We’ve talked a lot about anterior cruciate ligament (ACL) injuries, because they account for around 40 per cent of all knee injuries. Which means they are one of the most frequent problems seen by orthopaedic surgeons like Mr Punwar.

ACL injuries are particularly prevalent amongst athletes – particularly in sports like basketball and football, where pivoting occurs a lot. But anything that involves a sudden stop or change in direction can cause an ACL tear.

How do you know if your knee injury is a torn ACL?

Here are five major signals that your injury is a torn ACL:

A popping sound

This is probably the biggest giveaway of an ACL tear. At the time that the injury occurs, if you hear a popping sound coming from the affected knee, it is likely to be ligament damage.


The most common sign of an ACL tear is pain in the affected knee. Patients often report that the pain is immediate and worsens when they try to stand up. Athletes are unable to return to play. Of course, pain alone is not necessarily indicative of a specific injury. Most injuries will cause a certain level of pain – but in combination with the popping sound and other symptoms listed here it could suggest a torn ACL.


Whilst with some injuries swelling occurs slowly in the hours after the event. With an ACL tear the swelling tends to be immediate and obvious. This is because the ACL has a good blood supply which is disrupted when the ligament tears.

Instability/difficulty walking

Many patients with ACL tears report that they are unable to stand or put weight on the affected knee after the injury. Some say that when they try to stand, the knee buckles or gives way beneath them. It would therefore be very difficult for people with this injury to walk unaided. Other parts of the knee, such as the shock absorbers, are often damaged at the same time as the ACL which can lead to locking and clicking.

Is it possible to have a partially torn ACL?

It is not only possible, but in fact very common to have a partial tear. Research has shown that between 10 and 27 percent of ACL injuries are partial tears. ACL tears are graded into three categories:

  • Grade 1 is the mildest category, where the patient is usually still able to walk and has some knee stability. The ligament has been stretched, but not fully torn
  • Grade 2 tears are where the ligament has been further stretched and is partially but not completely torn
  • A complete tear is Grade 3

What should I do if I think I have an ACL tear?

Following immediate treatment in an emergency department, if you think your knee injury might be an ACL tear, the best thing is to have it assessed by a specialist. Patients are usually given crutches, painkillers and have an X-ray in the emergency department but it can be difficult to make a definitive diagnosis at that time.

Orthopaedic surgeon Mr Shah Punwar is highly experienced in knee injuries and will perform a thorough examination as well as organising an urgent MRI scan where necessary. The road to recovery can be quite long after an ACL injury. Mr Punwar offers both careful surgical reconstruction and a personalised rehabilitation plan to get you back to sport as soon as possible.

If you have concerns about your knee injury, and would like to book a consultation with Mr Punwar at either of his practice locations, please call his LIPS practice team on 0208 194 8541.

Knee osteoarthritis is a relatively common condition, affecting up to 45 per cent of people during their lifetime. 19 percent of people over 45 have some degree of osteoarthritis in the knee, and that figure increases to 37 per cent in the sixty plus age group.

However, despite its prevalence, people are often unsure why they developed the condition, and wonder if they need surgery for knee osteoarthritis. Mr Punwar sees a lot of patients that have suffered with knee pain for a long time before seeking treatment. In this article we will be clearing up some confusion around knee osteoarthritis.

Osteoarthritis is often termed non-inflammatory (‘wear and tear’) cartilage damage separating it from the inflammatory joint conditions such as rheumatoid arthritis which is increasingly treated with modern drugs. There is some overlap between the two types of joint arthritis.

What causes knee osteoarthritis?

The exact cause of knee osteoarthritis is not yet known, but we do know of some things that can increase your risk of developing the condition:


The more weight there is to carry, the greater the stress placed through the knees. In a normally aligned leg 60% of weight is carried through the inner part of the knee explaining why the inner (medial) part of the knee often degenerates first. Your risk of developing joint pain and osteoarthritis increases with weight.


