UNDERSTANDING HEALTH INSURANCE TERMS

Navigating your way through health insurance benefits can be a challenge. It is very important to understand the terminology especially when deciding which benefits will work for you and finding a plan that will best meet your needs. This brief glossary will provide insight for some of the more common terms when dealing with health insurance.

co-insurance: in indemnity, the monetary amount to be paid by the patient, usually expressed as a percentage of charges.

co-payment: in managed care, the monetary amount to be paid by the patient, usually expressed in terms of dollars.

consumer driven health care (CDHC): refers to health plans in which employees have personal health accounts such as an health savings account, medical savings accounts or flexible spending arrangement from which they pay medical expenses directly.

deductible: the portion of medical costs to be paid by the patient before insurance benefits begin, usually expressed in dollars.

denial: refusal by insurer to reimburse services that have been rendered; can be for various reasons.

eligibility: the process of determining whether a patient qualifies for benefits, based on factors such as enrollment date, pre-existing conditions, valid referrals, etc.

exclusions: services that are not covered by a plan.

flexible spending arrangements (FSAs): an account that allows employees to use pre-tax dollars to pay for qualified medical expenses during the year. FSAs are usually funded through voluntary salary reduction agreements with an employer.

gatekeeper: in managed care, it refers to the provider designated as one who directs an individual patient's care. In practical terms, it is the one who refers patients to specialists and/or sub-specialists for care.

health maintenance organization (HMO): a form of managed care in which you receive your care from participating providers.

health savings account (HSA): a savings product that serves as an alternative to traditional health insurance. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.

managed care: a method of providing health care, in which the insurer and/or employer (policyholder) maintain some level of control over costs and utilization by various means. Typically refers to HMOs and PPOs.

member: a term used to describe a person who is enrolled in an insurance plan; the term is used most frequently in managed care.

non-participating provider: any health care provider or organization that does not have a contractual agreement with an insurance company to provide care to eligible patients for a contracted or discounted fee. Patients can receive services from non-participating providers if they have out-of-network benefits as a part of their insurance plan or if they wish to pay cash for the service but they will miss out on in-network discounts. (Same as "out of network provider")

open enrollment: a set time of year when you can enroll in health insurance or change from one plan to another without benefit of a qualifying event.

out-of-pocket: money the patient's pays toward the cost of health care services.

participating provider: a health care professional or organization that has a contractual agreement with an insurance company to provide care to eligible patients under certain defined conditions and often at discounted and/or contracted fees. (Same as "in network provider")

payer: the party who actually makes payment for services under the insurance coverage policy. In the majority of cases, the payer is the same as the insurer. But, as in the case of very large self-insured employers, the payer is a separate entity under contract to handle the administration of the insurance policy.

policyholder: purchaser of an insurance policy; in group health insurance, this is usually the employer who purchases policy coverage for its employees.

preferred provider organization (PPO): a form of managed care in which the member has more flexibility in choosing physicians and other providers. The member can see both participating and non-participating providers. There is a greater out-of-pocket expense if member sees non-participating providers.

premium: the cost of an insurance plan shared by employer and employee.

provider: one who delivers health care services within the scope of a professional license.

reimbursement: refers to the payment by the patient (first-party) or insurer (third-party), to the health care provider, for services rendered.

POSSIBLE CAUSES OF THAT PAIN IN YOUR BUM

Sciatica is one of the most common diagnoses that we see in physical therapy. But what exactly is sciatica and how do physical therapists treat this complex diagnosis? The simple answer is the treatment is all dictated by the source.

Generally, Sciatica is a term that is commonly used to describe pain, weakness, numbness, or tingling that radiates down the back of the leg. Typically, the symptoms follow the distribution of the sciatic nerve, but there can be some confusion as to the source of the pain especially when the patient’s symptoms are referred. Our job as PTs is to determine the source of the nerve irritation or referral origin and treat it accordingly. This is often accomplished with a thorough musculoskeletal exam and typically without the need for costly medical imaging. Alongside misalignment caused as a result from weak musculature of the hip, below are the most common causes of sciatica seen in PT and how we typically treat them.

1. Disc Herniation:

The most common source of sciatica is pressure on the sciatic nerve from a herniation or protrusion of a spinal disc. This pressure on the nerve can create an irritation and inflammatory response causing symptoms to radiate down the leg following the path of the nerve that is compressed.

What can physical therapy do to help patients with sciatica caused by a disc herniation?

  • Studies have shown that patients respond well to repetitive lumbar range of motion in improving sciatica symptoms related to lumbar disc herniation. Typically the direction that most patients report relief of their symptoms is lumbar extension. However, a thorough physical therapy assessment will help decide a patient’s specific “directional preference”.
  • Core stabilization exercises in conjunction with lumbar range of motion are also effective at reducing sciatica symptoms. PTs tend to focus on strengthening the transversus abdominis and gluteal muscles in both static and dynamic activities.
  • Patient education is probably the most important component of the rehab of disc herniation. Patients are educated on proper sitting and standing postures as well as proper body mechanics with lifting activities to avoid causing further disc herniation.

2. Stenosis:

Narrowing of the space where the spinal cord or nerve roots exit the spinal canal is called stenosis. If the space is narrowed, that can create pressure on the cord or the nerves causing pain to radiate down the leg.

Stenosis is typically seen in a condition called degenerative disc disease. Our discs are located between the bony vertebrates and over time they can start to lose some of their height. This loss of height causes the narrowing of space seen in stenosis.

Another cause of stenosis is tiny little bone spurs called osteophytes that can form in the spinal cord or nerve root space.

What can physical therapy do to help patients with sciatica caused by stenosis?

