Getting Your Ankle Off on the Right Foot Again

Almost everyone has heard of total hip replacement and total knee replacement. But fewer people are familiar with total ankle replacement (also called total ankle arthroplasty).

Although it looks like a simple hinge joint, the ankle actually involves much more complex movement, absorbing forces up to five times body weight. Many conditions, such as severe osteoporosis, rheumatoid arthritis and post-traumatic arthritis, can cause degeneration of the ankle joint, leading to severe pain, swelling and immobility.

Until recently, the only choice to repair a degenerated ankle was to fuse the shin bone (tibia) to the top foot bone (talus), a procedure called ankle arthrodesis. This eliminated pain but left the ankle completely immobile.

When total ankle replacement (or TAR, for short) was first performed in the 1970s, the two-part prosthesis implanted was not very successful. Nowadays, ankle prostheses are made of three pieces of plastic and metal. While not perfect, they relieve pain and allow movement of the joint. These improvements have enabled TAR to become part of the treatment used to correct ankle arthritis.

Ideal candidates for TAR:  

  • are older than 50 years of age
  • have a degenerative ankle that has not responded to nonsurgical treatment
  • are physically active but do participate in activities that put heavy stress on the ankle

 People who undergo TAR need six to 12 weeks of rehabilitation to adjust to their new joint. Physical therapy can improve range of motion and strengthen the ankle while controlling pain. Because the ankle prosthesis does not move in quite the same way as a natural ankle, gait training, initially with an assistive device, is necessary. If you and your doctor decide that TAR is right for you, we will be glad to work with your surgeon to develop a postoperative rehabilitation program that will get you and your new pain-free ankle moving again.

Get Your Golf Game in the Swing

It is a glorious Saturday morning; you have put the stress of work behind you. All week long, you have been looking forward to playing golf. But when one of your foursome suggests walking the course, you suddenly become a little nervous. Yet riding in a golf cart robs you of much of the health benefits of golfing.

Golf can provide a terrific workout. In addition to exercising the muscles used to swing a club, golfers who walk the course frequently cover as much as four miles in 18 holes, a distance that passes quickly as you think about your game and talk with friends. And you gain even more health benefits when you carry your own clubs and burn more calories in the process. If the clubs are too heavy to carry, walk anyway and use a pull cart for your bag.

Technique is very important for more than just your score. Because the golf swing contorts the body, you can injure yourself. Therefore, you must warm up properly. Stretch several times a week to increase your flexibility, making it easier to swing your clubs. Strengthening your core muscles will give you looseness in your backswing and follow-through, and help you hit longer drives.

Stretching and strength training will give you better body control and power, critical elements for a successful golf game. But they must be performed correctly for you to realize their benefits.

Realistically, your golf swing is a reflection of your physical attributes and limitations. We will be happy to work with you and analyze your needs, developing a program that will increase your flexibility and functional strength, give you better balance and the power to hit drives far down the fairway, and help you prevent injuries. Before your next tee time, call our offices or stop in to set up an appointment and see what we can do for you and your golf game.

Relieving Dowager’s Hump Through Exercise

Older individuals with osteoporosis often develop spinal kyphosis, resulting in the formation of a pronounced hunchback, sometimes called a “dowager’s hump” (kyphos means “hump” in Greek). Kyphosis occurs because a spinal vertebra, usually at the level of the rib cage, becomes weak and porous.

Eventually, something as innocent as a sneeze or cough causes the vertebra to collapse, a situation called a compression fracture. Compression fractures are not always painful and often go undetected. When only the front part of a vertebra collapses, the spine tips forward, putting additional strain on the other vertebrae, causing them to collapse too. Soon, a noticeable hump develops.

People with kyphosis often experience muscle pain in the neck, shoulder and back from the misalignment of the spine. They also have an increased risk of falling and, in severe cases, may have difficulty breathing because the lungs cannot fully expand. Our staff will be happy to provide guidance in these areas.

Another way to reduce pain, improve balance and reduce the risk of falls is through an exercise program designed to

  • strengthen the spinal extensor muscles
  • increase flexibility
  • improve spinal proprioception, or the ability to maintain stability and balance

Age is no deterrent to beginning such an exercise program. A study conducted in 2009 by the Department of Physical Therapy and Rehabilitation Science at the University of California, San Francisco, showed that even 80-year-old women with kyphosis maintained gains in spinal strength, flexibility and physical performance one year after completing a 12-week exercise program.

