Watch this video of Mr Dan Withers, Consultant Orthopaedic Surgeon specialising in the knee discussing ‘Common Knee Problems and Golf.’
This video was recorded as a part of SSC Evening for Golfers in January.
Mr Dan Withers is a Consultant Orthopaedic Surgeon specilising in the knee at SSC.
Hello, my name is Dan Withers, I am one of the knee surgeons here at the Sports Surgery Clinic. Thanks for watching my talk here on ‘Common Knee Problems and Golf’. To put a disclaimer out there, if anyone is watching this and is hoping to reduce their handicap, there is no money-back guarantee, I won’t be able to help you with that, but hopefully, I will be able to teach you a few things about the common issues with the knee and golf’
Just to talk about the background, as a knee surgeon most of the operations that I would perform are things like knee replacements – that includes partial knee replacements and total knee replacements. Then the other half of what I do is a lot of sports knee injuries, mostly the famous ACL ligament reconstructions, surgery on meniscus injuries and various other ligaments, and also doing some operations on knee cap patella instability. When you talk about the knee, the anatomy of the knee, what the knee is made up of its bones, ligaments, and meniscus. The bones that make up the knee include the Femur or thigh bone, the Tibia or shin bone, and the Patella or knee cap at the front of the knee, that’s are the 3 main parts of the knee. In between the main hinge parts of the joints of the thigh and shin bone, we have C shape cushions, on the inside of the Medial Meniscus and one on the outside of the Lateral Meniscus, essentially they act as little shock absorbers and distribute the forces that go through the knee joints. Then the other part of the knee is the ligaments, there are four main ligaments, you can see two green ones on either side there, that’s the medial collateral ligament, towards the inside part of the knee and then the lateral collateral ligament, that goes towards the outside part of the knee. The blue ligament there is the Anterior Cruciate Ligament and then the yellow one there is the Posterior Cruciate Ligament. The Anterior Cruciate Ligament is the main sort of stabilizer for the rotary and stability of the knee and then the Posterior Cruciate Ligament stops the backward motion of the shin bone or the thigh bone.
The most common issues that would relate to golf, now there js a lot of different knee issues, but two main ones that I would see would be related to Osteoarthritis of the knee joint and Meniscal Tears. They are defiantly two of the most common things. Funny enough, two of the most high-profile golfers, have those injuries, Brook Koepka had a dislocated knee cap, whenever he had his injuries, then Tiger Woods, he had a torn ACL, which he had reconstructed, but subsidence to the reconstruction, I think he had some ongoing issues because of the instability and he had a couple of other operations, they did a proper job on it last year.
The Articular Cartlidge of the knee joint, basically what happens in osteoarthritis is the ‘wear and tear’ thing, the main issue of Anterior Cartlidge, it’s normally that nice shiny tissue on the end of the bone that allows the joint to glide on top of each other. The main issue really with it is that it has no nerve or blood supply, so whenever it is damaged it doesn’t have the acute ability to regenerate itself. It affects pretty much every joint of the body, but very commonly it affects the knee and the hip, and also the neck and back, which would be other common areas that would be affected.
Sometimes you hear various people talking about different stages of Osteoarthritis (OA) and really what that means, these pictures here are from arthroscopic pictures of the knee, you can see the cartridge. In picture A there, you see the little probe pressing into the cartridge, it’s a little soft and you see the indentation there, this is very, very early stages of wear and tear of the cartilage and that’s stage one. Stage 2 is pictures B and C, at that stage, you start to get a little bit of fraying and fibration of the cartridge itself. In picture D there, you see some partial thickness loss of the cartilage and then in pictures E and F, it actually wears right down to the bone and sometimes you might hear people saying they have stage 4 OA or bone on bone, which is another common phrase people may use.
The risk factors for OA include age – everyone, as you start to get older develop some sort of wear or tear, and around about 50% of people, of adults over their lifetime, will develop symptoms at some stage or another of OA with around aboutb25% having symptoms related to the hip over their lifetime. Obesity causes more forces to go through the knee. The more pressure and the more wear and tear can develop, history of the previous injury, family history, overuse, and also muscles weakness and imbalance. They can all be risk factors in developing OA.
