I would like to keep playing or play golf again – Knee pain, knee replacement and golf

Ross Hauser, MD

A lot of people play golf with knee pain. As you will see in some of the example stories, case histories, and research below, many golfers play through pain with the help of various remedies and self-help treatments. Eventually, their knee will hurt them so much that they will seek out medical attention. For many people, this medical attention will be very successful. For others, the medical attention they sought sent them on a journey of surgical recommendations and waiting for their knee to get so bad that they will be considered candidates for knee replacement. Once confirmed for knee replacement, some of these people become that group of patients that seek advice on how to avoid the knee replacement and some will seek advice on how to play after knee replacement in a knee that is causing issues.

Before we move on, the vast majority of patients who have knee replacement can continue to play golf. It is typically the level of knee degeneration and the level of recovery that dictates if a golfer can return to the course with the same degree of success following knee replacement as they had before the knee replacement.

Article summary:

• Before the knee replacement – worsening handicaps and riding the cart.
• I am currently taking Percocet and gabapentin.
• I had cortisone, hyaluronic acid, stem cells, PRP, and cortisone, now I need a knee replacement.
• I have chronic knee issues from multiple meniscus arthroscopic surgeries.
• I need to wait for my knee to get bad enough for knee replacement.
• I am way too young for knee replacement. But have had numerous knee surgeries. 
• Knee instability, rotational forces, developing osteoarthritis.
• What can you do about your knee pain and your golf game?
• Golf after knee replacement – the change in a handicap?
• When knee instability remains after knee replacement – it wears out the hardware like it wore out your knee – you become “metal on metal.” Problems golfing after knee replacement.
• The pain on the outside of the knee.
• How can we help these problems? The often overlooked and ignored cause of pain after knee replacement – the Knee Ligaments and Knee Tendons.

The swing that leads to knee osteoarthritis

A December 2022 paper (1) lead by doctors at Stanford University looked at thirteen professional male golfers who hit five shots using a 5-iron club to see what happened to the golfer’s lead knee during the swing. What the researchers were looking for was what put the knee at risk for osteoarthritis. What they found was swinging with a narrower stance width, more weight shift and shoulder sway towards the hole during the downswing were associated with a higher peak knee adduction of the lead leg, whereas a greater valgus angle at address was associated with a higher peak knee abduction of the lead leg. The researchers concluded: “Based on these findings, we anticipate future research to support postural changes, particularly a wider stance width and restricted shoulder sway for golfers who are classified to be at high risk of developing medial compartment knee osteoarthritis, as well as a lower valgus (tibial medial tilt) angle at address for those classified to be at high risk of developing lateral compartment knee osteoarthritis.

“swinging with a narrower stance width, more weight shift and shoulder sway towards the hole during the downswing were associated with a higher peak knee adduction of the lead leg”

Before the knee replacement – worsening handicaps and riding the cart

Many golfers that we see will spend a lot of money on clubs, gadgets, and remedies that will attempt to improve their handicap despite worsening knee pain. As you are reading this article and it is likely that you have knee pain and that you golf or recently stopped golfing it is also likely that you have tried the following:

• You are riding the cart instead of walking.
• You have altered your swing and grip.
• You have watched many videos on lead knee dynamics.
  • You have pain on the outer knee of the lead knee. The right-handed golfer will develop pain on the outer left knee, the left-handed golfer will develop pain on the outer right side of the knee.
  • Many golfers will alter their swing to flare out the lead leg, the lead toe being off-angled with the hopes that this will alleviate the knee pain.
  • Many golfers may use this technique to limit back and hip pain as rotational movement from the torso to the knee may be suppressed.
  • For more on sports-related outer knee pain please see our article Iliotibial band friction syndrome – Sports-related knee pain.
• You have watched many videos on core strength and hamstring strengthening.
• You bought the best knee brace you can find.
• You are taking alternative weeks off or prolonged rest periods between rounds.

Before you reached this point it is probable that you already had:

• Your own unique anti-inflammatory regiment
  • You figured out how to take painkillers and anti-inflammatories for maximum benefit before you played and after you played.
  • You bought a really good ice bag.

Here are some example stories we hear.

These are the people who reach out after they went online and bought creams, oils, braces, and sleeves. They have familiar histories of cortisone injection, a lot of physical therapy, a lot of chiropractic care, acupuncture, massage therapy, shoe inserts. They are reaching out because “nothing is working anymore.”

I am currently taking Percocet and gabapentin

The person will write that they have a bone on bone knee, they walk with a limp bad enough that some days they have to use a cane to take the pressure off their knee. They write: “I am currently taking Percocet and gabapentin” for their pain. In some patients, they report that they have a full range of motion so it is not a problem of advanced arthritis. But in the end, they still have pain and write “I want to play golf again but even getting in and out of the golf cart is painful, much less any thought of actually walking the course.”

