golf and knee arthritis

Ditch the golf cart if you have knee arthritis

If you’re into sport, chances are you’ve played golf. It’s often the go-to pursuit for so many retired professional sportspersons, and for obvious reasons: it allows you to stay competitive well into later life with minimal strain and stress. The health benefits are manifold, as well: it’s been estimated that you’ll be walking for over six and a half miles while playing the average round of golf, which more than takes care of your daily recommended walking distance.

That is, of course, if you’re not using a golf cart. On the face of it, golf carts are an absolute boon, especially for those of us suffering from knee osteoarthritis. And if you’re already suffering from knee arthritis, wouldn’t forgoing the cart aggravate your ailment even further? According to a study into golf and knee arthritis that has recently been published in America, it seems that the answer is ‘no’.

Having a stroll won’t take its toll

Plenty of golfers suffering from knee arthritis seem to think that golf carts are a life-saver: in the late 80s, 45% of all golf rounds in America were played with a cart. Nowadays, that percentage has rocketed up to 69%. However, the new study – the first of its kind, conducted by the Shirley Ryan Ability Lab and Northwestern Medicine, and presented at the Osteoarthritis Research Society International Annual Meeting in Liverpool in April – demonstrates that playing a round on foot the course provides significantly higher health benefits. More importantly, walking is not associated with increased pain, cartilage breakdown or inflammation.

The study analysed the on-course habits of 15 participants – ten who had knee osteoarthritis and five who were of similar age, but were OA-free. The participants were invited to play 18 holes on foot one day, and then a round with a golf cart on a different day. The research team compared their heart rates to determine the intensity of exercise performed and took blood samples during each round to measure markers of cartilage stress and inflammation.

Dump the cart, exercise your heart

The researchers found that, prior to starting either of the rounds, the participants with knee osteoarthritis had an average pain score of 1.3 (on a scale of 0-10). When they played the round walking the course, they had an average 2.1-point increase in pain score. When they played the round using the golf cart, they experienced on average a 1.5-point increase – a difference that is deemed not clinically significant.

The research team also measured blood-based biomarkers of cartilage stress and inflammation. Although both methods of transportation caused an increase in these markers (as would be expected with regular walking), there was no difference between the rounds.

When walking the course, golfers with knee osteoarthritis spent more than 60% of the round with heart rates in the moderate intensity heart rate zone – which corresponds with other adequate exercise activities. When driving on a cart, however, golfers spent 30% of the round in that range. While this figure is lower, it still fulfils daily exercise recommendations.

So, while walking the course offers the most significant health benefits – and is not the aggravating factor on knee OA as first thought – the study found that riding the course with a golf cart during a round (and the walking that still comes with it) still offers cardiovascular benefits and helps fulfil daily exercise guidelines.

We know what excess body weight does to the joints, particularly the joints of OA sufferers, so the advice is clear: leaving the cart outside the clubhouse is a far better long-term option, because the idea that extended periods of walking is going to shorten your golfing lifespan is nothing to worry about. But the good news is that while walking is better than the cart, using the cart over not playing golf at all is still the better exercise option.

partial knee replacement

Partial vs full knee replacement examined

The argument between total knee replacement and partial knee replacement is one that has been raging for some time amongst the medical community. And so far, the battle is being won by the total replacement adherents: out of the 98,147 instances of knee replacement surgeries carried out in the UK in 2016, 91% of them were total knee replacements.

However, a new report conducted by researchers from Oxford University may start to turn the tide: according to their findings, many more people than first thought who are facing surgery for knee problems would be better off with a partial rather than total knee replacement.

As we know, partial replacements have long been seen as the suitable procedure for people who have suitable for people who have arthritis in just one side of the knee – usually the inner side, and only when the ligaments inside the knee are still strong. The benefits of partial knee replacement surgery are obvious: the patient has to contend with a smaller incision and minimally invasive surgery. However, the general rule of thumb has always been: if in doubt, take it all out in the form of a full knee replacement.

The case for partial knee replacement surgery

Recently, though, the research team – from the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS) – examined real data from a very large range of patients about their operations, their GP visit and their own reported quality of life outcomes, and concluded that partial knee replacements can be better for certain patients and could save the NHS a fortune.