However, there is a large proportion of people who are a-symptomatic of OA, as I say if you scan a lot of peoples knees, to some degree you might see a little bit of wear and tear, there have been studies performed before where people have had MRI’s of their knee and around about 40% of adults over 40 years old show signs of Osteoarthritic change on the scan, some may have been fairly minor ranging up to the more severe stage 4. Reasons, why you may not develop symptoms, could be to do a lot with the strength of the muscles around the joint itself and the biomechanics have an important role themselves in keeping the symptoms of OA. This is actually an interesting little study as well, sometimes people may get a little bit worried that they might need to go through some form of knee replacement or something like that, but actually, this study here that is from Spain and involved around 50,000 people and they looked at around 50,000 people, and everyone who was diagnosed with a GP with having OA change, only 30% of those people who had a diagnosis had to go through a knee replacement. As mentioned before obesity/increased weight was a risk factor that increased your risk of requiring some sort of knee replacement. As mentioned this is what OA looks like, you get wearing away of the cartilage and that wears down to the bone. You also may develop little bits of extra bone called Osteophytes as your bone tries to regenerate but does it abnormally.
The symptoms, well the main symptom is pain and the pain can be quite severe, some patients may have a limited range of motions/stiffness, swelling, pain after standing for long periods and walking around the golf and some people may develop night pain, that can be an indication of its getting quite bad where you may need to consider some form of knee replacement or some form of treatment. How do you diagnose it? A clean x-ray or MRI scan will show it up, as you can see here in the picture of the knee on the left of the screen where you can see very severe arthritic change here there is no gap between the joint, where the other knee here you can see a gap between the joint there.
Treatment – I would start with conservative management, taking simple painkillers, starting with a simple thing like paracetamol or anti-inflammatory, sometimes it’s not a bad idea to say if you’re going for a round of golf to take a few anti-inflammatory 1 or 2 hours before you go out to play and that may prevent a build-up of pain that may develop during the round or after. Weight loss – as we said would help and it is well known that around 7 times your body weight through the knee on certain activities, so even if you lost one kilo that’s 7 kilos of force less through the knee joint. Sometimes people ask about supplements – if you look at the evidence for supplements, there is no clear evidence that any supplement prevents osteoarthritis. There is some evidence to suggest things like glucosamine and chondroitin may have a small role in pain relief of symptomatic OA. It’s all about breaking the pain cycle, you will develop pain and because you have pain will start to become less active because you don’t want to be injured more, your muscles become deconditioned and less strong and more forced on the joint. It then turns into a vicious cycle, it becomes more painful and weaker.
This is something interesting here, everyone, as they get older, will have decreased muscle strength and this is an MRI scan showing quite clearly of someone who had an MRI scan of their thigh at age 25 on the left there and then at age 63, the same person who can see the muscle there is a lot smaller. The main muscle groups you want to strengthen up when you have issues with the knee are the quadriceps muscles and the glute muscles which are your bum muscles. You can do that by starting with some simples things like a bit of conditioning on an exercise stationary bike, there is good evidence that aquatic therapy is good for OA and reduces symptoms, Then there are some simple exercises that you could do like some straight leg raises and then you can do that with some resistance bands. You can do single-leg hip raise, hip bridge and wall sit, goblet squats. They can help a lot in terms of symptoms.
If you are still in a lot of pain, you might consider injections to help, there any many different types of injections – there is a standard Corticosteroid, Hyaluronic Acid, and Platelet Rich Plasma. If you have tried all these options and are still having pf pain, this is something you may end up having, this is a total knee replacement. This is an x-ray of that afterward, then this is something called a partial knee replacement which is also quite a good option, this is used on people who have very specific wear and tear and has slightly easier recovery and slightly quicker.
That’s OA, the other thing I mentioned is Meniscal Tears. Meniscal Tears are very common they occur frequently. If you scanned everyone over 40 years old you would see probably 30% of people would have a meniscal tear, not everyone will have symptoms, and the most common type of tear would probably be a degenerative tear. Normally the symptoms of Meniscal Tears would be a short history and it develops quite quickly, people tend to have sharp pain, sometimes people may have some catching and locking.
Diagnosis- Is done through an MRI scan as you can see here this is looking at the knee from the side, the blue arrow is posting to the posterior or the back part of the meniscus itself and on that scan, there is a distinct black triangle, you can see the white line at the back of the triangle in the back and that signifies a tear.
