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Synthetics ligaments in the knee: Deja vu or innovation ?

6 Jul, 17 | by BJSM

By Lars Engebretsen MD, PhD.

Are you old enough to remember these orthopedic implants: GoreTex, Dacron, Polyester, Polypropylen, or carbon fibers? Let me remind you that these were not raincoats, mountaineering apparel or shoelaces— they were knee ligament substitutes!

I am old enough to have tried these as substitutes for torn ACL or PCL, or augmentations for knee and ankle ligaments. The promise? Speedy return to sports. However, invariably it resulted in a shortened sports career.  The synthetic ligament had two end points: either early synovitis due to the knees reactions to the foreign body or worse, material failure of the synthetics and spreading of intraarticular particles resulting in catastrophic cartilage damage, bony erosions and eventually premature osteoarthritis

Why a blog about this now? I just returned from the ISAKOS (International Society of Knee Surgery and Orthopedic Sports Medicine) congress in Shanghai. 5000 surgeons from all over the world witnessed news in sports traumatology. Unfortunately they also listened and watched new talks, symposia and poster sessions on synthetics as ligament substitutes. In fact, the very first video demonstration – a highlight lecture – featured synthetics.

As in the late 70s and early 80s, the basic science evidence for graft substitutes is flimsy. The industry data is proprietary — unavailable for scientific discussions. The industry does not want to share among competitors. It goes beyond my understanding how the FDA and EU regulators can approve products without what I believe to be valid basic science. Very few, if any academic groups are doing research in this area. My anxiety is that we are repeating the mistakes of the 70s and 80s in our quest to achieve an early return to sports and prolonging some veteran careers veterans.

Perhaps there is a need for synthetic augmentation in some cases of multiligament injuries, but this use must be based on solid basic science. Biomechanical and molecular biology materials testing, small and large animal trials, and controlled, pilot studies for new materials are needed. Industry has a large responsibility for this if they are promoting synthetics ligament implants.

Remember, as sport medicine physicians our prime task is: Do No Harm! And I can tell you from personal experience — synthetic ligament substitutes have resulted in much harm and sorrow for our patients. Our task is to challenge industry to invest and publish basic science research in this field. Stay far away from synthetic ligament substitutes until this is accomplished!


Professor Lars Engebretsen has published over 400 articles and book chapters, with a citation index (H-index) of 56. He is among the world’s most productive researchers. He uses clinical, epidemiological and basic science methods to address questions in the areas of general sports medicine, knee ligaments, cartilage as well as the prevention of sports injuries and illnesses.

He was inducted into the AOSSM Hall of Fame in July 2015 and became an ESSKA Honorary member in 2016 and an ISAKOS Honorary member in June 2017 . He received the Nordic Prize in Medicine in 2016.

What can we learn from Zlatan Ibrahimovic’s knee injury? Focus on PCL implications

26 Apr, 17 | by Karim Khan

The PCL gets much less attention than its anterior partner. What might be going through Zlatan’s mind?

If we start with a player who has suffered an isolated mild to moderate (Grade I-II) PCL injury, we find the player can do well with quality physiotherapy reahabilitation because because surgical reconstruction tends to improve the grade of instability but it does not provide the player with a normal knee.  Acute PCL injuries with bony avulsions are treated surgically. Most isolated Grade III lesions can be treated non-operatively using a specially designed PCL brace that holds the tibia in an anterior reduced position that gives the PCL an opportunity to heal.  Unlike the common intra-articular ACL tear, acute isolated PCL injuries can heal.

Unfortunately, Zlatan appears to have both an ACL and a PCL tear 

In the case at hand, it is NOT an isolated PCL injury. Media reports suggest Ibrahimovic also had an ACL injury (with the possibility of posterolateral corner injury not being mentioned but still present)  A multi-ligament injury has the potential of neuromuscular injury which, when present, has an ominous prognosis. Even without that complication, the prognosis must be very guarded for an elite level football player to return to the demands of high level play with an ACL/ PCL reconstruction.

My goal when seeing similar patients is to ensure they have a stable knee they can walk on and live with. There are anecdotal reports of athletes returning to play after multiple ligament knee reconstruction but when scrutinised, the players are usually the slower lumbering players like football lineman — not players whose success relies on them being quick and agile.

It’s important for the clinicians involved to spend lots of time explaining prognosis to players who suffer serious injury and the rehabilitation team must communicate well and work together.

Professor Mark Hutchinson was a member of the United States Olympic Games sports medicine team at the Rio de Janeiro (2016) and has provided care to the leading teams in the Chicago region for over 20 years. He is a BJSM Senior Associate Editor and you can listen to him on two knee-related podcasts here:

1) Does everyone who ruptures her/his ACL need a knee reconstruction? 

2) Does arthroscopy benefit the patient with knee pain and a proven meniscal tear on MRI?

Oh yeah, almost forgot…

Professor Hutchinson is the star of BJSM’s YouTube page where his pearls on how to examine the knee, shoulder, hip, groin have been viewed over 6 million times. Thanks Hutch!

All roads lead to Rome – Running a marathon on ACL injured knees

9 Aug, 16 | by BJSM

By Catherine Lester

I ran my first marathon in Rome in April, albeit slowly. I had never run further than 10km as of December last year.  My dad asked me if I was sure I should be running – in 2008 I injured my left anterior cruciate ligament (ACL), medial collateral ligament (MCL) and both menisci skiing and in 2012 I ruptured my right ACL.  Both have subsequently been reconstructed and rehabilitated.  My left knee has had a lateral meniscal debridement and a failed medial meniscal repair followed by a meniscectomy.

all roads lead to rome - picture

Me on left in the front with my significantly faster friends before the start of Rome Marathon, April 2016

What are the risks associated with the repetitive load of marathon training in a previously injured knee? Wearing my ‘SEM Clinician’ rather than my ‘athlete’ hat, what do we tell our patients? 

The May BJSM featured the old knee in the young athlete and particularly focused on pivoting sports.(1)  Whilst perhaps not relevant to marathon running, their recommendations were to allow the patient to be the boss of their decisions, to embrace shared decision making in deciding on return to play and to present risk and information that is relevant to the athlete.(1)

Recreational running is on the increase.  Spend a day either spectating or working medical support at the London marathon and you will quickly learn that not all marathon runners are equal.  Running a marathon attracts avid charity fundraisers, people coerced by friendly ‘peer pressure’ and in some instances it has become a sporting event ‘everyone’ would like to do at least once.  Runners come in all shapes and forms and the average age is getting older.(2)  Because of this variable body shape and increasing age it is easy and almost logical to expect to see an increased incidence of osteoarthritis (OA) secondary to the repetitive joint load involved in training and completing a marathon.

If you sustain an ACL injury you will have a greater chance of developing OA down the line.(3)  It is a well-known complication with a prevalence of 10-90% at 10-20 years following an injury.(4)  But what are the risks of OA in a previously injured knee when running a marathon?

