An Active Retirement: Getting Back To Doing What I Love

Article first published on Farrer Park Hospital

Painful and stiff shoulders in your later years do not have to hold you back from keeping fit and pursuing activities you enjoy. That was a priority for Madam Sakina Hoosenally, in her 70s, when she considered treatment options for her shoulder arthritis. She shared with us about her experience of living with shoulder arthritis and why she decided to go ahead with the surgery.

An Active Retirement

Though retired, Madam Sakina still taught yoga classes in the morning. She also swam daily when the weather permitted. Staying on her own, she desired to live independently for as long as possible.

Several years ago, both of her shoulders started causing her pain. She also had a hard time lifting her arms. “I found it was coming in the way of my yoga teaching … I couldn’t do many of the poses and it was just very frustrating,” she said.

Though the pain was not unbearable – she noted that many people could live with it – she found that it was interfering with her way of life, such as cooking for herself and affecting her sleep.

She reflected that she is now in her early 70s, and if she lives till her 90s, it won’t do to prolong the discomfort.

Seeking Treatment

After visiting several doctors, a friend recommended Dr. Ruben Manohara to Madam Sakina, a consultant orthopedic surgeon specializing in trauma management, sports injuries, and degenerative conditions.

Dr. Manohara diagnosed Madam Sakina with severe osteoarthritis of the shoulders. Shoulder arthritis affects 16% to 20% of those older than 65 years of age1, although it can occur as early as your 40s and 50s. In terms of its prevalence, he explained that there is no Singapore registry/data on shoulder-specific arthritis.

“Shoulder arthritis can be degenerative from overuse as well as genetic causes, from rheumatoid arthritis, from previous trauma, following massive rotator cuff tear and could occur following a joint infection,” he added. Besides the age related factor, he said the other risks factors include gender, race, suffering from gout and shoulder instability.

The condition refers to damage, usually wear and tear, of the cartilage, which covers the ends of bones to create a low-friction environment and allows the bones to glide smoothly over each other when the joints move. When the cartilage breaks down, the exposed bones may rub against each other and cause pain.

Symptoms often include shoulder pain, weakness, swelling or tenderness at the joint, and pain that could last for months or years2.

Dr. Manohara recalled that at that point, Madam Sakina had already tried treatments such as steroid injections and non-medical treatment like acupuncture, ayurvedic and physiotherapy, but to no avail. She was also unwilling to take painkillers over the long term and sought to resolve the pain with shoulder replacement surgery. “I was looking to restoring my mobility, and allowed me to continue exercising and teaching, and get on with my daily lifestyle.”

“When I first saw her in 2021, she was already living with the condition for four years. A replacement would have predictable, reliable good outcomes, in terms of pain relief, function and longevity of the implant,” Dr. Manohara explained.

“Such surgery would allow her to carry on with yoga, swimming, and other daily activities without pain and sleep without discomfort.

In addition, downtime was not an issue – even patients in their 70s to 80s usually recovered relatively quickly and easily after the procedure, compared to other major joint replacements.

For Madam Sakina, her friends’ support also helped her decide to go for surgery for her right shoulder.

The Key to Good Recovery

Following the smooth recovery of her right shoulder, Madam Sakina opted to also undergo surgery for her left shoulder about six to seven months later. She had her sights set on both shoulders being mobile enough for her to execute the downward facing dog pose and salutations in yoga that she had not been able to do for some years. She also wanted to be able to swim the freestyle stroke, which required both shoulders.

To her, an upbeat attitude was a huge help in recovering from the procedures. “Having gratitude and having a positive outlook is very important in recovery in your rehab,” she said. Madam Sakina also highlighted the importance of having a goal to look forward.

During the healing process, Madam Sakina was cautious when carrying heavy items such as groceries, usually using the arm that was not operated on to lift these. She also waited for a few more weeks before getting back to driving.

“I focus and work hard through exercise and regular physiotherapy to help me get back my mobility. For me, my right shoulder healed in 4 to 5 months after the operation while my left is about 90% healed 4 months since my surgery in March. For patients who are not dedicated to the rehab, it might take much longer,” she added.

