We will often receive emails from people who will say “I am 59 years old, very active. I have wear and tear damage in my knee I am being told to lay off or stop weight lifting and running. I can still play golf but it now hurts on some of the swings. My orthopedist is suggesting a knee replacement to keep my active. Can your treatments get me back to my running and weight lifting and make golf less painful for me?”
Someone who is still active, even through some pain, is usually a good candidate for stem cell therapy, however candidacy for treatment is something that would usually require a physical examination to confirm. But can stem cells offer some hope? I will talk about this later in this article.
I will also get emails asking me about golf after knee replacement. Generally speaking, some can play golf, some have difficulty but typically, people who play golf are not among the most enthusiastic about getting a knee replacement.
Sports and the knee replacement – the knee replacement will not be able to keep up with an active lifestyle.
For some people, there is a thought that knee replacement will allow them to return to their sport better than ever. This is not always the case. Some people have more realistic expectations about returning to their sport after a knee replacement, for these people they do not have to be better than ever, the just need to play at any level. One aspect of returning to the game many do not count on is that their knee replacement will not be able to keep up with their active lifestyle.
Golf and wearing out the knee replacement
Let’s go right to a December 2020 study (1) on golf and knee replacement. In this research doctors discovered that golfers are wearing out the knee replacements much faster than they should. Here is what the orthopedic surgeons of this study said, the ending is somewhat remarkable.
“Sport with an endoprosthesis (a knee replacement) is controversially discussed (meaning resuming certain sports with a knee replacement should not be allowed), whereas golf with a knee endoprosthesis is usually allowed.”
- The surgeons are questioning if everyone should be allowed to return to golf because they are suggesting, based on a case study, “that playing golf can lead to severe wear of the prosthesis (the knee replacement hardware). The wear pattern of the components of the prosthesis suggests increased rotational loads. A change to a constrained prosthesis was made because of metal-to-metal contact. It is important to inform the patient before surgery about sports with endoprosthesis. Athletic loads are not part of prosthesis testing according to ISO (International Organization for Standardization).”
The knee replacement had to be replaced because golf wore it out
This is the surgeon’s report again:
- “The wear pattern of the components of the prosthesis suggests increased rotational loads. A change to a constrained prosthesis was made because of metal-to-metal contact.”
The knee replacement had become just like a bone on bone knee. The plastic between the femur replacement metal and the tibia replacement metal had worn out. Instead of bone on bone, the knee had become metal on metal.
- “It is important to inform the patient before surgery about sports with endoprosthesis. Athletic loads are not part of prosthesis testing.”
The surgeons are also suggesting that patients be told that their knee replacement may not be tested for these types of stress and there can be the possibility that too much golf will send you back to another knee replacement.
Doctors suggested that patients ride a bike instead of playing golf
A knee replacement going metal on metal after golf is not a new revelation. In 2008 (2) doctors wrote:
“The expectation of returning to sports activities after total knee arthroplasty (replacement) has become more important to patients than ever. To (the researcher’s) knowledge, no studies have been published evaluating the three-dimensional knee joint kinematics during sports activity after total knee replacement.”
The researchers looked at, through 3D models, what happens to a knee replacement during cycling and during golf. They found that both the golf swing from the set-up position to the top of the backswing, and the stationary cycling from the top position of the crank to the bottom position of the crank, produced progressive axial rotational motions. However, the golf swing from the top of the backswing to the end of the follow-through produced significantly larger magnitudes of rotational motions in comparison to stationary cycling. Excessive internal-external rotations generated from the top of the backswing to the end of the follow-through could contribute to accelerated polyethylene wear (in the knee replacements). However, gradual rotational movements were consistently demonstrated during the stationary cycling. Therefore, stationary cycling is recommended rather than playing golf for patients following a total knee replacement who wish to remain physically active.
Its the front knee that takes the most rotational force. If that is the knee being replaced, be careful retuning to golf.
For most, golfer’s knee pain is a degenerative process caused by the repetitive motions of the golf swing and the twisting of the forward knee in the follow through. The force of continued impact on the knee is usually manifested as chronic, dull pain; cracking or popping sounds from the knee while walking; and, pain from swelling and inflammation. These symptoms can come on slowly or more rapidly depending on the technique of the golfer and the remedies they chose to administer to themselves.
