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.

knee-arthritis-in-women

Poor muscle strength linked to increased risk of knee osteoarthritis in women

knee-arthritis-in-womenA recent report from Arthritis Care & Research magazine has come up with an interesting conclusion on the subject of knee osteoarthritis: women with poor strength in their leg muscles are significantly more likely to develop arthritis of the knee, while men with equally poor leg strength aren’t at risk.

It’s not surprising that so many problems can occur with our knees – after all, they’re the largest and one of the most complicated joints in our body, needing to be strong enough to support our weight (and the stress we put upon them through running, lifting, and a welter of day-to-day activities) and flexible enough to allow us to move freely.

Knee osteoarthritis is a condition which damages the surfaces of the knee and causes a range of problems. The cartilage over the main surface of the knee joint and beneath the kneecap thins out and roughens, which causes the bone beneath the cartilage to thicken. Meanwhile, the tissues in the joint react to the changes by going into overdrive, and the bone at the edge of the joint starts to grow outwards and forms spurs. In extreme cases, the synovium – the tissue between the thigh and shin bones – can swell and produce extra fluid.

Bringing your joint to account

All these changes are nothing more than your knee reacting to the inflammatory process and attempting to repair the damage. Sometimes it works, which results in the condition being put right all by itself. Sometimes it doesn’t, which causes instability in the joint and a worsening condition over time. Symptoms of long-term knee osteoarthritis include prolonged pain and stiffness, crepitus (a crunching or creaking sensation in the joint) and swelling. In severe cases, the pain is so intense that sufferers have difficulty sleeping.

There are many factors that can bring on knee osteoarthritis: it can be brought on with age, weight gain, or overwork. You’re more likely to develop it if your parents have suffered from it, or if you’ve had other knee problems in the past, and – yes – if you’re female.

Why are women more prone to knee osteoarthritis?

According to the report, it appears to be an issue with the thighs. Due to their close proximity to the knee, they’re the main provider of stress to the joint – and while female weight gain targets the thighs, male weight gain is generally distributed in the stomach and chest areas, causing the thighs to take the strain and naturally gain more muscle, resulting in less knee stress.

There’s also a case to be made for extra knee stress being brought about by the wearing of heels, which put extra strain on the hips, toe joints and knees.

The solution? Losing weight obviously helps, as does the timely and sensible use of painkillers when needed, but if all non-surgical interventions fail to improve pain and mobility levels adequately, then a surgical solution in the form of knee replacement surgery may be your best option.

Artificial knee joint

The debate: partial v total knee replacement

Total Knee ReplacementThere’s been an argument raging amongst the medical community for a while now, and I’ve been following it with interest. It’s been a long-held view that a total knee replacement is better than a partial one – for reasons we’ll go into later – but recent high-profile developments may suggest that the tide is beginning to turn back to the partial side.

The case for total knee replacement

While total knee replacement – the replacement of both ends of the bones in the knee with metal and plastic – is most commonly used on older patients, who have usually already undergone less drastic (and ultimately less effective) treatment. It has been viewed for a long time as the cure-all procedure, as it theoretically eliminates any further problems in that area, especially when the client suffers from severe three-compartment (inside, outside and front-of-knee) arthritis.

It’s also a much easier procedure for the practitioner to perform: after all, taking the entire engine out is a lot less hassle than extracting a few valves and cogs. There has also been a greater reliability rate with the total knee replacement over the years, despite the longer recovery time.

The case for partial knee replacement

However, the tide may be turning towards the partial approach. Despite its undeniable success rate, there are many downsides to total knee replacement: the loss of feeling, the long and arduous recovery period, the fact that half of all patients experience pain in the knee area after a decade or so, and the sheer cost of the procedure. Consequently, as developments in knee repair technology are starting to catch up, the decision to go partial or full is starting to get trickier.

There have been huge advances in pain and bleeding control, risk management and physical therapy of late which suggest that partial knee replacement is making a comeback. The most newsworthy non-sporting knee surgery of the decade so far – George W Bush’s unicompartmental procedure on both knees in 2014 – allowed him to take up his cycling hobby again within a few months, something that would have been difficult at best with a total knee replacement. Once seen as a bit of a punt in the hope that further deterioration won’t happen and some feeling will remain – or the delaying of the inevitable for a few years – the partial procedure has developed a new lease of life.

Which knee replacement surgery is best for you?

The short answer, as always: it depends on many factors. If you’ve kept your weight down, are in good health and are still physically active, you stand more chance of a successful partial replacement. If you’re overweight and inactive, you may be pointed towards a full replacement. My job is to assess the requirements and expectations of the individual patient and recommend the best option for them.

