Knee Surgery Prehab

The importance of Prehab: how to prepare for knee surgery

Knee Surgery PrehabIf you’ve suffered a serious knee injury and are awaiting surgery, the temptation may be to wrap yourself up in cotton wool and rest the knee as much as possible until the big op. New thinking, though, is that ‘prehab’ can be key to ensuring a rapid recovery and return to play.

In a 2013 study published in the American Journal of Sports Medicine, researchers looked at the effect a six-week exercise programme had on patients about to undergo ACL reconstructive surgery compared to a group that underwent no preparation. Twelve weeks after the operation both groups were tested for strength, function and patient outcome and the group that had undergone prehab were found to have better function and patient outcome and, significantly, returned to sport earlier than the other group.

Thankfully, the benefits of prehabilitation – a programme of therapy that not only physically prepares the client for surgery but also puts them in the optimum frame of mind to deal with whatever the procedure throws at them, with the goal of getting them back to their peak in the earliest time possible – are becoming better known.

While an extended period of RICE (rest, isolation, compression and elevation) is a given during the pre-op period, it’s also essential to introduce an element of low-level exercise. Not only does it strengthen the knee, increase flexibility and help the patient recover faster, it also gives them the feeling that they’re actually doing something to get back on track.

Mental preparation is key

There are numerous exercises that are suitable for an injured athlete to prepare themselves for surgery, and an orthopaedic surgeon such as Mr Jonathan Webb will work closely with the physio team to design a programme that will work best for the specific injury. But it’s equally important to consider the mental state of the client, because they’ve suffered far more damage than an injured knee.

Whether the client is a professional player or a hobbyist, they’re someone whose life revolves around physical activity. In a lot of cases, their sporting activity is more or less who they are. If they’re a pro, their career can be on the line, and they could be forced into thinking about giving up what they’ve spent a considerable part of their life on sooner rather than later. Even if they’re a weekend player, they have to consider giving up the activity they love, or at least being forced to spend a long time away it. In both cases, there’ll be a sense of disconnection: a feeling that they’re letting their teammates – and themselves – down.

Allay fears, set realistic goals

Obviously, this isn’t the optimal state of mind to be in when preparing for surgery, and prehab is the best way to counter that. The patient can become realistic about the timescale of recovery, with the goal of eliminating any frustration and demotivation that can occur both before and after surgery. It can also allay any fears the patient has. Most importantly, it can make them feel part of the team at a time when they feel they’re holding the rest of the squad back.


New study evaluates the risk of developing osteoarthritis after ACL injury

It’s one thing suffering from and getting over anterior cruciate injury, but a recent study from the Journal of Orthopaedic Research has flagged up an alarming side-effect: the heightened risk of osteoarthritis amongst recovering ACL sufferers.

Osteoarthritis-risk-after-ACL-injuryOsteoarthritis – a condition where joints become damaged, preventing their free movement and causing excessive pain – is the most common form of arthritis in the UK. Nearly nine million people in this country have undergone treatment for osteoarthritis, and it usually kicks in during the late forties. It’s an ailment that affects women more than men and, if you’re over 45, there’s a 33% chance that you’re one of the sufferers.

Unsurprisingly, the most affected joints in this country are the knees. According to Arthritis Research UK, an estimated 4.71 million people here have knee osteoarthritis – and with the onset of increased nationwide obesity and an ageing population, those numbers are expected to increase to 5.4 million at the end of the decade and to 6.4 million by the year 2035. In the US, the medical bills are even more of an issue: osteoarthritis comes only after heart disease, cancer, mental and trauma-related disorders in the list of costliest medical conditions.

How does osteoarthritis develop in ACL sufferers?

The Journal of Orthopaedic Research study – which involved tracking the progress of thirty athletes going through ACL reconstruction over six months – discovered that post-ACL patients multiply their risk of knee arthritis by anything from three to five times more than someone who hasn’t incurred this injury.

There are manifold reasons for this. Agitating the joint with repetitive knee adduction moments (the combination of the ground reaction force that passes medial to the centre of the knee joint, and the perpendicular distance of this force from the centre of the joint – otherwise known as ‘walking on it’) is a key element. Factor in the inability for the cartilage to regenerate itself fully after injury due to the lack of a blood supply, and it’s clear that an ACL procedure could cure one ailment while opening the door to another.