The interior damage to the knee
The knee can be injured in many ways in golf including ligament damage. The ACL (anterior cruciate ligament), the MCL (medial collateral ligament) and the PCL (posterior cruciate ligament), are powerful ligaments responsible for holding the knee, the thigh bone (femur) and the shin bone (tibia) in their proper place in respect to each other.
When these ligaments suffer from excessive wear caused by a twisting golf swing, they become lax, they loosen up and a tight knee becomes a “wobbly knee.” When the thigh and shin bone are allowed to become hypermobile they can grind down and wear out the protective padding between them, the meniscus and the articular cartilage.
The articular cartilage is the protective padding covering over the bottom of the thigh bone and the top of the shin bone. The meniscus is the soft pad between the bones that absorb the impact of walking, running and jumping. When they wear down, bone-on-bone osteoarthritis occurs.
There are many treatment options available to the golfer. Most physicians will recommend a conservative route rich in anti-inflammatory medications, ice, pain-killers, and rest. When these options fail, as most times they do, the next conservative option is to “live with it,” or have the surgery.
The front knee in the golfer is at the greatest strain and risk, and so is the knee replacement
Building on the research above, a 2017 (3) study suggested that the front knee in the golfer is at the greatest strain and risk. Here is what these researchers said:
“Golf is commonly considered a low-impact sport that carries little risk of injury to the knee and is generally allowed following total knee arthroplasty. Kinematic and kinetic studies of the golf swing have reported results relevant to the knee, but consensus as to the loads experienced during a swing and how the biomechanics of an individual’s technique may expose the knee to risk of injury is lacking.”
Basically there is no consensus as to the loads experienced during a swing and each player’s swing is somewhat unique and may present different types of load results. In other words one golfer may wear out a knee replacement, another may not.
The researchers’ objective “was to establish (1) the prevalence of knee injury resulting from participation in golf and (2) the risk factors for knee injury from a biomechanical perspective, based on an improved understanding of the internal loading conditions and kinematics that occur in the knee from the time of addressing the ball to the end of the follow-through.”
Findings: “Studies reporting kinematics indicate that the lead knee is exposed to a complex series of motions involving rapid extension and large magnitudes of tibial internal rotation, conditions that may pose risks to the structures of a natural knee or (a knee that has been replaced). . . Compressive loads ranging from 100 to 440% bodyweight have been calculated and measured using methods including inverse dynamics analysis and instrumented knee implants. Additionally, the magnitude of loading appears to be independent of the club used.”
Again, researchers suggested that the patient be made aware that if their front golfing knee is being replaced, there could be issues.
So can you get back to the game after knee replacement? Yes. How well will you do? Let the researchers tell you
Here is the title of a May 2020 study: A Playtime and Handicap Analysis of 143 Regular Golfers After Total Knee Arthroplasty at Minimum 2-Year Follow-Up. (4) Here is the summary of this paper:
“Regular and competitive golfers are concerned by the ability to recover their previous activity golfing after total knee arthroplasty. The purpose of this study was to conduct targeted analysis of the effect of unilateral (one side) total knee replacement on the playtime and golf level in a population of experienced golfers, with a minimum follow-up of two years.
Questionnaires were distributed to the French Golf Federation’s golfing members. Those who were older than 50 years and had undergone a unilateral primary total knee replacement provided information on the timing of return to play, mode of movement on the course, pain during golfing, physical activity (based on a standard scale), level of golf and weekly playing time, before and after surgery. In addition, surgeons’ recommendations and level of arthroplasty satisfaction were collected.
The average time to return to the 18-hole course was 3.7 months. Participants surveyed at a minimum 2 years after knee replacement played at a higher level than before surgery with a handicap improvement of 0.85 and increased their average weekly playtime from 8.9 to 10.2 hours. Knee pain while playing golf decreased after surgery (6.13 to 1.27 on the visual analog scale).
