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In Motion August 2011

A Pain in the Hip: Is Arthroscopy the Solution?

By James Rosneck, MD

Hip pain isn’t only limited to runners and golfers. In fact, it is estimated that 15 percent of adults in the United States suffer from hip pain. Thanks to improvements in technology and knowledge, doctors are more likely to find the cause of your pain, as well as treat it successfully.

Active people are more likely to have non-arthritic hip pain. Symptoms usually develop slowly over time, but sometimes are the result of an injury. Hip pain frequently causes patients to be unable to complete their daily activities. Those with hip pain often complain of deep pain that is worse when pivoting back and forth, running, playing sports, and sitting for long periods of time.

If you are experiencing hip pain, you should see your doctor, who will take a thorough history and give a physical exam. Then, he or she might order an MRI. Before considering surgery such as hip arthroscopy, your doctor will most likely suggest other treatments first. These include anti-inflammatory medication, physical therapy, and a change in your activity patterns.

Your doctor may recommend hip arthroscopy if you have:

  • A labral tear: a tear in the cartilage that surrounds the ball and socket hip joint
  • Femoro-acetabular impingement: when the hip bone grows abnormally around the socket, causing damage
  • Loose bodies: pieces of bone or cartilage moving around the joint
  • Snapping hip syndrome: when a tendon painfully rubs against the hip joint

Hip arthroscopy is a procedure that gives doctors a clear view of the joint so they can treat problems more easily. A small camera is inserted into the hip joint and then your surgeon uses miniature surgical tools to fix whatever is causing the pain.

Patients typically do not stay overnight in the hospital; the surgery itself only takes between one and three hours. Post-operative recovery usually involves physical therapy and can take anywhere from three to six months. Short term effects of the surgery show that patients have experienced full recovery and large decreases in pain.

Dr. Rosneck is an orthopaedic surgeon, specializing in hips, knees and shoulders. He sees patients at the Sports Health Center, Beachwood Family Health and Surgery Center and Solon Family Health Center.

Do Your Feet a Favor

Learn the do’s and don'ts of shopping for shoes

By Sara Creasy, DPM

When it comes to shoes, women tend to shop till they drop for that perfect pump while most men would rather wear the same classic pair forever. But in this battle of the sexes, neither group has it quite right. Sara Creasy, DPM, a Cleveland Clinic podiatric surgeon, shares tips for choosing shoes that are good for your feet and your overall wellness.

DO try running shoes.

“Most companies put a lot of their technology into the running shoe,” Dr. Creasy says. Better technology means better support for your feet. Running shoes also have more styles designed specifically for people with high arches or flat feet, she says.

DON’T stick with soft soles and sandals.

Flat or soft-soled shoes can cause heel pain and plantar fasciitis (pain in the bottom of your feet), while shoes that expose your skin can lead to calluses, dry skin and fissuring, or cracking. Instead, look for shoes that cover your feet and have firm soles.

DO pick shoes shaped like your feet.

The shoebox (the front of the shoe that surrounds your toes) should be rounded or oval to mirror the shape of the feet, Dr. Creasy says. If the shoebox is too narrow, it can aggravate bunions and cause corns or a neuroma (pinched nerve). There should be a fingertip of length between your longest toe and the tip of the shoe, she suggests.

DON’T wear too-high heels.

High heels put pressure on the metatarsal bones in the balls of the feet as well as the lumbar and spinal regions of the back, Dr. Creasy says. Over time, they also can shorten the muscles and tendons in the back of the legs. How high is too high? Dr. Creasy suggests looking for heels less than 2 inches. Or if you do wear ultra high heels, avoid wearing them on consecutive days or for longer than four hours at a time.

DO protect your feet as they age.

The qualities of a good shoe become even more important as you age, Dr. Creasy says. “You’re more likely to have a foot problem as you put more miles and time on your feet,” she explains. As feet age, they also lose some of the fat pad that provides natural cushioning, so Dr. Creasy suggests older individuals wear shoes or slippers around the house.

DON’T wear the same shoes forever.

How often people should replace their shoes depends on how much they stand and walk in them. You need to replace your primary walking shoes at least once a year, Dr. Creasy says, but some athletic shoes may need to be replaced every three to six months.

DO try on new shoes.

To find shoes that truly fit, it helps to try them on because shoe sizes aren’t universal across different brands. For better results, try them on at the end of the day — feet swell after daily use. Dr. Creasy recommends finding a store with clerks who are certified to help you find shoes that fit properly.

DON’T settle for sore feet.

If your feet hurt when you get home from work, don’t immediately chalk it up to a long day. If you regularly experience foot pain, call your doctor. “Foot pain isn’t normal,” she says. Some patients fear complicated surgeries, but Dr. Creasy says that treatment can be simple. “We often suggest surgery on your shoes before your feet.”

Dr. Creasy is a podiatrist, specializing in all podiatry services, foot and ankle injuries, forefoot surgery and diabetic foot care. She sees patients at Medina South Medical Office Building, Cleveland Clinic's main campus and Cleveland Clinic Middleburg Heights.

