Knee injuries, specifically those affecting the anterior cruciate ligament (ACL), are increasingly prevalent among young athletes. Furthermore, recent stories following the ‘ACL injury epidemic’ in Women’s Football demonstrates how important it is to ‘tackle’ the issue.

These injuries are notoriously challenging to treat, with a high risk of re-injury, making early prevention paramount. Enter ‘Power Up to Play’, a targeted, evidence-based warm-up program designed to safeguard the athletes of tomorrow from such injuries.

Here, we’ll explore the invaluable role of a proper warm-up, and the importance of the ‘Power Up to Play’ routine.

Why Warming Up Properly is Key to Preventing Knee Injuries

There is a way to lower the risks of developing a knee injury, and it lies in our warm-up routine. Warming up the body before strenuous physical activity significantly reduces the risk of injury. It prepares and loosens the muscles, making them less likely to strain or pull.

For adolescents and young adults, playing sports isn’t just beneficial for their physical health, but also their mental well-being, friendships, and team-building skills. However, these benefits can be marred by injuries such as ACL tears. Sports involving abrupt direction changes, jumping, and knee twisting can spike ACL injury rates, leaving athletes at risk.

A tear in the anterior cruciate ligament poses significant concerns, especially in adolescents. Their bodies are still growing, making the recovery process longer and more complicated. Surgical intervention carries its own risks, including a higher likelihood of re-injury and future joint arthritis, compared to adults.

What is Power Up to Play?

‘Power Up to Play’ is a brief yet powerful warm-up routine that’s been proven to substantially cut down on serious knee injuries when integrated into a player’s regular training or pre-match routine.

Ideally, athletes should follow the program at least 2-3 times a week to ensure safer, more effective performance.

The program involves a dynamic mix of running, plyometrics, stretching, sport agility exercises, and strengthening. It’s vital to maintain correct form throughout all the exercises to get maximum benefits and injury prevention.

‘Power Up to Play’ helps to strengthen key muscles, reinforce robust body positions, and improve stability and control. With a focus on safer landing techniques, the program takes significant strides in knee injury prevention, offering athletes a smarter, safer path to the playing field.

Treating an ACL Injury

While the ‘Power Up to Play’ warm-up program is a valuable tool in preventing knee injuries, it’s essential to understand the steps to recovery should an ACL injury occur.

The course of treatment, whether surgical or non-surgical, hinges on various factors, including the severity of the injury, the patient’s overall health, and their activity levels.

Treatment focuses not only on physical healing, but also providing patients with strategies to optimally recover and get back on their feet. It is critical to approach the healing process with patience, diligence, and proper guidance.

To find out more, book a consultation with Mr Shah Punwar by calling 020 8194 8541.

Having a strong focus on your rehabilitation after surgery can make a huge difference to your results. Also, a young family and an active career were big incentives for Joe to make a strong comeback after his ACL surgery with Mr Punwar.

Here, Joe talks about his ACL experience, and hopes to inspire others to take their rehabilitation as seriously.

Joe’s ACL Injury

It was ten years ago that Joe suffered an injury when snowboarding in France. When he returned to the UK, an arthroscopy revealed existing issues within the knee tissue that may have led up to his injury. The scan showed that as well as trauma, there was a problem with blood supply to the ACL causing a weakness.

Then, Joe faced two choices – either knee reconstruction or managing his ACL condition. Wanting to avoid the risks of surgery, he chose the self-management path. But this meant avoiding impact sports like football and running, two things he enjoyed.

It was some years, and three children later, when participating in contact exercises that were part of his safety training for the police, that his weak knee gave way. This highlighted a need for surgery to fix his knee instability permanently.

ACL Repair Rehab

After his ACL reconstruction, Joe was determined to recover well, both for his family as well as his career. He had already begun some physio before the operation, although he said after the operation he really had to push through it.

“Friends of mine had told me that the success of your repair depends on strictly following the physio, so that’s what I did. Also, the physio before surgery to prepare you for what’s to come.”