Because people with kyphosis have weak bones and experience compression fractures, engaging in the wrong exercise can cause further damage. Your exercise program should be designed by a physical therapist who understands kyphosis and can determine, in consultation with your doctor, how you can safely exercise. We will be happy to talk with you about beginning a program that will strengthen spinal muscles and increase flexibility to minimize your kyphosis symptoms.

Working Out with Exercise-induced Asthma

Another name for exercise-induced asthma (EIA)–exercise-induced bronchoconstriction–is more descriptive of what your condition actually involves: The passages that carry air into and out of your lungs become constricted when you exercise, resulting in asthma symptoms, such as wheezing, coughing, shortness of breath and chest tightness. These symptoms do not necessarily occur during exercise but usually begin within five to 20 minutes afterwards.

Fortunately, several strategies will permit you to exercise even if you have EIA:

  • Work out in the water (swimming or water aerobics) because humidity in the air you breathe will help prevent symptoms.
  • Avoid cold-weather sports because cold, dry air can trigger asthma attacks.
  • Participate in team games, which require only intermittent stretches of activity, instead of prolonged stretches of individual exercise.
  • Warm up at a moderate intensity before your usual exercise.

If these strategies do not reduce your EIA symptoms, medications may prevent their development. To open your lung passages in advance, your doctor may suggest that you use an inhaled bronchodilator before working out. A puff or two of albuterol (a short-acting beta-agonist) or of salmeterol (a long-acting
beta-agonist) with the corticosteroid fluticasone, for example, helps many people. If that is not sufficient, daily medication to keep your asthma under long-term control may work.

Another possibility is that specific allergens are causing or worsening your EIA. Talk to your doctor about whether this might be the case, and determine if allergy-desensitization injections might help. Given over the course of several years, such shots help your immune system react less violently to allergens.

In consultation with your physician, we will be happy to design workout routines that take both your fitness goals and your EIA into account.

Lifting Weights Following Breast Cancer Surgery

In the past, breast cancer survivors were told not to lift anything even moderately heavy–not a bag of groceries, not a suitcase, not their children. They also were warned against using their arms strenuously–no scrubbing floors or raking leaves.

The thinking behind these prohibitions was that exercising the arms could increase the chance of developing or exacerbating lymphedema, a painful swelling caused by a buildup of lymph fluid. Most likely to occur in women who have had underarm lymph nodes removed or damaged by radiation as part of their cancer treatment, lymphedema can develop at any time–even years–after cancer treatment.

In 2009, Dr. Kathryn Schmitz led a study at the University of Pennsylvania that suggested such prohibitions may have been too restrictive. The authors looked at breast cancer survivors with stable lymphedema. Half the women were enrolled in a controlled weight lifting program that met twice a week for 13 weeks while the other half did not exercise at all. After one year, the women who lifted weights experienced significantly reduced symptoms of lymphedema, compared with those women who did not exercise. The weight lifters also gained upper body strength.

These results do not mean that breast cancer survivors should ignore what their doctors have told them about heavy lifting. The women in the study began by lifting only one to two pounds and added weight only under strict supervision. What the results do suggest is that controlled resistance exercise may help breast cancer survivors with lymphedema relieve the symptoms and prevent the condition from worsening.

However, Dr. Schmitz noted that weight lifting by breast cancer survivors is not a do-it-yourself proposition. It is essential, she said, for women to “work with a well-trained certified fitness professional to begin weight training. Do not try to start this kind of program on your own. Train with a physical therapist or a certified fitness professional who specializes in lymphedema or works with cancer patients.”

Our experienced staff will be happy to work with you and your doctor to develop an exercise program to improve your postcancer lifestyle, resume as much of your routine as possible and avoid the symptoms of lymphedema.

Should You Lose the Shoes?

A 2010 Harvard University study suggested that running barefoot can reduce the risk of running-related injuries. These findings have many people wondering if they should get rid of their classic running shoes. The barefoot runners actually wear a sock-like shoe called “Five Fingers.”

Runners who wear shoes tend to hit the ground on their heels with a more powerful force. Barefoot runners, on the other hand, have a springier step and land toward the middle or front of the foot. With heel injuries common in runners, a transition to barefoot running could benefit some people.

