Aims. Hip and knee arthroplasty is commonly performed for end-stage arthritis. There is limited information to guide golfers on the impact this procedure will have postoperatively. This study aimed to determine the impact of lower limb arthroplasty on amateur golfer performance and return to play. Methods. A retrospective observational study was designed to collect information from golfers following arthroplasty. Data were collected from 18 April 2019 to 30 April 2019 and combined a patient survey with in-app handicap data. Results. A total of 2,198 responses were analyzed (1,097 hip and 1,101 knee). Of the respondents, 1,763 (80%) were male and the mean age was 70 years (26 to 92). Hip arthroplasty was associated with a mean increase in handicap of 1.03 (95% confidence interval (CI) 0.81 to 1.25). No difference was seen between isolated leading or trailing leg (p = 0.428). Bilateral hip arthroplasty increased handicap (p < 0.001). Overall, 1,025 (94%) maintained or increased the amount of golf played, 258 (23.5%) returned to iron shots at six weeks, 883 (80%) returned to club competitions at six months, 18 (1.6%) had persistent pain, and 19 (1.7%) were unable to return to play. Knee arthroplasty was associated with a mean increase in handicap of 1.18 (95% CI 0.99 to 1.38). Trailing leg arthroplasty alone was associated with higher postoperative handicap (p = 0.002) as was bilateral surgery (p = 0.009). Overall, 1,009 (92%) maintained or increased the amount of golf played, 270 (25%) returned to iron shots at six weeks, 842 (76%) returned to club competition at six months, 66 (6%) had persistent pain, and 18 (1.6%) were unable to return to play. Conclusion. Hip and knee arthroplasty enables patients to maintain or increase the amount of golf played. The majority return to competitions within one year. Return to iron shots occurs from six weeks. A small increase in handicap following surgery is expected and is larger in patients undergoing bilateral surgery or those with knee arthroplasty to their trailing leg. Patients may still experience pain when playing golf. Cite this article: Bone Jt Open 2022;3(6):510–514

Aims. Golf is a popular pursuit among those requiring total hip arthroplasty (THA). The aim of this study was to determine if participating in golf is associated with greater functional outcomes, satisfaction, or improvement in quality of life (QoL) compared to non-golfers. Methods. All patients undergoing primary THA over a one-year period at a single institution were included with one-year postoperative outcomes. Patients were retrospectively followed up to assess if they had been golfers at the time of their surgery. Multivariate linear regression analysis was performed to assess the independent association of preoperative golfing status on outcomes. Results. The study cohort consisted of a total of 308 patients undergoing THA, of whom 44 were golfers (14%). This included 120 male patients (39%) and 188 female patients (61%), with an overall mean age of 67.8 years (SD 11.6). Golfers had a greater mean postoperative Oxford Hip Score (OHS) (3.7 (95% confidence interval (CI) 1.9 to 5.5); p < 0.001) and EuroQol visual analogue scale (5.5 (95% CI 0.1 to 11.9); p = 0.039). However, there were no differences in EuroQoL five-dimension score (p = 0.124), pain visual analogue scale (p = 0.505), or Forgotten Joint Score (p = 0.215). When adjusting for confounders, golfers had a greater improvement in their Oxford Hip Score (2.7 (95% CI 0.2 to 5.3); p < 0.001) compared to non-golfers. Of the 44 patients who reported being golfers at the time of their surgery, 32 (72.7%) returned to golf and 84.4% of those were satisfied with their involvement in golf following surgery. Those who returned to golf were more likely to be male (p = 0.039) and had higher (better) preoperative health-related QoL (p = 0.040) and hip-related functional scores (p = 0.026). Conclusion. Golfers had a greater improvement in their hip-specific function compared to non-golfers after THA. However, less than three-quarters of patients return to golf, with male patients and those who had greater preoperative QoL or hip-related function being more likely to return to play. Cite this article: Bone Jt Open 2022;3(2):145–151

