As we now move into the winter we are preparing for the shorter, colder days ahead. Temperatures in the UK are predicted to plummet to an average of around 4 degrees Celsius along with expected frosts. Winter is well known for causing significant challenges for those who are suffering from ongoing joint pain, and it’s not just one aspect that is responsible for this.

There are several contributing factors that can make dealing with joint pain through the colder months quite problematic.

Under Pressure

One of the primary factors that lead to winter knee pain is the changes in the air pressure. Prior to the cold weather arriving, the barometric pressure falls which causes the fluid and gas within the joint to expand which can lead to an uncomfortable feeling of painful pressure around your nerves.

Cold and Humidity

The cold temperature paired with higher humidity influence the cellular structure of both bone and cartilage. These changes can lead to feelings of expansion and contraction which can induce pain.

The nerves within your joints increase in sensitivity during the colder months and the lower temperatures can cause this sensitivity to increase.

As the temperature drops from the changing seasons, it can cause the fluid within the joints, called synovial fluid, to thicken. As a result, this thickened fluid impedes flow around the joint which can cause them to become stiffer.

Inactivity and Staying Indoors

During the winter months, it is common for activity levels to decrease. As the days become shorter and colder, people tend to spend more time indoors. This reduction in mobility is harmful to joints as they remain inactive which may lead to increased stiffness pain.

Staying indoors can also reduce the levels of Vitamin D your body absorbs from the sunshine. Some studies have shown a link between Vitamin D deficiency and joint pain, so it is important to ensure you have a nutritious diet or take supplements to boost your Vitamin D.

Treatment Options for Joint Pain

There are many things that can help to reduce the occurrence of joint pain in the winter which include wearing warm clothes, keeping fit and active, staying hydrated and immersing yourself in a warm bath.

Floatation therapy can also help alleviate the symptoms of joint pain as floating in warm water helps to remove the effect of gravity on the body and reduces the strain and stress on joints.

If joint pain is becoming unbearable and interfering with life, then you can talk to Mr Punwar about the different surgery options. If there is widespread cartilage damage that is causing you a lot of pain and discomfort, you might consider a joint replacement. To find out more, get in touch to arrange a consultation with Mr Punwar.

Cartilage damage is a common type of injury that often involves the knee joints, although it can also occur in other major joints around the body including the hips, ankles and also elbows. Here we look at the causes of damage and symptoms that lead to choosing knee cartilage repair surgery.

The Role of Knee Cartilage

Cartilage is a tough but flexible structure that forms the main type of connective tissue throughout the body. It forms a firm tissue that covers the surface of joints which gives them protection from impact, as well as allows the bones to slide comfortably over one another during active movement.

Usually, cartilage damage happens as a result of an impact injury, often sustained in sports, or through continual wear and tear over time.

Osteoarthritis Risk Factors

Osteoarthritis is a long-term condition that is directly linked to cartilage damage. This happens when the protective cartilage surrounding the joint breaks down, leading to swelling and mobility issues. The exact cause for this is unknown but risk factors include previous joint injury, conditions such as rheumatoid arthritis, family history, age and obesity.

Symptoms of Knee Cartilage Damage

Unfortunately diagnosing cartilage damage can be a challenge as it cannot be found through a physical examination alone. The symptoms of cartilage damage can include;

  • Joint pain
  • Swelling or stiffness of the joint
  • Clicking of the joint
  • Locking or catching joint

Magnetic Resonance Imaging (MRI) scans are commonly used to detect damage within the cartilage as the scan is able to produce detailed images to determine if there is any damage present.

Knee Arthroscopy Options

An arthroscopy is a form of keyhole surgery that is used to treat and diagnose joint issues. A small medical telescope is inserted into the knee joint in order for the internal structure to be accessed. The small incisions required means that the surgery is less painful has faster healing times and also promotes a lower risk of any infections occurring.

The following types of knee surgery are on offer with Shah Punwar:

Meniscal Surgery

Meniscal tears often occur due to twisting injuries which can lead to swelling, pain, clicking and issues with stability. Often, these types of injuries are unlikely to heal on their own requiring the meniscus to be either trimmed or removed entirely.

