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The MDT approach to Paediatric Knee Management as a region The role of rehab in ACL injuries in adolescents and adults

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Summary

Discover the evolution of a pediatric knee multidisciplinary team at Adam Brooks in this engaging session. Learn valuable insights into rehabilitation as it pertains to adolescent ACL injuries. Dive into the mid-to-late healing stages and understand the necessary steps to aid a patient successfully return to sport. Discover how this ongoing work emphasizes the importance of collaboration between adult and pediatric orthopedic specialties, discussing a variety of pathologies. Insights into the rising incidence of ACL injuries in adolescents, factors increasing risk in females, and the role of biomechanics and physiotherapy will also be explored. Your participation clearly underlines a commitment to your professional understanding and improving patient outcomes. Such knowledge is not just beneficial for adult and pediatric medical professionals, but also for orthopedic surgeons, radiologists, and physiotherapists. Don’t miss this opportunity for a comprehensive look at this fascinating subject.
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Description

Infection

Pain

Alignment

Soft tissue Injuries

Learning objectives

1. Understand the origins and evolution of the pediatric Knee Multidisciplinary Team (MDT) at Adam Brooks, and its role in the management of pediatric knee injuries. 2. Recognize the role of rehabilitation at different stages (early, mid, late), and its importance in returning the patient to sport following adolescent Anterior Cruciate Ligament (ACL) injuries. 3. Identify the challenges and inconsistencies related to the management pathway for pediatric adolescent patellofemoral dislocations at Aden Brooks, and understand the need for improved collaboration between adult and pediatric orthopedic specialties. 4. Explore the incidence of ACL injuries in the adolescent population, especially in females, alongside the intrinsic and extrinsic factors contributing to the risk of these injuries. 5. Learn about the British Orthopaedic Association's guidance for the management of ACL injuries in the skeletally immature individuals, and understand how multidisciplinary teams (MDTs) fit into the bigger picture of these guidelines.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

About if you're about to move on to the next slide. Um It'll show you what we're talking about. Um So we're gonna discuss the evolvement of um a pediatric knee MDT here at Adam Brooks. Um and how that kind of came about. Um And then we're gonna overlook the the role of rehab in the adolescent ACL injuries. Um Specifically, we're gonna look um a bit about rehabilitation, the early mid and late stages of rehab and how we get someone back into returning into sport. Um So if you'd like to move on to the next side, super. Um So basically, the E MDT arose from a project by one of my colleagues um in around late 2022 or 2021 I say, um where we were looking at the pathway and outcomes of um pediatric adolescent patellofemoral dislocations here at Aden Brooks. Um We were finding that um the pathway was relatively inconsistent. Um and our management um was quite variable or people's management was quite variable. Um Some would come through fracture clinics, some would be seen in A&E some would get referred to us here in physio, whereas us wouldn't get any physio. Um So we kind of wanted to create some continuity and um establish some, some guidelines. Um But actually, it turned out um we kind of evolved the, the knee MDTA little bit more from it instead. Um So we identified there was a need for that collaboration between adults and pediatric orthopedic specialties um particularly within the complex cases. Um And with those that were skeletally immature, so they're still growing um at R MDT, um all different pathologies are discussed. So, um it might be those with ACL injuries, but it might be those with um chondral defects or, or younger people or um a variety of different things if you'd like to move on to the next slide. Um So this is our current working model here at Ain Brooks. Um So there's a monthly virtual meeting. Um So it's the third Thursday of every month. Um There's multidisciplinary teams. So there's physios and consultants which go. Um My colleague actually is a little bit more involved than I am. So, um I'm not sure if there's anyone else that attends um registrars, I think as well. Um But there's a multicenter participation with that as well. Um The general um form is that there are case discussions um between um everybody, there's sharing of practice and knowledge on those kind of specialty areas. Um And sometimes reviewing relevant publications and things like that as well. Um So we found it to be a really supportive and kind of open forum for um both the adult and the pediatric um specialties. Um So there's a, a lot of knowledge um that can be gained on, on both sides. Um And we've found that it improves our understanding um from a physio perspective as well and improves our kind of patient outcomes and, and their journey as well, kind of thing. Cool. So if you like to move on to the side, so we're just thinking about how, um, our MDT uh fits into the kind of bigger picture of, um, and we're gonna look a little bit more about ACL injuries specifically. Um So because there's been quite a substantial increase in um, er, the incidence of ACL injuries in particular in um, the adolescent population and pediatric population. Um, there's been a lot of guidance reviews um in particular in uh