Hip pain – 21 months to diagnosis?


A study by Burnett et al in the Journal of Bone and Joint Surgery (2006) documented an average time from injury to accurate diagnosis for hip pain due to labral tears as 21 months.  People with this type of hip pain saw an average of 3.3 providers before definitive treatment was initiaited.  In 17% of their study group of 66 patients, surgery was recommended on a different anatomic site.  Once the correct diagnosis was made and the hip arthroscopy was performed, 89% of the patients were clinically better off than before surgery.  That is positive.

Hip pain can originate from a number of structures and as a result can be easily misdiagnosed.  Low back pain can refer pain to the hip area.  Sacroiliac joint dysfunction can too.  Hip pain can be due to bony problems such as impingement or due to damage to the cartilage structure around the socket, that is the labrum (similar to the shoulder – see an earlier post on this blog).  It can originate from strain or tearing of the lignaments around the hip joint as well as from all the many muscles which control the hip joint.  In addition, pain may originate from the pubic area where the abdominal muscles and the hip adductors attach, commonly called athletic pubalgia or a sports hernia.  Finally, hip pain can be a consequence of referred pain from the leg.

Hip pain is typically localized to the groin area.  It may also be felt laterally over the outside of the hip or in the buttock.  There may be clicking, popping and snapping in the hip joint associated with the pain.  Walking, running, ascending and descending stairs, putting shoes on (figure 4 sitting) and lying on the affected side may be challenging.

Your to do list:

  1. If you have back pain that radiates to the hip area (buttock, side of your leg, groin) ask your doctor or physical therapist to evaluate the hip.  At Custom Physical Therapy we check the hip with every low back pain patient so we do not miss the diagnosis.
  2. Educate yourself on the hip so you can ask questions of your doctor and physical therapist.  Do not let your hip pain get misdiagnosed and take 21 months to be correctly treated.
  3. Call us at Custom Physical Therapy if you have any questions regarding your hip pain.  Mention you are calling with specific questions regarding this post on hip pain.  We can answer your questions.
  4. There are some really top notch hip doctors in Reno, Nevada.  Call us if you want to know who they are.
  5. Please forward this on to your friends, family and coworkers via email, Facebook, Twitter or word of mouth.

Thank you for being part of Custom Physical Therapy.  Here’s to your healthy hips!

Physical therapy

Knee Pain! Osteoarthritis!


To my fellow Boomers out there ….. How are your knees doing?  We are an active sector of the population and we want to remain that way for the health benefits (and the fun!) thereof.  Knee pain due to osteoarthritis, whether one or both knees, has a dramatic impact on a person’s ability to continue with their chosen active lifestyle and, if it gets painful enough, may impact activities of daily living such as getting into and out of a car or a chair, cooking a meal or simply walking.

 WHY KNEE OSTEOARTHRITIS?

Osteoarthritis affects 25 million North Americans and is symptomatic in 13% of people aged 55 years and older.  It has been shown to be the most frequent cause of functional disability including being dependent on alternative forms of mobility due to the tremendous pain with walking.  Ouch!  The prevalence of osteoarthritis is rapidly increasing due to two main factors.  Firstly, the aging of the American population (that includes us!) is increasing the share numbers of people older than 55 years.  Secondly, the rapidly increasing obesity in our population is increasing the rate of joint degeneration.  One study reported 83% of males who had knee osteoarthritis were obese compared to 42% of males without it.  Wow!  Now there is a statistic that says a lot and leaves nothing to the imagination as to what we need to do to address the issue.

WHAT IS IT?

Osteoarthritis is the joints response to structural damage caused by mechanical problems.  It is the body’s attempt to repair a joint under unusual stress and often leads to a stable, pain free joint.  If this process fails (is insufficient for the magnitude of mechanical stress placed on the joint) the knee becomes symptomatic and hence functionally debilitating.

MECHANICAL STRESS YOU SAY?

Pathological mechanical stress of the knee joint may be due to:

  1. Increased overall load through the weight bearing joint surfaces (e.g. obesity).
  2. Reduced load bearing surface area thereby increasing the pressure (same force through a smaller area) exerted through the joint (e.g. misaligned joint: bandy or bow-legged).
  3. Repetitive impulsive loading of the joint (e.g. trauma, doing moguls).