  • Our goal in PT is typically to help improve ROM in the lumbar spine to help open up the narrowed space. Patients with stenosis often respond well to lumbar flexion or bending exercises, which is in contrast to the lumbar extension exercises often seen in disc herniation. However, a thorough physical therapy exam will help determine the appropriate stretches/range of motion exercises.
  • As with disc herniation, core stabilization and posture/movement retraining are important for patients with sciatica caused by stenosis.
  • Functional dry needling (i.e. Trigger point dry needling) is also very effective for patients with lumbar stenosis. By using tiny, hair thin needles, we can quickly decrease the muscle tightness of spinal muscles, resulting in decreased compression of the lumbar vertebrae. We will discuss dry needling more in the last section.

3. Piriformis Syndrome:

Deep in your buttock/gluts is a muscle that runs diagonally from the outside of your hip to the lowest part of your spine. This muscle, called the piriformis, can get short and tight or even be in spasm. In 85% of the population, the sciatic nerve runs just beneath the piriformis and in the other 15% it runs through the muscle. The sciatic nerve can become compressed and irritated when the piriformis is taught or in spasm creating symptoms of sciatica down the back of the leg.

What can physical therapy do to help patients with sciatica caused by piriformis syndrome?

  • Typically, a physical therapist will prescribe a thorough home exercise program that includes stretches for the piriformis, hamstrings, and glute muscles (see linked video for example of a piriformis stretch).
  • Sciatic nerve glides/flossing can be effective at getting the sciatic nerve moving again if it is trapped by the piriformis, especially in conjunction with the stretches above (see linked video for example of a sciatic nerve glide).
  • A common theme with all of the causes of sciatica is core stabilization. Core and glute strengthening exercises will help to reduce the demands put on the piriformis muscle with daily and recreational activities (see linked video for an example of a core exercise).
  • Trigger point dry needling has also been found to be very effective at quickly reducing the tension of the piriformis.

UNDERSTANDING BALANCE

Balance is a complex process involving the reception and integration of sensory input and the planning and execution of movement. It’s the ability to control the center of gravity over the base of support in any given sensory environment. Reflexes are automatic responses by the peripheral or central nervous system to help support postural orientation and maintain balance; they occur rapidly enough to not be under volitional control.

Balance is a result of the interaction of three separate systems in the body:

  • The Visual System, which helps us see things in the environment and orient us to the hazards and opportunities presented.
  • The Vestibular System (the inner ear), which provides the brain with information about the position and motion of the head in relation to gravity.
  • The Proprioceptors/ Somatosensory Receptors which are located in joints, ligaments, muscles, and the skin to provide information about joint angle, muscle length, and muscle tension all of which is gives information about the position of the limb in space.

The brain needs input from all three systems to distinguish motion of the self from motion of the environment. Any mismatch in these inputs can produce nausea, vomiting and dizziness. Some common examples that we all experience are

  • The sense of perceived motion when sitting in a car at a stop light and the car next to you creeps forward, causing you to slam on your brakes
  • When on a boat, proprioceptors perceive a rocking boat under your feet, but your eyes see a steady horizon.

More long-term complications with balance can make an affected person feel persistently unsteady or dizzy. In fact, as many as four out of ten Americans will at some point experience an episode of dizziness significant enough to send them to a doctor. These issues can be caused by improper function of the systems mentioned above, health conditions, or as a side effect from some medications. In severe forms, a balance disorder can intensely impact day-to-day activities resulting in an inability to function and cause psychological distress.

BRACHIAL PLEXUS PALSY

A brachial plexus palsy happens when the nerves of the brachial plexus have been damaged during birth. The brachial plexus is a set of nerves that control the muscles of the arm. Palsy means not being able to move muscles in an area (paralysis).

Nerves are soft, tube-like structures inside the body. They contain many small fibers (filaments), like a telephone cable or a thick electrical cord. These small fibers carry signals from the brain to control the muscles. Nerves also carry signals from the skin to the brain. This is how we feel things on our skin.

The nerves of the brachial plexus go out from the spinal cord under the collarbone and into the armpit. From there, they branch out into individual nerves that control the muscles in the shoulder, elbow, wrist and hand.

When nerves in the brachial plexus get damaged, signals cannot travel like usual from the brain to the arm muscles. So some or all of your child’s arm muscles may no longer work. When this affects only the shoulder and elbow muscles, it is called an Erb’s palsy. When it affects all of the muscles of the arm, hand and wrist, this is known as a total plexus palsy.

Brachial Plexus Palsy in Children

Brachial plexus palsies usually happen because of a stretch injury to your child’s head, neck and shoulder. This can happen during birth, especially when the birth is difficult or complex. Sometimes a child’s shoulder will get stuck against the mother’s pelvis. This can result in a stretch injury as your child is being delivered.

The brachial plexus may be injured if a baby's shoulder gets stuck on the mother's pelvis during birth.

In older children, a brachial plexus palsy can occur because of an injury where the neck and shoulder get stretched.

Many children with a brachial plexus palsy recover on their own. But if the condition does not completely resolve within 1 month, it usually has lasting effects. That’s why we encourage you to have your child assessed 1 month after their birth or injury if they have not fully recovered. If treatment is needed, it’s important to begin early and to have ongoing therapy.

Physical and occupational therapy can reduce problems with stiffness or other bone problems that can happen as a result of the injury. Some children need to wear splints to help position their joints while the nerves are recovering. Some need surgery to repair their nerves.

