It was 1998, just another year for most people. But for me it was the year that ignited my desire to play football with Kildare. The Lilywhites had reached the All Ireland football Final, something that had not been seen since 1935 and has not been replicated since, and my Dad and I had been with them every step of the way; from the first victory over the Dubs in Leinster until the final whistle of agonising defeat against Galway in the All Ireland Final. My appetite to wear the white jersey had been sufficiently whetted and I would spend the remainder of my youth sacrificing post Leaving Certificate holidays and numerous other typical teenage mischief trying to fulfill that ambition.
Each game and encounter would intrigue me more, but what also grabbed my attention was the domineering figure of the man in white wearing number 6 on his back. Not only was his dominance from that position plain for even a budding 16 year old footballer like me to see but so too was the cumbersome looking black brace he wore around his left knee. Although oblivious to it at the time this inquisitiveness was not only the beginning of my love/hate relationship with Gaelic football but also my love/hate relationship with all things injury related.
“We do not stop playing because we grow old.
We grow old because we stop playing”.
Benjamin Franklin 1706-1790
So just what was the deal with this brace around Glen Ryans left knee and what effect was it having? I’m not entirely sure exactly what injury he was carrying at the time, more than likely a meniscal or cartilage injury, but he played throughout that campaign winning an All Star for his contributions. How much of the credit can be given to his trusted knee brace and what were the consequences of continuing to play with such an injury? If you are a first time reader of these blogs, before reading any further you should note the following: I am cynical, skeptical and question most things sport and physiotherapy related. If something works I want to know how and why, ideally with some research to back it up. So things I talk about are not just made up. They are my opinion, but based on sound scientific evidence. But equally if it makes you question me then good, I’ve got you thinking too.
Back to knees. A previous knee injury does predispose that individual to future knee injury and risk of osteoarthritis (OA). If you’ve undergone a cartilage tear or anterior cruciate ligament injury then you’ve got an increased risk for future knee OA. OA is a mixed group of conditions that lead to signs and symptoms in a joint which are associated with defective integrity of the articular cartilage. Such symptoms include pain, stiffness, swelling, instability and muscle weakness all of which can become quite disabling if allowed to develop. In Ireland almost 1 million people are living with arthritis. But what is the criteria that classifies someone as having arthritis as opposed to some ‘wear and tear’ which we hear so much of. Is there even a difference? Is this figure of 1 million modest and is there actually more out there that just haven’t been given the infamous label?
Like many conditions nowadays with the advent and progressions with radiological imaging and investigations people feel a scan or xray necessary for confirmation of osteoarthritis. And if we want to put a label on something, like we love to do, to be absolutely conclusive then go ahead. But evidence would suggest that this can be diagnosed in the clinic setting over a quick chat with the patient and a couple of simple tests. This can be a very time and cost efficient way to rule in (or out) the presence of OA in the knee. To rule in OA firstly the person will present with knee pain (goes without saying really). But then if at least 3 of the following are also present we can confirm the presence of OA:
- age > 50
- stiffness lasting less than 30 mins (knees with OA like moving so will generally improve with activity)
- crepitus (noisy creaking): note to any burglars – if this is you get your knees checked as you can be heard squeaking up and down the stairs.
- bony tenderness
- bony enlargement
Following this approach has 95% sensitivity for detection of OA which is actually higher than x ray (91%), however x ray is more specific telling us exactly where that wear and tear is (American College of Rheumatology criteria for diagnosis of knee pain). So if you suspect you may be developing onset of OA and are wondering whether you need an x ray or not a visit to a Chartered Physiotherapist for assessment to see whether an xray is warranted is a good place to start.
As we’ve started this article with knees let’s stick with knees but similar principles apply across the board. There are well documented risk factors for the development of knee OA, some modifiable and others not so much (Silverwood et al 2014):
- Previous knee injury including minor surgery (Bad news for Glen!)
