Total knee replacements -- or total knee arthroplasties (TKA) have become one of the most performed orthopedic surgeries in the world. According to the Agency for Healthcare Research and Quality, in 2017, more than 754,000 knee replacements were performed in the United States. In the PT clinic I treat as many patients after total knee replacements as any other orthopedic surgery. In orthopedic healthcare, total knee replacements are widely regarded as one of the most successful surgeries. The AAOS notes that over 90 percent of replacement knees are still functioning after 15 years.

​Knee replacements are most often done when a person’s knee joint develops severe arthritis. This is when the cartilage in the knee joint -- at the bottom of the femur (“thigh bone”) and the top of the tibia (“shin bone”) -- degrades and the joint becomes painful and usually inflamed. Cartilage acts as padding in the knee joint and to decrease friction as the knee moves. When a person loses most of the cartilage in the knee this can be described as “bone on bone” arthritis and can require a TKA. Most of the time this loss of cartilage is due to wear and tear and is described as osteoarthritis. In some cases this can be caused by an inflammatory condition called rheumatoid arthritis or trauma like a motor vehicle accident.

​Knee replacement surgery was first performed in 1968. Since then, improvements in surgical materials and techniques have greatly increased its effectiveness. Recently more and more surgeons are utilizing robotic guided surgical techniques and generally with excellent outcomes.

​In a traditional TKA the surgeon uses preoperative x-rays, intraoperative anatomical landmarks, and manually positioned alignment jigs to guide bone cutting and implant positioning. These handheld techniques can lead to less reliable alignment-guide positioning, inadvertent sawblade injury to the knee muscles and ligaments, and limited ability to fine-tune the implant positioning. Suboptimal implant positioning may lead to poor functional recovery and reduced implant survivorship. (At this point I should note that I work with many surgeons who have done hundreds or thousands of these traditional TKAs with great clinical outcomes.)

​Robotic TKA uses computer software to convert anatomical information into a virtual patient-specific 3D reconstruction of the knee joint. The surgeon uses this virtual model to plan optimal bone cutting and implant positioning based on the patient’s unique anatomy. An intraoperative robotic device helps to execute this preoperative patient-specific plan with a high level of accuracy. The action of the sawblade is confined to the preoperative surgical plan which limits soft-tissue injury and bone trauma.

A 2019 systematic review about robotic total knee replacement found the following:

• Robotic TKA improves the accuracy of implant positioning compared to conventional jig-based TKA.
• Cadaveric studies have shown robotic TKA is associated with reduced injury to the soft tissue around the knee compared to conventional jig-based TKA.
• Robotic TKA is associated with decreased postoperative pain, enhanced early functional rehabilitation, and decreased time to hospital discharge compared to conventional jig-based TKA. However, there are no differences in medium- to long-term functional outcomes between conventional jig-based TKA and robotic TKA.
• Limitations of robotic TKA include high installation costs, additional radiation exposure, learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.

If you are considering getting a TKA there is clearly a lot of evidence that robotic TKA are effective and in some ways superior to a traditional TKA. That being said, there are many other factors to consider when looking for a surgeon to do your TKA including:

• Number of TKAs the surgeon has done: in general I recommend surgeons who have done hundreds of TKAs as they are both proficient and efficient in the operation. The less time you are on the operating table, the less opportunity for tissue damage or infection.
• Relationship with a surgeon: if you have a surgeon you know and trust who uses a traditional technique you are still likely to have excellent outcomes. 
• Proximity to home: if there aren’t surgeon’s in your immediate area who do robotic TKAs you may have to travel for your surgery and pre-op and post-op visits.

Once you've made your decision don't forget the importance of rehab! All of our physical therapists are experts in both pre and post op knee replacement rehab. For more information about what to do once  you've made this big decision, check out this informational page and reach out to one of our clinics to set up an appointment!

October is National Physical Therapy Month and we here at Altitude wanted to take a moment to celebrate and reflect on why each of us pursued a career in this profession. Physical Therapy is a very rewarding profession and nearly 100% of the time, physical therapists choose this path due to a deep desire to help others. Please enjoy these career catalyst stories from our PTs here at Altitude! 