There’s not a lot you can do about this one but knee cartilage, like most collagen based connective tissues in the body, articular cartilage tends to get weaker over time, which can lead to damage from minor injuries.

Joint trauma

This could be one big accident, like a broken bone, or a series of mini traumas (from a high impact sport such as football), which over time can lead to widespread osteoarthritis

Lack of exercise

In case you were thinking you’d better pack away your running shoes to save your knees, conversely too little exercise can also cause problems. Poor muscle tone puts extra stress on the knee, and lack of movement prevents joint (synovial) fluid from circulating. Lack of movement also leads to stiffness which can affect function.

Family history

If anyone in your family has had osteoarthritis in the knee, your chances of developing the condition are increased.


Women are 40 per cent more likely to develop osteoarthritis than their male counterparts. Female knees often start to bend outwards (knocked knees) leading to pain on the outer part of the knee joint, which is particularly painful. Men are more likely to develop the pattern of osteoarthritis where the knees bend inwards (bow legs) putting stress on the inner aspect of the knees.

Overall a combination of genetic and lifestyle factors affects your risk of developing knee osteoarthritis (OA).

What are the symptoms of knee osteoarthritis?

If you’re not sure whether you’ve got knee osteoarthritis, these are the symptoms to look out for:

  • knee pain that is worse when you are moving it
  • a warm feeling in the knee joint
  • swelling
  • stiffness
  • less movement in the knee
  • a creaking or cracking sound when you move the knee

How should knee osteoarthritis be treated?

How you treat the problem very much depends on the individual. If you are overweight, your doctor may suggest weight loss, which can provide a surprising amount of relief. Certain strengthening exercises can also be helpful in mild cases.

You might be prescribed painkillers or anti-inflammatories, or your doctor may suggest corticosteroid or hyaluronic acid injections into the knee joint. Physiotherapy and knee supports can also be useful.

If your knee osteoarthritis is very advanced, best shown by ‘bone on bone’ appearances on X-ray, and these other options aren’t working, it may be time to consider surgery.

In these end stage cases patients are often woken from sleep with knee pain and are unable to do their activities of daily living independently, such as driving and shopping.

Types of surgery for knee osteoarthritis

There are several types of surgery that can be used to treat knee osteoarthritis, and the right one for you will depend on many factors. Here is a brief rundown of the surgeries available:

Total knee replacement

This is for more severe cases where there is widespread cartilage damage, accompanied with pain and functional loss. It involves the removal and replacement of the entire knee joint. Mr Punwar only uses modern implants with a proven track record. He  ensures that every effort is taken to minimise tissue damage and promote rapid recovery. Emerging technologies such as custom made knee replacements are producing promising results. There is an added benefit of having implants tailored to individual anatomy. Please discuss with Mr Punwar if you are interested in finding out more about custom knee replacement surgery.

Partial knee replacement

This is increasing in popularity as the benefits of minimally invasive surgery are becoming clear. However, partial knee replacement needs to be performed in carefully selected patients for the best chance of success. Surgery involves replacing just one of the knee’s three compartments – the inner (medial), knee cap (patellofemoral) or outer (lateral) knee. By far the most common partial knee replacement involves the inner side of the knee only.

Benefits of the partial knee replacement approach include bone conservation, lower medical risks and faster recovery. Also, better function as all the natural knee ligaments are preserved. There are risks of other parts of the knee wearing out over time but generally partial knee replacement patients are very satisfied.

Knee arthroscopy

A form of keyhole surgery, this involves entering the knee through a tiny incision and using a telescope to view. The joint damage is assessed and minor procedures are performed to smooth the knee joint and remove inflamed tissue. This procedure is usually suitable for less severe cases and is no longer widely used in the treatment of knee osteoarthritis.

Knee osteotomy

As with partial knee replacement, this is suitable for (usually younger) patients whose knees are poorly aligned. The procedure involves the removal of a small wedge of bone from either the femur or tibia. This is then replaced with bone graft or a synthetic replacement. The realignment of the leg changes the load distribution on the knee, reducing pain in the affected compartment.