Rugby Knee Injury

Six Nations puts spotlight on knee injuries – again

Rugby Knee InjuryLike every other rugby fan – and especially as an English Rugby fan – my heart went out to George Kruis when I heard of his knee ligament injury, which he suffered in training in the run-up to England’s first Six Nations game. Not only is he ruled out for the rest of the Six Nations, but it’s also pretty certain that his chances of making the British and Irish Lions squad is now slim to none.

It’s a shocking blow for the Saracens forward, who was really starting to establish himself as a major part of the England squad, but not an uncommon malady. As we’ve pointed out before, knee injuries account for the most number of missed days in the rugby world – and out of all the things that could go wrong with that part of the body, the most common injury occurs with the ligaments – the ailment that George has succumbed to.

So is the constant array of knee injuries that crop up during the season nothing more than an unavoidable part of a very physical contact sport, or are there preventative measures that can be taken? Well, let’s start by taking a look at other sports that closely resemble rugby and see what their statistics are…

It’s not just rugby union

We can argue all day – usually with Americans – about the ‘toughness’ of rugby compared to American football, but despite all the padding and protection, the most common injuries in gridiron also occur around the knee area, especially to the cartilage. And while NFL players are allowed to wear knee braces that are much sturdier than the ones allowed in rugby, the problems remain the same – enormous pressure on the knees, which are magnified by the extra weight carried by the players. Not to mention the problems caused by artificial turf.

When it comes to the other sports that come close to rugby – Gaelic football and Australian Rules football – there’s an interesting divergence. Both are vaguely similar, with their heavier reliance on kicking, but while the Irish sport has ACL injuries as its most common malady, Aussie Rules’ most regular injury involves hamstring strain. Pitch size might be the key factor here: the Australians cover much more ground, and there’s far more space to cover, meaning the grind-it-out methodology of rugby doesn’t apply – however brutal the tackles are.

Different league

Finally, we come to the obvious comparison: rugby league. You may be surprised to learn that knee issues aren’t even in the top three most common injuries: in reverse order, it’s dead legs, ankle damage and shoulder dislocations. Maybe it’s because of the six-tackle rule: maybe the faster pace and the higher impact of those limited tackles has something to do with it.

So, after taking all these facts on board, what does that tell us the spate of injuries to the knee in the Union code? It’s clear that an expanded pitch, a greater emphasis on kicking and the introduction of a limit on tackles would greatly reduce strain upon the knee – but then again, it wouldn’t be rugby union anymore, would it?

Preventing Skiing Knee Injury

Ski injury prevention: beware the 5 B’s

Skiing is often thought as a highly risky sporting activity – something about sliding down a mountain at great speed strapped to two boards – but in an evaluation of most dangerous sports, Forbes magazine found that skiing fell significantly behind a whole host of other pastimes. Furthermore, technological advances and the use of helmets has meant that ski injuries have declined in recent years.

However, even with this decline, the knee is still very prone to incurring trauma when skiing, accounting for a third of all ski injuries. The most common cause of these knee injuries is rotation and I have identified the five Bs to watch out for:

1. Bindings

The introduction of bindings – the device that connects the boot to the ski, which releases when certain force limits are exceeded, such as a spill or collision – was a huge development in on-piste safety which addressed the two main dangers of the era: ankle injuries and lower leg fractures. The ‘downside’ of that was an increase in the rise of anterior cruciate ligament injuries and the knee sprain becoming the most common injury in skiing.

So, what have bindings got to do with knee injuries? Well, a common occurrence is when someone is travelling too slowly for the bindings to release, and falls – resulting in the ski going one way and the body weight going the other, resulting in an unnatural rotation of the knee. This incident is usually prevalent amongst beginners, but more experienced skiers can come a cropper when they set their bindings too tight.

2. Bad snow

Snow quality is a huge factor in skiing injuries and for obvious reasons: if it’s too hard-packed or icy, it’s harder to grip the surface with your ski edges and can cause more severe injuries if you take a spill. On the other hand, if the snow becomes sticky and slushy, the danger of slow-turn injuries and failures in binding releases increase dramatically.

Make sure you keep tabs on the quality of the snow as the day wears on, and adjust your style accordingly – or call it a day if you’re not comfortable with it. Early season skiers usually encounter more hard and icy surfaces: late season skiers are usually forced to contend with slushier snow. Wherever you are, it makes sense to consult local knowledge and weather reports. Here’s a more detailed guide to the complexities of snow quality.

3. Bottom of the run

By this, I mean towards the end of the day, when too many skiers are more fatigued than they realise and start to lose concentration and consideration for others.