January 2021 the British. Um, sorry, I'm not very good at the, the acronyms, but the British Association for Surgery of the Knee and the British Society of Children in orthopedic Surgery, um, had a survey within their committee, um looking at um ACL injuries and how they're managed and things like that. Um So from their recommendations, they um highlighted that um an MDT approach is necessary or at least the surgeon that is doing the, um, the reconstructions, uh they're doing a high volume of them, um, so that they're kind of um familiar and, and frequently doing the the operation. I think they found that around sort of 85% of um a cr reconstructions in this glut immature was done by adult surgeons or as an 85% of surgeons were doing those surgeries and only 25% of pediatric surgeons um made up their caseload. Um The British Orthopedic Association in May 2022 have also put out their guidance for the management of ACL injuries in the skeletally and mature. And that's with reference to the um sort of assessment diagnosis and um surgery and postoperative care if we'd like to move on. Um So the incidence, as I had mentioned has significantly increased in adolescent ACL injuries over the last um couple of decades, both the volume overall. So both within males and female has increased dramatically, but the the female right rate is much higher per athletic exposure. So, um it's been shown to be about 2 to 8 times that of the male counterparts, for example, in basketball, um, they've shown that it's six times more likely to have an ACL injury if you're female than if you're male, if you're playing at the same level, um and the same age kind of thing. Um So it's an increase per athletic exposure. Um So why are females generally more um prone to or at risk of ACL injury? It's because um they have a decreased biomechanical and neuromuscular control of the knee. Um, they have greater knee abduction angles and um movements. Um and they have higher ground reaction forces during their landing. Um And they've got reduced um uh sort of joint stiffness um compared to male counterparts. Um So on the next slide, I'll just go into a little bit more detail about some of the factors that come into um the risk of ACL injuries. Um So if you just want to move on, so next five days, could I have the next slide, please? Uh uh Anyway, I'll, I'll go on to talk about them. Um And then you'll, you'll see on the Yeah, perfect, sorry, thank you. Um er So I've put it down into some intrinsic and extrinsic factors and this is probably not an exhaustive list of um all the risk factors for ACL. Um the, the FM brackets means it's a high risk um for the female population. Um So on the intrinsic side, um your increased Q angle. So we know that that affects your um er sort of loading mechanics um and impact in, in that kind of thing when you're landing, jumping all of those things. Um So if you must have that increased angle that puts them more at risk, um generally in the pediatric population and the adolescent population, there's a lot more dynamic valgus at the knee um because of weaker hip abductors um as they are growing and strengthening, that is an area that we commonly see that is quite weak, which means again, as associated with that Q angle when you are landing and your, and your biomechanics are impacted. There's a lot more valgus force at the knee. Um, putting stress on that, on that um, knee joint, um, quads dominance um, over hamstring dominance is a thing that's, um, again, a little bit more, um, frequent in the, the female population. So it's just where they're, they're a lot stronger in that muscle group. Um, and, and kind of those forces that are exerted over the knee change, that biomechanics increased bone anteversion. Um again, um, often seen and links towards those weak hip abductors. So all coming into play together um and an increased um tension through the ACL as well with those kind of angles. Um poor nutrition, fatigue and poor sleep. Um kind of all go a little bit together. Um in terms of um that reduced um reaction speeds and um ability to control the body. Um, it's actually, um, there's been a lot of research into female footballers. Um, and that's again where sort of that fatigue and poor sleep has come into play. And um, we also know that actually it's quite, er, adolescent athletes are probably quite undernourished, generally not undernourished, but find it harder to feel they do a lot of sports a lot of the time. Um, and keeping up with that whilst they're growing is also quite a challenge. Um, hormones generally also affect more of our, a female population, um in particular, their sex hormones which are um going around at that time and laying down more fat. Um, this can then disrupt a little bit of the, the body weight and then your strength to power ratios are affected as well. Um And again, your, um that just throws you off balance in your biomechanics and your understanding of how your body is working and adolescents and Children are going through those periods of um growth, we lose our reception and we have to regain those skills and that learning. So again, all falling into those biomechanical um sort of changes which are happening. Um Meaning that we are less control around our knees. Um Some of the extrinsic factors, um they're training to a higher level. Um but some of the er ground surfaces and the surfaces that they're playing on are not appropriate for are, are not matching that level of performance. Um There's lots of uneven hard ground um and, and access to, to nicer pictures are, are, are less available. Um, footwear has been a thing that again, with the female um high sporting football population at the