GAIT DYSFUNCTIONS

Gait dysfunctions are changes in your normal walking pattern, often related to a disease or abnormality in different areas of the body. Gait dysfunctions are among the most common causes of falls in older adults, accounting for approximately 17% of falls. This guide will help you better understand how gait dysfunctions are categorized, and how treatment by a physical therapist can help you regain a healthy gait. Physical therapists are experts at identifying the root causes of gait dysfunctions, and designing treatments that restore gait.

What are Gait Dysfunctions?

Gait dysfunctions make the pattern of how you walk (ie, your gait) appear “abnormal." Most changes in gait are related to underlying medical conditions. Gait dysfunctions can be related to disorders involving the inner ear; nervous system disorders such as Parkinson's disease; muscle diseases such as muscular dystrophy; and musculoskeletal abnormalities such as fractures. In many cases, treatment of the underlying medical condition will help normalize the gait pattern.

Common classifications of gait dysfunction include:

  • Antalgic. This type of gait dysfunction is often caused by bearing weight on a painful leg. It can be related to arthritis or a traumatic injury, and is what many people refer to as a "limp." People with this dysfunction take slow and short steps, and quickly try to shift their weight off of the sore leg, ankle, or foot, and back onto the unaffected leg.
  • Cerebellar Ataxia. This gait dysfunction is often seen in individuals who have a condition of the cerebellum (a region of the brain), drug or alcohol intoxication, multiple sclerosis, or have experienced a stroke. The affected individual will have a wide-based stance (feet wide apart), and display inconsistent and erratic foot placement.
  • Parkinsonian. This type of gait dysfunction is often related to Parkinson’s disease and is characterized by short, shuffled steps.
  • Steppage. This dysfunction occurs in people with "foot drop" (an inability to lift the ankle), which is related to conditions, such as lumbar radiculopathy and neuropathy. Because the ankle will "slap" off of the ground, the individual will often lift the leg higher at the knee and hip, to clear the foot when taking a step./li>
  • Vestibular Ataxia. This pattern is often related to vertigo, Meniere’s disease (an inner-ear condition), and labyrinthitis (a type of inner-ear disorder in 1 ear). It causes people to walk unsteadily, often falling toward 1 side. 
  • Waddling. This pattern often arises from muscular dystrophy and myopathy, and causes individuals to walk on their toes, while swaying side-to-side.

Note: These are only a few of the many possible gait dysfunctions. If you suspect you are walking differently, call your physical therapist for a gait assessment.

How Is It Diagnosed?

There are many different strategies and tools that can help a physical therapist diagnose a gait dysfunction. While other health care professionals are educated in the screening for potential conditions related to the gait abnormality, a physical therapist is the expert in diagnosing the actual type of gait dysfunction. Your physical therapist will ask you questions, such as:

  • When did you notice you were walking differently?
  • Is the problem getting better or worse?
  • Has it resulted in a fall or any additional problems?
  • Are you in pain while you walk?
  • Have there been any recent changes in your medical history, including changes in medications?

Your physical therapist will also conduct certain tests to learn more about your condition. Your assessment may include:

  • Observation. Your physical therapist will ask you to walk back and forth, to observe any abnormalities in your gait pattern. 
  • Gait speed measurements. Your physical therapist will time your walking speed. Studies have shown that complications like falling are related to how fast you walk.
  • Balance tests. Your physical therapist may also assess your balance to determine your risk of falling.
  • Strength and range-of-motion measurements. These tests can help determine whether the dysfunction is due to musculoskeletal limitations. A physical therapist may utilize tools, such as a goniometer to measure your joint motion, or dynamometer to measure your strength. 
  • Reflex and sensation screenings. These measurements will help your physical therapist determine whether a neurological (brain or nervous system) condition is present.

How Can a Physical Therapist Help?

Physical therapists play a vital role in helping individuals improve their gait. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals. Your physical therapist will design an individualized program to treat your specific condition.

The treatment strategy may include:

Pre-Gait Training. Your physical therapist may begin your treatment by having you perform activities and exercises that will help you understand how to improve your gait, without taking a single step. These exercises may include simple activities, such as having you stand and lift your leg in place, to more complex strategies like stepping in place and initiating contact with your heel to the ground, prior to other portions of the foot. 

Gait Training. Your physical therapist will help you focus on retraining the way you walk. Because the underlying condition may be vestibular, neurological, or muscular, variations in the training exist. Your physical therapist will design the safest and best training for your specific condition.

Balance and Coordination Training. Your physical therapist may prescribe balance activities for you to perform to help stabilize your walking pattern.

Neuromuscular Reeducation. Your physical therapist may employ neuromuscular reeducation techniques to activate any inactive muscle groups that may be affecting your gait.

Bracing or Splinting. If the gait dysfunction is due to significant weakness or paralysis of a ligament, your physical therapist may teach you how to use adaptive equipment, like a brace or splint, to help you move.

TMJ DISORDER - JAW PAIN

Temporomandibular joint disorder, or dysfunction, (TMD) is a common condition that limits the natural functions of the jaw, such as opening the mouth and chewing. It currently affects more than 10 million people in the United States. It is sometimes incorrectly referred to as simply “TMJ,” which represents the name of the joint itself. TMD affects more women than men and is most often diagnosed in individuals aged 20 to 40 years. Its causes range from poor posture, chronic jaw clenching, and poor teeth alignment, to fracture or conditions such as lockjaw, where the muscles around the jaw spasm and reduce the opening of the mouth. Physical therapists help people with TMD ease pain, regain normal jaw movement, and lessen daily stress on the jaw.

What Is Temporomandibular Joint Disorder?

