Joint Surgeons of Sacramento

Joint Effort Newsletter
Hip or Back? Congratulations! Senior Connection FYI Past Issues HMOs Revisited Insurance Reminder Volume 1, Issue 1 Volume 2, Issue 1 Volume 2, Issue 2 Volume 6, Issue 1 Volume 7, Issue 1 JOINT SURGEONS OF SACRAMENTO 1020 29th Street Suite 450 Sacramento, CA 95816 Ph: (916) 733-5066 Fx: (916) 733-8705 RELATED ITEMS Meet Our Doctors Map and Directions Take a Tour of Our Office HIP & KNEE INFO Total Hip Replacement Total Knee Replacement		Volume XII, Issue 1 Winter 2001 Is It My Hip, Or Is It My Back? By William L. Bargar, M.D. Nearly every day in the office I see a patient who comes in complaining of “hip” pain, only to determine that it is coming from the back. It is confusing, but I think it might be helpful, and avoid unnecessary office visits to review how I determine if the symptoms are coming from the hip or from the back. Location of the pain Pain originating in the hip joint: • Usually occurs in the groin. It can spread down the front of the thigh and even be felt in the groin. • Sometimes can be felt on the side of the hip. It feels like a deep ache. • Can also be in the buttock, but is usually low in the buttock. Pain on the side of the hip, sometimes running down the outside of the thigh, can be due to “trochanteric bursitis.” This is always tender to pressure directly over the “trochanter,” which is the bump of bone you feel at the side of your hip. This pain doesn’t really come from the hip joint, but comes from a bursa over the trochanter. Pain originating in the lower pack • Is usually felt in the buttock. Usually it is higher in the buttock than the pain that comes from the hip joint. • Is usually felt near the “sacroiliac joint” a joint that is located a little above and on either side of the cleft between the buttocks. • Can run down the back of the thigh, and spread to the calf, ankle or foot. This is called “sciatica.” Note: Pain originating in the hip can radiate to the knee, but never radiates to the ankle or foot. Character of the pain Pain originating in the hip joint: • Is usually an ache, but can at times be sharp. • Occurs with movement of the hip joint. • Occurs with change in position, such as getting up from a chair; getting in or out of the car or putting on your shoes or socks. • Is worse when taking the first few steps when beginning to walk, then usually feels better after walking a short distance, but usually worsens again during or after long walks. We call this “start-up pain.” • It is almost always better at rest. • It can occur at night, but usually it is when you move the hip, such as turning over in bed. Pain originating in the back: • Usually is an ache, but can sometimes be like an electric shock. • Usually does not occur when first beginning to walk, but gets worse with walking distances. Therefore, it is not a “start-up” type pain. • Can also occur at night, but is usually a more constant pain associated with maintaining certain positions. Comes on with: • movement of the spine; • coughing, sneezing or grunting; • changes in position; • staying in one position for a long period of time, like sitting in a car or standing for long periods, or after prolonged walking. Associated symptoms Hip joint pain can be felt in the knee. We call it “referred pain.” The same nerves that carry signals from the hip joint also carry them from the knee joint. So pain originating in the hip joint can feel like it is coming from your knee. It differs from true knee pain in that the pain referred from the hip is usually generalized. True knee pain is usually on one side of the knee. If the knee pain originates in the hip, it should not be painful to move the knee. Assuming the knee is otherwise normal, there should be no swelling in the knee and no other knee symptoms such as catching, locking or giving way. Most people who feel “hip” pain due to problems with their back also have a long history of intermittent low back pain. They may be fooled since the buttock pain is new. “Hip” pain originating in the back can be associated with numbness, usually in the heel, foot or ankle. There may also be weakness of specific muscle groups such as those that hold the big toe up. “Foot drop” resulting in a limp can also occur due to complete nerve root compression. There can also be problems with urinary or bowel incontinence, but this is more rare. What can you do, and what can we do? Well, first remember that we are Hip and Knee Specialists, and we do not treat, or try to diagnose, back problems. If you develop a pain in the buttock that sounds like the pain described above as originating in the back, it is best to wait at least three weeks and avoid any heavy lifting or unusual activity. Acute back pain is usually self-limiting and will gradually subside. If it does not improve, or if it worsens, and you have a history of back problems for which you have seen a physician in the past, make an appointment first to see that physician or your primary care doctor. If he or she thinks it could be your hip, then come see us. If on the other hand, your pain seems more typical for pain originating in the hip joint as described above, waiting a few weeks will do no harm, and many times the symptoms will resolve spontaneously if they don’t try taking some anti-inflammatory medicine. You may have some for other conditions, or you can buy some over-the-counter such as ibuprofen (Motrin, etc.) naprosyn (Aleve) or Orudis. Give it a two or three week trial. If there is no improvement, make an appointment to see us. Of course, things are rarely “classic” in their presentation. It is possible to have arthritis in both the hip and the back at the same time. Sometimes pressure on a nerve occurs high in the back and can result in groin pain. Conversely, sometimes hip joint pain can be felt mainly in the buttock. If we can’t tell by physical exam or x-rays, it may be