Cartilage Surgery

If the cartilage lining the joint is damaged then it can be probed and any loose flaps can be carefully smoothed. If the damage is full-thickness then a cartilage restoration procedure known as a microfracture may be considered. This is where small holes are made in the surface of the joint which aims to stimulate a healing response.

If you would like to find out more about knee cartilage repair options that would be suitable for you, get in touch to arrange an appointment with Mr Punwar.

A hip replacement is a common type of surgery where a damaged hip joint is replaced with an artificial one. This can totally transform quality of life and offers relief from a very painful joint as well as improved mobility. Adults of any age can be considered for this surgery however it is most common for individuals between the ages of 60 and 80.

Mr Shah Punwar uses both cemented and uncemented stem systems usually with an uncemented metal socket. He only uses hip components with a 10A* rating which are proven to have excellent long-term results on the National Joint Registry (NJR). Mr Punwar will be happy to discuss the choice of implant and the NJR during consultations.

What To Expect Post Operatively

After hip replacement surgery, you will be cared for by Mr Punwar’s healthcare team who will monitor you and ensure that you are well hydrated and managing any pain. You can expect to be in hospital for at least a few days and Mr Punwar will check on you to ensure that you are regaining mobility and have a satisfactory post-operative X-ray.

Nausea, loss of appetite, and constipation are all common following surgery but will usually return to normal function after a few days. Medication can be prescribed to aid recovery from these.

It is very common to experience ankle swelling and some bruising around the operation site and this usually takes several months to resolve.

During the first four-6 weeks following surgery, some general hip precautions may be advised in order to protect the hip whilst the muscles are healing eg: sleeping on your back and avoiding leg crossing, however following this period your normal sleeping position and activities can be resumed.

It is generally recommended that you refrain from driving until 4-6 weeks post-surgery as you will need to ensure that you are able to perform an emergency stop and put your foot down on the brake and clutch safely.

Rehabilitation After Hip Replacement Surgery

Following hip replacement surgery, you should be able to put all of your weight through your new hip, however, you will be guided with a rehabilitation programme provided by a highly skilled physiotherapist. Initially, you may need the assistance of walking aids however you will quickly progress to becoming independent.

You will be advised to take analgesic medicine to help reduce any pain or discomfort and allow you to maximise the required physiotherapy in order to aid a rapid return to normal mobility. You will have regular check-ups with Mr Punwar to make sure that you are recovering well.

Complications After Hip Replacement Surgery

In order to prevent the risk of developing any blood clots post-surgery, you are likely to be prescribed anticoagulation medication in either injection or tablet formulations. You will also be provided with anti-embolism stockings to wear which are also designed to help reduce the risk of blood clots.

There is less than 1% chance that the ball joint can dislocate from the socket. But the highest chance of this happening is within the first 6 weeks as the tissues around the hip are not fully healed. This is why some general hip precautions are usually advised.

It is also important to monitor your surgical wound as this will need to be kept clean and dry with the dressing changed regularly in order to reduce the chances of any external infection occurring.

Get In Touch

If you would like to find out more information about hip replacement surgery, please get in touch to arrange a consultation with Mr Punwar.

As we are now learning to adapt to life alongside COVID and slowly returning to normal lives, athletes across the globe are eager to return to the arena. However, questions are being raised by professionals as to whether the prolonged break in training regimes could result in an increase in the occurrence of immobilising injuries – particularly anterior cruciate ligament (ACL) injuries.

A primary concern raised by professionals is that the break-in practice could lead to a higher rate of injury, re-injury, and time loss as a result of delayed and potentially compressed workload and gameplay as events resume.

Anterior Cruciate Ligament Injury

An ACL injury is a tear or sprain of the anterior cruciate ligament which is one of the strong bands of tissue that helps to connect your thigh bone (femur) to your shinbone (tibia). Most ACL injuries occur during sports after a sudden stop or change in direction along with jumping and landing and are very common in sports such as football and basketball.

After surgery, it is unlikely that an athlete would return to play for at least nine months – which is a significant chunk of an athlete’s career. And re-tear rates are as likely as 20%. Although strengthening muscles around the knee, as well as balance exercises, can go a long way to reduce the risk of this happening.

Prolonged Breaks In Athletic Performance

The break forced by COVID is likely to have resulted in the deconditioning of important physical qualities associated with performance, as well as reductions in competitive match fitness and sport-specific skills.