We aim to determine the differences in lower limb joint kinematics during the golf swing of patients who had undergone Total Knee Arthroplasty (TKA) and a control group of native knee golfers. A case-control study was undertaken with ten golfers who had undergone TKA (cruciate retaining single radius implant) and five age and matched golfers with native knees. Each golfer performed five swings with a driver whilst being recorded at 200Hz by a ten-camera motion capture system. Knee and hip three-dimensional joint angles (JA) and joint angular velocities (JAV) were calculated and statistically compared between the groups at six swing events. The only significant differences in knee joint kinematics between TKA and control groups was a lower external rotation JA in the left knee during the backswing (p=0.010). There was no significant difference in knee JAV between the groups. Both hips demonstrated significantly (p=0.023 for left and p=0.037 for right) lower flexion in the TKA group during the takeaway swing event, and there was lower internal rotation in the backswing and greater external rotation in the downswing of the right hip. There was also slower left hip extension JAV in the downswing. Normal knee kinematics were observed during the golf swing following TKA, with the exception of reduced external rotation in the left knee during the back swing and the right during the down swing. The differences demonstrated in the hip motion indicate that they may make compensatory movements to adjust to the reduced external rotation demonstrated in the knee

Aims. The primary aim of this prospective, multicentre study is to describe the rates of returning to golf following hip, knee, ankle, and shoulder arthroplasty in an active golfing population. Secondary aims will include determining the timing of return to golf, changes in ability, handicap, and mobility, and assessing joint-specific and health-related outcomes following surgery. Methods. This is a multicentre, prospective, longitudinal study between the Hospital for Special Surgery, (New York City, New York, USA) and Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, (Edinburgh, UK). Both centres are high-volume arthroplasty centres, specializing in upper and lower limb arthroplasty. Patients undergoing hip, knee, ankle, or shoulder arthroplasty at either centre, and who report being golfers prior to arthroplasty, will be included. Patient-reported outcome measures will be obtained at six weeks, three months, six months, and 12 months. A two-year period of recruitment will be undertaken of arthroplasty patients at both sites. Conclusion. The results of this prospective study will provide clinicians with accurate data to deliver to patients with regard to the likelihood of return to golf and timing of when they can expect to return to golf following their hip, knee, ankle, or shoulder arthroplasty, as well as their joint-specific functional outcomes. This will help patients to manage their postoperative expectations and plan their postoperative recovery pathway. Cite this article: Bone Jt Open 2023;4(7):490–495

Introduction. Golf is a recommended form of physical activity for older adults. However, clinicians have no evidence-based research regarding the demands on the hips of older adults during golf. The purpose of our in vivoobservational study was to quantify the hip biomechanics of older adult golfers. Methods. Seventeen healthy older male golfers(62.2±8.8 years, handicap 8.7±4.9) free from orthopaedic injuries and surgeries volunteered for participation in this IRB-approved study. A 10-camera motion capture system recorded kinematics, and two force plates collected kinetic data. Participants performed eight shots using their own driver. Data processing was performed in Visual3D. The overall range of excursion and three-dimensional net joint moments normalized to body weight for the lead and trail hips were extracted. Results. Kinematics (mean excursion and range) of lead and trail hips in all three planes during a golf swing are presented in Table 1. The trail leg experiences higher excursion in the sagittal plane, while the lead leg has more frontal plane movement. Average maximum net joint moments of the lead and trail hips were 1.2 ± 0.2 and 1.7 ± 0.3 Nm/kg, respectively. Conclusion. Our study is the first to quantify the kinematics and kinetics of the hip joint in healthy older male golfers. While the golf swing is often considered to be a predominant transverse plane motion, our results indicate considerable excursion at the hip joints in all three planes. Furthermore, the trail leg experiences 40% greater loading than the lead leg throughout the swing, suggesting that the trail leg may have a larger impact on golf performance while also leaving it more susceptible to overuse injury. For clinicians with patients who experience osteoarthritis of the hip or who have recently undergone hip surgery, this study may provide novel insight into the demands of golf on the hips. For any tables or figures, please contact the authors directly