The key finding was that the choice between a partial or total replacement varied from surgeon to surgeon – as did the success of the operation. And the surgeons who carried out more partial replacements had better outcomes from them than surgeons who performed fewer of them. As Co-Lead researcher Prof David Murray pointed out, this was a very important finding.

“If surgeons aim to use partial knees in a quarter or more of their knee replacements this will substantially improve the results of knee replacement and will save money,” said Professor Murray. “In addition, more partial knee replacements will be done and more patients will benefit from this procedure.”

One size knee op may not fit all

According to the research team, the next step is to investigate the potential benefits of partial knee surgery in more cases. However, they are keen to stress this shouldn’t be an across-the-board mind-set: they went to great lengths in the report to stress that while their research demonstrates that partial knee replacements can be better and cheaper for patients over 60, the long-term benefits for partial surgery in the under-60 bracket are less clear when compared to those of total knee replacements.

The cost benefits offered by partial knee replacement surgery are obvious – less theatre time, less equipment needed, and a patient occupying a hospital bed for an average of one day less. The benefits for the patient are similarly clear: less time in theatre, a quicker recovery time, and the fact that the patient feels more like they still have their own knee, instead of a ‘bionic’ one.

The lesson to be learned from this study is that surgery should always be tailored to the patient’s individual requirements which is the hallmark of Mr Jonathan Webb’s approach.


ACL tears in women

Why are women more susceptible to ACL tears?

It’s a conundrum which has bothered sports experts for years, and it’s borne out by statistical weight: women are two to four times more likely than men to tear the anterior cruciate ligament. But why? A recent study conducted by Duke University in Durham, North Carolina endeavoured to solve the mystery, and their findings make interest reading.

According to previous research, the reason why women are more susceptible to ACL tears pointed to an assumption that it was because their knees move differently – but the team at Duke weren’t so sure. So, they deployed a forensic approach to reconstruct injuries by examining bone bruises on the knees of 15 men and 15 women with torn ACLs.

While other studies have deployed patient interviews and slow-motion replays, the Duke team realised that video footage was ineffective in determining the precise position of the knee and the time of injury through footage. Instead, they used MRI scans taken within a month of the ACL rupture, identified bruises on the surface of the two large bones that collide when the ACL tears – the femur and the tibia – and then used 3D modelling and computer algorithms to reconstruct the position of the knee when the injury occurred. Their findings? Males and females actually have the same position of injury.

The team at Duke have been using their advanced imaging and modelling technology to great effect over the past decade in the field of ACL research, including debunking the notion that an inward buckling of the knee was the cause of an ACL tear, discovering that landing on an extended knee was the prime culprit. So, when they make a statement, the sports medicine world takes notice.

However, this current report still leaves us in the dark as to why women are more susceptible to ACL tears than men. Here’s what we know so far:

  • Women tend to have a narrower intercondylar notch – the groove in the femur through which the ACL travels – and a smaller ACL, which makes them more prone to injury.
  • Women typically have a wider pelvis, which makes the thigh bones angle downward more sharply than in men, which leads to more pressure applied to the inside of the knee, which can cause the ACL to tear.
  • Women’s ligaments tend to have more laxity, or ‘give’, than men’s, leading some experts to conclude that the excessive joint motion could be a factor in a higher ACL tear rate.
  • Research shows that the muscles stabilising the knee may take a millisecond longer to respond in women than in men, leading experts to speculate that this minuscule difference in contraction time could lead to a higher rate of injury.
  • Female athletes typically have weaker hamstring strength when compared to male athletes, leading to the hamstring having difficulty in balancing the power of the quadriceps, which in turn can lead to injury.

As with all athletes, regardless of sexual orientation, conditioning, strength training and proper coaching are your best defence against an ACL tear. Therefore, if you feel your training programme is lacking any of those factors, it’s time for a rethink.

knee pain

A new approach to lessening knee pain?

There’s a huge paradox facing the medical profession at the moment: while surgical innovations are being found all over the world, they all come at a huge cost to budgets and resources. And that dilemma is impacting on osteoarthritis professions more than most.

While the techniques and procedures have come on in leaps and bounds since the turn of the century, the demands foisted upon the profession are piling up.