“The day after surgery, I remember doing some basic foot pumps. It felt so alien! My body was telling me not to do it. It was only having read up on it and understanding how important it was that I pushed through with the exercises.”

A ‘model patient’ for ACL surgery

The success of Joe’s approach to his rehab was evident at his four-week check-up with Mr Punwar. Joe spoke to another patient that had surgery a week before his own repair. The other, seemingly younger patient, was on crutches, whereas Joe had arrived on foot, and without any walking aids. “I didn’t say anything because I didn’t want him to feel bad,” said Joe.

Mr Punwar has performed successful ACL surgery on patients of all ages. But although there is no age barrier, the ideal candidate is one that is motivated to get back to their activities.

“Dedication to prehab as well as good post-operative rehabilitation is the best way to achieve a full and successful recovery,” says Mr Punwar.

Mr Punwar uses the UltraSTAR surgical technique for ACL surgery, using a single, quadrupled semitendinosus graft. Studies have shown that this method can lead to better outcomes.

Joe gets running for charity

Now a huge convert to physio, Joe is continuing to recover well. He is working through a ‘Melbourne ACL rehabilitation guide’, supplementing his regular post-op physio sessions with a framework of guided exercises.

Four months after ACL repair surgery with Mr Punwar, Joe joined fellow workmates in a ‘Run, Row, Ride’ challenge raising funds for vital rehabilitation equipment, helping those with lymphoedema after cancer treatment. This was his first mile run on a treadmill since the operation 4 months ago and Joe is hoping that it will inspire others.

“This was an amazing day, to be able to be involved in such an important charity event and organised by the people that got me there.”

Joe left a 5-Star review for Mr Punwar on the Iwantgreatcare website as follows:

Shah ACL Review

Experienced consultant knee and hip surgeon, Mr Shah Punwar is now able to offer patients extended appointment times at The Blackheath Hospital, London.

Evening consultations are available between 5.30pm and 8.00pm, on alternate Tuesdays.

Contact the clinic on 0208 318 7722 or email Punwar.admin@lips.org.uk to book an appointment.

A study carried out by Heart Research UK found that people that received certain hip replacements in the 2000’s, could now be at risk of heart disease. This follows a deeper analysis of the heart health of those patients who received the metal-on-metal replacements, which revealed some disturbing findings.

Although concerning news for those patients affected, this has brought into focus the cardiovascular health risk for anyone undergoing hip surgery. Following this research, more advanced testing measures are being developed that will only lead to better outcomes for patients.

The Heart Research Study

Metal-on-metal implants made from a cobalt and chromium alloy were once believed to be a more durable alternative to the ceramic or polyethylene implant materials. This was a good option for the young and active. But, in fact, the lifespan was significantly shorter.

Although some loose debris is expected after any replacement, metal debris is more toxic. Over time, implant loosening caused metal ions to contaminate the blood. This caused tissue damage and inflammation around the joint, leading to pain, muscle as well as organ damage.

Research carried out at the University of Strathclyde looked at blood samples of 30 patients that had received metal-on-metal implants. It found varying levels of cobalt present in the blood, and further ultrasound analysis revealed abnormal contractile function in their hearts.

The researchers believe that cobalt interferes with calcium levels in heart cells, reducing their ability to contract. This could potentially lead to heart dysfunction in some patients.

Modern Hip Replacement Implants

Unsurprisingly, metal-on-metal bearings are no longer used for hip replacements and are exclusively used for hip resurfacing procedures these days.

Mr Punwar typically uses a combination of metals, ceramics and plastic materials for hip replacements. When using a metal head, a plastic liner will be used, or a ceramic head with a plastic liner for younger patients. All of his materials are 10* rating, and proven to have excellent long-term results on the National Joint Registry (NJR).

It is important to understand there are always risks associated with a major surgery such as a hip replacement. All aspects of the surgery, including risks and your suitability, will be discussed with you before you decide whether you want to go ahead. Mr Punwar and his team will provide a comprehensive aftercare programme and you will have regular check-ups following your surgery.

