They occur more often in the older player and in players who have already suffered a previous leg injury. As with all sport injuries the incidence increases with the hours of play and the level played at. In rugby the incidence has been shown to be 5.6 injuries per 1000 hours of play and in semi-professional soccer players at 3.0 injuries per 1000 hours of play. There is evidence that injuries occur more often in the second half of games and perhaps a warm up after half time would be a good idea. High volumes of training in the week preceding a match have been shown to increase the incidence of muscle tears. The reinjury rate could be up to 30.

Passive and active warm-up and muscle stretching before training and competition have been advocated as effective injury-prevention strategies, even though there is limited evidence to demonstrate that these activities reduce the incidence of muscle strains.

Hamstring strengthening has been shown to reduce the incidence of hamstring muscle strains. In our experience at the Sports Injury Surgery athletes in Ireland playing at relatively high levels in all sports have poor hamstring strength as measured by Biodex Isokinetic Testing and have an imbalance between their Quadriceps and their Hamstrings with an overemphasis on quadriceps muscle strength.

We have also found that core stability and proprioception is poor. It has been shown that training in core stability and proprioception will reduce the incidence of muscle tears in the legs.

Studies have also shown that identification of muscle imbalances with an isokinetic measuring device such as the Biodex and then correcting these imbalances with a focused training programme will reduce the risk of hamstring muscle tears.

We advocate the use of the Nordic Hamstring Strengthening exercises to reduce the risk of tears and then retesting on the Biodex machine to prove that the hamstring muscles have indeed strengthened.

Tears can also be treated in the initial stages with platelet injections. see Platelet Therapy for more information. This technique uses the body’s own growth factors in the blood to promote healing.

Lifestyle

The first line of treatment is to look at your lifestyle. In general exercise is good for your joints. You should have your muscles in peak condition for your age. You can see your physio to discuss an exercise programme that is specific for you. It is wrong to believe that avoiding exercise will help. Of course you will have to be sensible and if an activity is particularly painful then this should be avoided. You should try to substitute another activity to stay fit.

Extra weight is a burden on your joints and perhaps a reduction in your weight should be considered. What specific foods you eat do not affect your joints and there are no specific foods that are good or bad. In general the fitter and stronger you are the less pain you will have from your arthritis even though the actual wear does not change.

Medication

You may be prescribed anti-inflammatory drugs. These can be used for short term periods. They can reduce swelling but mainly act as painkillers. They do not really affect the course of the disease. Paracetamol is a pain killer and is not classified as an anti-inflammatory drug. It is the first drug that should be used for pain. It can be used regularly and has relatively few side effects.

It is uncertain if Glucosamine actually improves the cartilage in osteoarthritis. It seems to improve pain. It is considered a supplement rather than a drug. The American Academy of Orthopaedic surgeons recommends that glucosamine and/or chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic osteoarthritis of the knee.
This recommendation was based on a report from the Agency for Healthcare Research and Quality. The report was based on one random controlled trial and six systematic reviews on the use of chondroitin sulfate, and/or glucosamine, or hydrochloride among patients with osteoarthritis of the knee.
The random controlled trial found that glucosamine and/or chondroitin did not have any clinical benefit, though five of the six systematic reviews concluded that glucosamine and/or chondroitin are superior to placebo.
Since the Random Controlled Trial is stronger science than the systematic reviews, the AAOS based their decision on the one study.

Surgery

If the wear is not advanced then an arthroscopy can be useful. It is difficult to predict the outcome in the arthritic knee. Some people do very well. In general an arthroscopy gives temporary relief. An arthroscopy is particularly good for catching and locking symptoms.

If the wear is more severe a total knee replacement is the best treatment. It is a very good operation for pain and function is very good also. 1 in 20 patients will have a problem with a knee replacement. This may be infection or loosening. The knee replacement can last up to 15 years. It will wear more quickly with more use and then it can be replaced. It may not be as easy to replace the knee for the 2nd time.

