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Interviewer: As technology and practices have improved, more people than ever are receiving joint implants. In fact, "The Journal of Rheumatology" projects as many as 600,000 joint replacements in the U.S. by the year 2030.

With more folks receiving an implant, how do you take care of it and ensure that it lasts as long as possible? To answer those questions, today, we are joined by Dr. Mike Archibeck. He is an associate professor with the Division of Adult Reconstruction at University of Utah Health.

Now, Dr. Archibeck, for someone who has just barely received a replacement joint, whether it be a knee or a hip or something like that, what do they need to know about taking care of it for, say, the first year after surgery?

Dr. Archibeck: Yeah. So I think I'm primarily going to talk about total knees and total hip replacements. That's kind of the purview of the Adult Reconstruction Division in the Department of Orthopedics. So we do total knees and total hips as well as revision total knees and total hips.

And so there are a few things that are generic in regards to how to maximize your recovery early after surgery. Most would consider the first year as kind of the recovery period. It's been shown that both hips and knees generally do improve over that year, even though the vast majority of the improvement is in the first few months.

And during that first year, there are a few things you can do to kind of maximize the outcome and protect it from the dangers. Early after surgery, one of the most common complications is a blood clot in the leg or something that we call a deep venous thrombosis. So, usually, patients are prescribed some form of blood thinner. It could be aspirin. It could be something stronger. So being sure to do bed exercise during the day, get up about every hour or so, and go for a short walk.

You also want to be sure that the wound heals. So one of the concerns early after surgery is infection. Try not to overdo it such that the knee or hip area becomes too swollen, that can slow or compromise wound healing, and being sure to avoid any other types of infections that you might get early after surgery, like a urinary tract infection or a skin infection.

So if any of those things develop, or dental issues, you want to touch base with your surgeon and be sure those are treated so they don't potentially get into the bloodstream and make it to the hip or knee replacement.

And then recovery-wise, some patients participate in formal physical therapy. And more commonly now, more and more patients are doing kind of directed physical therapy, but working on whatever the tasks might be that the therapists direct you to do.

So with a knee, early after surgery, one of the high priorities is working on range of motion. A hip, less of a concern range of motion, but with both, starting to work on gait training initially with a walker, and then subsequently, weaning to a cane, and gradually off. Usually, that process is coached by the therapist or the surgeon and his team.

And trying to avoid overdoing it. Like I mentioned, you can really set yourself back if you do too much too soon. You can get swollen, wound healing can be slower, and it can just be more painful and kind of slow the recovery process.

So, again, the main things to be careful about are watch for the signs of blood clot, which would be significant swelling in that leg that does not respond to elevation, protecting the wound from infection, and just being an active participant in your recovery and physical therapy.

Interviewer: For someone who has received a joint replacement or is about to have joint replacement surgery, the recovery takes anywhere from 10 months to a year. So when will they see the most improvement? I mean, when will they start walking again?

Dr. Archibeck: Yeah. So, with both, you'll really be walking the day of surgery, obviously to a limited degree, and you'll be using a walker typically. But with both, you're generally able to place as much weight on that implant or that extremity as you want.

But like you mentioned, the first few months, the improvement is very rapid. So week to week, you see a significant improvement.

The improvement after those first few months is a little more subtle. So you may not notice dramatic changes like you do early after surgery, but it will continue to improve, and you gain more confidence in it, and you think about it less as time goes by.

But most people kind of describe the first six weeks as the majority of the recovery, so that's really the time frame when the focus is on avoidance of complications. So blood clot, infection, things like that.

Interviewer: Wow. So after the first year, the body is healed up, we've made sure that the wounds are not getting infected, we're not getting clots, etc., but now we have a piece of hardware in our body. What do we have to do to make sure that we're taking care of the implant and make sure that we get as long of a use out of that implant as possible?

Dr. Archibeck: There are several things that are important to know. So one is how do these things fail? And there's a little bit of a difference with knee replacement and hip replacement, but in general, they can still fail by infection. So, obviously, that's a life-altering event if it occurs.

And generally, it's felt that that is caused by a remote infection that then enters the bloodstream and finds its way to the joint replacement. So, unfortunately, a chunk of metal like a hip and knee replacement is always more susceptible to infection than a native healthy joint.

So you just want to take generally good care of yourself. Keep your dental work up to date. That can be a potential source of infection.

Interviewer: Really? Dental work?

Dr. Archibeck: Yeah. In the past, they used to recommend antibiotics prior to any dental work, and that still is a bit of a controversial topic, but that's not felt to be absolutely necessary unless you're high risk or have multiple joint replacements. But again, that's a topic you'll get different opinions about.