However, a new treatment developed by the Vascular Institute of Virginia could provide a solution to waiting lists and precarious budgets: a minimally invasive treatment which could provide relief for people with knee osteoarthritis by blocking certain arteries in the knee, in order to reduce the inflammation that occurs with osteoarthritis. While it doesn’t repair the damage wrought by OA, it claims to reduce pain and improve flexibility.

In a small clinical trial of 13 sufferers of severe knee OA pain, researchers found that the treatment – known as geniculate artery embolization – led to reduced pain and improved knee function up to a month after treatment for the majority of patients.

How geniculate artery embolization works

The procedure begins with the insertion of catheters into key arteries in the knee through small incisions in the skin, with the help of medical imaging. Once the connections were made, microspheres are injected into the arteries, which block the flow of blood. The procedure takes between 45 to 90 minutes and doesn’t require hospitalisation or follow-up physical therapy. Out of the 13 test subjects, eight of them reported a decrease in pain, reduced joint stiffness, and improved physical function in the knee – and none of the thirteen subjects reported any major problems resulting from the procedure.

Why geniculate artery embolization could reduce pain

Geniculate artery embolization focuses on blocking arteries in the knee for a particular reason: because OA researchers believe that chronic inflammation in the joint causes new blood vessels to form and grow into the cartilage, the synovial membranes that line the joint capsule and the nearby bone – bringing new sensory nerves with them. By blocking these newly-formed vessels, the cycle of inflammation and damage is broken.

That’s the theory, in any case: another, more long-term study monitored 72 similar patients over an average of two years. And while 86 percent of them reported improved symptoms, a third of them had to undergo the procedure a second time.

So, is GAE the magic bullet for knee OA? While certain experts have estimated that it would be more expensive than most standard drug treatments for mild-to-moderate knee osteoarthritis, it could be a real solution for more severe incidences – particularly when you factor in the elimination of recovery time after knee replacement surgery. For now, the jury continues to be out – but we’ll be following any further developments with interest.

arthritis and ageing

Arthritis and ageing

We are fast becoming an ageing population and, according to Arthritis Research, we’re getting even older than we think, as the average lifespan of the world’s population goes up by five whole hours every day, meaning a child born a year from today will statistically live 76 days longer than one born today. Good news if you’re planning on having a long life – not so good news if you’re planning to live that life free of arthritis, one of the most common ailments that afflict us as we age.

While it’s true that arthritis is not an age-specific malady – research proves that the average ages that people develop it is between 30 and 60, and many babies are born with it – the fact remains that arthritis and ageing go hand-in-hand, and will have a profound effect on the society of tomorrow – after all, in a world where people are already starting to retire later in life, arthritis is going to have a major effect on our ability to keep going.

FoxO on the run

So why does the risk of arthritis increase as we get older? A recent study conducted by the Scripps Institute in California investigated that very dilemma. And according to their findings, the key to delaying and even avoiding arthritis is all down to a certain protein.

FoxO proteins get their name from the term ‘forkhead box’, which describes the shape of the motif formed by scores of amino acids which bind to a DNA structure. Also known as the Winged Helix, they play a very important role in the regulation of genes that perform a range of tasks – including cell growth, proliferation, differentiation, and longevity.

Previous research conducted at the Scripps Institute determined that a lack of FoxO develops in cartilage as our joints age and that people with osteoarthritis have a marked decrease in the genes our cells needed for autophagy, which is the process that allows our cells to remove and recycle damaged elements in order to stay healthy.

No FoxO, no lubricin

For the new study, researchers used mice with FoxO deficiency in cartilage and a control group of mice with no FoxO deficiency, in order to monitor how FoxO proteins affect maintenance of cartilage throughout adulthood. They noticed a severe difference in the mice with FoxO deficiency: their cartilage degenerated at much younger age than in the control mice. The FoxO-deficient mice also had more severe forms of post-traumatic osteoarthritis induced by meniscus damage and were more vulnerable to cartilage damage during treadmill running.

Researchers deduced that the FoxO-deficient mice not only had autophagy defects, but they also were unable to produce enough lubricin – a lubricating protein that normally protects the cartilage from friction and wear. This deficiency was associated with a loss of healthy cells in a cartilage layer of the knee joint called the superficial zone.

In other words, if you’re lacking in FoxO proteins, the problems start – and the cells in the cartilage can’t do the necessary repair jobs. Hopefully, the next step will be to discover why FoxO proteins drop off as we age, and how we can keep them there for as long as possible.