The only way to be certain which of these surgeries is best for you is to have a thorough 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.

Orthopaedic surgeon Mr Shah Punwar is to speak at a GP webinar hosted by BMI Blackheath Hospital. The focus of the webinar is to provide guidance on which hip and knee cases need to be prioritised following the COVID pandemic. Mr Punwar is currently seeing a high volume of knee sports injuries that are presenting very late as well as end stage arthritis.

Entitled ‘Primary Care – Tackling the hip & knee backlog: What cases do I prioritise?’, this is an orthopaedic online education event for GPs and other healthcare professionals.

This event is an online event and will take place via Microsoft Teams – click here to book your place on the event.

When talking about knee injuries, there is often some confusion between the terms ‘meniscus tear’ and ‘cartilage tear’. In fact, the terms are frequently used interchangeably by patients. So, is there a difference between a meniscus tear and a cartilage tear to the knee, and if so what is it?

Meniscus v cartilage

The easiest way to clarify the situation is to look at what is meant by the words ‘meniscus’ and ‘cartilage’.

Cartilage is one of the body’s connective tissues. There are two types of cartilage in the knee joint: articular cartilage, which covers the ends of the bones that make up the knee, and meniscus cartilage, which forms a sort of cushion between the bones.

So is meniscus a type of cartilage?

That’s right. So if a doctor refers to an injury as a cartilage tear, they could mean a meniscus tear. In fact, the majority of cartilage injuries to the knee are meniscus tears, which might be behind the confusion, as doctors may not see the need to specify.

Articular cartilage injuries

Although less common than meniscal tears, injury to the articular cartilage of the knee does happen. This can present as cartilage thinning; fissures or flaps within the articular cartilage, or cartilage defects.

Common symptoms of articular cartilage injury include:

  • Pain
  • Swelling of the knee joint
  • Locking or giving way of the knee

How does articular cartilage damage happen?

As with most knee injuries, articular cartilage damage is often a result of trauma, such as injury. It can, however, be linked to inflammatory joint conditions such as arthritis, so it is important to get it thoroughly assessed by a specialist.

Meniscus tears

Meniscus tears are the most common knee injuries. Symptoms include:

  • Swelling or stiffness in the knee joint
  • Difficulty straightening the knee
  • Locking or giving way of the knee
  • A popping sensation when the injury occurs

As you can see, symptoms of both injuries are strikingly similar, so a thorough examination is necessary to determine which type of injury you have.

How do meniscus tears happen?

Meniscus tears can occur during any activity which causes the knee to twist or rotate the knee. It is common among athletes, particularly basketball and netball players.

Treating a cartilage tear

If you think you may have torn the cartilage in your knee, the first thing to do is to have your injury assessed by a specialist – and the sooner you do this, the better. Meniscal tears do not tend to heal by themselves, but orthopaedic surgeon, Mr Shah Punwar is highly experienced in dealing with these types of knee injuries.

During your consultation, Mr Punwar will talk through all the different treatment options with you, including physiotherapy and surgery.

A knee arthroscopy might be performed, whereby the inside of your knee is examined with an instrument called an arthroscope. This is inserted through an incision close to the knee, and both articular cartilage and meniscus procedures can be performed. The good news is that recovery is usually very quick with minimal tissue damage.

If you have concerns about a knee injury, and would like to book a consultation with Mr Punwar to discuss treatment options, contact us by calling 0808 273 6283 or emailing info@shahpunwarortho.com .

A study published in the Bone and Joint Journal has found that large numbers of patients who are waiting for a joint replacement in the UK are suffering from pain that is ‘worse than death’.

The COVID pandemic and its ramifications have resulted in thousands of patients across the UK having non-urgent operations cancelled or delayed, including joint replacement surgery.

A study was carried out by researchers from the University of Edinburgh. It found that the number of patients suffering from agonising pain due to a delay in surgery has almost doubled compared to pre-pandemic figures.