While our feet are designed to absorb the intense impact from running, it does
not mean you should throw out your shoes just yet. The footwear itself is not necessarily the problem; it is the way people change how they run to accommodate their shoes. Newly developed footwear better mimics the way our feet strike the ground when we run barefoot.

If you are used to wearing “fancy” footwear, a better transition might be to wear less constrictive shoes. It is important to recognize that if you are able to run comfortably using your present shoe type, you may be best served by continuing to wear them, rather than attempting to alter what has worked for you.

If you do choose to run barefoot, we can help you make the transition safely and successfully. Barefoot running can require more force from the calf muscles, and the Achilles tendon may be stretched. See us for a program of exercises designed to provide greater strength in these areas.

We will also work with you to reduce running injuries and find the best form and footwear to help you get the most out of your runs. And we can teach you the correct running technique, whether you choose to wear shoes or not.
Lubricating Your Arthritic Knee

A decade ago, individuals who had osteoarthritis of the knee were limited in their options for treatment: anti-inflammatory medications, cortisone injections, reduced activity or surgery. Viscosupplementation, a relatively new treatment involving injections of a lubricating substance called hyaluronan, has become available for patients who suffer from this painful condition or who are unable to tolerate nonsteroidal anti-inflammatory drugs.

In a healthy knee, the bones smoothly glide over each other, thanks to shock-absorbing cartilage and lubricating synovial fluid. Patients who have osteoarthritis often have less synovial fluid than normal. When the cartilage breaks down and the gel-like synovial fluid deteriorates, you end up with the pain and stiffness of osteoarthritis.

In viscosupplementation, an injection of hyaluronic acid (a substance naturally present in that precious synovial fluid) can boost the production of synovial fluid, increase joint mobility, offer pain relief and reduce inflammation. These injections go by several brand names, including Synvisc, Orthovisc, Euflexza and Hyalgan.

While viscosupplementation is not a “cure” for osteoarthritis, some studies have found that these injections can reduce pain and improve function for up to
26 weeks. If you are trying to avoid knee surgery, and other treatments have not alleviated your pain, viscosupplementation might be worth a trial. In fact, a
2008 Canadian study suggested that these injections, together with a strong physical therapy program and additional medications, could treat the pain and stiffness of osteoarthritis just as effectively as knee surgery.

Viscosupplementation can certainly work hand in hand with your physical therapy. The injections may improve function and comfort in your knee, so that we can build strength and flexibility in the affected joint through exercise–which is a tried-and-true (not to mention a safe and natural) way to treat osteoarthritis.

Weight-bearing Following Total Knee Replacement

How much weight will you be allowed to place on your leg after total knee replacement surgery? This is a very important question, the answer to which depends on a number of factors.

Weight-bearing following the surgery may be partial or full, depending on the surgeon’s approach. A critical part of the question is whether the surgeon uses a cemented or uncemented device when performing the procedure.

Years ago, total knee surgery frequently required six to eight weeks of walking with a cane, crutches or walker, but if the cemented approach is used, you can put weight on the leg almost immediately. Typically, you will use an assistive device for a few weeks as needed, often beginning with a walker or two crutches and soon transitioning to a single crutch (under the opposite arm/side) or cane (again, in the opposite hand/side).

Physical rehabilitation will begin in the hospital almost immediately. Since mobility is essential, you may be fitted with a continuous motion machine that will slowly straighten and bend your knee as you lie in bed, allowing you to pedal and pump your ankles to promote blood flow in your legs, and regain range of motion and muscular control of the knee.

When you go home, you will continue the exercise program so you can progress. Most programs include walking short distances several times daily. If your knee becomes sore after your walks, use a cold pack and decrease the distance of your walks but do not stop. Sticking to your exercise regimen is vital to your continued improvement and ultimate recovery.

Our staff has extensive experience in total knee rehabilitation, and we will be happy to talk with your surgeon and you to develop a rehabilitation program that will get you back on your feet. Feel free to call us or visit our offices to see how we can assist you during your rehabilitation.

Bracing Yourself Against Arthritic Knee Pain

Here is the catch-22 of physical therapy: Reducing pain requires physical work, but physical work can cause pain that makes it extremely difficult to do that work. Patients with arthritis of the knee joint often find that using a brace allows them to perform strengthening exercises more easily. But some people wrongly believe that a brace can “cure” arthritis or alleviate the symptoms entirely.