After getting replacement surgery for both shoulders, carrying out her yoga poses was “much better than before”.

Aspiration for Health and Lifestyle

Looking back at the process of seeking and receiving treatment for shoulder arthritis, Madam Sakina said that the decision to undergo shoulder replacement surgery depends on the person’s aspiration for health and lifestyle.

“Not everyone may have the same urgency, need, or shared my goals.”

Receiving the treatment aligned with her personal life goals of sustaining her yoga practice and living independently for as long as possible. Though her left shoulder is still in the process of recovering, she is grateful for her regained mobility. She acknowledges that while a lot of hard work went into her rehabilitation, her mindset is that “it’s not going to get worse. It can only get better.

Orthopaedic Nurse Specialists Training With Arthrex

At Shoulder Elbow Orthopaedic Group, we understand the honour and responsibility bestowed on us when patients trust us with their health. Our orthopaedic multi-disciplinary team is committed to a shared purpose to ensure the best care for our patients. 

Arthrex Orthopaedic Nurses Specialists Training, Orthopaedic Training, Shoulder Elbow Orthopaedic Group, Orthopaedic Clinic Singapore

Hence it is not only crucial for our orthopaedic surgeons to be equipped with updated surgical skills and knowledge. However, it is also important that the Shoulder Elbow Orthopaedic Group’s orthopaedic nurse specialists receive training to update and improve their skills and knowledge. 

On 23 Feb 2022, we closed all Shoulder Elbow Orthopaedic Clinic branches so our nurses, accompanied by our orthopaedic specialists, could attend a hands-on skills training workshop. 

Arthrex Nurses Specialists Orthopaedic Training, Orthopaedic Training, Shoulder Elbow Orthopaedic Group, Orthopaedic Clinic Singapore

Thank you, Arthrex, for helping our nurses learn invaluable skills that will aid our aim always to provide better care for our patients.

Cochin International Orthopaedic Summit 2021(CIOS 2021)— “Complications in Orthopaedics”

Date and Time: Oct 14 2021, 18.40 – 19.40

Dr Ruben Manohara has been invited to speak at Cochin International Orthopaedic Summit 2021. Where he will be part of the session – “Upper Limb Complication – Shoulder”. Dr Ruben Manohara will be giving two talks. They are:

  1. My Worst Case Around the Shoulder
  2. How to Avoid Complications in Clavicle Fracture Fixation

He is honoured to be part of the CIOS 2021 faculty and happy to contribute to the international orthopaedic community.

CIOS 2021 will feature an innovative combination of engaging interactions with international experts, cutting-edge surgical demonstrations, and instructional symposia that will offer live Q&A with premier faculty and renowned regional hosts about Complications in Orthopaedics from various branches of Orthopaedics. 

Fellow doctors can register for the Orthopaedic Summit via this link


Cochin International Orthopaedic Summit 2021, CIOS 2021, Dr Ruben Manohara, Shoulder Elbow Orthopaedic

Treatment Options For Massive Rotator Cuff Tears | PhysioActive Talk

Date and Time: April 30 2021, 12:30pm – 2:00pm
Guest Speaker: Dr Desmond Ong, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic

Dr Desmond Ong joined our partners at PhysioActive to discuss rotator cuff tears and how they are a common cause of shoulder pain.

Rotator cuff tears become more common with age and can rob many of their ability to do the things they enjoy and their independence in their golden years. Dr Desmond touched on how non-surgical treatment options can improve one’s pain.

Learn how to better care for patients suffering from rotator cuff tears and the various treatment options available and how each option brings its own set of benefits. For more information on rotator cuff tears and the respective treatment options go to

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options, Insight and Evidence

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Massive Rotator Cuff Tears, Treatment Options

Dr Desmond Ong, Shoulder Elbow Orthopaedic, PhysioActive, Joint Preserving Options, Classic Transfers

The Reverse Total Shoulder Replacement | How Can It Help Your Patients?

