Chronic Ankle Instability

Chronic ankle sprain and instability treatment

Chronic ankle sprain and instability treatment

What Causes Chronic Ankle Instability?

People who have a sprained their ankle may develop chronic (long-lasting) ankle instability. It is considered to be chronic if the ankle joint still gives way too easily six months after the first sprain, or if the ankle is sprained again within six months of the first sprain. One quarter of all sporting injuries are ankle related, and 85% of the time these are lateral ligament complex problems.

This kind of instability can develop if the ankle ligaments are overstretched or torn, and heal too loosely (mechanical instability). The interactions between the bones in the ankle and the surrounding ligaments and muscles may be disrupted too. The body has an unconscious awareness of movement and spatial orientation within the body, known as proprioception. This helps to coordinate the movements of the joints by using unconscious reflexes to stabilize them and keep the body balanced. So if an ankle feels permanently unstable, this might not only be caused by overstretched ligaments, but also by a problem with proprioception or resulting problems with muscle coordination.

Chronic Ankle Instability Treatment Options

There are a few different treatment options for chronic ankle instability. At first “functional treatment” is tried, involving physiotherapy to strengthen the joint, and possibly wearing an ankle brace or rigid tape to stabilize it.

One common approach is called neuromuscular training. The aim is to improve the stability, strength and coordination of the ankle. Studies show that neuromuscular training can speed up the healing process of ankle stability and mobility in the first few weeks. But there is not enough research to be able to say what effects this treatment has in the long term.

If the joint remains unstable despite training because the ligaments are too loose, surgery may be considered. One option is to shorten and tighten the ankle ligaments. This is not a very common approach and is usually utilized when all other avenues have been exhausted.

Chronic Ankle Instability Rehab

Chronic Ankle Instability Rehab

Chronic Ankle Instability Surgery Recovery & Rehab

Getting back to sport after surgery

Ankle instability often leads to problems with muscle coordination. For this reason, ankle exercises are a very important part of rehabilitation after surgery. Wearing an ankle brace during this time may also help. Braces not only support the joint from the outside – the pressure will also help you develop a good sense of muscle coordination again.

People probably benefit from starting movement, strength and coordination exercises two to three weeks after surgery at the latest. Studies suggest that people who do this become active again sooner than those who wear an ankle brace for six weeks and do not do any exercises during that time. In the studies, the participants who started doing exercises and strength training earlier were able to go back to work about one to two weeks sooner. They were also able to do sports again about three weeks earlier. But after about two years no advantages could be seen anymore: the stability and mobility of the affected ankle were the same in both groups.

Physiotherapy Vs surgery?

There were no studies comparing surgery directly with physiotherapy or other treatments. For this reason, it is not possible to say who might benefit most from surgery or how effective it is compared with non-surgical (conservative) treatment.

It is also not clear how the different surgical procedures compare with one another. There are only few small trials on this, and they do not provide reliable results. More research is needed to be able to answer this question.

Overall, it is currently not clear whether surgery leads to a faster recovery than strength and coordination training does. But if the ankle remains unstable because of loose ligaments, surgery might be an option. Whichever treatment you go for: with a little patience, sprained ankles usually become stable again.

If you are suffering from an ankle injury and are looking for a Sydney CBD physio contact the team at Sydney Physio Solutions who can help you get back on your feet again.

Superfoods – the Fermenting Frenzy!

Over the past decade the term ‘superfood’ has became a house-hold name and has seen many people fighting over the last bunch of kale in the supermarket! However, there is a new trend that has recently risen to the nutritional hall of fame: fermented foods.

I’m sure we all know a few friends that have traded in their morning coffee for a glass of kombucha, but is there any truth to the claims of endless health benefits associated with the ancient process of fermenting that has been practiced by humans for thousands of years? Can we supplement our physical health and performance by swapping our sweet potato for a side of kimchi? Let’s have a look at some of the facts:

What actually are ‘Superfoods’?

There is no official standard for what is classified as a ‘superfood’. It is commonly understood that any natural food containing a high-concentration of nutrients, such as antioxidants, qualifies for the title. A few of the favourites in this category include berries, acai, kale, chia seeds and coconut oil – extra virgin of course!

Despite the hype, it is important to take a holistic view of diet and exercise. Choosing your groceries based on high antioxidant content alone is not going to help you reach optimal health or that next fitness goal.

Why ferment your food?

The main reason that people ferment their food in the modern era is for the suggested health benefits that it provides. Fermentation is a metabolic process where organisms, such as bacteria or yeast, covert organic compounds such as sugars and starch into alcohol or acids.

For example: Lacto-fermentation uses bacteria to convert sugar and starch into lactic acid. This produces foods such as yogurt, fermented vegetables like saurkraut and kimchi, and cheese.

I have a ‘gut’ feeling about some of the benefits of fermented foods..

Fermented foods contain ‘good bacteria’ and microbes which can increase your gut health.

Other suggested benefits include:

  • Increasing the levels of micronutrients in foods
  • Aiding digestion. Fermented milk products for example can contain enzymes which help to break down lactose, potentially making it easier to digest for people who are lactose-intolerant.
  • Increased availability of minerals. Some natural foods such as legumes and seeds contain phytic acid, which binds zinc and iron together. This means our bodies aren’t able to utilise these minerals. The fermentation process breaks this acid down, allowing our body to use those minerals.
  • Changes taste: If you prefer a tangy or sour twist to your food, this could be for you. Similarly, the process produces carbon dioxide, giving the food a bubbly quality; like soft-drink but without the guilt.

Be sure to read the fine print

Lacto-fermented vegetables are one of the most common fermented foods in Australia. Be warned: these are not mass-produced. So if you are buying these products, such a sauerkraut, from the supermarket then chances are they have either been preserved using vinegar or the organisms are already dead. You would be much better served setting your kitchen bench up as a fermentation station, or visiting your local health-food store or delicatessen for these products.