To discuss whether total hip replacement surgery is the appropriate option for you, call 0808 163 1268 or email Punwar.admin@lips.org.uk to arrange a consultation with Mr Shah Punwar.

Arthrogenic muscle inhibition (AMI) can occur after knee injuries or surgeries, resulting from neural inhibition that causes failure in quadricep activation. Its impact on quadricep strength is significant, as knee extensor peak torque may decrease by 80 to 90% within one to three days following knee joint surgery.

While this effect lessens over time, residual levels of AMI can persist for up to four years after the initial joint trauma. AMI also seems to be a constant presence in arthritic joint diseases, contributing to a considerable amount of quadricep muscle weakness.

Here, we look at how AMI can impact rehab after knee surgery, and how it can be effectively managed.

AMI could prove to be a barrier to rehab after knee surgery

AMI poses a major challenge in the rehabilitation process for those with arthritis or recovering from knee injuries and surgeries. By better understanding its root causes, improved treatment methods can be created that will benefit patients with knee joint issues. AMI can also hinder the process of strengthening the quadriceps, especially during the initial months following an injury or when there is significant joint damage.

The severity of AMI can depend on factors such as the angle of the knee joint, extent of joint damage, and the time since the injury. Its cause is linked to alterations in the output of sensory receptors within the joint, influenced by joint looseness, inflammation, damage to joint receptors, and swelling.

Spinal reflex pathways that may contribute to AMI include the group I nonreciprocal (Ib) inhibitory pathway, flexion reflex, and gamma-loop. There is also initial evidence that suggests higher-level pathways could play a significant role.

How can AMI be effectively managed?

Potential treatments to combat AMI include cryotherapy, transcutaneous electrical nerve stimulation, and neuromuscular electrical stimulation. In cases where there is strong inflammation alongside joint issues, nonsteroidal anti-inflammatory drugs and intra-articular corticosteroids (injected into the joint) may also be effective.

A recent study has shown that cryotherapy and physical therapy can help to effectively manage AMI. A comprehensive review of intervention effectiveness was carried out, following the guidelines and methodologies established by Arksey and O’Malley, as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

The search terms used included a range of keywords related to knee injuries, quadriceps activation, arthrogenic muscle inhibition, and neuroplasticity. Each article’s risk of bias was assessed using the PEDro criteria, while the overall quality of evidence for each intervention was evaluated using the GRADE approach.

The review found moderate-quality evidence supporting the effectiveness of cryotherapy and physical exercises in boosting quadriceps activation after ACL injuries and reconstruction. As a result, these treatment methods are recommended for managing AMI.

Mr Shah Punwar has occasionally seen AMI in patients after knee surgery. Book an appointment today if you suspect you have AMI following a recent surgery, or to discuss the risk involved if you are due to undergo a knee procedure.

Long-distance runners are often cautioned about the potential wear and tear on their joints. However, a recent study has revealed that running distance, frequency, and speed are not linked to a higher risk of osteoarthritis.

In this blog, we explore the findings of this latest research and look at the factors that do increase the risk of knee arthritis.

What did the latest study find?

The latest research was presented at the American Academy of Orthopaedic Surgeons (AAOS) 2023 Annual Meeting.

In the study, investigators collected data from 3,804 runners who took part in either the 2019 or 2021 Chicago Marathon. The participants provided information on their running history, weekly average mileage, and typical running speed. Also, any known osteoarthritis risk factors such as BMI, family arthritis history, and prior hip and knee injuries that affected their ability to run.

On average, the runners were around 44 years old and covered 27.9 miles per week. Most respondents (37.3%) had completed two to five marathons, approximately 21% had finished six to 10 marathons, and 17% were participating in their first marathon.

With an average of 15 years of running experience, 1,892 participants reported previous hip or knee injuries, and 413 had undergone knee or hip surgery. In total, 36.4% mentioned experiencing hip or knee pain in the past year, while 7.3% had been diagnosed with arthritis.