Date and Time: Jan 6 2021, 12:45pm – 2:00pm
Guest Speaker: Dr Ruben Manohara, Consultant Orthopaedic/Shoulder Surgeon at Shoulder Elbow Orthopaedic Clinic,

Dr Ruben Manohara was invited by EISAI to speak to over 65 fellow doctors on the reverse shoulder arthroplasty and how it is considered one of the most significant technological advancements in shoulder reconstructive surgery over the last 30 years.

It reliably decreases pain and improves function for patients with rotator cuff-deficient shoulders. Such has been the success of this procedure, that it has led to a rapid expansion of the indications, to include more complex elective and trauma cases. Initially used in the more elderly patients, there is an increasingly higher demand in active ‘young seniors’.

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI Ruben Manohara, Shoulder Elbow Orthopaedic, EISAI

Subchondroplasty | An Alternative to Knee Replacement Surgery

Date and Time: 6 June 2019, 6.30pm
Venue: Peach Garden at Hotel Miramar
Guest Speaker: Dr Bernard Lee Chee Siang, Orthopaedic Surgeon at Sportsin Orthopaedic Clinic, Gleneagles Medical Centre

Dr Bernard Lee was invited as a Guest Speaker by Eplus Healthcare and Zimmer Biomet to give a talk about Subchondroplasty to a group of Orthopaedic Surgeons. He is one of three pioneer surgeons in Singapore who has been trained to perform this procedure.

Dr Bernard Lee, Eplus Healthcare, Subchondroplasty

Below are some of the main takeaways from his talk:

What is Subchondroplasty?

Dr Bernard Lee, Eplus Healthcare, Subchondroplasty

Subchondroplasty involves injecting a bone substitute into painful, damaged parts of an arthritic knee.

This surgical procedure can help patients with knee osteoarthritis. This has been shown to reduce knee pain and improve knee function significantly, without having to resort to joint replacement surgery.

70% of patients who underwent subchondroplasty avoided a total knee replacement for two years or more.

Radiologic Assessment before operation.

Your doctor may do X-rays and an MRI scan to assess the extent of your knee problem, and to determine if subchondroplasty is a good option for you.

Subchondroplasty has seen relatively good results in patients. It has helped some of them continue their lifestyle and work:  


1) A 67-year-old PE teacher was having severe knee pain and had difficulty climbing stairs and bringing his students for lessons.  Being an active person, he was not keen to undergo joint replacement surgery. After a few months of trying alternative forms of treatment, he underwent Subchondroplasty.  As the weeks passed, his pain improved, and he was able to continue working as a PE teacher. Currently, he is two years from his surgery, and his pain is almost completely gone.  He can still go for long walks every day and is still working as a PE teacher!

2) A lady in her early 50s was having knee pain due to knee arthritis that was aggravated by having to stand for long hours in her sales job.  After having tried other forms of treatment and supplements to no avail, she underwent Subchondroplasty. Now at two years after surgery, she only has occasional pain and can stand and walk for long durations at work without difficulty.

Subchondroplasty may not work for everyone.  However, it does provide an alternative to joint replacement surgery in certain patients.  Results will vary, and it is best that you discuss this option thoroughly with your Orthopaedic Surgeon.

For more information, please visit:

Key Hole Surgery

Often when the topic of surgery comes up during the discussion with my patients, the question of how big will my scar be or how many stitches will there be comes up. The pleasant surprise will then commonly be that with current technology, many sports related joint injuries can be treated via small key holes now.


New Technology?

Truth is “Minimally Invasive (MIS)”, “Keyhole”, “Bandaid”, “Scope” surgery is not exactly that state of the art nowadays as it has been around for almost a century now and can safely be considered to be the mainstay treatment for most sports injuries.


Arthroscopic surgery has been reported since the 1910s but the technology and application greatly took off after the invention of fibre-optic cable when images can be projected into a television monitor. This saves us from having to struggle peering through a small peephole lens. This plus high definition lenses and monitors has made doing such procedures much clearer, easier and thus safer. Afterall, a surgeon should only operate on what he/she can see clearly.


So what exactly is KeyHole surgery.