​There's a term we use in physical therapy called "respect the healing process." I've decided to shed a little more light on what we mean by this. Ultimately, the body is supposed to go through certain processes after an injury. These phases are inflammation, proliferation, and remodeling. Each phase has its frustration with respect to our patients. Contrary to popular belief, physical therapy will not make any of these phases go FASTER. 

​The inflammation phase is the immediate response to an injury. It is the swelling and the PAIN! Physical therapy works to help manage this phase through soft tissue work, light joint mobilizations, TENS units, exercise for facilitation and activation of surrounding musculature, gradual return of range of motion and more. The goal of getting into physical therapy this early is so that we can be prepared to move into the next phase: proliferation. 

​The remodeling phase is when we restructure the scar tissue to align appropriately with the component it is trying to heal as well as increase exercise demand and tolerance for the surrounding areas. For example, if the achilles tendon was injured or slightly torn, we will emphasize exercise and hands on work to promote the vertical nature of the fiber alignment in the achilles tendon. This is also achieved with select tissue loading that is usually more weightbearing and functional.

​This is the phase where physical therapy transitions to a routine more targeting your goals. If you want to get back to hiking, we will start lunges and squats. If you want to get back to running, we would start light plyometric and speedwork. These exercises are built upon the exercises you've been doing in the proliferation phase. As you can see from the chart above, this is the longest phase of healing. I always like to tell my patients that once you injure a structure or tissue once, you are at a greater risk of injuring it again. Physical therapy will give you all the keys and exercises necessary to reduce this risk as much as possible!

The phases of healing are overlapping in nature but never to be rushed. Physical therapy guides each patient individually through inflammation, proliferation and remodeling to ensure the best recovery and reduce your risk of re injury. A key component during your physical therapy experience at Altitude is that we will identify how you injured yourself in the first place which I have found is the best approach to not letting it happen again! Remember, you can start physical therapy even BEFORE you get injured, too! :-) ​

Yoga is a group of physical, mental, and spiritual practices or disciplines which originated in ancient India. Yoga is one of the six orthodox schools of Hindu philosophical traditions. There is a broad variety of yoga schools, practices, and goals in Hinduism, Buddhism, and Jainism. The term "yoga" in the Western world often denotes a modern form of Hatha yoga, yoga as exercise, consisting largely of the postures called asanas. 

In order to teach Yoga you have to study five areas:

• Yoga techniques and postures (the practice)
• Yoga philosophies, history and lifestyle
• Human anatomy, physiology and psychology
• Methods of teaching Yoga
• Practical teaching training (in front of a class)

​Studies have found the incidence of pain in Yoga practitioners caused by Yoga is more than 10% per year - which is comparable to the rate of all sports injuries combined among the physically active population.

There is some evidence that regular Yoga practice is beneficial for people with high blood pressure, heart disease, aches and pains - including lower back pain - depression and stress.

• Improve general wellness
• Relieve low-back pain and neck pain
• Help people manage anxiety or depressive symptoms
• Help people quit smoking
• Help people who are overweight or obese lose weight

​The National Center for Complementary and Integrative Health (part of the NIH) suggests the above findings, however they note "Although there has been a lot of research on the health effects of yoga, many studies have included only small numbers of people and haven't been of high quality. Therefore, in most instances, we can only say that yoga has shown promise for particular health uses, not that it has been proven to help".

Created by Joseph Pilates in the 19302, Pilates was first called Contrology and inspired during WWI while held in camp for four years. Joseph was a nurse-physiotherapist and his goal was to create lifelong sustainable exercise at a low cost. Pilates recognized that the brain controls mobility and stability of the body. Specific muscles are used in a functional sequence at controlled speeds - emphasizing quality, precision and control of movement. Complex movements are broken down step-by-step to internalize the pattern.

Regular practice should lead to:

• Enhanced body and self-awareness
• Improved core stability
• Improved coordination and posture
• Uniform muscle development
• Decreased stress

Similarities: strength, flexibility, fitness, importance of breath
Differences: Pilates emphasizes core strength while yoga emphasizes flexibility

Depending on classification it may make sense for you to do one or the other, or both, or possibly neither!

Factors:

• Low back pain classification
• Underlying condition
• Time and Interest
• General activity level

See an expert at Altitude! All our physical therapists are experts in identifying movement patterns and dysfunctions as well as classifying the best way to treat your low back pain!

