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A Total Hip Replacement  – or THR as we like to call it in this business – is a surgical procedure in which diseased cartilage and bone, located at the head of the femur and acetabular cap, are replaced with artificial materials (a prosthesis).

More often than not, this is an elective procedure. Therefore, many older patients come to me for advice on whether or not to go for a THR. What I always tell them is that as with any surgical procedure there are potential risks, so it should not be entered into lightly and should be seen as a last resort. In my opinion, the biggest factor is how the operation will affect quality of life. If one’s current hip condition is impairing function to a significant extent – such that quality of life is severely diminished – then a THR would be of great benefit.

Who needs a THR?

• Patients with severe Osteoarthritis
• Patients who have tumours  in the hip that have destroyed the hip joint rendering it dysfunctional
• In cases of avascular necrosis (hip joint is destroyed due to lack of blood supply) can develop due to fractures, drug and alcohol abuse and other diseases.
• Patients with intense chronic pain persists despite the use of anti-inflammatories for more than 6 months, adversely affecting sleep, ability to work and movement.

A THR is not recommended for patients with:

• A current hip infection
• Paralysis of quadriceps
• Severe blood disease
• Nerve disease affecting the hip
• Severe mental dysfunction
• Morbid obesity i.e. weighing more than 140kg

If possible, once one has decided to have the operation, it would be of great benefit to  start pre-operative strengthening exercises to assist with rehabilitation post-surgery.

To prevent post operative risks, rehabilitation starts immediately after the operation. This includes circulatory and isometric exercises. On Day 1 post-surgery patients are usually sitting up, out of bed and working on strengthening the quadriceps. By Day 2 patients are walking with an assistive device (normally a walker). Physiotherapy is critical in the coming months to regain strength and functional activity.

For the first 3 months post-surgery it’s prohibited to lie on one’s side or cross one’s legs as the hip could dislocate in these positions. After 6 months normal daily activities should continue comfortably.

Always remember to inform your health care professionals that you have had a THR and avoid strenuous activities, running, contact sports etc as this will decrease the life span of your THR. Swimming is a very good way to strengthen and increase the mobility of your hip without causing too much strain on and friction at the joint.

Andrew Savvides

PhysioPRO

Having had an unusual number of patients at my practice with this condition, I decided to tell you a little more on Plantar Fasciitis…

Plantar Fasciitis (PF) is a painful and often prolonged injury. The source of the pain is a thick “band” under the foot, connecting the heel bone (calcaneus) to the toes, which becomes inflamed. It is usually associated with morning pain (first few steps) felt under the heel. Pain is usually also present following sitting or standing too long, climbing stairs or after exercise.

Some of the risk factors include very high or very flat foot arches, wearing shoes that are not supportive of the arch, sudden increase in weight and unaccustomed exercises. Having tight Achilles tendons and calf muscles have also been shown to increase the risk of this injury, hence ladies that wear high heels a lot are prone to developing it.

So I had to ask my self why the sudden increase in this condition lately? Well it turns out most of my patients started feeling pain from the change of winter to summer. They went from supportive boots or closed shoes to wearing flip-flops with absolutely no arch support, almost overnight. This lead to stretching and irritation of the band, and hence the start of PF.

Treatment modalities that have proven effective are:

• Soft tissue release and stretching of the calf complex (see stretches as per “A real pain in the calves“)
• Stretching the plantar fascia (by rolling a golf ball under the arch)
• Icing under the foot to relieve pain
• Strapping to support the arch
• Using a gel heel cup to alleviate pressure

I have found that dry needling the plantar fascia reduces pain, and I also recommend that most of my patients avoid wearing flat, unsupportive shoes. A good trick to stretch the band and relieve pain at the same time is to freeze a bottle of water and then use this cold, hard bottle by rolling it quite hard underneath the arch.

Im not quite sure why, but doctors still send patients with PF for x-rays to look for something called a “heel spur”? Having this spur is not a diagnostic feature (i.e. you could have the spur and NOT have PF) and surgery to remove this bone formation is rarely necessary.

As mentioned, the condition can sometimes take up to a year to heal, so don’t prolong your pain, come see your physiotherapist.

Ric@PhysioPRO

Recently, I’ve attempted to make a quite subtle return to running and the gym (in a valiant attempt) to get healthy by shedding a few kilo’s. At times I’ve felt strong, right on target, and confident. But, nothing could have prepared me for the pain in my calves caused by muscle fatigue due to weakness and tightness. So I’d like to take the time to discuss basic exercises to strengthen and stretch the calve muscles and solve these problems…

Calf muscle anatomy

Gastrocnemius (Gastrocs): is the muscle which has two heads and is visible from outside as two diamond heads. It has 2 functions: Bending the knee and raising your heel.