I had cortisone, hyaluronic acid, stem cells, PRP, and cortisone, now I need a knee replacement.

We will get emails from active 60 plus-year-old men and women who describe their situation of severe osteoarthritis and very unstable knees. They have a history of cortisone injections (Please see our article What are the different types of knee injections for bone on bone knees) and various types of hyaluronic acid injections (please see our article: Research and reviews of Hyaluronic injections for Knee Osteoarthritis, and they have “worn out” or they “no longer help.”

They will tell us that they have tried stem cell injections combined with PRP injections and then follow-up PRP injections at one-month intervals. Some will tell us these injections did not work at all (Please see our articles When stem cell therapy works and does not work for your knee pain, and, Platelet Rich Plasma for Knee Osteoarthritis: When it works, when it does not work.) Some will tell us that these injections helped them initially and helped them in part return to favorite activities including golf.

However, some will also suggest that the injections exceeded my expectations. So why are these people writing looking for help? Their treatment programs may have been interrupted by a change in their doctors or their doctor’s recommendations. They may tell us that their knee continued to deteriorate causing greater issues with pain and stability. Some of these people were in fact going to get more PRP but their doctors convinced them, “this time, you should have cortisone.” The cortisone helped but now my doctor says I am too far gone and I need a knee replacement.

I have chronic knee issues from multiple meniscus arthroscopic surgeries

More often we will get people contacting us with a history of chronic knee issues from multiple meniscus arthroscopic surgeries and the development of “early” onset of arthritis in their knees. They will have been prescribed multiple prescriptions for physical therapy, as mentioned above cortisone injection and hyaluronic acid injections. Some people will suggest that they feel that “I am only being managed towards knee replacement and I would like to play some golf without looking up new ways to alter my swing and stance every coming of weeks to compensate for my knee pain.”

I need to wait for my knee to get bad enough for knee replacement

This is a familiar story. A person will have significant knee pain but not enough evidence on an MRI that they are currently a candidate for knee replacement. They have also tried many treatments and remedies but their knees get worse. They have “tried everything.” “Nothing is helping anymore.” Some people have simple goals: “I would just like to walk and play golf again.” Or: “I can’t get a knee replacement and I have been basically told that as soon as my knee is bad enough on MRI I can get a knee replacement. I do not want to wait this out. I want to play golf.”

I am way too young for knee replacement. But have had numerous knee surgeries. 

This too is a common story. The person will tell us that they have a history of multiple knee surgeries starting with ACL reconstruction when they were a teenager. A few years later they may have had ACL Revision surgery and meniscus repair. This second surgery was very successful in some until they say “until they needed another meniscus surgery.” They will tell us that they are only in their 30’s and their knee constantly grinds, snaps, crackles, and pops on certain movements. They have a lot of swelling and instability. It feels like their knee can give out. They too had extensive physical therapy but now even that hurts too much. Please see our articles After ACL Reconstruction: Complication and post-surgery treatment options: Do you need revision surgery?

I want to walk the course again

For some people walking the course is playing golf. Many people, because of various surgeries and degenerative joints and spines, can no longer walk the course. They are happy just to be able to swing the club again. But others simply “want to play a few rounds of golf a week again. I want to be able to walk 18 holes and not have to ride in a cart.”

What are we seeing in this image? Knee instability, rotational forces, developing osteoarthritis

In this illustration, we start with a normal knee and see the progression of degenerative knee disease develop. The knee is made up of numerous ligaments, the MCL, the one being described here is one. The caption reads The progression of knee osteoarthritis. When a simple ligament injury is not resolved, the result can be knee instability that can progress to the complete breakdown of the articular knee cartilage and the knee itself.

In this video Ross Hauser, MD demonstrates a test for knee joint instability and shows a short before and after an ultrasound real-time image demonstrating knee instability. This is one of the tests we utilize for patients with chronic knee pain to help locate and grade the severity of the knee instability and tissue damage. Knee instability is the root cause of almost all painful knee conditions, including osteoarthritis.

What can you do about your knee pain and your golf game?

Do you really need medical research to confirm that your knee will hurt more if you walk the course? You may be no but your doctor does because it helps guide general recommendations for treatment.

A July 2021 study in the American Journal of Physical Medicine & Rehabilitation (2) compared the acute effects of walking the golf course versus using a golf cart during a round of golf on biological markers of joint disease, joint pain, and cardiovascular parameters in individuals with knee osteoarthritis.

The people in the study were:

• Were over age 50
• Had just completed two 18 hole rounds of golf. One round where they walked the course and one round where they used a golf cart.

In knee osteoarthritis participants, walking the course was associated with significantly higher step count and duration of moderate/vigorous physical activity but did lead to a significant increase in knee joint pain.

The conclusion of this study suggested: If your knee hurts, use the cart.