While we wait to discover why these proteins deplete as we age and how the process can be reversed, there are certain steps you can take to minimise the development of osteoarthritis.

  • Manage occupations risks – certain occupations involve repetitive movements which can increase wear and tear on your joints
  • Maintain a healthy weight – extra weight means extra stress on your joints. Controlling our blood sugar levels is also important as diabetes can trigger inflammation. It also makes a regular exercise harder which leads us to our next preventative measure
  • Keep moving – low impact exercise, whether aerobic or strength training can help you maintain healthy joints and strengthen the supporting structures of the knee or hip
  • Rest – regular exercise is important but do not overdo it and if an activity is causing discomfort then you should discontinue it until you’ve received advice from an expert

For more advice, call us on 0203 195 2443.

Bristol Joint Replacement Centre

Mr Jonathan Webb heads up new joint replacement service in Bristol


Bristol patients in need of hip or knee surgery now have a new joint replacement service dedicated to getting you moving as quickly as possible.

Knee specialist Mr Jonathan Webb has brought together a team of experienced and expert joint surgeons to form the Joint Replacement Centre at Nuffield Health Bristol Hospital, The Chesterfield. The surgical team have all performed a high volume of hip and knee replacement procedures over the years and offer the highest levels of clinical care and expertise, backed by Nuffield’s unrivalled commitment to patient care.

Mr Webb, who was instrumental in bringing together the consultant team, explains: “We have chosen to join together as an expert clinical team, following many years of working alongside each other in Bristol, to provide the best possible care for patients requiring hip and knee replacements.

“The Joint Replacement Centre programme is based on the latest clinical evidence and best practice, delivered by highly specialist, carefully selected orthopaedic surgeons. We are there to support patients all along the way; from assessment, diagnosis and treatment through to recovery and beyond.”

Stiffness after knee replacement surgery

How to treat a stiff knee after replacement surgery

After going through the challenges of knee replacement surgery, there’s nothing more demoralising than becoming afflicted with knee stiffness and often patients can experience a similar lack of mobility to their pre-surgery state. Although it’s not a complication that Mr Jonathan Webb’s knee replacement patients commonly experience, it’s worth addressing.

There are two main options for the practitioner when it comes to knee stiffness after knee replacement surgery: the first is to accept that the patient still has a way to go before the new knee ‘beds in’, and to recommend a regime of exercise and manual therapy whilst being overseen by a trained physical therapist, to gradually ease the knee into its workload. As a matter of fact, most practitioners will try this route as a matter of course.

If that doesn’t work – or in cases where it’s clear that the replacement knee procedure hasn’t ‘knitted’ effectively – then further surgery is advised and there are a number of options to explore:

MUA procedure

‘MUA’ stands for Manipulation Under Anaesthesia, and it does what it says on the tin: the patient is anesthetised, then the surgeon moves the joint through a full range of motion in an attempt to break through areas of fibrosis and scar tissue.

An arthroscopic exam and debridement

This involves examining the joint with an arthroscope (a camera fitted into the head of a needle) to see what’s preventing the knee joint from working, and then removing any dead, infected or damaged tissue therein, in order to give the living tissue the room it needs to do its business.

An open incision with revision

Simply put, the practitioner deduces that the new implant has been improperly positioned or has moved since it was fitted – or has malfunctioned – and goes in for a remove-and-replace procedure.

But which works best? A systematic review recently conducted by the Department of Orthopedics at New York’s Mount Sinai Hospital in New York City attempted to answer that question, by reviewing all of the articles on the three surgical techniques over a 42-year period. Although the bulk of the information over the years was sketchy at best, they managed to break down what they discovered by age, sex, time lapse between the replacement and adjustment procedure, and which technique was deployed.

The study concluded that the majority of procedures were conducted between two weeks and three months after the initial replacement surgery,

Results of each treatment approach were measured using change in knee motion and total motion. Any complications that affected the patients’ recovery or outcomes were also analysed.