​One of the things I absolutely love about the physical therapy profession is our ability to teach our patients how to take care of themselves. We are so fortunate to have the education and knowledge to help our patients prevent further injury to the best of our ability. 

​The answer that any business-minded physical therapist will tell you is that you should ALWAYS come see us! But that’s not always feasible for everybody… I will tell you that I firmly believe you should seek guidance whenever you start a new workout or exercise routine to ensure proper form and reduce your risk of injury. As human movement experts, physical therapists are more than qualified to help smoothly transition and initiate new exercise regimens.

​In my 8 years of working as a physical therapist, I’ve learned a lot about what someone’s body can tolerate in terms of exercise and physical activity. Here’s a pretty unpopular opinion: body aches and pains are normal! Of course everyone wants to be pain-free all the time, but that’s just not reality. In fact, it’s why the phrases like “it hurts so good,” and “feel the burn,” even exist! Working out and exercising pushes our body beyond its limits so it can continue to strengthen and improve. 

​Back to the question at hand: self care versus physical therapy.  As I mentioned above, always seek advice and instruction prior to initiating any new workout or physical activity to avoid injury. That being said, my advice, which may differ from other physical therapists, is to evaluate your pain/discomfort on three aspects:

​If your pain is piercingly sharp, my recommendation is to seek physical therapy right away. If the pain lasts longer than 48 hours, I recommend getting it checked out. Lastly, if the pain is super consistent - for example every single time you step downstairs it hurts in exactly the same way - having someone fully evaluate it is the best way to go. 

​Our body will have aches and pains here and there when we transition into a new workout routine, or go skiing for the first time in the season, or initiate a running program after sitting on the couch for months. These are expected and relatively normal. However, if you notice that the pains become sharp, last a long time, and are consistent - give us a call! To get you started with your new routine or evaluate your pain, we can utilize our telemedicine platform! This allows us to gather a full history of your pain/injury and complete a movement screen. Then we can get you started on your road to recovery as quickly as possible through exercise and advice - and ultimately avoid serious injury!

​If you’ve ever had pain in your jaw (or currently have pain in your jaw) you’re not alone!  According to the National Institute of Dental and Craniofacial Research, the prevalence of jaw pain is about 5-12% of the population.  It is more common among individuals aged 20-40 years and is about twice as common in women as men.  Jaw pain can range from a mild annoyance to something which is so severe that it limits an individual’s ability to talk, eat, and brush their teeth.  Many providers - physicians and dentists alike - don’t quite know the best way to address their patients’ jaw pain, and many people have no idea that physical therapy can be so helpful in treating this condition.  Before I tell you how physical therapy can help, let’s get a little better understanding of the anatomy of the jaw and the various things that can go wrong.

​When we talk about jaw pain, we are usually referring to the temporomandibular joint, known as the TMJ for short.  You can feel this joint just in front of your ears, try it!  Place your fingers at the back part of your cheekbone just in front of your ear and open and close your jaw.  That’s your TMJ!  A fun fact is that you can also feel the TMJ move if you put your finger just inside the tragus of your ear, which is the little cartilage flap on the front of your ear.  If you place your finger just on the inside of that and open and close your jaw, you can also feel your TMJ moving.  The joint you’re feeling joins your mandible (jaw bone) to the temporal bone of your skull.  There is an articular disk that separates the two joint surfaces.

​When you come to physical therapy for jaw pain, you might be told that you have temporomandibular dysfunction (TMD for short.)  This just means that something in that joint, or the structures surrounding that joint, isn’t functioning properly.  Symptoms of this can be pain, clicking, popping, grinding, clenching, or tightness.  It is important to note, though, that popping or clicking on their own don’t necessarily mean that something is wrong and that you need to seek treatment.  In the absence of any other symptoms (such as pain or tightness,) clicking and popping can be just fine.  Sometimes, you can also get symptoms which might not seem directly related to your jaw but can be associated with jaw dysfunction.  These can include neck pain or stiffness, headaches, ringing in the ears, and even dizziness.  These symptoms can be caused by dysfunction of the joint, the muscles around the joint, the articular disk, or any combination thereof.  Your physical therapist will help narrow down which structures to focus on based on tests and measurements performed at your first visit, as well as from taking a thorough history to better understand how your symptoms began.