Purpose:. The reverse total shoulder arthroplasty (RTSA) was approved for use by the United States FDA in 2004. Since its introduction, its popularity for treating a number of shoulder conditions has grown considerably. However, many patients inquire about the potential to return to playing recreational golf, and at present there are no published data about how the RTSA prosthesis affects the golf swing. The purpose of this study is to evaluate the biomechanics of the golf swing in patients with RTSA, as well as the postoperative changes in handicap, driving distance, and holes played/week. Methods:. A review of patient records for those that had an RTSA placed between June 2004 and December 2008 was performed. These patients were sent a questionnaire inquiring about details of golfing before and after RTSA. Patients who were still golfing after implantation of the RTSA prosthesis were selected for six-camera motion analysis testing of their golf swing. Computer analysis program was used to calculate parameters to biomechanically describe the golf swing. Results:. Of the 97 patients that had an RTSA placed during the specified time period, 23 patients responded to the questionnaire and only 3 patients had ever and were still playing golf. A mean increase of 2.3 points in the handicap as well as a 33.3 yard decrease in driving distance was observed. The number of holes played per week decreased by 12 postoperatively. Motion analysis of the golf swings in patients with an RTSA showed decreased motion compared to high handicap golfers at the peak of the backswing at every shoulder parameter measured (forward flexion, horizontal adduction, external rotation); however, these differences were not statistically significant. The mean postoperative external rotation in our patients was 26.2°. Discussion:. Though patients can return to golf after RTSA, self-reported trends towards worse handicaps, decreased driving distances, as well as decreased number of holes played/week were found. Furthermore, the RTSA prosthesis changes the biomechanics of the shoulder, resulting in alterations in ROM, specifically external rotation. Patients with the prosthesis in the leading and trailing shoulders compensate by increasing rotation through their torso during follow-through or increasing abduction during the backswing, respectively. Slower swing speeds during backswing and downswing were also observed. Conclusion:. Patients can continue to play golf after RTSA; however, they may observe slower swing speeds, increases in their preoperative handicaps, as well as decreased driving distances. Possible changes in their swing may also occur that will require compensatory mechanisms to complete a full swing

INTRODUCTION. Golf is considered low-impact sport, but concerns exist about whether golf swing can be performed in safe manner after THA. The purpose of this study was to clarify dynamic hip kinematics during golf swing after THA using image-matching techniques. METHODS. This study group consisted of eight right-handed recreational golfers with 10 primary THAs. Each operation was performed using a posterolateral approach with combined anteversion technique. Nine of ten polyethylene liners used had elevated portion of 15°. Continuous radiographic images of five trail and five lead hips during golf swing were recorded using a flat panel X-ray detector (Fig. 1) and analyzed using image-matching techniques (Fig. 2). The relative distance between the center of cup and femoral head and the minimum liner-to-stem distance were measured using a CAD software program. The cup inclination, cup anteversion, and stem anteversion were measured in postoperative CT data. Hip kinematics, orientation of components, and cup-head distance were compared between patients with and without liner-to-stem contact by Mann-Whitney U test. RESULTS. At the top of backswing, lead hips showed 26 ± 11° ER, and trail hips showed 24 ± 19° IR. At the end of follow-through, lead hips showed 24 ± 19° IR, and trail hips showed 24 ± 12° ER. The mean cup inclination and anteversion, stem anteversion, and combined anteversion were 40 ± 5°, 18 ± 11°, 33 ± 14°, and 50 ± 8°, respectively. The minimum liner-to-stem distance showed the smallest value of 3 ± 4 mm at the maximum ER. Bone-to-bone and bone-to-implant impingements were not observed in all hips at all phases. The liner-to-stem contact was observed in four hips with elevated liners (two trail and two lead hips; Fig 3). Patients with elevated liner-to-stem contact demonstrated significantly (p < .05) larger maximum ER and larger cup anteversion than patients without contact. The mean cup-head distance was 0.9 ± 0.5 mm of translation. No significant difference was found in the flexion/extension and adduction/abduction at the maximum ER, cup inclination, combined anteversion, and cup-head distance between patients with and without contact. DISCUSSION. Golf swing produced approximately 50° of axial rotations in both lead and trail hips after THA. The mean cup-head distances showed less than 1.0 mm, and there was no significant difference between patients with and without neck-liner contact. Therefore, we consider that dynamic stability without excessive hip rotations or subluxation was demonstrated during golf swing. Despite no evidence of component malpositioning, elevated liner-to-stem contact was observed in 40% of hips with significantly larger ER and cup anteversion. Because the liner-to-stem contact may be a concern with regard to the long-term prognosis following THA, further attention must be given to the anteversion of the components and the use of elevated liner at the time of surgery. To view tables/figures, please contact authors directly