Obviously, unless you happen to live in the Alps, skiing is not a hobby one can pursue whenever you like, and the whole point of your holiday is to get on the slopes, but there’s a fine balance between getting the ski time you desire and giving your body the chance to recover for the next day. After a day on piste, you are strongly advised to partake in a ten-minute cool-down session (simply walking on the spot will suffice), followed by a routine of stretching exercises, such as lunges, calf raises, and groin and calf stretches.

4. Boredom

It can’t be stressed enough: not only is skiing an incredibly strenuous physical activity, it’s also a hugely taxing mental experience. Furthermore, the short and exciting bits are punctuated by queuing for ski-lifts, dealing with skiers of varying experiences and skill levels, and distractions such as low sunlight.

Simple solution to this: if you feel your concentration waning, remember the latter half of the words ‘skiing holiday’ and do something else that you’d normally do on a break. Which leads to the fifth ‘B’…

5. Boozing

Preventing Skiing Knee InjuryThere’s no getting around it – the temptation to push the boat out in a nearby chalet bar and get stuck into the Glühwein can be overwhelming, but there’s a price to pay when you overdo it. The dulling of reactions, loss of concentration and the removal of inhibitions can be a recipe for disaster when on skis and the French have recently introduced stiff penalties for those caught drunk skiing, claiming that one in five ski accidents in France are due to drinking.

Surgery is not always necessary after a knee injury – modern skis can allow the recreational skier to continue their favourite pastime. My rule of thumb is always whether the patient is willing and able to adapt their lifestyle to the reduced capability of their knee joint or if the knee needs to be adapted to suit their requirements.

New-treatment-for-meniscus-tears

Stem cell ‘bandage’ has been trialled in meniscus tears

New-treatment-for-meniscus-tearsA potentially interesting development has recently been announced in the treatment of one of the most common knee injuries. Utilising the still burgeoning technology of stem cell research, the practice of harvesting stem cells from patients’ bone marrow and using them to knit together tears in the meniscus area has been trialled at Liverpool and Bristol universities – with encouraging results.

The menisci are the C-shaped discs of tough, rubbery cartilage which act as shock absorbers around the knee. Each knee has two of them: one at the outer edge of the knee and one at the inner edge, and they undergo a lot of stress throughout the day as they balance and evenly distribute weight and force and provide stability across the knees.

When a tear of the meniscus occurs, it can therefore cause significant problems. It’s usually caused by twisting or turning quickly, often with the foot being planted while the knee is bent. As time goes on, the cartilage becomes less supple and pliable, increasing the risk of meniscus damage.

How will you know when you’ve suffered a meniscal tear?

One word: pain. And lots of swelling. In minor cases, the swelling will get worse over the first three days before receding, but flare up again whenever you flex your knee. There’ll be prolonged stiffness of the knee after a week or two, which will fade away. The meniscus has a limited blood supply, meaning the tear – no matter how minor – can be incapable of healing itself, and the pain can come and go for years if left untreated.

In more extreme cases, when the tear is large, a piece of the torn meniscus can lodge in the hinge mechanism of the knee. This can cause anything from irregular catching and popping in the knee to a prolonged locking of the knee, which will typically require surgery to correct.

How a meniscus tear is treated

Your knee specialist will want to know about your regular physical activities, any past injuries in the knee area and what you were doing when the pain began. This will be followed by a physical exam which will involve X-rays and/or MRIs and checks for tenderness, range of motion and stability in both knees.

Treatments for a meniscus tear can range from a simple course of RICE (rest, isolation, compression and elevation), icepack treatment and anti-inflammatory medications to surgical procedures to repair or remove part of the meniscus. Rehabilitation programmes usually concentrate on maintaining muscle strength in the quads, hamstrings, calves and hips.

Previously, the menisci were routinely removed when torn, but now we know how important their contribution is to a healthy knee, so the aim is to repair if possible. If the ‘stem cell bandage’ trial continues to produce such encouraging results, we could see a new and more effective alternative to surgery and reduce the chances of developing debilitating symptoms such as osteoarthritis in later life.

Ohio-State-University-study-into-brain-and-ACL-injuries

Beyond the body: new research looks at the full impact of an ACL injury

A recent study in the Journal of Orthopaedic & Sports Physical Therapy has claimed that to regain full function after an injury to the ACL, or anterior cruciate ligament, goes beyond the physical and actually requires ‘retraining’ the brain.

According to a controlled laboratory study by the Ohio State University Wexner Medical Center released in November 2016, it was determined that parts of the brain which controlled leg movements went into a lag during the recovery period during an ACL injury, particularly when extending and flexing the knee. In other words, instead of relying on movement and spatial awareness, recovering patients had started to over-rely upon their vision when they didn’t need to before. One researcher compared it to walking in the dark: moving with less speed and confidence, with a strong mistrust in their natural instincts.