Temporomandibular joint disorder (TMD) is a common condition that limits the natural function of the jaw, such as opening the mouth and chewing, and can cause pain. The temporomandibular joint (TMJ) is a hinge joint that connects your jaw to your skull in front of your ear. The TMJ guides jaw movement and allows you to open and close your mouth and move it from side to side to talk, yawn, or chew. TMD can be caused by:

  • Bad posture habits. One of the reasons TMD is so common is because many of us spend a great deal of time sitting at a desk, where we often hold our heads too far forward as we work. But there are many other kinds of bad posture. Sitting in the car for a long commute, working at a checkout station, always carrying your child on the same hip—all can place the head in an awkward position and cause jaw problems. The "forward head position" puts a strain on the muscles, disk, and ligaments of the TMJ. The jaw is forced to "rest" in an opened position, and the chewing muscles become overused.
  • Chronic jaw clenching ("bruxism"). Many people clench their jaws at night while they sleep, usually because of stress. Some clench their teeth throughout the day as well, especially when dealing with stressful situations. This puts a strain on the TMJ and its surrounding muscles.
  • Problems with teeth alignment ("malocclusion"). If your teeth are positioned in an unusual way, greater stress is placed on the TMJ when performing everyday jaw motions, such as chewing.
  • Fracture. In a traumatic accident involving the face or head, a fracture to the lower jaw may result and cause TMD. Even when the fracture is fully healed, TMJ stiffness and pain may remain.
  • Surgery. Individuals may experience a loss of TMJ mobility and function following certain kinds of surgery to the face and jaw.
  • Trismus ("lockjaw"). This condition—where the jaw muscles spasm and the jaw cannot be fully opened—can be both a cause and a symptom of TMD. Other causes of trismus include trauma to the jaw, tetanus, and radiation therapy to the face and neck.
  • Displacement of the disc or soft-tissue cushion located between the ball and socket of the TMJ, which causes popping or clicking of the jaw and, frequently, pain.
  • Arthritis in the TMJ.

How Does it Feel?

The symptoms of TMD can be temporary or last for years. Jaw pain is the most common symptom.

CAUTION: Jaw pain also can be a symptom of heart attack. Seek medical care immediately if jaw pain is accompanied by: 

  • Chest pain
  • Shortness of breath
  • Dizziness
  • Left arm pain
  • Numbness in the left arm
  • Nausea

TMD can cause the jaw to lock or get stuck in a certain position. You may experience headaches, feel pain when chewing certain foods, or have difficulty fully opening your mouth.

TMD symptoms include:

  • Jaw pain
  • Jaw fatigue
  • Difficulty opening your mouth to eat or talk
  • Ringing in your ears
  • Dizziness
  • Headache
  • Popping sounds in your jaw
  • Neck pain
  • Locking jaw

How Is It Diagnosed?

To identify the cause of your symptoms, your physical therapist may:

  • Review your medical history, and discuss any previous surgery, fractures, or other injuries to your head, neck, or jaw.
  • Ask you to describe your pain, including headaches, and observe any pain patterns in the neck and TMJ.
  • Conduct a physical examination of your jaw and neck, including the soft tissue and muscles in the area.

Your physical therapist will evaluate your posture and observe how your cervical spine—the upper portion of your spine, situated in your neck—moves. Your physical therapist will examine your TMJ to find out how well it functions and whether there are any abnormalities in your jaw motion.

If, after the examination, your physical therapist suspects that your pain is a result of the position ("alignment") of your teeth, the therapist will refer you to your dentist for further examination.

How Can a Physical Therapist Help?

Your physical therapist can help you restore the natural movement of your jaw and decrease your pain. Based on your condition, your therapist will select treatments that will work best for you. Your treatments may include:

Posture Education. If you sit with your head in an increased forward position, you are placing greater strain on the muscles beneath your chin, causing the lower jaw to pull back and the mouth to be in an open position even when resting, increasing stress on the TMJ. You also might be overworking the jaw muscles to force the jaw closed so your mouth isn't open all the time. Your physical therapist will teach you to be aware of your posture so that you can improve the resting position of your jaw, head, neck, breastbone, and shoulder blades when you're sitting and walking.

Improving Jaw Movement. Physical therapists use skilled hands-on techniques (manual therapy) to gently increase movement and relieve pain in tissues and joints. Your physical therapist may use manual therapy to stretch the jaw in order to restore normal joint and muscle flexibility or break up scar tissues ("adhesions") that sometimes develop when there is constant injury.

Your physical therapist will teach you special "low-load" exercises that don't exert a lot of pressure on your TMJ, but can strengthen the muscles of the jaw and restore a more natural, pain-free motion.

Special Pain Treatments. If your pain is severe, your physical therapist may provide treatments, such as electrical stimulation or ultrasound to reduce it.

Referral to a Dentist. If your TMD is caused by teeth alignment problems, your physical therapist can refer you to a dentist who specializes in TMD, who can correct the alignment with special appliances, such as "bite guards" that create a natural resting position to relax the TMJ, relieve pain, and improve jaw function.

PELVIC PAIN AND WHAT TO DO ABOUT IT

Pelvic pain is pain felt in the lower abdomen, pelvis, or perineum. It has many possible causes and affects up to 20% of the population in the United States, including women and men. Pelvic pain is considered "chronic" when it lasts for more than 6 months. Physical therapists help people experiencing pelvic pain restore strength and flexibility to the muscles and joints in the pelvic region, and reduce their pain.

What Is Pelvic Pain?