An audit of a group of dislocations (7 out of 66 hip replacements) revealed a problem with the Charnley Golf Ball cup when used with the posterior approach. Sixty-six consecutive Charnley hip replacements in one institution by one surgeon using the posterior approach over a one year period are presented. The dislocation rate prior to the introduction of the Golf Ball cup was less than 1%. The overall dislocation rate after the introduction of the Golf Ball socket rose to 10.6%. Four patients suffered one dislocation, 2 patients suffered two dislocations and 1 patient suffered a dislocation and spontaneous reduction. Five patients were revisions hip replacements and 61 primary hip replacements. Two of the revisions dislocated. A study of the type of acetabular component type in this series showed there were 17 Wroblewski Angle Bore Sockets (WAB), 11 ogee long posterior wall sockets (OGLPW) and 38 golf ball (GB) sockets making a total of 66 hip replacements. Of the 17 patients with the WAB the dislocation rate was 0 %. Of the 11 OGLPW patients the dislocation rate was 0 %. However in the 38 patients with golf ball sockets the dislocation rate was 18% (7/38). All the dislocations were anterior. The acetabular component position was flexion 15–30 degrees (mode 30 degrees) and anteversion 0–10 degrees (mode 0 degrees). The numbers were not large enough to produce any statistical correlation. All femoral stems were set to 0 degrees anteversion. Following this audit we discontinued the use of the golf ball socket with the posterior approach and have had no further dislocations in primary hip replacement using either the OGLPW or the WAB sockets. Surgeons who use the posterior approach should be warned about the problems of a high anterior dislocation rate when using the Golf Ball cup

The Wroblewski golf ball acetabular cup was introduced by surgeons using the trochanteric osteotomy approach for revision total hip replacement (THR) in order to reduce the rate of dislocation. We have routinely used the Ogee long posterior wall (Ogee LPW) and the Wroblewski angle bore cups in THR. Although the new Wroblewski golf ball cup performed well there was a significant early rate of dislocation of 20%. Our rate of dislocation over a period of ten years using the Ogee LPW and Wroblewski angle bore cups had been 0.52%. We present our findings and an investigation as to why the new cup has such a high rate of dislocation when used with the posterior approach. We show that a relatively small change in the design of the acetabular component resulted in significant adverse clinical results

Introduction

Tennis and Golfers elbows (TE, GE) are difficult conditions to treat. Ultrasound guided steroid injection (UGSI) is one of the treatment modalities in treating refractory TE and GE. We present our clinical experience and short to mid-term results of patients with TE and GE treated with UGSI.