A recent systematic review by van Meer et al.(3) looked at both tibiofemoral and patellofemoral OA after ACL injury. Their review concluded the medial meniscal injury/meniscectomy is a positive predictor for tibiofemoral OA and OA of the knee joint where the compartment was unspecified.  The same cannot be said for lateral meniscal injury/surgery where there is conflicting evidence. In addition, there was conflicting evidence on the development of osteoarthritis in an ACL reconstructed knee versus a conservatively managed cruciate ligament.(3)

The knee is the most injured structure during distance running accounting for up to 42%(5) of running injuries.  Traditionally this has been iliotibial band and patellofemoral joint injuries however meniscal injuries are starting to be more common.(2)  Previous injury and running mileage over 40 miles or more per week have been proven to be significant risk factors for developing a running injury,(2) but this mileage does not necessarily cause OA.  It is important to note that other research suggests that 40 years of running 20-40 kilometres weekly does not lead to OA in individuals without previous injury(6). Leech et al. wrote an editorial citing ten papers and concluded that overall there is insufficient evidence that recreational running contributes to the development of OA.(7)

A literature search revealed an article entitled ‘To run or not to run: A post-meniscectomy qualitative risk analysis model for osteoarthritis when considering a return to recreational running’.(8)  The author summarised the predictors for OA into a table and while meniscus surgery and injury were included so were age, female gender, body mass index and pre-existing radiographic or arthroscopic evidence of OA.(8)

They concluded their paper with two phrases which could be adopted into one’s clinical practice that symptomatic OA in a patient following meniscal surgery ‘is a probability and not a certainty’ and ‘runners are a self-selecting group’, in other words generally those who experience significant symptoms choose not to partake in long-distance running.(8)

In summary, the risks of developing osteoarthritis of the knee are complex and often multi-factorial.  I am at risk and am likely going to develop OA, certainly radiographic even if not symptomatic, particularly in my left knee, but did running Rome marathon increase this risk significantly?  I think it is unlikely, as there is insufficient and conflicting evidence to support this.  This experience will further reinforce my current clinical practice; that ‘never’ is very rarely an answer.  As Sport and Exercise Medicine clinicians I feel we need to be educating patients in order for them to make their own risk assessments and I believe that often the gained benefits of taking part in physical activity of any nature outweigh the risks in most scenarios.


Catherine Lester is a speciality registrar in SEM currently based in Cambridge. She works with Bedford Rugby club and the GB and England women’s hockey teams under the CMO.

Farrah Jawad is a SEM registrar in London and co-ordinates the BJSM Trainee Perspective blog.


  1. Ardern CL, Khan KM. The old knee in the young athlete: knowns and unknowns in the return to play conversation. Br J Sports Med. 2016;50(9):505-6.
  2. Fields KB. Running injuries – changing trends and demographics. Curr Sports Med Rep. 2011;10(5):299-303.
  3. van Meer BL, Meuffels DE, van Eijsden WA, Verhaar JA, Bierma-Zeinstra SM, Reijman M. Which determinants predict tibiofemoral and patellofemoral osteoarthritis after anterior cruciate ligament injury? A systematic review. Br J Sports Med. 2015;49(15):975-83.
  4. Lohmander LS, Englund PM, Dahl LL, Roos EM. The long-term consequence of anterior cruciate ligament and meniscus injuries: osteoarthritis. Am J Sports Med. 2007;35(10):1756-69.
  5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95-101.
  6. Konradsen L, Hansen EM, Søndergaard L. Long distance running and osteoarthrosis. Am J Sports Med. 1990;18(4):379-81.
  7. Leech RD, Edwards KL, Batt ME. Does running protect against knee osteoarthritis? Or promote it? Assessing the current evidence. Br J Sports Med. 2015;49(21):1355-6.
  8. Baumgarten B. To run or not to run: a post-meniscectomy qualitative risk analysis model for osteoarthritis when considering a return to recreational running. J Man Manip Ther. 2007;15(1):E1-E15.

Cutting sporting Australians to their knees: time for more investment in sports injury prevention

29 Jun, 16 | by BJSM

By David Hunter, Florance and Cope Professor of Rheumatology

Australia flagAustralians’ passion for their favourite sporting pursuits is almost unmatched by any other country throughout the world. We pride ourselves on our sporting heritage and the records that our minnow sized population has been able to achieve in an ever expanding sporting world. Not detracting from the importance of physical activity, our love for sport is counterposed by the risks inherent in not practising sport safely.

How common is this problem?

Every year approximately 20,000 Australians tear the main ligament in their knee and about half of those require reconstruction. The major burden of these injuries is amongst our young adults (15 to 25-year-olds) and this appears to be rising at about 5 to 6% each year. These injuries appear to be more common in females potentially as a consequence of anatomical and physiological differences. They are so common they now lead to five times more hospital admissions than road injuries.

What are the consequences?

Separate from the pain and diminished sports participation, knee injuries can also lead to reconstructive surgery, osteoarthritis and potentially, joint replacement. Thirty to forty per cent of participants experiencing a major sports-related injury will discontinue playing sport and/or will significantly reduce their physical activity levels. Approximately 60% of young persons who sustain a knee injury will develop osteoarthritis within 10 to 15 years.

This can be prevented

Robust evidence supports that over half of these injuries could be prevented if young people received appropriate balance and agility training. This training teaches them how to land properly on their knee and move so that the potential for injury is not sustained. A preventive training program should include exercises that are done 2-3 times a week over the course of the entire season, take no more than 15 minutes to complete, and can be incorporated by coaches into regular training sessions. Many forward thinking countries around the world have implemented such training programs with great success. An Australian sports injury prevention program targeting all 12 to 17-year-olds and high risk 17 to 25 – year -olds would cost $1 million per year and cut future public health costs by $120 million over four years.

An effective response to sports injury prevention is now needed in order to make sport safe for all participants and reduce the later community burden of osteoarthritis. Sport has many salutary benefits and we strongly encourage increased “safe” participation in sport. The major sporting codes are all on board and we need funding to ensure the Australian sports commission can train coaches and trainers properly in implementing these sports injury prevention programs. Discussions have been had with the respective federal sports/health ministers of successive Labor and conservative governments without success. Will Smith’s recent movie appropriately highlighted concerns related to concussion and the threat of litigation for the NFL. Young sporting Australians deserve the right to practice sport safely-our mutual love for sport supports that wish.


Potential association between the current recommendations for ski binding adjustment and the high prevalence of knee injuries in female skiers?

16 Dec, 15 | by BJSM

By Gerhard Ruedl and Martin Burtscher

Department of Sport Science, University of Innsbruck, Austria

Take home message: Are women’s bindings set 15% too high – and increasing risk of knee injury?

