Hip Arthroscopy and the Crazy, Complicated Joint for Walking.


Some Background

The hip joint is built for stability during weight bearing activities such as walking, running, getting out of a chair, ascending and descending stairs and squatting to the floor to pick something up. The bony geometry of the hip reveals a deep socket (acetabulum) surrounding the ball (head) of the thigh bone (femur). The acetabulum and the femoral head are covered with cartilage. The angle of the shaft of the femur relative to the head, the amount of rotation in the shaft of the femur (torsion) and the depth of the acetabulum has an impact on the biomechanics of the joint and, if abnormal, the need for hip arthroscopy. Measurement of these angles by the physical therapist and the orthopedic surgeon in addition to performing special testing to stress structures of the hip helps in developing a clinical picture in the presence of hip pain.

(From Wikidoc.org)

A cartilaginous structure surrounding the acetabulum, the acetabular labrum, can become torn due to degenerative processes or through trauma.

Surrounding and encasing the joint is the capsule which includes strong ligaments (capsuloligamentous complex). This structure gives additional stability to the joint during movement. These stabilizing structures include the iliofemoral, ischiofemoral and pubofemoral ligaments. Together with the ball and socket bony structure, the strength of these ligaments makes it hard to dislocate a normal hip – thank our lucky stars!

Hip Ligaments.jpg

(From http://www.medillsb.com)

Muscles, attached from the pelvis to the femur, create movement and stability during weight bearing on the limb. The primary movers of the hip joint are the gluteus maximus, gluteus medius, gluteus minimus, iliopsoas and the various adductor muscles. In addition, there are the quadriceps (front of the thigh), particularly the rectus femoris, and the hamstrings (back of the thigh) to consider as well as the hip rotators, situated deep to the gluteus musculature.

To the left you seethe outer hip muscles. Peel them away and you reach the deeper muscles, as seen in the image immediately above. So, based on the complex muscular anatomy, and how important these muscles are in normal walking, as well as all other weight bearing function, be skeptical of healthcare providers who feel no physical therapy is needed after some kind of surgery. You must retrain the muscles to work correctly.

Important biomechanics

Consider this. Each time we transfer weight onto one of our legs, the hip abductors (gluteus medius) must contract to stabilize the pelvis (not permit it to sag on the non-weight bearing side). The importance of this from a rehabilitation standpoint is that the physical therapist will focus a great deal of attention on maximizing the functional strength of this muscle, it being so vital in recovery of a normal gait pattern.

Trendelenberg gait

(Picture from the Oregon Exercise Therapy Blog)

Here is a video of the abnormal gait pattern seen due to weak hip abductors – a Trendelenberg Gait.

Hip Arthroscopy

Hip arthroscopy is commonly used to address acetabular labral tears and femoroacetabular impingement as well as capsular repair. It may also be used to remove any chondral flaps due to arthritis within the joint. During an arthroscopy the surgeon may also perform a soft tissue release to alleviate muscle pain due to tendons or parts of a muscle rubbing on a bony prominence.

In a future post, I hope to convince one of the orthopedic surgeons, who specializes in hip arthroscopy, to detail his thoughts on the indications for hip arthroscopy. Maybe he can also give some insight into why he feels physical therapy is beneficial following such a surgery.

Your Call to Action

If you walk with a limp without pain and feel off balance or are concerned your leg will give way on you, it may be that you need very specific strengthening exercises to correct your gait and prevent falling. After all, if you prevent falls, by strengthening supplemented by specific fall prevention training, you avoiding impact in hitting the ground, i.e. falls, and thus you avoid more severe injuries such as fractures.

Call a physical therapist and get in for an evaluation and a suitable exercise/balance program. You will be glad you did!

Battling El Nino with Your Core in 10 minutes.


El Nino is arriving with massive amounts of snow and rain, right? We all hope for drought relief but with the forecasted “big winter” comes the need for strength and control of your hidden muscles to weather (pun intended) the wet, cold, white, slippery Reno-Sparks-Lake Tahoe area.

A generally accepted definition of “the core” is the muscles from below the neck and above the upper thigh (shoulders to hips). The importance of these muscles is in injury prevention, maintaining erect, “regal” posture and providing a base for functional strength (the ability to push a heavy door open, get in and out of a car, stand up out of a chair or lift a box form the floor to a counter). Training all the core would take all day if you try to isolate each muscle individually. So, do 3 exercises and get nearly all of them done in less than 10 minutes!

“YTWL” – shoulder and back muscles.

Keeping your body straight over a therapy ball beneath your lower abdominal-pelvic area and feet against the wall, raise your arms in 4 different planes noted by “YTWL”. Arms overhead at a 45° angle between head and shoulders, in line with shoulders, elbows tucked into your sides flexed 90°, and finally rotation of shoulders up with upper arms at shoulder level. No therapy ball? Just do it off the corner of your bed.

The Y of the YTWL Series

The Y of the YTWL Series (see YouTube channel for video)

Front Plank – abdominals, butt and shoulder.

Lying prone, support your body in a straight line from shoulders to ankles resting on your elbows and toes. Pull your navel in and up (“make yourself skinny”) and pinch your glutes together while rounding out your shoulders. Hold this position for up to a minute (must have perfect technique the entire hold). Repeat three to five times.

Front plank

Front plank (see YouTube channel for video)

Clamshell Progression – Hip muscles.

Lay on your side, knees bent to 90° and hips at 45°, one leg atop the other. Rotate your hip out by lifting your top knee while keeping feet together, 10 times. Rotate foot up keeping thighs together 10 times. Lift top leg parallel to bottom and rotate 10 times around the axis of the femur. Straighten your hip, keeping knee at 90° and rotate 10 times around the femurs axis. Tough people, repeat 3 times on each side.

