good evening and welcome to doctors on call I'm Dr Peter nen professor and head of the Department of Family Medicine and biobehavioral health and Associate Dean for Rural medicine at the University of Minnesota medical school duth campus I'm your host for our program tonight on lower extremity knee foot foot and hip problems the success of this program depends on our viewers so please call with your questions or email them to ask pbsn north.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Billy h a physician who is board certified in family medicine and Sports Medicine practicing emergency medicine at the clo Memorial Hospital Dr Christy halman an orthopedic surgeon with Orthopedic Associates of duth and Dr Luke woodstrom an orthopedic surgeon with Essentia Health Orthopedics and Sports Medicine our medical students answering the phones tonight are Hank Larson from Spring Valley Wisconsin Joe Miller of St Michael Minnesota and Connor mikek from Redwing Minnesota and now on to tonight's program on lower extremity knee foot and hip problems and uh Dr wistrom already the first question is for you how might a patient better prepare their individual health prior to surgery sure that's a good question and something we get in clinic quite a bit um a lot of patients that we're seeing are going in for uh joint replacement eventually and so optimizing some health factors there can make a big difference so patients that have diabetes getting the blood sugar under good control is very important um it can really help with healing if patients can um get off of nicotine products avoid smoking um if we know that they're going to have surgery down the road working on weight loss ahead of time uh can make a big difference especially in recovering from a hip or knee replacement um and then in the days leading up to surgery making sure that patients are getting good sleep getting plenty of rest hydrating well um those are kind of the key factors thank you you and uh Dr hman uh there's certainly been much attention regarding the injury to uh a professional Aaron Rogers and his uh Achilles tendon um what can we anticipate about his return or what would a patient anticipate for the time to return after an Achilles tendon repair okay so after the repair of an Achilles tendon typically the earliest return to sport is going to be around um six months and the reason for that is when we repair that tendon we're bringing the ends back together however the tendon still needs time to heal and remodel into a nice functioning tendon and then once you start the rehabilitation you're really retraining your brain and the muscle and tendon so that everything's working together as a functional unit now when we see professional athletes like Aaron Rogers having this type of injury we have to remember that he's a professional athlete he's in Prime condition and he has a whole team that's rehabbing him and getting him back to sports and he also has some other motivations where for our typical patient we want you to have that best outcome and we want to really decrease that risk of retaing so we may take a little bit more cautious approach in terms of getting you back thank you for that and uh Dr H for a 55-year-old patient with knee pain for about a year uh on daily walks and uh somewhat worse on the trails or with squatting what might be the cause and what could be done to help with this discomfort yes well as we move through life um our cartilage pads can start to wear a little bit thinner uh than normal and they can cause some symptoms such as swelling or locking or discomfort um if you think about the the carage pads themselves they're they're called the meniscus there's a meniscus on the inside part of your knee and on the outside part of your knee and you can think of them as little shock absorbers or like little rubber Donuts almost and as they start to wear down uh they can tear and as we get into our 30s and 50s we we see more of this than we do earlier in life on an MRI you can see in this picture that um there's a signal in that little red circle and that is a tear in that cartilage pad called the meniscus and that can cause discomfort uh with walking or squatting or um like the patient is asking about on Trails um these Kings can be treated um by strengthening the quadricep muscles um cortisone injections and then there are other mechanisms of of treating these tears as well thank you Dr wistrom what are signs and symptoms of an infected joint that would lead a patient to seek care sure uh so there can be some symptoms in the joint itself and there can be some more systemic symptoms so in the in the infected joint itself typically you're going to see swelling uh The Joint can be uh very painful um it will feel warm to touch um maybe may even feel hot uh typically there's going to be uh pain uh with even gentle range of Motion in the joint um and then if someone is suffering from an infected joint they may feel systemic symptoms such as fevers chills um may have some general aches almost flu like symptoms um that does not always come on right away um but typically you will see those uh uh the swelling in the joint is is one of the big ones so thank you and Dr uh hrom the uh meniscal tear does the uh patient definitely need surgery or