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Medicare has found a wide range of costs associated with hip and knee joint replacement surgeries across the country.  The average costs range from $16,500 to $33,000 per joint replacement according to Medicare.  So, in an effort to control costs, Medicare has implemented a program in selected areas, (one of which is the Carlisle, Harrisburg, Hershey area), which will run for 5 years.  The program, called Comprehensive Care for Joint Replacement (CJR), is estimated to have a cost savings to Medicare of $153 million over the 5 years.  In this model, hospitals are given a target cost per episode which includes the following: the hospitalization for the surgery, the physician costs, any long term care or rehabilitation required, home health costs, outpatient rehabilitation and any readmissions.  If the episode costs exceeds the target costs, the hospital must pay back to Medicare a percentage of the overage.  If the episode costs are below the target costs, the hospital system receives a percentage of the savings.  Hospitals are allowed to partner with other providers to share in the risks and/or rewards.

So, what does all this mean for patients?  Patients who have hip or knee replacements shouldn’t notice any change other than some post procedure satisfaction surveys.  Patients may still choose their rehab facility and providers regardless of the affiliations or collaborations between hospitals and other providers.  Patients still have a choice, so continue to choose wisely and remember you should be the focus of care, not a bonus or penalty.

 

Ann D. Dennison, PT, DPT, OCS

References:  APTA webinar on Comprehensive Care for Joint Replacement Model

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The Iliopsoas and Low Back Pain

Our last blog dissussed what the iliopsoas muscle group consists of and its anatomical position in the body.  Today’s blog will discuss how this muscle group may cause low back pain.  Despite the fact that the iliopsoas is made up of more than one muscle, the psoas major is typically the muscle most involved with low back pain due to its origins at the L1 to L5 vertebrae of the low back. 

The psoas muscle itself can be irritated and cause pain along the front of the hip and deep in the abdomen, but the low back pain that it causes is typically due to the position into which it pulls the low back.  When the psoas muscle is shortened and tight, it has the ability to pull the vertebrae of the back forward.  This forward pull creates an increased curve at the low back.  It is natural to have some degree of a curve at the low back, but an excessive curve increases pressure where it does not belong and thus may cause pain. 

In addition to pulling the low back vertebrae out of their proper positions, a shortened psoas muscle can also affect the position of the pelvis.  The pelvis is comprised of several bones, but the important thing to note with this topic is that there are two halves to the pelvis.  If the psoas muscle is excessively tight or short, overtime it can cause one side of the pelvis to rotate out of its correct position.  This rotated position can create pain at the low back, pain in the pelvis or sacrum region, and even cause nerve compression resulting in irritation down the leg on the same side or opposite side of the tight psoas muscle.

Dysfunction at the psoas can result in a plethera of symptoms depending on how long irritation has been present and how much the mechanics of the body have adjusted to compensate for the symptoms.  Pain may be present with several activities including standing, walking, running, rising from sitting, walking up steps, or lunging forward. 

In order to treat back pain as a result of psoas dysfunction, the psoas itself as well as the resulting mechanical changes to the body must be addressed.  Manual techniques may be used by a physical therapist to correct any alignment issues.  These techniques include manually mobilizing the lumbar or pelvic region, and other manual treatments like massage, deep tissue release, and relaxation techniques can also be used to decrease tension and irritation at the psoas muscle.  Stretching is also an important component to rehabilitation following psoas dysfunction.  The psoas muscle must be gradually stretched which can be achieved in a lunge position with the painful hip in the back and gently leaning into the lunge until a stretch is felt at the front of the hip.  If the backside of the hip becomes tight as a result of any alignment issues, then stretching may also be needed for the back of the hip.  Strengthening of the abdominal and hip muscles, especially those along the outside and back of the hip, is also necessary in order to improve function and reduce the risk of symptom reoccurance.  There are a wide variety of exercises that can be performed to strengthen these muscles and a physical therapist can set up an appropriate exercise program for home use.

We hope this blog was informative.  If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions. Thank you for reading and stay active.