What can be done to avoid osteoarthritis?

Although research into the repair of cartilage injuries is still in its infancy, there’s a feeling that something can be done and soon. Much focus has been directed on the possibilities of stem cell research and one hospital in Switzerland is reporting early successes with a procedure that involves removing cartilage from the nose, then growing and shaping it, and transplanting it in the knee area.

Until then, it’s essential that taking steps as early as possible to implement a post-op rehabilitation programme – and ensuring that patients stick to it – is the best solution at the moment.


As Autumn Internationals kick off, England’s run of injuries raises concerns

As England’s Autumn internationals get underway when they meet South Africa at Twickenham on Saturday, some of our best players will be watching from the sidelines because it’s already been a brutal season for some of the leading figures in the game.

Maro-Itoje-rugby-knee-injurySam Jones was unfortunate enough to break his leg during a judo session, which will delay his national debut for some time, and Anthony Watson broke his jaw in a training session. James Haskell’s already-dodgy toe gave out in the test series against Australia, and is spending the start of the season in a protective boot. Manu Tuilagi’s groin injury has flared up again. And right before the beginning of the Four Nations, Maro Itoje fractured his hand in a Saracens game and has been ruled out for all four tests. And, at the time of writing, it appears that Courtney Lawes’ place in the squad may be in doubt after suffering a swollen knee during a training session.

It goes without saying that rugby is a very physically demanding sport, and injury is part of the game – but is there something else happening here? A recent article in the Guardian certainly seems to think so, drawing comparisons between the demands of the professional game on today’s players and what top-flight footballers have been experiencing for years: an increased workload brought about by international tournaments, conflicts between club rugby and the national associations, and an off-season that’s getting shorter and shorter. The Lions squad, for example, won’t be booking their holidays until July next year and then going straight into pre-season training.

Putting aside random events like getting on the wrong side of a judoka, what’s the main injury in rugby? For one of the most gruelling contact sports in the world, the answer may surprise you: a study conducted by the American Journal of Sports Medicine came to the conclusion that knee injuries accounted for the highest number of missed days in the rugby world.

Rugby and knee injuries

Out of all knee-related maladies covered in the study – conducted amongst twelve English clubs over the course of two seasons – anterior cruciate ligament accounted for the greatest proportion of days missed, followed by medial collateral ligament injuries. Most of the severe injuries happened during contact – mostly in the tackle – and flared up more frequently in the final quarter of a game more than at any other time.

Players in the back position suffered more than anyone else. Sixteen per cent of knee injuries occurred during training, and each club in the study suffered an average of ten knee injuries per season, clocking up a total of 353 missing days, and 1 in 20 of a club squad being out of action at any one time due to knee injuries.

While the more gruesome rugby injuries are always going to grab the headlines, knee problems are the chief cause of missed play. An orthopaedic surgeon such as Mr Jonathan Webb that specialises in the knee works with rugby players at all levels, aiming to return them to play as quickly as possible.


Will I need surgery to repair an ACL tear?

ACL-injury-options-BristolFor those unlucky enough to damage their knee, whether through trauma or sporting injury, the most likely injury is to the ligament and, amongst knee ligament injuries, the anterior cruciate ligament is the most vulnerable, accounting for 49% of injuries.

A surgical procedure to repair a tear to the anterior cruciate ligament, commonly known as ACL reconstruction, is a possibility. But, is surgery always necessary? Swedish researchers led by Dr Richard Frobell, published a report in 2010 which stated that 60% of ACL reconstructions could be ‘avoided in favour of rehabilitation’. They then followed that report up with a follow-up study in 2013, published in the British Medical Journal, that confirmed their findings.

The researchers claimed that there was no increased risk of developing osteoarthritis or requiring meniscal surgery later on if the patient underwent physiotherapy alone. The level of function, pain and activity were also no different. Half of the group that hadn’t undergone surgery initially went onto have a procedure to address instability, but the delay in surgery also had no discernible difference in outcome to those that underwent surgery immediately.

Why is an ACL reconstruction necessary?