how do you determine that so with meniscus tears there's there's several types of Tears so the one we commonly think of is the traumatic tear it happens you know when we're doing sports activities or we have a trauma or injury and that tends to be a more acute tear um in a younger patient those ones are typically repaired in a young patient we really want to preserve that meniscus now as we were talking about earlier as we get older and we get more wear in our knee as we beat up that cartilage and that meniscus cushion we get some tears in there those tears tend to be more degenerative more wear and tear type tears and on those a lot of times we can treat them conservatively with injections and strengthening the leg and other conservative type measures but occasionally we try those and we continue to have symptoms and those ones we can go in and either repair or trim some of those um kind of hang nail tears to the meniscus out to relieve the mechanical symptoms but that does remove some of the meniscus which certainly is kind of helping lead to some arthritis so that's why we try that non-operative tear or non-operative treatment in the degenerative type tears thank you Dr hman and just following up you mentioned that um little bit of removal do you uh notice that on follow-up Imaging that removal so if we did an MRI after surgery we can certainly see in there parts of the meniscus where we've trimmed it so the meniscus will not have that smooth normal Contour after some of it has been removed thank you uh Dr hog what about the uh healing of planter fasciitis at the heel and about how long does that take planter fasciitis can be a very painful process for people who are working on hard floors such as concrete floors spending a lot of the time uh on their feet uh during their work days um ways to go about uh treating planner fasciitis and time frame kind of depends on the person um one of the ways of going about it will be to where softer soles or a heel cushion is one one way of doing it the other can be wearing a a walking boot uh that can really shut the heel down and really give it a rest um typically what I counsel patients is about every 3 to six weeks you'll notice some improvement um normally it's not 3 to six days but if you think a little bit further down the road uh I think that's when things will start to come around that's encouraging yes Dr wistrom uh an individual has stepped in a pothole twisted their knee and the posterior knee is now swollen and painful unable to move the knee much at all what could that injury be it could be a few different things um so a twisting injury uh of the knee you certainly worry about a meniscus tear an acute meniscus tear uh that can cause acute onset pain it can cause limited range of motion and and swelling um with posterior swelling you would also think about about the possibility of a Baker cyst also known as a poal cyst and so that's swelling in the back of the joint that's coming from uh basically too much fluid in the joint itself and it gets pushed to the back and so if arthritis is exacerbated that can cause excessive joint swelling that can get pushed into the back of the knee and present that way and if the knee feels swollen it can make it feel tight and it can and it can reduce range of motion and then another thing to think about anytime there's any sort of a u an acute injury uh twisting mechanism or trauma to the Joint uh you always want to be consci conscientious of the possibility of a fracture too and that could present that way as well so um coming in and getting some Imaging starting with an x-ray um is is certainly important in in a setting like that thank you and Dr haltman a uh viewer asks from duth are there new types of knee Prosthetics um so we've made a lot of prog progress I would say in the last decade of ways to treat arthritis and um cartilage injuries within the knee so the main prosthetic that we see is the metal components where there's essentially a metal cap on the end of your thigh bone and a metal tray on the top of your shin bone with a plastic piece in between that lets them Glide now the equipment and device makers are constantly upgrading what things are made out of how long our plastic lasts and things like that but other things that we've been working on are ways to restore the cartilage so some of the surgeries we have available um are things like the Macy procedure where we grow out your cartilage cells and we actually put a cartilage patch in that cartilage pothole that you have within your joint um another procedure we have is called an osteochondral aligra where we take cadaver cartil and Bone and we basically make a little socket where you've got that divot and put a new bone cartilage plug in there um now as we get older and our arthritis gets worse we typically end up with that knee replacement with the metal and plastic that's in there but certainly in our younger and more active patients we've been progressing more towards the biologic options as well do your patients ask you about how their body responds to the uh kadav graft so typically the Cav D graft will go through multiple tests to make sure that there's um no infection or other materials or bacteria in there and then we do wash it and process it before we