"If it was my knee I'd be having it!" 

Premier League Head of Medical & European Head Physio, Peter Friar, shares his thoughts on the use of OSTENIL® injections for professional football players

(To watch the video clip on YouTube please follow this link or click on the first image below).

“Ostenil – we’ve used considerably I think, but I think it’s still quite underused in a lot of our areas. We often use it for players that are just coming to a point of their career where they’re starting to get some degenerative change, either in the ankle, or – more often – in the knee; and I’ve never seen a bad reaction to it, I’ve only ever seen positive reactions to an Ostenil injection. 

 

The procedure we will go through really is, we discuss the player’s symptoms and then it will be decided if this is the way forward. If Ostenil was an option, which regularly it can be for these kind of players, then we would discuss it with the player; and the first thing the player will say is, “Is it steroid? I don’t want steroids.” And the good thing is, we can say, “No, it’s a natural product that your body produces anyway, we’re just supplementing it, and it’s absolutely of no problem whatsoever.” And I always say to them, what my answer to every player is, “If it was my knee I’d be having it.” So, you know, I think if you can say that to a player, hand on heart, “If this was my knee this is what I would do”, then that sets the player’s mind at rest.

I’ve only ever seen positive reactions to an Ostenil injection.  

First and foremost, you’re trying to make sure that the player plays for the club, but also, he looks after himself as a human being. You don’t want players coming in and being utilised as a commodity, and then sent off to just look after themselves. You want the player to flourish at the club and perform his best for the club, but also have a future outside of the club. And our input in terms of that will certainly help them achieve that kind of aim.

We had a player here who had a chondral issue, and the chondral issue was dealt with surgically. And, again, you may argue that possibly that could have been staved off if we had used Ostenil earlier, who knows, you know, you just don’t know that. But he started to take them as a consequence of post-surgical stiffness and irritation, and once he’s realised that the effect it had on him it made him feel almost like the knee was as if it had not had surgery. He, you know, every time he got to the point, every 4 or 5 months, it felt the knee was starting to drop off again, he was starting to feel some irritation, a little bit of effusion in the knee, he’d have a top-up. Prolonged his career without a doubt. He had serious knee problems.

Ankle-wise – you can use it in the ankle, and, again, for the same reasons. Somebody has a degenerative change in the ankles, and that happens a lot in football because of the pivoting, rotational nature of the game, and the joint surfaces are getting roughened up. And, you know, an Ostenil injection into that ankle, again, will make it feel a lot more comfortable, will settle it down and allow the player to get back on the pitch and maybe prolong his career. And, I’ve seen that a number of times. We use it more often in the knee, but the ankle, certainly, we’ve used it on quite a few occasions with this club and my previous club.
 
Often trauma can then lead to degenerative change. We know ACL injuries, for instance, can have an accelerating effect on early onset of osteoarthritis. So in the athletic population, that’s massive. You pick up an ACL injury early in your career, and we know if you’re trying to get another 15 years out of your career then the likelihood is in that time you’re going to start picking up some more degenerative change because the mechanics of the knee have changed. So Ostenil can really help to get over that, and prolong that career and allow the players to play with more comfort, less irritation, more training time, and generally, you know, have a more successful and long career as a player, without too much, you know, too many aspects of their career and their training being affected by this degenerative change.

Ostenil can really help to prolong that career.  

A lot of the time, I think, HA could be there for the prevention of these onset issues. So we could use it when we start to feel that a player has a developing problem, we can use HA to help him reduce the acceleration of these issues, you know, chondral defect issues, this kind of stuff. From a surgical perspective, it would depend on the surgery, it would depend on the state of the knee. If you have an ACL without any complications, the ACL comes back, it’s very clean, his knee is clean, he has no degenerative change and it's just an isolated ACL, they would just let nature do what it does. Now then, it would be an interesting study to see whether these degenerative changes didn’t occur with the intervention of annual Ostenil injections, for instance. So these are all things we need to learn a little bit more about, but, all I can say is, you know, from the players that we’ve used it on, I just think it sometimes is the only answer. 