While it’s only natural to have your confidence knocked after an injury, the idea that you can’t trust your natural instincts adds a huge mental knock to an equally debilitating physical setback, particularly to a sportsperson. So, what’s causing this – and how can it be avoided?

Where seeing is more important than believing

The study, involving 15 people who had undergone ACL surgery and 15 who hadn’t, put participants through repeated cycles of knee flexion and extension, and surmised that the half of the study group that had been through ACL surgery displayed increased activations in the contralateral motor cortex, lingual gyrus, and the ipsilateral secondary somatosensory area (in other words, the parts of the brain that dealt with processing visual stimuli), and diminished activation in the ipsilateral motor cortex and cerebellum – the part of the brain which regulates and coordinates muscular activity. In other words, they were placing more emphasis on what they saw over how they felt.

Could strobe glasses help?

Ohio-State-University-study-into-brain-and-ACL-injuriesOn the surface, there’s a simple explanation for this: when it comes to the human body, you tend not to miss something until it’s gone, or at least stopped working. In the case of ACL injury, there has been a long layoff period: the wait to get treated, the two weeks of zero movement after surgery, and a period of slow rehabilitation that can last up to six months. That’s a long time to be away from the use of a part of your body that you largely took for granted.

Factor in the statistic that sportspersons who have experienced an ACL injury are anywhere between 30 to 40 times more likely to suffer a second injury in that area compared to an equivalent athlete who hasn’t had one, and it’s clear that an element of doubt will be at the back of the mind of anyone who has undergone ACL surgery.

The scientists at Ohio State are trialling an interesting technique to remedy the overreliance on sight: strobe glasses. The idea is to visually distract clients whilst they work out, in an attempt to re-wire their brain back to its pre-injury state and forcing them to rely on instinct once more.

Knee Surgery Prehab

The importance of Prehab: how to prepare for knee surgery

Knee Surgery PrehabIf you’ve suffered a serious knee injury and are awaiting surgery, the temptation may be to wrap yourself up in cotton wool and rest the knee as much as possible until the big op. New thinking, though, is that ‘prehab’ can be key to ensuring a rapid recovery and return to play.

In a 2013 study published in the American Journal of Sports Medicine, researchers looked at the effect a six-week exercise programme had on patients about to undergo ACL reconstructive surgery compared to a group that underwent no preparation. Twelve weeks after the operation both groups were tested for strength, function and patient outcome and the group that had undergone prehab were found to have better function and patient outcome and, significantly, returned to sport earlier than the other group.

Thankfully, the benefits of prehabilitation – a programme of therapy that not only physically prepares the client for surgery but also puts them in the optimum frame of mind to deal with whatever the procedure throws at them, with the goal of getting them back to their peak in the earliest time possible – are becoming better known.

While an extended period of RICE (rest, isolation, compression and elevation) is a given during the pre-op period, it’s also essential to introduce an element of low-level exercise. Not only does it strengthen the knee, increase flexibility and help the patient recover faster, it also gives them the feeling that they’re actually doing something to get back on track.

Mental preparation is key

There are numerous exercises that are suitable for an injured athlete to prepare themselves for surgery, and an orthopaedic surgeon such as Mr Jonathan Webb will work closely with the physio team to design a programme that will work best for the specific injury. But it’s equally important to consider the mental state of the client, because they’ve suffered far more damage than an injured knee.

Whether the client is a professional player or a hobbyist, they’re someone whose life revolves around physical activity. In a lot of cases, their sporting activity is more or less who they are. If they’re a pro, their career can be on the line, and they could be forced into thinking about giving up what they’ve spent a considerable part of their life on sooner rather than later. Even if they’re a weekend player, they have to consider giving up the activity they love, or at least being forced to spend a long time away it. In both cases, there’ll be a sense of disconnection: a feeling that they’re letting their teammates – and themselves – down.

Allay fears, set realistic goals

Obviously, this isn’t the optimal state of mind to be in when preparing for surgery, and prehab is the best way to counter that. The patient can become realistic about the timescale of recovery, with the goal of eliminating any frustration and demotivation that can occur both before and after surgery. It can also allay any fears the patient has. Most importantly, it can make them feel part of the team at a time when they feel they’re holding the rest of the squad back.

Osteoarthritis-risk-after-ACL-injury

New study evaluates the risk of developing osteoarthritis after ACL injury

It’s one thing suffering from and getting over anterior cruciate injury, but a recent study from the Journal of Orthopaedic Research has flagged up an alarming side-effect: the heightened risk of osteoarthritis amongst recovering ACL sufferers.

