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.

Anterior Cruciate Ligament Tear: the classic knee injury

We lay claim to the title of the world’s greatest sporting nation and it is true that sport is a national obsession, both as spectators and getting onto the field of play at every level. Yet, it is also true that sport and injury go hand in hand.

The knee is the most common joint to incur injury during sport and injuries to the ligament account for approximately 40% of all knee injuries. Of the four ligaments that stabilise the knee joint, the anterior cruciate ligament, commonly known as the ACL, is the most necessary and the most vulnerable, accounting for almost half of all knee ligament injuries.

The ACL is a band of tough, fibrous tissue that connects the thigh bone to the shin bone, running through the knee joint. The cruciate ligament is essential for balancing the knee joint when twisting, pivoting and landing, as it prevents the tibia from rotating and sliding forward.

Here are some of the common questions about ACL injury:

1. How will I know if I have torn my ACL?

An ACL tear is usually the result of a sudden injury. Typically, you will feel and even hear a ‘pop’, accompanied with sudden pain. Once the initial pain abates, it is usually succeeded by stiffness, swelling and discomfort. There is often instability in the knee and it may ‘give way’ or buckle when turning or landing.

2. Why does the ACL often fail to heal?

Unlike the other ligaments that support the joint, the ACL passes through the middle of the joint and is surrounded by joint fluid. Synovial fluid in the joint is designed to dissolve and prevent blood clotting in the joint so scar tissue on the ligament cannot form, making healing of the ACL challenging.

3. Can I live with a torn ACL?

Every component of the knee joint works together; if the ACL tears then there is increased strain on the meniscus. If the meniscus gets worn down then we are left with just articular cartilage to protect our bones and, over time, this can deteriorate, resulting in osteoarthritis.

If you have incurred an ACL injury, then you have a number of treatment options:

  • Live with it! If you modify your activities so you do not engage in sporting pursuits that involve twisting motions then many people find it is possible to perform all normal, everyday activities without an intact ACL. However, patients that partake in competitive sports such as hockey, football and rugby, may find that lack of stability in the knee is hampering their ability to play.
  • A rehabilitation programme aimed at strengthening the supporting muscles can help provide the stability the knee requires.
  • A tear, either partial or total, to the anterior cruciate ligament can be resolved with surgical intervention. Mr Jonathan Webb, an orthopaedic surgeon that specialises in knee surgery, sees many ACL injuries in his Bristol and London knee clinics.

4. What is the rationale for treatment of the ACL?

The approach adopted by London and Bristol orthopaedic surgeon Mr Jonathan Webb is to return the patient to a level at or approaching their former level of activity. This can be achieved either through conservative treatment or, if required, with surgery.

He takes into account your age and activity level, while also assessing the degree of tear and resultant instability. Surgery will usually return you to full participation and may also prevent future problems such as osteoarthritis developing.

5. Who should I see for ACL reconstruction?

An ACL reconstruction is performed by an orthopaedic surgeon who has specialised in treating the musculoskeletal system. A consultant orthopaedic surgeon that has focused on the knee and has an interest in treating sports injuries can also be fundamental to achieving a successful ACL reconstruction. Former England rugby player and orthopaedic surgeon Mr Jonathan Webb only treats knee injuries and conditions. For more information or to book a consultation, call 08450 60 44 99 to speak to one of his team.

Mr Jonathan Webb becomes the RFU representative on the World Rugby Council

All change at the RFU; as a new chairman takes over from Jason Leonard in August, we have the exciting news that Mr Jonathan Webb has recently been appointed as one of two RFU representatives on the World Rugby Council, replacing Bill Beaumont who has become the Chairman of World Rugby.

In the late 1980s and early 90s, Jonathan played club-level rugby at Bristol and then Bath, before representing England as fullback in 33 Test matches, scoring 296 points for the national team. He participated in two Rugby World Cups and in the 1991 World Cup final, which England lost to Australia, he was the only English scorer. Among the honours he received, he was voted the Rothman’s Rugby Player of the Year in 1992 and now joins the RFU board as a representative at World Rugby, the international governing body of rugby union.