Any other bacterial infections, so common ones would include urinary tract infection, skin infections on that leg or other areas, obviously sinusitis, pneumonia. As you typically would if those things develop, you just want to be diligent about getting them looked at and treated, and more so if you have prosthetic joints.

I mean, obviously, we're talking about hip and knee, but there are elbow replacements, ankle replacements, and others. So any bacterial infection can potentially go to those areas. So just kind of taking good care of yourself like you generally would.

Implants can wear out. So, luckily, hip and knee replacements, the materials that we use have significantly improved over time over the last couple of decades. And so, even at 20 years, most are still functioning well, but they do wear and tear.

So a few things you can do in that regard. It's generally recommended that you avoid repetitive, high-impact activities, such as running, for exercise or aggressive cutting and pivoting sports. Things like walking, hiking, biking, swimming, golfing, dancing, most people feel like skiing is fine, are all activities that are absolutely fine to do and don't need to be limited at all. You can do as much as you want.

Then there are those in-betweeners, like tennis, pickleball, skiing, where some of those the risk is more the risk of a fall. But generally speaking, those activities are felt to be okay too, just avoiding the really high-intensity cutting and pivoting type things.

The other thing that can help add to the longevity of an implant is maintaining a good body weight. So it's been shown that the risk of wear and tear . . . and by that, I mean the plastic can wear or parts can loosen. The risk of those issues arising increase a bit as your BMI, or body mass index, increases. So trying to maintain a good body weight is helpful. Avoiding high-impact activities.

And then another rare cause of failure would be an injury of some type. So the implants themselves are very durable. But obviously, the bone adjacent to the implant can be susceptible to fracture or injury.

Especially as you get into your advanced years, being careful to avoid situations that might put you at risk for a fall or an injury, making sure your home is safe in regards to no obstacles on the floor or edges of rugs, and just kind of doing your best to minimize the risk of a fall. A fracture around an implant obviously is considered a failure and typically requires surgery to correct.

With that being said, though, like I mentioned, when patients ask, "How long do these things last?" we give a relatively simple answer, like, "Hopefully 15 to 20 years." But to be honest, even at those intervals of time, the vast majority are still functioning well. Yeah, they're pretty durable implants.

Interviewer: What I'm hearing is after you get your joint replacement, if you take care of your body, your health, your weight, and so on, that your implant can last as long as 15 to 20 years?

Dr. Archibeck: Yeah, I think that's fair to say. The other thing that I should mention is that even if a joint replacement is functioning well, it's wise to see your physician. And recommendations vary, but I would say probably about every five years.

So the first year, there's a regimen of post-op visits. Usually two weeks, six weeks, maybe three months, a year. After that, though, we usually let patients go for a while. And it's wise, though, to return and get an X-ray and be evaluated, I would say, anywhere from every five to ten years.

The reason being is that there are things that can occur with the hip replacement or knee replacement that aren't always painful. So if you get a little bit of plastic wear, that might be something that we would be able to see on X-ray, but may not be a painful problem.

And sometimes, if caught early enough, the solution to that issue is relatively simple. If caught late, when it's maybe resulted in loosening of an implant, it can be a much more problematic issue to correct.

So routine follow-up, even after that first year, is wise. Especially as you get to the 15- to 20-year interval of time since surgery, then it becomes even more important because that's about when our concern kind of increases a little bit in regards to the risk of some of these wear-and-tear type mechanisms of failure.

The other thing that's worth mentioning is beyond just having it last a long time, obviously all patients want it to be as comfortable and functional as possible. And it's true that a hip replacement and a knee replacement probably will never feel like a totally normal joint, but the closer we can get it to that, the better.

And typically, hip replacements, for whatever reason, seem to approximate a normal hip more closely than a knee replacement. In other words, it's much more common to have some residual symptoms with a knee replacement.

But the most common reasons we see patients back who maybe had a knee replacement or a hip replacement five years ago, 10 years ago, and just somehow, again, feel concerned that it's not as comfortable as possible, or as they were hoping it would be, include weakness.

So that early post-op time frame, like we mentioned, it's important to work on strengthening. Maintaining that strength is equally as important to allow that hip or knee to function as good as it possibly can.

Again, maintaining a good body weight. It's been shown that if your BMI kind of creeps up a little bit, sometimes the patient's satisfaction level with their replacement decreases. So even though it's not intuitive that that would be the case, maintain a good body weight, maintain good strength.

And obviously, if it really seems like something is wrong, if it's painful and it seems to be not resolving or worsening, then you definitely want to see your physician to kind of rule out any concerning findings.

But again, continuing with those strengthening exercises, maintaining a good body weight, those things can help the joint replacement function most effectively for a long period of time.