necessary to numb the hip joint by injecting a local anesthetic and then ask the patient to test it by performing the activities that usually cause pain. If the pain is relieved, it means it is coming from the hip joint, whereas if it is not relieved it means it is coming from outside the joint (usually from the back). Hip injections require fluoroscopy and must be scheduled at the hospital or imaging center. Bone scans are also occasionally helpful in sorting out the origin of the pain when the plain x-rays are normal. If all this sounds confusing, call us. We’ll talk you through it. Return to top Congratulations & Good Luck! Mary, a long time employee has just completed her dream of becoming a Registered Nurse. She received her degree from American River College and has accepted a position at Sutter Roseville Hospital in their Telemetry Unit. Her goal is to eventually work in the Emergency Room. Return to top The Senior Connection All classes are held on the second Wednesday of each month from 10:00 a.m. to Noon. Eskaton Village, 3939 Walnut Avenue, Carmichael. Their phone number is 888-334-3490 or www.eskaton.com. Spring 2001 classes: March 14 Mix or Match Medications Pharmacist: Norman Fong discusses the interactions between herbal remedies and traditional medications. April 11 Making your Memory Work for You. Discover ways to stimulate memories to retain information. May 9 Flowers? Get Bloomin’ Ready for May Inventive ideas for creating the garden of your dreams. June 13 Skin Scan How does our skin communicate to us? Dr. Ely tells us how. Return to top FYI… In July of 2000 the Department of Managed Health Care became a new department under the Business, Transportation and Housing Agency, whose responsibility is to license and regulate HMOs. The following is provided for your information: Dept. of Managed Health Care HMO Help Center 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 888-466-2219 916-229-0465/fax 977-688-9891 TDD http://www.hmohelp.ca.gov Return to top Recap of Past Joint Effort Issues: Vol. I No. 1…..Hydroxylapatite Coating, X-Rays & Your Health Vol. II No. 1…...ROBODOC Vol. II No. 2…..The Indications for Total Hip and Knee Replacements Vol. III No. 1…..Journey to the East: Orthopaedic Surgery in China Vol. III No. 2…..Selecting a Hip Implant: Whether or Not to Use Cement Vol. IV No. 1…..A Brief History of Knee Replacement Vol. IV No. 2…..Bo Don’t Know Hips!!! Vol. V No. 1…..We do Knees, Too! Vol. V No. 2…..Osteolysis, the Next Challenge in Joint Replacement Vol. VI No. 1…..Just How Safe Is the Community Blood Supply? Vol. VI No. 2…..Insurers Demand Silence on Myths of Managed Care Vol. VII No. 1…..Funny Money – Hospital Charges vs. Costs Vol. VII No. 2…..Medical Board of California Quality of Care in a Managed Care ……Environment: Statement of Concern Vol. VII No. 1…..”New Recommendation” Antibiotic Prophylaxis For Dental Work Vol. VIII No. 2…..More on Dental Prophylaxis Vol. IX No. 1…..Transitions Vol. X No. 1…..Osteoporosis: What is it? Vol. XI No. 2…..Osteoporosis: Decreasing Your Risk. Our Joint Effort issues, as well as the patient joint scheduling booklet you receive after scheduling surgery contain a myriad of information that you should retain and refer back to when you have questions. Should you want a past issue of a newsletter, please call or drop our office a note, we will be glad to send you one. Return to top Medicare HMOs Revisited By Thomas Blumenfeld, M.D. In the Joint Effort of Winter 1994/1995, a reprint of a letter to the editor of the Business Journal was included. In this letter, written by the Executive Director of the Sacramento El Corado Medical Society, the risks and benefits of enrolling in a Medicare HMO were detailed. The benefits appeared primarily financial, while the risks appeared to be failure to continue to see one’s usual physician, redirection to other doctors, and failure to provide services that the enrollee either had before, or assumed were included. In six years, this situation has not changed. Weekly I talk with patients who can no longer see their long time internist or family practitioner because they no longer accept that HMO plan. This is extremely distressing and represents not only loss of continuity of medical care, but loss of a familiar face and the comfort that a strong patient-physician relationship can bring. For seeing specialists such as an orthopaedist the situation is even worse. Because of drastically reduced reimbursements, many specialists have joined their medical colleagues in dropping HMO plans. As there are fewer specialists, in some areas patients have no one that they can see. There is a solution. As in many things in life, it involves money. With sufficient notice, a patient may disenroll from their managed Medicare HMO plan, and use their Medicare benefits as their primary insurance. While this may lead to an increase in costs that some patients over 65 cannot bear, particularly in the area of prescription drugs, the trade off is that you will most likely be able to see the doctor of your choice. If you wish to have a secondary insurance assist with medical costs, choose one that doesn’t constrain your choices in your doctor. If you need further information in regards to the above, a good place to start is by contacting Medicare at 1-800-MEDICARE (633-4227) and asking what you would or would not have to pay for various medical needs (i.e. prescriptions, hospitalizations, laboratory or special studies). With this information, make a decision and restore your choices in health care. Return to top Insurance Reminder If you have an HMO insurance, and you change your Primary Care Physician, you MUST notify us of the change and provide a copy of your new insurance card showing the new PCP’s name, address, and phone number. This is very important as it affects where we must submit our bills for reimbursement. Return to top