Golf after knee replacement – the change in a handicap?

Many people do very well with a knee replacement. Some people even can get back on the course. The key component to remember with knee replacement is that it can help you play golf again. Walking the course or improving your handicap is typically not part of the knee replacement benefits. But they can be.

In a late 2020 study (3) examining hip and knee replacements, doctors wrote in the Journal of Surgical Orthopaedic Advances.

“Although the vast majority of arthroplasty surgeons allow patients to return to participation in golf following total knee arthroplasty (replacement) and total hip arthroplasty (replacement), there is relatively little published data regarding how total knee replacement or total hip replacement affects a patient’s golfing ability. The purpose of this study was to determine how golfers’ handicaps change following total knee replacement and total hip replacement.”

Before we examine this study’s conclusion, it should be pointed out that many golfers with knee and hip pain before replacement surgery suffer from a worsening handicap. In this study, the patient/golfers were asked if they (a) continued to play golf after their replacement surgery and (b) what was their pre and post-surgical handicaps. What were the results?

• Handicap increased 0.9 strokes one year following total hip replacement; however, this difference was not statistically significant (the golfers played at about the same level).
• Handicap increased 0.3 strokes one year following total knee replacement; however, this difference was not statistically significant (the golfers played at about the same level).

The researchers concluded: “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 (knee or hip replacement).

An average increase in handicap of 1.18

A June 2022 study in the  journal Bone & Joint Open (4) found knee replacement was associated with an average increase in handicap of 1.18. Trailing leg replacement alone was associated with higher postoperative handicap as was bilateral surgery. Overall, in the study of hip and knee replacement (patients getting one of these surgeries)

• 92% maintained or increased the amount of golf played
• 25% returned to iron shots at six weeks
• 76% returned to club competition at six months
• 6% had persistent pain after knee replacement, and
• 1.6% were unable to return to play.

The vast majority of golfers are very satisfied with knee replacements

A May 2023 paper in the European journal of orthopaedic surgery & traumatology (6) comes from Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, the PGA European Tour Performance Institute, Edinburgh Medical School, University of Edinburgh, and the Medical and Scientific Department, The R&A (The royal and ancient) Golf Club, at St. Andrews. In this paper researchers looked to see if golfers had a better outcome for knee replacement than non-golfers. Here are the learning points of that research:

• Approximately 10% to 20% of patients with joint arthroplasties (replacements) are golfers. The aim of this study was to assess if being a golfer is associated with functional outcomes, satisfaction or improvement in quality of life (QoL) compared to non-golfers following total knee arthroplasty.

The study group consisted of a total of 514 patients undergoing total knee replacement. This included 223 (43.3%) male patients and 291 (56.7%) female patients, with an overall average age of 70 years.

• The preoperative Oxford Knee Score (OKS) was significantly higher (better function and knee pain) in golfers.
• The goal of the study question was answered as: “There was no difference in postoperative outcomes between golfers and non-golfers.”
• However, of the 48 patients who reported being golfers at the time of their surgery, 43 (89.6%) returned to golf and 88.4% of those were satisfied with their involvement in golf following surgery.

When knee instability remains after knee replacement – it wears out the hardware like it wore out your knee – you become “metal on metal.” Problems golfing after knee replacement

A December 2020 case history (3) comes to us from doctors at the Orthopedic University Clinic in Rostock, Germany. It was published in the German medical journal Der Orthopäde (The orthopedist). What is interesting about this case history of a patient who was wearing out his knee replacement faster than he should of playing golf was that the cause of this advanced degenerative knee replacement was wear and tear. It wasn’t hardware failure, it was continued knee instability after the replacement surgery.

• The surgeons noted that the excessive wear of the hardware suggested the patient had increased rotational loads. (Knee instability was causing a wobbly knee).
• Another surgery had to be performed to change the patient’s knee replacement hardware because he was “metal-on-metal”
• The knee replacement was changed to a constrained prosthesis that would limit rotational motion.

One of the reasons that people are in our office with continued pain after knee replacement is that they are being told that eventually, or sooner, rather than later if the pain persists, they will have to have revision surgery to adjust or replace components of the knee replacement. As the case history presented above did.

A recent study however from orthopedic surgeons in Italy published in the Current Reviews in Musculoskeletal Medicine (4) simply states “(Pain after knee replacement) can be related to a lot of different clinical findings, and the surgeon has to be aware of the various etiologies that can lead to failure. Pain does not always mean revision, and the patient has to be fully evaluated to have a correct diagnosis; if surgery is performed for the wrong reason, this will surely lead to a failure.”