Clamshell # 4

Clamshell # 4 (see YouTube channel for video)

To see a video of each exercise on our YouTube channel, go to The El Nino Core Program .

El Nino dump your snow, your rain and whatever icy weather you care to bring us. Our core is now ready for shoveling snow, lifting and carrying sand bags (hope not!) and preventing falls when slipping on ice. Bring on those pressure changes that make my back ache – El Nino we got the work done before you came!. See you when you arrive, that’s if you don’t chicken out again!

Smoking, Health and Forest Fires.


Living in Reno, Nevada, we are frequently engulfed in smoke from forest fires around the area. Last year it was the big Yosemite fire, this year we were living under a blanket of smoke from the massive King Fire just east of Sacramento, California. Air quality was in the unhealthy range day in and day out. With clean air in the Truckee Meadows so dependent on the wind direction, we were praying for wind direction changes and the return of our Nevada blue skies.

Someone told me about a scene he saw at his work during the time we were blanketed in smoke. He left for lunch and walked past the smoking area outside the building. He saw two people smoking outside in the already smoky air and one waving her hand, cigarette in the other, “This smoke is killing me!” We humans are a funny bunch!

So I thought I would have some fun with that and take a photo. My disclaimer: I am not a smoker and never have been and boy did I learn something about smoking in the brief 10 minutes I had cigarettes going for the photograph!

  1. My tongue felt fury.
  2. My wife did not enjoy our first kiss.
  3. My clothes smelt of smoke immediately afterwards and this did not disappear until I washed them.
  4. I coughed immediately.
  5. I had to brush my teeth and take a shower right away.
  6. If I disliked it so much then it must be addicting as I struggle to believe those who have chosen to smoke don’t eventually bypass these sensations and thereby continue to smoke.

Smoking and our Reno Air Quality

Smoking and our Reno Air Quality

My Dad was a thoracic surgeon with a specialty in lung and esophageal cancer. As a consequence, I have always been very aware of the health issues related to smoking. I have never been addicted to anything (some who know me well may say I am addicted to exercise, talking to strangers and coffee!). I have seen numerous patients who smoke despite having significant reasons not to. For example, one person I recall had COPD, was on oxygen, had cardiovascular disease and had recently had a spine fusion (smoking delays healing) and was still smoking. Some of these smokers are in the healthcare profession too. Putting these factors together suggests to me that whether we like it or not, smoking must be incredibly addicting. Everyone who smokes knows it is bad for their health but they continue doing it. This begs the question: “What makes people change?”

People change because the pain of their present situation (smoking) is more than the pain of making the change (the withdrawals after stopping?). The pain of smoking depends on the individual and is different for each person. Some may see their wife pregnant and decide to stop smoking on account of the youngster about to be born. Some will have significant ongoing disease and still keep smoking (not painful enough yet). I have even spoken with someone who had simply given up as the disease process had gone too far.

I feel somewhat cheap talking about smoking cessation as I am not a cessation specialist nor am I a smoker who has kicked the habit. I have a real interest in why people change. This is the reason for my post. That being said, I recently met an incredible man. During his lifetime he stopped alcohol, methamphetamine, smoking and violence all cold turkey!

How is it he was so strong and quit all those things and many of us struggle?

It is not osteoporosis that causes fractures.


We all know someone who has had a bone mineral density test and been diagnosed with osteopenia or osteoporosis.  This means they have lower than normal bone mineral density and hence their bones may be more fragile.  This in itself does not necessarily cause fractures but does need to be addressed.

A comprehensive, multifaceted approach to the treatment of osteopenia and osteoporosis will have a significant impact on bone density.  Clearly there are suitable medications one can take which your physician can address (beyond my scope of practice for sure).  I am sure you have all seen the numerous commercials on TV for these medications with that classic … “Ask your doctor about Boniva (or whatever medication they are advertising)” at the end.

The predictive value of bone mineral density measurements has been called into question in that it can under or overestimate density by 20% to 50%.  If it underestimates the density of the bone, you may receive unnecessary treatment.  If it overestimates bone mineral density you may not receive the most effective treatment.  So, what should you do?

Recognize that it is the fall that causes fractures and not the osteoporosis or osteopenia.  So if you address the physical limitations causing falls you will reduce the frequency of falls and thus reduce fractures.  75% of fractures occur in people without osteoporosis.  80% of low impact fractures occur in people who do not have osteoporosis.  Yes, it is the falls.

Preventing falls among older adults reduces the incidence of fractures, sometimes by over 50%.  Scientific evidence supports a reduction in fall frequency through strength and balance training, followed by reductions in the number of psychotropic drugs, dietary supplementation with Vitamin D and calcium and, in high risk populations, assessment and modification of home hazards.

This is where physical therapy is involved.  A fall prevention program should include targeted strengthening and stretching, static and dynamic balance training, posture modification, home hazard removal and of course an ongoing home exercise program which should be completed on a daily basis.

How do you know if you, a friend or a family member may need a fall prevention (and hence fracture prevention) program?  Answer “YES” to one of the questions below and you should consult with a physical therapist.

  1. Do you have difficulty going from a sitting to a standing position?
  2. Have you fallen without a known precipitating event?
  3. Have you fallen more than once in the past 6 months?
  4. Does it take you longer than 13 seconds to get up from a seated position and walk 10 feet?
  5. Do you have osteopenia or osteoporosis?
  6. Are you unsure if you would benefit from a fall prevention program?

Do your own assessment and decide if you, a family member or a friend may need to address balance issues with a physical therapist.  You will be glad you did.