Pelvic pain can be caused by:

  • Pregnancy and childbirth, which affect pelvic muscles and cause changes to pelvic joints
  • Pelvic joint problems from causes other than pregnancy and childbirth
  • Muscle weakness or imbalance within the muscles of the pelvic floor, trunk, or pelvis
  • Changes in the muscles that control the bowel and bladder
  • Tender points in the muscles around the pelvis, abdomen, low back, or groin areas
  • Pressure on 1 or more nerves in the pelvis
  • Weakness in the muscles of the pelvis and pelvic floor
  • Scar tissue after abdominal or pelvic surgery
  • Disease
  • A shift in the position of the pelvic organs, sometimes known as prolapse

How Does it Feel?

The pain in your lower abdomen and pelvis may vary; some people say it feels like an aching pain; others describe it as a burning, sharp, or stabbing pain, or even pins and needles. In addition, you may have:

  • Pain in the hip or buttock.
  • Pain in the tailbone or pubic bone.
  • Pain in the joints of the pelvis.
  • Tender points in the muscles of the abdomen, low back, or buttock region.
  • A sensation of heaviness in the pelvic region or even a sensation as if you are sitting on something hard, like a golf ball.

Signs and Symptoms

  • Inability to sit for normal periods of time.
  • Reduced ability to move your hips or low back.
  • Difficulty walking, sleeping, or performing daily activities.
  • Pain or numbness in the pelvic region with exercise or recreational activities, such as riding a bike or running.
  • Pain during sexual activity.
  • Urinary frequency, urgency, or incontinence, or pain during urination.
  • Constipation or straining with bowel movements, or pain during bowel movements.
  • Difficulty using tampons.
  • Imbalance when walking.

How Is It Diagnosed?

Your physical therapist will complete a thorough review of your medical history, and perform a physical examination to identify the causes of your pelvic pain and any joint issues, muscle tightness or weakness, or nerve involvement. The exam may include:

  • Pelvic girdle screening.
  • Soft tissue assessment.
  • Visual inspection of the tissues.
  • Reflex testing.
  • Sensation testing.
  • Internal assessment of pelvic floor muscles.

Your physical therapist also will determine whether you should be referred to a physician to assist in your interdisciplinary plan of care.

How Can a Physical Therapist Help?

Based on the examination results, your physical therapist will design an individualized treatment program to meet your specific needs and goals. Your physical therapist may:

  • Show you how to identify the appropriate muscles, such as the pelvic floor, deep abdominals, and diaphragm.
  • Educate you on how to use these muscles correctly for activities like exercise, posture correction, getting up from a chair, or squatting to pick up a child or pick something up from the floor.
  • Teach you exercises to stretch and strengthen the affected muscles and retrain them, so they work together normally.
  • Teach you techniques to improve blood flow and tissue function in the pelvic area.
  • Teach you appropriate pelvic floor muscle exercises.

 Depending on your symptoms and level of discomfort, your physical therapist may decide to use biofeedback to help make you aware of how your pelvic floor muscles work, and how you can control them better. Your physical therapist may attach electrodes to the area to measure your muscle activity as it displays on a monitor, and will work with you to help you understand and change those readings. Your physical therapist also may use gentle electrical stimulation to improve your awareness of your muscles.

ACL TEAR TREATMENT AND RECONSTRUCTION

The treatment options following an ACL tear are individualized for each patient depending on age, activity level, and the presence or absence of injury to other structures within the knee. In general, surgery is recommended for young patients who are active and for those in whom the ACL tear is associated with injury to other structures in the knee. Nonoperative (nonsurgical) treatment may be recommended in older or more sedentary patients.

The main reason to have surgery is to restore stability to the knee so it no longer gives out or slides too far forward, which is often painful. The other reason — perhaps the most important reason — is to protect the articular cartilage in the knee from being damaged. It is also important to protect the medial and lateral menisci in the knee.

The meniscus is a fibrous type of cartilage that sits between the ends of the tibia and femur, and is attached to the lining of the joint. There are two separate meniscal cartilages in the knee, each somewhat C-shaped: one on the inner half of the knee (the medial meniscus), and one on the outer half (the lateral meniscus). [Figure 1] The medial and lateral menisci primarily serve as shock absorbers between the ends of the bones to protect the surface or articular cartilage. With recurrent episodes of giving way, the meniscus can be damaged or torn, causing it to lose its shock-absorbing capability. Without a functioning meniscus, the articular cartilage is exposed to increased pressure and “wears” away, leading to arthritis. Additionally, the articular cartilage may be directly injured or damaged with each episode of giving way.

Nonsurgical Treatment

Nonsurgical treatment consists of physical therapy, activity modification and use of a brace. The goal of physical therapy is to strengthen the muscles around the knee to compensate for the absence of the ACL. Specifically, strengthening the muscles in the back of the thigh (the hamstrings) is helpful. Activity modification can be very successful. Sports that do not involve cutting, such as jogging, cycling or swimming, can often be performed successfully.

In addition to therapy and activity modification, use of a hinged sports brace can be attempted. While bracing may be effective in some patients, in others, instability episodes may continue despite their use.

Surgical Treatment and ACL Reconstruction

Once the ACL tears, it has usually sustained enough damage that attempts to surgically repair it are not successful. Consequently, better results are obtained if the ACL is surgically replaced or reconstructed with another tendon from around the knee. [Figure 2]There are a number of surgical options for reconstructing the ACL. The type of procedure done may vary from patient to patient depending on a specific surgeon’s preference as well as factors unique to an individual patient.

The surgical procedure is most commonly performed using arthroscopic techniques. Using one or two small incisions on the knee, the graft is taken from the patellar tendon or hamstring tendons, and a tunnel is drilled into both the tibia and femur. The graft is threaded across the knee, leaving a piece of bone in each of the tunnels and the patellar tendon in the position of the original ACL, thus reconstructing the ligament. [Figure 2] The graft is then secured in this position, most commonly by “wedging” a screw between the side of the bone and the tunnel. [Figure 3] Alternatively, the graft can be secured by other techniques — staples, sutures, buttons, etc. These fixation devices are usually left in place permanently.