Measuring pain

The research team gathered information from patients awaiting treatment at ten hospitals across the UK. The sample included four in Scotland and one in Wales and used an internationally-recognised points system to calculate results.

The points system uses a scale from one to zero, where one represents good health and zero represents death. 35% of patients waiting for hip replacement surgery who were surveyed scored below zero. A state that is considered to be worse than death.

For comparison, a similar study was carried out in Scotland between 2014 and 2017. It found that 19% of patients waiting for hip replacement scored below zero. So that figure has grown by nearly 100% in the intervening years, a fact which surgeons mainly attribute to the pandemic.

Edinburgh orthopaedic surgeon Chloe Scott, author of the study, said that patients’ quality of life was reduced for every six months they spent on a waiting list. She told The Times:

“Many of these patients are in constant pain. They are therefore put on really strong opiate medication by their GP, which is not what is recommended for arthritis.”

She added that many patients are also suffering from sleep deprivation as their pain levels prevent them from sleeping.

Why are patients waiting so long?

Operations on the NHS have always been subject to waiting lists. But patients waiting for a joint replacement surgery rarely have to wait longer than a year. However, the pandemic has meant that all but the most urgent of operations have been cancelled or postponed.

This is partly due to the increased risk of COVID infection in a hospital setting. But also to the divergence of a large number of staff and resources to the treatment of COVID patients.

However, now that infection numbers have fallen to their lowest rate since September 2020. Furthermore, over 50% of the UK population has received at least one vaccine dose. Surgeons are now calling for massive investment in the health service to get things moving again.

What can be done?

Whilst the prime minister is promising massive investment in the health service soon, that’s not much help to patients who are suffering now.

Mr Shah Punwar and his colleagues are doing their best to reduce NHS waiting times through efficiency drives, and patients can help their own chances by asking their GP for a referral.

If you are awaiting a joint replacement operation and are in severe pain as a result, you can ask your GP for a referral at either of Mr Punwar’s practice locations using the NHS Choose and Book service.

For more information, please contact us or you can email info@shahpunwarortho.com .

Hip replacement is a very common form of surgery. The most common reason for needing a hip replacement is osteoarthritis affecting the hip joint.

Osteoarthritis usually affects older people. Some studies even suggest that most people aged over 60 show some signs of a degree of osteoarthritis.

There is no time limit on hip replacement surgery. If you are over 90, fit and well, and need a hip replacement, there is no medical reason to not have treatment. There are risks involved in any surgical procedure, which your surgeon will discuss with you in your initial consultation.

What are the signs that I need a hip replacement?

If you suffer from osteoarthritis, the chances are that your GP is aware of your condition. If you are having regular check ups, they will refer you for surgery once it becomes necessary.

However, there are some signs to look out for that could be indicative of the need for surgery:

  • A grinding sensation in your hip (known as crepitus)
  • Lack of movement in the hip joint
  • General pain and stiffness in the hip and groin that is not being helped by medication or other treatment
  • Difficulty in getting out of low chairs, cars or the bath
  • Difficulty putting your shoes and socks on

How do I decide if the time is right for a hip replacement?

It is vitally important that you and your surgeon look together at all the factors leading to surgery. You can then make a decision about whether or not a hip replacement is necessary at this juncture.

Some factors you might want to consider and discuss with your GP or surgeon are:

  • Are your hip problems affecting your ability to get around?
  • Does this impact your quality of life?
  • Do the benefits of the surgery outweigh any risks?
  • Have you difficulty sleeping?
  • Do you have any underlying medical conditions that may increase the risk of surgery?
  • Are you prepared to attend the necessary physiotherapy sessions after surgery, to ensure that the operation produces optimal results?

Should I have a hip replacement privately, or on the NHS?

Again, this is a decision which everyone must make according to their own individual needs. Hip replacement surgery is certainly available on the NHS. There is no reason why the outcome should be any different if you choose to use a private provider.

One major consideration, however, is the waiting time. Even under normal circumstances, the waiting list for hip replacement surgery on the NHS can be lengthy. In light of the current Covid-19 pandemic, it is hard to know how long you might have to wait before an operation is available through the NHS.