Are you one of the over 200 million recreational skiers practicing this fascinating sport on snow covered ski slopes during the winter months? You might know that the injury risk among recreational skiers halved during the past 20 years.

It’s true that release bindings largely prevented tibia and ankle fractures, at least in adult skiers, knee injuries still represent the major injury type — about 1/3 of all ski injuries [1,2]. Female skiers have twice the knee injury risk and an about  three times the ACL rupture risk compared to males. Importanty, knee injured females still report an about 20 percent points higher failure of binding to release when compared to males [1,3].

man and women skiing

According to the official ski standards (ISO 11088 standard) [4] for binding values, skiers have to differentiate between skiing speed (slow to moderate vs. fast), terrain (gentle to moderate vs. steep) and skiing style (cautious vs. aggressive) to classify themselves into one out of three skiing types without considering any sex-specific differences.[4]

Assume a male and a female skier of equal age, height, and weight and of equal ski shoe sole length, and both classifying themselves as type-3 skier (fast speed, steep terrain, aggressive style). They both would get the same binding setting values without considering any sex factor. However, there are at least two potential sources of error which could represent an explanation for the higher number of failure of binding release among female skiers.

First, a recent study by Brunner et al.[5] found that males, more skilled skiers, and risky skiers perceived their actual speed as fast, moderate and slow when skiing up to 10 km/h  faster compared to females, less skilled and cautious skiers. Therefore, one might suspect that compared to a ‘slow to moderate’ or ‘fast’ male skier the binding setting for a ‘slow to moderate’ or ‘fast’ skiing female is too high resulting in a higher number of failure of binding release as sexes seem not to differ neither with regard to the date of last binding adjustment,[6] nor with regard to not correctly adjusted bindings,[7] nor with regard to self-reported types of falling in the case of an ACL injury.[1,6]

Second, a study by Werner and Willis[8] found that muscle strength is highly correlated with the ability to release the ski binding in a self-release test. Due to the equal weight of the male and female skier in the aforementioned example it has to be considered that the weight-to-strength ratio is negatively influenced by the higher fat mass in females[9] maybe partly explaining the sex difference in the lack of binding release due to less muscular strength among females.

Although the ISO 11088 standard[4] does not consider female sex, it is important to know, especially for female recreational skiers, that according to ISO 11088 standard point B.4 the binding setting may be lowered by 15% upon request of the skier in the following cases:

  1. a) Skiers who have satisfactory experience with lower settings regarding the manufacturer’s recommendations may request settings based on their experience;
  2. b) Skiers who have skiing experience without inadvertent releases may request a setting up to 15% lower than recommended by the manufacturer, approximately achieved by moving one line up in the Table B 1;
  3. c) Skiers having certain characteristics such as neutral skiing technique, defensive attitude, high degree of control, may request a setting up to 15% lower than recommended by the manufacturer, approximately achieved by moving one line up in the Table B 1.

Regarding point B.4 c), the terms “neutral skiing technique” and “defensive attitude” are very subjective and therefore may strongly vary between individuals and sex. When assuming that the terms “neutral skiing technique” and “defensive attitude” are – according to the ISO 11088 determination of skier type[4] – largely synonymous with a cautious (or smooth) skiing style in contrast to an aggressive (or risky) skiing style, our findings of an earlier study[10] that self-reported risk taking behaviour on ski slopes is independently associated with male sex (OR: 1.99) and a higher mean skiing speed (53 vs 45 km/h) are gaining in importance. In other words that means that a cautious behaviour on ski slopes is associated with female sex and a lower mean skiing speed.

In a second study[11] we demonstrated that mean skiing speed (measured with a radar speed gun) of more than 2100 skiers and snowboarders is significantly lower among female compared to male skiers and snowboarders (40 vs. 47 km/h).  In addition, we interviewed a subgroup of about 550 skiers and snowboarders and divided these persons into a faster (59 km/h mean speed) and slower skiing group (36 km/h mean speed).[11] The slower group was independently associated with female sex, higher age, lower skill level, snowboarding (vs. skiing) and cautious behaviour.[11] In a third study we evaluated whether self-reported risk taking behaviour on ski slopes was associated with the personality trait sensation seeking.[12] Again, self-reported cautious behaviour was associated with female sex, higher age, lower skill level, and less mean score of Sensation Seeking.[12]

Taken together, our results clearly highlight that female sex is associated with a more cautious behaviour and a less mean skiing speed on ski slopes indicating that the terms “neutral skiing technique” and “defensive attitude” may especially apply to female skiers.

Therefore, keeping in mind the clearly higher failure of binding to release among female skiers suffering from knee injuries, a 15% lower ski binding setting would likely be appropriate for the majority of female recreational skiers.


  1. Ruedl G, Helle K, Tecklenburg K, et al. Factors associated with self-reported failure of binding release among ACL injured male and female recreational skiers: A catalyst to change ISO binding standards? Br J Sports Medicine (in press)
  2. Burtscher M, Ruedl G. Favourable Changes of the Risk-Benefit Ratio in Alpine Skiing. Int. J. Environ. Res. Public Health 2015; 12 (86): 6092-6097. doi: 10.3390/ijerph12060000x
  3. Greenwald RM, Toelcke T. Gender differences in alpine skiing injuries: a profile of the knee-injured skier. In: Johnson RJ, Mote CD, Ekeland E, eds. Skiing Trauma and Safety, 11th J. ASTM Intl. 1997, Balitmore:111-21.
  4. International Organization for Standardization. Assembly, adjustment and inspection of an alpine ski/binding/boot (S-B-B) system ISO 11088, Geneva, Switzerland, 2013
  5. Brunner F, Ruedl G, Kopp M, et al. Factors associated with the perception of speeds among recreational skiers. PloS One. 2015 Jun 29; 10(6):e0132002. doi: 10.1371/journal.pone.0132002. eCollection 2015.
  6. Ruedl G, Webhofer M, Linortner I, et al. ACL injury mechanisms and related factors in male and female carving skiers: a retrospective study. Int J Sports Med. 2011;32: 801-6.
  7.  Ruedl G, Pocecco E, Sommersacher R, et al. Differences between actual and recommended binding z-values. In: Müller E, Lindinger S, Stöggl T, Pfusterschmied S, eds. 5th ICSS-Congress, 14.-19. Dec. 2010, St. Christoph, Austria. Book of abstracts: 141.
  8. Werner S, Willis K. Self-release of ski-binding. Int J Sports Med. 2002;23:530-35.
  9. Sinning WE. Body composition and athletic performance. In: Clarke DH, Eckert HM, eds. Limits of human performance. The academy papers. Champaign, 1985: 45-56.
  10. Ruedl G, Pocecco E, Sommersacher R, et al. Factors associated with self reported risk taking behaviour on ski slopes. British Journal of Sports Medicine 2010, 44 (3): 204-206. 11.   Ruedl G, Sommersacher R, Woldrich T, et al. [Mean speed of winter sport participants depending on various factors]. Sportverletz Sportschaden. 2010;24:150-53.
  11. Ruedl G, Abart M, Ledochowski L, et al. Self-reported risk taking and risk compensation in skiers and snowboarders are associated with sensation seeking. Accid Anal Prev. 2012;48:292-96.