The findings included:

  • Manipulation under anaesthesia (MUA) and arthroscopy are more effective in removing adhesions and other tissue debris than open surgery
  • MUA alone (without arthroscopy) appears to give the treated knee the most motion
  • Using an open incision to gain access to the joint had the worst results overall
  • The earlier the MUA, the better the results – but later MUA treatment is still effective

The moral of the story is that if you’ve had knee replacement treatment and you’re still struggling to get up the stairs, don’t assume that it’s something that will correct itself – get in touch with your practitioner as soon as possible so they can effectively eliminate any stiffness after knee replacement surgery.

arthritis therapies

New therapies being developed to treat arthritis in the future

Osteoarthritis continues to be one of the most common physical ailments to affect an already-ageing population, but an array of new treatments and potential arthritis therapies have been unveiled already this year. Some are still at the trial stage, while others are already being used around the world. Here are three ventures which could be worth keeping an eye on…

Stem cell research to the rescue?

The University of Liverpool’s Institute of Integrative Biology has announced a three-year collaboration with the American global medical technology company Anika Therapeutics, in an attempt to develop an injectable mesenchymal stem cell (MSC) therapy for osteoarthritis treatment.

The idea that stem cell treatment could alleviate the symptoms of – and even cure – arthritis isn’t new: a 2014 trial run by the Robert Jones and Agnes Hunt Orthopaedic Hospital Foundation Trust (RJAH) in Oswestry, Shropshire and funded by Arthritis Research UK and a 2015 study conducted in Ireland produced encouraging signs in the possibility of patients’ own stem cells being able to generate joint tissue: now the medical companies are sensing a commercial breakthrough, we could see a sizeable advance in the near future.

Could a protein injection alleviate arthritis pain?

Interesting news from the Keck School of Medicine at the University of Southern California: the development of an injection designed to combat the pain of osteoarthritis.

Deploying a protein called RGGD 423 – which regenerates cartilage and reduces inflammation by communicating with a molecule, called glycoprotein 130, which is responsible for promoting cartilage development when we are mere embryos, the injectable therapy is aimed at people who are suffering from an early to a moderate level of arthritis, and experts are already speculating that if the project comes to fruition it could save the NHS up to £1 billion per year.

However, as the project enters the trial stage, side effects – including high blood pressure, stomach ulcers and even strokes – have been detected. So, don’t expect to see this on the market in the very near future.

Could South Korea lead the way on OA?

Meanwhile, in South Korea, the single-shot treatment is already a reality. The cell gene therapy treatment Invossa was approved last summer, after undergoing clinical trials over there and in the US, where it was developed by TissueGene, a subsidiary of South Korea’s Kolon Group.

Invossa is a cell-meditated gene therapy – only the fourth of its kind to have been approved anywhere around the world – and according to trials conducted in the US, 88% of patients who were treated with it reported improved symptoms for up to two years. While Invossa is entering phase 3 trials in the US, the Koreans are already planning to produce and sell it in their domestic market in the near future, before exporting it to Japan. So, while it might take a while for Invossa to reach our shores, it’ll have gone through the most rigorous trials before it does.

Currently, none of these therapies is available in the UK market but if you like to discuss your treatment options, call 0203 195 2443 to arrange a consultation with Mr Jonathan Webb.

ACL reconstruction long-term success

Looking at the ACL reconstruction long-term success

Arthroscopic anterior cruciate ligament surgery is considered the gold standard treatment for ruptures of the ACL. Without this intervention, it is commonly thought that this injury can lead to functional knee problems such as instability, pain, associated meniscal injuries and, eventually, develop into osteoarthritis that can greatly impact on quality of life.

Among all the wealth of clinical data on ACL reconstruction, there are not many studies into the long-term outcome of ACL reconstruction. Often the injury is compounded by other trauma to the structures of the knee – the meniscus, collateral ligaments and damage to the chondral surface – and these related injuries impact on any evaluation.

One study that has evaluated the long-term outcome of ACL reconstruction surgery was recently published in the American Journal of Sports Medicine.  It was authored by the North Sydney Orthopaedic and Sports Medicine Centre, where I undertook a Fellowship in 1996, training under world-renowned knee specialists Leo Pinczewski and Merv Cross.

The first step was to select patients to review; initially 333 patients were identified who had been diagnosed with an ACL rupture. All wanted to return to sports that involved sudden changing of direction or pivoting or were experiencing periods of instability that wasn’t responding to rehab.