Interviewer: Now, going back to that idea of satisfaction, if a patient gets a replacement and is able to take care of it for those 15, 20, or more years, what kind of improvements in quality of life can they expect after receiving a joint replacement?

Dr. Archibeck: That's a good question. The good news is that the vast majority of patients, even though they may have some residual symptoms, feel as though they're dramatically improved when compared to their status preoperatively.

So like I mentioned, it's often the younger patients that maybe notice the limitations or the shortcomings of joint replacement because of maybe their demands of it or their expectations of it.

Because they're just by nature more active, they may notice those limitations a little more than a very elderly patient that maybe isn't as active. Those patients often feel like, "Hey, this does feel pretty normal to me," whereas, maybe the younger, more active patient feels that they're still a little limited by it.

But like I mentioned, most patients, younger or older, generally feel significantly improved after surgery.

And as I mentioned earlier, they should expect to be able to participate in those activities that I mentioned without significant pain: walking, hiking, biking, swimming, things like that. The more demanding activity is, so things like stairs, squatting, walking up or downhill, long hikes, it's not uncommon to still maybe develop a little fatigue or a little ache in the joint. And those things, unfortunately, may persist.

So, with knee replacement, it's been estimated that about 15% to 20% of patients continue to have some degree of what they describe as pain, even though most patients are still very satisfied. Hip replacements, it's a little less. So maybe 5% to 10% of patients still have occasional pain. So, yeah, unfortunately, not a totally normal joint, but definitely typically a significant improvement.

Although the things that I mentioned, like infection or injury, are extremely scary and worrisome, they are very, very rare. And most people do very well after hip or knee replacement in regards to a significant improvement in their quality of life, both in regards to the level of pain that they have as well as their level of function and the activities that they're able to participate in.

Interviewer: You hurt your back. What can you do on your own, and when should you go see a doctor? Dr. Andrew Joyce is a physical medicine and rehabilitation specialist. He's also an expert at helping patients manage neck and back pain.

Dr. Joyce, I was shocked to find out that low back pain is the number two reason Americans see their healthcare provider. Is it for this kind of acute back pain that we're talking about that they're usually seeing their doctor for?

Dr. Joyce: In most cases, yes. I think a lot of people have chronic low back pain as well, but I think most of us tend to see a lot of acute low back pain, and particularly my primary care colleagues see tons of it.

Interviewer: And we're talking in this particular Q&A that we're doing together about acute back pain, which is back pain that you were just doing something and you hurt yourself, right? Is that kind of what we're talking about there?

Dr. Joyce: Yeah. And it doesn't even have to be doing anything in particular, but you wake up, you have back pain, and you don't know where it came from. Or you were lifting something and tweaked something, threw out their back is a common phrase that people will use, all of those count as what we're talking about today.

Interviewer: And technically, when you say "acute back pain," that's back pain that lasts less than four weeks, right, four weeks or less?

Dr. Joyce: Depending on which guidelines you use, some people say four weeks, some people say less than six weeks, but somewhere in that range.

Interviewer: All right. So, but if I hurt my back like one day, I don't know how long it's going to last. So is there a better way to kind of determine what type of back pain I have? I suppose if I was doing something, it's pretty obvious that, oh, well, I tweaked my back doing that. But like this wake up scenario, how could I tell that maybe that isn't a symptom of something bigger? Because a lot of times back pain is a symptom of other things, isn't it, you've got to kind of rule out?

Dr. Joyce: Yeah. Yeah. And so that's when we start looking at kind of these what we call red flags. So it's very common that people will hurt their back, and oftentimes the pain can be very severe and debilitating. Severity doesn't always correspond with something being necessarily worse. There's actually set of red flags that we look for to kind of try to triage and look for people who might be at risk for having other sources of back pain that warrant further investigation.

Interviewer: All right. So before we kind of get to then acute back pain, I think it's really important to hit those kind of red flags to somebody can make an informed decision that they need to see their healthcare provider sooner than later, or trying to take care over themselves. What are those red flags?

Dr. Joyce: Big ones are trauma. Obviously, if you were like in a car accident, that would factor in. If you have new fevers, numbness, tingling, weakness in your legs. If you have a history of cancer, if you're having any bowel or bladder changes, you use any blood thinners, have cancer, have IV drug use, all these things could put potentially be risk factors. And those were reasons that we'd want you to be evaluated more soon.

Interviewer: And if a patient doesn't believe that that's the case, if they truly just believe, oh, I must have slept funny, or I did something, what can a patient do on their own for acute back pain before they need to see a doctor? What are some recommendations you would have?

Dr. Joyce: Yeah. So the first thing we actually recommend is that you avoid bed rest. Fifty years ago, everyone got recommended, "Oh, just stay in bed, let yourself heal." And what we found is that we were actually giving people a lot of bad advice.