moment, they're doing a lot of research around and it's all about where the cleats are, are configurate. Um so that your weight distribution um is changed as well. And also finding that the friction coefficient if you're running on hard ground or uneven ground or if you're, um that can be another factor in it obviously the sport that you do. So, um the volume of pivoting, decelerating, jumping within that sport um plays a big role in your increasing your risk. So we know that sports like basketball, netball, football, um lacrosse, which has been started quite a lot in the US, um are all high risk sports. Um, Children, especially this goes with the higher level of training are tending to be a bit more specialist in sports these days rather than um undertaking a variety. So again, they're um not getting a global strengthening sometimes and they're, they're overplay one sport quite a lot. The seasons tend to be a bit longer as well. Um, and, and sort of the intensity of training is increasing if I want to head on to the next side. Yeah, perfect. Um, so diagnosis, um obviously they may be a little bit delayed depending on where they present. Um, they come through various routes for us, um, maybe directly through the GP, um or they might come through A&E with a soft tissue injury, um, or they might just come to see physio privately or in the NHS. Um, Children are generally poor historians. So again, that can sometimes affect the, the um speed of diagnosis, um because we're unsure of what's happened generally. Um, but probably there's a bit of a lack of awareness of um these kind of injuries in, in the pediatric and adolescent population generally. Cool. Um, so, er, the guidance um that the British Orthopedic Association put out, um in 2022 said that the um non operative management of acr ruptures is possible. Um But we tend to want them to avoid those pivoting sports um and have a quite a strict adherence to a rehab protocol. Um So again, that's learning your biomechanics and, and maintaining that rehab throughout your um sort of skeletal maturity. Um So this probably isn't very ideal for a lot of teenagers. Um They want to get back into things. It's sport is social. Um And, and that's where um we want to kind of keep them involved in sport as well. Um They said if there is a meniscal pathology is present then or there's persistent instability, then we should go for surgical recent instruction and it not be delayed until they're skeletally mature. Um It's also stated that they should have rehab in centers which are age specific rehabilitation experience. Um That's so that they can get the physical um rehab that they need, but it's also psychologically matched for their maturity as well. Um So if it's perfect. Um So we're looking at the goals of our surgical intervention. Um So what we want to do is restore a stable well functioning need that allows for that active healthy lifestyle across the individual's lifespan. Um We want to reduce the impact of existing and future meniscus or chondral pathologies. Um And we want to minimize any risk of growth arrest um, along with any femoral and tal deformity. Ok. Cool. So, um, essentially, er, we're gonna look a little bit more at the rehab specifically for an adolescent that is mid or post pubertal. Um, the rehab may change slightly if they are pre prevital, um, just based on their ability to strengthen and how they strengthen in slightly different ways. Um, so I thought we'd just actually focus on the rehab for mid to post prenatal. So they're gonna look more at the similar to an adult protocol. Um So the value of the, the prehabilitation, so actually quite important here um of trying to regain strength. So we've seen that a twen just a 20% difference um preoperatively as a predictor for poor quad strength and low um self reported function um after surgery. So the, the more we can minimize that um discrepancy, the better. Um if you're going into it with a 40% asymmetry, that's a lot to gain. Um There has been shown that sort of the strength gains within adults uh around 2% a week. So if you think of that up to, you're trying to get a 40 or 50% back, that's a considerable amount of time and that's without the sort of postoperative um er strength deficits that you get as well. Um So a lot of the progression through rehab is actually based on sort of limb sense symmetry. So building back up um to to minimize the deficit between each leg. Prehab can also give you that time to work on somebody's movement patterns. So, addressing their current movement patterns, um and getting them to um learn how to squat and lunge properly. These should all be safe movements and done within sort of what pain allows. But if we can enhance the biomechanics preoperatively, that is gonna carry over a little bit better to our postoperative management. Um So it gives us that window of opportunity to address those movement patterns. We can also brace in the preoperative period. Um And it said that we should probably do that for um sort of the prevention of instability. So if you do have a really unstable joint and they haven't got a meniscal injury at that time, um it might be worth bracing to prevent any meniscal injuries. Um Also, especially in um some of our adolescent population, they're so keen to get back to sport. Um They don't want to sit out for a long time. Some of our surgical waiting times at the moment can be significantly long. So 6 to 12 months, that's a long time for somebody to be out of their sport. Um We don't want to encourage them to go back to playing sport, but if it's hard, if they're gonna do it anyway, we want to make them as safe as possible or find a way that they can um be