go in and then we do give it a bath in PRP or the patient's own whole blood um before we insert it so most people tolerate very well and having a reaction with the um kind of the donor tissue is usually not a problem with those graphs thank you for explaining that Dr wistrom um what are impacts or changes on the knees ankles and feet as a result of obesity yeah good question so obesity increases loading through the the weightbearing joints um and so this can um over time accelerate cartilage wear um compared to someone that's at a normal weight range so um even with walking uh there's going to be increased Force through that joint and increase stress through the cartilage so essentially the cartilage can wear down faster thank you um Dr haltman what are some of the influences on the duration of a hip replacements longevity in a patient okay so the hip replacement is one of the best orthopedic surgeries that we have patients do very well with with this um and the current kind of main thing that determines how long it lasts is really lifestyle and patients body habitus so um in our older patients that are mainly walking around their houses walking around the neighborhood the hip lasts a long time in our younger patients that are doing more high impact things you're putting a bit more stress on the implants and you can get a bit more wear now we we' had great improvements with the components that we put in the hip um we use different materials such as metal and Ceramics and Plastics and I would say the modern hip implant is lasting at least 20 30 years in a majority of our patients oh that's tremendous yeah Dr hog a uh patient asks how long it will take for a pulled quadriceps muscle to feel um not as painful so when they're using their leg well that's a good question the quadriceps is a large muscle group that's very powerful and so typically we think about large muscle groups taking quite a bit longer to heal or settle down than smaller muscle groups uh with a quadricep tendonitis depending on the severity um boy you can expect uh to be out about a month uh depending on the age of the patient uh it always seems like younger folks will bounce back more quickly than we think um but typically what I would say is about uh 4 to six weeks uh for an injury like a like a quad tendinitis thank you Dr Holman uh caller asks how common are blood clots after knee surgery so definitely having a big surgery like a knee replacement is a big shock to the body the body doesn't know the difference between surgery and trauma so it's kind of reaction and clotting factors do increase within the bloodstream um the risk of a blood clot is fairly low however after a big surgery like a knee replacement we typically will place the patient on aspirin or other blood thinners to minimize that risk with knee surgeries like a scope or an ACL it's a smaller surgery the risk is lower um and certainly the more the patient is able to get up and move around is going to lower that risk of blood clots thank you Dr wistrom a uh viewer from Superior asks can a back problem cause knee pain and vice versa yeah that that is uh certainly a possibility um knee pain uh can certainly alter someone's gate um and walking with a with an affected gate can cause increased stress through the low back especially someone that has prior existing back issues such as arthritis or disc bulging uh back pain uh can cause knee pain typically if it's going to cause pain in the lower leg though it will radiate down and it won't be isolated to just the knee um not saying that that can't happen but that would be a less common presentation usually you'd see the pain radiating uh down the leg sometimes with lower leg weakness sometimes with numbness thank you uh Dr H ear earlier we heard about the baker's cyst and a viewer asks how long does it take to heal biger cysts are swelling behind the knee that can kind of come and go come and go normally and naturally uh sometimes they can be tiny so tiny that you can only see it on Imaging and other times they can be about as big as a softball um when you think about the body's time to resorb that that fluid uh it can be a really long time sometimes before it will it will completely kind of disappear over a period of months other times they can actually pop on their own and cause a lot of discomfort behind the knee and into the calf so much that it can it can fool doctors into thinking that it's a a deep vinous thrombosis or a blood clot but uh typically it can take uh several weeks for those to aate thank you Dr haltman from a viewer who's already had a hip replacement to years ago on the left the left foot turns a bit white after showering could rain noes worsen as a result of surgery and any suggestions about evaluation um I mean certainly you know rods does have that reaction and is associated with the the nerves in the area and anytime you have a surgery um certainly it can alter kind of what your Baseline status is um if you're noticing that you know it's happening more frequent or symptoms are changing then you know it's certainly something that is worth having looked at especially for what might be going on y both with nerves and vascul potentially okay um drct does the uh SI joint move like other joints oh there's um a little