Gerhard Ruedl  is a Senior Assistant Professor, Department of Sport Science, University of Innsbruck, Austria. His research interests include: risk factors (e.g. risk-taking behavior) leading to injuries and use of protective equipment (e.g. helmets) among alpine skiers and development of motor performance and weight status among school children

Martin Burtscher is a Full Professor at the Department of Sport Science, University of Innsbruck, Austria. His research interests include: exercise physiology with emphasis on mountain sports activities; physiological and pathophysiological effects of altitude and hypoxia; epidemiology and prevention of accidents and emergencies in skiing and mountaineering; life-style interventions in health and disease mainly focusing on exercise, environmental and nutritional aspects.

Assessing when it’s the right time to have a knee replacement

1 Dec, 15 | by BJSM

By John Orchard (@DrJohnOrchard)


The Scandinavians have done it again – leading the world of orthopaedic outcome research with the first high-quality RCT to assess Total Knee Replacement (TKR) [1]. Danish investigators randomised 100 eligible patients (average age 67, BMI 32) to either TKR (n=50) or conservative care (n=50). Fortunately for knee surgeons – who have copped an absolute pounding from Evidence-Based Medicine in recent years regarding use of knee arthroscopy in knee osteoarthritis [2]– the headline read “TKR effective at significantly decreasing pain and increasing function”. Also, 26% of those randomised to non-surgical treatment crossed over to TKR during the 12 month follow-up period. The non-surgical group also improved over the 12 months, and the authors couldn’t rule out an additional surgical placebo effect contributing to the improvement over and above the trial effect for the non-surgical patients.

The sting in the tail for the surgical results was that the TKR group had a much higher rate of related (which was expected) and also general medical (less expected) complications over the 12 month follow-up period. Serious complications thought to be related to the surgery or knee OA occurred in 16% in the surgical group versus 2% in the non-surgical group. However, total serious adverse medical events in general in the populations were 48% versus 12% over the 12 month period. That is, having a TKR seriously challenges the patient’s general health in this older, generally overweight population. Not so much as, having a femoral neck fracture (e.g. there were no deaths in the TKR RCT, whereas femoral neck fractures among 80-year old women have an 8% first year mortality rate) but enough to warrant warning patients about this increased risk prior to their undergoing TKR.

This makes the decision as to whether to undergo TKR a very difficult one (and hence one that should be probably made by the informed patient rather than the surgeon): do the more likely improvements in pain and function of a TKR outweigh the significantly increased risk of a serious adverse event if I decide on surgery?

In helping to advise a patient on this difficult decision, here are factors to take into account:


(1) Current fitness level. Pain is subjective but fitness and activity levels are objective. No one likes pain but if the pain is bearable you can safely live with some. Low activity levels are very hazardous to long term health – we now know it is dangerous to be immobile/sedentary.

Thus, if knee pain is preventing a patient from being able to undertake adequate regular exercise, then the benefit of TKR is substantially increased, as the procedure offers the potential to exit this high risk group. We can quantify adequate physical activity easily with respect to walking – about 6000 or 7000 steps a day is adequate – and if the knee allows this level of activity the imperative for TKR should be a lot less. Steps per day can easily be measured using a fitness tracker or smartphones (Figure 1).

john orchard knee figure 1

Figure 1 – 6000 or 7000 steps per day is adequate physical activity and knees which allow this level of activity probably don’t warrant the risks associated with Total Knee Replacement. However knees which can’t withstand this sort of load may warrant TKR.

(2) Background medical risk. Given the main argument against TKR is the risk of major medical complication, a person with higher than normal baseline medical risk should be more cautioned against surgery. Pre-existing cardiac or renal disease, history of DVT requiring anti-coagulation, being a smoker, and diabetes are all relative contra-indications, as they increase the risk of catastrophic medical complication. If none of these risk factors are present, a patient may be in a lower risk group and can be more confident of avoiding serious complication.

(3) Recent cortisone injection into the knee [3] and previous knee arthroscopy [4, 5] (which both are erroneously still used routinely) lead to increased risk of complication in TKR. A patient who has had these interventions, especially recently, is in a higher risk group of a bad result with TKR and can be relatively advised to hold off.

(4) Whether conservative care has “failed” or simply has not been attempted. Unfortunately the success rate of conservative treatment of knee OA is not particularly encouraging, but success rates of certain treatments are not zero. Exercise programs (moderate loading) are recommended based on evidence, as is weight loss. Physiotherapy may help, particularly in cases where significant pain is arising from the patellofemoral joint (clue to this may be severe pain on steps or lunge movements). There is some evidence that hyaluronan gel injections or platelet rich plasma (PRP) injections can help in knee OA, and, in contrast to knee arthroscopy or cortisone injections, current evidence suggests that these can be attempted without penalty. That is, they provide a slightly better response than placebo injection, without major risk of significant harm.


(1) X-ray or MRI severity of disease. The X-ray (MRI should generally not be used for a knee with OA) findings should establish the diagnosis of knee osteoarthritis, but there are some cases of mild-moderate OA on X-ray which have severe symptoms and other cases where severe changes on an X-ray are associated with mild symptoms only. “Treat the patient not the X-ray” applies here. Similarly it is speculative and probably an error for an expert to look at a knee X-ray and say “this knee has 5 years left in it – that’s when you’ll need to come back for a knee replacement”. Since function and X-ray severity correlate quite poorly, using X-ray to predict clinical deterioration is unwise. Walking tolerance is much more relevant to the TKR decision than X-ray severity.

(2) The patient’s age. There has been a tendency for some surgeons to proclaim “60-65 is the best age group to get a knee replacement, as patients are young enough to do well and old enough to potentially survive the rest of their life without needing a revision”. There is some truth in this logic, but it shouldn’t be used to encourage a patient of 60-65 years to undertake TKR when it is not really needed, as there is no automatic guarantee of deterioration. Similarly if a patient in 50s or even 40s is horribly debilitated by knee pain and unable to walk more than a few thousand steps per day, it could still be the correct decision to proceed with an uncemented TKR earlier in life on the understanding that a revision procedure will likely be needed.


John Orchard is an Australian sports physician. He has no conflicts to declare other than treating knee osteoarthritis patients in clinic, occasionally with injection therapies. His views are personal and not necessarily representative of organisations he is affiliated with. You can read more at and/or follow @DrJohnOrchard on Twitter He is a Felllow of the Australasian College of Sports Physicians (ACSP) and the ACSP is one of BJSM’s 23 member societies.


