Saturday 23 January 2016

dont rely on an X-ray with Hip Pain

Hi!  nothing for months and then wow!  2 in a week.

here we are again. Must be doing more reading these days.

What we have always known and is not often highlighted is that:

 if you have hip pain doesn't mean you'll see anything on X-Ray and if you have hip changes on X-ray  doesn't mean that you'll have any pain.

 have a read of this:

 it shows that just because you have Xray changes doesn't mean you'll have pain from it... and just because you have pain from it doesn't mean you'll have Xray changes.  And this applies to all your joints. If changes in your joints happen over a long period your body/brain does not see this as a problem that needs to highlighted to you then it doesn't do anything about it. You feel nothing; just maybe some stiffness.  It is normal.

It is when changes occur quickly in the body that the warning system kicks in and the brain tells you that you need to do something about it. Move!, change what you are doing; its a protection mechanism that comes from when we were hunter-gatherers. What you are doing is harming me; change what you are doing and that will help. Stop stressing that knee...

Long term pain is another matter... we will discuss

Friday 22 January 2016

Most low back MRI referrals show abnormalities

Hi again

well its been awhile but never too late...

Just read today this interesting article on imaging using MRI scanners and looking at those who are referred for them when suffering with low back pain.

Nearly ALL patients who have low back pain and are referred by their GP for an MRI are shown to have prolapsed discs. The referring criteria was suspicion of serious pathology or patients who have severe sciatica for who surgery is indicated because they are failing to respond to conservative treatment over 6 to 8 weeks.

This study was done in the Netherlands and it shows that if it comes to it and you are referred then the likely findings (72%) will be herniated disc often with nerve root compression.  Spondilolithesis is  18%, 13% is spinal stenosis, 37 is fracture and 0.3% is discitis.

This  considers the biomedical model where a diagnosis is made using these type of techniques. As MSK experts we would take the biomedical model in to consideration but we would also consider many other factors. The biomedical model does not indicate treatment

Is you want to read more then go to:

Wednesday 28 January 2015

NIGEL's BLOG - WEEK 10 - 16

This takes us up to now!

Sorry I haven’t written about my experiences recently, but I have been too busy in gyms and more recently I have been out cycling on a road bike, but only about ten miles and avoiding steep hills, it has to be said!

My knee is slowly recovering and becoming stronger, but it takes time and a lot of hard work, to try and build the muscles of your thigh (quadriceps and hamstrings) and the muscles around your hip back up.

In the gym I am working on static bike, cross trainers and rowing machines and I can pretty much fully straighten my knee and I am staring to achieve more bend (flexion) in it, which is especially helped by the rowing machine.

I spend about three hours a week in the gym, trying to go three or four times and I also swim.
I can now push 40kg with my right leg, on the leg press machine, which has been hard won!
When I started on the leg press I could only press 5kg, because of what is called reflex inhibition. It’s a strange feeling, because you do not feel especially weak in the leg, it’s more that you just can’t do the push required, you might if your life depended on it, but somehow your brain is not switching your muscles on!!!!!!!!!!!

Walking is still a bit of a problem. In that I have to be careful to walk properly and people still say to me, usually if i’m tired, ‘are you limping’?

Although I can now achieve five or six mile walks, even on the Downs, quite happily, without repercussions.

I spend some time, in the last two weeks, on the treadmill, in front of a mirror, watching how I walk, but I still avoid running, but I hope to soon.

Physiotherapy is going well, with Alison  and we are working a lot on balance, hop activities, squats, lunges and continued awareness of quality of movement and control.

Next stage, aim to run, get back to mountain biking, increase twisting and turning activities and join the opera!

Speak soon and remember ‘Mind your body’!!!!!!!!!!!!! NIgel

Tuesday 9 December 2014


I am gradually but steadily improving and feeling much happier about my knee.
During this time the bend (flexion) in my knee, is steadily improving and I am feeling far less general fatigue.

I gradually increase what i'm doing and join the gym and start to initially do cross trainer and light bike work, together with some upper body work and towards week eight, I bring in some work on the rower, which further improves my knee bend and progress the weight on the leg press, to around 40kg.

I am also gradually increasing the swimming, so in total, by the end of week ten I am trying to do four or five sessions a week. I am amazed that although I feel quite confident on the cross trainer and on the bike, I still feel miles away from being able to jog or kick, in any way.

When swimming, I am avoiding any kick motion and when doing breastroke I avoid the traditional way of moving my legs and draw my legs up towards my chest, but this is difficult, as my bend is limited. If I walk for any distance, my leg tires and I have to be conscious not to limp, but this steadily improves during this time and by the end of the phase, I can walk reasonably well for a few miles.

I start to cycle on a cycle lane, at about seven weeks and my Physiotherapy is slowly improving, with Alison 'putting me through my paces' and we work hard on balance, including single balance leg work. The most difficult thing, in terms of confidence,is stepping down, as I go downstairs and this is sometimes still painful around my knee cap.

I look forward to doing things, such as playing tennis or even just to have a gentle hit and I feel that this will soon be achievable, not playing but just having a gentle hit, as part of my rehabilitation, perhaps by mid-January! I am also thinking about mountain biking with my friends, which again I hope to achieve by the end of January.