Apart from the knee replacement there are other operations that may be suitable for you. Not every knee is suitable and the operations are in themselves as big as a knee replacement. You can discuss this with your surgeon.

The following is a summary of the recommendations in the American Academy of Orthopaedic Surgeon’s clinical practice guideline, The Treatment of Osteoarthritis (OA) of the Knee. This guideline was explicitly developed to include only treatments less invasive than knee replacement (arthroplasty). This summary does not contain rationales that explain how and why these recommendations were developed nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information. We are confident that those who read the full guideline and evidence report will also see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility. This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician and other healthcare practitioners.

GRADING THE RECOMMENDATIONS
Following data extraction and analyses, each guideline recommendation was assigned a grade that was based on the total body of evidence available using the following system:
A: Good evidence (Level I Studies with consistent finding) for or against recommending intervention.
B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.
C: Poor quality evidence (Level IV or V) for or against recommending intervention.
I: There is insufficient or conflicting evidence not allowing a recommendation for or against intervention.
Final grades were based upon preliminary grades assigned by AAOS staff, who took into account only the quality of the available evidence. Workgroup members then modified the grade using the ‘Form for Assigning Grade of Recommendation (Interventions)’ shown in Appendix VIII

CONSENSUS DEVELOPMENT
The recommendations and their grades of recommendation were voted on using a structured voting technique known as the nominal group technique.25 We present details of this technique in Appendix IX. Each recommendation was constructed using the following language which takes into account the final grade of recommendation.
Guideline Language Grade of Recommendation
We recommend A
We suggest B
An option C
We are unable to recommend for or against I

Patient Education and Lifestyle Modification

Recommendation 1
We suggest patients with symptomatic OA of the knee be encouraged to participate in self-management educational programs such as those conducted by the Arthritis Foundation, and incorporate activity modifications (e.g. walking instead of running alternative activities) into their lifestyle.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 2
Regular contact with self help groups to promote self-care is an option for patients with symptomatic OA of the knee.
Level of Evidence: IV
Grade of Recommendation: C

Recommendation 3
We recommend patients with symptomatic OA of the knee, who are overweight (as defined by a BMI>25), should be encouraged to lose weight (a minimum of five percent (5) of body weight) and maintain their weight at a lower level with an appropriate program of dietary modification and exercise.
Level of Evidence: I
Grade of Recommendation: A

Rehabilitation

Recommendation 4
We recommend patients with symptomatic OA of the knee be encouraged to participate in low-impact aerobic fitness exercises.
Level of Evidence: I
Grade of Recommendation: A

Recommendation 5
Range of motion/flexibility exercises are an option for patients with symptomatic OA of the knee.
Level of Evidence: V
Grade of Recommendation: C

Recommendation 6
We suggest quadriceps strengthening for patients with symptomatic OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Mechanical Interventions

Recommendation 7
We suggest patients with symptomatic OA of the knee use patellar taping for short term relief of pain and improvement in function.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 8
We suggest lateral heel wedges not be prescribed for patients with symptomatic medial compartmental OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 9
We are unable to recommend for or against the use of a brace with a valgus directing force for patients with medial uni-compartmental OA of the knee.
Level of Evidence: II
Grade of Recommendation: Inconclusive

Recommendation 10
We are unable to recommend for or against the use of a brace with a varus directing force for patients with lateral uni-compartmental OA of the knee.
Level of Evidence: V
Grade of Recommendation: Inconclusive

Complementary and Alternative Therapy

Recommendation 11
We are unable to recommend for or against the use of acupuncture as an adjunctive therapy for pain relief in patients with symptomatic OA of the knee.
Level of Evidence: I
Grade of Recommendation: Inconclusive

Recommendation 12
We recommend glucosamine and/or chondroitin sulfate or hydrochloride not be prescribed for patients with symptomatic OA of the knee.
Level of Evidence: I
Grade of Recommendation: A