  1. Skou ST, Roos EM, Laursen MB et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med 2015; 373:1597-1606
  2. Thorlund J, Juhl C, Roos E, et al. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015;350:h2747.
  3. Cancienne JM, Werner BC, Luetkemeyer LM, et al. Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty? J Arthroplasty. 2015 Nov;30(11):1879-82.
  4. Brophy RH, Gray BL, Nunley RM, Barrack RL, Clohisy JC: Total knee arthroplasty after previous knee surgery: expected interval and the effect on patient age. J Bone Joint Surg Am 2014;96:801-5
  5. Piedade S, Pinaroli A, Servien E, et al. TKA outcomes after prior bone and soft tissue knee surgery. Knee Surg Sports Traumatol Arthrosc 2013;21:2737–43.


Return to Sport After Total Knee Replacements?

5 Dec, 14 | by BJSM

By Alexander Wood

knee run

The number of total knee replacements (TKR) performed annually has doubled over the last decade1. TKR is common in the young population2 and an increasing number of elderly patients are playing sport and sustaining sports related injuries3. Considering the above factors combined with improvements in life expectancy and in overall general health4, more patients will likely require or demand a knee replacement, and question the likelihood of returning to sport.

Return to sport post TKR

Whilst a total knee replacement does not preclude a return to sport, research suggests that patients can return to light sporting activities like walking, swimming, golf, yoga and cycling5. Despite this, research also suggests that far less people who regularly participate in sports prior to surgery, participate in sports after surgery4,6,7, and that only around one in twenty patients will return to sports after surgery6. Five years after a TKR, one in twenty patients reported participating in more than 2 hours of sport, compared to almost one in ten prior to surgery4. Notably, this effect may be associated with other age related impairments8.Whilst it may be possible to return to sport after a TKR, it should not be a primary reason for individuals to undergo a TKR; the evidence suggests that sports participation decreases rather than increases.

Will I be able to run or ski post TKR?

Running or skiing post TKR is not advised8 although this is currently debatable.  However, only 1-2% of patients participate in these activities post TKR4.  The advice from the American Academy of Orthopaedic Surgeons10 is to avoid activities like jogging, racquetball and skiing and the NHS strongly advises against running and jumping11.

Should I participate in any sport after a TKR?

Whilst any sport may increase the wear on implants, the benefits of aerobic activity outweigh these possibilities and therefore health practitioners should encourage patients to participate in aerobic activity post TKR12.


Elderly patients are increasingly participating in sport and consequently the number of  knee replacements are on the rise.  Whilst the polyethylene used in total knee replacements and their survivorship has improved, current advice for patients is that activity level is not likely to increase after a TKR. Lastly, encourage patients to perform aerobic exercise post TKR surgery, but avoid high impact sports.


  1. Weinstein AM, Rome BN, Reichmann WM, Collins JE, Burbine SA, Thornhill TS, Wright J, Katz JN Losina E. Estimating the burden of total knee Replacement in the United States. JBJS AM 2013 6;95(5):385-92
  2. Wood AM, Keenan A, Arthur C, Aitken S, Walmsley P, Brenkel I, “The Functional Outcome of Total Knee Replacement in Young Patients: A 10-Year Matched Case Control Study,” Open Journal of Orthopedics, Vol. 3 No. 2, 2013, pp. 128-132. doi: 4236/ojo.2013.32024.
  3. Court-Brown CM, Wood AM, Aitken SA. The epidemiology of acute sports-related fractures in adults. Injury 2008; 39(12):1365-72
  4. Huch K, Muller KAC, Sturmer T, Brenner H, Puhl W, Gunther KP. Sports activities 5 years after total knee or hip arthroplasty: the ulm osteoarthritis study. Ann Rhem Dis 2005;64:1715-1720
  5. Accessed 14 August 2014)
  6. Bradbury N, Borton D, Spoo G, Cross MJ. Participation in Sports After Total Knee Replacement. AJSM 1998:26(4);530-535
  7. Hopper GP, Leach WJ. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee Surgery, Sports Traumatology, Arthroscopy. 2008;16(10):973-979
  8. Zahiri CA, Schmalzried TP, Szudzczewicz ES, Amstutz HC. Assessing activity in joint replacement patients. J Arthroplasty 1998;13:890-5
  9. Kuster MS, Spalinger E, Blanksby BA, Gachter A. Endurance sports after total knee replacement; a biochemical investigation. Med Sci Sports Exerc 2000;32:721-4
  10. (Last Accessed 14 August 2014)
  11. (Last Accessed 14 August 2014)
  12. McGrory BJ, Stuart MJ, Sim FH. Participation in Sports after Hip and Knee Arthroplasty: Review of Literature and Survey of Surgeon Preferences. Mayo Clin Proc 1995;70:342-348


Alexander Wood BSc MB ChB, MSc (SEM) FRCSEd (T&O)

ST8 Trauma and Orthopaedics, Royal Victoria Hospital Newcastle UK


Not just about the knee! Return to Play Conference “The ACL”, Melbourne July 26, 2014

18 Jul, 14 | by BJSM



The return to sport following an ACL reconstruction is often discussed in the media in terms of timelines, often with little regard to the athlete or an understanding of the process not being all about the knee. The ability to withstand multi joint, multi directional movement is vital at high load in a linear then multi planar movements. This requires the integrated care of surgeon, physiotherapists and physical trainers alongside strength and conditioning staff.

Programs around the world are addressing ACL injury risk using 3D motion capture technology to quantify these movements accurately and with joint moment and angular vector, The Sports Surgery Clinic, Dublin are utilising this technology to map individualised rehabilitation programs to expediate return safely with increased performance goals. As part of this initiative the clinic are launching a Global Research Foundation later in 2014. The aims of the foundation are to conduct original research with Global Centres focussing initially on 3D Biomechanics return to Play rehabiliation and the  rapid translation of original research, and as part of the goals education is a strong one.

To highlight the process of return to play rather than the injury itself the Foundation are holding a Conference in conjunction with The Centre for Health Exercise and Sports Medicine in University of Melbourne bringing together expertise in injury prevention, the psychology of injury and also the techniques of surgery but a focus on the strength, rate of force development, linear and multidirectional running resilience required to safely return to play. The Conference will be discussing much of the evidence behind 3D Biomechanics and also  concurrent injury with Professor Julian Feller from Melbourne and Bert Mandelbaum from the US from a surgical perspective. Dr Kate Webster will speak on the Psychological challenges and impact of rehabilitation and Dr Andrew Jowett will speak on the financial and emotional costs to clubs.

Prof Martin Schwellnus from Cape Town will talk on the Risk factors including genetics for ACL injury and Dr Eanna Falvey on ACL injury Prevention and Dr Andy Franklyn-Miller on the 3D Biomechanics of multi directional sport performance. Rehabilitation and linear and multi directional return will be discussed by Enda King from SSC, and Suki Hobson and Mike Snelling from Australia.