Two kinds of knee braces are used to help patients with arthritis. A “sleeve” brace, made of an elastic, rubbery material called neoprene, is worn snugly over the knee to provide support and compression. Shifting pressure from the inside of the knee to the outside, the custom-fit “unloader” (also called an “off-loader”) brace uses a rigid construction (usually made from foam and plastic) that limits movement and increases stability.

Both types of braces have proved effective in studies to varying degrees. Sleeve braces are cheaper, more comfortable and easier to use. While they can provide relief from symptoms and may even help prevent further injury by properly supporting the affected knee, they do not improve function. In other words, you feel better while you are wearing the sleeve brace, but it ceases to be effective the minute you take it off, hence, the reason we often have you wear the brace during exercise–to enhance the effectiveness of your strengthening.

Unloader braces have fared better in most studies. These braces actually alter the way muscles contract, effectively relieving pain and improving knee function and endurance. They are quite expensive and can be uncomfortable to wear, however, and many patients find them too restrictive for long-term use.

Long story short? Think of knee braces as a tool in your therapy arsenal. The best nonsurgical chance you have to regain healthy knee function is through exercises that strengthen your hips and knees–and the best way to do that is through physical therapy. We can advise you on the best use of a knee brace as part of a total exercise program designed to alleviate your arthritis symptoms.

Physical Therapy: An Alternative to Back Surgery

It may seem counterintuitive for a surgeon to recommend physical therapy instead of back surgery, but lumbar fusion is not appropriate for everyone. Many people suffering from back pain can benefit from physical therapy.

Physical therapy can strengthen the back and move the protruding disk away from the affected nerve. Pain management procedures may relieve pain. With some patience and tolerance, physical therapy may help you avoid lumbar surgery.

One important thing you can do is to avoid slouching or leaning in a single direction, thus placing less strain on the spine. If you sit or bend in one position for too long, remember to twist or bend in the other direction to relieve muscle tension and balance the stress. Add to this some simple stretching exercises you can perform at your desk, such as rolling your shoulder blades 10 times, squeezing your shoulder blades 10 times or slowly turning your head over each shoulder 10 times. These exercises will help keep your tissues comfortable and mobile.

In addition, the following therapies often allow us to enhance the effects of exercise for the patient:


  • electric stimulation
  • massage
  • heat/cold therapy
  • ultrasound
  • diathermy
  • hydrotherapy
  • joint mobilization

Remember: Physical therapy comes with education. Because this information cannot take the place of your surgeon’s advice, always seek a physician’s opinion on important matters such as lumbar health. We can work with your surgeon to design a program that helps you manage back pain and could allow you to avoid surgery.

Concussions Call for Caution

Concussions result from a blow to the head that causes the brain to be shaken inside the skull. Especially among children and young adults who participate in impact sports, such as football or basketball, concussions can be quite common. However, because concussions are often described as “mild,” we may forget that they are significant brain injuries.

Neuroscientists estimate that the brain is not fully mature until a person reaches his or her mid-20s. Therefore, even a mild concussion can result in problems with cognition and day-to-day functioning. And experiencing a second concussion, called second-impact syndrome, before the effects of the first concussion have completely resolved can cause major long-term brain damage–even death.

Symptoms of a concussion include headache, nausea, vomiting and dizziness. Because a person who has sustained a concussion may feel no symptoms when at rest, anyone who has experienced a possible head injury needs to move around a bit. If any symptoms of a concussion ensue, the person should not return to the field of play.

If headache, nausea, vomiting or dizziness lasts longer than 15 minutes or the athlete shows any indication of posttraumatic memory loss, even if there is no loss of consciousness, the athlete should not return to action until he or she has gone at least one week without exhibiting any symptoms at rest or during exertion. If the person loses consciousness for any length of time, no matter how brief, he or she should not return to sports for several weeks or even months, depending on individual response. Symptoms usually go away without treatment.

The best recovery technique involves physical therapy–to teach the brain to compensate for the injured or unhealed areas–and rest. If your young athlete has been diagnosed with a concussion, we can design an exercise program that will enable him or her to return safely to sports activity while lessening the risk of another concussion.

Pin It on Pinterest

Share This