 

Kateri Kane PT, DPT

Advanced Physical Therapy and Fitness, Mechanicsburg, PA          

 

Resources:

http://www.physiokinetics.gr/pdf/PDIS_introduction_0[1].pdf

http://jaoa.org/article.aspx?articleid=2094465

http://www.somatics.com/psoas.htm

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More frequently lately I have been seeing patients with injuries to their iliopsoas muscle group.  This muscle area is a good one to discuss because it is not as commonly known as areas like the quadriceps and hamstrings and can be confusing for people to understand because it involves both the hip and the back.  Let’s delve a little further into what makes up this muscle group.

The iliopsoas is made up of two separate muscles: the iliacus and the psoas major.  The iliacus starts at the inner surface of the hip bone known as the ilium and connects to an area on the upper inner surface of the thigh bone (femur) known as the lesser trochanter.  The psoas major starts at the bodies of the vertebrae that make up the low back and extends to connect to the less trochanter (same as the iliacus).  In approximately 40% of the population there is an additional muscle called the psoas minor that also belongs to this muscle group.  It connects to the body of the L1 vertebrae and extends down to a portion of the pubic bone known as the inferior ramus.  Together these muscles assist with lifting the leg into a bent position as when walk up steps, assist with rotating the hip outward, and help to bend the trunk at the waist when the legs are in a fixed stationary position as when sitting up from a lying down position.

Now you know what the iliopsoas is made up of, but what is iliopsoas tendonitis?  Tendonitis is a term that means inflammation of the tendon; therefore, iliopsoas tendonitis would mean inflammation of the tendons of the iliopsoas muscles.  Inflammation can result in pain and discomfort during various hip motions that involve activation of the iliopsoas including walking up steps, sitting up, walking, and running, to name a few.  Positions that put the muscle group on stretch like lying down with the legs straight instead of bent or lunging forward with the painful hip in the back can also be aggravating, especially when symptoms are particularly flared up.  The condition can often be associated with a snapping or clicking sound at the hip during movement, which is why it can also be referred to as “snapping hip.”

Treatment of iliopsoas tendonitis depends on the severity of the condition.  The milder the symptoms are, the less invasive the treatment is.  When the symptoms are mild, individuals often just need to modify their activities to limit overuse of the iliopsoas and take anti-inflammatory medication.  Cortisone injections may also be utilized.  If the symptoms persist, however, further intervention may be warranted.  Physical therapy can assist with guiding you through recovery and regaining previous function via an exercise program heavily geared toward stretching and gradual strengthening, as symptoms and strength allow.  A less common intervention which is used only when symptoms continue to persist despite conservative treatment is surgery.  A surgeon may choose to fully release the tendon, partially release the tendon, remove inflamed tissue, or attempt to lengthen the tendon via small incisions.  Once again, surgical intervention is not as common and typically conservative treatment with physical therapy and relative rest from aggravating activities is all that is needed.

In first addressing this topic we noted that the iliopsoas can be confusing because it may involve both the hip and the back.  Our next blog will discuss the effects of the iliopsoas muscle group on the low back.  We hope this blog was informative.  If you have any questions on this topic or any others in which you are interested, feel free to leave any questions, comments, or suggestions. Thank you for reading and stay active.

Resources:

http://www.sportsinjuryclinic.net/anatomy/human-muscles/iliopsoas

http://breakingmuscle.com/mobility-recovery/everything-you-need-to-know-about-the-iliopsoas

http://emedicine.medscape.com/article/90993-treatment

http://health.ucsd.edu/specialties/surgery/ortho/areas-expertise/sports-medicine/conditions/hip/Pages/iliopsoas-tendonitis.aspx

http://www.hindawi.com/journals/crior/2013/361087/

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Disclaimer:  The information in this medical library is intended for informational and educational purposes only and in no way should be taken to be the provision or practice of physical therapy, medical, or professional healthcare advice or services. The information should not be considered complete or exhaustive and should not be used for diagnostic or treatment purposes without first consulting with your physical therapist, physician or other healthcare provider. The owners of this website accept no responsibility for the misuse of information contained within this website.