involved in some aspects, but that limit the complications, super. Um So the other side of rehabilitation, rather the physical side is the psychological preparation. Um So there's a lot of education and expectation topics that they, that they should be talked about. Um So they want, they need to understand the rehab and what it's going to involve. Um And what our expectation and aims are of that rehab process um managing sort of the school and the social environment, especially within that first six weeks after surgery. Um So that they, a lot of, again, our adolescents are in sort of exam time or school time. So um minimizing that disruption to their school environment um or having work that's being set and things like that and social activities as well. Obviously, it's an opportunity to talk them through um how there is variability in the rehab process and there and it's a very individual recovery time. Um There are generalized guidance but um and time frames, but actually, it's not when you achieve a time frame that you can move on and we can let you do more and, and go back into doing things. It's very much a performance driven rehab. So um that it's almost, it's those biomechanics, it's those movement patterns, it's that strength and symmetry that um is gonna help move the performance on and, and progress through the rehab process. Um The, so talking the expectations in that very acute phase. So within the first week or two it's been shown that sort of like lowering the preoperative anxiety, reduces postoperative pain. Um and anything we can do to reduce that postoperative pain period um is very beneficial. Um So, in terms of our rehab, um it's very much a dynamic multijoint neuromuscular control is the focus of our rehab. We are trying to get people to learn their body to have control over it, to have good biomechanics. Kind of, as you can see in this picture of this chapter in a single leg squat. Um There should be a really good alignment um between the hip, knee and the ankle. We follow the Sheffield Protocol here at Adam Brooks, um which was generated in um 2019, I believe. Um and looked at the, the current evidence in, in um adolescent and pediatric rehab. Um So that's the one we tend to follow at the moment it goes through and every rehab should go through differentiating between strength reception and cardiovascular fitness. We want to target all of those areas um Equally. Um So that we're building kind of a, a rounded um individual at the end that we look at all those things throughout those stages. There's a variety of kind of um phases and the way that it's named within the literature that I found. So, um some people call it acute, mid late stage return to sport. Um The Sheffield Protocol has five phases and the first three are broken down into the sort of acute phase um and mid and return to sport is kind of um the last two phases, basically. Um So the acute phase, um so our main priority within that phase is managing pain and swelling. Um We know that that arthrogenic pain is going to cause muscle inhibition and muscle atrophy, we want to minimize the muscle atrophy as much as possible. Um So getting that under control, um walking, moving with crutches and getting confidence in that kind of, um, those mechanics is really good. We want to gain the full extension at the knee. And that's the, the thing we want to get back the quickest in terms of range of movement. It's really important for, um, that normalizing gait pattern. We can't walk with a flexed knee. Um And we're gonna reduce our, our strength gains within that. Um And when you can sort of manage that holding that terminal knee extension, um, in stance, we can, we're moving off the crutches and things like that. Um So that, that phase is really important to get them off to a really good start. It's really hard in adolescence because the these fundamental bits that tend to be quite boring. Um And they're not interested as much as, as doing sort of like their later stage and it, it's hard to get them to do exercises. Um But it's about drilling into them that the fundamentals set you up in a good space for the rest of it. Um There are restrictions which may come into play which delay this phase. Um So if there has been a miniscule repair that's been needed, um This might put them in a brace for a while or it might um er affect their weight bearing status so that again could cause delay and we can only try and reach the ceiling that we can within that phase. Um So the one restriction again, that they all would have in the space that we follow, I think again, the evidence is um particularly in the adolescent population, um Everyone has different opinions on um but we don't like to do open chain quads work within sort of um this phase just for the stress and um that it puts through that graft. Um So outcomes that we're looking for at this stage and generally by so by the end of this 12 week period, um that we've restored full range of movement that we've got good power in all major lower limb muscle groups, um that there shouldn't be any swelling anymore and that they're able to walk 20 minutes um without crutches, pain free. Um So that will be in a straightforward um sort of routine patient. So, um the next er, talks about mid to late stage rehab. So this is quite a long period. So in the Sheffield protocol, probably go from about week 12 to 27. Um So again, this is where we're building most of our strength um in our movement mechanics as we have done with the prehab. So squats lunges, um dead lifts, car phases, all those kind of things to get everything nice and strong. We're building in our proprioception with instability tasks. So standing on wobble