You can return to golf after knee replacement – maybe not at the level you wish
In the above study, people got back to the game within 4 months after knee replacement. They played a little more than an hour a week and the knee replacement helped them regain almost a stroke. However another study says not everyone will achieves those results;
A September 2020 study in The Journal of the American Academy of Orthopaedic Surgeons,(5) wrote: “As the numbers of senior golfers increase, many will consider a hip or knee joint replacement over their lifetime. The relationship of joint replacement to the rate of return and validated level of play has not been well defined.”
In this study too, the researchers sent out a questionnaire to a regional golf association’s membership regarding their joint replacement. Members with valid Golf Handicap Information Network numbers and with at least five pre- and post-joint replacement scores were included. Prospectively collected rounds of play and handicap differentials were used for the analysis.
- The sites of joint replacement include 50 hips (41.7%) and 70 kness (58.3%).
- Plays per month after the first joint replacement increased from 5.2 to 5.6.
- Handicap differentials increased from an average of 15.8 to 17.3.
- Average return to play was 62 days.
- Twenty-eight players who had a second joint replacement saw an increase in plays per month from 4.2 to 6.3 and an increase in handicap differentials from 19.3 to 20.2.
Conclusions: After the initial joint replacement, amateur golfers will likely play more frequently; however, the level of play will typically decrease slightly. The same effects are seen after a subsequent joint replacement.
Knee Replacement does not improve golf handicap
Many people think that a knee replacement will make them play better. A late 2020 study (6) suggests differently: Here is what a team of orthopedic surgeons reported:
“Although the vast majority of arthroplasty surgeons allow patients to return to participation in golf following total knee arthroplasty and total hip arthroplasty, there is relatively little published data regarding how total knee arthroplasty or total hip arthroplasty affects a patient’s golfing ability. The purpose of this study was to determine how golfers’ handicaps change following total knee arthroplasty and total hip arthroplasty.
We mailed a questionnaire to patients who had underwent primary total knee arthroplasty or total hip arthroplasty. . . and asked whether they played golf and for their golf handicap information network number. We then obtained handicap data for each patient that provided a number.
Handicap increased 0.9 strokes 1 year following total hip arthroplasty; however, this difference was not statistically significant.
Handicap increased 0.3 strokes 1 year following total knee arthroplasty; however, this difference was not statistically significant.
Our study demonstrates that despite improved implants, surgical techniques, and rehabilitation protocols that golf handicap does not change significantly following lower extremity total joint arthroplasty.”
Returning to the game means riding the cart for many
One thing that is not typically discussed in returning to golf after knee replacement is how many golfers walk the course after the surgery? First let’s look at golfers with knee osteoarthritis before knee replacement. A July 2021 study (7) compared the acute effects of walking the golf course versus using a golf cart during a round of golf on biological markers (inflammation occurrence and rise) of joint disease, joint pain, and cardiovascular parameters in individuals with knee osteoarthritis.
The researchers found: “In knee osteoarthritis participants, walking the course was associated with significantly higher step count and duration of moderate/vigorous physical activity (72.2% vs. 32.6% of the round) but did lead to a significant increase in knee joint pain. . . Walking the course optimizes the duration of moderate/vigorous activity during a round of golf, but the golf cart is a beneficial option in those with exacerbated joint pain and inflammation that would otherwise limit participation.”
For some people, the thinking is that once they get a knee replacement, they can walk the course again without significant pain. A study in The American journal of sports medicine (8) sought to find out:
In this study the researchers sent out questionnaires to golfers who had knee replacement; Of the 93 responses:
- Fifty-seven percent reported they had returned to golf within 6 months after total knee arthroplasty.
- Eighty-one percent of respondents reported golfing as frequently, or more frequently, than before knee replacement.
- Notably, golfers reported less pain while golfing after total knee arthroplasty than before and 94% of respondents reported currently enjoying golf as much as or more than before surgery.
- Twenty-eight percent of respondents stated that they walked the course, rather than using a motorized golf cart, before surgery, while only 14% walked the course after surgery.
“Conclusion: In this population of golfers, total knee arthroplasty reliably relieved pain that had been previously experienced while golfing, and increased or maintained this group’s enjoyment of playing golf. However, 86% of these patients reported using a cart while golfing. Further patient education is needed regarding the potential health benefits of walking during golf after total knee arthroplasty.”
Before the knee replacement 28% walked the course. After the knee replacement, 14% walked the course. Half of the golfers no longer walked the course.