Aims. Return to sport following undergoing total (TKA) and unicompartmental knee arthroplasty (UKA) has been researched with meta-analyses and systematic reviews of varying quality. The aim of this study is to create an umbrella review to consolidate the data into consensus guidelines for returning to sports following TKA and UKA. Methods. Systematic reviews and meta-analyses written between 2010 and 2020 were systematically searched. Studies were independently screened by two reviewers and methodology quality was assessed. Variables for analysis included objective classification of which sports are safe to participate in postoperatively, time to return to sport, prognostic indicators of returning, and reasons patients do not. Results. A total of 410 articles were found, including 58 duplicates. Seven articles meeting inclusion criteria reported that 34% to 100% of patients who underwent TKA or UKA were able to return to sports at 13 weeks and 12 weeks respectively, with UKA patients more likely to do so. Prior experience with the sport was the most significant prognostic indicator for return. These patients were likely to participate in low-impact sports, particularly walking, cycling, golf, and swimming. Moderate-impact sport participation, such as doubles tennis and skiing, may be considered on a case-by-case basis considering the patient’s prior experience. There is insufficient long-term data on the risks to return to high-impact sport, such as decreased implant survivorship. Conclusion. There is a consensus that patients can return to low-impact sports following TKA or UKA. Return to moderate-impact sport was dependent on a case-by-case basis, with emphasis on the patient’s prior experience in the sport. Return to high-impact sports was not supported. Patients undergoing UKA return to sport one week sooner and with more success than TKA. Future studies are needed to assess long-term outcomes following return to high-impact sports to establish evidence-based recommendations. This review summarizes all available data for the most up-to-date and evidence-based guidelines for returning to sport following TKA and UKA to replace guidelines based on subjective physician survey data. Cite this article: Bone Jt Open 2022;3(3):245–251

Abstract. Background. Femoroacetabular impingement (FAI) has been extensively investigated and is strongly associated with athletic participation. The aim of this systematic review is to assess: the prevalence of cam-type FAI across various sports, whether kinematic variation between sports influences hip morphology, and whether performance level, duration and frequency of participation or other factors influence hip morphology in a sporting population. Methods. A systematic search of Embase, PubMed and the Cochrane Library was undertaken following PRISMA guidelines. The study was registered on the PROSPERO database (CRD4202018001). Prospective and retrospective case series, case reports and review articles published after 1999 were screened and those which met the inclusion criteria decided a priori were included for analysis. Results. The literature search identified 58 relevant articles involving 5,683 participants. Forty-nine articles described a higher prevalence of FAI across various ‘hip-heavy’ sports, including soccer, basketball, baseball, ice hockey, skiing, golf and ballet. In studies including non-athlete controls, a greater prevalence of FAI was reported in 66.7% of studies (n=8/12). The highest alpha angle was identified at the 1 o'clock position (n=9/9) in football, skiing, golf, ice hockey and basketball. Maximal alpha angle was found to be located in a more lateral position in goalkeepers versus positional players in ice hockey (1 o'clock vs 1.45 o'clock). A positive correlation was also identified between the alpha angle and both age and activity level (n=5/8 and n=2/3, respectively) and also between prevalence of FAI and both age and activity level (n=2/2 and n=4/5), respectively. Conclusions. Hip-heavy sports show an increased prevalence of FAI, with specific sporting activities influencing hip morphology. Both a longer duration and increased level of training also resulted in an increased prevalence of FAI

Cam-type femoroacetabular impingement is caused by bone excess on the femoral neck abutting the acetabular rim. This can cause cartilage and labral damage due to increased contact pressure as the cam moves into the acetabulum. However, the damage mechanism and the influence of individual mechanical factors (such as sliding distance) are poorly understood. The aim of this study was to identify the cam sliding distance during impingement for different activities in the hip joint. Motion data for 12 different motion activities from 18 subjects, were applied to a hip shape model (selected as most likely to cause damage, anteriorly positioned with a maximum alpha angle of 80°). The model comprised of a pointwise representation of the acetabular rim and points on the femoral head and neck where the shape deviated from a sphere (software:Matlab). The movement of each femoral point was tracked in 3D while an activity motion was applied, and impingement recorded when overlap between a cam point and the acetabular rim occurred. Sliding distance was recorded during impingement for each relevant femoral point. Angular sliding distances varied for different activities. The highest mean (±SD) sliding distance was for leg-crossing (42.62±17.96mm) and lowest the trailing hip in golf swing (2.17±1.11mm). The high standard deviation in the leg crossing sliding distances, indicates subjects may perform this activity in a different manner. This study quantified sliding distance during cam impingement for different activities. This is an important parameter for determining how much the hip moves during activities that may cause damage and will provide information for future experimental studies