cushions or unstable surfaces um with two legs building through to one leg, introducing sort of throwing, catching kind of tasks um to all build that proprioception in um we will throughs. Um So what we want again are foundations of good biomechanics of squat landing and form. Um when we're, we want good absorption of a landing, particularly building into from a height. Um And, and we shouldn't have that knee valgus when we are absorbing that impact of landing, we then want to progress parametric with power through double leg and single leg with distance and height. Um And then we also in conjunction with that, we will build running in along that side of that. So running in straight lines um to building through running and changes of direction and some basic agility drills. So the outcomes at that stage um is having a hop index of um over 75% of the other legs. So that's basically a standing um single leg hop forwards in comparison to the non operative side. Um It has to be served within our adolescent and um population. We're not just looking at how far you can jump and how much of a comparison it is to your side. We want that landing to be solid and repeatable and reproducible. So biomechanically sound at the end of that stage as well, not just the fact that the numbers work. So next slide looks at um the return to sport phase. Um and this is what should be thought of as a phase rather than just right, you can return to sport. Um It is still work in itself moving through the inclusive strength prick reception, appropriate acceptive skills, cardiovascular, fitness and biometric work, we would increase the volume of sports specific training. So, um, cutting or change of direction drills, introducing a bit more equipment using a ball, football, if they're football player, that sort of thing. Um, and, and almost you want to work through those planned agility drills and um sport specific drills at the end of that phase if, if they are managing well with those things, that's when we want to start building in what we call sort of chaos into activity because sport is essentially chaos when you're out on that field with, you know, 11 half, however many other people that are all of that age, um, there is things to react to, there's people to react to and the competitive element comes across as well. Um, so it's very different going from a preplanned, right? I'm gonna run forward and cut at 90 degrees and this is what's expected of me. Now, in this drill to, I'm running forward. Oh, there's someone in front of me. Oh, there's a ball, there's a change of direction, an unplanned event basically. Um One of the other things to build into that phase is exposure of cliometrics under fatigue. So quite often I am programming cliometrics into the, the beginning pha um part of somebody's rehab session because we wanna work on cliometrics when we're freshest when we've got the most power because that's how we're gonna build our power and strength. Um But actually, we are running, hopping, jumping throughout the entire of the game. So actually, we need to build it in a little bit more when we're tired. Do we still have that ability to control our knee valgus? Um And that's really important in that return to sport phase. Um We know it's important for their confidence um in order to be able to rent home to sport. So that's why that phase is actually really, really important. Um So the outcomes are looking at hop index of over 85%. And um whilst the protocol kind of says we want strength no less than 90% of the other side. Actually, we do probably want to um get beyond that. So we want to go to 100 and 10% of what the strength was beforehand kind of thing. So we want it more dominant the other side um that goes into our next slide, which actually um is on injury prevention. So the reinjury rate um in our adolescent population is as high as um a third. So, um up to 30% and it's been shown to be um 2.7 times higher than in adults. Um So actually this is when uh getting them even better and than they need to be kind of thing is really crucial for that part. Um There's actually a really high cont your injury rate as well, um which is why our rehab throughout all of those phases would look at both sides as well and try and um encourage um sort of strength training bilaterally as well, not just focusing on the operated side. And so, er, the prevention, prevent injury and enhance performance. So pe um is a project that was done by um in Santa Monica in um the US, they basically were looking at the volume of ACL injuries in female um soccer players and they um developed a program, a warm up program um that was known as FIFA 11 plus, um based on these principles that they um er understood. And so it was all about muscle activation prior to um prior to sports. So massive activation, um preparing biomechanics and landings, um and making sure that, that, that people were physically ready um to go into sport warm ups have traditionally sort of been very halfhearted, bit of stretching, bit of a jog around the pitch. Um But these resources have been really useful for lots of, um, teams, um, and for injury prevention, um, it has shown that it could, um, prevent injury by up to 50%. So, uh, the power up to play is also, um, endorsed by the, er, British orthopedic Association and that, that's based on the principles from prevent injury and enhance performance. And then the last thing, sorry, I know I whittled through because I was a bit short on time. Um is just the considerations of rehab um within this cohort of patients. So, um returning to sport is obviously one of our goals of surgery as well. Um But we, the psychological readiness, we have to