The physical and psychological impact of competitive environments can also add an extra level of pressure, especially for athletes who have not been in these situations for a prolonged period of time.

Along with the increased risks of playing sport in a world still adapting to COVID, such as play that meets social distancing requirements, there are also concerns that this extra pressure could be detrimental to athletes’ ongoing mental health and ability to cope.

Returning To Play after ACL surgery

Returning to sport after the pandemic is likely to come with its own challenges and there are still many unknowns. However, it is vitally important that individuals use the tools available and seek advice to reduce the risk of both injury and re-injury.

Surgery to repair an ACL tear can help you to return to your previous athletic form but when training or a fully supported rehabilitation programme has been compromised during lockdown, a graded return to full training is recommended.

For more advice on ACL injuries or if you have any other questions about returning to sport after surgery, get in touch with Mr Punwar today to arrange a consultation or book online.

Researchers from Lund University in Sweden have discovered that out of all cruciate ligament injuries, 69% can be explained by genetics.

This discovery may have important implications when predicting those individuals who are at higher risk of developing this type of knee injury. It will also enable more individualised injury prevention plans.

Anterior Cruciate Ligament (ACL)

The anterior cruciate ligament (ACL) injury is one of the most commonly occurring knee injuries and is especially common among those who undertake sports on both amateur and professional levels.

The anterior cruciate ligament is a ligament in the knee which joins the femur (upper leg bone) with the tibia (lower leg bone) and its primary purpose is to keep the knee stable. It is commonly injured through motions such as sudden stops, changes in direction, and after jumping and landing with impact.

Genetic Origin

The more obvious risk factors, particularly for those in sports, that result in an anterior cruciate ligament rupture include playing on surfaces with high friction, and making sudden stops or pivoting. However new research is suggesting that it is also associated with risk factors that have a genetic origin. This includes bone geometry of the knee, malalignment and generalised joint laxity. This type of injury has also been linked to hypermobility.

An anterior cruciate ligament rupture can lead to reduced quality of life and is associated with up to 10 fold increased risk for developing osteoarthritis of the knee.

Osteoarthritis Genes Discovered

Almost 9 million people in the UK suffer from osteoarthritis, a degenerative joint disease where joints become damaged, painful and often very restricted. There is no current treatment for osteoarthritis and it is often managed through pain relief and often eventual surgery.

New research investigating the genetics behind osteoarthritis has revealed nine novel genes for osteoarthritis which will help to identify genetic risk factors for the disease. This might be a stepping stone into the understanding of osteoarthritis and the development of treatments.

By revealing how these genes contribute to osteoarthritis, this research could open the door for new treatments to help millions of people.

Get In Touch

If you have concerns about your knees and have a family history of knee joint problems, Mr Punwar can carry out a thorough examination, as well as MRI scans if necessary.

Mr Shah Punwar is highly experienced in treating ACL tears, as well as treating those with osteoarthritis. He can help advise on how to manage your condition and give you a personalised treatment plan. Get in touch and book a consultation today.

Knee replacement surgery is an operation to replace the damaged parts of your knee and is also known as knee arthroplasty. If there is widespread cartilage damage within the knee accompanied by pain and limited movement, a knee replacement may be the best option.

Before Knee Replacement Surgery

Before the surgery takes place, you will be able to speak to Mr Punwar in a consultation. He will make sure that you understand and are comfortable with the treatment and he will be able to advise on what to do beforehand to help ensure that it is a success. You should let him know if you are taking any medication, as this needs to be considered before you undergo any invasive surgery.

It’s also important to keep yourself fit and healthy especially in the build-up to your operation. This includes maintaining a healthy weight, exercising regularly and also making sure that you stop smoking several weeks before the operation.

In terms of skin preparation, it is a good idea not to shave or wax the area where the incision is likely to be and try to have a bath or a shower either the day before or on the day of surgery to prepare your skin and reduce the chances of infection.

During the Procedure

Once you are safely anaesthetised, an incision will be made on the front of your knee. Any damaged joint surfaces are removed and then replaced with an artificial knee joint. Mr Punwar only uses modern implants that have a good track record, and he will try to minimise tissue damage.

The skin is then closed using either stitches or clips and secured with a surgical dressing to keep the wound clean and minimise the risk of infection. To aid this you will also be given antibiotics before your surgery and several doses following the procedure to give you the best coverage.