The Rise of Partial Knee Replacement

By Bernard Stulberg, MD

In the past, severely arthritic knees would most often be completely replaced surgically. During the late 1990s, new techniques for knee replacement, or arthroplasty, were developed. This led to an increase in partial knee arthroplasty (also called unicompartmental arthroplasty, or UKA). With this new technology, surgeons are taking an approach to not fix what isn’t broken.

In UKA, only the damaged cartilage is replaced. The knee is divided into three “compartments”: medial (inside), lateral (outside) and patellofemoral (between the knee and the thighbone). If the medial or lateral compartment is the only one that needs to be replaced, then the patient could be a good candidate for UKA.

Why would a patient prefer UKA over total knee arthroplasty, or TKA?

  • Shorter recovery period: The operation itself takes less time than a TKA and an overnight hospital stay is rarely required. Most patients can return to normal activity in less than three weeks.
  • Smaller incision: Because UKA implants are smaller than TKA implants, the surgery site will be much smaller (3-4 inches in UKA compared to 8-10 inches in TKA).
  • Feels more like a “real knee”: Less bone is removed during a UKA, leaving more of a patient’s natural knee intact.
  • Future options: Since more of the natural knee is left untouched and not replaced by metal, UKA leaves opportunities open for more advanced procedures in the years to come.

Because of the advancements in UKA technology, patients who were previously thought to be candidates for TKA only are now being considered for UKA. There are many different styles of UKA, but they come under two major types:

  • Mobile bearing UKA: which can only be used for medial (inner side) osteoarthritis of the knee
  • Fixed bearing UKA: used for both medial and lateral (outer side) osteoarthritis of the knee

Both types have metal trays fixed to the tibia bone. In the mobile bearing type, the polyethylene component is mobile, while in the fixed bearing component, the polyethylene is locked into the base plate. Each has features that may be of advantage for a particular patient. Patients report similar range of motion for each. Your surgeon will decide which is best for you.

UKA is not for everyone. Patients with a deformity or inflammatory arthritis may not be good candidates for UKA. If you are considering a knee replacement, it is important to talk to your physician to decide which one is best for you.

Dr. Stulberg is an orthopaedic surgeon, specializing in joint replacement. He sees patients at Lutheran Hospital, Hillcrest Hospital and Cleveland Clinic's main campus.

Staying Active with Osteoarthritis (OA)

By Bijal Jayakar, MD

What is Osteoarthritis?

Osteoarthritis (OA) is the most common type of arthritis. It affects individuals 25 years and older. It mostly affects cartilage, which is the hard but slippery tissue that covers the ends of bones where they meet to form a joint. Healthy cartilage allows bones to glide over one another. In OA, the surface layer of cartilage breaks and wears away. It causes the bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Overtime, the bone may lose its normal shape.

Which joints are commonly involved in OA?

Commonly, the upper and lower spine are involved as well as the knees, hips and hands, mainly the hand joints furthest away from the wrist, just below nails.

What are the most common risk factors for OA?

Do you know the most common modifiable risk factor for OA is obesity? Other modifiable risk factors include joint injury or being associated with certain occupations that require repetitive bending and heavy lifting. Women are at higher risk for OA and the risk increases with age.

What are the symptoms?

Patients gradually experience pain and stiffness in their joints.. In hand OA, bony nodes develop on the hands. For patients with knee osteoarthritis, it becomes difficult to walk, climb up and down the stairs or get in and out of chairs.

How is OA diagnosed and managed?

OA is diagnosed with a thorough medical history and physical examination by the physician. X-ray studies may be needed and blood tests are done to rule out other conditions, such as rheumatoid arthritis (RA), in which the rheumatoid factor test is usually positive.

Treatment for OA utilizes a multi-disciplinary approach, involving your primary care physician, rheumatologist, orthopedist, physical therapist and occupational therapist.

The main goals of treatment are to control pain and improve function. Did you know that among older adults with knee OA, moderate physical activity at least three times per week can reduce the risk of arthritis-related disability by 47 percent? Strengthening exercises and aerobics are a central part of treatment. They can be performed with weights or with exercise bands, inexpensive devices that add resistance. Activities to improve range of motion and balance are important. I usually recommend brisk walking and low impact aerobics.

Weight loss is key to improvement. For every pound of body weight you gain, your knees gain three pounds of added stress. For hips, each pound translates into six times the pressure on the joints. After many years of carrying extra pounds, the cartilage that cushions the joints tends to break down more quickly than usual. Easing the pressure on joints by shedding extra pounds can reduce pain in OA-affected joints. This will help you feel and move much better.

Medical treatment includes use of acetaminophen (Tylenol®), non steroidal anti-inflammatory drugs and other pain relieving medications. Discuss with your doctor corticosteroid injections and relatively newer treatments called viscosupplements, like Hyaluronic acid substitutes. Finally, surgical options should be discussed with your orthopedic surgeon.