consider um anecdotally. I found that there's a lot of anxiety within particularly the female population, um and their confidence returning back to, to sport. Um Generally, we know that they are slower to build strength gains. So that's why their rehab is gonna take longer. And we have to look at the movement mechanics and their strength gains before we move them on to another stage, um or letting them return into. But um we have to consider the impact of their, their ongoing growth and development. Um because um like that proprioceptive um changes that are consistently ongoing. Um So we want them to, to keep going and working consistently at rehab. Um, the, the difficulty in this population as well though, um could be their eagerness to return to play. So, you know, six months after surgery. They're like, yeah, II can jog now, let me get back into it kind of thing. Um, and it's almost trying to, to slow them down to make sure they're as ready as they, they can. Um, I think this applies to adults as well but almost building a learning curve. Um, kids are learning their bodies and, and sort of their responses to things. I had a girl recently who I gave the, gave the girl a head to go running, she ran three days in a row and um then was in quite a lot of discomfort. So it was, it's basically that education as we're going through all of these stages. Um And sort of then them also learning. What do I need to look out for in a year's time in two years? Time? Is my biomechanics still good. Am I still, am I warming up properly before games and things like that? Um And the final thing is almost there access to equipment and gyms for strength training and things like that. What is accessible to them. Um It's just something to consider during that rehab process. I think gyms are a lot better at getting younger kids involved these days. Um But some of them aren't at the stage where they're going to, they're not going to gyms and things like that. And so access to equipment um which can be useful, might be more difficult kind of thing. Um Yeah, that was uh, yeah, pretty much it. Sorry. Um That was a lot of fast talking from me. No, thank you. That's a very, uh, that's an amazing talk on like oversight of what we do because normally we just put ACL rehab on the phone and something magic happens. So that's, that's, uh, that's really in to know, I guess the question, um, the questions that there's no questions so far on the chat, the questions I've always had is that what's your ideal state? You have an ideal world of injury? Day one, pick up day two. Uh, spoken to us surgery. Whe when's your ideal surgery? Um, ideal rehab, prehab time and ideal rehab time. No, that's, yeah, that's really interesting. Um, I don't know if my answer would vary based on a child versus an adult as well. Um, because I was listening to, um, cos there's a lot of strength and conditioning with adults at the moment and they, the high level football athletes, for example, go into surgery within a week of injury. Um, and that's mainly just so that the, the loss of muscle, um, is, is minimized as much as possible. Um, but I think there is a lot of value in that, that prehab time for managing expectations and understanding what's gonna happen. Um, I have had traumatic ACL s that actually they don't have that prehab time and they don't have prepare because they've come almost through a trauma and they probably are more complex because they've had other things that have happened at the same time. Um, but actually they aren't mentally as prepared and engaged in the rehab afterwards because everything's just happened so quickly. So, I mean, ideally you probably want surgery within, you know, and I know ideal word within three months kind of thing. 23 months. Um, and then, yeah, but I guess as soon as possible it is still better. And, and the other, the other thing I was gonna ask is in terms of muscle strength because you said it needs to be at least more than 90%. It's something that's not very measurable for the patient. And is it something that you measure in clinic or? Um yeah. So um yeah, uh we probably would try and measure it in clinic. Um Although it's probably not something we do quite as much as we could do kind of thing. Um So the the physical strength testing that you can have a handheld dynamometer, um that kind of measures that strength output. Um I think we um other ways you could do it is on some of the machi the equipment. So a single leg press um is quite a useful tool for kind of um judging arbitrary on, on a weight, what can you manage kind of in between? Um And, but I think for me still a lot more, it's all about um sort of that judgment of control and, and sort of, um, and you can tell when someone a, if their endurance isn't as good then their strength is not going to be as good. Um, and if their instability is there and their, their ability to absorb impact or their fatigue is quicker, that strength isn't there kind of thing. So, um, but yeah, I'm sure there's lots of other that have good stuff out there as well. Yeah, I do the, I do the, um, if it doesn't look like the other side, uh, and you've not listened to physio, then you should not do sports. Yeah, definitely, definitely. Don't go out to the, er, sport unless you've um, yeah, been fine seeing us for quite a bit. Thank you very much for joining us today. Cool. No problem. Thank you. So, uh, we'll have a very quick 3 to 5 minute break and I know I know it, Mitchells here. We'll try to kick off perhaps at 332 or 323 minute break in between and in the middle and I can go through the, it and see in terms of uploading slides and stuff. Ok. Can you hear us, MS Mitchell? No, I can't hear you.