What about golf and other sports?
We see many active patients who are not convinced a joint replacement will help them return to their game. German researchers see the same type patients. In a study, the doctors from the University Medical Center Hamburg-Eppendorf echoed what we see here (9):
- “An increasing number of physically active patients not only need to know if they will basically be able to engage in sports after undergoing replacement. They also would like to know whether or not they will be able to resume their preoperative activity levels.”
The doctors collected data on patients considering hip, knee and shoulder replacement: These are the questions they wanted to answer for these patients.
- What is the impact of physical activity on an the replacement?
- What level of sports can be achieved after a joint replacement?
- What types of sport are recommended for patients replacement?
Here are the answers they came up with:
- The commonly known recommendation to exercise low-impact sports such as hiking, swimming, cycling or golf at a moderate intensity remains valid for all types of prostheses in all joints.
- Having undergone total hip or knee arthroplasty, most patients with a high preoperative activity level return to sports after 3-6 months, albeit with a clear tendency to lower intensity and a shift from high-impact to low-impact sports.
- There is a significant discrepancy between previous expert recommendations and the actual activity levels that may be achieved after the implantation of a joint prosthesis.
Are bone marrow aspirate stem cell injections an option?
Above you read about people before knee replacement who had a rough time walking the course. Knee replacement did not help many golfers resume walking the course. What about bone marrow aspirate stem cell therapy? In this therapy, bone marrow is drawn from the iliac crest or pelvis wing in a simple procedure. The stem cells from that bone marrow is then injected into the knee area.
This is research from doctors affiliated with the South Carolina Orthopaedic Institute and the University of Miami. it was published in the prestigious, Orthopaedic journal of sports medicine.(10)
“Cell-based therapies and regenerative medicine offer safe and potentially efficacious treatment for sports-related musculoskeletal injuries. Basic science and preclinical studies that support the possibility of enhanced recovery from sports injuries using cell-based therapies are accumulating; however, more clinical evidence is necessary to define the indications and parameters for their use. Accordingly, exposing patients to cell-based therapies could confer an unacceptable risk profile with minimal or no benefit. Continued clinical testing . . . to determine the relative risks and benefits as well as the indications and methodology of treatment.”
In the Journal of Knee Surgery (11) doctors from the Department of Orthopaedic Surgery, University of Pittsburgh had this to say:
- Biologic agents (bone marrow stem cells and blood platelets or PRP therapy) are gaining popularity in the management of bony and soft tissue conditions about the knee. They are becoming the mainstay of nonoperative therapy in the high-demand athletic population. . . . Studies assessing the utility of stem cells have shown encouraging results in the setting of osteoarthritis. “As the volume and quality of evidence continue to grow, biologic agents are poised to become an integral component of comprehensive patient care throughout all orthopedic specialties.”
Bone marrow derived stem cells injections may act as a protector against continued osteoarthritis degeneration of the knee joint
In the the American Journal of Sports Medicine,(13) doctors at the Mayo Clinic have released a study on the effectiveness of bone marrow derived stem cells for knee osteoarthritis in the active patient. In this prospective, single-blind, placebo-controlled trial, 25 patients with pain in both knees from osteoarthritis were randomized to receive bone marrow derived stem cells into one knee and saline placebo into the other.
- Bone marrow was aspirated from the iliac crests and concentrated in an automated centrifuge.
- The resulting bone marrow aspirate concentrate (this is explained in the video below) was injected into the arthritic knee and was compared with a saline injection into the other knee, thereby utilizing each patient as his or her own control.
Early results show that bone marrow derived stem cell injections are a safe to use and is a reliable and viable cellular product. Interestingly, pain scores in both knees decreased significantly from baseline at 1 week, 3 months, and 6 months. Pain relief, although dramatic, did not differ significantly between treated knees in the early stages.
Our research:
In June of 2018, our research team published the paper Short-Term Outcomes in Treatment of Knee Osteoarthritis With 4 Bone Marrow Concentrate Injections. This research appeared in the medical journal: Clinical medicine insights. Arthritis and musculoskeletal disorders.