KeyHole or Arthroscopic surgery is a type of orthopedic surgery that utilizes an instrument called an arthroscope which essentially is a lens connected via fibre-optic cable to a monitor. It is so called keyhole or minimally invasive as it can be performed requiring only small incisions, usually around around ¾ of a centimeter. These incisions are called portals. The word arthroscope is from the Greek words meaning “to look at joints.” The arthroscope is made up of a lens and a light source, and is connected to a video camera. The surgeon can view the inside of the joint directly through the arthroscope, or an image may be displayed on a monitor. This image gives the surgeon a clear view of the tissue inside the joint. The surgeon can then use other tiny instruments specially designed for arthroscopic surgery to perform necessary procedures. Arthroscopic surgery can be used as a diagnostic tool, or for therapeutic procedures ranging from easing the pain of arthritis patients to mending torn ligaments. This range from shoulder stabilization, rotator cuff repair, capsular release for frozen shoulder, acromioclavicular joint reconstruction (dislocation of the outermost part of the collar bone which many cyclist suffer from after a fall), tennis elbow release, knee meniscus debridement (clean up)/ repair, ligamentous (anterior and posterior cruciate) reconstruction, hip labral debridement repair. This is on top of the diagnostic arthroscopies we do for the joints and debridement of these joints.


Why KeyHole?


First I must quantify that although this technique is and can be used for many sports related injuries when all non operative options have been exhausted, it is not for every patient and every condition. In certain situations, trying to struggle through 4 to 5 small holes each around ¾ cm may cause more damage then just doing a simple mini-open procedure with a 3-4cm incision,

Nevertheless, extended exposure of joints during open surgery prolongs recovery and increases pain and risk of complications, such as infection and stiffness. Minimally invasive surgeries, in general, result in less pain and swelling after surgery than open techniques. As a result, arthroscopically treated patients tend to heal faster and begin rehabilitation earlier and, subsequently, return to normal activity and work sooner.

Technically, using a lens also allow surgeons to see certain parts of the joint that would otherwise be inaccessible through a limited mini-open incision as the lens can get into awkward corners of the joint easier.

Arthrocopic surgery has made some previously very long and arduous ones a lot more controlled and straightforward. This allow us to provide our patients a more predictable outcome in terms of results.

In some surgeries, arthroscopic techniques have become mainstays over open procedures like shoulder stabilization surgery, rotator cuff repair, acromioclavicular joint reconstructions, knee meniscus and ligamentous reconstruction. This is to an extend that the open surgery is only reserved for complex or revision (repeat) surgeries.

Another benefit of arthroscopy is that a lot of these procedures can be performed in an day surgery setting which can often reduce cost.


So what’s the down side?

As of all surgical procedures, there are risks. Like in all joint surgeries, risks include bleeding into the knee joint, damage to the cartilage, meniscus/labrum, or ligaments in the joint, blood clot in the leg (deep venous thrombosis), injury to a blood vessel or nerve, compartment syndrome when the fluid we use to pump into the joint to work (yes we work in an underwater environment) leaks into the calf area of the leg, infection in the joint and joint stiffness. Unique to arthroscopy, equipment failure accounted for a significant part of the complications. Arthroscopy is a technical procedure requiring a wide range of equipment (camera and monitor, surgical equipment, pump, tourniquet, etc.) that can malfunction or break during a procedure.


Arthroscopy, one of the greatest advances in orthopedic surgery in the 20th century, has been around for a almost a century. It offers a minimally invasive alternative to standard open surgical techniques, which often require extended incisions for adequate joint exposure to the extent that it has become the mainstay for many conditions. Decreased complications, pain, shorter recovery, and the resulting cost savings are proven advantages. Without a doubt, the advances of arthroscopic surgery will allow us to return our patients back to their peak performance a lot faster and with a lot less pain and fuss. With improvements in fibre-optics, lens and monitor technology, it will also allow surgeons to see clearer and as a result do better work for our patients, producing better results and allowing our patients not to have to live with their pain.