What we recommend now is actually that you try to stay as active as you can tolerate. For most people when they're having an acute back pain flare, they're pretty uncomfortable. So even simple things like getting up, showering, cooking a meal, eating can be somewhat uncomfortable, but our recommendations are to actually try to stay active because recovery is faster when you do that.

Interviewer: And is that because you're getting more blood to the area? What's going on there? Do we know?

Dr. Joyce: I'm not sure if we have exact answers on that. Some of it is that we're probably reducing some of the stiffness. When people have a lot of back pain, they don't move their muscles, they get really stiff and that can cause more pain.

I think we're also testing it. Some people with back pain are really afraid that they're going to do damage and so they don't do anything. And so then their muscles start getting weaker. Within a week, you can lose a large percentage of your overall muscle mass just by not moving and staying in bed. And so by keeping your muscle strong and keeping you moving, you help stretch and strengthen those muscles and help your body on the way to recovery.

Interviewer: And this extra moving, you're not going to hurt yourself most of the time. Is that correct?

Dr. Joyce: As long as you don't have one of those red flags, in most cases, you are able to go out and do whatever you need to do, knowing that there may still be some pain due to this flare-up. But it's safe to go out and be active. In fact, it's kind of the treatment of choice at that early stage.

Interviewer: All right. So get active or just be active as much as you can tolerate. What are some other things that a person could do before they go see a doctor?

Dr. Joyce: They can try over-the-counter medications. So nowadays, we have the Salonpas patches or other lidocaine patches that people can use. There are a variety of topical creams. There's Tylenol. There's oral anti-inflammatories that people can take. All of those are over-the-counter and are medications that patients can try out.

Additionally, this somewhat depends on your insurance plan, but sometimes you can get direct access to physical therapy without even needing to see a doctor in certain cases. And so that's often a reasonable place to start.

Interviewer: And then what amount of time doing those types of things should a patient wait until they start to see some relief or start to be concerned that, "Oh, maybe this isn't acute"?

Dr. Joyce: Yeah. So I would give it at least two weeks and see how you're feeling at that point. If at that point you're not getting better, that might be a good time to at least start scheduling an appointment with your doctor. Most patients with back pain will recover within two weeks.

The next set will kind of get better over the course of six weeks. And definitely if it's been over six weeks, it's probably worth seeing a physician to evaluate you.

Interviewer: And then when you come into your physician, you could go to a primary care physician, or could you come to an expert such as yourself at that point? What would you recommend there?

Dr. Joyce: If you have a good, established care with a primary care physician, I think that's a great place to start, and they will often be able to help you. If you have any concerns, or if for some reason you're not able to get in, or you don't have a primary care physician, we're always happy to see people and get people in from the ground up and make sure that they're getting treated appropriately.

Interviewer: All right. And then what types of things would you do at that point for a patient that has gone two to four weeks not necessarily seeing the kind of recovery that they'd like? What are you looking for at that point?

Dr. Joyce: Yeah. So, at that point, we likely would get some imaging, probably starting with an X-ray, just to check to see that the bony structures are intact and there's no new issues. And sometimes there are things on the X-rays that can clue us into other potential sources of pain that we might not otherwise be able to see just from our physical examination.

We'd prefer a full history and a physical examination to really get a better picture of the back pain and understand how it fits in with your other medical conditions and if there's any other rarer conditions that we really need to be looking at.

At that point, then we make a decision, based on everything, on what the next treatment plan should be, whether it be a formal referral to physical therapy, whether it be more advanced imaging in preparation for certain procedures, and considering different injections.

Interviewer: What about surgery at that point, or when does that come into play?

Dr. Joyce: Most patients don't need surgery. And that's one of the great things. The natural history of these, which means how people do if we do nothing and just let people live their lives, is that most people recover with it over time. It just can be very debilitating during that time.

And so, in most cases, surgery isn't recommended. If you do have one of those red flags, I think it's worthwhile to get evaluated, and then we can see whether surgery makes sense. But in most cases, there's nonsurgical options that we will try first and see if we can help get this under control or get your pain better before having you meet with the surgeons.

Interviewer: And then how about you using opioid medications for back pain? Is that ever a good idea?

Dr. Joyce: In most cases, I would say probably not. There are always exceptions to the rule, so I don't want to say never. But in general, opioids aren't really a first-line treatment for back pain. And if you look at the CDC or you look at other organizations, such as the American Academy of Family Medicine, they don't recommend opioids. And part of the reason is that they've been shown to have higher risks, which we all know through the opioid epidemic, but also no significant benefit when compared to other over-the-counter medications. So Tylenol and Advil versus opioids, the studies show that they're roughly equal in terms of controlling the pain and the opioids carry a much greater risk. So, in most cases, we try our best to avoid opioids because we don't want to risk our patient's health.

