The impact of total knee arthroplasty on golfing activity

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Introduction
Total knee arthroplasty (TKA) is one of the most commonly
performed orthopedic procedures at present (1). In 2010,
over 600,000 TKAs were performed annually in the United
States. Among older patients in the US, the per capita
number of primary TKAs doubled from 1991 to 2010
(from 31 to 62 per 10,000 Medicare enrollees annually) (2).
By 2030, the number of TKAs performed annually in the
US is projected to increase by 673 percent to 3.48 million
procedures annually (3).
The recent and projected increase in TKA procedures
is due in large part to an aging Baby Boomer generation,
those born between 1946 and 1964. The 2006 U.S. Census
Bureau data indicated that this generation forms over 26
percent of the United States population, approximately
78 million individuals (4). As this generation enters
retirement, the expectation of maintaining an active
lifestyle remains paramount, and can be facilitated by joint
arthroplasty.
Candidates for TKA are also, on average, receiving
arthroplasty at a younger age than in previous decades. In
2000, the average TKA patient was 69 years old, but by
2010 the average age had dropped to 66, according to data
from the National Hospital Discharge Survey produced by
the Centers for Disease Control (CDC) (5).
Original Article
The impact of total knee arthroplasty on golfing activity
Doug Vanderbrook, Afshin A. Anoushiravani, Casey M. O’Connor, Curtis Adams, Darryl Whitney,
Jason Tartaglione, Jared Roberts
Department of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
Contributions: (I) Conception and design: D Vanderbrook, AA Anoushiravani, CM O’Connor, C Adams, J Roberts; (II) Administrative support: All
authors, (III) Provision of study patients: AA Anoushiravani, CM O’Connor, D Whitney; (IV) Collection and assembly of data: AA Anoushiravani,
D Whitney, J Tartaglione; (V) Data analysis and interpretation: AA Anoushiravani, D Whitney; (VI) Manuscript writing: All authors; (VII) Final
Approval of manuscript: All authors.
Correspondence to: Casey M. O’Connor, MD. Department of Orthopaedic Surgery, Albany Medical Center, 43 New Scotland, MC-184, Albany, NY
12208, USA. Email: Oconnoc1@amc.edu.
Introduction: Total knee arthroplasty (TKA) is frequently performed among individuals who golf. This
study examines the effect of TKA on pre- and postoperative pain, frequency of sport participation, handicap,
driving distance, use of a cart, and overall game enjoyment.
Methods: This is a survey-based retrospective review of 71 patients after primary TKA at a tertiary medical
facility in upstate New York. Patients were evaluated using postoperative pain scores and asked to complete a
survey that included questions about their return to sport.
Results: A total of 71 patients were included, with an average age of 70 years old. Postoperatively 85%
of patients returned to play within 7.9 months, driving distance increased by 4 yards, patients’ golf game
improved by 1.07 strokes, and pain during and after golf was signicantly decreased. Most patients did not
change golf cart usage, and reported unchanged or improved performance in and enjoyment of golf.
Conclusions: We found that a majority of patients undergoing TKA returned to playing golf
postoperatively. Patients were more likely to report decreased pain both before and after play and positive
changes to their golf game. Our results suggest that most patients can expect to return to golf after TKA and
the majority will enjoy the sport with less pain postoperatively.
Keywords: Total knee arthroplasty (TKA); golf, patient outcomes; postoperative activity
Received: 05 February 2021. Accepted: 13 June 2021.
doi: 10.21037/aoj-20-37
View this article at: https://dx.doi.org/10.21037/aoj-20-37
6

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A significant amount of overlap exists between the
estimated 29 million Americans who participate in golf and
those who have received or are considering a TKA. A 2012
demographic study by the National Golf Foundation (NGF)
reported that greater than 60% of US golfers were over the
age of 50 (6). The number of golfers with TKA is expected
to rise as the aging population attempts to maintain an
active lifestyle. Many patients will inquire on the effects
TKA may have on their golng ability.
