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!

Awesome video: Ankle Pain, Popping and Tendinitis.


(Cool 11 second video to watch!)

The fibula and tibia of the lower leg join the talus, one of the 26 bones in the foot, to create the ankle joint. There are, therefore, many places to experience ankle pain, foot pain as well as popping during our daily functional activities such as walking or running. Add in all the tendons which cross the front of the ankle, the well known Achilles tendon at the back of the ankle and the two peroneal tendons passing immediately below the lateral maleolus (outer ankle bone) as well as the tibialis posterior and flexor tendons of the toes passing around the bottom of the medial maleolus (inner ankle bone) and we now have possibilities of a tendinitis and tendon tears.

Today at our Custom Physical Therapy clinic in Sparks we had a fantastic example of peroneal tendon subluxation (popping over the lateral maleolus) and the patient permitted us to video it. Clearly we had fun watching the peroneal tendon popping over the lateral maleolus! Check it out here!

In this case it was not painful but you could see how it may result in tendinitis (inflammation of the tendon) if it the popping continues.

If you have concerns about foot or ankle pain, feel free to call us (775-331-1199) or, better yet, swing by any of our three Custom Physical Therapy clinics (Sparks, South Reno or Northwest Reno) to ask one of our 9 physical therapists to take a quick look and give you some advice.

Custom Physical Therapy looking for a Physical Therapist.


Custom Physical Therapy is seeking an outdoorsy, mountain biking, hiking, Lake Tahoe loving, skiing, camping, life loving outpatient orthopedic physical therapist to join us in Reno, Nevada.


We love what we do and are expanding because of the experiences our patients have and the absolutely amazing people who work at Custom Physical Therapy. Yes, I am biased but it’s totally true.


If you are a PT or know of someone who is a PT or a new grad and may be interested in working with us, contact me at (775) 813-2332 or ameintjes@usphclinic.com.

I’d love to chat with you.

André

(Aka owner/physical therapist/chief goofball)

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?

Reasons to Choose Custom Physical Therapy


5 Simple Things to do Before a Knee Replacement.


Pre-operative conditioning!

Vital in determining the post-operative outcome of a total knee replacement.

Ask anyone who did the right things before surgery.

Sharine came in to see us for a single visit to learn what to do and then exercised daily until the day before her knee replacement.  “After watching my Mother and my husband go through knee replacements I took the advice from Andre’ and my surgeon to exercise and strengthen the muscles in my legs as well as other parts of my body. I am now about 3 1/2 weeks after surgery and I must say it has helped me. I am told that I have reached goals that others do not reach this soon. You MUST exercise before your surgery and I would recommend you start at least 6 weeks before.”  Her husband, Bob, had a knee replacement without pre-op instruction.  “Eight years ago I had a knee replacement. I was dismayed at how weak my “good” leg was!  I had the good fortune to be treated at Custom Therapy.  I learned that anyone having this surgery should or must exercise weeks before the event to ease the recovery period.  My wife just had her knee done.  We went to André 6 weeks prior for his counsel.  He examined her and recommended a course of pre-surgery exercise.  Having done without myself and seeing her result and progress I cannot recommend more strongly that others should absolutely follow this advice.”

  1. Ride a bike daily.

Bike riding creates controlled movement in a non-weight bearing position so will be less traumatic to the joint than walking or any other weight bearing exercise.

  1. Stretch hamstrings and calf muscles.

This helps get/keep your knee straight.  Painful knees are typically kept in a slightly flexed position for comfort which shortens these muscles. 

  1. Stretch your knee into full extension.

It can be done sitting in a chair with your heel on a coffee table or ottoman or lying face down on your bed with the edge of the bed just above your knee. 

  1. Pull your heel to your butt.

This will maximize your knee flexion.  The more range you have before your surgery, the more you will regain afterwards. 

  1. Strengthen your quads.

Your goal is to maximize your quad recruitment pre-operatively; this makes it easier to contract them after the trauma of the surgery.  A simple quad set, SAQ, or SLR (my favorite) is what is needed.

Your Call to Action:

  1. If you are planning on having a total or partial knee replacement consult a physical therapist as to what you need to do preoperatively to maximize your post-operative outcome.
  2. Forward this post to someone you know who may be having a total/partial knee replacement.
  3. Please post your comments regarding your experience with having or not having preoperative exercises and how they helped you. 

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.

Antibiotic treatment of Low Back Pain


I recently came across an interesting pair of research papers in which low back pain was treated with antibiotics successfully.  This research is published in the European Spine Journal April 2013, volume 22, Issue 4, pages 690-696 and 697-707.

This concept took me by surprise.  Dic herniations can apparently become infected with the bacteria from plaque in your teeth and from acne.  The link between dental hygene and cardiovascular disease, and I think diabetes (not sure), has previously been documented so I do not think this premise is a far stretch.  The authors investigated nuclear disc material from patients who underwent surgery for annular tears and removal of visible nuclear tissue.  43% of patients had evidence of infections.

They then treated patients with chronic low back pain and vertebral bone edema with antibiotics for 100 days (that’s a long time).  The antibiotic treatment significantly improved the chronic low back pain when compared to placebo.

Well!  I am somewhat taken aback but realize this is very interesting and may explain some cases of low back pain that do not progress as well as they should.

Your call to Action:

  1. What do you think of this?
  2. If you are a healthcare provider, post your comments please.
  3. Forward this onto someone who may have some comments and have them post their thoughts to our blog.
  4. Have an incredible week!

Swelling and Knee Function


The most read post on this blog deals with “Swelling, Effusion, Edema and Bruising – What’s the difference?”.  I will take the concept one step further and discuss how knee swelling or joint effusions impact your ability to control your knee extension when you walk.

So, you injure your knee and develop swelling inside the joint.  You may notice your knee giving way.  That means when you transfer weight onto your injured leg the knee buckles.  This is due to the quadriceps (front of your thigh) not contracting efficiently and hence not controlling the knee in extension.  Knee extension is vital in walking because it stabilizes the leg to accept the transferred weight from the opposite leg when you are in stance phase of gait.  If the knee is unable to go fully straight while stepping onto it you have difficulty swinging the other leg through to take another step.

This happens because of the swelling (and possibly pain too) within the joint.  A neural reflex is set up by distension of the joint structures.  It passes through the spinal cord and back to inhibit the quadriceps.  It is then difficult to contract them at the right time and with sufficient speed during the gait cycle.  Hence, unsafe walking and difficulty going up and down stairs, for example.  You may notice immediate deterioration of your ability to contract the quadriceps following injury with a joint effusion.

To regain quadriceps function and hence to restore normal and safe walking you must control the swelling (see earlier post on this topic), avoid increasing it by careful activity modification and do specific exercises to regain normal quadriceps function.  Physical therapists will instruct you in specific neuromuscular reeducation exercises to restore the quadriceps recruitment pattern.  Such exercises may include seated quad sets, straight leg raises or short arc quad recruitment.  These may be done with neuromuscular electrical stimulation (not TENS – that’s for pain and totally different type of current form) to facilitate recruitment of the muscle.  In addition, you will be given terminal knee extension exercises in standing such as straightening the knee against a wall with a towel roll behind your knee against the wall or fully extending your knee against tension created by an elastic sports cord.

So, controlling swelling in a joint is necessary to regain function of the muscles moving that joint.  This process is used in all knee injuries that result in joint effusions as well as in all postoperative rehabilitation, for example, following ACL reconstruction, meniscus repairs and debridement as well as total knee replacements.

What have you found helpful in the past?

What worked for you?  What didn’t?

Post your comments here so other people can learn from your experiences.  We would love to here from you.