The knee is a hinged joint and the anterior cruciate ligament runs through the joint, connecting the femur to the tibia and preventing the tibia from sliding in front of the femur. It is also required for rotational stability of the knee and, as a result, is often damaged when a player lands or pivots awkwardly.

If you’ve torn our ACL, whether partially or completely, then you’ll usually be aware of it immediately. Patients often report a ‘popping’ sound and experience pain and swelling straightaway. The knee may also feel unstable and give way.

It is important to seek medical advice if you suspect you’ve torn your ACL; a partially torn ACL can ‘recover’ if you follow a prescribed rehabilitation programme. However, a completely torn ACL may leave sufferers experiencing instability, with the knee giving way even while performing normal activities, which prevents a return to sport.

Why won’t the ACL heal itself?

The body is an amazing machine, capable of self-healing much of the damage we do to it. However, the position of the anterior cruciate ligament means that the body cannot heal even a partial tear. One of the other main ligaments of the knee, the medial collateral ligament, runs outside the knee joint and, when torn, a blood clot forms that provides the scaffold for new collagen tissue to form and fill the tear. However, the ACL runs through the knee joint which is continually flushed with lubricating synovial fluid. This fluid prevents formation of a blood clot.

During your knee injury consultation with Mr Jonathan Webb, the extent of the injury to your ACL will be evaluated with a physical examination and MRI scans. Other factors to take into account is the degree of stability in the knee joint and your personal circumstances: Do you perform light manual work? Would you like to return to a demanding sport that requires pivoting, cutting and landing? Are you very active or lead a relatively sedentary life?

Once the picture has been built up, Mr Webb can offer expert, impartial advice on whether ACL reconstruction surgery is the right option for you. To arrange a consultation at either his London or Bristol knee clinics, call 08450 60 44 99.


How long does it take to recover from a total knee replacement?

Total-knee-replacement-recovery-LondonWith over 80,000 knee replacement ops performed each year in the UK, this procedure to replace damaged bone and cartilage in the knee joint may seem ‘routine’, but concerns about recovery often weigh heavily with patients and this is a common question during consultations at Mr Jonathan Webb’s London knee replacement clinic.

Recovery after any operation always depends on the individual and the pre-existing condition of the knee.

Short-term recovery after a total knee replacement

In the short term, the aim is for the patient to be walking with either minimal help or no aid at all and for any discomfort to be much reduced. This is typically achieved within six weeks of the procedure.

Long-term recovery after a total knee replacement

In terms of returning to all normal activities, work and even the sports or exercise you may have enjoyed in the past, recovery can take anything from three months to a year, depending on what you wish to achieve. Extreme or high contact sport is not usually recommended after a total knee replacement, but a return to exercise and less strenuous activities are much encouraged.

Surgical wounds and soft tissues need to heal and the replacement parts have to bond to the bone. Swelling and pain typically settle down after three months but it can take up to a year for swelling in the knee to fully dissipate.

In conclusion

Patients may be worried about the recovery process after a total knee replacement, but if you are contemplating this procedure then you are likely suffering from osteoarthritis and experiencing a degree of discomfort and stiffness in the knee joint that is affecting your quality of life and the ability to perform even everyday tasks. Typically, patients experience a marked improvement in pain and mobility after the procedure.

Physical therapy is encouraged to restore full mobility to the knee joint and also strengthen the supporting muscles which may have weakened over time.

To find out if you’re suitable for a total knee replacement and to ask any further questions, please call 08450 60 44 99 to arrange a consultation with Mr Jonathan Webb at either his London or Bristol knee clinics.


6 key stages of rehab after ACL reconstruction surgery

6-stages-of-ACL-reconstruction-rehabThe most frequently asked questions in an ACL consultation are often in regard to recovery, particularly for those that have incurred a sports injury and are keen to return to play as soon as possible.

Choice of knee surgeon is key to the success of your ACL reconstruction, but the surgery is only one aspect. Physical therapy during the rehabilitation process is essential for a successful and quick recovery.

The key stages of ACL reconstruction recovery

# 1: Reduction of pain and inflammation

The first aim immediately after your operation is to reduce any pain and swelling resulting from surgery. Everyone’s experience of pain differs, but typically the knee will feel sore for the first few days. This is easily controlled with pain relief. The knee will have a tendency to swell in the weeks and months after surgery, but frequent icing of the knee and elevation will help reduce inflammation.