Our study seeks to provide further information
regarding TKA and return to golf in several areas
undiscussed in current literature. This study aims to
thoroughly evaluate the effect of TKA on golf performance
including comparing pre- and postoperative pain during
and after golf utilizing a visual analog scale of pain,
frequency of postoperative play, handicap, driving distance,
use of a cart, and overall game enjoyment. Our goal is
to address specific patient expectations with substantive
data. Our hypothesis was that TKA would decrease pain
experienced during and after golfing, and would improve
golfers’ ability to continue play.
We present the following article in accordance with the
STROBE reporting checklist (available at https://dx.doi.
org/10.21037/aoj-20-37).
Methods
Study design
The study has been performed in accordance with the
ethical standards in the Declaration of Helsinki (as revised
in 2013) and has been carried out in accordance with relevant
regulations of the US Health Insurance Portability and
Accountability Act (HIPAA). IRB approval was obtained at
the Albany Medical Center (NO.: IRB#4073). All patients
signed a consent form to participate in this study.
In total, two thousand consecutive patients undergoing
primary TKA between January 2009 and March 2014
were mailed a 29-item survey specic to the patients’ golf
performance, frequency of participation, timing of return
to play, presence of pain, use of a cart postoperatively, and
other golf-related questions.
In order to assess for pain intensity both pre- and
postoperatively, survey candidates were instructed to
complete the Visual Analogue Scale (VAS) of pain intensity.
The VAS pain score is the most commonly utilized
instrument for the evaluation of pain intensity; its validity
and reliability, especially in scoring acute pain, has been
well-substantiated in previous literature (7). The VAS pain
score consists of a line with two descriptors representing
extremes of pain intensity {i.e., no pain [0] and extreme
pain [10]}. Patients rate their pain intensity by making a
single mark on the line best representing their level of pain.
Subsequently, the VAS is scored by measuring the distance
from the “no pain” end of the line, ranging in value from 0
to 10.
Inclusion criteria for our study included all patients who
received elective, primary TKA from one of ve senior adult
reconstruction specialists at our institution. Indications for
TKA included osteoarthritis (OA), rheumatoid arthritis
(RA), and post-traumatic arthritis. All patients who received
a revision TKA or another total joint arthroplasty (TJA)
were excluded from this study.
The surveys and a paid return envelope were sent by
mail to the patients’ address. All patients signed a consent
form to participate in this study. In addition, guidelines
set forth by the Health Information Privacy and
Portability Act (HIPPA) were thoroughly reviewed and
implemented.
Statistical analysis
Descriptive statistics were used to assess baseline
characteristics including: age, gender, laterality of implant,
and handedness. Comparisons of pre- and postoperative
VAS pain scores and golf cart use were performed using
sample t-tests. All survey outcomes were reported as
arithmetic means and percentiles. When appropriate,
standard deviations (SD) and ranges were also reported.
Statistical analysis was conducted using Excel software
(Microsoft Corporation, Richmond, Washington, USA). A
P-value of <0.05 was considered statistically signicant.
Results
Baseline characteristics
Of the 2,000 surveys mailed to patients, 482 (24.1%)
responses were received, of which 141 patients reported
playing golf. 49 patients reported having received another
TJA and were subsequently excluded from the study;
patients were also excluded for revision surgery or other
factors outlined above. Ultimately, 71 patient responses
were included in this study with a minimal follow up time
of 1-year post-TKA. Descriptive statistics of baseline
characteristics indicated that the average age and gender

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Table 1 Baseline demographics and other characteristics of TKA
patients who reported playing golf
Demographics and characteristics of golfers N (% of total)
Average age [in years] 70 [56–93]
Male, avg. 70
Female, avg. 71
Gender
Male 52 (73.2)
Female 19 (26.8)
TKA laterality
Left 35 (49.3)
Right 36 (50.7)
Right handedness 71 (100.0)
Preoperative patient inquiry regarding golf 37 (52.1)
Surgeon provision of advice on golf game 35 (49.3)
Table 2 Patient-reported postoperative time to resume golf and
subsequent golng frequency
Patient-reported golf participation N (% of total)
Resumed golfing 60 (84.5)
Months prior to resuming, avg. 7.9
Golf frequency postoperatively
Never 11 (15.5)
Rarely (1/month) 17 (21.5)
Occasionally (2–7/month) 21 (30.8)
Frequently (8+/month) 22 (30.8)