Soleus: lies beneath the gastrocs and is not really visible. The soleus raises the heel as in calf raises.

Strengthen your calve muscles…

Progression can be made by starting off using body weight and then adding weight/resistance as strength improves.

1. Seated Calf Raises: Seated calf raises targets the soleus as gastrocs is almost inactive during bent knee exercises.

2. Standing Calf Raises: Standing calf raises emphasizes both calve muscle.

Stretches for tight calve muscles

Stretches should be held for 30 seconds and repeated 6 times

Straight Knee: Straight knee primarily stretches the gastrocs.

Bent Knee: Bent Knee stretches target more of the soleus since the gastroc muscle is contracted.

There could be various causes of calf pain for e.g. muscle stiffness and/or weakness, a muscle strain (tear), lower back injury with nerve involvement, poor posture, blood circulation problems and even serious causes such as cancer. Therefore, it is essential that you be assessed by a physiotherapist or other medical professional if the problem persists and/or gets progressively worse.

Many patients come into my practice with various complaints of knee, hip and sometimes ankle pain. They give me a rather strange look when I ask to test their bum muscle strength (more specifically a muscle called Gluteus Medius).  Invariably, most end up shocked at how weak this muscle is when it only takes one of my fingers to push down their whole leg…

So why is the strength of this muscle SOOO important? Well, of late, researchers have found that this muscle is possibly one of the most important muscles when it comes to pelvic, hip, knee and ankle stability. It controls rotational as well as vertical movement of the pelvis and lower limbs, and as such has a massive influence on how ones leg moves and functions during activities.

For example, a common knee condition known as ITBFS (Ilio Tibial Band Friction Syndrome) was once believed to be the result of the ITB being tight and thus “rubbing” on the femoral condyle, leading to inflammation and pain. We now know that a major cause is in fact due to the femur (upper leg bone) ROTATING inwards and the ITB remaining almost STATIONARY. This means that to fix the cause of the problem, the femoral ROTATION needs to be addressed. This is where the Gluteus Medius (GM) comes in, as it controls rotational stability.

ITBFS is not the only problem that can be attributed to a weak GM. Other common injuries include:

• Trochanteric bursitis
• Medial knee ligament sprain
• ACL (Anterior Cruciate Ligament) Sprains/tears
• Patellofemoral Pain Syndrome
• Achilles tendinopathy
• Lower Back Pain and the list goes on…

Due to its influence on biomechanics, it can also have an effect higher up the Kinetic “chain”, and as such, a shoulder or elbow problem could in fact be stemming from a weak GM!

It’s worth mentioning that this muscle appears to be weaker in female athletes, and accounts for the higher incidence rates of ACL tears in this population. The USA is implementing preventative programs in order to reduce the rate of a possible career ending injury. A complete program can be downloaded from www.smsmf.org/pep-program.

A very basic exercise to start training the GM is called “the clamshell” exercise (see images below). Try to complete three sets of fifteen repetitions. When done correctly, you should feel a deep burn on the side of your bum.

If you are suffering from any of the above mentioned injuries or you would just like to prevent them, come in to your nearest PhysioPRO branch where you will be assessed for GM weakness, and then given the appropriate training program depending on your needs.

Till next time, TIGHT BUMS…quite literally

Ric@PhysioPRO

With summer on our doorstep and days getting longer and warmer many people are taking to the outdoors to find their fitness fix. And, what better way to enjoy this country’s spectacular natural areas and climate than through mountain biking or cycling. Many have set the annual 94.7 Cycle Challenge as their goal, and with the event around the corner beginners and experienced cyclists alike have been taking to streets and off-road trails in preparation.

Aside from knowing where the best spots are to enjoy a post-cycle breakfast, what else do cycling enthusiasts really need to know? Fitness and preparation for any sporting activity include understanding the associated risks – making this an opportune time to delve into common cycling injuries.

There will always be traumatic injuries that result from falls and other unplanned adverse events, the effect of which a physiotherapist will do their best to mitigate, to encourage healing. However what many physiotherapists deal with is the effect on the body of the repetitive motion and rhythm of cycling, which can cause what is called a repetitive strain injury due to incorrect biomechanics.

Common biomechanical faults:

• Forward head posture with craniovertebral extension (causing many cyclists to suffer neck pain)
• Thoracic kyphosis (the spinal curve being exaggerated due to the cycling position)
• Posterior pelvic tilt (the pelvis tilted backwards)
• Hip adduction and internal rotation (the hip turned inwards and across the body also due to the cycling position)

These postural problems can be minimized far in advance of commencing cycling by spending a little extra money on ensuring that a bicycle is set up correctly for an individual’s unique physiology – by a professional.

Something as simple as making sure your saddle is at the correct height and that your cleats are in the right position – and not rotated – can go a long way towards preventing much future discomfort and injury.