Interviewer: And when you're talking about over-the-counter painkillers for back pain, do you just follow the directions on the boxes to what your dosage should be, or generally do you recommend to your patients a higher dosage?

Dr. Joyce: It depends on the medication, but, in general, I probably will recommend for Tylenol, you can take up to two Extra Strength Tylenols, and you can do that three times a day as kind of a high-level dose of Tylenol.

And then for the anti-inflammatories, the low doses of the medication tend to be more pain relievers. And at the higher doses, they tend to have a little bit more anti-inflammatory effect. And so sometimes, for a medication like Advil, we can recommend up to three tablets of regular Advil three times a day.

Any more than that, you should probably be seeing a doctor or checking in with them to make sure you're not using too much medication because that can have other side effects.

Interviewer: So maybe you or a loved one has a bony protrusion on your foot. It's maybe painful, maybe not. It's a bunion. How exactly does one treat a bunion and what kind of results can one expect from the treatment options?

We're here with Dr. Devon Nixon. He is an orthopedic surgeon at University of Utah Health, with an emphasis on lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, before we kind of go into treatments, let's just start real basic. What is a bunion exactly?

Dr. Nixon: A bunion is an interesting thing that we see really commonly in clinic. It's more than just a bump that's forming on the inside part of the big toe. What's actually happening is there's a complex three-dimensional change that's occurring where one portion of the toe is beginning to move towards the inside, which then drives the big toe part towards the second and third toe. And it may begin to even cross over under those second and third toes.

Interviewer: And is there any way to, say, prevent them?

Dr. Nixon: I wish there was a way to prevent them. They're very common, and certainly not everyone with a bunion needs surgery. And so there are plenty of things to do to try to make them more comfortable, like modifying your shoes or adding a toe spacer. But unfortunately, those options don't necessarily change the long-term progression, which is that the bunion may slowly increase over time.

Interviewer: So let's go back a little bit with that. When you're talking about treatments, you said it's not necessarily surgery. If we're not doing surgery, what are the other options available, and what are you actually treating with those?

Dr. Nixon: Like most things in my practice and in most orthopedic practices, there are nonsurgical and surgical treatments. And the nonsurgical things that many patients choose to do are to add some modifications to their shoes. So they get them in wider forms to help reduce some of the irritation on the inside part of the big toe, which, for many patients, is one of their biggest pain drivers.

Another thing is they can add over-the-counter gel inserts that slide between the big toe and the second toe to help push the toe a little bit out of the way to make it more comfortable.

And those are all driven based on symptoms. So the choice of whether or not to move forward with surgery is a patient-driven choice. It's certainly not one that I will make for them. My goal is to help them have the information they need to make the right choice.

But the options after modifying your shoes and adding an insert, there's not a lot of in-between. So, unfortunately, the conversation may then move towards, "What are my surgical options?" which are to help get the toes straighter and to help remove the bump.

Interviewer: So let's move on to those surgical options. As an orthopedic surgeon, any time a patient hears the word "surgery," there's a little bit of anxiety. There's a little bit of weighing the risks and benefits. Kind of walk us through the surgery. Not necessarily the nuts and bolts of everything, but as a patient, is this an outpatient procedure? How long can I expect to recover, etc.?

Dr. Nixon: Absolutely. I mean, I'm a surgeon, but I'm extremely sensitive to the fact that no one wants to go through surgery. And my job will never be to sell anyone on the surgery. It's the patient coming in to tell me that this is what they think is the best option for them. They feel like they've tried these other things.

And then the different technical options for surgery vary from patient to patient. So it's driven by a lot of factors, some of them clinical, some of them on the X-ray, some of them very patient-specific.

But largely, what we're doing is we're trying to correct the bunion by straining the big toe. And you can do that by either cutting the bone and shifting it. We call that an osteotomy.

You can fuse certain joints around the big toe. So one of them is fusing a joint closer to the middle of the foot, and we call that a Lapidus procedure.

And then another procedure is, depending on the patient, if they have some arthritis that's developed, you can fuse the actual big toe joint itself.

But a lot of these decisions of what to do from a surgical perspective are not uniform to everyone. So that's a conversation that we all have in clinic. If patients feel like they're at a surgical level, I look at the X-rays, I talk to them, get a good history, understand their activity level, what are their goals, and if there's any arthritis present, and then we talk about, "What are these varying treatment options?"

Interviewer: So a surgery like this, how long can someone expect to be undergoing treatment? How long does the procedure last and how long is recovery?