Joint Effort Newsletter

Hip or Back?

Congratulations!

Senior Connection

FYI

Past Issues

HMOs Revisited

Insurance Reminder

Volume 1, Issue 1

Volume 2, Issue 1

Volume 2, Issue 2

Volume 6, Issue 1

Volume 7, Issue 1

JOINT SURGEONS
OF SACRAMENTO
1020 29th Street
Suite 450
Sacramento, CA 95816
Ph: (916) 733-5066
Fx: (916) 733-8705

RELATED ITEMS
Meet Our Doctors
Map and Directions
Take a Tour of Our Office

HIP & KNEE INFO
Total Hip Replacement
Total Knee Replacement

Volume XII, Issue 1
Winter 2001

Is It My Hip, Or Is It My Back?
By William L. Bargar, M.D.
Nearly every day in the office I see a patient who comes in complaining of “hip” pain, only to determine that it is coming from the back. It is confusing, but I think it might be helpful, and avoid unnecessary office visits to review how I determine if the symptoms are coming from the hip or from the back.

Location of the pain

Pain originating in the hip joint:
• Usually occurs in the groin. It can spread down the front of the thigh and even be felt in the groin.
• Sometimes can be felt on the side of the hip. It feels like a deep ache.
• Can also be in the buttock, but is usually low in the buttock.
Pain on the side of the hip, sometimes running down the outside of the thigh, can be due to “trochanteric bursitis.” This is always tender to pressure directly over the “trochanter,” which is the bump of bone you feel at the side of your hip. This pain doesn’t really come from the hip joint, but comes from a bursa over the trochanter.

Pain originating in the lower pack
• Is usually felt in the buttock. Usually it is higher in the buttock than the pain that comes from the hip joint.
• Is usually felt near the “sacroiliac joint” a joint that is located a little above and on either side of the cleft between the buttocks.
• Can run down the back of the thigh, and spread to the calf, ankle or foot. This is called “sciatica.” Note: Pain originating in the hip can radiate to the knee, but never radiates to the ankle or foot.