After the surgery, you will be cared for by Mr Punwar’s healthcare team who will monitor you and ensure that you are hydrated and managing any pain.

Mr Punwar will keep a close eye on you whilst you recover in the hospital for a few days after the procedure, ensuring that the results meet your expectations. It can take up to 2 weeks for your wound to heal and you will be given plenty of after-care advice.

You will have regular check-ups with Mr Punwar to make sure that you are recovering well. Most individuals recover and return to their normal activities within 6 weeks.

If you would like to find out more information about knee replacement surgery, please get in touch to arrange a consultation with Mr Punwar.

The most common form of arthritis of the hip joint is osteoarthritis (OA). This is characterised by pain and stiffness in the hip, usually worsening over time.

There is, however, another form of arthritis that can affect the hip joint. It is called rheumatoid arthritis (RA) – a chronic, inflammatory, progressive autoimmune disease.

Here, we take a look at the differences between these two forms of arthritis, what causes them and how they can be treated.

Osteoarthritis causes

OA of the hip is often known as a ‘wear and tear’ condition. This means that it can really affect anyone, as it is caused by overuse of the hip joint. This can occur in sport, or as a result of occupations which involve repetitive squatting. A break of the hip joint can also lead to OA years later. Problems with the hip in childhood and subtle anatomical mismatches between the ball and socket joint can also lead to OA in later years.

It usually presents in older people, however there is an increasing prevalence of osteoarthritis in younger people. It commonly starts in the 50s and affects women more than men.

Mainly affecting those who have led extremely active lives, or who are seriously overweight, it leads to pain mainly felt in the groin and difficulty bending down to put shoes & socks on or to get out of a low chair.

Rheumatoid arthritis causes

Rheumatoid arthritis is an autoimmune condition. This is when the body’s immune system has decided to turn on itself and start attacking healthy cells. It is still unknown exactly why this happens, but it is believed to have a genetic link. This sets up an inflammatory reaction in the joint with synovitis (inflammation of the joint lining) and erosions into the bone. The bone often becomes softer than in OA and this can lead to deepening of the hip socket and thinning of its floor.

Rheumatoid arthritis is more common in people with a family history of the condition. And similarly to OA, it also tends to affect more women than men.

Symptoms – osteoarthritis versus rheumatoid arthritis

The main difference in the symptoms of osteo versus rheumatoid arthritis, is that the problem may affect just one hip joint, rather than both. In both conditions pain is felt in the groin area or buttocks and sometimes on the inside of the knee or thigh.

Sufferers of both conditions may also experience a grinding sensation when trying to use the affected hip. Furthermore, they may find that the joint seems to ‘lock’ into place.

Rheumatoid arthritis often affects both hips. But people who have rheumatoid arthritis often first experience symptoms in the smaller joints, such as in the hands or feet. Then it spreads to larger joints like the hips. Other specific symptoms of RA include:

  • Pain and stiffness that may feel worse in the morning or after periods of resting or sitting
  • Pain that may lessen with movement and increase with vigorous physical activity

Treatment – osteo versus rheumatoid arthritis

Because rheumatoid arthritis is a chronic, progressive condition, symptoms are often managed using medication to prevent ‘rheumatoid flares’. This can help to alleviate some of the pain and swelling and in recent years, with the introduction of novel drugs, has led to a large reduction in severe rheumatoid cases.

Osteoarthritis can also be treated with medication, but other ways of managing symptoms are also recommended. People often find relief by making lifestyle changes and minimising the activities that aggravate the condition. This might mean switching your sport of choice to something lower impact.


With both osteo and rheumatoid arthritis, surgery is something of a last resort. If your symptoms cannot be relieved with medication or lifestyle adjustments, then hip replacement surgery may be the answer.

Generally, total hip replacement surgery presents the best option for arthritis sufferers. This removes the whole hip joint and replaces it with a new surface. Mr Punwar uses both cemented and uncemented stems with excellent long-term results together with an uncemented metal socket. Cemented sockets are sometimes used with very weak bones, particularly in rheumatoid sufferers. Hip replacement relieves the pain of arthritis and restores movement to the hip joint.