The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR). The study group comprised the membership of the New Knee Golf Society (NKGS) and 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR. The functional outcome was recorded using the Oxford knee score. A total of 299 knees (TKR only) in 209 patients were included in the final analysis. The mean age was 70 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (90%). The mean post-operative period was 5 years. We found 196 patients (94%) returned to playing golf after a mean of 4.6 months following the TKR; 184 (88%) continue to play at review; 93% claimed significant improvement in their capability to play golf following TKR. However, none claimed to have achieved a significant improvement in their handicap. Seventeen knees (5.7%) underwent revision surgery. Six knees (2%) were revised for infection at mean 17.3 months and eleven (3.7%) for aseptic loosening or instability at mean 5 years. Seven left knees (lead knee) of eleven right-handed golfers required revision for aseptic loosening. Varus collapse of the tibial component in the lead knee was observed. The main problems experienced after playing 18 holes were knee stiffness (47%) and swelling (18%). Oxford Knee Scores: 69% excellent; 27% moderate functional impairment; 4% poor outcomes. Although the capability to play improved the handicap remained the same. We found that the left TKR in a right-handed active golfer is more likely to require revision, which may be due to the increased torque on the lead knee

Introduction and Aims: This study was designed to assess the impact of lower limb arthroplasty on performance and other outcome measures in active golfers. The aim was to obtain justification data prior to proceeding with a much larger prospective study. Method: Subjects were selected for inclusion in the study on the basis of having undergone lower limb arthroplasty surgery and actively playing golf at a social or competitive level at least fortnightly. Data was collected retrospectively by the use of a self-administered, patient-orientated questionnaire. Pre- and post-joint replacement data was obtained for: Australian Golf Union (AGU) handicap; driving and longest iron distances; frequency and duration of golf rounds played; use of motorised assistance; and pain, stiffness, swelling and subjective performance scores. Demographics, length of time to return to playing golf post-operatively and post-operative complications were also recorded. Results: Results were obtained from 25 subjects with 33 joints in total replaced, 24 male and one female, mean age 70.6 years (range 53–81 years) and average time to survey post-arthroplasty was five years and 10 months. The right knee was replaced in 30.3% of subjects, left knee 27.3%, right hip 24.2% and left hip 18.2%. Eight of the 25 subjects reported complications with three requiring further surgery. There were no reports of dislocation. The average time taken to resume golfing activity post-arthroplasty was 15.4 weeks (range 5–52 weeks). Subjects demonstrated a mean increase in their AGU handicap of 1.6 strokes (p< 0.05). Average drive distance off the tee shortened by 8.6 metres (p< 0.05), with a similar change for average longest iron length, in the magnitude of 7.4 metres (p< 0.05). There was no significant change in the numbers of rounds played per month, with a mean of 8.9 pre-joint replacement and 8.3 after surgery. Wilcoxon signed-ranks test values were significant (p < 0.05) for comparison of pre to post-joint replacement, showing a decrease in reported symptoms of pain, stiffness and swelling following joint replacement. A highly significant (p< 0.001) finding was a reduction in the subjective impact of joint symptoms on golf performance post-arthroplasty. Conclusion: Although subjects seem to be more satisfied with their golf by playing with less joint pain, stiffness and swelling, they appear to do so with an actual decrease in objective performance. These significant findings support conducting a much larger prospective study looking at the impact of arthroplasty on golf activity, and vice versa

Introduction: The aim of this study was to investigate the function, limitations and disability of a large cohort of active golfers following total knee replacement (TKR). Materials & Methods: The study group comprised the membership of the New Knee Golf Society (NKGS), UK. 211 members were reviewed with a questionnaire which asked the patient’s experience & difficulties of playing golf before and after TKR. The functional outcome was recorded using the Oxford knee score. A total of 299 knees in 209 patients were included in the final analysis. The mean age was 69.6 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (89.6%). The mean post-operative period was 5.1 years. Results: 196 patients (94%) returned to playing golf after a mean 4.6 months following the TKR. 184 (88%) continue to play at review. 92.8 % claimed significant improvement in their ability to play and enjoy golf following TKR citing reduction in pain and improved walking ability as the reasons. However, none claimed to have achieved a significant improvement in their handicap. 17 knees (5.7%) underwent revision surgery. 6 knees (2%) were revised for infection at mean 17.3 months & 11 (3.7%) for aseptic loosening or instability at mean 4.9 years. 7 left knees (lead knee) of 11 right-handed golfers required revision for aseptic loosening. The main problems experienced after playing 18 holes were knee stiffness (47%) & swelling (18%). Conclusion: Although the ability to play improved the handicap remained the same. The left TKR in a right-handed active golfer is more likely to require revision which may be due to the increased torque on the lead knee