The general belief has been that running might elevate the risk of osteoarthritis due to the increased stress on joints compared to walking or standing. However, the study’s findings revealed no connection between osteoarthritis risk and factors such as weekly mileage, duration of running experience, the number of marathons completed, or running speed.

What factors increase the risk of knee arthritis?

While the study didn’t find any correlation between long-distance running and increased arthritis risk, it did reveal some risk factors. Runners with a history of knee or hip surgery, or past hip or knee injuries, had the highest likelihood of developing arthritis.

Other factors that contribute to the development of osteoarthritis include increasing age, which is the strongest risk factor. Also, being female, as hip osteoarthritis is nearly twice as common in women compared to men. Obesity also plays a role by increasing the load on weight-bearing joints, making knee arthritis over three times more likely and speeding up disease progression.

Both high bone density and low bone density can impact the risk of osteoarthritis. The former increases the likelihood of developing the condition, and the latter raises the chances of rapid progression.

Protecting the knees in long distance runners

Even though marathon running and arthritis are not inextricably linked, safeguarding your knees during long-distance runs remains crucial. Key practices to adopt include proper warm-up routines, selecting appropriate running shoes, and progressively increasing the distance.

If you encounter knee discomfort after running, don’t hesitate to schedule a consultation with Mr. Shah Punwar.

Having travelled the World in the military, and working as a chef at top class events including the London Summer Olympics 2012, Brian knows all about excellent service. After his total knee replacement surgery with Mr Shah Punwar, he likened the procedure to ‘a five star plus hotel experience’.

Having led a very active life, including playing football and working long shifts on his feet, Brian developed arthritis in both knees. Brian was taking medication for the pain and received regular injections from his physio. But his pain was getting more severe, so he was referred to Mr Shah Punwar for total knee replacement surgery.

He takes us through his knee surgery experience with Mr Punwar and his team.

Discharged in 19 hours!

On the day of surgery 5th January, Brian remembers signing in and going straight up to the ward at The Blackheath Hospital. There he was greeted warmly by the surgical team that all introduced themselves.

“Everyone was so friendly. They were just gorgeous people!” He said.

“When I went down for the surgery, the anaesthetist explained everything that was going to happen. The whole thing was so pleasant!”

Not squeamish, Brian was happy to watch them perform the operation on his right knee under a spinal anaesthetic. “I was peeking over the screen to see what they were doing,” he chuckled. The surgeon fitted the implant, then closed the wound with staples and a special surgical dressing.

After the surgery, when Brian was back in the recovery room he enjoyed being given pots of tea. He recovered that night on the ward, already using a walking frame to move around and visit the toilet, refusing any manual support offered by the nurses.

Keen to get home to get home to his girls (two beautiful black cats) he was determined to pass his early morning checks with the physio. He proved that he could walk with crutches and get up stairs – making it up a whole floor! He was given some pain relief medication to take away, and was able to leave the hospital just 19 hours after his surgery began.

Brian’s recovery – preparing for his other knee replacement

“My neighbours, everybody, couldn’t believe I was walking so quickly,” said Brian. He was already visiting the local shops, and using uneven steps down to his garden to play with his two cats.

Now building up strength with more walking, he said that he feels no pain in his operated knee. The only evidence of the surgery is a very neat, straight line. Mr Punwar has been monitoring his progress in readiness for his second surgery, expected before the Summer. Then, he is planning to go back to living in Tanzania in Africa with ‘his two girls’.

His final word on knee surgery with Mr Punwar,

“I highly recommend it. I’m just so pleased! I couldn’t give Mr Punwar and his team high enough praise.”

Knee replacement surgery can be a life-changing treatment for those suffering from severe knee pain and limited mobility. This common procedure is carried out on thousands of patients each year, helping them to regain a better quality of life.

Prior to undergoing a knee replacement, it helps to know what to expect. In this blog, you’ll discover the answers to the most asked questions about the surgery. This includes what to expect before, during, and after the procedure.