Change in golfing frequency
No change 33 (46.5)
More frequent 15 (21.1)
Less frequent 23 (32.4)
Table 3 Patient-reported subjective impact of total knee
arthroplasty on overall golf performance, game enjoyment, and pain
during play
Golf Performance N (% of total)
Average change in total # of strokes −1.07 (−10 to +18)
Average change in driving distance (yds.) 4 (−50 to +50)
Increased difficulty in strokes 11 (15.5)
Decreased difficulty in strokes 22 (31.0)
Change in golf swing 18 (30.5)
Cart usage pre- and post-TKA
No Change 39 (76.5)
Preoperative cart to postoperative walking 7 (13.7)
Preoperative walking to postoperative cart 5 (9.8)
Perceived Performance after TKA
Same 29 (49.2)
Improved 25 (42.4)
Worse 5 (8.5)
Pain during golf after TKA
Same 3 (5.1)
Better 53 (89.8)
Worse 3 (5.1)
No response 12
distribution of study participants was 70 years and roughly
3:1 male to female (Table 1). There was an equal distribution
of patients receiving left and right TKA. Moreover, all
patients were right-hand dominant. Preoperatively, 52.1%
of patients reported asking their orthopaedic surgeon
about golf, and 49.3% stated that their surgeon gave advice
regarding likely outcomes for their golf game before and
during their recovery course.
Postoperative golf outcomes
In our patient population, 85% of respondents who had
previously played golf returned to play within an average
of 7.9 months after TKA (Table 2). 22% of respondents
reported playing golf postoperatively less than or equal to
once a month, whereas 62% of those surveyed reported
playing golf two or more times a month. 11 patients stopped
playing golf postoperatively for reasons ranging from
increased knee pain to poor general health. Additionally,
68% of respondents indicated they played golf more
frequently or the same as preoperatively, while 32% played
golf less often than before.
Overall, a majority of respondents noted positive changes
in their golf game postoperatively (Table 3). On average,
respondents stated that their golf game improved by 1.07
strokes (range, ‒10 to +18 strokes) and their driving range
increased by 4 yards (range, ‒50 to +50 yards). The majority
(53.5%) of respondents did not report any increased or

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decreased difculty with golf strokes. 31% of respondents
reported decreased difficulty with golf strokes, especially
when driving, while 16% of respondents endorsed increased
stroke difculty, primarily when driving or in the sand traps.
Three-quarters of respondents did not change their use
of golf carts before or after TKA, however, 13.7% surveyed
reported using golf carts preoperatively but walking the
course postoperatively. 10% of patients reported new
use of carts postoperatively (Table 3). Overall, 91% of
patients reported their perceived golf performance was
the same or improved postoperatively. Moreover, 90% of
respondents reported that their knee pain while playing
was comparatively better following TKA than it had
been preoperatively. Lastly, 95% of respondents reported
enjoying golf the same or more after their primary TKA.
Patients’ VAS pain scores were consistent with these
overall positive outcomes (Table 4). Respondents indicated
that their pain before primary TKA during and after golf
averaged 6.6 and 5.3, respectively, thus demonstrating
moderate to severe levels of pain. Postoperatively, VAS
pain scores both during and after golf activity dropped
to an average of 1.3. This decrease in VAS pain scores
was statistically significant (P<0.001) and represented a
signicant postoperative reduction in pain during and after
golf activity of 77% and 71%, respectively.
Discussion
The results of our study demonstrate that a majority of
patients undergoing a TKA were able to return to golng
activity post-operatively. Post-operatively patients were
likely to continue playing at the same frequency as they
did preoperatively or at an increased frequency. Overall,
respondents were more likely to reect positive changes in
their golf game post-operatively.
Our study indicates that most golfers (85%) in our
TKA population are able to return to golfing activity at
an average of 7.9 months after surgery. These results are
similar to a 2009 study by Jackson et al., nding that 57% of
TKA patients return by 6 months with a 94% overall return
rate (8). Another study by Mallon et al., likewise indicated
an average return to play of 5 months in 83 avid golfers
(9,10). In 2004, Chatterji et al., reported an average return
to play time of just 3 months; however, this study included
only 6 patients with more than half of the golfers surveyed
reporting having ceased golfing postoperatively (11). We
noted that our return of an average 7.9 months may have
been influenced by geographic location and a relatively
short playing season as opposed to more favorable golng
conditions found elsewhere.
