Sports Medicine & Orthopaedics

Most surgical meniscus repairs unnecessary


Nina Jullum Kise, PhD candidate, orthopaedic surgeon and senior consultant, performs an arthroscopic procedure on the meniscus of a patient.

Three out of four people could avoid knee surgery with a new form of exercise therapy, with significant cost savings for society.

Injury to the menisci, the cartilaginous discs within the knee joint, can be painful when running, and can cause the knee to give way or ‘lock’. Such injuries are troublesome and sometimes painful, and can prevent you from exercising or attending work.

A new study shows that exercise therapy is just as effective for treating meniscus injuries as surgery. PhD candidate and orthopaedic surgeon Nina Jullum Kise is in charge of the study. She is a senior consultant at the Department of Orthopaedic Surgery, Martina Hansen’s Hospital in Bćrum, Norway

No difference between surgery and exercise
A total of 140 patients with meniscus injuries in Norway and Denmark took part in the study. They drew lots for treatment with either exercise or surgery.

Commenting on the study, Dr Jullum Kise says: “Two years later, both groups of patients had fewer symptoms and improved functioning. There was no difference between the two groups.

“However, those who had exercised had developed greater muscular strength. This is consistent with previous research, which showed that surgery yielded no additional benefits for patients who had had exercise therapy.”

The current study is the first to compare cases where the patient had only exercise therapy or only surgery.

Big savings
Dr Jullum Kise believes that as many as three in four could be spared surgery with the right exercise therapy programme.

In 2015 almost 11,000 people in Norway underwent arthroscopic meniscus repair, a form of keyhole surgery. However, the general trend is to place more patients on exercise therapy programmes and hold off on surgery.

“A single meniscus operation is estimated to cost taxpayers in excess of 16,000 Norwegian kroner (about US$1900). And then there’s absence from work on top of that,” remarks Dr Jullum Kise.

Although exercise therapy also has costs, these are lower than for surgery. Reducing the number of surgical meniscus repairs would thus lead to significant savings for society.

Training with physiotherapist
In the study, the patients attended training sessions with a physiotherapist 2-3 times a week for 12 weeks.

“The exercise therapy programme involves a warm up and various types of strength training. It is built up in stages that become more challenging as the patient improves and becomes stronger,” explains Dr Jullum Kise.

Each patient receives a personalized training programme, and learns to do the exercises under the supervision of a physiotherapist. Once they have learned the exercises, they train on their own but attend weekly sessions with the physiotherapist for adjustments and to be given new exercises.

May counteract osteoarthritis
Menisci are crescent-shaped discs of cartilage on both sides of the knee joint. The meniscus is a shock absorber that distributes weight across the joint and atthe same time stabilizes the joint when you walk or run.

“We hope that the stronger muscles of the exercise therapy group may counteract osteoarthritis, a type of arthritis that often occurs in patients who have undergone surgery for a meniscus injury,” says Dr Jullum Kise.

In principle there are two types of meniscus injury.

  • Acute injuries, which often occur in younger people who might, for example, twist a knee during downhill skiing.
  • Wear and tear (degenerative) injuries, which are the fi rst sign that the joint is beginning to break down, socalled osteoarthritis.

Young people with acute injuries shouldundergo surgery. That way, the meniscus can continue to protect the cartilage in the joint. Damage due to wear and tear cannot be repaired surgically, but thejoint can be cleared of worn tissue that would otherwise cause the knee to lock or to give way.

Robot therapist hits the spot with athletes Prototype robot is being used in trials for sports rehabilitation


Trials of a prototype robot for sports therapy have just begun in Singapore, to create a high quality and repeatable treatment routine to improve sports recovery, reducing reliance on trained therapists.

The robot named Emma, short for Expert Manipulative Massage Automation, has already treated more than 50 patients in trials including professional athletes for conditions ranging from tennis elbows, stiff neck and shoulders, to lower back pain.

Emma is a robotic arm that comes with a 3D stereoscopic camera and a custom made 3D-printed massage tip. It uses sensors and diagnostic functions to measure the response of a patient and the stiffness of a particular muscle or tendon. The detailed diagnostics are analysed and uploaded to the cloud so the patient’s recovery can be closely monitored over time.