Hip replacement surgery can have a dramatic impact on the quality of life. But you should always be aware of the risks, and be able to make an informed decision about the best time to undergo surgery. For more information, please call us on 020 8194 8541 to arrange a consultation with Mr Punwar.

There has been a dramatic increase in recent years of female athletes suffering from knee injuries. In Australia, the AFLW (Australian rules Football League for Women) saw 12 ACL injuries last season.

It is tempting to assume that this rise in knee injuries is mostly due to the increased media coverage that women’s sport is seeing. And that certainly goes some way to explain why we’re hearing about them.

But new research has shown that AFLW players are nine times more likely to suffer a knee injury than men. So this suggests that there is a biological cause.

Anatomical differences

One major reason put forward by medical experts for this gender imbalance when it comes to knee injuries, is the anatomical difference between men and women.

And the anatomical differences that cause the problem are not in the knees themselves, but in the pelvis and hips.

The female pelvis is designed for childbirth. This means the cavity is shallower and wider than in the male pelvis, and it tilts forward. This forward tilt impacts on the angle of the hip joint, which in turn can cause the femur (thigh bone) to be angled inwards.

As a result, unless the muscles in the core, hips and thighs are extremely strong, there is a tendency for the knees to be angled slightly inwards, which increases the risk of anterior knee injuries.

Hormonal differences

The other reason cited – although in fact it does tie in with the first – is hormonal. When boys go through puberty, they experience a rush of the hormone testosterone. This allows them to build muscle quickly.

The skeletal structure also changes during puberty, both for boys and girls. The skeleton becomes taller and denser, and an influx of testosterone allows boys’ bodies to cope with that. This means that the muscular structure is able to support the skeleton.

Women do have a small amount of testosterone in their system, but not enough to have a significant impact on their muscles. So while their skeleton increases in density and height, they don’t have the same muscular structure to support it.

How can women avoid ACL injuries

The key to avoiding knee injuries is to increase the strength of the hip and thigh muscles. Any weakness in these muscles will correspond to problems in the knee. This includes anterior knee pain or patellofemoral syndrome as well as ACL tears.

In Australia, as a result of this recent research, the AFLW has instigated a ‘prep to play’ regime. This focuses on the implementation of specific strengthening exercises for the hip and thigh muscles.

Another way to help protect your knees from injury is to practise ‘balance training’ – this essentially means trying to balance on one leg on progressively less stable surfaces. This helps to build up the muscles around the hip, knee and ankle.

Mr Shah Punwar is highly experienced in treating ACL tears and has an excellent track record. He submits all his ACL cases to the National Ligament Register, allowing long term follow-up and monitoring of outcomes.

Surgery to repair an ACL tear can help you to return to your previous athletic form, but expect a structured rehabilitation programme to prevent re-injury. Also, if you are returning to contact sports, expect to be on the bench for at least nine months post-surgery.

If you have concerns about ACL injuries and would like to consult with Mr Punwar, please call us on 020 8194 8541 or email .


Outer – or lateral – knee pain is common, particularly amongst runners and athletes. However, the actual cause of the pain can be difficult to pinpoint. This part of your knee forms a crossing point for lots of different anatomical structures.

The Iliotibial (IT) band is often blamed for outer knee pain, but there are actually several other possible causes. Read on to find out the most common causes of lateral knee pain.

Iliotibial band syndrome

The ‘IT band’ is a common cause of lateral knee pain in runners. The iliotibial band is a long strip of tissue running right down the outside of your thigh, from hip to knee. Iliotibial band inflammation is an overuse syndrome that often occurs in long-distance runners, cyclists, and other athletes. However, it can be further aggravated by poor flexibility, poor training habits and anatomical imbalances.

How to identify ITB syndrome

ITB pain usually gets worse when you are exercising, as the friction between the ITB and the knee joint is increased. The pain tends to be greatly reduced when you rest the knee.

You may hear snapping or popping noises coming from your knee that accompany the pain, and in severe cases there may be some swelling.

Treating ITB syndrome

The best and most effective treatment for ITB syndrome is to stop the activity that has caused the problem. At least for a few weeks.

You can speed up the healing process by applying ice to the knee and by stretching. A foam roller can be useful to help massage the area during these stretches.

More severe cases may need medical or even surgical intervention. If your knee does not heal after a few weeks of rest and stretching, you should visit your GP.