Obesity increases the overall load through the joint and overwhelms the joint tissues resulting in osteoarthritis.  Being bandy or bow-legged reduces the weight bearing surface area in the knee joints (shifts it from throughout the knee to one side or the other of the joint) and results in excessive wear and tear of the joint on the outer or inner surfaces respectively.  Sustaining a serious injury to the knee in which ligaments are torn and the joint surfaces are banged together in the injury may initiate the osteoarthritic “repair” process as well.  Thus, when stress on the joint tissues exceeds their physiological tolerance breakdown ensues and osteoarthritis begins.

HOW CAN WE ADDRESS THE CAUSATIVE FACTORS?

Weight loss in an effort to attain a normal body weight for your frame is paramount in reducing the forces through the knees.  Walking results in a force through the knee equal to 3 – 4 times your body weight each step.  If you lose 20 – 50 pounds in an effort to attain your normal weight, you reduce the forces through your knees by 80 – 200 pounds each step you take!  Talk about happier knees!  An 11.2 pound weight loss over a 10 year period has been shown to reduce the likelihood of developing knee osteoarthritis by 50%.

For misaligned knee joints (those of you who are bandy or bow-legged) there are unloading braces to modify (increase) the load bearing surface and hence reduce stress to the one side of the affected knee.

In all osteoarthritic knee joints muscle weakness, joint stiffness and poor balance are factors.  Muscles around the knee joint serve to cause movement in bending and straightening the knee, can reduce mechanical stresses to the joint by absorbing loads applied to the limb (e.g. cushioning during landing a jump or when skiing) and stabilize the knee joint during daily tasks of walking, running, lifting and carrying to name a few.  Patients with knee osteoarthritis are 20% to 40% weaker in their quadriceps than people without the condition.  As the disease worsens the knee muscle activation patterns become less efficient and less specific and joint proprioception (the brain’s ability to know what is happening at the joint and react accordingly) is suppressed.  A well constructed, evidence-based physical therapy program will improve strength, range of motion and proprioception and result in improvements in physical function, pain and quality of life.  Modifying the mechanical problems causing the osteoarthritis together with addressing the inflammatory and pain aspects of the disease process through pharmacological intervention from your physician can result in an 86% success rate in improving your function.  Who would not like that!?

All our physical therapists at Custom Physical Therapy have undergone specialized training for treating osteoarthritis.  The therapists work as part of a team comprised of you the patient, your physician and the physical therapist.  Using physical therapy interventions to modify the mechanical factors impacting the progression of osteoarthritis together with the physician addressing the pharmacological aspects and the patient being compliant with an exercise and stretching program (see our very first post on this blog) as well as brace use, if prescribed, the team of patient-physical therapist-doctor minimizes the effect of the disease process on your function.

YOUR CALL TO ACTION!

  1. If you are overweight start a simple lifestyle change that entails weight loss (Call Joe Dibble, dietician at Sierra      Strength and Speed, for a consult.  He is really knowledgeable and practical.)
  2. Call Custom Physical Therapy so we can evaluate your      arthritic knees and set you up with appropriate treatment.
  3. Forward this post to someone you know who has sore      knees or you think may be interested in the information.

You are encouraged to call Custom Physical Therapy to talk to one of our accredited physical therapists about your knee pain.  You may be a candidate for this customized evidence-based program specifically developed to improve your function which deteriorated due to knee osteoarthritis.

Break a Leg? Literally!


I really enjoyed Laura’s blogging of her total knee replacement.  I think this is a great idea and one which can help other people who are potential knee replacement candidates get a sense of what the process looks like from a patient’s perspective.

Great job, Laura.  We all hope you are doing well.

Break a Leg? Literally!.

It is Your Right to Choose Your Physical Therapy Clinic.


At Custom Physical Therapy, we come across many people who are not aware that it is their right to choose where they do their physical therapy. We also see patients who do not know that they can (and should) request their doctor to refer them to physical therapy if they think they need it.

