Dr. Google will likely tell you that “a bursa is a closed fluid-filled sac that functions as a gliding surface to reduce friction between tissues of the body” and you will likely get little argument with that definition from a proper physician. “Bursae” is the plural form of “bursa.” The major bursae are located next to the tendons of large joints, such as the shoulders, elbows, hips, and knees. When a bursa becomes inflamed, the condition is known as “bursitis.” It is possible that a bursa can become infected, but this is not very common.
A very prevalent type of bursitis that physical therapists treat (in fact, a very common source of hip pain in general) is known as “trochanteric” (so named for its proximity to the greater trochanter of the femur) bursitis”. Trochanteric bursitis will usually cause pain (and tenderness to touch) of the outer hip (and sometimes the thigh), making it difficult to lie on the involved side and thus, making it difficult to sleep. This particular bursitis is also often made worse with excessive walking. Treatment of noninfectious bursitis by your medical doctor will often include rest, ice, medications for inflammation and sometimes, an injection into or near the bursa. Your doctor may also write a prescription for physical therapy.
Your physical therapist can help by focusing directly on reducing pain through hands on care, ultrasound, electric stimulation or other modalities however, (usually when pain is down to a manageable level) much focus should be on the mechanical reasons that the bursa became inflamed to begin with. This will generally have to do with participation in certain activities (or not participating in any activity!) joint mobility, muscle length and strength. This will generally be treated with various combinations of exercise and stretching. Additionally, physical therapy can help by educating you about what caused the condition to begin with and what you can do to prevent this from occurring in the future. This will often be accompanied by a home exercise program.
Hip Osteoarthritis and Arthroplasty
There are a few different types of arthritis however, osteoarthritis is the most common and frequently referred to as just plain “arthritis”. Arthritis literally means “joint inflammation” however, the hallmark characteristic on x-ray is it’s degenerative component. Also known as degenerative joint disease (DJD for short), osteoarthritis is more likely to develop as we age. It causes pain (and sometimes swelling) in the body’s joints, such as the knees or hips.
Osteoarthritis occurs when inflammation, “wear and tear” and/or injury to a joint cause a breaking down of cartilage tissue. In turn, that breakdown causes pain, swelling, and can cause deformity. Cartilage is a firm but rubbery material that covers the ends of bones in normal joints. The primary function of cartilage is to reduce friction in the joints and serve as a “shock absorber.” Although cartilage may undergo some repair when damaged, the body does not grow new cartilage after it is injured.
The changes in osteoarthritis usually occur slowly over many years. As this process happens, the joints and surrounding tissues may get stiff and unfortunately, not moving only makes the pain worse. Not moving will also lead to muscles that get tight and weak, causing decreased function. Physical therapy can be quite helpful in addressing this in most cases. If the joint degeneration is quite severe then physical therapy may lead to only temporary (or no) relief. If this is the case, stem cell technology holds exciting potential, but joint replacement surgery is presently the treatment of choice.
Total Hip Arthroplasty
When hip arthritis reaches it’s painful apex, a “total hip arthroplasty (THA)” or simply, hip replacement may become necessary. Generally speaking, “joint replacement” refers to a surgical procedure whereby a arthritic or dysfunctional joint surface is replaced with an orthopedic prosthesis. The goods news is that there has never been a better time to get a hip replacement if you need one. For many years patient’s would have “hip precautions” after surgery 2nd to the fashion in which the surgery was performed. Currently, more and more surgeon’s are adopting the “anterior approach” to hip replacement surgery, making “hip precautions” a thing of the past and shortening recovery times. This usually translates to a need for less physical therapy after surgery, though PT is usually still necessary. During this time your therapist will work on improving your range of motion, strength and safely transitioning you into higher level activities you may want to participate in.
The “hip” refers to a ball-and-socket joint composed of the head of the thigh bone sitting in a “socket” called the acetabulum. It allows the upper leg to bend and rotate at the pelvis. A “hip fracture” is a break in the upper quarter of the femur (thigh) bone, an injury to the socket (acetabulum) is not considered a “hip fracture.” Management of fractures to the socket involves different considerations. Management of a hip fracture depends on the extent of the break; surgery may or may not be necessary. The type of surgery used to treat a hip fracture is primarily based on the bones and soft tissues affected or on the level of the fracture.