Lateral meniscus tear

The meniscus is a piece of cartilage that sits between your thigh and shin bones, forming an integral part of the knee joint. The outer section of the meniscus can tear – sometimes suddenly as a result of injury, or sometimes slowly with wear and tear over time.

How to identify a lateral meniscus tear

With this type of outer knee pain, you will probably find yourself unable to go on with your usual sporting activity, as the knee may well give way at the joint.

There may also be some swelling and stiffness, and difficulty extending or flexing the knee.

Treating a lateral meniscus tear

Again, rest is the most important thing, with some ice to alleviate the swelling. You may also be advised to elevate the knee. Physiotherapy may also be helpful once you are ready to start using the knee again.

If the injury is not responding to these treatments, surgical treatment may be necessary.

Lateral collateral ligament sprain

Another band of tissue, the lateral collateral ligament (LCL) is much thinner than the ITB and runs from the thigh down to the femur. This is the ligament that keeps your knee on the straight and narrow, preventing it from bowing out to the side.

Injuries to the LCL are most common after a sudden stop, or a twisting motion. However a strong blow to the inner knee can also do it.

How to identify LCL sprain

When you sprain your LCL you may well hear a ‘pop’ sound, and there will almost certainly be some swelling and pain. You may also feel that the joint is unstable. But one unique identifier of LCL sprain as opposed to other outer knee injuries, is numbness or tingling in the foot. This is because the LCL is located close to a nerve that runs down to your foot.

Treating LCL sprain

Surgery is not usually used to treat LCL sprain, unless it forms part of damage to another structure in the knee. Immediate treatment involves resting the knee, applying ice and elevating the joint to reduce swelling.

This may be followed with splinting the knee, or even using a brace to keep it in place. Physiotherapy can also be useful to get the knee back to its former state.

One more option

If none of these sounds like it could be the cause of your knee pain, and you can’t think of a specific precipitating event, then osteoarthritis can be another cause of outer knee pain. Your GP can refer you for specialist treatment if this is the case.

If you would like some expert advice about your knee pain, the best plan is to have a consultation with Mr Punwar. To book an appointment with Mr Punwar at either of his practice locations, please call his LIPS practice team on 0208 194 8541.

Traditionally, knee replacement surgery has been something of a one-size-fits-all procedure. Whilst the prostheses are of course available in different sizes, they are standard sizes. So the surgeon has to choose the one that is the closest fit to the patient’s actual knee.

We are staying active until much later in life now, and more young people are having knee replacement surgery. A knee replacement that allows for greater functionality has become necessary.

Custom knee replacements

Standard knee replacement surgery can still be very effective. But surgeons like Mr Punwar want to be able to offer their more active patients something that best suits their needs. Above all, the surgery should allow them to return to a level of activity that is similar to what they are used to.

To achieve this, the patient’s knee is scanned using a CT scanner. This information is then fed into special software that will turn the scan into a 3D model of the patient’s knee joint.

This means that the prosthetic knee replacement is an exact replica of the patient’s own knee. Therefore it should function almost as well as the original knee.

Who is a suitable candidate for custom knee replacement?

Anyone who is a candidate for knee replacement surgery could opt to have a custom knee replacement. However younger patients with an active lifestyle will get the most benefit from having a totally personalised procedure.

How long do custom knee replacements last?

As with standard knee replacement surgery, a custom knee replacement should last for at least twenty years. The concept is too new for any data to be available yet. However, many surgeons believe that a custom joint should last longer, as a better fit means less wear on the bones beneath.

Are there any advantages in terms of the surgery itself?

Because the replacement is an exact match of the patient’s own knee joint, there should be less bone cutting required during surgery. So, in theory, the operation may be quicker than a standard knee replacement procedure.

This also means less disruption to the tissue, so recovery may be slightly quicker too. However, it is important to follow your surgeon’s post-operative advice and not do too much too soon.

Are there any aesthetic benefits?

Yes – because the prosthesis is an exact model of your natural knee. Once the swelling has gone down, the look of your knee should be pretty well preserved. In addition, the improved mobility the procedure provides should make your knee replacement pretty much undetectable.

If you would like to find out more about customised knee replacement surgery and whether it would be a good fit for you, book a consultation with Mr Punwar. For an appointment at either of his practice locations, please call his LIPS practice team on 0208 194 8541.

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