In addition to the ACL reconstruction, additional procedures may be done to other structures within the knee if injury is present. A torn meniscus can be either repaired or trimmed (meniscectomy), and other ligaments can be repaired or reconstructed as well.

Figure 3

Allografts most frequently used today are of the bone-patellar tendon-bone type or from the Achilles tendon at the heel, and come from cadavers that have been screened for infectious diseases, e.g., hepatitis and AIDS. The risk of AIDS from one of these grafts is not known, but it is generally believed to be one out of 1 million. All allografts are carefully screened and tested before they are used in surgery.

How long does rehabilitation take after surgery?

The exact course of therapy may vary somewhat depending on the specific type or reconstruction done, particularly if additional meniscus or ligament surgery was done. Physical therapy is done in a supervised setting in conjunction with a trained therapist. Early in the course of recovery, visits may be two to three times per week, but later, once every week or two is often sufficient. Home exercises are done on days not scheduled for a formal therapy session.

The rehabilitation following ACL reconstruction includes essentially three phases. The first phase of rehabilitation consists of controlling the pain and swelling in the knee, regaining knee motion, and getting early return of muscle strength. The operated leg is typically placed into a brace immediately after surgery.

Initially, weight bearing is allowed with crutches and is progressed to full-weight bearing independent of crutches as swelling, motion and muscle strength allow. Most patients are on crutches for one week, although some may be on crutches longer and some shorter. This phase typically takes six to eight weeks.

The second phase emphasizes recovery of full knee motion and muscle strength. Cycling, running on the treadmill and light jogging are started in this phase. In some patients, a sport brace is obtained to replace the postoperative knee brace. This phase typically lasts from two to four months after surgery.

The final phase consists of graduated return to full activity. Normal muscle strength, coordination and the absence of swelling are required for successful return to activity. A brace may be recommended early in the return to cutting and pivoting sports. This phase occurs at four to eight months after surgery, depending on the particular patient and the nature of his or her activities.

A patient’s rehabilitation is monitored closely by both the therapist and surgeon for evidence of potential problems. Most significantly, patients are cautioned not to attempt a too premature return to full activity, which may cause the knee to be inflamed or reinjured. In every patient, the graft must both heal into place and be incorporated into the knee. Too much stress too soon may increase the risk of graft failure.

What are the potential complications after surgery?

Most patients experience no complications and return to full activity between six and eight months after surgery. However, the most common complications include pain in the front of the knee and loss of knee motion.

Pain in the front of the knee occurs in 10 to 20 percent of patients. Fortunately, it can usually be controlled by modification in the physical therapy protocol. Loss of motion occurs in less than 5 percent of patients and is most common in patients with limited motion before surgery. In some individuals, intermittent pain and swelling occur with activity despite a successful ligament reconstruction. This is often related to the amount of meniscal or cartilage injury that was present and identified at the time of surgery.

In the absence of identifiable causes, a small percentage of patients will end up with a persistent detectable increased amount of motion in their knee (a “loose” graft). This may be related to stretching of the graft over time or due to an additional injury.

Will I be able to return to my previous sporting activities?

Approximately 85 percent of patients return to their previous level of activity without restrictions. In the other 15 percent, full return may be limited by a number of causes: pain, swelling, persistent laxity, change in lifestyle related to age, intentional choice or other unidentifiable causes.

PT GUIDE TO WRIST FRACTURE

A wrist fracture is a break in one of the bones near the wrist. In the United States, 1 out of every 10 broken bones diagnosed is a wrist fracture. Injury can occur as a result of a trauma, such as falling while playing sports or simply tripping when walking down a sidewalk. Children are susceptible to wrist fractures because of the high-risk sports they commonly play. A child may sustain a wrist fracture falling off a bike, playing football or soccer, or falling off playground equipment. Wrist fractures are also common in women after menopause, and frequently occur in the elderly population due to falls. A physical therapist can help individuals who have sustained a wrist fracture regain normal wrist motion, strength, and function, and learn how to prevent future fractures.

What Is Wrist Fracture?

A fracture is a crack or a break in a bone. Wrist fractures due to falls happen most often when people stretch the arm straight out to catch themselves as they fall. The wrist is made up of 8 small bones called carpal bones, and 2 bones in the forearm called the radius and the ulna. A wrist fracture is diagnosed when any of those bones breaks or cracks. The most frequently fractured bone is the radius, the bone in the forearm that is closest to the thumb.

There are 3 types of bone fractures:

  • Type 1 – a "nondisplaced" fracture, where the bone is broken but is still in a normal position.
  • Type 2 – a fracture where a fragment of bone is shifted from its normal position.
  • Type 3 – the most serious type of fracture, with multiple breaks of the bone or bones.

Type 1 and 2 fractures usually are treated without surgery. Type 3 fractures, however, usually require surgery.

How Does it Feel?

A fractured wrist is usually painful and movement is affected. If you have sustained a wrist fracture, you may experience:

  • Pain in the area of the fracture, which could be anywhere in the wrist, depending on which bone was affected. The pain can radiate from the wrist into the fingers, and even into the forearm.
  • Swelling in the wrist and possibly in the hand, usually on the top surface of the wrist and hand.
  • Tenderness to touch in the wrist.
  • Difficulty and pain when moving the wrist or fingers      

How Is It Diagnosed?