The next step was to eliminate any patients that had associated trauma to the knee; other ligament injury, chondral damage or meniscal injury. The clinic then had 90 patients remaining in the study. A standardised operative technique was used as the surgeons performed an isolated reconstruction using patellar tendon autografts. Following on, a standardised post-operative recovery protocol and rehabilitation programme was also prescribed for all patients, including a prohibition on returning to competitive sports that involve pivoting or sidestepping for six to nine months after surgery.

Evaluating long-term outcome of ACL reconstruction surgery

The experts at the North Sydney Orthopaedic and Sports Medicine Centre evaluated the patients first at yearly intervals and then at 10, 15 and 20 years after surgery, offering a really fascinating insight into the longevity of this surgical option. In fact, I was one of the authors of the paper that first reported on these 90 patients, at two years post-surgery.

At 20 years, 36 per cent of patients had sustained another anterior cruciate ligament injury. Interestingly, only 9 per cent re-injured the same knee whereas 30 per cent suffered a ligament rupture in the other knee, with three developing an injury in both.

The highest rate of reinjury was in patients under the age of 18 when the initial procedure was performed – something to bear in mind when treating younger patients with a ruptured ACL.

Another insight that the study gave was the gender differential; women were much less likely to reinjure the reconstructed ACL, possibly because they were far less likely to participate in strenuous activity post-surgery, but they reported worse knee function scores. Kneeling pain was present in the majority of patients and was persistent over 20 years.

ACL reconstruction and prevention of osteoarthritis

The study also evaluated the development of osteoarthritis (OA) in these ACL reconstruction patients as other studies have suggested it can play an important prevention role. Degenerative change was identified using radiography in 27 per cent of patients at five years, 51 per cent at 15 years and had risen to 61 per cent at 20 years. However, only a very low proportion of patients reported moderate to severe symptoms. The suggestion is that ALC reconstruction surgery may not prevent OA but can reduce premature degeneration.

football knee injuries

The importance of the warm-up: new study has shown football knee injuries in children cut in half

They might be smaller, but don’t be fooled: children’s sports injuries are deadly serious, particularly in team sports. For example, did you know that underage footballers are more likely to contract bone fractures and injuries of the upper extremities than their adult counterparts?

Call it a lack of technique, or the fact that their bones are still developing, or a willingness to chase the ball and get stuck into tackles – or, more likely, a combination of all three – but injuries in youth sports are a serious concern. So it was good to hear some heartening news last month from the University of Basel.

According to a study conducted by that university’s Department of Sport, Exercise and Health and published in the academic journal Sports Medicine, a warm-up programme developed specially for children can reduce football knee injuries by around 50 per cent.

The twenty-minute rule

 The study – which involved the monitoring of 3,900 players from 243 teams based in Switzerland, Germany, Holland and the Czech Republic – involved dividing the teams into a control group who went about their normal business, and an intervention group who adopted the ‘11+ Kids’ programme – a twenty-minute regime of seven warm-up exercises which were undertaken before every training session.

After just one season, the results were clear for all to see: the injury rate of intervention group was 48 per cent lower than the control group, while the rate of severe injury fell by as much as 74 per cent. The people behind the study are now recommending that all youth footballers should be adhering to a warm-up programme at least once – and preferably twice – a week.

Why would a selection of simple exercises cause such a change in the football knee injuries rate? There a clue in the name. By keeping the muscles warm, athletes of all sporting disciplines can nip a lot of potential problems in the bud. A warm-up session can prevent acute maladies such as hamstring strains and other overuse injuries, and steadily and safely prepare the body for a session of intense activity. As well as preparing the body, a proper warm-up session also focuses the mind, helping the athlete to get in the zone and concentrate fully.

Rugby got there first

As someone who is very much involved in the RFU, I also have to say that it’s good to see the round-ball game taking note of what the rugby community cottoned onto long ago: our injury prevention programme Activate sought to address the injury problem in our own sport, and came to the same conclusion – that player-conditioning was a key solution to bring down the injury rate in youth and adult rugby.

The programme has proven to be a resounding success: amongst youth players, teams who were highly compliant with the Activate regime achieved a 72 per cent reduction in overall match injuries, while the adult teams achieved a 40 per cent reduction in lower injuries – while both groups achieved a 59 per cent reduction in concussions. So it’s clear that in both codes, it makes sense to take time to warm up.