Before knee replacement surgery

Prior to having knee surgery, you should try to keep yourself as fit and healthy as possible. This means maintaining a healthy weight and exercising regularly. Avoid shaving or waxing the area where the incision will be made, and if you smoke, make sure you quit a few weeks before the surgery.

These recommendations will help to reduce the risk of complications, as well as aid in the recovery process. Mr Punwar will be able to give you specific pre-op care advice you can follow to prepare for the procedure. His expert team are always on hand to answer your questions.

During the procedure

During a total knee replacement procedure, also known as knee arthroplasty, the damaged or worn out knee joint will be replaced with an artificial implant made of metal and plastic components.

The surgery is typically performed under general anaesthetic and will take around 90 minutes to complete. Your surgeon will make an incision on the front of the knee, before removing the damaged cartilage and bone.

The ends of the thigh and shin bone are then prepared to fit the new artificial joint. Mr Punwar only uses modern implants that have an excellent track record.

The implant is positioned and secured in place before the incision is closed with stitches or clips. Then, a surgical dressing is applied to keep the wound clean and to minimise infection. You will be given antibiotics before your surgery and several doses following the procedure to give you the best coverage.

Recovery after knee replacement surgery

The recovery process after a knee replacement surgery can vary depending on the individual and the specific type of surgery performed. In general, it typically takes up to six weeks to fully recover and to return to normal activities.

Immediately following the surgery, you will need to stay and be monitored in the hospital for a few days to manage pain and begin physical therapy. Pain and swelling can be eased with medication, ice, and elevation. After a couple of weeks you will be booked in for a wound check to ensure the skin incision has healed properly.

After being discharged from the hospital, patients typically attend physical therapy sessions 2-3 times a week for a total of 4-6 weeks. You will also be given exercises to do at home. It may take a few weeks, but you may be able to start putting weight onto the knee in as little as a few days.

It is also important to note that knee replacement surgery does not necessarily restore the knee to its normal function. This means you may have some limitations when carrying out certain activities. Mr Shah Punwar will give you plenty of after-care advice. He will let you know what kind of activities you should avoid and what kind of activities you can do.

If you have more questions about what to expect from total knee replacement surgery, book a consultation with Mr Shah Punwar now. He has carried out hundreds of knee replacement surgeries and can answer any questions you have.

Hip replacement surgery is an operation to replace an arthritic, damaged hip joint. When there is significant cartilage loss in the hip joint causing pain, stiffness and mobility issues, a full replacement of the joint may be required. By the time hip replacement is necessary patients are often waking in pain at night and unable to put their shoes and socks on. Getting out of the bath or low chairs and car seats can be a struggle.

Understandably, you may have a lot of questions when you are told you need surgery. Here, we reveal the answers to some of the most common questions patients have about the procedure.

Before hip replacement surgery

Prior to undergoing hip replacement surgery there are things you should do to help limit the risks, and ensure the procedure runs smoothly. While the risks of hip surgery are minimal, it helps to ensure you are as fit and healthy as possible before the surgery.

Partaking in gentle exercise such as walking or swimming, will help to strengthen the hip muscles and aid in your recovery. If you smoke, you should also aim to quit a few weeks before the surgery. Nicotine has been proven to complicate healing, and it significantly increases the risks involved.

You will be given antibiotics to take before the surgery, and once again afterwards to reduce the chance of infection.

It is important that the skin around the hip and leg is in good condition at the time of surgery.

Other medical conditions, such as diabetes, should also be under control and there will be a pre assessment process to check general fitness for surgery. This will include routine blood tests.

Mr Punwar will advise you on the best ways to prepare for the surgery and his expert team are always on hand to answer any questions you may have.

During the procedure

Hip replacement surgery takes between 1 to 2 hours to complete. A consultant anaesthetist will see you prior to surgery and discuss the options available.

You will generally be given a spinal anaesthetic, ensuring you don’t feel anything during and shortly after the procedure.