An x-ray is the best way to diagnose a wrist fracture. If you have sustained a fall and are experiencing any of the symptoms mentioned above, you need to visit an emergency room, an urgent-care center, or your physician to get a complete diagnostic x-ray.

If a physical therapist suspects that you have a wrist fracture, the therapist may arrange for an x-ray and refer you to an appropriate physician. Your physical therapist can check for damage to other joints and muscles, and make sure that the nerves and blood vessels in your wrist, forearm, and hand have not been affected by the broken bone. In most cases, people with fractures visit a physician with a specialty in managing bones and joints (an orthopedist). Depending on the type of fracture, the physician might prescribe a cast or a sling to immobilize the area for a period of time until the fracture is healed. The amount of healing time varies, depending on the individual and the type of fracture, and can be anywhere from 4 to 10 weeks. If the fracture is severe, surgery will be required. The recovery time may be longer following surgery, depending on the severity of the injury.

How Can a Physical Therapist Help?

Your physical therapist will work with you following a wrist fracture to help you regain normal wrist motion, strength, and function, and will provide education and training to help you prevent future fractures.

While Your Wrist Is In a Cast or a Sling

While your bone heals, your arm will be in a cast or a sling to keep it still and promote healing. During that time, it is important to ensure that the arm does not get too stiff, weak, or swollen. Depending on the amount of activity that is allowed for your type of fracture, your physical therapist will prescribe gentle exercises to keep your shoulder, elbow, and fingers moving while you are in the cast or sling.

Most people with wrist fractures will slowly return to exercising the other arm and the legs, so that the rest of the body doesn't get out of shape while the fracture is healing. Your physical therapist can help you adapt your exercise program, so that you can maintain your overall strength and fitness without interfering with the healing of your wrist.

When the Cast or Sling Is Removed

After your cast or sling is removed, your wrist will most likely be stiff, and your arm will feel weak. Your physical therapist will examine your wrist, and select treatments to improve its function and restore strength to your arm.

Your rehabilitation will include treatments to:

Reduce Pain. Your physical therapist might use either warm or cold therapeutic treatments, or electrical stimulation, to help control pain or swelling in your wrist, hand, or arm.

Relieve Stiffness. Your physical therapist may use skilled hands-on techniques (manual therapy) to enable your joints and muscles to move more freely with less pain.

Increase Your Strength and Ability to Move. Physical therapists prescribe several types of exercises during recovery from a wrist fracture. Early on, your physical therapist can help you begin to gently move your elbow, using "passive range-of-motion" exercises. As your arm gets stronger, you can exercise it yourself without weights ("active range-of-motion" exercises). Once the bone is well-healed, you can begin to perform resistance exercises, using weights or elastic bands. In addition to prescribing range-of-motion and strengthening exercises, your physical therapist can help you retrain your muscles to react quickly when you need to protect yourself from a fall.

Get Back to Your Daily Activities. Your physical therapist will help you remain independent by teaching you how to perform your daily activities (eg, dressing, working on a computer, and cooking), even while wearing a cast or a sling. Once you can move your arm freely without pain, your physical therapist may begin adding activities that you were doing before your injury, such as using your arm for dressing, grooming, and housekeeping. Your physical therapist will design your individualized program based on an examination of your wrist, goals, level of physical activity, and general health.

Prepare for More Demanding Activities. Depending on the requirements of your job or the type of sports you play, you might need additional physical therapy tailored to meet specific demands. Your physical therapist will develop a specialized program to address your unique needs and goals.

Prevent Long-Term Disability. Everything your physical therapist prescribes for you will help prevent long-term disability by:

  • Returning the arm to a strong level of fitness.
  • Restoring full movement and strength in a safe manner, while healing occurs.
  • Assessing the fracture to make sure that you can return safely to previous home and work activities.
  • Guiding you to a safe return to sports and other physical activities. A return too early after a fracture may increase the risk of another fracture.
  • Recommending protective equipment, such as wrist guards, for use during sports.

Can this Injury or Condition be Prevented?

In addition to helping individuals prevent long-term disability following a wrist fracture, physical therapists can help different at-risk populations prevent fractures.

  • For the aging population, avoiding falls and other trauma is the best way to prevent fractures. Physical therapists are experts at determining your risk of falling, and can teach you how to perform balance exercises and take precautions to avoid falls. They also can perform work and home safety evaluations to make sure that your daily environment is safe.
  • For postmenopausal women with osteoporosis leading to a higher risk of wrist fracture, a physical therapist can teach weight-bearing exercises to help build stronger bones. Your physical therapist also may refer you to a nutritionist for vitamin D supplements or other dietary changes to help make your bones stronger. Education in proper posture and body mechanics and joint protection techniques can be helpful in preventing strain on the wrist and arms.
  • For children, wearing proper protective gear, such as wrist guards, can reduce the risk of a wrist fracture when playing certain sports. Making sure that playground equipment your child uses is safe and built on a soft surface can also reduce the risk of wrist fractures due to falls.

PT'S GUIDE TO PELVIC FRACTURES

A pelvic fracture is a break in 1 or more bones in the pelvis. It is sometimes referred to as a "hip fracture" or "broken hip" because it occurs in the bones that make up the hip area. A pelvic fracture causes difficulty walking or standing. It can also cause abdominal pain, bleeding from pelvic cavities, and difficulty urinating. Pelvic fractures in the United States are relatively rare, making up 0.3% to 6% of all fractures. Pelvic fractures are most common in people 15-28 years of age. In people younger than 35, males suffer a higher incidence of pelvic fractures than females. In people older than 35, females suffer pelvic fractures more often than males.

What is a Pelvic Fracture (Hip Fracture)?

