Professor Cathal Moran has treated thousands of patients, including farmers, during his many years as an orthopaedic surgeon. Many of these patients presented with degenerative osteoarthritic changes in their knee joints.

“While farmers are not necessarily more prone than anyone else to arthritis, they are active people – always out and about,” he says.

“In turn, anyone wanting to stay active into their 60s and 70s will often come up against the issue of arthritis. There are options out there to allow farmers and those with knee pain to keep fit and active. These include physiotherapy and exercise, anti-inflammatory medication and injections. It’s also important to know that modern knee surgery, if necessary, is a safe and effective thing to do for the right indications, and it can give people many years of good-quality life when they are otherwise struggling.”

Professor Moran is based at the Sports Surgery Clinic and the Blackrock Clinic in Dublin, as well as having a satellite office in his home town of Galway. He sees patients referred from across the entire country. These include injured athletes, players and patients with all forms of arthritis. The incidence of arthritis is growing, he adds, as is their need for non-surgical and surgical help to deal with it. Both men and women are affected.

Arthritis of the knee

The knee joint is one of the most common joints affected by osteoarthritis, he states.

“That’s because it’s a weight-bearing joint. Arthritis can be described as a disease of the joints that causes pain, swelling and stiffness. Through each decade of life, the wear and tear on the knee can increase. Arthritic changes may not cause symptoms initially, but as people move into their late 40s, 50s and 60s, this wear and tear of the joint can typically cause such symptoms.”

Treatment path

So, what’s the first thing to do if you are experiencing knee pain?

“Typically, people would go to their GP for advice,” he says. “He/she would take a history and ask about what makes the aches and pains worse or better and examine the knee. An x-ray would usually be arranged to show the extent of damage and to exclude anything more significant going on, such as a fracture or, in very rare cases, a bone tumour that might be causing pain. X-rays give a very clear picture of the bony architecture and bone change that is typically seen in advanced arthritis. Early interventions – treatments that can be done locally – would follow, as required,” he adds.

This may include some anti-inflammatory medication prescribed by the person’s GP.

“This would help alleviate not just the symptoms, but also help the patient undertake an exercise programme.”

Motion is lotion

Exercise and movement being a good thing is something that Professor Moran would like to highlight.

“That’s because many people have some fears of this causing more damage, but the exercises are a form of medicine,” he says. “Rather than just reaching for an over-the-counter tablet, exercise can often be the first way of treating knee pain. Using icepacks on the knee in the evening after rest or after extreme use can be helpful, too.”

Weight management is also very important.

“Even small weight losses can reduce the impact on the joints a lot,” he says.

“Low impact activities, such as swimming, cycling, jogging or tennis are good, also. Using a knee brace or crutch can be useful if the pain is particularly severe.”

Professor Cathal Moran.

When the person consults an orthopaedic specialist, an MRI as well as an x-ray may be recommended.

“The MRI is useful where the diagnosis isn’t clear from the patient history and examination and the x-rays,” he says.

“They are usually more useful for assessing earlier or soft tissue-type conditions, or assessing the extent of cartilage or meniscus damage of the knee following injury. An MRI would also be done if the person is experiencing symptoms at a stage where it would be unusual to have arthritis.”

Next option - injections

When a patient first comes to see him, Cathal’s hope is to get the person moving through non-surgical means; using physiotherapy and exercise routines as mentioned above. The next step (if this hasn’t worked) is to try injections into the joint.

“We use cortisone, which is an anti-inflammatory medication. We also use hyaluronic acid, which is a lubricating gel, and then, in certain cases, we’ve options of biological agents like platelet-rich plasma and cellular treatments.”

He suggests that several options should be tried before going down the route of surgery.

“It’s not clear which one of the injections has benefit over the other, so I would recommend trying one or two forms of injections before considering surgical procedures,” he says.

Types of arthritis surgery

For people whose pain hasn’t responded to non-operative treatment, whose walking is limited and who are being kept awake by pain at night, a joint preservation approach may be discussed (for example, a cleanout arthroscopy) to deal with isolated cartilage tears, osteotomy, and partial knee replacement.


“Osteotomy is where we change the mechanical axis or the weight-bearing axis of the joint to offload the most affected part. This is only suitable in certain cases where the rest of the knee is in relatively good shape and, typically we might consider young, male, manual workers for this,” Cathal says.

Partial knee replacement

Replacing either the inner half of the knee or the outer half may also be considered because of wear and tear to the inner joint or the outer side of the knee joint. This is known as a partial or unicondylar replacement. Advantages of a partial knee replacement are that it is associated with less risk in terms of swelling, infection and improved or quicker recovery rates in suitable patients.

Total knee replacement

When there is more extensive wear of the joints, a total knee replacement is considered.

“The advantages of it are in restoring good function and comfort to the patient. However, it is important for the patient to know that they are not getting back the knee they had 20 years ago, but instead a metal and polymer substitute. Managing people’s expectations in terms of outcomes in this regard is important.

“We know that people over 60 years of age can do very well with them but in people under 55, particularly men, there can be an increased risk of unsatisfactory outcomes,” he adds.

Realistic expectations are important

Unrealistic expectations can sometimes be involved too, unfortunately.

“Some patients hope to restore everything to what they would regard as normal or how they were many years before, but it is a substantial procedure and the risks and benefits need to be discussed in full after a clinical and x-ray review. However, it is important to note that joint replacements done at the right time in life can be hugely beneficial.”

Occasionally, farmers can be too stoic about it, in his experience, and let it go on to a very advanced stage where knee replacement surgery might have helped them to be comfortable and active for many years before that.

“Others may present too early,” he adds. “It’s about getting the balance right because joint replacement is one of the most effective surgical procedures of any kind anywhere in the world and knee and hip replacement are part of the bedrock of orthopaedics at the end of the day.”

Assessment process

  • Consultation to assess the knee clinically.
  • Up-to-date x-rays.
  • Trialling the least-invasive options, such as physiotherapy and injections.
  • When joint replacements are required, full discussions are had and the patient will be booked in for three to five nights in hospital.
  • Pre-op assessment at clinic to determine medical fitness for the operation will also be undertaken by a specialist medical team in advance.
  • Exercise and strengthening programs in advance of surgery.
  • A replacement, when required, usually takes place under spinal anaesthetic with a sleeping tablet also administered.
  • Procedures generally take one to two hours.
  • Pain relief medication is provided.
  • Patient is advised to link up with a local physiotherapist for support, which is a key part of people doing well after the operation.
  • Most patients spend four to six weeks on crutches.
  • Most will be doing well after three to four months but it may take a year to feel fully recovered.
  • The patient needs to be invested in having the operation and be aware they will need a lot of support after the operation and that exercises are important to get the joint moving again. “We see very successful outcomes in people who are heavily invested in engaging with this. The more work people put in, the more efficiently they progress and the better they do overall,” Cathal says. “If knee pain is keeping you awake at night or interfering with your quality of life, the key is to get assessed properly because there are good treatment options out there for you now. You won’t be rushed towards a joint replacement if it’s not for you.”
  • Treatment abroad scheme

    Public hospital waiting lists for joint replacements are lengthy so it is important to seek advice early if you are experiencing pain and don’t have private medical insurance. Having treatment in ?Northern Ireland or abroad (paying upfront or getting a Credit Union loan that will be reimbursed by the HSE) is another option. See the Irish Country Living article about treatment abroad at this link or follow the QR code here using your phone.

    For more information

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