Osteoarthritis-risk-after-ACL-injuryOsteoarthritis – a condition where joints become damaged, preventing their free movement and causing excessive pain – is the most common form of arthritis in the UK. Nearly nine million people in this country have undergone treatment for osteoarthritis, and it usually kicks in during the late forties. It’s an ailment that affects women more than men and, if you’re over 45, there’s a 33% chance that you’re one of the sufferers.

Unsurprisingly, the most affected joints in this country are the knees. According to Arthritis Research UK, an estimated 4.71 million people here have knee osteoarthritis – and with the onset of increased nationwide obesity and an ageing population, those numbers are expected to increase to 5.4 million at the end of the decade and to 6.4 million by the year 2035. In the US, the medical bills are even more of an issue: osteoarthritis comes only after heart disease, cancer, mental and trauma-related disorders in the list of costliest medical conditions.

How does osteoarthritis develop in ACL sufferers?

The Journal of Orthopaedic Research study – which involved tracking the progress of thirty athletes going through ACL reconstruction over six months – discovered that post-ACL patients multiply their risk of knee arthritis by anything from three to five times more than someone who hasn’t incurred this injury.

There are manifold reasons for this. Agitating the joint with repetitive knee adduction moments (the combination of the ground reaction force that passes medial to the centre of the knee joint, and the perpendicular distance of this force from the centre of the joint – otherwise known as ‘walking on it’) is a key element. Factor in the inability for the cartilage to regenerate itself fully after injury due to the lack of a blood supply, and it’s clear that an ACL procedure could cure one ailment while opening the door to another.

What can be done to avoid osteoarthritis?

Although research into the repair of cartilage injuries is still in its infancy, there’s a feeling that something can be done and soon. Much focus has been directed on the possibilities of stem cell research and one hospital in Switzerland is reporting early successes with a procedure that involves removing cartilage from the nose, then growing and shaping it, and transplanting it in the knee area.

Until then, it’s essential that taking steps as early as possible to implement a post-op rehabilitation programme – and ensuring that patients stick to it – is the best solution at the moment.

Maro-Itoje-rugby-injury

As Autumn Internationals kick off, England’s run of injuries raises concerns

As England’s Autumn internationals get underway when they meet South Africa at Twickenham on Saturday, some of our best players will be watching from the sidelines because it’s already been a brutal season for some of the leading figures in the game.

Maro-Itoje-rugby-knee-injurySam Jones was unfortunate enough to break his leg during a judo session, which will delay his national debut for some time, and Anthony Watson broke his jaw in a training session. James Haskell’s already-dodgy toe gave out in the test series against Australia, and is spending the start of the season in a protective boot. Manu Tuilagi’s groin injury has flared up again. And right before the beginning of the Four Nations, Maro Itoje fractured his hand in a Saracens game and has been ruled out for all four tests. And, at the time of writing, it appears that Courtney Lawes’ place in the squad may be in doubt after suffering a swollen knee during a training session.

It goes without saying that rugby is a very physically demanding sport, and injury is part of the game – but is there something else happening here? A recent article in the Guardian certainly seems to think so, drawing comparisons between the demands of the professional game on today’s players and what top-flight footballers have been experiencing for years: an increased workload brought about by international tournaments, conflicts between club rugby and the national associations, and an off-season that’s getting shorter and shorter. The Lions squad, for example, won’t be booking their holidays until July next year and then going straight into pre-season training.

Putting aside random events like getting on the wrong side of a judoka, what’s the main injury in rugby? For one of the most gruelling contact sports in the world, the answer may surprise you: a study conducted by the American Journal of Sports Medicine came to the conclusion that knee injuries accounted for the highest number of missed days in the rugby world.

Rugby and knee injuries

Out of all knee-related maladies covered in the study – conducted amongst twelve English clubs over the course of two seasons – anterior cruciate ligament accounted for the greatest proportion of days missed, followed by medial collateral ligament injuries. Most of the severe injuries happened during contact – mostly in the tackle – and flared up more frequently in the final quarter of a game more than at any other time.

Players in the back position suffered more than anyone else. Sixteen per cent of knee injuries occurred during training, and each club in the study suffered an average of ten knee injuries per season, clocking up a total of 353 missing days, and 1 in 20 of a club squad being out of action at any one time due to knee injuries.

While the more gruesome rugby injuries are always going to grab the headlines, knee problems are the chief cause of missed play. An orthopaedic surgeon such as Mr Jonathan Webb that specialises in the knee works with rugby players at all levels, aiming to return them to play as quickly as possible.