Character of the pain

Pain originating in the hip joint:
• Is usually an ache, but can at times be sharp.
• Occurs with movement of the hip joint.
• Occurs with change in position, such as getting up from a chair; getting in or out of the car or putting on your shoes or socks.
• Is worse when taking the first few steps when beginning to walk, then usually feels better after walking a short distance, but usually worsens again during or after long walks. We call this “start-up pain.”
• It is almost always better at rest.
• It can occur at night, but usually it is when you move the hip, such as turning over in bed.
Pain originating in the back:
• Usually is an ache, but can sometimes be like an electric shock.
• Usually does not occur when first beginning to walk, but gets worse with walking distances. Therefore, it is not a “start-up” type pain.
• Can also occur at night, but is usually a more constant pain associated with maintaining certain positions.

Comes on with:
• movement of the spine;
• coughing, sneezing or grunting;
• changes in position;
• staying in one position for a long period of time, like sitting in a car or standing for long periods, or after prolonged walking.

Associated symptoms
Hip joint pain can be felt in the knee. We call it “referred pain.” The same nerves that carry signals from the hip joint also carry them from the knee joint. So pain originating in the hip joint can feel like it is coming from your knee. It differs from true knee pain in that the pain referred from the hip is usually generalized. True knee pain is usually on one side of the knee. If the knee pain originates in the hip, it should not be painful to move the knee. Assuming the knee is otherwise normal, there should be no swelling in the knee and no other knee symptoms such as catching, locking or giving way.

Most people who feel “hip” pain due to problems with their back also have a long history of intermittent low back pain. They may be fooled since the buttock pain is new. “Hip” pain originating in the back can be associated with numbness, usually in the heel, foot or ankle. There may also be weakness of specific muscle groups such as those that hold the big toe up. “Foot drop” resulting in a limp can also occur due to complete nerve root compression. There can also be problems with urinary or bowel incontinence, but this is more rare.

What can you do, and what can we do?
Well, first remember that we are Hip and Knee Specialists, and we do not treat, or try to diagnose, back problems. If you develop a pain in the buttock that sounds like the pain described above as originating in the back, it is best to wait at least three weeks and avoid any heavy lifting or unusual activity. Acute back pain is usually self-limiting and will gradually subside. If it does not improve, or if it worsens, and you have a history of back problems for which you have seen a physician in the past, make an appointment first to see that physician or your primary care doctor. If he or she thinks it could be your hip, then come see us.
If on the other hand, your pain seems more typical for pain originating in the hip joint as described above, waiting a few weeks will do no harm, and many times the symptoms will resolve spontaneously if they don’t try taking some anti-inflammatory medicine. You may have some for other conditions, or you can buy some over-the-counter such as ibuprofen (Motrin, etc.) naprosyn (Aleve) or Orudis. Give it a two or three week trial. If there is no improvement, make an appointment to see us.

Of course, things are rarely “classic” in their presentation. It is possible to have arthritis in both the hip and the back at the same time. Sometimes pressure on a nerve occurs high in the back and can result in groin pain. Conversely, sometimes hip joint pain can be felt mainly in the buttock.

If we can’t tell by physical exam or x-rays, it may be necessary to numb the hip joint by injecting a local anesthetic and then ask the patient to test it by performing the activities that usually cause pain. If the pain is relieved, it means it is coming from the hip joint, whereas if it is not relieved it means it is coming from outside the joint (usually from the back). Hip injections require fluoroscopy and must be scheduled at the hospital or imaging center. Bone scans are also occasionally helpful in sorting out the origin of the pain when the plain x-rays are normal.
If all this sounds confusing, call us. We’ll talk you through it.

Return to top

Congratulations & Good Luck!
Mary, a long time employee has just completed her dream of becoming a Registered Nurse. She received her degree from American River College and has accepted a position at Sutter Roseville Hospital in their Telemetry Unit. Her goal is to eventually work in the Emergency Room.

Return to top

The Senior Connection
All classes are held on the second Wednesday of each month from 10:00 a.m. to Noon. Eskaton Village, 3939 Walnut Avenue, Carmichael. Their phone number is 888-334-3490 or www.eskaton.com.

Spring 2001 classes:

March 14
Mix or Match Medications
Pharmacist: Norman Fong discusses the interactions between herbal remedies and traditional medications.

April 11
Making your Memory Work for You.
Discover ways to stimulate memories to retain information.