How Can I Stay Active with OA?

The muscles around a joint are like shock absorbers in a car. The stronger they are, the more they help to protect the joint against everyday forces of walking and other activities.

The basic components of an exercise prescription are activities that improve flexibility, muscle strength and endurance. Some flexibility exercises include an inner leg stretch and hip and lower back stretches.

Some resistance exercises, such as the chair stand and the hip extension are helpful:

Chair stand: Sit at the front of the chair, knees bent, feet flat on the floor. Lean back in a half-reclining position with your arms crossed and your hands on your shoulders. Keeping your head, neck and back straight, bring your upper body forward, and then stand up slowly. Sit back down slowly and return to your original position. Repeat four to six times; build up gradually to eight to 12 repetitions.

Hip Extension: Holding onto the back of a chair for balance, bend your trunk forward and slowly raise your right leg straight behind you. Lift it as high as you can without bending your knee or pitching forward. Pause. Slowly lower the leg, returning to the starting position. Do four to six repetitions. Repeat with the left leg.

What Are the Best Exercises for those with OA?

Do exercises that offer low stress to the joints, such as walking, stairmaster and elliptical. These type of exercises do not heavily stress the joints and help burn calories.

Do not let a rainy day bring your energy down. If the weather is not good outside, try doing squats at home or lightweight exercises. Working out to exercise videos is a great option.

When it comes to exercise, your emotional well-being is as important as your physical conditioning. Change your mind set. Being positive can help you live a more active lifestyle. Some important tips: Be flexible in your schedule, think about the benefits of the exercise and try and relax. This is your time, enjoy it. This may be the first time in your day that you are doing something for yourself. You deserve this time!

Keep an exercise journal. It provides accountability and encouragement. You can get more motivation when you see positive trends in your exercise journal.

Get to know your body and learn when to stop. Do not over exert a body part that is hurting. Overuse can cause joint damage. Switch to an exercise that puts less weight on that joint. Swimming, water aerobics and using a stationary bike are good alternatives.

Exercise will also help weight loss, which will help with osteoarthritis too. Walking for 30 minutes will burn about 200 calories, equivalent to one glazed doughnut. Thus being consistent and gradually increasing the time and intensity of your exercise will help lose weight.

Weight bearing exercises, not only will help build muscles and tendons needed to support the joints, but also build strong bones. These include jogging, hiking, tai chi, yoga and some resistance training exercises. Against old beliefs that running is not good for the joints or causes osteoarthritis, this has not been consistently proved in studies. However, once you have osteoarthritis, usually low impact exercises are recommended.

Exercising with a group is always a constant motivation. This makes it fun and exciting and not routine and boring!

It is important you select an exercise program that is enjoyable, easily done and possible to accomplish. Set a goal to exercise at least three to four days a week.

Dr. Jayakar is a general rheumatologist, specializing in rheumatoid and osteoarthritis, psoriatic arthritis and lupus. She sees patients at South Pointe Hospital and Chagrin Falls Family Health Center.

Technological Strides in Upper Extremity Joint Replacements

By William Seitz, MD

Arthritis of the shoulder, elbow and wrist often results in pain, weakness and substantial loss of mobility and function. Patients who experience arthritis of the upper extremities often have trouble with daily tasks such as eating, dressing and grooming. In the past, surgeons had limited ways to improve these patients’ frustrations, often left only with the option of fusion of the joint area, which reduces pain but completely impairs movement. With more technology, new techniques for both biological and artificial joint replacement are available.

Shoulder: Instead of trying to fit a patient into a pre-existing implant, shoulder replacements are now more adaptive. Made up of several smaller pieces, modular implants are inserted with minimally invasive surgery on both sides of the joint in order to exactly replicate the patient’s anatomy. For those who want to conserve more of their own natural bone, such as younger patients or those with the end stage arthritis or massive rotator cuff disease, conservative technology has been developed in the form of joint resurfacing, which removes less bone.

Elbow: Arthritis patients usually find the inability to bring their hand up to their mouth debilitating. With new technology, doctors can reduce arthritic pain by using a semi-constrained elbow joint replacement, which aims to preserve more of the patient’s own joint. When trauma and/or arthritis has led to partial wear-down of the elbow joint, customized replacements have been extremely successful in returning stability and forearm rotation while reducing pain.

Wrist: When it comes to arthritis and instability in the wrist, doctors have developed a customized prosthesis to restore a normal range of motion. Technology now permits doctors to resurface the entire wrist, allowing patients to return to near-normal motion while relieving pain.

Cleveland Clinic's Department of Orthopaedic Surgery provides comprehensive, quality care to people of all ages for a wide range of orthopaedic diseases and musculoskeletal impairments. Our goal is to help people overcome their impairments and return to more pain-free, functional lives. To schedule an appointment with one of our orthopaedic physicians, call toll-free 866.275.7496.

Dr. Seitz, is an orthopaedic surgeon specializing in hand and upper extremities. He sees patients at Lutheran Hospital and Beachwood Family Health Center.

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