The player perspective is most important and  will be represented by the high profile Geelong player Daniel Menzel who has had 4 ACL reconstructions including a LARS reconstruction and will be interviewed by Dr Peter Brukner on his challenges, thoughts and rehab experiences. It is not just about the knee.

Few places remain – join us in Melbourne

The Dublin SSC team will also be delivering a 1/2 day workshop for those working with Elite athletes on the 3D Athletic Groin Pain  Rehabilitation program via Olympic Park Sports Medicine Centre on Sunday 27th July.

Time to stop meniscectomies for degenerative tears: Practice must catch up with evidence

15 Jun, 14 | by BJSM

By Kay M Crossley (@KayMCrossley) , Joanne L Kemp (@JoanneLKemp), Charles Ratzlaff, and Ewa M Roos (@Ewa_Roos)


In 2002, a randomised controlled trial (RCT) in the New England Journal of Medicine [1] made us all sit up and take note. The trial was remarkable because participants were randomised to arthroscopic debridement (including chondroplasty, removal of debris and partial meniscectomy), arthroscopic lavage (sham surgery), or placebo surgery (skin incisions only).

Arthroscopic surgery is no better than sham

The intervention (arthroscopic treatment) group never reported less pain or better function than the placebo group at any follow-up time point. This contradicted contemporary practice, where arthroscopic debridement was commonplace for knee osteoarthritis, including in younger patients and in sports medicine settings. The sports medicine and orthopaedic community continued to promote knee arthroscopy, moving the focus from knee osteoarthritis to arthroscopic partial meniscectomy. Since degenerative meniscal tears are part of the knee osteoarthritis disease process [2], this re-branding (‘menisectomy’ instead of ‘debridement’) allowed surgeons to continue performing essentially the same operation, but under a different guise.

In the past 12 years, five more RCTs have evaluated knee arthroscopy; one examined debridement [3] and four specifically focussed on meniscectomy [4-7]. Of these, Sihvonen and colleagues [6] reported no benefits of partial meniscectomy over sham arthroscopy. Importantly, this study was done in those who we would have thought were most likely to benefit (ie. patients with a degenerative tear, but no radiographic osteoarthritis).

Thus, despite the difficulties inherent in conducting RCTs of surgical treatments, six high quality RCTs failed to provide any evidence that arthroscopic meniscectomy provides additional improvements in pain relief or physical function over placebo/sham surgery[1-6]or non-surgical treatments, such as physiotherapy [3,5,7]. These findings are consistent, regardless of whether concomitant debridement was performed or not.

This high quality evidence trumps the positive results from uncontrolled case series studies and dictates that meniscectomy is an ineffective treatment for symptomatic degenerative meniscal tears. In addition, while degenerative meniscal tears increase the risk for incident radiographic osteoarthritis [8], long-term follow-up studies following meniscectomy provide an equally bleak picture: people undergoing meniscectomy have an approximate ten-fold increase in osteoarthritis at 10-20 years compared to controls [9-10].

Arthroscopy for degenerative meniscal tears no longer supported

The increasing evidence against meniscectomy is reflected in the recent guidelines. The UK’s NICE guidelines [11] state: “Do not refer for arthroscopic lavage and debridement as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, ‘giving way’ or X-ray evidence of loose bodies)”. However, the assimilation of meniscal tears within the osteoarthritis process makes the differential assessment of “clear history of mechanical locking” challenging [12] and subgroup analyses from aforementioned RCTs suggest no difference in treatment effect in those with mechanical problems. Even the leading body for surgeons, the American Academy of Orthopaedic Surgeons [13] state: “We are unable to recommend for or against arthroscopic partial meniscectomy in patients with osteoarthritis of the knee with a torn meniscus.”

Dr. Hutchinson's knee exam tutorial: available

Dr. Hutchinson’s knee exam tutorial: available on BJSM YouTube channel:

So why are patients still subjected to this procedure?

Millions of people worldwide undergo meniscectomy for degenerative meniscal tears, despite no additional benefit to that from sham surgery, placebo surgery or nonsurgical treatments. Patients are subjected to unnecessary and substantial costs and risks. While fewer arthroscopies were performed for patients with knee osteoarthritis over the past decade [14-15], rising rates of meniscectomy are reported over the same period [14-16]. Notably, there was a 2-fold increase for patients aged 35-55, and a 2.7-fold increase for those older than 55 years [16].

Approximately half a million arthroscopic knee meniscal procedures are performed annually in the US alone [14-17]. This may reflect that arthroscopic meniscectomy is funded through Medicare in the United States, whereas debridement with or without meniscectomy for knee osteoarthritis is not. It may simply reflect that contemporary practice is not keeping pace with the evidence. Or it may reflect the opinions of a recent editorial in Arthroscopy, which states that “patients who may not be of entirely sound mind are selected as research subjects (in placebo controlled surgical studies), and research performed on such individuals would not be generalizable to mentally healthy patients”[18]. The authors also argue that it is unethical to perform sham surgery (ie a surgery without a therapeutic intervention). However, arthroscopy (ie. meniscectomy [6] or debridement [1]) provides no benefit and, hence is not therapeutic. Their own reasoning suggests that both arthroscopic debridement and meniscectomy are unethical.

Sports medicine clinicians (physicians, surgeons, physiotherapists and other allied health professionals) have an important role to bring clinical practice into line with the evidence. Recent high-quality RCTs [1-3, 5-7,19], clinical guidelines [11-13] and editorials [20-21] inform us that meniscectomy for degenerative meniscal tears is no more beneficial than placebo/sham or physical therapy approaches. And armed with this information, we must make informed, evidence-based decisions regarding optimal patient care and challenge the continued practice of meniscectomy.


1. Moseley JB, O’Malley K, Petersen NJ, et al. A Controlled Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. New England Journal of Medicine 2002;347(2):81-88 doi: doi:10.1056/NEJMoa013259[published Online First: Epub Date]|.

2. Englund M, Roemer FW, Hayashi D, et al. Meniscus pathology, osteoarthritis and the treatment controversy. Nature Reviews Rheumatology 2012;8(7):412-19

3. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. The New England journal of medicine 2008;359(11):1097-107 doi: 10.1056/NEJMoa0708333[published Online First: Epub Date]|.

4. Herrlin S, Hallander M, Wange P, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 2007;15(4):393-401 doi: 10.1007/s00167-006-0243-2[published Online First: Epub Date]|.

5. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. New England Journal of Medicine 2013;368(18):1675-84 doi: doi:10.1056/NEJMoa1301408[published Online First: Epub Date]|.