Pain Relievers

Recommendation 13
We suggest patients with symptomatic OA of the knee receive one of the following analgesics for pain unless there are contraindications to this treatment:
Paracetamol [not to exceed 4 grams per day]
Non-steroidal anti inflammatory drugs (NSAIDs)
Level of Evidence: II
Grade of Recommendation: B

Recommendation 14
We suggest patients with symptomatic OA of the knee and increased GI risk (Age >= 60 years, comorbid medical conditions, history of peptic ulcer disease, history of GI bleeding, concurrent corticosteroids and/or concomitant use of anticoagulants) receive one of the following analgesics for pain:
Paracetamol [not to exceed 4 grams per day]
Topical NSAIDs
Nonselective oral NSAIDs plus gastro-protective agent
Cyclooxygenase-2 inhibitors

Level of Evidence: II
Grade of Recommendation: B

Intra-Articular Injections

Recommendation 15
We suggest intra-articular corticosteroids for short-term pain relief for patients with symptomatic OA of the knee.
Level of Evidence: II
Grade of Recommendation: B

Recommendation 16
We cannot recommend for or against the use of intra-articular hyaluronic acid for patients with mild to moderate symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: Inconclusive

Needle Lavage

Recommendation 17
We suggest that needle lavage not be used for patients with symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: B

Surgical Intervention

Recommendation 18
We recommend against performing arthroscopy with debridement or lavage in patients with a primary diagnosis of symptomatic OA of the knee.
Level of Evidence: I and II
Grade of Recommendation: A

Recommendation 19
Arthroscopic partial meniscectomy or loose body removal is an option in patients with symptomatic OA of the knee who also have primary signs and symptoms of a torn meniscus and/or a loose body.
Level of Evidence: V
Grade of Recommendation: C

Recommendation 20
We cannot recommend for or against an osteotomy of the tibial tubercle for patients with isolated symptomatic patello-femoral osteoarthritis.
Level of Evidence: V
Grade of Recommendation: Inconclusive

Recommendation 21
Realignment osteotomy is an option in active patients with symptomatic unicompartmental OA of the knee with malalignment.
Level of Evidence: IV and V
Grade of Recommendation: C

Recommendation 22
We suggest against using a free-floating interpositional device for patients with symptomatic unicompartmental OA of the knee.
Level of Evidence: IV
Grade of Recommendation: B

Meniscus: this is a crescent shaped fibrocartilage that is between the bones in the knee joint. It acts as a shock absorber. We are taking weight through the meniscus on every step we take. It is therefore no surprise that theses structures can wear and eventually tear even through normal life.

There are actually 2 in the knee. If worn or torn they cause pain on the side of the knee where the problem is along the line of the joint. The pain is worse when twisting or bending. Sometimes there is a build up of fluid in the knee.

They can also be torn in a sudden twisting injury or on bending down. Then they can actually get stuck in the joint causing locking.
About ½ of people with an anterior cruciate ligament tear also have a tear of a meniscus.

The diagnosis can be made by a proper history and examination. An MRI can be useful in a small number of cases if there is any doubt after the examination. In fact the MRI is most useful when the patient has little trouble and needs the reassurance of a normal scan to get them back to full activity.

A tear can only be treated by an arthroscopy. At the arthroscopy the tear is usually trimmed back with power tools and electrosurgery devices. In a small number of cases there is a smooth tear that will hold a stitch well. In this situation the tear can be repaired with special stitches that are placed inside the knee while it is viewed on the monitor without the need for open surgery (keyhole surgery). This happens most commonly in the younger patient with a sudden injury.

When a tear is trimmed back the patient can usually return to full activities after 4 weeks.

When a tear is repaired with stitches it will take at least 3 months before the patient can go back to sport.

Cartilage: there is confusion when talking about cartilage injuries. The meniscus is also called cartilage but it is the covering cartilage of the bones that we are talking about here. The ends of the bones in the knee are covered by hyaline cartilage. This varies from about 3 to 5 millimetres in depth. Again we are walking and running taking weight through the cartilage every day. It can wear. This starts as a softening, then fissuring and then the cartilage starts to break up. It can start to come away from the bone and leave it exposed.