Dr. Nixon: Yeah. The surgery is an outpatient procedure. You go home the same day. The main goal is that . . . Depending on which type of surgery to do, it doesn't really change the fact that for the first four to six weeks, we're going to be keeping you off of your foot in terms of full weight out at the big toe.

If we're cutting the bone, doing what we described as an osteotomy, we need that bone to heal. And if we're trying to get joints to fuse, then we need those bones to heal together too. And so there is a form of protected weight-bearing, which can be challenging if it's your right foot because it's going to limit your driving.

But the first two weeks, you have sutures in. They get removed at two weeks. And then between Weeks 2 to 6, you're kind of protecting your foot, and then usually get X-rays around the six-week mark. Depending on the type of surgery you had, we may begin to advance your weight-bearing so that you're putting more full weight on the big toe.

Interviewer: Now, is there much physical therapy or anything involved with this particular procedure?

Dr. Nixon: Physical therapy is certainly a very reasonable thing to consider. And for some patients, they think that it's helped them considerably. Some of that depends on the type of surgery and the surgeon's specific decision-making. Not all bunions need physical therapy afterwards, but certainly plenty of patients that I operate on benefit greatly from physical therapy.

Interviewer: And what is the success rate for a procedure like this?

Dr. Nixon: It depends a little bit on the operation you do. So one of the things that we're trying to address if you have both a bunion and arthritis, if you have the big toe joint fused, and if that goes on to fusion, which can occur in about 90% or so of patients, then those are some of our happiest patients. They do quite well. They can remain very active.

The downsides to a fusion are that it does limit the motion in the big toe. So getting back into high heels is challenging. Getting back into certain types of activities, like certain yoga poses, the toe just won't let you do that. So that is one of the downsides, but it certainly is a very powerful and successful operation.

If we are preserving the joint and we are cutting the bones, then patient satisfaction is usually in the 80% to 90% range. Patients do quite well from those operations.

Whichever one you choose, they do require some level of recovery. And I would be lying to you if I said that it's a fast recovery. Some patients recover faster than others, but the first couple of weeks, there's going to be some swelling involved, so it's really important to keep it elevated. But as you begin to progress your recovery, you'll begin to get that swelling down and hopefully be able to quickly transition back into regular shoes, as we allow you to, once we get X-rays that confirm that everything has healed up well.

Interviewer: What is something that you as a surgeon would tell to give that last bit of kind of confidence to someone who's considering bunion surgery?

Dr. Nixon: I think what's really important is that the decision-making is all by the patient. My job or any of my partners' jobs is just to make sure that you have the right information to make the decision.

And at the end of the day, patients can get a lot of good pain relief and a lot of satisfaction and a lot of improvement from having their bunion corrected, whichever method you choose.

And like most things in life and in medicine, they all have some form of a pro and con weighing, a pro and con assessment, but whichever one you choose, patients do quite well from these operations. There is a recovery involved, but ultimately, patients do quite well.

Interviewer: Physical therapy. It helps in more ways than you might think. We'll examine that next on The Scope.

Announcer: Health tips, medical news, research, and more, for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: You know, many people only have kind of a tip-of-the-iceberg idea of what physical therapy is and what the benefits are, and, I guess, even for me, I primarily think about a physical therapist as somebody who helps me recover after, like, a knee injury, or surgery, or some sort of traumatic injury like a car crash, but Rob Singleton is a physical therapist at University of Utah Healthcare, and he says that there are actually other ways that physical therapists help, and you've been down many of the paths. You started out in the common one, which is, like, the orthopedics.

Rob: Yeah, about 22 years ago when I graduated, I started out in, you know, right out of school in sports medicine, orthopedic rehab. And I think that's kind of the common area that most people think about when they think about physical therapy, is like, you know, your typical ankle sprain, knee sprain . . .

Interviewer: I've got a wrist problem.

Rob: . . . football injury. Yeah, carpal tunnel, all that kind of stuff.

Interviewer: Sure. So you started out there, and then you got more and more specialized. Explain that path.

Rob: Well, I did that for about seven years, and then had an opportunity to come up to the university, and actually filled in for a therapist who was working in wound care.

Interviewer: Wound care?

Rob: Wound care. So physical therapy, we do a lot of wound care.

Interviewer: That just boggles my mind. I never imagined that. And what's the ultimate reason that you would seek out a physical therapist to do wound care?

Rob: Typically it's for ulcers, either like a diabetic ulcer, stasis ulcer, venous ulcer.

Interviewer: And then the goal of that physical therapy for that wound is to keep it from getting worse, to help it heal?

Rob: Yeah, keep it clean, help it heal.

Interviewer: Got you, all right. And then you've moved on from even that, now.