The early stages of degeneration are generally just a discomfort around the knee, sometimes it can be described as a ‘burning’ pain; they feel sometimes like it’s bone-on-bone. Some players might actually describe it, “I feel like it’s bone-on-bone”, and they start to have moderate diffusion, which is like a bit of swelling in the knee. But, generally, they just feel like discomfort. And they’ve had no history, no twisting history. You’ve got certain tests you can do on the knee to try and elicit the same pain, and this pain will tell you whether the pain is coming from the joint surface or not, or from the ligaments, or the soft tissue. So we can test them for that thing, but generally, they’re coming in and they are just not comfortable on the pitch, they have limitations to either flex or extension. And, as they start to do this, it develops quite … it’s quite obvious to pick them out, because there is no reason for their knee pain. They’ve not had a kick, they’ve not twisted and turned and caused any problems. You know, you can rule out a meniscal injury quite easily, and so you’re left really with the bony surface. And if that bony surface is roughened up and starting to degenerate, then is the time you can start using, you know, the Ostenil to try and improve performance, improve availability. Any players that have taken the Ostenil injections, they always come back in and say, “The knee feels great!” So it was different to how it was pre...

What HA will allow is if the knee is more comfortable they can go back to the basic strengthening programmes that they’re on, because the loading issues in the knee… You know we try to load them on the pitch, we want to load them in the gym as well to get them stronger, because the stronger they are around the knee then the less the joint is going to take the forces. So, giving them HA is to allow them to be more comfortable, will allow them to get back in the gym more, do more work, which will again have a secondary effect in terms of reducing the degenerative change in the knee.

I wouldn’t say any player at that point would get back to being, you know, 100% “brand new”, but they are a lot more comfortable. Sometimes they come in and say, “My knee does feel perfect”. But that depends on the stage, and if you pick them up earlier and start introducing it earlier, maybe, you know, maybe we’d get to the point where we can keep this degenerative change at bay.

I can’t ever remember anybody having an Ostenil injection and saying it never made any difference. It usually makes a difference, and it often makes a very significant difference.  

It’s a 2-minute job. A good surgeon knows exactly where to inject it into the knee itself. They sterilise the area, inject it, and then the only thing you get is the knee is a little bit full for maybe 24 or 48 hours where it feels… because they’ve injected fluid into the knee; and then over that next 24 hours, maybe 48 for the prolonged ones, they probably can’t train. Certainly, in my experience, it’s usually only 24 hours where we keep them off it, and then after that they’re back into their normal training routine. So, it’s definitely a very short, very pain-free, minimally invasive procedure.

The alternatives, you can see that every day when you talk to old coaches and stuff, you know, the cortisone injections that were taken, you know the famous cases like Tommy Smith for Liverpool, who you know was crippled by these cortisone injections that he apparently had. And you know, there are well documented cases out there you know, about the players and the effect of all these things. And, at the time, that was our best knowledge. 

The best practice now isn’t driven by that, and I do feel that we know that the HA is a naturally producing product, it’s just a supplementation. It’s just like taking a supplement, and we’ve just had a player in here now taking a supplement. He feels it’s helped him with his power and everything else, and with the HA supplementation, and for me it just seems crazy that we don’t offer this more often in every aspect of our population. 

Taking it all the way back 25 – 30 years, if you had any kind of issue with a knee you were pretty much facing the end of your career. And now you look at players, the players are coming back with ACL problems, they are coming back in 6 – 8 months and are back on the pitch and finishing their career. Whereas before, if you had an ACL you were pretty much finished, you know, in the game. Same with meniscal injuries, and anything where the change in the knee or the joint is such an issue that they just simply cannot function any more. 

Of course, for us it’s about keeping the squad available, keeping it playable, not just available but able to perform on the pitch. It’s okay having a squad, but if you can’t perform because they’ve got a stiff knee, or a stiff ankle, you know, it’s no point having them in the squad in the first place. So it’s not just about availability, but it’s about performance as well.

It just seems crazy that we don’t offer this more often.

I can’t ever remember anybody having an Ostenil injection and saying it never made any difference. It usually makes a difference, and it often makes a very significant difference. It’s interesting talking to the old coaches that have them, they’ve been through all this, they’ve been through these degenerative changes and they come looking for it. We are not suggesting to them, “Come and get an Ostenil injection”, they come looking for it."    

Peter Friar, Premier League Head of Medical & European Head Physio