Hip replacement surgery can have a dramatic impact on your quality of life. It is important to make an informed decision about when is the right time for you to undergo surgery.

If you would like to find out more, or to book a consultation with Mr Punwar, please contact us.

As well as self-pay and insured patients, Mr Punwar is happy to see NHS Choose&Book patients who can ask their GPs or specialist physiotherapists for direct referrals at either one of our BMI practice locations.

Knee injuries are all too common – particularly at the moment, when running is seeing an all-time popularity surge as people have come to realise the huge boost it can offer to your mental health.

The temptation can often be to ignore a knee injury; if exercise is your release, then you don’t want to risk being told to stop. Some people might choose to push through the pain, or to rest it for a couple of days or weeks in the hope that it sorts itself out.

A cautionary tale

A recent revelation by singer and presenter Olly Murs was that he left his knee operation too long. He is now in a ‘two-year rehab programme’ as a result. It just goes to show the importance of seeking early diagnosis of any knee injury.

A recent study from the Netherlands published in the British Medical Journal showed the effect of delays in treatment. It showed a significant improvement in outcomes for patients who had early surgery on ACL (anterior cruciate ligament) injuries, compared to those who delayed the reconstructive surgery.

And in Mr Punwar’s own experience in treating knee injuries, often associated tears to the meniscus (a piece of cartilage that provides a cushion between the femur and the tibia, acting as a shock absorber for the knee) are worse when there has been a significant delay between injury and treatment.

Inevitably the Covid pandemic has had a knock-on effect on these delays leading to even later presentations. This is something which Mr Punwar and his research team at University Hospital Lewisham are currently studying.

When to visit a knee injury specialist

It can be hard to know what constitutes an actual injury, and what is just some tenderness from overexerting the muscles or a mild knee sprain.

As a general rule, these are the signs that should have you heading to the clinic:

  • You can’t put weight on the affected leg
  • There is swelling around the knee
  • You felt or heard a ‘pop’
  • You can’t straighten your knee fully – or, conversely, there is too much movement in the joint
  • Your knee keeps buckling (giving way)

If you are experiencing one or more of these signs, get your injury checked out as soon as possible.

Early treatment for knee injury

In fact, there isn’t really a downside to seeking early diagnosis and treatment of a knee injury. The best-case scenario is that no serious injury will be found. If this is the case, some light physio and a bit of rest to the affected knee should have you back up and running in no time.

And in the event that your knee injury is more serious, early diagnosis means early treatment. This also means better and faster results.

Regardless of the gravity of your injury, the sooner you get it assessed and treated, the sooner you can begin to return to your chosen activity.

If you have concerns about a knee injury, and would like to book a consultation with Mr Punwar to discuss treatment options, contact us by calling 0808 273 6283 or emailing info@shahpunwarortho.com

Shah Punwar Orthopaedics is happy to offer patients a new practice location at the BMI The Sloane Hospital in Beckenham. Our Kent Orthopaedic Clinic will start offering appointments from Wednesday 14th April. Please book via the BMI booking line on 0808 273 6283 or it’s now possible to book your appointment with Mr Shah Punwar online via the BMI booking system:


The anterior cruciate ligament (ACL) is a ligament in the knee, which joins the femur (upper leg bone) with the tibia (lower leg bone) and its function is to keep the knee stable. ACL tears are common amongst sportspeople, both professional and amateur.

ACL injuries generally occur when the knee is bent backward, or twisted. This can happen when you change direction quickly, land from a jump or slow down from running, all of which are common in pivoting activities like football, rugby or skiing.

There are of course other, non-sports-related ways to injure your ACL. Other common causes are falling off a ladder or missing a step on the stairs.

Mr Shah Punwar is highly experienced in treating ACL tears and has an excellent track record, but what can you do to increase the chance of your surgery’s success?