Rob: Yeah. So I did that for a while, and then got really interested in rehabilitation for neurological injuries, brain injury, spinal cord, stroke, and then was on the inpatient rehab unit for about eight years, mainly working on the spinal cord injury team.

Interviewer: Got you. So, boy, we've already learned a couple of things that I didn't know physical therapists did--wound care, and I guess, now that you've mentioned it, like, neurological things. That makes sense. What are some other areas a physical therapist might work in that I never would have guessed before?

Rob: Oh, wow! You know, there's therapists in pain clinics that works, you know, with pain management, and you have, of course, the orthopedic. There's acute physical therapists who work in the hospital, on the hospital floors with, you know, either in the intensive care units or the regular units. And really they're kind of the first line of defense as far as the hospital goes, you know, because your therapy starts right there. So they're the building block, really.

Interviewer: Gotcha. So there's a lot of different areas that physical therapists work. Is their kind of one overriding, though, goal or mission of what it is that you do, regardless of where you are?

Rob: Yeah. I guess if you could put physical therapy, define it by one word, it would be mobility. We're the profession that wants to get people moving, you know, either back on your feet, or moving in your wheelchair, or, you know, however you move. We want to get you back.

Interviewer: Regardless of the reason that is inhibiting your movement?

Rob: Yeah, back functioning, moving, being mobile, being as independent as possible.

Interviewer: So, like, even in the burn unit, it just occurred to me, like, when a young child burns their hands, that can cause mobility issues. A physical therapist would be there helping them with that.

Rob: There are physical and occupational therapists in the burn unit, you bet.

Interviewer: So when it comes to physical therapy and the overall kind of, what they call the continuum of care for patients, I'm trying to think . . . I was going to say, like, toot your own horn, you know. What is it you guys have, but . . . but let's maybe go the opposite direction. What would it be like without physical therapists?

Rob: Wow! That's an interesting question.

Interviewer: Like how it change . . .

Rob: People wouldn't get pushed as hard after their surgeries or injuries to get better, I don't think. You know, and that was, I think, probably historically how it was, that if you had a major surgery, or an injury, or an illness, you would be discharged from the hospital and go home, maybe have some nursing care, and then you'd kind of be just left to your own accord to get better.

Interviewer: To figure out on your own, yeah.

Rob: Yeah, to start getting up, to start moving.

Interviewer: So with physical therapists in the picture now, you push patients to get better, which helps them heal faster, get back to their life in a way that . . . like it was before, so it's not less than?

Rob: Yeah, and research is very clear that, you know, early mobility leads to faster recovery.

Interviewer: And the trend is getting, you know . . . get people up quicker and quicker. My mom had a knee surgery and she was up the next day.

Rob: Yeah, and I know they're doing a study now on in one of the inpatient acute units on really early mobilization in the intensive care units, and that's showing some really promising results because, you know, when I was up there, it was kind of, "Oh, you know, let him be for a little bit. Don't push him too hard. Get him moving." But towards the end of my stay in the inpatient intensive care units, it was really, you know, "We've got to get these people up as quick as we can, as safely as we can."

Interviewer: What are some common misperceptions about physical therapy or physical therapists that you run into?

Rob: I think probably the biggest misconception is that that we like to torture people.

Interviewer: You don't?

Rob: No, we're really . . . well, you know, I speak for myself, for the most part, very loving, giving, healing kind of people, tend to be very gentle, but we can push you. But we certainly don't want to inflict pain. Pain can certainly become part of the process, but it's not our goal to hurt you.

Interviewer: At kind of the end of the day, if, you know, somebody is just finally kind of having their mind broadened as to what physical therapists can do, and that they help in a lot of different areas, how would somebody know if maybe a physical therapist would be somebody they want to seek out for a condition or an issue they have, you know, beyond the obvious?

Rob: Well, I think you know, with the internet and Google, if you type in your condition and how it's treated, with most things, you're going to see therapy, in some sense, come up as a treatment option.

Interviewer: So maybe a good new paradigm for somebody to have is that physical therapists, instead of just being in one place, are probably everywhere.

Rob: Yeah, and I think people, you know, would be quite surprised when they come into clinics and there's a physical therapist there.

Interviewer: It's nice.

Rob: You know, we're in a lot more areas than people really realize.

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Dr. Miller: Rest, ice, and stretching are not the only ways to repair tendon injuries. We're going to talk about some of the new treatments next on Scope Radio.

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Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Nick Monson. He's a physician here at the University of Utah in the Department of Orthopedics. He's a non-operative physician and he specializes in sports medicine. Nick, what's the story? I understand there are some new treatments out there to help with folks who have tendon injuries that have become chronic.