Emma is created by a graduate of Nanyang Technological University, Singapore (NTU Singapore) whose start-up company is incubated by the university.

Emma is currently undergoing user trials at Kin Teck Tong, a modern medical institution with a chain of clinics that offer sports injury rehabilitation and painmanagement through the integration of advanced sports science and traditional Chinese medicine.

NTU graduate Albert Zhang, the creator of Emma who founded the startup AiTreat to develop and eventually market this innovation, said he wanted to solve some of the challenges faced by sportstherapy and pain management clinics, such as a shortage of trained therapists and a need to deliver high quality therapy consistently.

“We have designed Emma as a clinically precise tool that can automatically carry out treatment for patients as prescribed by a physiotherapist or Chinese physician,”said Zhang, who graduated in 2010 from NTU’s Double Degree programme in Biomedical Sciences and Chinese Medicine.

“This will be one of the first robots out in the market specifically for use by sports therapists and Traditional Chinese Medicine (TCM) physicians. Our aim is not to replace the therapists who are skilled in sports massage and acupoint therapy, but to improve productivity by enabling one therapist to treat multiple patients with the help of our robots.”

Emma, which has a user-friendly interface and recommended guidelines for various sports injuries, was designed by Zhang based on his experience of treating sports injury as a licensed TCM physician in Singapore for the past five years.

The robot also has several safety features working in tandem with advanced pressure sensors to ensure the safety and comfort of its patients. Coco Zhang, Executive Director of Kin Teck Tong, said the new physiotherapy robot has the potential to be a disruptive innovation, especially for the sports science and pain management industry.

“Just like countries such as the United States, Europe, Japan and China, Singapore is also facing a rapidly aging population. Over the next decade, more people are going to suffer from physical ailments such as arthritis and will be seeking treatment,” Coco Zhang said.

“Since the younger generation prefer knowledge-based jobs rather than physically intensive jobs such as massage therapists, there will likely be a shortage of trained therapists in future. In our trials with the robot, the experience has been very good, as it can perform most treatments as well as our therapists.”

Physiotherapy meets the Cloud
Emma is equipped with sensors and diagnostic functions with detailed diagnostics sent to the cloud for analysis and generation of performance reports of the patient’s progress. With Emma, patients can accurately measure their recovery using precise empirical data.

This is valuable for athletes as their injuries, treatment and recovery can now be measured and monitored by theirphysician and therapists. In addition, the treatment programmes can be adjusted based on the progress of the patients’ recovery.

Zhang and his teammates won the Microsoft Developer Day Start-up Challenge earlier this year and the propriety cloud intelligence used by Emma is supported by Microsoft. After the clinical trials are completed, a second-generation robot will be developed that is more compact and mobile.

See Emma in action

The best way to improve muscle strength

Engaging in short, explosive leg contractions is the most effective way of strengthening muscles, Loughborough research reveals.

The study, led by Dr Jonathan Folland, Reader in Human Performance and Neuromuscular Physiology at Loughborough University, is the first to directly compare short, explosive contractions lasting less than one second with sustained contractions lasting three seconds.

Strength training is widely regarded to be an effective way of boosting the physical performance and health of all individuals, from high performing athletes through to older people and those undergoing rehabilitation following injury or who are suffering from conditions such as osteoarthritis.

The results showed that explosive contractions are an easier and less tiring way of increasing strength and functional capacity of the muscles, and therefore a highly efficient method of training. The method increases strength by assisting the nervous system in ‘switching on’ and activating the trained muscles. In comparison, the more traditional sustained contractions – which demand a lot of effort and soon become tiring – are actually a more effective way of increasing muscle mass. Increasing muscle mass may be the main training goal for some people, including athletes in some sports, for aesthetic reasons or metabolic health.