I am not sure that increased levels of activity cause this wear as it can be seen in sports people and in people who do very little. It can also be seen in any age group.

Cartilage wear can lead to swelling and pain in the knee. However it does not affect everyone in the same way. Some have a lot more trouble than others with similar levels of wear.

Cartilage wear is diagnosed by a history and examination. An x-ray is the best investigation as this will give the best indication as to whether the patient needs a knee replacement or not. Obviously there is no point in having arthroscopic surgery (keyhole surgery) if you need a knee replacement. I find that MRI is very poor at demonstrating early cartilage wear and I feel that it is not needed as a routine investigation.

In the early stages it can be treated with rest and physiotherapy. If not settling an arthroscopy can make a great difference. Loose cartilage and cartilage about to fall away from the bone is removed with the arthroscopic shaver. The edges of the damaged cartilage can then be treated with an electrosurgery ablator which seals it.

Sometimes some small holes can be placed in the underlying bone to release the bone marrow with its stem cells. These cells have the ability to grow a scar like cartilage over the defect. This is called the microfracture technique.

This treatment can slow down the progression of the wear and relieve pain and swelling. However not surprisingly not all knees are sorted out and wear can continue. Patients who continue to have a lot of trouble may need a knee replacement.

Return to full sports is more uncertain after cartilage injury. It usually takes 3 months and it is very advisable to have the muscles in peak condition as this will protect the knee. Some people may decrease their activity level because they are just not able to do what they did before because of swelling and discomfort in the knee.

At the present time techniques to replace and regenerate hyaline cartilage are been used on an experimental basis and they have not yet been clearly shown to definitely benefit the patient. It is likely however that sometime in the next 5 years a good, safe, beneficial technique will emerge from the research.

It is possible to have excellent pain relief with over the counter pain killers that you can buy in the pharmacy or even the corner shop.

It is important to know what the actual name of the drug in the packet is and not just the brand name. I will refer to the actual drug name in all cases. You should ask your pharmacist for help in finding out what the actual drug is. The actual drug name is on the leaflet inserted in every packet. This keeps things simple and avoids using 2 of the same drugs even though they have different brand names.

You must not take any tablets that you have had an allergic reaction to in the past.

The first drug to use is Paracetamol. This is best started before the operation at a dose of Paracetamol 1g 4 times in the day. Check on the packet what 1g is but it is usually 2 tablets. As always you can check with your pharmacist if in doubt.

Continue the Paracetamol 1g 4 times a day after the operation. If you still have pain then you add a different drug as well as the Paracetamol rather than stopping the Paracetamol.

The next drug to add is Ibuprofen at a dose of 400mg 3 times a day. Again check with your pharmacist about the different brand names of this drug and the dose.

Do not take Ibuprofen if you have a history of stomach problems.

Both Paracetamol and Ibuprofen come with added Codeine and you may find these a little stronger if needed. Again ask your pharmacist.

In summary you can take

Paracetamol 1g 4 times a day

And

Ibuprofen 400mg 3 times a day

These drugs can be bought in the pharmacy and the corner shop without prescription. They will provide very good pain relief after orthopaedic surgery. If you have other pain medication at home contact me to ask if it is OK to use it. It is very likely that this medication will be fine for you.

Breandán Long

You may have some pain in the knee after discharge. I have put local anaesthetic in the knee, which will probably last for 6 hours. Take tablets such as Paracetamol, Solpadeine, Aspirin or Nurofen before it gets too bad. Any painkiller that you have for a headache will be good.

You may get some discomfort from the wounds through which the instruments were put.

Click For Pain Relief Advice

It is best to take things easy for 3 days at least and not to walk too much. It might be from 1 to 6 weeks before you can go back to work depending on your job. It is unlikely that you will be able to drive for the first week.

You can put your full weight on the leg and walk around as normal when you feel up to it.