Pain and swelling restricts our ability to walk normally and one of the chief aims of ACL reconstruction rehab in the early stages is to ensure the patient returns to normal movement as quickly as possible.

# 2: Restoration of full knee extension

Normal range of movement of the knee joint encompasses full extension with a completely straight knee and flexion, which is a fully bent knee joint. After an ACL reconstruction, the pain and swelling is often alleviated by keeping the knee bent slightly. This can result in tightening of the tissues so restoring full knee extension is of prime importance and range of motion and stretching exercises are recommended.

A 2012 study in the American Journal of Sports Medicine found that long-term prevalence of osteoarthritis after ACL reconstruction was lower in patients who achieved and maintained normal range of motion in the knee joint.

# 3: Restoration of normal gait

After ACL reconstruction, the patient will often feel reluctant to bear their full weight on the treated knee, but this is crucial for restoring a normal gait. Exercises that strengthen the supporting muscles of the knee, particularly the quadriceps, are advised.

# 4: Increase in knee flexion

This is typically less of an issue after ACL reconstruction, but an increase in knee flexion should be balanced with knee extension exercises. Stretching and functional motion exercises are recommended.

# 5: Proprioception

This is your body’s sense of the position of your joints as they are in motion and is required for balance and stabilisation and therefore is essential for preventing injury. Balance training can help to improve knee proprioception when recovering from reconstructive surgery.

# 6: Preparing for a return to sport

Strength, motion and control of the knee in both legs will all be taken into consideration when evaluating your readiness to return to sport. The athlete should also be emotionally and psychologically ready. Knee surgeon Mr Jonathan Webb will work with your physical therapist, guiding you through every stage of your recovery after ACL reconstruction.

To arrange a consultation at either his Bristol or London knee clinics, call 08450 60 44 99.


What’s the difference between total and partial knee replacement?

partial-vs-total-knee-replacement-surgeryCurrently, there are approximately 80,000 knee replacement procedures performed in the UK every yearOsteoarthritis is the damage of the surfaces of our joints and during a knee replacement operation the worn ends of the bones and damaged cartilage are removed and replaced with metal and plastic replacement joints. Indications for this surgery are the pain and limited range of movement associated with osteoarthritis, but there are several different variations and techniques available and long-term success is dependent on choosing the right procedure for you.

Total knee replacement vs partial knee replacement

The knee is composed of three separate compartments – the inside of the knee, known as the medial compartment, the lateral compartment on the outside of the knee and the patellofemoral compartment, found on the front of the knee.
In the knee only one compartment can be affected – usually the medial compartment – and, for these patients, a partial knee replacement may be appropriate.

During a partial knee replacement, the anterior and posterior cruciate ligaments are preserved, whereas in a total knee replacement they will be removed. Preserving as much of the body’s natural tissue and structure is always the aim of any surgical intervention.

At our London knee clinic, the degree of damage to the knee will be fully assessed, but a good candidate for a partial knee replacement will also be of a healthy weight and still have a good range of motion.

Risks and benefits of total knee replacement and partial knee replacement surgery

A partial knee replacement procedure is a less invasive procedure so less damage to the bone and soft tissue, fewer possible complications and a faster recovery. Typically, there will be better range of movement once recovered.

The big difference between a partial and total knee replacement is that there is a higher risk of revision for a partial replacement and any revision procedure has a higher chance of complications and worsening of function afterwards.

The non-surgical alternative to knee replacement surgery

Knee replacement surgery is not always the only option for those suffering from osteoarthritis of the knee. There is a ‘shelf life’ for an artificial joint and the earlier you have a knee replacement, the greater the chance you’ll have to undergo further surgery in the future.

Knee surgeon Mr Jonathan Webb will always advise you on the surgical options and explain the pros and cons of having surgery or delaying it until later. To arrange a consultation at either our London or Bristol knee clinics, call 08450 60 44 99 to speak to Mr Webb’s secretary.


Even Olympic stars suffer from patellar tendonitis

It might be commonly known as jumper’s knee, but patellar tendonitis can affect men and women across the whole range of Olympic sports.