Recuperation from ACL injuries

The journey to recovery from an ACL tear can be a long one and there is a serious risk of re-injury if a structured rehabilitation programme is not followed closely, particularly among athletes.

Surgery to repair an ACL tear can help you to return to your previous athletic form. However for contact sports, a delay in returning to the playing field of at least nine months can prevent re-injury.

One particular study showed that for every month that a return to full play was delayed, post surgery, the risk of reinjury was reduced by 51%.


Physiotherapy forms a crucial part of the recovery process after surgery on an ACL tear. Any athlete will know that it is important to warm up your muscles prior to commencing a sporting activity.

Physiotherapy performs this same function, but on a more gradual, long-term basis. This allows an injured body part to fully recover and regain strength before it is called back into action again.

The idea of fitting regular physiotherapy sessions into your schedule might seem too much to contemplate. But a recent study published in the British Medical Journal (BMJ) showed that even minimal physiotherapy can be effective in aiding recovery from ACL surgery.

We would always recommend however that a full physiotherapy programme is adhered to for optimal results.

Pre-operative physiotherapy

A growing body of evidence suggests that having physiotherapy before your surgery leads to a beneficial outcome. Indeed some patients may be able to avoid surgery altogether by following a good physiotherapy programme.

One study, published in the American Journal of Sports Medicine, found that patients who received pre-operative physiotherapy had better functional outcomes for the knee, with the benefits lasting for over two years after surgery.

Some components of a physiotherapy programme before ACL surgery might be:

  • Exercises to improve strength in the hamstring and quadriceps
  • Treatment to control swelling in the knee joint
  • Balance exercises
  • Neuromuscular training – this involves learning how best to jump and land in order to protect your knee

Pre-op physiotherapy is known as ‘prehabilitation’ and, combined with good post-operative physiotherapy and a delayed return to sport, is the best way of achieving a full recovery with reduced risk of re-injury.

For more information on ACL surgery or to book an appointment, please contact us by calling 0808 273 6283.

The maxim ‘no pain, no gain’ has just been reinforced by the publication of a recent Canadian osteoarthritis study, published in Osteoarthritis and Cartilage, the official journal of the Osteoarthritis Research Society International. The study has shown that working through any initial pain caused by exercise will pay off in the end as pain levels will decrease.

Osteoarthritis is the most common form of arthritis and can affect any joint in the body, although the large weight-bearing joints such as the knees are particularly susceptible. It occurs when the cartilage that protects and cushions the ends of your bones wears down, causing pain and stiffness. It’s thought that 8.5 million people suffer from osteoarthritis in the UK.

The study, from researchers at Western University’s Wolf Orthopaedic Biomechanics Laboratory (WOBL), found that rather than giving up exercise when it hurts, persistence pays off.

“You really shouldn’t be afraid of exercise. We know it can sometimes hurt when you move a joint with OA, but as long as you’re careful about it and take a break when you have substantial amounts of pain, it’s actually better for you to keep exercising,” said Trevor Birmingham, a physical therapy professor at Western who is also Canada Research Chair in Musculoskeletal Rehabilitation.

A 12-week neuromuscular exercise programme was devised for knee arthritis patients. During the supervised therapy sessions, participants were questioned about their perceived exertion and pain levels.

Rather than aerobic or strength training, neuromuscular exercise focuses on postural control and balance. For example, ensuring your knee is in the correction position while performing the various exercises.

Listening to your body

With any exercise programme it is essential that you listen to your body. Patients on the Western study knew to expect there would likely be some pain experienced at the start of the exercise programme but that this should subside. However, if the pain went above a certain threshold then the exercises would be modified.

Orthopaedic surgeon Mr Shah Punwar explains to his patients that there is much evidence that moderate exercise and even running is good for osteoarthritis, contrary to what used to be taught.

A 2013 study that compared the effects of running vs walking, found that running significantly reduced the risk of requiring a hip replacement, in part due to its weight loss benefits.

For more advice on management of osteoarthritis, call 0808 163 1268 to arrange a consultation with Mr Shah Punwar.

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