The vision of World Rugby is to harness the sport’s character-building values to engage new audiences, young and old, a vision that Mr Webb shares: “I believe the game is still one of the greatest team sports, enriching and enhancing the lives of all those involved. I look forward to doing all I can to help develop and improve rugby not just in England, but around the world, to ensure its future growth.”

Mr Jonathan Webb combines his duties on the World Rugby board with his practice as a Consultant Orthopaedic Surgeon in Bristol and London.


Cricket and the knee

Common-cricket-knee-injuriesThe English cricket season has commenced and all eyes turn to Headingley this month as they host the first of England’s international matches, with the national team hoping to capitalise on last year’s triumph in the Ashes.

Although cricket may seem worlds’ away from the high impact nature of rugby or football, injuries are common in the game. The spine and lower back may be a vulnerable area for bowlers and fast bowlers, in particular, but we take a look at the types of knee injuries that cricketers can incur throughout a lengthy season.

3 most common ways to injure the knee in cricket

Problems with the knee are either the result of a sudden tear or strain or due to years of overuse:

#1 Cartilage tear

The cartilage is the tough, flexible tissue that covers the end of bones and allows the bones in your knee joint to move smoothly as the knee goes through its wide range of movement. The knee also has two cartilage discs called the meniscus, which act as shock absorbers. The medial meniscus is found in the inner side of the knee and the lateral meniscus is located on the outer part of the knee.

The lateral meniscus is less likely to be injured, but it can occur when the knee twists. The medial meniscus is much more prone to injury as it is attached to the medial ligament. A small tear may respond to a non-surgical approach of rest and rehabilitation, but a more severe tear usually requires surgery if you want to return to the game.

Although plagued by a variety of different injuries throughout his career, Freddie Flintoff was finally forced to retire from Test cricket due to a meniscus tear.

# 2 Ligament tear

During sporting activities, the knee is subjected to extreme forces and it is the ligaments that surround the knee joint that resist this force, keeping the knee secure and stable. The most vulnerable of the ligaments is the anterior cruciate ligament, commonly known as the ACL, and it can tear, either partially or completely as a result of twisting or a sudden change in direction. Surgical repair of the ACL can restore stability.

In 2014, Australian batsman Usman Khawaja was forced out of international games for nine months with a torn anterior cruciate ligament in the left knee, but returned to the national team after undergoing surgery.

# 3 Patellar tendinopathy

This can be the bane of bowlers as their patella tendon is continually put under strain during the delivery action, leading to the tendon fibres breaking down.

The patella tendon is positioned just below the knee cap and attaches the patella to the tibia or shin bone and it is put through the maximum stress when running or landing. Over time, the pain and discomfort felt when playing cricket will continue when at rest, with stiffness and lack of mobility that is often worst first thing in the morning.

Patellar tendinopathy usually doesn’t get better without intervention and there is rarely a quick fix for this knee condition and you may require a lengthy period of rehab. In 2014, South African batsman JP Duminy was sidelined for six weeks, missing internationals against Australia, due to chronic patellar tendinopathy.

However, one of the most horrific injuries in sport was the knee injury that ended David Lawrence’s cricketing career in 1992. In the middle of his delivery stride, his left patella shattered, with spectators hearing the ‘spine-chilling’ crack across the ground.

The lengthy nature of cricket games, coupled with the bursts of acceleration and deceleration and twisting action of bowling and batting, means that a cricketer’s knees are as vulnerable to injury as high impact sports such as football and rugby. Mr Jonathan Webb, orthopaedic adviser for Gloucestershire County Cricket Club, offers treatment for a wide range of knee conditions. To arrange a consultation at either his Bristol or London clinics call 08450 60 44 99.