A pelvic fracture is a crack or break in one or more of the pelvic bones, which are located at the base of the spine. The pelvis is often referred to as part of the hip. (When you "put your hands on your hips," your hands are actually resting on your pelvic bones.)

A pelvic fracture can result from a low-impact or high-impact event.

Low-impact pelvic fractures most commonly occur in 2 age groups: adolescents and the elderly. Adolescents typically experience fractures of the tips of 1 of the pelvic bones, resulting from an athletic injury (football, hockey, skiing) or an activity such as jogging. Pelvic fractures also can occur after minor falls in people with osteoporosis or even occur spontaneously when bones are weak. The elderly frequently suffer fractures of the thicker part of the pelvic bones. These "pelvic ring fractures" result from falling onto the side of the hip. These falls can be caused by balance problems, vision problems, medication side effects, general frailty, or unintended obstacles such as pets underfoot, slippery floors, or rumpled rugs. Low-impact pelvic fractures often are mild fractures, and they may heal with several weeks of rest. Physical therapy is very helpful in restoring strength and balance in these cases.

High-impact pelvic fractures most commonly result from major incidents such as a motor vehicle accidents, a pedestrian being struck by a vehicle, or a fall from a high place. These pelvic fractures can be life-threatening, require emergency room care, surgery, and extensive physical therapy rehabilitation.

How Can a Physical Therapist Help?

Pelvic fracture recovery often involves surgery or long periods of bed rest. In the case of athletes, avoidance of sport activities is recommended until pain has resolved. During these periods of rest, which are usually weeks to months, a person often loses strength, flexibility, endurance, and balance abilities.

Physical therapists can help you recover from a pelvic fracture by improving your:

  • Pain level
  • Hip, spine, and leg motion
  • Strength
  • Flexibility
  • Speed of healing
  • Speed of return to activity and sport

When you are cleared by your physician to begin physical therapy, your physical therapist will design a specific treatment program to speed your recovery, including exercises and treatments you should do at home. This program will help you return to your normal life and activities and reach your recovery goals.

The First 24-48 Hours

Your physical therapist may help you learn to use crutches so you can move around your home without walking on the leg of the injured side. This will more commonly apply to low-impact pelvic fractures, as in athletes. More severe pelvic fractures will require a wheelchair, in which your physical therapist can instruct your safe usage.

Reduce Pain

Your physical therapist can use different types of treatments and technologies to control and reduce your pain, including ice, heat, ultrasound, electrical stimulation, taping, exercises, and special hands-on techniques called manual therapy that gently move your muscles and joints.

Your physical therapist will choose specific activities and treatments to help restore normal movement in the leg and hip. These might start with passive motions that he or she applies to your leg and hip joint, and progress to active exercises and stretches that you perform yourself. Treatment can involve hands-on manual therapy techniques called "trigger point release" and "soft tissue mobilization," as well as specific stretches to muscles that might be abnormally tight.

Improve Strength

Certain exercises will benefit your healing at each stage of recovery, and your physical therapist will choose and teach you an individualized exercise program that will restore your strength, power, and agility. These exercises may be performed using free weights, stretch bands, weight-lifting equipment, and cardio exercise machines such as treadmills and stationary bicycles. For pelvic fractures, muscles of the hip and core are often targeted by the strength exercises.

Improve Balance

The hip area contains many muscles that are vital for balance and steadiness when walking or performing any activity. Your physical therapist will teach you effective exercises to restore strength and endurance to these muscles so that you can regain your balance.

Speed Recovery Time

Your physical therapist is trained and experienced in choosing the treatments and exercises to help you heal, get back to your normal life, and reach your goals faster than you might be able to on your own.

Return to Activities

Your physical therapist will collaborate with you to decide on your recovery goals, including return to work and sport. Your treatment program will be designed to help you reach these goals in the safest, fastest, and most effective way possible. Your physical therapist will use hands-on therapy and teach you exercises and work re-training activities. Athletes will be taught sport-specific techniques and drills to help achieve sports-specific goals.

Prevent Future Problems

Your physical therapist can recommend a home exercise program to strengthen and stretch the muscles around your hip, upper leg, and core to help prevent future problems, such as fatigue and walking difficulty. This program may include strength and flexibility exercises for the hip, thigh, and core muscles. Your physical therapist will also review with you and your family ways to prevent falls in your home. These fall-prevention strategies may include clearing the floors of loose obstacles (throw rugs, mats), using sticky mats or chairs in the shower, preventing pets from walking near your feet, and using non-slippery house shoes, as well as installing grab bars or rails for the shower, toilet, and stairs.

If Surgery Is Necessary

If surgery is required, your physical therapist will help you minimize pain, restore motion and strength, and return to normal activities in the speediest manner possible after surgery.

Can this Injury or Condition be Prevented?

Pelvic fracture can be prevented by:

  • Warming up before starting any sport or heavy physical activity. Your warm-up should include stretches taught to you by your physical therapist, including stretches for the muscles on the front, side, and back of the hip.
  • Increasing the intensity of an activity or sport gradually, not suddenly. Avoid pushing yourself too hard, too fast, too soon.
  • Following a reasonable and safe nutritional plan. Nutritional factors can contribute to osteoporosis, which can put you at higher risk of pelvic fracture.
  • Maintaining good balance skills. Balance problems can increase the risk of falling and thus increase the risk of incurring a pelvic fracture. Physical therapy can help maintain and improve balance ability, which can help prevent falls.
  • Driving safely to avoid motor vehicle accidents.
  • Clearing your house of obstacles that you could trip over, and eliminating slippery walking surfaces.