​Treatment for TMJ pain often includes a combination of techniques including joint mobilizations, soft tissue techniques, home exercises, and even dry needling.  Your therapist will tailor your exact treatment plan to you based on their findings at your initial evaluation.  With this individualized treatment plan, physical therapy can be highly effective at treating any unpleasant jaw symptoms you might have!

​Simply put, the deep neck flexors are the equivalent of the core for the neck. When we think about our core, we often are referring to our abdominal muscles in the trunk. These mostly support our low back or lumbar spine. The good news is that we have similar supportive musculature for our neck - the deep neck flexors!

​There are two main muscles that make up the deep neck flexor group: the longus capitis and the longus colli. In as lay terminology as possible, the longus capitis muscle attaches from the base of the skull to the front side of vertebrae from C3-C6 and the longus colli muscle runs along the front of the spine from C3 down to T3. Any rehabilitation that is focused on improving a forward-head / rounded shoulders posture or any rehabilitation from a neck injury should include some form of exercise for these muscles. The typical exercise is something we call the “chin tuck.” I often refer to this as “the sit up for the neck.” 

​The challenging part of this deep neck flexor group is being able to isolate and access it without recruiting other neck musculature. When you truly look at the anatomy of the neck, you can see that this deep neck flexor group is named such because it lies “deep” to the esophagus and trachea. This is where the challenge of access comes into play because there are many muscles that work easily but are “superficial” to the esophagus and trachea. These muscles are used for swallowing, talking, chewing, etc. So, in physical therapy, we need to teach our patients how to turn those muscles off and turn the deeper ones on! 

​We learn in physical therapy school that strong deep neck flexor muscles are able to hold a chin tuck and lift position for 30 seconds. In my 8 years of working as a physical therapist, I can attest that upon initial evaluation of these muscles I have never had a patient be able to do that. With practice and guided exercise, my patients are able to strengthen this unique muscle group and this ultimately leads to improved stabilization of the neck. This equals significantly less neck pain and improved posture. 

​Most of our patients understand the importance of core strengthening to help maintain health and reduce injury in the low back. The same holds true for the “core of the neck.” If you have any questions or feel like this is an area of your routine that you are missing, any physical therapist at Altitude would be happy to help you properly learn how to strengthen this deep neck flexor group. It’s a small group of muscles but they sure are important!

​We get this question a LOT in our profession. Much like every other question in our industry, the answer is not so straightforward. I’ve been working as a physical therapist for 25 years and have been casting orthotics for 20 years and I still don’t have the exact answer to this question! However, I have learned a great deal regarding this topic over time, and I’m here to share it with all of you.

​First let me start out by saying that I truly don’t believe everyone needs orthotics. Sometimes it is a matter of wearing the correct shoe or supplementing with the correct exercise. That being said, by the time someone comes to see a physical therapist with a significant gait abnormality, it can be very challenging to fix it through manual therapy and exercise. We start walking around age 1, the arches in our feet finish developing around age 10, and it usually isn’t until age 30, 40, or 50 that we start thinking we are walking funny. That’s potentially 20, 30, 40 YEARS of an established motor program that needs to be reset. Now, I said “challenging” to fix it…. not impossible.

​The way we decide if someone truly needs orthotics is if all our other avenues fail. As movement experts, we use external support as a last resort. We first assess your posture from head to toe. We look for things like scoliosis, leg length discrepancies, hip dysfunction, ankle restrictions, big toe mobility, balance issues and strength. We use manual therapy techniques like joint mobilizations, dry needling, taping, and myofascial release to improve quality of gait movement. We emphasize strength throughout core, hips, knees, ankles and feet to ensure proper motor control.

​Depending on what the issue is, we typically can identify if someone is a good candidate for orthotics after 8-10 sessions of physical therapy. That usually equates to around 6-8 weeks of care. If we don’t see a significant change in gait AND you, as the patient, don’t report an improvement with our strategies, we dive into the orthotic discussion.