Dr. Monson: Well, one of the things that we've been really looking at over the last decade or two is the usage of ultrasound and the ability to find issues within tendons or joints or different areas of the body by an in-office imaging modality which is ultrasound, kind of like looking at babies. But now, rather than just looking at babies, you can actually look in and see a tendon. Then, what you can do is you find that area of pathology or the area of irritation within a tendon. You can actually see it with the ultrasound, which makes it much easier for us to actually find approaches to attack that area of issue in patients.

The areas develop typically from overuse. It also happens because tendons just notoriously don't have a great blood supply to them, and blood is what brings the healing factors to our body. So when you don't have that healing component coming to the tendon, it has a hard time healing. That's the way that we've addressed it.

Dr. Miller: So how do you use the ultrasound to guide treatment? And what are these treatments that you're using now?

Dr. Monson: Yeah. So one option is something called PRP, platelet-rich plasma. There's also another treatment option which is in the same family, which is called stem-cell therapy. These are both areas of a lot of excitement. The research on them is still forthcoming. In the orthopedic usage of it, or in the tendon issues, we've seen that it does seem to provide benefit for patients. It's a discussion I have with them. It's not always the perfect option. But for a lot of patients, it's something that we can offer where, ultimately, it involves a blood draw.

We take the blood off of a patient. We spin that blood down. We take the healing components of that blood and actually reinject that into the tendon under visualization of ultrasound so we can find that area that looks like it's irritated or has the issue. We directly inject into that area using that PRP injecdate that we've harvested from the patient by a blood draw. Then we can stimulate regrowth of the tendon as the theoretical purpose of it. But often, what it seems to do is cause the inflammatory reaction in the area, or it just kind of stimulates the healing in the area, and has provided a lot of relief for our patients.

Dr. Miller: Which tendons do you usually look at when you consider this therapy, or which tendons do you most frequently treat?

Dr. Monson: It can be done on any tendon that there is noted pathology in. So if you see an area of issue, it can be done in just about any tendon. Tendons that we typically think of, of having frequent issues are the shoulder, so the rotator cuff. We think about tennis elbow, so that's on the outside of the elbow. Golfer's elbows, on the inside of the elbow. We'll do it there. We see it in knees, particularly for people that have something called jumper's knee which is at the tendon of the knee. Achilles' tendon. Even in like the plantar fascia, this can be done.

Dr. Miller: These tendon injuries, they're not short-term injuries. Would these be folks that have chronic problems with the tendons that would be over weeks or months, perhaps?

Dr. Monson: Certainly. Yeah. Yeah. So that's usually, somebody will come to see me. They have a new injury, we'll work them through the things that we have the best evidence for, what we know works. Things like rest, avoiding aggravating activities, pain modification, medications. Then also, eccentric exercises are very important. We have good research showing that those are helpful.

Dr. Miller: What are eccentric exercises?

Dr. Monson: Yeah, so those are the exercises where the muscle is fired but it's actually lengthening at the same time. So we're lengthening a tendon and muscle unit while there is force.

Dr. Miller: Well, for stretching.

Dr. Monson: Yes, correct.

Dr. Miller: Okay. So how do you use the ultrasound to guide your therapy?

Dr. Monson: So the ultrasound, first of all, identifies the lesion. So then I know exactly where I need to go. The second thing you can do is the ultrasound will actually, if I place a needle into a patient, I can follow the course of the needle the entire time. I can see the surrounding nerves. I can see the surrounding blood vessels and I know exactly where I'm at. First of all, it's very effective for safety or avoiding those structures that we don't want to hit. But second of all, it helps us target very directly where we want to be within a tendon and make sure that we're in the correct spot.

Dr. Miller: Now, I'm assuming before you enter, you have a patient undergo this type of treatment, you have gone through the standard therapy. So they've gone through a physical therapy. They've done the stretching. They've done the icing, and they're just not getting results.

Dr. Monson: Correct. There's one other procedure that we've added to this as well. It's a needle procedure as well. So that means that it's not done in an operating room, but it is done in a procedure room where we, again, identify that area of concern. We're able to use a specialized needle tip that it pulsates at the very tip of it very quickly, about 17,000 times per second.

Dr. Miller: That's fast.

Dr. Monson: We're talking about a millimeter of movement. Yeah, it's fast. It's not a lot of movement. It's enough that it actually, you think of it as kind of pulverizing the tissue in there. It's emulsifying the tissue is the term that we use. It's the same technology that cataract doctors, or eye doctors, use to remove cataracts out of patients. It breaks up the tissue, removes it from the body, and then leaves the healthy tissue around it. This is a newer treatment, probably in about the last five years that this one's been out. For the same tendon issues that we just talked about, this is another treatment option for patients that's been very promising so far.

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