You could put a bag of ice over the bandage for 20 minutes at a time to decrease pain and swelling.

Some swelling in the knee is common after the arthroscopy. It might take 4-6 weeks for this to settle down.

The crepe bandage and wool wrapped around your knee should be taken off 2 days after the operation. If it feels too tight it is no harm to take it off sooner than this.

If there is a tubigrip bandage on your knee instead of the crepe bandage please leave this on for 1 week.

The sticking plasters underneath should be left on for 1 week after the operation. Do not get them wet. You can take them off yourself or wait for the clinic.

There are no stitches in the wounds. Sometimes the wounds ooze a little blood.

Straight leg raising exercises. Lift your leg about 30 degrees when lying down. Hold for 30 seconds. Do 10 repetitions.

If the knee becomes hot or red contact us straight away.

If you have any problems do not hesitate to contact us.

The operation is done under a general anaesthetic. In most cases it will be done as a day case. If you have a medical condition you may need to stay in overnight.

2 or 3 small cuts (about 1 cm in length) are made in the front of the knee. The camera goes in through one of these and instruments go in through the other cuts. It is possible to move the structures in the knee with a probe to see if they are damaged. This is an advantage over a MRI scan. If structures are damaged they will be either removed or repaired. Sometimes it is not possible to improve the knee by doing arthroscopic surgery as the wear and tear may be too advanced. Patients who are older, with a lot of wear and tear and in poor physical condition generally do not benefit from an arthroscopy.

It may not be possible to improve your knee because you have an ongoing degenerative process.

1 in 50 patients will require a 2nd arthroscopy to tidy the knee up further.

You probably will be able to walk fully on the knee after surgery. Some people are put on crutches depending on what is done in the knee.

The operation is done under a general anaesthetic. This carries certain risks to the heart and the lungs.

These risks are very low and only 1 in 1000 patients will have any problem. The risks will be increased if you have a medical condition such as angina, high blood pressure, asthma, airways disease or diabetes or if you are overweight. It is important to discuss any medical condition prior to surgery. Please bring all tablets that you are on when you are coming in.
Please ring the office if you have a cold or a flu illness.

The actual arthroscopy itself also carries its own risks to the leg.

About 1 in 200 people will develop a significant clot in the leg. This can be treated by so called blood-thinning agents for 6 weeks. A very small number of these clots will travel to the lungs. The risk is greater if you have had a clot in the past or have vein problems. It is important to stop the oral contraceptive pill 4 weeks prior to surgery.

About 1 in 1000 people will develop an infection in the knee. This infection may clear up with antibiotics in hospital. However in some cases it may cause permanent damage to the joint leading to arthritis.

The small cuts may go through skin nerves, which may cause some numb areas or even pain. This usually improves with time and is only a problem in less than 1 in 100 patients.

I hope this does not alarm you. The risks involved are very small. Everything will be done to make sure that you have no problems. Please discuss anything you are worried about.

Please note that although you will be having an arthroscopy, what is done inside the knee can vary greatly between patients. Your discomfort and recovery time may be very different from someone who had the operation on the same day.

Make sure that you have pain killers (Nurofen, Aspirin or Paracetamol) to take after the operation.

It is best to take Paracetamol every 6 hours on the day before the operation and afterwards.

Breandán Long

Afterwards you will be placed in a cast for 4 weeks and will need to stay off it on crutches.

If the deformity is very bad the correction will not be as good. In most cases the result is acceptable but not perfectly straight. It should get rid of the pain from the bunion but pain in the sole of the foot is difficult to predict afterwards.

The recovery time afterwards can be as long as 1 year. Swelling in the foot can last this long. Most people are walking around well 2 weeks after the cast is removed.

The operation is done under a general anaesthetic. This carries certain risks to the heart and the lungs.