The study investigated the effect of the different contractions on the participants’ quadriceps muscles located on the front of the thigh. The selected participants (43 healthy males in their twenties) had not completed lower body strength training for 18 months and were not involved in systematic physical training. One group did the explosive contractions, one group did the sustained contractions, and a third group acted as a control group. The participants trained with 40 contractions repeated three times a week for three months. The force produced by every contraction was prescribed and monitored to ensure it was either explosive or sustained. An extensive range of performance and physiological measurements were done before and after the training to assess the changes.

Dr Folland, from Loughborough University’s School of Sport, Exercise and Health Sciences, part of the National Centre for Sport and Exercise Medicine East Midlands, said: “The easiest way to make muscles stronger has been debated by fitness and sports professionals for many years, but this study shows that it doesn’t have to mean lots of pain for any gain.

“Whereas traditional strength training is made up of slow, grinding contractions using heavy weights which is quite hard work, this study shows that short, sharp contractions are relatively easy to perform and a very beneficial way of building up strength. These short, explosive contractions may also be beneficial to older individuals and patient groups such as those with osteoarthritis, who would benefit from getting stronger, but are reluctant to undergo tiring sustained contractions.”

  • doi: 10.1152/japplphysiol.00091.2016

Sheikh Khalifa Medical City – a national leader in amputee rehabilitation

Over the past decade or so there has been a substantial increase in investment in rehabilitation medicine around the world, leading to the specialty becoming a frontline health service. Compared to the 1950’s and 1960’s, people who sustain severe and complex injuries now have a higher chance of living independent lives with a good quality of life because of advancements in rehabilitation medicine.

The Physical Medicine and Rehabilitation (PM&R) Institute at Sheikh Khalifa Medical City (SKMC) provides a broad range of specialised rehabilitation services in a multidisciplinary and consultative environment to the people of Abu Dhabi and the United Arab Emirates.

The Institute has evolved to become the national leader in medical rehabilitation care. It was established in 2009 at SKMC, one of Abu Dhabi Health Services Company hospitals. The Institute uses the most up-to-date international methods of administering interdisciplinary, acute and post-acute rehabilitation with a patientcentred approach.

All of the Institute’s consultants are qualifi ed by leading institutes in the West and are fully trained and accredited in the field of rehabilitation medicine.

The Institute offers comprehensive medical rehabilitation services, and includes the following facilities: Acute rehabilitation unit, Outpatient clinics, Satellite inpatient therapy areas, Outreach/Outside SKMC Interdisciplinary consultations.

The aim of the rehabilitation is to ensure patients have successful prosthetic use and can lead an independent life.

Phases of rehabilitation

  • Pre-prosthetic, prosthetic and post prosthetic training
  • Lifelong follow up
  • Management of complications Some elderly amputees can have other co-morbidities such as ischemic heart disease, hypertension, end stage renal disease with dialysis, and arthritis which can pose a number of challenges in amputee rehabilitation.

Eligible amputee patients who have congenital or acquired limb defi ciency are provided inpatient and outpatient services at PM&R Institute.

Outpatient services

  • Patients of all age groups are assessed by a multidisciplinary team consisting of physiatrist, prosthetist, rehabilitation nurse, physiotherapist and occupational therapist
  • Regular follow ups for repairs, maintenance, modifi cations and prevention of complications.

Inpatient services

  • Meetings between the multidisciplinary team and the patient, carers and family are arranged to discuss goal setting
  • Weekly formal multidisciplinary meetings for each patient are conducted to identify problems, set goals, monitor progress and plan discharge

Seating clinic

The seating clinic is only one arm of SKMC’s fully integrated equipment provision service which is a crucial component of any rehabilitation service.

The PM&R Institute at SKMC provides twice weekly clinics for those individuals who have congenital or acquired disabilities secondary to trauma or illness.

The clinics are led by consultants and are run by SKMC’s interdisciplinary team which includes a doctor (consultant accredited in the speciality of medical rehabilitation) supported by an occupational therapist, physiotherapist and a rehabilitation nurse – all specialised in equipment service provision.

B4 ward
The B4 ward at SKMC is a tertiary neurorehabilitation and general rehabilitation unit. It is a consultant-led medical rehabilitation unit.