Common sports injuries faced by women

Disclaimer: This article first appeared in Shape Magazine as an Interview with Gleneagles

1. What are some of the most common sports injuries faced by women?

Women are increasing involved sports locally and the incidence of sports injury has increased as a result. Common injuries include those affecting the shoulders, elbows, wrists, back, hips, knees, foot and ankle. Different sports places increase stresses in different anatomical parts of the body and thus result in varying injuries. Sports injuries are broadly divided into 2 main groups

  • Traumatic injuries (sprains, muscle pulls, fractures, dislocations etc)
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc)

Even in running, looking at the scientific literature, we can see that women indeed do, on the whole, get injured more often than men do.  But the difference is not quite as drastic as popular wisdom might hold—a 2002 study of around two thousand patients at a Vancouver, Canada sports injury clinic found that women represented 54% of injuries, with men taking up the other 46%.  But among some specific injuries, women are at significantly higher risk such as Anterior Cruciate Ligament (ACL) Tears.

2. What musculoskeletal and biological makeup differences between both genders contributes to sports performance and injuries?

There are many factors that attribute to the differences in injuries between the genders. The main reasons include

a. Anatomical Factors

Taking ACL injuries as an example: these factors include pelvis width, Q-angle (the angle between a line connecting a point on the front of the hip bone and the center of the kneecap and another connecting the kneecap and a point on the upper shin-bone), size of the ACL, and size of the intercondylar notch (where the ACL crosses the knee joint). Larger pelvis width, Q angle, smaller ACLs and a smaller intercondylar notch places females at a higher risk.

*  – Q angle is the angle formed by a line drawn from the ASIS to central patella and a second line drawn from central patella to tibial tubercle;
    – an increased Q angle is a risk factor for patellar subluxation;
    – normally Q angle is 14 deg for males and 17 deg for females;
           – Agliettis et. al. Clin. Ortho 1983:
           – 75 normal males:    Q angle = 14 deg (+/- 3)
           – 75 normal females: Q angle = 17 deg (+/- 3)
    – biomechanics of patellofemoral joint are effected by patellar tendon length & the Q angle;

b. Biomechanical/ Neuromuscular factors

Women have been found to have differences in biomechanic movements of the knee seen when pivoting, jumping, and landing — activities that often lead to an ACL injury. There is also a relatively greater imbalance between quadriceps and hamstring muscles (with the quads being stronger in females), which can contribute to knee injuries.

c. Training/ Conditioning factors (doll games vs ball games)

Until recent years, males are involved training actively for competitive sports at an early age compared to females. As such they are physically better conditioned to withstand sports injuries. Hence, boys being involved in ball games as compared to girls being involved in doll games at an earlier age. Nevertheless, the combination of the greater susceptibility and a 10-fold increase in the female sports population since the inception of Title IX in the United States has resulted in a dramatic increase in the number of ACL injuries in females. Locally, increased emphasis in sports and fitness has also allowed us to witness a large increased in the number of females involved in recreational and competitive sports and consequently an increase in the number of injured females.

d. Hormonal factors

Female sex hormones (i.e. oestrogen, progesterone and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and decrease neuromuscular performance and, thus, are a possible cause of decreases in both passive and active knee stability in female athletes.

3. Are there certain sports that put women more at risk of injuries than men?

In view of the factors that lead to an increased risk of certain sports injuries, high demand sports involving planting and cutting, jumping with a poor landing, stopping suddenly or changing directions quickly (Soccer, Volleyball, Skiing, Lacrosse, Football, netball etc) can put women at a higher risk of knee sports injuries compared to men. Extrapolating this to other injuries including the shoulder/elbow/hip/ foot and ankle, women may also be at a higher risk of sustaining certain injuries compared to their male counterpart. For shoulder injuries, the combination of not having strong shoulder muscles, including the rotator cuff and periscapular muscles, and having generally supporting tissues that are more lax can lead to instability in the shoulder.

4. What are some sports that put women at an advantage compared to men? How so?

There are some sports where flexibility may play a greater role such as gymnastics where women are at an advantage. Interestingly, women are at a lower risk of hamstring injuries compared to men in a National Collegiate Athletic Association’s (NCAA) Injury Surveillance System (ISS) regarding all hamstring strain and rupture injuries in male and female soccer players between 2004 and 2009. Men were significantly more likely to suffer a hamstring injury during the in-season than women. Men are also more likely to suffer recurrent hamstring injuries.