Most people are referred to us by their physician, physician’s assistant, nurse practitioner, case manager or chiropractor. These providers partner with us in your recovery. We work together, as your “recovery team”, to provide the needed interventions for your speedy recovery.
 What about you? How should you be involved in the decision-making process?

1. You must be an informed consumer of healthcare.

Thus this blog! We want you to use this blog as an information source, a place to discuss (POST) your questions with other members of the Custom Physical Therapy community and our clinicians. Learn! Learn! Learn! Being informed takes effort on your part. We are here to answer any questions either by phone, in person or after you post them on the blog. Your choice. Obviously, we cannot give you concrete medical advice through the blog but we can give you access to information that may be in our head! We can direct you to appropriate resources if need be. This is an invitation to you whether you are a patient of ours, a prior patient or someone who has not visited our three clinics at all.

2. Actively participate in your healthcare.

To do this you need to be informed sufficiently to ask questions. Yes, you need to ask questions. Lots of them! Ask questions until you understand what interventions are being proposed by your doctor, nurse practitioner, physician’s assistant, case manager, physical therapist or chiropractor. This new understanding you have allows you to accept or reject what interventions we propose. You can also request other interventions – as long as you, the patient, are informed, i.e. you have done your homework! Educate yourself then actively participate in your care.

3. Make sure you know who you want to treat you.

Which clinic you attend and which provider (physical therapist) you want to be treated by is your choice. As long as they are on your insurance provider list (in-network) you will be covered by in-network benefits and typically pay less out-of-pocket than if you see someone who is out-of-network. You can, however, go out-of-network if your provider of choice hasn’t signed a contract with your health insurance company. You may then have a higher out-of-pocket expense.
At Custom Physical Therapy we try to match your out-of-network out-of-pocket cost to your in-network cost. So, never think you cannot see us if we are out-of-network. We will check your benefits and let you know what your out-of-pocket cost will be before you schedule your first appointment.

When should you request physical therapy if your doctor or other healthcare provider does not recommend it to you?

For any musculoskeletal issue there is a high likelihood physical therapy will benefit you.  Afterall, we specialize in the rehabilitation of musculoskeletal problems.  These include, but are not limited to, low back pain, neck pain, headaches, shoulder problems (weakness, pain, stiffness), arm and leg problems, ankle sprains, and numerous other conditions.  If you are unsure, call us at one of our clinics and we will be honest with you and tell you if we are an appropriate route to get you back to full function.

Regarding low back pain, research has documented the longterm benefits of physical therapy when started within 2 weeks of the onset of low back pain. Treatment with medications only (anti-inflammatories, muscle relaxers and/or pain killers) and no physical therapy resulted in an 85% reoccurrence within 1 year of resolution of the episode of low back pain, which took 3 months on average to resolve. Medical management combined with physical therapy (specific exercises and manual therapy interventions) only had a 35% reoccurrence!  That’s a huge difference!  Worthwhile I would say! It is totally appropriate for you to request physical therapy at the initial visit to your doctor for your low back pain.

Another condition where you should specifically request physical therapy immediately is for an ankle sprain, even if it is a slight one. Chronic ankle sprains may occur if early rehabilitation is not pursued.  There is a greater likelihood of arthritis in the ankle joint each time you traumatize the joint by spraining it. Research on ankle sprains shows that one sprain leads to another and then another if the brain’s ability to control the ankle in unstable situations (known as proprioception) is not retrained.  This involves being instructed in specific exercises to enable the brain to “adjust” to the faulty information, due to the ankle sprain, arising from the muscles, ligaments and tendons which control the ankle joint.

IN SUMMARY:

  1. Be proactive with your healthcare and learn as much as you can.
  2. Ask questions to gain understanding.
  3. You choose who you see for physical therapy.
  4. You can and should request physical therapy when you think it is needed.

 YOUR CALL TO ACTION!

  1.  Post a question concerning your health on this blog. If we do not know the answer, we will find it for you from another expert in the field.
  2. Check out the videos on the blog and rate them. Why do you think they are good?
  3. What topics would you like to see covered in this blog?
  4. Ask a friend to do action 1 through 3 above.  This will get our information out to many others with your help.

See you for the next post!  Plan on once a week visits to this blog for new information!