6. Sihvonen R, Paavola M, Malmivaara A, et al. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. New England Journal of Medicine 2013;369(26):2515-24

7. Yim JH, Seon JK, Song EK, et al. A comparative study of meniscectomy and nonoperative treatment for degenerative horizontal tears of the medial meniscus. American Journal of Sports Medicine 2013;41(7):1565-70

8. Englund M, Guermazi A, Roemer FW, et al. Meniscal tear in knees without surgery and the development of radiographic osteoarthritis among middle-aged and elderly persons: The multicenter osteoarthritis study. Arthritis and Rheumatism 2009;60(3):831-39

9. Roos H, Laurén M, Adalberth T, et al. Knee osteoarthritis after meniscectomy: Prevalence of radiographic changes after twenty-one years, compared with matched controls. Arthritis & Rheumatism 1998;41(4):687-93 doi: 10.1002/1529-0131(199804)41:4<687::aid-art16>;2-2[published Online First: Epub Date]|.

10. Englund M, Lohmander LS. Risk factors for symptomatic knee osteoarthritis fifteen to twenty-two years after meniscectomy. Arthritis & Rheumatism 2004;50(9):2811-19 doi: 10.1002/art.20489[published Online First: Epub Date]|.

11. National Institute for Health and Care Excellence (NICE). Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis. In: NHS, ed. UK, 2007.

12. Englund M, Roemer FW, Hayashi D, et al. Meniscus pathology, osteoarthritis and the treatment controversy. . Nat Rev Rheumatol 2012;8(7):412-9

13. American Academy of Orthopaedic Surgeons. Treatment of Osteoarthritis of the Knee – Evidence based guidelines 2nd Ed., 2013.

14. Kim S, Bosque J, Meehan JP, et al. Increase in outpatient knee arthroscopy in the United States: a comparison of National Surveys of Ambulatory Surgery, 1996 and 2006. . J Bone Joint Surg Am 2011;93(11):994-1000

15. Potts A, Harrast JJ, Harner CD, et al. Practice patterns for arthroscopy of osteoarthritis of the knee in the United States. Am J Sports Med 2012;40(6):1247-51 doi: 10.1177/0363546512443946[published Online First: Epub Date]|.

16. Thorlund JB, Hare1 KB, Lohmander LS. Large increase in arthroscopic meniscus surgery in the middle-aged and older population in Denmark from 2000 to 2011. Acta Orthop 2014;May 6. [Epub ahead of print]

17. Cullen K, Hall M, Golosinskiya A. Ambulatory surgery in the United States, 2006. National health statistics reports. In: Statistics NCfH, ed., 2009.

18. Lubowitz JH, Provencher MT, Rossi MJ. Could the New England Journal of Medicine Be Biased Against Arthroscopic Knee Surgery? Part 2. Arthroscopy 2014;30(6):654-55

19. Herrlin S, Hallander M, Wange P, et al. Arthroscopic or conservative treatment of degenerative medial meniscal tears: a prospective randomised trial. . Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2007;15(4):393-401

20. Buchbinder R. Meniscectomy in Patients with Knee Osteoarthritis and a Meniscal Tear? New England Journal of Medicine 2013;368(18):1740-41

21. Jarvinen T, Sihoven R, Englund M. Arthroscopy for degenerative knee- a difficult habit to break? Acta Orthopaedica 2014;85(3):215-17


Kay M Crossley: School of Health and Rehabilitation Science, University of Queensland, 4072, AUSTRALIA, @kaymcrossley

Joanne L Kemp: Australian Centre for Research into Injury in Sport and its Prevention (ACRISP), Federation University Australia, Ballarat 3353 AUSTRALIA,

Charles Ratzlaff: Bone Radiology, Rheumatology, Brigham and Women’s Hospital / Harvard Medical School, Boston, Massachusetts, USA,

Ewa M Roos: Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, DENMARK


Paul McGinley – an interview on 21 years in pro golf, and lessons learned from knee injury recovery

8 Nov, 13 | by Karim Khan

This interview was published in the Aspetar Sports Medicine Journal and is reproduced with the kind permission of Aspetar – Qatar Orthopaedic and Sports Medicine Hospital.

If you want the excellent Aspetar Sports Medicine Journal sent to you just email your address to:

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Paul McGinley

Aspetar Cover Issue 6

–       Interview by Velvet Garvey

Paul McGinley’s entrance into the world of professional golf was unconventional. While he showed early potential, it was for a different sport – Gaelic football. But as a rising star, a knee injury excluded him from the sport he loved. With a need to channel his passion and athletic talent he turned to golf and quickly rose up the ranks from amateur to pro.

But the ethos of football never left him, and throughout his career he has excelled in the team events and earned a reputation as a good sportsman and great leader. Thanks to this reputation he has recently been awarded one of golf’s highest honours: the captaincy of the European Ryder Cup team. Known as a quiet achiever, here he talks about his constant injury, the changing game and the one thing on tour he can’t live without.

Firstly, congratulations on your recent captaincy.

Thank you. I am thrilled. Absolutely thrilled!

You started golf with an injury which is quite rare in an athlete. Tell us about your time playing Gaelic football and the injury you suffered?

Gaelic football was what I started with. If you had asked me as a young boy, would I have been a professional golfer by the time I was 18 years old, I would have said absolutely no way. There’s more chance of me going to the moon than being a professional golfer. I wasn’t bad at golf – about an 8 handicap – but I was really good at Gaelic football. I was going to play in the very top level but then I broke my knee cap and I did a lot of damage around it. I have had 8 operations on it since. Well, 6 on one knee, 2 on the other.

That injury and being told that I could no longer play football meant that I had to redirect my desire and my competitiveness in a completely different direction. It was going to be all Gaelic football and all of a sudden all that energy that I was putting into football got driven into golf. I started to play golf 12 months of the year and got down to scratch handicap quite quickly.

It also meant that I could study. With a degree in Marketing already, I studied International Business at a college in America where I could study and play. At the time I didn’t know if I was going to be good enough to turn pro but I knew that after 2 years in America I would either go into business or be good enough to play golf. I needed that time to prove to myself that I was good enough as a golfer and I did. I dominated the amateur scene in Ireland and had a good college career in America and that’s why I turned pro.

Has that injury affected you throughout your golf career?

Yes, no doubt.

Do you have a regimen that you follow for your knee injury?

For me, it’s about maintenance now. I do a lot of swimming and have cut back on my gym work. Over the years I have done a lot of work building up the muscle around my knee and getting it strong. But the bottom line is, the debris still breaks off the patella every now and again and floats around, so every 2 years I have to go in for an arthroscopic procedure and have it cleaned out and tidied up. So there is no cartilage left, it’s just bone on bone. Right now, as I’m sitting, I can feel it. On the golf course it’s fine. It’s not pain that is the problem, it is the anticipation of pain that makes me get in bad positions with my swing and basically back off it. It is my left knee. So it’s the same as Tiger’s (Woods), same as Ernie’s (Els). If you’re a golfer and you’re going to have a knee injury, the right is the one to have it on, not the left because all the impact goes through the left.