bit of Mobility to the SI joint but it's not a very highly mobile joint so um and as that joint uh in time some people will develop arthritis in that joint and it can stiffen and increase stress through that joint can cause pain if it's not if it's the little motion that it does have is restricted and Dr H what are some common injuries to the muscle glutitis Maximus and medius um there are overuse injuries associated with those largely that can cause the hip to hurt and so typically when you're working somebody up for hip pain you will think about those muscle groups um those muscle groups are are commonly ignored when it comes to training programs um because typically athletes and people will focus on uh the the larger muscle groups even though we use our glutitis medius and Maximus every day for activities of daily living we don't often uh specifically train those body parts so it can be a little bit complicated as to kind of what the ideology of the pain is and we're talking about muscles like that thank you Dr haltman about uh preparing ing for surgery in the operating room how does the team ensure that the surgery will be done on the correct side okay so always a big concern when you're going in for surgery um so typically when you go in for surgery like say you're having a knee replacement the doctor is going to meet with you in the preop area and at that point they're going to go over what the procedure is that we're doing what side we're doing it on and then they'll have a marking pen kind of looks like a little Sharpie and they're going to put a mark right in that area of the surgery on the correct extremity and they're going to check with you so I'll typically ask my patient what are we doing today and what leg are we doing on it or it on and can you point to where we're going to do this and then we mark it and then um when nursing comes in they're going to check the procedure with you again when anesthesia comes in they'll check the procedure if you're getting any sort of block or numbing injection prior to surgery the anesthesia team will also Mark that side of the leg and then when you get into the operating room before we start the procedure and before we do anything everybody in the O room is going to go through and say um their parts of the surgery so who is the patient what are we doing what side are we doing um it on have we given antibiotics all of these things so there's lots of checks that have been put in place to make sure that the procedures the is correct the patient's correct and the site is correct thank you for that very reassuring um regarding a uh a patient with foot numbness age 67 and not diabetic what uh Dr hog might be some potential causes and and not diabetic not diabetic yet foot numbness uh that is a peripheral neuropathy and so there can be different reasons why people will have a peripheral neuropathy one is from a low back problem like a bulging dis typically we will see a lack of sensation or pain in a foot or in the extremity and we will see evidence of that sometimes with a diminished reflex in the ankle other times uh there can be chronic diseases or or even acute things that can cause there to be uh numbness in the foot but typically what we'll think about when we hear that will be to ask about underlying back problems or or dis bulging problems or arthritis in the low back as well Dr wistrom briefly uh what are some considerations for the right medication choices safely for arthritis pain in a patient in their 80s oh sure so um the the main category atories of uh medications that we're using for arthritis is uh would be non-steroidal anti-inflammatories so medications like ibuprofen or an aoxin and then the other c main category would be U acetaminophen and so when you're when you're talking about the non-steroidal drugs like ibuprofen you want to make sure that uh patients have a good kidney function um so they should have their uh their kidney function checked um and ensure that that's working properly before recommending that uh and then the other thing is making sure that uh they don't have any history of GI uh discomfort so uh stomach discomfort uh reflux ulcers um there are some other considerations depending on what other medications they're taking if someone is on a blood thinner like warrin they probably don't want to be on a nonoral anti-inflammatory because that can also thin the blood uh so looking at uh a patient's medication list is important before U making recommendations like that with uh Tylenol or acetaminophen uh probably the biggest factor is uh liver function as that medication is processed through the liver and this is a brief question before we wrap up Dr H um how long can a patient get occasional cortisone shots just briefly yeah typically what we would think about is um a couple of times a year maybe a little bit more frequently than that but typically we try not to overdue cortisone shots yes thank you well I want to thank thank our panelists Dr Billy H Dr Christy hman and Dr Luke wistrom and our medical student volunteers Hank Larsson Joe Miller and Connor michek please join Dina clayon next week for a program on Grief and loss when our guests will be Dr Deb semil Roth coral popowitz and Bridget Benson thank you for watching good night 1