These risks are very low and only 1 in 1000 patients will have any problem. The risks will be increased if you have a medical condition such as angina, high blood pressure, asthma, airways disease or diabetes or if you are overweight. It is important to discuss any medical condition prior to surgery. Please bring all tablets that you are on when you are coming in. Please ring the office if you have a cold or a flu illness.

You may have some numbness around the wound area which rarely is permanent but may last a few months.

There is a 1 in 100 chance of getting a wound infection. This can usually be treated with antibiotics and cleaning of the wound.

You will be in hospital 1 or 2 nights.

After the operation you will be supervised walking on crutches by the physiotherapist.

You will be seen again at the clinic after 4 weeks when your cast will be taken off.

Breandán Long

This means that the space at the top of the shoulder will be enlarged to prevent the shoulder from impinging.

Tears of the rotator cuff can be small or quite large. The bigger the tear is and the older the patient the more difficult it will be to repair. In some cases it will be impossible to repair the tendon. The camera will show the extent of the tear if there is one present.

The recovery time afterwards can be as long as 1 year. You may still have pain during that time as bad as you had before the operation but it will gradually decrease.

Tears of the rotator cuff are often the result of the normal aging process so the risk of a re-tear in the older patient is about 40.

The operation is done under a general anaesthetic. This carries certain risks to the heart and the lungs.

These risks are very low and only 1 in 1000 patients will have any problem. The risks will be increased if you have a medical condition such as angina, high blood pressure, asthma, airways disease or diabetes or if you are overweight. It is important to discuss any medical condition prior to surgery. Please bring all tablets that you are on when you are coming in.
Please ring the office if you have a cold or a flu illness.

You may have some numbness around the wound area which rarely is permanent but may last a few months.

There is a 1 in 100 chance of getting a wound infection. This can usually be treated with antibiotics and cleaning of the wound.

You will be in hospital 1 or 2 nights.

After the operation your arm will be in a sling for 6 weeks if you have had a rotator cuff repair. Otherwise you will be allowed to use the arm.

You will be seen again at the clinic after 1 week when your dressing will be taken off. It is likely that you will require further follow up and physio as appropriate.

Please visit our downloads page for Scapular Rehab Programmes.

Breandán Long

If you fall on your arm or your side you can tear the rotator cuff. Your x-ray will be normal. If you cannot lift your arm away from your side you probably have torn your tendon. Only surgery will repair the tendon.

In the under 30 age group there is no degeneration of the tendons and it can be treated well by a programme of scapular exercises. The shoulder is brought in to proper alignment and the impinging type pain is relieved.

In older patients the rotator cuff tendons are degenerating or if you like slowly wearing. The body is not able to continue to heal the tendons and they gradually get worse. There is no inflammation. The tendon may be impinging against the bone at the top of the shoulder called the acromion. This may add to the wear. The wear can go on and result in an actual hole in the tendon. This can deteriorate and lead to exposure of the head of the humerus which will then rub bone on bone on the acromion.

The condition can be diagnosed by a good clinical examination. An ultrasound or an MRI will help to outline the extent of the wear. The MRI can show what extent the tendon has retracted and what atrophy there is in the muscle. This will help decide if the tendon can be actually be repaired.

Treatment

Initially physiotherapy will help. The physio will instruct the patient in rotator stabilisation exercises which will correct or at least reduce the impingement. However the wear of the rotator cuff tendons will not actually change.

Please visit our downloads page for Scapular Rehab Programmes.

Steroid injections can help in the short term but again do not actually heal the tendon. However healing of the tendon is not actually necessary to decrease the pain.

Surgery can be the answer when the above does not solve the problem. A sub-acromial space decompression will increase the space at the top of the shoulder so that the shoulder has more space when lifting it up. It can take 3 to 6 months for a full improvement. The operation is done with the arthroscope (key hole surgery) so there are no large wounds.

During the operation the integrity of the cuff is assessed. Even though scanning is done before the operation tears of the cuff can be better seen with the arthroscope. Repairing these tears with sutures can result in actual healing of the tendon. Healing of the tendon will take away the pain and prevent joint wear and tear.