There is light at the end of the tunnel!

Wednesday 19 November 2014

Bone-Patella Tendon-Bone ACL Graft.

Which Graft should you consider for ACL reconstructive surgery?

This is an often debated question and the literature has many references to which is most appropriate for an individual.

The broad categories include

Autograft (Patients own tissue)
Allograft (Harvested tissue from a donor)
Synthetics (Manufactured material)

I will not drag open the debate but simply point each individual to the internet for interest and to discuss with their surgeon, the most appropriate graft for their reconstruction. Ultimately it is the patient’s choice.

My reasons and beliefs for my choice of graft are set out below.


I reserve this for revision surgery in my practice but will also offer autograft in revision should the patient prefer (sometimes using he opposite limb to harvest the graft). Allograft is expensive, has a slightly higher risk of failure in young people and possibly has a higher risk of infection. However there is no donor site morbidity (discomfort and some loss of function associated with autograft harvest from the patient).


This must be the graft of choice for first time ACL reconstruction. Typical grafts include, Bone-Patella tendon-Bone (BTB), Hamstring, and quadriceps tendon.

I choose BTB as my graft of choice as I have most experience with this graft. My harvest technique through small cuts and tunnelling out the graft allows a reduced level of discomfort on kneeling and ache at the front of the knee (a common complaint from patients who have a long midline incision to harvest the graft).
The fixation of BTB is very strong and if a patient is unlucky enough to suffer a rupture of the graft, there is good bone and not tendon within the placement tunnels making revision surgery easier.
Perhaps more importantly in professional footballers, there is now growing evidence of a reduced failure rate with BTB compared to Hamstring. This is perhaps the most compelling reason to use BTB over Hamstring.
It is important to understand that this is a personal choice and has worked well for my patients.


These can be used to augment an auto or allograft but rarely used at present as the main choice.

Will we ever know which is the most appropriate? In the UK now, a registry has recently been set up to record outcome after ACL reconstructive surgery. In time this should give us more evidence of the best graft choices in a set of circumstances and in any one particular surgeons hands. Visit for more details.


Work is becoming easier towards the end of week 4 and I am looking forward to being able to stop wearing my brace, as I feel it is becoming too much of a ‘security blanket’.

Robin likes his ACL patients to wear the brace, which limits the amount of bend you can get in the knee to 90 degrees, for four weeks after the operation.

Surgeons vary with this, some not liking their patients to wear a brace at all and others advising two weeks of wearing it, but Robin stresses that the research shows that in the long run, the wearing of the brace for four weeks, increases the long term stability of the knee, but this may be more for only the type of re-construction I have had (patella tendon-see above).

The brace runs from the thigh to the ankle and you tighten it with straps and it does give you a lot of support and confidence. The down side is that your muscles don’t have to work as hard and so you lose more tone and bulk, which you need to compensate for, by doing plenty of exercises.

Another down side is that when you put the brace on in the night, for example if you need the loo, the velcro makes a terrible noise, when you take the brace off again, waking anyone in the vicinity!

On the Thursday of this week, so four weeks post op, I remove the brace and I do feel much weaker than I have done!

But I also feel much freer and I go for my first swim.

I am careful not to do any kicking movement but I am an ok swimmer and love the feeling of being able to do front crawl, with my legs just dragging behind me.

It feels fantastic, a re-gained freedom, something I can do. I also enjoy just gently bending and straightening the knee, with my back to the pool wall.

I am feeling that things are improving but I am very aware of the fact that ACL re-constructions are very vulnerable at the four to six week period, as the blood supply is starting to reduce in the graft, before the graft becomes re-vasularised, after about the six week period.

As I got into the water and out, I was very aware of this and wore a pair of wetsuit shoes, to help me grip and I moved very carefully.    

Pain is not really an issue now and I am improving all the time, with my Physio, with Ali, although swelling around my knee cap, is still a big problem, which is worse in people who have had the patella tendon graft and not really an issue in people who have a hamstring graft.


I hobble onto the train and walk up through the park, with my crutches,( of course) and go to work, for the first time, since the operation.

Over the weekend I have been able to do a short amount of walking, without my crutches, but only indoors.

I deliberately have a very light day, with only four or five patients and I have gone in to work a bit later than normal.

My feeling is one of happiness, to be back to work and I am glad I have broken in lightly and for me it would have been harder to leave work for longer. I am pleased to be back and have found it a little easier than I expected.

My second day back at work ,is extremely tiring and I realise that I had been existing on adrenalin, by the end of the day, although it is a light one, I am shattered. If you can take three or four weeks off work, after an ACL, do so!!!!!!!!!!!!!!!!

I struggle through the week, but I am helped massively by Alison Orchard, as I start my Physiotherapy with her, in earnest and she gets me through the week.   
The physio involves her helping to mobilise my knee cap and get me used to the scar being palpated and helping me achieve closed chain exercises, which basically means exercises, where you have your foot on the ground, as you are not meant to do any open chain exercises, where your foot is off the ground.

With the physio, I improve, achieving more flexion (bend) of the knee and extension (straightening) but I am still struggling with swelling.