You must have a really good relationship with your surgeon if you have to go back every 2 years!

Yeah! There are two surgeons that I have used: one in Ireland and one in England. One of them especially, I know very well. I’m at the stage where they can help me in an emergency, like last year I had to pull out of a tournament because my knee was inflamed, which it does now and again when the fluid builds up. Usually I have to get that fluid drained off but last year I had a cortisone injection just to calm it down a bit. If there is any problem at all I get onto my surgeon and he sees me straight away, even if it is 7 am before his clinic opens. He will get me in, do an MRI, check it all out and see where we are at and give me advice on what to do.

Would you say that has affected your attitude towards preventing injuries?

Yes. Although I worked with a trainer, I think a lot of the damage I did over the years was when I was doing stuff of my own. It was when I wasn’t paying enough attention to form or to technique in terms of lifting weights and that kind of stuff. It was more about getting in, getting the reps done and getting out. One of the lessons I learned is that I should have paid real attention to getting the technique 100% correct. Some of my injuries were caused by poor technique and going through the routine, rather than being really specific about getting the technique perfect.

You have been playing for 21 years. How has the game changed from a physical point of view?

Massively. The physical change and the physical specimens of the guys on tour nowadays are completely different. Body shapes are so different. Guys are so much younger, so much more athletic and so much more powerful. The guys spend so much more time in the gym. When I came on tour 5% of players, maybe less, worked in the gym. Now, I would say 97% of players work in the gym.

What do you think it takes for those young guys to become number 1?

Well there is no doubt about it: a power game is essential. The game is so much easier if you’re powerful nowadays and a lot of the modern technology is very much allied with fast club head speed. So, the better you swing the club and the faster you swing the club, you get more out of modern technology. Having said that, the shorter hitters can still compete and some shorter hitters do, but you need to have a very strong short game and strong mind if you’re going to compete when you’re a shorter hitter, whereas it is a distinct advantage if you can hit the ball a long way in the modern game.

Charlie Beljan drew some attention to his nutrition this year and said that he is going to start focussing on eating well. What is your attitude to nutrition?

My grandmother used to say to me, “a little bit of everything won’t do you any harm”. So, if I fancy an ice cream, I have an ice cream. If I fancy a bar of chocolate I have a bar of chocolate, but I won’t overdo it. From my own experience (this isn’t everybody’s opinion) but for me, if I punish myself by never having any chocolate and I eat and go to the gym and do everything 100% and my whole life revolves around my golf, then I become a poorer player because I don’t have the ‘feel good’ factor.

I don’t have any hard or fast rules, except when it comes to breakfast. I have porridge every single morning. I travel with it on tour. If I’m going to somewhere like China, where I know they don’t have porridge, I bring my own sachets. Also, my cousin makes great oatmeal cookies so I take them with me to snack on. They are pure oatmeal with some raisins in them, no sugar or anything. I had them this morning for breakfast. They’re great because they’re easy and I have to base my eating times around my tee time.

Do you have anyone who gives you nutritional advice?

Yeah, I have sought advice in the past and used nutritionists so I am aware now what is best for me. The only problem is that if you listen to a nutritionist, their advice is so strict so I take a little bit from it but also focus on just feeling good.

As a golfer you shine in the team events. Do you think that Gaelic football had something to do with that?

No doubt. The team ethos of Gaelic football was instilled in me from when I started playing at about 4 years old. Gaelic football is an Irish game played only in Ireland, except for Irish expats who play it abroad. It is deeply ingrained into the Irish culture and it’s all about the team – the closeness of the players and the bonds that they form is what makes a great team.

Do you think there is an argument for athletes specialising in more than one sport?

Definitely. I have a 12-year-old son who is very good at golf and cricket and rugby and soccer. I want him to play every kind of sport. I don’t want him to specialise. If he gets to 15 or 16 and he starts getting serious about becoming competitive, maybe then he can specialise.

Growing up in Dublin, I played a wide variation of sports like golf, Gaelic hurling, soccer, running and swimming. All of those sports were very important in my development. Also, I think it’s kind of sad if a kid specialises in one sport from an age of 10 or 11 to the exclusion of every other. I don’t think that’s the right thing to do and I never encourage it when people ask me for advice about if kids show a good skill level in golf. I always say to just keep playing other sports, keep forming bonds with other people and be competitive in different arenas. Because the competitiveness you learn in different arenas can still be brought to your golf game. Golf is not just about hitting the golf ball around – it’s the ability to compete and you can learn that by playing other sports too.

You famously conceded a putt to J.J. Henry at the Ryder Cup in 2006. How important is good sportsmanship to you?

Of course it’s important. I feel that I live my life being a very fair and open person and I like to think that I play sport in the same way. The putt that I conceded in the Ryder cup was for no other reason than a fan ran onto the green and obstructed the other golfer’s line as he was trying to line up the putt. The match was all over and I was done, but more importantly, Henry wasn’t getting a fair chance to hole his putt because this guy was grabbing all of the attention and damaging his line. That’s why I conceded it. I wasn’t very popular because a lot of people had me backed to win and I only had a half game instead of a win! A lot of people have mentioned that to me since but I don’t regret it. It was the right thing to do under those circumstances.

When you are on tour do you travel with a medical team?

No, I use the physios on tour. They’re very good and they know my knee as well as anybody by this stage. We also have a doctor that travels with the tour and he is very familiar with my injuries as well. The main thing now is avoiding making it worse. I’m never going to make it any better; it is never going to be 100%. So I need to maintain it through proper physio, making sure that the muscles around it remain strong, and doing low impact stuff like swimming. I do very little gym work now, so stretching and swimming are the two things that maintain me.

Do you have a coach who travels with you?

My coach is Bob Torrance but he doesn’t travel with me because he is in his 80s now. He has coached me all my career and he will be my coach until one of us goes to the ‘fairways’ in the sky!

I have a great relationship with him. He’s a very strong character. I really admire him and love being in his company. We have a personal relationship. There are a number of people I seek advice from and get their opinions too, but ultimately Bob is my coach and he will always be so.

How do you train for the mental side of the game?

I don’t think you train for it. I think you have that instinct in you from a young age. I think what you need to do is remain fresh. You want to prepare your mental game so that when you get on the golf course, you feel like a greyhound. You want that ‘freshness’ as a golfer.

What does it take to be a good golfer?

A wide variety of things. You have to be physically fit, mentally fit and mentally tough. You’ve got to have a good technical golf game and you have got to be well-managed and have good council around you from friends and family. It is the whole package – it’s not just one or two things. As great as we think we are, we are not good enough to do it on our own. We need good people around us.

Editor’s note: Just a reminder that you can see examples of past Aspetar Sports Medicine Journals by clicking here.

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