The treatment for it – initially should be conservative management, I would normally recommend people to try some physiotherapy for at least 6-8 weeks, if it’s very painful we would try an injection to dampen down that pain and then if it is not settling then an arthroscopy can be done to debride the tear.
At some rates, knee problems are extremely common and the most common for golfers would be OA and Meniscal Tears. Conservative management is feasible in most knee conditions. I would always recommend trying this as first-line management. Physiotherapy strength and conditioning are extremely important. That is all I have, if you have any questions id be more than happy to answer except any on golf as I’m defiantly not going to be any help to any of you, thank you very much once again.
Yes, parameniscal cysts are very common and there quite commonly found on MRI’s, basically they occur from some degeneration of the meniscus tissue itself and then you get a little bit of a fluid collection around the meniscus. If it’s pain-free I would leave it alone, unless it started causing problems.
This is a very common finding, even people with normal knees can find that it can crack, pop, and do all sorts of things. It’s generally never anything to worry about and a lot of the time what it can be is a little bit of roughness of the joint surface underneath the knee cap, and if it is not causing any pain at all, it’s generally fine, and it’s not to worry about that there doing any damage. I would just carry on as normal.
Knee replacement is a quality of life operation, so really it depends how bad the pain is and how much that is impacting on your quality of life and restricting all your daily activities, so if it gets to the point where you are on painkillers every day, you might not be able to walk more then 5-10 minutes before you’re getting paid, you’re having a lot of swelling, maybe you can’t even sleep at night with the pain, those are all sort of factors that you might start saying would indicate it’s time to get a knee replacement.
For me, age doesn’t matter as much, it’s about the symptoms and how much that’s impacting your quality of life. With regards to getting back to say something like golf, it would probably take I would say at least 3 months before you get back to any type of golf.
it’s much like the knee, I always say to everyone to some degree all of us will have a little bit of wear and tear in our joints, in our knee and your hip and some people may be affected with symptoms of it and others may not.
It depends on your symptoms and there was a slide there that I mentioned that around 30 % people of people in their lifetime would need a knee replacement and haven’t had a diagnosis of OA, so there is a large majority of people I would say of people who have wear and tear and don’t have the symptoms that would fit to need something like a hip replacement.
I suppose the short answer is yes, some people get relief off it, others don’t, it probably would help in the more mild-moderate cases of OA. It is as I mentioned one of the first-line treatments either hyaluronic acid or steroid injection or a platelet-rich plasma injection, it would be the initial treatment for me to try conservative management, so you inject it and get some physiotherapy.
Then give it a period of around 4-6months and see what type of benefit that would have and then you know to base your decision on whether or not you need to do something further based on how long relief that they’ve had from it.
If you look at a lot of the evidence on this, there’s not t great deal of evidence to say that any brace is actually going to do anything physically but what I normally say to people is if they feel as if it’s given some sort of symptomatic relief then I would say you can try it, normally I would say not too spend too much on any sort of fancy braces but yeah if it is given some type of relief, I would say go ahead yeah.
That’s very, very common and what it is normally, maybe as I mentioned in the talk there are two main parts of the knee, there Is the main hinge part between the thigh bone and the shin bone and then the other part is between the knee cap and the thigh bone, your patella, so it’s extremely common to get a little bit of wear and tear underneath the patella and when you have patellar wear when you’re coming downstairs or inclines, that’s the moment that part of the joint is being loaded more, so roughly about seven times your body weight that goes through the knee on these activities and that’s why it’s probably more sore doing these activities.
I have to say but whenever people do have patellofemoral degenerative changes it can be very well managed conservatively and generally doesn’t end up needing any knee replacement as such because it’s only really on activities such as going downhill or going downstairs.
If you have a meniscus tear and you’re pain-free I would say, yeah you should play on, it doesn’t mean you’re not going to cause any more damage to it, and if you are completely pain-free then sometimes you may not even need the surgery for it because as I mentioned before meniscal tears they can be a-symptomatic as well so if your managing fairly well and you’ve got the tear it doesn’t necessarily mean that you need to go and have the operation.
It depends on what type of tear it is, the orientation of the tear but generally the most common type of tear is degenerative meniscus tear and those types of tears don’t heal as such but what I normally say is they can become a-symptomatic whereby yes you have a tear but it does cause any symptoms but it doesn’t necessarily heal itself.