- Gender (females at increased risk)
- Increasing age
- Occupational risks
How the condition is managed can be a balancing act but strong evidence exists in support of keeping active and mobile. OA knees like being moved. So move them. Every synovial joint is lubricated with synovial fluid. Much like the hinge of a door that hasn’t been opened in a while is creaky the first few times it’s opened it becomes less squeaky and stiff with more movement. Similarly with the knee if sitting for a long period it can be stiff to get going again but improves within a short time once mobilising again. Guidelines for the management of knee OA are now well established (Nelson et al 2014). And it doesn’t mean straight to the operating theatre. It actually means get moving with aerobic activity and strength training.
The most modifiable risk factor is a reduction in weight if that person is overweight. But this is often the most difficult to alter due to the very problem they face…knee pain. Catch 22! But all is not lost. There is a temporary solution: Cue Glen’s knee brace!! I typically don’t like bracing or taping. I’d much rather correct a problem through strengthening a weakened structure however this is a perfect scenario where a knee brace can provide sufficient support to allow some aerobic activity, necessary for weight loss. While it was important for Glen Ryan to persevere through an All Ireland series in pursuit of his goal it is equally important for someone that may be overweight putting too much load through their joints to persist to reach their goal. Pain medication and anti-inflammatories can also be helpful at this stage. The benefits of getting the individual active again far outweigh the downside of wearing a brace temporarily (See previous blog on weight loss).
Different types of exercise have been investigated. Research will tell us that both land and water based activities benefit the patient with knee OA with land based exercises proving more beneficial (Land et al 2008). (On an aside here research will also tell us running does not cause OA. I take any opportunity to get that message out). But if land based activities are too painful to perform then water based activities such as hydrotherapy or aqua aerobics may not be a bad substitute. Using the buoyancy of water makes movements that might typically be painful to do on land easier to perform. Resistance training to strengthen the structures around the knee are effective at reducing knee pain in OA patients. Both heavy and light resistance training have been investigated, both improving symptoms (Jan et al 2008, McQuade et al 2011). This could be some squatting or lunge based exercises done in a correct and initially supervised manner to ensure correct technique.What has also been shown is that manual therapy as performed by Chartered Physiotherapists along with such exercise interventions is even more beneficial to improve pain and function in OA of the knee (French et al 2010).
So far what we’re talking about doing is:
- aerobic activity: 20-30 mins 3-5 days per week
- resistance training: 40-60% of a one rep max 2-3 days per week
- mobilisation techniques: where a physiotherapist will carry out joint mobilisations.
What about supplementation? If it helps take it. Glucosamine is routinely prescribed now for OA and available off the shelf. So too is a new product called Movial Plus which aims to increase synovial fluid production and stimulate synovial cell production. This, coupled with the treatment outlined above will ensure optimal recovery and keep you away from the operating theatre for another few years.
Fast forward 6 years. It is 2004 and I have just been part of a victorious Leinster U-21 winning team and earned a spot in the Kildare senior football squad. Due to injuries I get called in for my first Championship start in the first round of the Leinster Championship playing along side that same number 6 from 1998. We lose to Wexford. We play Offaly in the ‘back door’ the following week. I get a start again. We lose again. It is one of Kildares worst Championship campaigns in years, yours truly being substituted ten minutes into the second half. I shouldn’t have started with a ‘niggly’ hamstring (ahem excuse) but I wasn’t giving up my opportunity now that I had worked my way in. Unfortunately, despite some brands making extravagant claims, braces for dodgy hamstrings didn’t exist then and still don’t. Perhaps I was not specific enough with my childhood ambition. I had said I wanted to play with Kildare. What I should have said was: “I want to win with Kildare”. There’s a big difference. So along with all other Kildare football fans now I await the winning days.
Rob McCabe MISCP
MSc Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, Post Grad Dip Ortho Med
You can find more information at http://www.mccabephysiotherapy.com
McCabe Physiotherapy, Orchard House, Moorefield Rd, Newbridge, Co. Kildare
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