5. As a member of the medical panel for the upcoming BNP Paribas WTA Final Singapore presented by SC Global, do you foresee any common sports injuries that the professional women tennis players will likely encounter? Perhaps our humid weather and brand new court grounds may play a role in altering their performance?

Tennis injuries are also of 2 broad types:

  • Traumatic injuries (sprains, muscle pulls, fractures, etc) make up about 1/3 of injuries seen in tennis, depending on the age and activity level of the player. Most traumatic injuries occur in the lower extremity. They are not easily prevented, nor are they particularly related to tennis technique.
  • Overuse injuries (strains, tendonitis, tendinosis low back pain, etc) comprise about 2/3 of injuries experienced by tennis players. Overuse injuries occur in all areas of the body, and may be related to technique or to alterations in the athlete’s musculoskeletal system.

Common injuries include tennis elbow, shoulder injuries such as rotator cuff tears, stress fractures, muscle strains, knee ligament strains/ tears, ankle sprains/ ligament tears and also back injuries.

Specific to ACL injuries, tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground. Clay courts seem to be a better option for ACL deficient players.

6. What are some common injuries faced by recreational female tennis players?

Similarly, tennis injuries will include both traumatic and overuse ones. However, we do see a larger number of overuse injuries in recreational players. One of the reasons can be because of less consistent technique and form.

7. How can those tennis-related injuries be treated, and avoided?

There are multiple causes for the overuse injuries in tennis, including the need to perform repetitive forceful motions and strokes, inadequate rest and recovery, incorrect tennis specific conditioning, acquired inflexibility, and strength weakness/imbalance. Each injury may have unique causes that must be evaluated to avoid repeated injury, suggest proper conditioning programs, and allow safe return to sport. Because many parts of the tennis player’s body experience high loads on a repetitive basis, the musculoskeletal system must be prepared to withstand these loads. Much research has shown that an athlete cannot just play a sport to get in maximum shape for that sport, so a tennis player’s training plan should include a structured conditioning program that includes more than just playing tennis. Conditioning for tennis requires the exercises to be specific for the demands of tennis, and to be performed in a periodized manner in order to balance the workout load between conditioning and practice/play. As such, the roles of off the court strength training, conditioning, pre-game warming up and post-game stretching are very important.

When injuries occur, depending on the type and severity of injury, a consultation with your doctor will be advised. After a thorough medical examination and appropriate investigations, your doctor can then advise an appropriate management plan which will often include rest, cold compression, pain killers, anti-inflammatory medications, physiotherapy and rehabilitation. Surgery will be considered in cases where non operative management is not suitable.

8. How can a women’s menstrual cycle affect her sports performance? Is there a best and worst time for sports, according to the menstrual cycle?

There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. This is postulated to be due to oestrogen and relaxin’s direct effect on collagen metabolism and behaviour.

Oestrogen levels reach their peak during the follicular phase of the menstrual cycle just before ovulation and remain elevated until just before menstruation.

The effect of oestrogen on bone and ligaments include:

  • Inhibition of bone cells that breakdown bone (osteoclasts)
  • Inhibition of the development of new cells that breakdown bone
  • Promotes the survival of cells that build bone (osteoblasts)
  • Promotes the production of collagen in connective tissue including ligaments

Relaxin is produced during pregnancy; and in non-pregnant females during the luteal phase (2nd half) of the cycle. It peaks within 14 days of ovulation.

Effects of relaxin include:

  • Inhibition of collagen production
  • Promotes collagen breakdown

Taking into account the effect of these hormones, you might expect that women would be more vulnerable to injury pre-menstrually or at the beginning of the period when the ligaments would appear to be at their loosest. However, studies have shown inconclusive results. There are some studies that show there were more injuries than expected in the ovulatory phase of the cycle. In contrast, significantly fewer injuries occurred in the follicular phase. However, some have shown a greater than expected percentage of injury mid cycle where you would expect the tissues to be at their stiffest and thickest.