That said, the cycling position is not a natural one and following training in this position for extended periods of time many cyclists develop weakness of their hip extensors (which move hips backwards), their abductors (which move hips outward), lateral rotators (which turn the hips out to the side) and over activity of the hip flexors (which move hips forward), the adductors (which move hips inwards) and the medial rotators (which turn hips inward).

It is also very common for cyclists to have very tight calf muscles, which affects range of movement at the ankle making cyclists more prone to injury in that area. Remember to always stretch hip flexors, adductors, medial rotators as well as the calf muscles adequately before and after training.

It’s very important for cyclists to strengthen their hip extensors, abductors and lateral rotators. A very good way to do that is to start cross training i.e. exercising off the bike to target these muscle groups through other forms of exercise. It has also been shown that cyclists have a lower bone density -especially in the lumbar spine and hips – due to excessive calcium loss through sweating and all the hours spent on the bike. As cycling is a non-weight bearing activity it doesn’t promote an increase in bone density, but cross training – particularly doing weight-bearing exercises – will ensure bone density remains optimal.

Regards

Andrew Savvides

PhysioPRO

So in the last two articles, Mitesh discussed the relative advantages and disadvantages of barefoot running. It still comes down to personal preferences and some people are quite rightly saying, “But people have run marathons in running shoes for years and are ok, so why should I change?” Well, although this may be the case DURING their running careers, many of those long distance athletes are only NOW starting to suffer from knee, hip and ankle degenerative changes at a later age. Are their running shoes to blame or the distances they ran? No one can really say for sure, but since the evidence does show that running with shoes does increase the forces generated at the knee and hip during running, we can deduce that this contributes to their injuries.

But how does one start barefoot running? Do you suddenly ditch the expensive running shoes and take to the road?

The answer is NO, unless you want bad blisters and pain…!!

In his book entitled Barefoot running step-by-step, (it’s a worthwhile read if you want to take barefoot running more seriously, as is Born to Run-Christopher McDougall) “Barefoot” Ken Bob suggests the following program in order to ease into running without shoes.

The above is for injured or novice barefoot runners and he also gives a different table for non-injured veteran runners. Also, expect some small blisters and callous formation as this is part of “hardening” the foot.

Some important points to note when getting started:

• SLOWLY! Go slow at first and get used to it. If you do too much to quick you will most likely develop injuries.
• Walk around barefoot at home or in the garden as often as possible.
• Run “quietly”. Imagine you are running through a room of sleeping lions! If your foot hits the ground with a thud, then you are not absorbing shock correctly. To do this:
  • Shorten your stride (take smaller steps) to avoid hitting your heel against the ground. You should rather be landing on the ball or mid-foot section of the foot.
  • Make sure your knee doesn’t straighten out all the way when you swing it forward.
  • Avoid bouncing up and down. Keep a smooth, “light” feeling to the run.

People tend to start barefoot running on soft ground, but this is not ideal, as you are unaware of the impact you are actually placing on the foot. Rather start on a hard surface and you will quickly realise if you are going too fast/hard.

One last thing on minimalistic shoes (like Vibram’s 5 finger), yes they are good for protection and to get used to less cushioning, but they don’t give the same level of feedback as your naked skin which is the important part. If going barefoot is a 10/10, then minimalistic shoes are 3/10 and normal running shoes 1/10. That’s according to the hard-core bare footers!

My suggestion is to “supplement” your regular running with some barefoot/minimalistic running in between. Use it to strengthen the small foot muscles and alter your running biomechanics so that you place less impact on your joints. It’s quite addictive though and actually feels great having the dirt between your toes again…just like when you were a kid.

Ric@PhysioPRO

One of the theories of man being adapted for barefoot running is that evolution once saw us as being persistence hunters. Man has a highly evolved thermoregulation and breathing system, whereas animals must pant to take in air to cool their organ systems. So, we were able to ‘run down’ our prey for several hours, resulting in the animal simply collapsing from sheer exhaustion and overheating (Persistence hunting)…Food for thought…

Although we appear adapted to running bare, there are definitely some Disadvantages of Barefoot (minimalistic) Running. Here we mention these cons…

If you have no problems and no pain, do you really need to change anything? … Why fix what isn’t broken?…
Glass, nails, rocks, thorns and other bits and pieces can injure our feet. Shoes save our feet and also offers protection from blistering (on hot surfaces) and frostbite (on cold surfaces).

Switching to a minimal shoe or starting to go shoeless will usually result in blisters for the first few weeks until calluses are formed.

For most of us modern athletes, going minimalist will be a shock to our feet and our running system of muscles and joints will be overwhelmed. This could lead to injuries such as Achilles tendinitis, calf strain or medial knee pain when the typical heel lift is removed from the shoes.