The unit is designed in a way to allow the safe, secure and private provision of service for those who have both complex physical and as severe congenital disabilities.

The unit makes use of the latest technology and techniques for pain management, spasticity management, orthotic and prosthetic services, amongst others.

Triathlete regains her stride after minimally invasive hip procedure at the University of Chicago Medicine

Several years ago, Sara Llibre decided to celebrate her upcoming 50th birthday by re-kindling her athletic career. The mother of two started running and eventually did her first marathon. Within a few years, the suburban Chicago resident joined a triathlon team and completed her first Ironman (2.4-mile swim/112- mile bike/26.2-mile run) race.

But heavy training took a toll and a year-and-a-half ago, Llibre’s right hip hurt so much she could barely run. An MRI showed impingement (the hip bones rubbing together) and a labral tear in her hip. One doctor told Llibre she’d never run again.

Intent on getting a second opinion, she visited Sherwin S. W. Ho, MD, professor of orthopaedic surgery and director, sports medicine fellowship program, at the University of Chicago Medicine. The medical centre was founded in 1927 and is part of the University of Chicago, an institution that consistently ranks among the 10 best universities in the world.

“Dr Ho knows athletes and I could tell that he knew exactly from my description of the pain what I was dealing with,” said Llibre. “He didn’t promise me anything but he said chances were good that I could run again. And he was right.”

In January 2014, Ho performed a minimally invasive, outpatient procedure that repaired the impingement and tear. Eight months later, in September 2014, Llibre ran a pain-free Ironman Wisconsin and set a personal record while placing fourth in her age group. Now she’s looking forward to another personal record while competing in the Ironman competition in Louisville, KY.

“It just feels natural to me,” said the cheery Chicago public school teacher, about training and racing.

“If we get to these patients early enough, we can save the hip and allow them to continue with an active, healthy lifestyle,” explained Ho, an expert in sports medicine and minimally invasive arthroscopic procedures of the shoulder, elbow, hip, knee and ankle. “Especially in athletes such as Sara who want to do triathlons late in life, a surgery like this can give them additional miles and years on their hips.”

Just a decade ago, impingement (known as femoroacetabular impingement or FAI) often went undiagnosed and patients were told they were suffering from tendonitis or arthritis and to live with the pain. When the pain wasadvanced enough to show up as arthritis on an X-ray, patients would get hip replacements.

“Today with the advent of better MRIs and minimally invasive procedures, we can diagnose patients who have impingement and tears and treat them before they get arthritis,” explained Ho. “Our job as hip preservation specialists is to maintain our patient’s natural hip and avoid the need for hip replacement later in life.”

Impingement generally occurs with hip flexion beyond 90 degrees. The hip’s ball and socket are designed to flex to a certain degree but when you exceed that limit repeatedly, the two bones can bump into each other, causing pain and in Llibre’s case, damage to the labrum – a rim of cartilage around the socket.

A runner flexes tens of thousands of times over the course of a run. But other activities can aggravate hips as well: “Going up stairs, squatting to pick something up, sitting, biking, playing tennis, soccer, skating – pretty much everything we do is done with hips in flexion so that can predispose us to this particular problem (FAI),” explained Ho.

In Llibre’s case, Ho repaired the tear and addressed the biomechanical defect (impingement) by reshaping the bonesthat rubbed against each other. (Tendonitis and early arthritis can also be addressed during surgery.)

For Llibre, the 90-minute procedure was a life-changer. She was on crutches for almost four weeks but after three weeks started swimming and a few weeks later, began biking. Three months later she was running again, at about 80 percent effort. “I got such good advice from Dr Ho about how much I could do and when to back off -- and I didn’t have to back off a lot.”

Llibre’s now back to training six days a week, usually twice a day. “To me, Dr Ho is a miracle worker,” she said.

Ho is part of a team of University of Chicago Medicine orthopaedic specialists dedicated to comprehensive hip care. The team also includes Richard W. Kang, MD, MS, and Hue Luu, MD.

To learn more about the University of Chicago Medicine, please contact our International Programs office by
or calling +1-773-702-0506.


 Date of upload: 13th Sep 2016


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