Hip fractures most commonly occur from a fall or from a direct blow to the side of the hip. Some medical conditions such as osteoporosis, cancer, or stress injuries can predispose a person to fracture. The patient with a hip fracture will usually have pain over the outer upper thigh or in the groin. There will be significant discomfort with any attempt to flex or rotate the hip.f If the bone is completely broken, the leg may appear to be shorter than the non-injured leg. The patient will often hold the injured leg in a still position with the foot and knee turned outward (external rotation).
Once your physician has determined the extent of the fracture and the next immediate course of action, you will likely find yourself in physical therapy. This may occur after a period of rest to simply let a fracture heal, or it may occur post-surgery. In either case, your therapist will work with you to regain lost function (learning to walk again for example), normal mobility and strength of the hip, as well as working toward specific goals that a patient may have.
ACL Tear and Reconstruction
The Anterior Cruciate ligament is located in the knee and runs from the front of the tibia to the back of the femur. The ACL prevents the tibia from sliding or translating forward in front of the femur. The ACL is commonly injured in sports such as football, basketball and soccer which require a lot of pivoting, jumping and quick stops and turns. It can be caused by contact with another player or non-contact.
If the ACL is injured, it can cause extreme pain, a pop may be felt, the knee may swell within the next several hours and may feel very unstable to walk on. The ACL may or may not require surgery depending on the severity of the injury. If surgery is required, a graft can be taken from the patient’s hamstring, patella, or quadriceps tendon or using an allograft, which is taken from a cadaver, to reconstruct the injured ligament.
Physical therapy is important in the recovery of an ACL injury or reconstruction. Therapy after surgery may last 4 to 6 months and during this time your therapist will help guide you through exercises to help restore your range of motion, improve your balance, strengthen your knee safely, and return normal function.
Arthritis And Total Knee Replacement
Arthritis is an inflammation of the joints causing stiffness and pain along with possible redness, weakness, decreased range of motion and swelling. There are many different types of arthritis with the most common types being osteoarthritis and rheumatoid arthritis. Arthritis affects about 20 percent of the population.
With osteoarthritis, the ends of the bones which are covered with cartilage, have become worn out over time and begin to rub together causing increased pain and discomfort. This wear and tear on the bones can also cause inflammation and a loss of motion in the joints.
Rheumatoid arthritis is an autoimmune disease in which your own body begins to attack the lining of the joints, called synovium, and possibly other areas of the body. Rheumatoid arthritis usually attacks the smaller joints first and then moves to the larger joints. It can cause the bones to become misshapen or deformed and cause increased pain and inflammation.
For patients that have severe arthritis in the knee that continues to worsen and affect their daily routines, a doctor may recommend a total knee replacement. The patient may have several other symptoms that go along with needing a knee replacement including severe pain, chronic inflammation or swelling, and difficulty with normal daily activities like walking and climbing stairs. During a total knee replacement, also called a Total Knee Arthroplasty or TKA, the damaged surfaces of the tibia and femurs are removed and replaced with a new artificial metal and plastic implant.
Physical therapy can help teach patients how to safely return to their normal activities of daily living, such as walking with a walker or cane if needed or without an assistive device. Therapy treatments can help reduce swelling and pain in the knee, teach patients exercises to help strengthen the knee, restore balance and how to improve and maintain their knee range of motion.
Bursitis is an inflammation of the fluid filled sacs that surround the joint. Bursae provide cushion and lubrication between the bones and soft tissue such as tendons, ligaments and muscles. Signs of bursitis include localized swelling, tenderness, pain, redness or warmth near the joint. Bursitis can look like a large lump under the skin that may feel squishy to touch and vary in size.
There are 3 major bursae in the knee and any of them can become inflamed, tender and swollen. The most common type of bursitis is called prepatellar bursitis. This occurs in the front of the knee and causes a lump. It is sometimes called housemaid’s knee because it is caused by frequent or prolonged kneeling on hard surfaces. Certain sports that require constant or repetitive pressure on the knees like wrestling and volleyball can also cause prepatellar bursitis.
Bursitis can be caused by underlying conditions such as arthritis or gout, or repetitive movements such as running, injury or trauma, like a sharp blow to the knee. Runners may develop bursitis of the anserine bursa which is located slightly below and to the inner part of the knee. The infrapatellar bursa is located below the kneecap and can become injured and cause “Jumper’s Knee”.
Physical therapy can teach the patient exercises and stretches to maintain strength and range of motion. Therapists can also help to decrease swelling, pain and inflammation and help teach patient how to modify activities so that they experience less discomfort. Rest and ice to the affected area is important if the bursitis is caused by activities that constantly aggravate the bursae. Bursitis can be acute and only last for a short period of time or chronic and last anywhere from a few days to weeks and the bursitis may often return. It is important to keep the surrounding muscles strong and mobile to avoid atrophy and weakness especially with chronic bursitis.