The aim of this study was to evaluate the analgesic effect of extracorporeal shock wave lithotripsy (ESWL) in patients with refractory tennis elbow, golfer’s elbow and plantar fasciitis. Patients with tennis elbow (34), golfer’s elbow (11) and plantar fasciitis lesions (14) who had not responded to a minimum of six months’ conservative treatment were included in this three-year study of ESWL. Patients who were pregnant or had neurological problems, coagulation disorder and tumour in the area of treatment were excluded. Patients received 2 000 shock waves of 0.04 to 0.12 mj/mnf three times at monthly intervals. Patients were followed up for a minimum of six months and maximum of 36 months. The effectiveness of ESWL was assessed in terms of improvement in duration and severity of pain, functional disability, complication of treatment and recurrence. Good or excellent results were achieved in 67.65% of patients with tennis elbow, 45.45% with golfer’s elbow and 71.42% with plantar fasciitis. ESWL seems a useful treatment option, as effective administered monthly as weekly. Its effectiveness in cases of golfer’s elbow in questionable

1. Introduction. Such a Total Knee Arthroplasty (TKA) that is capable of making high knee flexion has been long awaited for the Asian and Muslim people. Our research group has developed the TKA possible to attain complete deep knee flexion such as seiza sitting. Yet as seiza is peculiar to the Japanese, other strategies will be necessary for our TKA to be on the overseas market. Still it is impractical to prepare many kinds of modifications of our TKA to meet various demands from every country/region. To this end, we contrived a way to modularize the post-cum alignment of our TKA in order to facilitate the following three activities containing high knee flexion: praying for the Muslim, gardening or golfing for the Westerner, sedentary siting on a floor for the Asian. We performed simulation and experiment, such as a mathematical model analysis, FEM analysis and a cadaveric study, thereby determining the optimal combination of moduli for the above activities respectively. 2. Methods. We modularized the post-cum alignment by three parameters in three levels respectively (Fig.1). The shape of the post's sagittal section and the total shape of cum were unchanged. The three parameters for modularization were the post location which was shifted anterior and posterior by 5 mm from the neutral position, the post inclination which was inclined forward and backward by 5° from the vertical, and the radius of curvature of the post's horizontal section which was increased and decreased by 2 mm from the original value. It is crucial to decrease contact stress between the post and cum during praying for the Muslim and during gardening or golfing for the Westerner, which would be realized by choosing the optimal location and inclination of post when kneeling for the Muslim and when squatting for the Westerner respectively (Fig.2). As for the Asian, it is desirable for them to perform various kinds of sedentary sittings on a floor without difficulties, which would be facilitated by choosing the optimal radius of curvature value to increase range of rotation when the knee is in high-flexion (Fig.2). First we performed a mathematical model analysis to introduce the kinetic data during sit-to-stand activities. Then by using the above kinetic data we performed the FEM analysis to determine the contact stress between the post and cum during praying, gardening or golfing. Finally we carried out the cadaveric study to determine the range of rotation at high flexion of the knee. 3. Results and Discussion. The results of FEM analysis demonstrated that the best modular set for the activities for Muslim and Westerners were so that the post location should be shifted by 5 mm and the post inclination should not be applied (Fig.3). The results of cadaveric study demonstrated that the radius of horizontal curvature should be increased by 2mm so as to increase the range of rotation especially when the knee is in high flexion. The subjects for our future study are to verify the validities of the above results through our simulator tests