ACL Tears in Tennis players

Tennis players did not admit to significant impairment when performing the majority of tennis strokes such as forehand, backhand, volleys, and serves. The major limitation referred to was landing after hitting a smash. This task has often been perceived by ACL deficient subjects as being difficult to carry out with confidence.8 Many players from the study group referred avoiding the smash entirely.

Interesting information was obtained about displacement while playing tennis. Injured players did not have significant impairment in forward running such as in “serve and volley” or “reaching a drop shot” movements. This finding was in agreement with previous studies—for example, Czierniecki et al found that running in a straight line may not generate sufficient rotational torque to initiate rotational instability in the cruciate deficient knee.9 In contrast, ACL deficient players show major limitation when trying to “stop suddenly and change direction”.

This type of stressful deceleration creates high anterior loading on the tibiofemoral joint.10 Both external varus‐valgus and internal‐external rotation place increased load on the knee joint during cutting movements compared with normal running.11 Varus‐valgus and internal‐external rotational movements are believed to be responsible for increasing knee joint ligament risk of injury. External flexion loads, valgus and internal rotation during sidestepping all have the potential to increase ACL and medial collateral ligament load substantially.11 The ability of normal subjects to undertake deceleration tasks without ACL rupture or giving way of the knee is attributed to the coordinated interactions among the ligamentous and other soft tissue passive restraints, joint geometry and congruency, friction between cartilage surfaces, active muscular control, and tibiofemoral joint compressive forces.10 Approximately 86% of shear forces are considered to be restrained by the ACL12; however, in ACL deficient knees these loads must be restrained by the articulating surfaces and the surrounding soft tissues.10

Most ACL injuries are indirect in nature yet occur during contact sports. Tennis involves tremendous forces during cutting, pivoting, and sudden deceleration manoeuvres; nevertheless ACL injuries are less common in tennis than in contact sports.13,14 In this series, most injuries occurred during contact sports such as soccer or rugby, but the exact mechanism (direct v indirect) was not determined. Sallay et al13 hypothesised that a tennis player is not as likely to sustain an ACL injury because of the ability of the neuromuscular system to coordinate muscular function in anticipation of each movement, with little surprise effect. Many investigators have indicated that anticipating a movement can change reflex responses and postural adjustments to minimise forthcoming perturbation and maintain appropriate posture.

Besier et al15,16 were able to confirm previous hypotheses indicating that knee joint moments increase under unanticipated conditions compared with preplanned manoeuvres, primarily because of a large increase in varus‐valgus and internal‐external rotational moments under unanticipated conditions. It is believed that unanticipated movement alters the external moments applied to the knee by reducing the time to implement appropriate postural adjustment strategies. Tennis may cause a low incidence of indirect ACL injury owing to the absence of frequent complete twisting manoeuvres and high jumping, as well as enough time for the player to anticipate strokes, especially from the baseline.

ACL injured players described significant impairment of their recreational tennis performance compared to preinjury level. Results from the present study may support the need for surgical treatment for competitive tennis players with ACL deficiency. Further studies are needed to determine the true incidence of ACL injuries in tennis, to analyse tennis motion knee biomechanics, and to establish the degree of improvement in tennis ability after ACL reconstruction.

Tennis players with an ACL deficient knee showed a clear incapacity to play on hard courts, where demanding eccentric deceleration motions occur. Frontal and rotational knee moments are thought to be increased when playing on hard surfaces owing to greater friction between the foot and the ground.11,17 Clay courts seem to be a better option for ACL deficient players.

Limitations of this study include problems associated with questionnaires, and shortcomings related to retrospective determination of the preinjury performance level.

In summary, complete rupture of the ACL is a debilitating injury that causes significant alteration of knee joint kinematics. Untreated patients have joint instability, chronic articular degeneration, and knee dysfunction. Tennis specific limitations related to complete isolated ACL rupture were clearly identified. Tennis players with an ACL deficient knee showed significant impairment of subjective sport performance, limitation in landing after smashing, limitation in stopping and changing direction, limitation when playing a three set singles match, and limitation in playing on a hard court surface compared with healthy controls.