In 2012, Rafael Nadal pulled out of the London Olympics with tendinitis in his left knee. Cycling star and Olympic gold medalist Victoria Pendleton has suffered from patellar tendonitis. Basketball legend and Team USA lynchpin Carmela Anthony’s dream of a third Olympic gold at Rio this month was in jeopardy due to a suspected combination of patellar tendonitis and osteoarthritis.

patellar-tendonitis-and-OlympicsOlympic weightlifters are often bedevilled with this particular knee condition due to the continual squatting action combined with heavy loads.

Patellar tendonitis is an overuse injury of the knee. The tendons are the strong bands of connective fibrous tissue that attach the muscles to the bones. The patellar tendon connects the bottom of the kneecap, known as the patella, to the tibia or shinbone. It is attached to the quadriceps muscles by the quadriceps tendon.

The patellar tendon assists with knee extension when you kick, jump or run so is used – and sometimes overused – in most sporting activities.

What is patellar tendonitis?

Tissue damage and inflammation of the patellar tendon due to overuse can result in pain located in the front of the knee and, eventually, difficulties performing even limited daily activities. Olympic stars risk developing this knee condition, but it can just as easily affect sports men and women at any level, in a wide range of activities. It is particularly common in those sports where there is constant jumping and landing such as netball.

It is usually characterised by a gradual development of pain in the knee cap and initially you may just notice the pain occur in rest periods after strenuous activity or during the warm-up period. However, the condition can easily worsen and the discomfort felt will start to affect function of the knee and even just walking or standing can exacerbate the pain. There may also be a sensation of knee weakness.

How will patellar tendonitis be treated?

The first step at Mr Jonathan Webb’s Bristol and London knee clinic will be to diagnose the condition. A comprehensive patient history and physical examination may be sufficient, but an MRI or ultrasound scan may be ordered to assess the severity.

Non-surgical treatment of patellar tendonitis may be sufficient. Physical rehabilitation may take a number of weeks or months and the patient will be advised to avoid sporting activities that will aggravate the problem, before a gradual return is advised. It is essential not to ignore the symptoms as this can lead to tears in the tendon.

If this is the case, then surgical repair of the tendon may be advised. To arrange a consultation for patellar tendonitis at Mr Webb’s London or Bristol knee clinics, call 08450 60 44 99 to speak to one of his tea


Knee surgery vs exercise: a new study evaluates the benefits of meniscus surgery

With an incidence rate of 61 people out of every 100,000 suffering an acute meniscus tear every year, according to the British Orthopaedic Sports Trauma and Arthroscopy Association, this is one of the most common knee injuries.

Meniscus-tear-knee-surgery-LondonThe meniscus are basically nature’s shock absorbers. They are the crescent-shaped pieces of cartilage that sit between the femur and tibia, one on the inner side of the knee and one on the outer side, they also distribute load in the knee and help spread lubricating fluid around the joint. Most trauma to the meniscus is caused during sporting activities, particularly any movement that involves twisting and bending the knee. However, the meniscus can also become worn over time, so many older patients can suffer a tear, despite there being no perceptible traumatic episode.

One option for treating a meniscus tear is surgical repair, but a new study, recently published in the British Medical Journal, indicates that exercise could be just as beneficial as surgery.

How will I know if I’ve torn my meniscus?

Typically, there will be a specific incident that involves twisting the knee, usually when changing direction suddenly during sport. You may hear a popping sensation when the trauma occurs.

In the immediate period, the knee swells up, but this usually dissipates. Afterwards, patients will commonly feel pain on either the inside or outside of the knee, depending on which meniscus is torn. They may also feel that the knee is unstable and ‘gives way’. Alternatively, the knee can ‘lock’ and the patient is unable to fully straighten the knee joint.

Consultant orthopaedic surgeon and knee specialist, Mr Jonathan Webb will typically be able to diagnose a tear of the meniscus based on patient history and clinical examination, but this diagnosis can be confirmed with an MRI scan.

Why is surgery offered after a meniscus tear?

Part of your evaluation at Mr Webb’s London or Bristol knee clinics is to assess your knee’s function. One consideration is that you will have an increased risk of developing osteoarthritis in the knee joint in the future. A conservative, non-surgical approach may be advised in the first instance and this recently published study from a combined team of Norwegian and Danish scientists highlights the importance of exercise to strengthen the supporting structures of the knee.