A 10-15 cm curved incision will be made at the side of the hip, before Mr Punwar dislocates and removes the femoral head. An uncemented metal socket will be attached to the pelvis, before a metal stem with a ceramic or metal head is implanted in the femur. The femoral stem may be cemented or uncemented depending on bone quality and shape. Mr Punwar will plan the surgery beforehand and make sure you are aware of the intended procedure.

Any blood loss will be minimised and the procedure will be carried out in an ultra-clean air operating theatre to minimise infection.

The wound will then be closed up with clips or sutures and protected with a surgical dressing to minimise the risk of infection.

Recovery from hip replacement surgery

The few days after undergoing hip surgery, Mr Punwar and the physiotherapy team will keep a close eye on you to ensure you are regaining mobility. A postoperative x-ray will be taken, and you may experience some bruising and swelling around the site of the operation. There may be some lower leg swelling. You will be given compression stockings to reduce swelling and guard against deep vein thrombosis. You will also be given daily injections of a low dose blood thinner to prevent thrombosis for 4 weeks. This is recommended by the National Institute for Clinical Excellence (NICE).

Pain relief will be prescribed as necessary to help your recovery. At 2 weeks a wound check will be performed to make sure the skin incision has healed well.

For a period of six weeks, you may need to take precautions to protect the hip such as sleeping on your back, sitting in very low chairs and avoiding crossing your legs. You will be provided with specific aftercare instructions you should follow, after the procedure by Mr Punwar and the physiotherapy team.

Ideally, you should avoid driving for 4-6 weeks after the surgery. In most cases, patients recover and can resume daily activities within six weeks. A review will be arranged 6 weeks after surgery. This ensures you are recovering as expected. Further follow-up will be arranged as required.

To discuss whether a hip replacement surgery is a suitable option for you, contact Mr Punwar today. You can call on 0808 1631268, or email punwar.admin@lips.org.uk.

Knee pain affects millions of people every day, leading to a lower quality of life and issues with mobility. Treatments for knee pain largely depend upon the root cause of the problem. For those suffering with pain due to bone marrow lesions, one option that is proven to work is subchondroplasty.

So, what is subchondroplasty for the treatment of knee pain? Learn everything you need to know below…

What is subchondroplasty?

Subchondroplasty is a minimally invasive procedure that aims to fill in subchondral bone defects. It is a fluoroscopically assisted procedure that uses AccuFill®Bone substitute material (BSM) to fill in the gaps.

The procedure tends to be carried out alongside an arthroscopy. This helps to both visualise and treat the problems discovered in the joint. The Accufill BSM hardens and creates new bone as the body heals.

Those who undergo a subchondroplasty report a reduction in pain and an improvement in quality of life. Having the procedure also doesn’t impact your ability to have further surgery if it is needed.

What types of knee pain will subchondroplasty help?

Subchondroplasty can treat subchondral bone defects which may occur due to osteoarthritis for example. Over time, conditions such as osteoarthritis can wear down the cartilage and bone. Not only is this extremely painful, but it can also lead to a loss of mobility.

A previous study has shown that subchondroplasty can also be highly effective at treating bone marrow lesions. The study also showed that the procedure could reduce pain and prevent the need for a total arthroplasty at the follow up stage.

Whenever the pain is caused by the bones, and not the tissue of the joint, subchondroplasty can help. As it is an outpatient procedure, patients can usually leave on the same day. It is provided via an injection into the bone, making it a minimally invasive procedure.

Seeking a diagnosis for knee pain

If you are experiencing any type of knee pain, it’s important to get to the root cause of it. If left untreated, knee pain can worsen, and you may start to lose function in the joint. This can limit your quality of life, preventing you from moving around and putting you at greater risk of other health problems.

To find out what might be causing your knee pain, contact Mr Shah Punwar today. Mr Punwar is a specialist in knee pain and he can determine the cause of your discomfort and the right treatment for you.

Soon, Mr Shah Punwar will be offering subchondroplasty treatment (Zimmer Biomet method), but he can discuss all of your treatment options that would give you the best results. It may be that a knee replacement is the best way to treat your knee pain permanently.

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