The pain on the outside of the knee

Let’s go back to the discussion on outer knee pain. This time let’s take the discussion to continued outer knee pain after knee replacement. Playing golf after knee replacement can result in this outer knee pain, even if the replacement surgery was deemed a 100% success.  The outside of the knee is where the ligaments and the tendons are. Most often these connective tissues are damaged either by the surgery or new stress, like golf, placed on them by the implant. In some golfers, this can be the reason why their knee continues to be unstable. This instability can pull at the ligaments and tendons. This can cause pain and nerve irritations. This nerve irritation can be below or above the knee or along with the kneecap.

I want to remind everyone again that many golfers have excellent results with their knee surgery. These are typically not the people we see in our office. We see the people who still have pain, non-hardware-related knee instability, and pain in the other knee from over-compensation among other challenges.

Is post-knee replacement knee pain coming from knee tendinopathy?

As just mentioned, there are tendons on the outer side of the knee.

Is it Knee Tendinopathy, Tendinosis, Tendonitis? In many patients we see, we find that the pain is coming from the outside of the knee. When the knee is replaced, the knee cartilage is now replaced with hard plastic, so lack of or loss of cartilage is not causing the pain. What can be causing the pain are the remaining tendons and ligaments that surround the outer portions of the knee. These tendons and ligaments have become weakened, they are loose and they are allowing for a wobbly knee situation. When the knee is wobbly, it is not moving correctly, it creates an unnatural and painful pull on these ligaments and tendons and this causes pain and instability. The strain on the knee tendons can cause chronic tendinopathy.

How can we help these problems? The often overlooked and ignored cause of pain after knee replacement – the Knee Ligaments and Knee Tendons

When a knee replacement is performed, the joint itself has to be stretched out so the surgeons can cut out bone and put it in the prosthesis. When the joint is stretched out, the knee ligaments and tendons that survive the operation will cause pain as they heal from the surgical damage. Sometimes the ligaments and tendons heal well. Sometimes they do not heal as well.

In this video, Ross Hauser, MD explains the problems of post-knee replacement joint instability and how Prolotherapy injections can repair damaged and weakened ligaments and that will tighten the knee. This treatment does not address the problems of hardware malalignment that our patient Jeannette described in the video above. 

Summary of this video:

It is very common for us to see patients after knee replacement who have these clicking sounds coming from knee instability. This is not instability from hardware failure. The hardware may be perfectly placed in the knee. It is instability from the outer knee where the surviving ligaments are. I believe that this is why up to one-third of patients continue to have pain after knee replacement. Dr. Hauser performs an ultrasound scan of the patient’s knee. Small, gentle stress on the knee reveals hypermobility. This is from the ligaments’ inability to hold the whole knee joint in place. Prolotherapy can be very successful in helping patients who had a knee replacement and still have knee pain. The treatment tightens the whole joint capsule.

Prolotherapy and Platelet Rich Plasma Therapy

We are going to briefly address two treatment options that we offer here at Caring Medical. We will explore these treatments more deeply below. These are non-surgical, injections. They are not cortisone, they are not gel shots.

Prolotherapy is an injection technique utilizing simple sugar or dextrose which causes a small controlled inflammation at weakened tissue. This triggers the immune system to initiate repair of the injured tendons and ligaments. Blood supply dramatically increases at the injured area. The body is alerted that healing needs to take place and reparative cells are sent to the treated area of the knee that needs healing. The body also lays down new collagen at the treated areas, thereby strengthening the weakened structures. Once the tendons and ligaments are strengthened, the joint stabilizes and the tendonitis or tendinosis condition resolves.

Platelet Rich Plasma Therapy is the use of a patient’s blood platelets and healing factors to stimulate repair of a tendon it is considered when tendon damage is more severe. We will be discussing these treatments further below and try to provide a realistic outlook as to if these treatments may benefit you.

Can we help you?

If this article has helped you understand treatment options for your knee pain and you would like more information, you can get help and information from our specialists

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References

1 Kim SE, Pham NS, Park JH, Ladd A, Lee J. Potential biomechanical risk factors on developing lead knee osteoarthritis in the golf swing. Scientific Reports. 2022 Dec 31;12(1):22653. [Google Scholar]
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4 Hoggett L, Frankland S, Ranson J, Nevill C, Hughes P. How does hip and knee arthroplasty affect golfer performance and what should be expected regarding return to play?. Bone & Joint Open. 2022 Jun 1;3(6):510-4. [Google Scholar]
3 Tischer T, Enz A, Kluess D, Lutter C, Mittelmeier W. Premature wear of total knee arthroplasty in sports shown in a golfer. Der Orthopade. 2020 Oct 23. [Google Scholar]
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6 Robinson PG, Kay RS, MacDonald D, Murray AD, Clement ND. Golfers have greater preoperative and equal postoperative function when undergoing total knee arthroplasty compared to non-golfers. European Journal of Orthopaedic Surgery & Traumatology. 2022 Apr 1:1-7. [Google Scholar]

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• Surgery
• NSAIDs
• Cortisone Shots
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