However, if symptoms are severe and affecting the patient’s quality of life and non-surgical methods have failed to provide relief, then an arthroscopic procedure may be preferred. Small incisions are made at the front of the knee and an arthroscopic camera is inserted along with specially designed surgical instruments that can either repair the meniscus or trim the cartilage, leaving only healthy tissue.

Mensical repair can achieve a success rate in excess of 80%, but patient selection is key, in terms of the age of the patient, the amount of existing wear and tear and the position and extent of the tear.

However, in the study of 140 patients in Norway and Denmark, with an average of 50 and suffering from a degenerative meniscus tear, it seems that exercise route could be as beneficial as surgery. The patients were split into two groups, one who opted for surgery and the other that embraced physical therapy to manage the symptoms.

In the exercise group, each patient received a personalised training programme that encompassed careful warm-ups and strength training, all under the supervision of a trained physiotherapist.

Orthorthopaedic surgeon and member of the team Dr Jullum Kise commented, “Two years later, both groups of patients had fewer symptoms and improved functioning. There was no difference between the two groups.”

It is important to note that the study focused on middle-aged patients – younger patients that have suffered a tear in the meniscus as a result of sudden trauma can respond very well to surgery. Mr Webb can offer expert, impartial advice on the best option for you, whether surgical or non-surgical. To arrange a consultation at his Bristol or London knee clinic, call 08450 60 44 99.

Is the craze for high intensity exercise a cause of concern for our knees?

In our increasingly busy lives, the claim that doing just 30, 15 or even 5 minutes of HIIT at a time was the sure fire way to lose weight and get fit seemed too good to be true. This was a workout that anyone could fit in between work, family and social commitments.

Top flight athletes have known for many years that high intensity interval training is essential to gaining a competitive advantage, but now every gym in the country is offering HIIT classes. However, if you’re not a top level athlete is HIIT safe, particularly for our joints?

HIIT health benefits

A workout that involves intervals of high intensity exercises, followed by short recovery periods, means you get maximum benefits:

  • High intensity training boosts endurance as it adapts the cellular structure of the muscles so you can increase stamina in any type of exercise or sport
  • It boosts your metabolism so you can burn calories and fat in a shorter time period
  • The period after your work out is called EPOC which stands for Excess Post-Exercise Oxygen Consumption. This process of increased fat burning usually lasts for two hours as the body continue to use more energy as it returns to a non-exercising state. The EPOC after HIIT is greater with up to 15% more calories expended than after a standard workout
  • It’s been proven to be beneficial for those suffering from chronic health problems and studies have shown that it might even be better for you than regular moderate intensity exercise. HIIT can lower glucose levels in those suffering from diabetes as proven in one 12-week controlled study carried out in Denmark
  • Rather than putting your heart under intolerable stress, HIIT exercise can actually reduce the chance of developing cardiovascular disease, by increasing peak oxygen uptake and the flexibility of our blood vessels and by strengthening the heart

HIIT typically utilises your own body weight rather than expensive gym equipment so it’s accessible to all and is often seen as far more enjoyable than just pounding away on a treadmill. This means you’re more likely to stick to it, which is really the most important consideration.

High intensity interval training and your joints

A HIIT class will usually be a combination of core, upper and lower body exercises, but many include key exercises such as squats, lunges and short bursts of sprinting. Jumping exercises, known as plyometric movements, can be particularly hard on the knee joint. All can lead to an inflammation of the patellar tendon that connects the kneecap to the tibia, commonly known as runner’s knee. Over time the inflammation can become so marked that it limits normal everyday activities and but very rarely results in a tear of the patella tendon.

It is imperative to avoid high impact not high intensity. Look for low impact exercise classes that minimise the pressure on your joints. If you are experiencing knee pain and stiffness that is affecting your work out, then an orthopaedic surgeon who specialises in treating the knees, such as Mr Jonathan Webb, can offer you assessment and diagnostic tests, before advising you on the appropriate treatment. To arrange a consultation at either his London or Bristol knee clinics please call 08450 60 44 99.