​From my personal experience, casting orthotics is the best way to go for the most custom design. There should be a non-weight-bearing foot assessment, a weight-bearing static assessment and a barefoot gait assessment. We know that not everyone should walk exactly the same way, but there are certain aspects of gait that should be apparent in every gait cycle. For example, the ability of the rearfoot (heel) to move through neutral should be present, but some patients will move through 10 degrees of motion whereas others may move through 3. That may sound like gibberish to you, but I share it with you so you can understand that not all gaits are created equal, but they serve their purpose to allow us to walk! Ultimately, I believe the orthotic should support the way your body wants to walk and not necessarily CHANGE it - an assessment we would make in our physical therapy visits. Custom orthotics can be quite the investment and there are semi-custom options that are available and help determine if a full custom option is worth it. These are typically heat-moldable but less durable. The BEST news:  Altitude can help you with any of your orthotic needs!

​So, to answer the question of “how do I know if I need orthotics?”.... the answer is to come see us! We can ensure a thorough evaluation and attempt all other options of exercise and manual therapy prior to making the orthotic decision. Like I said in the beginning of this post: not everyone needs orthotics. Let us help you figure it out!

​There has to be something like over 1 million different types of shoes out there, right? How do you know which shoe is best for you? The answer to that question is one that we hear in physical therapy school a lot….. IT DEPENDS!!! **also note that these are my professional opinions and I have no affiliations or relationships with any particular shoe brands**

​There are always going to be fads and trends when it comes to footwear. For example, the finger toes, the barefoot running shoe, the Skecher ShapeUPs, the HOKAS, the skater shoe, Converse, AirJordans, Asics, Nikes, and the list goes on and on. This blog is meant to cover shoe selection generically and finish with the burning question I get from aging runners - Should I switch to HOKAS (or cushioned shoes)??

​When it comes to shoewear, there are a lot of things to consider. Are you running? What type of surface are you running on? How often do you run? How far do you run? Are you walking? Where do you walk mostly? Are you in any foot pain? Do you have any pain with walking? Do you wear gym shoes all day? Do you wear high heels for work? Do you wear sandals in the summertime? It’s quite the specialty to pick the perfect shoe for someone and we almost never get it right the first time… 

​When you come to physical therapy and ask the question, “but which shoes are best for me?” your physical therapist will start asking the above questions. They’ll also follow it with a gait or running analysis in addition to a movement screen. They’ll check the range of motion of your low back, hips, knees, ankles, and the tiny joints in your feet. The most important thing about selecting a shoe is finding one that will SUPPORT your current and preferred movement pattern versus attempting to CORRECT it.  In my 7 years of working with runners and hikers in Colorado, I have only once ever recommended a MOTION CONTROL shoe for a patient. More frequently, we are able to address motor control deficiencies before relying on an external source, like a shoe, to correct any gait or running deviations. 

​Now, to address the most recent fad or trend in shoewear, I’m going to talk a little bit about HOKAS or shoes that have a lot of cushion. I took two intensive running courses over the past 7 years and they presented similar information regarding the theory behind HOKAS. The idea is that the significant cushion will reduce shock absorption through the rest of the body. The reason I write THEORY is that this is almost impossible to prove with the current technology (at least at the time I’m writing this blog). There are studies that show ground reaction forces when wearing HOKAS and when BAREFOOT. Ground reaction forces are a measurement of how hard you stomp on the ground. This measure has an equal and opposite force through your body.  Ultimately, the study found that there was no change in the magnitude of your ground reaction force. Where the study is limited is showing WHERE the ground reaction force is being absorbed. Hence, THEORY. With that great of a cushion, the assumption is a large amount of that force is being absorbed by the shoe and not your joints. 

​So, I always get the question from the aging runner - should I switch to HOKAS? And just as I started this blog, the answer is - IT DEPENDS! If I watch you run, jump, hop and I can see you have a difficult time with absorption through musculature and joints, I may recommend the HOKA-type shoe. But if I think it’s something that you can train and work up to, I would go down that path first. In my opinion, the downside of HOKAS is that the cushion significantly increases the distance between the sensors in your feet and the ground. Basically, your entire lower kinetic chain takes longer to process any feedback from the ground and this can often lead to ankle sprains, falls, and other injuries.

