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.

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.

Pain

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.

Swelling

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. This 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:

Obesity

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.

Age

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.

Gender

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:

 

Book Now