellofemoral pain syndrome and identified the need for further research into the effectiveness of gluteal strengthening in those affected.

Recent scientific research shows that people with poor quads and calf flexibility are also more likely to develop PFPS. The ailment can also be developed by people with a recent improvement in quad strength.

Often it’s the newly-converted members of the running community that are more likely to develop Runner’s Knee than their more experienced counterparts, who push themselves beyond their abilities or may be wearing poor or incorrectly fitted running shoes.

How to treat Runner’s Knee

In the short term, a period of RICE (rest, icing, compression and elevation) is recommended, along with a period of stretching involving lying on your side with your bad knee on top, bending the leg and them holding your ankle towards your behind, and holding it there for a period of 45 seconds with your knees together – an exercise you should perform for at least six times a day.

It goes without saying that while you’re experiencing pain in the knee area while you go about your day-to-day business, you shouldn’t think about running, but you should be looking at an exercise programme which can stretch and strengthen your quads and lower legs without adding to the problem.

Orthopaedic knee specialist Mr Jonathan Webb often recommends taking up pilates or yoga to improve strength above and below the knee joint. Many runners approach yoga with a great deal of skepticism, but its benefits for the dedicated runner are myriad, whether they are injured or not. Muscles and ligaments are gently stretched, circulation in the tissues is boosted and hip alignment is improved. In fact, strengthening the hips as opposed to focusing on the knees, can be very beneficial for those suffering from PFPS, according to a study published in the Journal of Athletic Training in 2015.

Researchers studied 199 people who’d been suffering symptoms of patellafemoral pain for at least four weeks, stemming from overuse rather than trauma. The subjects were divided into two groups, half that did knee and thigh exercises and half that focused on building up core and hip strength. Although the outcomes were similar, the hip group saw an earlier resolution in pain and greater strength gains, compared to those that followed purely knee rehab exercises.

When can I return to running?

PFPS is notorious for sticking around for weeks or even months, so don’t expect it to instantly go away just because you’ve started doing the right thing. The best-case scenario involves you detecting and isolating the problem as early as possible, taking a few days off to allow it to heal, and cautiously easing back into running – stopping the moment you feel the pain isn’t going away anytime soon.

Rarely does PFPS require surgery, but if symptoms persist you may require referral to an orthopaedic knee surgeon such as Mr Jonathan Webb. He will also be able to rule out other potential causes of the knee pain that may require surgical intervention.