​I also mentioned in the beginning of the blog that selecting the perfect shoe is incredibly challenging and that we almost never get it right the first time. There are so many factors in addition to what I’ve already discussed from a physical therapy standpoint. We need to take into consideration cost, cosmetics, comfort, durability, fit, and ease of getting them on and off. I may very well pick a shoe that I think is perfect for you, you’ll test it out and absolutely hate it! This is where your shoe history is incredibly helpful. I often find that whatever shoe you used to wear all the time is likely the correct shoe for you - we just may need to adjust your motor control for efficient muscle firing during walking or running.

​And if we simply cannot find the right shoe for you, that’s when we start considering orthotics. The question of “how do I know if I need orthotics?”.... Well, that’ll be for another blog post :) 

​There are many factors that can contribute to Achilles tendonitis and plantar fasciitis. The number one factor is usually an overuse of the gastroc-soleus complex. The two muscles in your calf join together at the Achilles tendon in the back of the heel. When this structure gets overused, it can pull the heel bone (calcaneus) in a way that irritates the plantar fasciitis in addition to it just getting irritated right at the Achilles tendon. 

​The real question we ask as physical therapists is “Why Are You Using Your Calf So Much!?” Ironically, your calf being tight may be the immediate source of your pain but more often than not your pain is probably coming from a lack of strength or range of motion somewhere else entirely. I have found throughout my experience in physical therapy and taking two intensive courses on running injuries that there are two main places that can cause an overuse of your calf muscle: 1. Hip Extension Range Of Motion and 2. Great Toe Extension Range Of Motion

​In the gait and running cycle, we have phases called “terminal stance” and “pre-swing,” which is when our toe just barely comes off the ground to take that next step forward. This particular position requires a certain range of motion at the hip and big toe. The hip should be able to achieve at least 10 degrees of extension and the big toe should be able to achieve at least 60 degrees (if walking) and up to 90 degrees (if running) of great toe extension. 

​If you take a look at this picture, you can see that the femur (thigh bone) is angled slightly behind a totally vertical line (imagine a straight line from the pelvis down to the ground) and that the big toe is starting to extend or bend as the foot/ankle rolls through. This position allows optimal contraction of our gluteus maximus muscle - the huge power generating muscle of the entire lower kinetic chain. When the range of motion is limited in the big toe, we cut the terminal stance and pre-swing phase of gait short. This means we get off of the foot more quickly and we don’t access the range of motion that allows the glute to work. Thus, we use something else - the CALF. The same principle applies with limited hip range of motion. If we can’t get our femurs to extend beyond neutral and into that 10 degrees of extension, the glute cannot properly fire so we again ask the calf to help with power more than we normally would. As luck would have it, when I have a patient come in with plantar fasciitis or Achilles tendonitis, they are usually lacking BOTH hip range of motion and toe range of motion - double whammy. 

​Can it be fixed?! YES! My approach to treating plantar fasciitis and Achilles tendonitis is to treat locally first. This means treating calf tightness to help with symptom management right away - massage, dry needling, stretching, etc. As the calf responds to treatment, we are able to shift gears to the actual origin of the injury. This usually includes manual therapy to the big toe or the hip to improve any limitations noted. Whilst improving the range of motion is a big component to improving the motor efficiency in your gait cycle, there needs to be accompanying functional exercises to promote muscle activation in the appropriate positions. This is where physical therapy can get really fun and creative using balance equipment, speed adjustments, plyometrics, and sport-specific exercises.

​There is this concept we discuss in physical therapy where we describe being strong throughout the available range of motion. What this means is that even if we improve your flexibility and range of motion, you’re still at risk for injury if you don’t know how to CONTROL that new range of motion. But once you learn to do this, your risk of re-injury is significantly less - assuming you keep up with your homework!

​This blog was meant to discuss the most common reasons plantar fasciitis and Achilles tendonitis may occur, but is certainly not all-inclusive. Overall, I want to remind all patients that the longer plantar fasciitis or Achilles tendonitis are bothering you, the longer it takes to heal. Don’t wait too long to get it checked out! Key identifying factors are sharp pain felt in the center of the heel, pain felt along the inside of the heel, pain in the arch of the foot, pain in your Achilles tendon, and pain with your first steps out of bed in the morning. If you feel like you have any of these nagging pains, let us know and we can get you started on your road to recovery!