May 9
Flowers? Get Bloomin’ Ready for May
Inventive ideas for creating the garden of your dreams.

June 13
Skin Scan
How does our skin communicate to us? Dr. Ely tells us how.

Return to top

FYI…
In July of 2000 the Department of Managed Health Care became a new department under the Business, Transportation and Housing Agency, whose responsibility is to license and regulate HMOs.
The following is provided for your information:
Dept. of Managed Health Care HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725
888-466-2219
916-229-0465/fax
977-688-9891 TDD
http://www.hmohelp.ca.gov

Return to top

Recap of Past Joint Effort Issues:
Vol. I No. 1…..Hydroxylapatite Coating, X-Rays & Your Health
Vol. II No. 1…...ROBODOC
Vol. II No. 2…..The Indications for Total Hip and Knee Replacements
Vol. III No. 1…..Journey to the East: Orthopaedic Surgery in China
Vol. III No. 2…..Selecting a Hip Implant: Whether or Not to Use Cement
Vol. IV No. 1…..A Brief History of Knee Replacement
Vol. IV No. 2…..Bo Don’t Know Hips!!!
Vol. V No. 1…..We do Knees, Too!
Vol. V No. 2…..Osteolysis, the Next Challenge in Joint Replacement
Vol. VI No. 1…..Just How Safe Is the Community Blood Supply?
Vol. VI No. 2…..Insurers Demand Silence on Myths of Managed Care
Vol. VII No. 1…..Funny Money – Hospital Charges vs. Costs
Vol. VII No. 2…..Medical Board of California Quality of Care in a Managed Care
……Environment: Statement of Concern
Vol. VII No. 1…..”New Recommendation” Antibiotic Prophylaxis For Dental Work
Vol. VIII No. 2…..More on Dental Prophylaxis
Vol. IX No. 1…..Transitions
Vol. X No. 1…..Osteoporosis: What is it?
Vol. XI No. 2…..Osteoporosis: Decreasing Your Risk.

Our Joint Effort issues, as well as the patient joint scheduling booklet you receive after scheduling surgery contain a myriad of information that you should retain and refer back to when you have questions. Should you want a past issue of a newsletter, please call or drop our office a note, we will be glad to send you one.

Return to top

Medicare HMOs Revisited
By Thomas Blumenfeld, M.D.
In the Joint Effort of Winter 1994/1995, a reprint of a letter to the editor of the Business Journal was included. In this letter, written by the Executive Director of the Sacramento El Corado Medical Society, the risks and benefits of enrolling in a Medicare HMO were detailed. The benefits appeared primarily financial, while the risks appeared to be failure to continue to see one’s usual physician, redirection to other doctors, and failure to provide services that the enrollee either had before, or assumed were included.
In six years, this situation has not changed. Weekly I talk with patients who can no longer see their long time internist or family practitioner because they no longer accept that HMO plan. This is extremely distressing and represents not only loss of continuity of medical care, but loss of a familiar face and the comfort that a strong patient-physician relationship can bring. For seeing specialists such as an orthopaedist the situation is even worse. Because of drastically reduced reimbursements, many specialists have joined their medical colleagues in dropping HMO plans. As there are fewer specialists, in some areas patients have no one that they can see.

There is a solution. As in many things in life, it involves money. With sufficient notice, a patient may disenroll from their managed Medicare HMO plan, and use their Medicare benefits as their primary insurance. While this may lead to an increase in costs that some patients over 65 cannot bear, particularly in the area of prescription drugs, the trade off is that you will most likely be able to see the doctor of your choice.

If you wish to have a secondary insurance assist with medical costs, choose one that doesn’t constrain your choices in your doctor.

If you need further information in regards to the above, a good place to start is by contacting Medicare at 1-800-MEDICARE (633-4227) and asking what you would or would not have to pay for various medical needs (i.e. prescriptions, hospitalizations, laboratory or special studies). With this information, make a decision and restore your choices in health care.

Return to top

Insurance Reminder
If you have an HMO insurance, and you change your Primary Care Physician, you MUST notify us of the change and provide a copy of your new insurance card showing the new PCP’s name, address, and phone number. This is very important as it affects where we must submit our bills for reimbursement.

Return to top