Fractures of the Lower Extremity And Osteoporosis
A fracture is a break in a bone or a stop in the continuity of a bone. Many fractures are caused by accidents, falls or from an overuse injury. Children who are very active are more susceptible to having broken bones as well as older adults with osteoporosis and who are at a high risk for falling. Overuse injuries are often caused from sports like running and can cause stress fractures from repeated stress or strain.
Patients with osteoporosis are very susceptible to fractures because their bones are very weak and fragile. Women are at a higher risk of developing osteoporosis as well as people with a thin or small body frame. Other risk factors include lack of exercise, poor nutrition with diets low in calcium and vitamin D and hyperthyroidism.
When someone has a fracture it can cause pain, swelling, bruising, inability to put weight on the broken bone, discoloration of the skin near the bone, possible deformity or angulation in the bone, and/or bleeding if the bone has broken the skin. If a larger bone is broken, someone may feel faint, nauseated, lightheaded or dizzy.
There are many types of fractures which can be open or closed and displaced or non-displaced. An open fracture, also known as a compound fracture, is where the bone breaks the skin and can cause bleeding and is more susceptible to infection. A closed fracture does not break the skin and there is no open wound. Displaced and non-displaced refers to the position of the bone and its alignment.
After the bone has healed, physical therapy can help decrease the patients pain and swelling, restore range of motion to the affected area and strengthen and stabilize the muscles that surround the site of the fracture. For patients with osteoporosis and/or fractures physical therapy can help them restore their balance and proprioception with exercises that will help them reduce their risk of falls.
The meniscus is a cartilaginous material that sits on top of the tibia bone at the knee joint. The meniscus acts as a shock absorber and helps to cushion and stabilize the joint with movements such as walking, running, bending and ascending and descending stairs. There are 2 C-shaped menisci in the knee, a medial meniscus and a lateral meniscus and each has a posterior and lateral horn.
A meniscal tear is a very common injury to the knee and can sometimes benefit from conservative treatment and other times it may require surgery to repair or eliminate some or all of the injured cartilage. A tear is often caused by twisting or hyper-extending the knee with sports or activities or damage from wear and tear or arthritis. If an injury occurs to the meniscus, you may experience pain, intermittent swelling, popping, locking of the knee or feeling as if it is stuck, and instability of the knee.
If surgery is needed for a meniscal tear, your physician may decide to do a menisectomy or a meniscal repair depending on the severity and type of tear. During a menisectomy, some or all of the damaged meniscus is removed since many meniscal repairs are not considered repairable. During a meniscal repair, the meniscus is sutured or stitched back together by the surgeon. A meniscal repair requires a much longer recovery period since the meniscus will have to heal back together after the surgery.
Physical therapy can help a patient with a meniscal tear before and after surgery to help stabilize the knee, strengthen the surrounding muscles and help the patient maintain adequate range of motion in the knee. Patients can also benefit from soft tissue massage and modalities such as ultrasound and electrical stimulation to help decrease the patient’s pain and swelling.
Patellofemoral Pain Syndrome
Patellofemoral syndrome is a pain that occurs directly under or around the patella or knee cap. It is also known as “runner’s knee” or “jumper’s knee”. Someone with patellofemoral syndrome may notice increased pain that feels dull and achy with activities like walking up and down stairs, squatting and sitting with their knee in a bent position for an extended period of time. Other symptoms of PFS may include knee buckling, catching or popping, mild swelling, and a grinding sensation.
Patellofemoral syndrome can occur from overuse injuries, surgery, or because of muscle imbalances and weakness in the legs. PFS is seen more in women than in men due to the increased angle between the femur and kneecap and from muscle imbalances around the knee. These factors can cause more mechanical force and strain on the knee and cause the patella to track incorrectly in the patellar groove, thus causing more pain and discomfort.
Physical therapy can help teach the patient exercises and stretches to help strengthen any muscle imbalances in your leg and around the knee, especially the quadriceps group, to help stabilize the knee. Patient’s are also given exercises and stretches to improve range of motion, decrease tightness in muscles and to help decrease pain. Therapists can help educate the patient on proper techniques for movements that pertain to the patient’s sport, like jumping or squatting. Soft tissue and taping techniques are often used to help decrease strain and friction on the patella.