In this research we were able to conclude that following treatment, short-term outcomes demonstrated that patients experienced less pain and were able to perform daily activities with less difficulty after the first Bone Marrow Concentrate (stem cell) injection and reported additional benefit with each subsequent treatment.
- You can read this research in its entirety at the US National Library of Medicine online:
In August 2018, our research team published the paper Short-Term Outcomes of Treatment of Hip Osteoarthritis With 4 Bone Marrow Concentrate Injections: A Case Series. This research appeared in the medical journal: Clinical medicine insights. Case reports.
In this study, we were able to document that the patients in this case series experienced decreased pain and improved functionality compared with baseline. On average, patients experienced successive decreases in resting and active pain after each treatment. Patients also experienced a mean increase in total overall improvement percentage and functionality score after subsequent treatments. Prior to Bone Marrow Concentrate (stem cell) treatment, 2 of the 4 patients had been advised to undergo total hip replacement. Following treatment, neither patient considered surgery.
References:
1 Tischer T, Enz A, Kluess D, Lutter C, Mittelmeier W. Premature wear of total knee arthroplasty in sports shown in a golfer. Der Orthopade.
2 Hamai S, Miura H, Higaki H, Shimoto T, Matsuda S, Okazaki K, Iwamoto Y. Three‐dimensional knee joint kinematics during golf swing and stationary cycling after total knee arthroplasty. Journal of orthopaedic research. 2008 Dec;26(12):1556-61.
3 Baker ML, Epari DR, Lorenzetti S, Sayers M, Boutellier U, Taylor WR. Risk factors for knee injury in golf: A systematic review. Sports Medicine. 2017 Dec 1;47(12):2621-39.
4 Pioger C, Bellity JP, Simon R, Rouillon O, Smith BJ, Nizard R. A Playtime and Handicap Analysis of 143 Regular Golfers After Total Knee Arthroplasty at Minimum 2-Year Follow-Up. The Journal of Arthroplasty. 2020 Jan 11.
5 Gorbaty JD, Rao AJ, Varkey DT, Muña K, Saltzman BM, Hamid N. Total Joint Arthroplasty and Golf Play: Analysis of Regional Golf Handicap Database. The Journal of the American Academy of Orthopaedic Surgeons. 2020 Sep 28.
6 Brown ML, Ashley BS, Copp SN, Ezzet KA. Lower Extremity Total Joint Arthroplasty Has Minimal Effect on Golf Handicap. Journal of Surgical Orthopaedic Advances. 2020 Jan 1;29(4):216-8.
7 Jayabalan P, Bergman R, Jauregui E, Hanaoka C, Stoker AM. The acute physiological effects of continuous versus intermittent walking during golf in individuals with knee osteoarthritis: a pilot study. American Journal of Physical Medicine & Rehabilitation. 2021 Jul 23.
8 Jackson JD, Smith J, Shah JP, Wisniewski SJ, Dahm DL. Golf after total knee arthroplasty: do patients return to walking the course?. The American journal of sports medicine. 2009 Nov;37(11):2201-4.
9 Oehler N, Schmidt T, Niemeier A. Total joint replacement and return to sports. Sportverletzung Sportschaden: Organ der Gesellschaft fur Orthopadisch-Traumatologische Sportmedizin. 2016 Dec;30(4):195-203.
10 Ajibade DA, Vance DD, Hare JM, Kaplan LD, Lesniak BP. Emerging applications of stem cell and regenerative medicine to sports injuries. Orthopaedic journal of sports medicine. 2014;2(2):2325967113519935.
11 Kopka M, Bradley JP. The Use of Biologic Agents in Athletes with Knee Injuries. J Knee Surg. 2016 May 20. [Epub ahead of print]
12 Filardo G, Perdisa F, Roffi A, Marcacci M, Kon E. Stem cells in articular cartilage regeneration. Journal of Orthopaedic Surgery and Research. 2016;11:42. doi:10.1186/s13018-016-0378-x.
13 Shapiro SA, Kazmerchak SE, Heckman MG, Zubair AC, O’Connor MI, A Prospective, Single-Blind, Placebo-Controlled Trial of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis. Am J Sports Med. 2017 Jan;45(1):82-90. doi: 10.1177/0363546516662455. Epub 2016 Sep 30.