An additional primary outcome measure of the current
study was a significant decrease in pain, as measured on
the VAS scale, both during and after golfing following
TKA. Mallon et al., previously showed that the majority of
patients had reduced golfing pain after surgery, especially
if done on the trail leg; this study did not quantify the level
of pain experienced by postoperative patients (9,10). Our
results, as shown above, demonstrate a dramatic decrease in
VAS scores for patients engaging in golf postoperatively.
The majority of golfers in the current study reported
golng more frequently after surgery. There was also a mild
increase in average driving length of 4 yards and an overall
score improvement by 1.07 strokes. This improved driving
distance is a contrast with a prior study showing a small loss
of 12.2 yards driving distance, yet is in agreement with that
study’s finding of an improvement of 1 stroke per round
post-operatively (9,10). However, both driving distance and
strokes gained are patient reported estimates with inherent
bias, and neither meet a statistically signicant threshold.
The limitations of the current study include a poor
response rate and inherent recall bias. Only 24% of study
candidates participated, representing a low response rate
compared to previous studies. A poor response rate was
expected as our study targeted patients undergoing knee
replacement as a whole rather than golfers in particular. Of
the surveys returned, nearly 30% were golfers, whereas less
than 10% of the US population over the age 50 are golfers.
Therefore, it is likely that many non-golfers chose not to
return the survey, leading to potential selection bias. There
is inherent recall bias given the fact that respondents were
asked to remember their pre-surgery golf performance,
experience, and perceptions of pain. Some respondents
may not have golfed for several years leading up to their
Table 4 VAS pain scores during and after golf
Pain during golf game VAS score P value
Prior to TKA 6.62
Following TKA 1.33
Overall reduction in pain 77% <0.001
Pain after golf game
Prior to TKA 5.32
Following TKA 1.29
Overall reduction in pain 71% <0.001

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TKA given their preoperative pain, with limited ability to
evaluate their pre-TKA golf experience. This bias could be
reduced by ensuring that patients had attempted golfing
within an established time frame prior to their TKA.
The majority of golfers in our study had neither
increased nor decreased difficulty with executing their
golf stroke postoperatively. Thirty one percent of patients
reported improved ease of using the driver, supporting
previous literature which showed similar improvement in
45% of golfers (9). This improvement in pain with driver
use is expected, as this particular club has been shown to
have increased flexion in the lead leg at the apex of the
backswing phase, and increased stress and moments in the
downswing and follow-through phase (12,13).
Our results indicate that return to golf after TKA can be
expected in most patients and that the majority of patients
will be able to enjoy the game with significantly less pain
than before surgery. Surgeons counseling their patients on
TKA should be able to instruct their patients that return to
golf after TKA is possible.
Future directions of the current research include
a prospective trial for golfers undergoing TKA that
could include sport specific therapy regimens pre- and
postoperatively.
Acknowledgments
Funding: None.
Footnote
Reporting Checklist: The authors have completed the
STROBE reporting checklist. Available at https://dx.doi.
org/10.21037/aoj-20-37
Data Sharing Statement: Available at https://dx.doi.
org/10.21037/aoj-20-37
Conicts of Interest: All authors have completed the ICMJE
uniform disclosure form (available at https://dx.doi.
org/10.21037/aoj-20-37). The authors have no conicts of
interest to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved. The study has been
performed in accordance with the ethical standards in the
Declaration of Helsinki (as revised in 2013) and has been
carried out in accordance with relevant regulations of the
US Health Insurance Portability and Accountability Act
(HIPAA). IRB approval was obtained at the Albany Medical
Center (NO.: IRB#4073). All patients signed a consent
form to participate in this study. This work was performed
at The Albany Medical Center, Albany, NY.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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doi: 10.21037/aoj-20-37
Cite this article as: Vanderbrook D, Anoushiravani AA,
O’Connor CM, Adams C, Whitney D, Tartaglione J, Roberts J.
The impact of total knee arthroplasty on golng activity. Ann
Joint 2021.