The sole of the foot (plantar surface) is usually soft and tender. Going without a generously soled shoe may initially cause plantar pain, and raise the risk of plantar fasciitis (inflammation within the sole of the foot).

And…let’s face it: It looks a little strange, so people will notice, and they may stare 🙂

In this next series of articles, The PhysioPRO team will discuss the latest craze of BAREFOOT RUNNING. We’ll tell you why its becoming so big, what the research says and also how to get started if you choose to do so…

To kick things off, Mitesh tells us if barefoot running is really good for you, or just another “power-balance” moment.

Remember the good old days when we were younger, laughed all the time…and ran barefoot in the garden…on the beach…even in the veld (…if you were lucky enough)…

Barefoot running as the name states is simply running without wearing any shoes on the feet. Running in thin-soled, flexible shoes, often called minimalist running, is biomechanically related to running barefoot. Barefoot running presently the source of much speculation and debate…begging the question, “is barefoot running good or bad for you?”

Scientists have found that those who run barefoot, or in minimal footwear, tend to avoid “heel-striking,” and instead land on the ball of the foot or the middle of the foot. In so doing, these forefoot runners use the architecture of the foot and leg to avoid hurtful and potentially damaging impacts, equivalent to two to three times body weight, that affect heel-strikers repeatedly.

According to a published article, in Nature magazine, “Humans have engaged in endurance running for millions of years, but the modern running shoe was not invented until the 1970s. For most of human evolutionary history, runners were either barefoot or wore minimal footwear such as sandals or moccasins with smaller heels and little cushioning.”

Although barefoot running or wearing minimal footwear may not be the fix for all injuries, there are some compelling claims for hitting the dirt running … literally 🙂

Development of a more natural running pattern (gait) and strengthen the deep muscles, tendons and ligaments of the foot.

Removing the heel lift of most shoes may help reduce injuries, such as calf strain or Achilles tendinosis, by stretching the leg muscles.

Runners will naturally land on their forefoot rather then the heel. The heel strike during running only came about because of the excessive padding of running shoes, but research shows this isn’t the most effective natural running stride. The most efficient runners land on the forefoot and keep their strides smooth, short, light and flowing. Landing on the forefoot also allows your arches to act as natural shock absorbers.

You may improve balance and proprioception. Without shoes, you activate the smaller muscles in your feet, ankles, legs, and hips that are responsible for better balance and coordination.

Research with regard to barefoot running points to either advantages or disadvantages. Some runners swear by barefoot running and others run injury free wearing running shoes. It may be impossible to come to a conclusion as to which is best.

All runners are different and what works for one, may not work for another.

Mitesh@PhysioPRO

With the winter gloom falling behind us, there’s nothing more inviting than the warm kiss of a summer morning to lure us into slapping on those tekkies and hitting the open road… Just a word of caution to the over-eager, de-conditioned victims of winter…Beware of shin splints!!

Shin splints describe a sharp, burning pain that occurs on the lower leg along the shin bone (tibia). It may occur on the outer front portion of the lower leg (anterior shin splints) or, on the back, inside area of the lower leg (posterior medial shin splints). Shin splints normally occur after repetitive stress causes micro trauma to the front leg muscle (tibialis anterior) or deep calf muscle (soleus) at the point of attachment to the shinbone, or irritation of the posterior tibialis muscle and inflammation of the bone lining (periosteum). Shin splints presents as a pain that increases with activity (running or weight-bearing exercises), and the pain usually decreases, but may linger after activity.

What are the Causes?

Training too hard, too fast, too soon. Sudden increases in intensity, or duration, or distance of running, often along with a lack of appropriate recovery between workouts.

Inadequate warm-up and stretching before training.

Muscle imbalances between back and front of the leg.  Other contributing factors include: Footwear which provide inadequate support, running on hard, cambered surfaces, biomechanical issues elsewhere on the body for eg. the lower back or buttocks.

Physiotherapy intervention

For immediate relief the ‘P.R.I.C.E.’ treatment method for controlling pain and inflammation will be utilised.

Other methods of reducing muscle tension and pain will include: Dry needling, Myofascial release, muscle energy techniques and electrotherapy modalities.

Various taping, bracing or strapping techniques can be applied to offload certain leg muscles and reduce stress on the bone lining.

Biomechanical assessment and correction.

Gradual exercise progression, in order to avoid re-injury, from non-weight bearing activities (cycling, swimming) to a pain-free, full return to activity (sport).

Training routine time and intensity re-assessment and amendment, so that there is no pain and discomfort before, during or after exercise and sport.

Referral to an Orthopaedic Surgeon and/or, Sports Physician if shin pain persists.

I hope this helps give a brief understanding of this painfull condition. Till next time…

Mitesh@PhysioPRO