If you do decide to ferment at home, hygiene during this process is very important as you are working with bacteria. So please take care to avoid contamination with microbes such as E. coli and botulnum, which have been linked to multiple illnesses.

Also be wary that some of these fermented products contain a high sodium content, particularly if lacto-fermentation has occurred.

The Verdict on Superfoods?

There certainly appears to be some health benefits associated with this latest craze, the most plausible being the live microbes that are added to the existing ones within our gut. This can aid in digestion and enhance our immune system functioning.

Some of the more far-fetched claims, such as reducing risk of cancer, do not appear to have any merit. In fact, the World Health Organisation has actually classified pickled foods as potentially carcinogenic.

My mantra as a physiotherapist is ‘knowledge is power’. If a client understands their condition, what contributed to it and what will help them recover, they are far more likely to achieve great outcomes. The same goes for nutrition. Be aware of whether the so-called ‘superfood’ you are eating actually lives up to the promise.

Don’t forget that correct nutrition is only one piece of the puzzle when it comes to optimal health. You also need to stay active and have an exercise routine that works for you.

Feel free to give us a call at SPS, where we pride ourselves on being experts in exercise prescription and advice.

Pilates and Lower Back Pain

Pilates for Lower Back Pain

Core Stability Exercise vs General Exercise for Chronic Low Back Pain

It has been well documented that Lower Back Pain, (LBP), is one of the most frequently reported disabilities (affecting between 60% – 80% of adults), we face in the community. Unfortunately, 40% of those suffering with LBP will not fully recover within the first 3 months.

As Physios and Pilates Clinicians, we see this type of presentation everyday.  A common back pain trigger can be from a poor lifting technique.  At Sydney Physio Solutions, we are continuously striving to find the best way of helping to improve the experience and recovery in this population group.

A recent study, published earlier this year, found that people with Lower back pain who undertook exercises to activate and gain control of their deep spinal stabilisers, aka “The Core”, had better outcomes in the first few months of treatment than those who didn’t.

In a nutshell……

  • “Core exercises”, (learning specific & correct activation of your muscles supporting the spine and pelvis), provide a better outcome during the first 3 months of intervention compared to general exercise alone for people with LBP.1
  • People with Lower back Pain (LBP) display a decreased activation or delay in Transverse Abdominus (deep abs), and Multifidus (supporting spinal muscles). Thus core exercises consist of regaining the strength of these muscles through specific training. 1

At Sydney Physio Solutions, all of our Pilates Clinicians are physios, and thus have the ability not only to assess your core in real time via Ultrasound, but can also guide you personally on what exercises will help and how to progress these if you suffer from lower back pain. Using this technology, you can guarantee you are receiving the most up-to-date, effective and evidenced based approach to managing your pain.

Back Pain Exercises: Low Back Pain Relief & Hamstring Strength for Squats

Looking for Physio in Sydney CBD to treat your lower back pain – Sydney Physio Solutions have two centrally located clinics in Sydney CBD as well as a clinic in Chatswood.


  1. Brian JC, Kenneth EG, Elizabeth RN, Lindsey EE. Core stability exercise Versus General exercise for Chronic lower back pain. Journal of athletic training 2017 Vol 52 (1) 71-72.

Pain Triggers – Shoulder Rides




Most parents know kids can cause pain… literally. Lifting and carrying children can result in stress and strain on the parent’s body, back, shoulders and neck. The shoulder ride is a typical suspect. Despite being great fun for the child, it can quite literally be a pain in the neck for the parent as sometimes it is just quicker and easier to pick up a child when walking a long distance.

So how can a parent minimise the stress and strain on their own bodies?

  • If you absolutely insist on lifting a child up onto your shoulders, try having them stand on a higher (make sure it is safe!) surface such as a table, so that they are at the correct height. Remember its always much better to lift with your legs, rather than your back and this is no different
  • There are carrying devices on the market to assist in carrying children on the back or shoulders. These devices are potentially a safer option for the parent, and avoids the child needing to use a tight grip on the neck or head to hold on.
  • If carrying a baby or infant in the arms be conscious of alternating sides regularly to avoid overloading on one side only.
  • Limit the amount of time or the regularity of shoulder rides.
  • Know when to say no. Don’t attempt it if you are tired, or sore.
  • Know your limits. At some point in time your child will be simply too big to carry. Try and explain to them that it is no longer safe to keep carrying them.
  • Learn a few smart stretches to help keep you limber. Your friendly physiotherapist can guide you, or help you out if you’ve already suffered the effects before reading this advice.shoulder-rides


If you suffer from neck or back, it is best to commence neck treatment straight away.  Your physiotherapist has numerous tricks that can help to quickly relieve your neck pain and muscle spasm.

If you have had neck pain or stiffness for a month or more, your GP may be able to refer you to a physiotherapist in Sydney as long-term stiffness can be treated effectively at any time.

If you are not sure what to do, please contact Sydney Physio Solutions for advice or to make an appointment with one of our neck physiotherapists.

Pain Triggers – Laptop Bags

laptop-bagsCarrying a heavy laptop bag can be a common cause of lots of joint issues including neck, shoulder, lower back or forearm pain. Laptops and all the paperwork that comes along with them often weigh more than we think and can cause significant postural asymmetries and abnormal joint loading – especially if we carry them for long periods and always on the same side.

Another common culprit is us females popping our heavy laptops and papers into our shoulder handbags – not only is this bad for our shoulder and neck but also bad for our bags!  

Consequently consider using a wheeled or rolling laptop bag and swapping arms regularly backpackto help keep these aches and pains at bay. A rucksack bag rather than an over the shoulder or carrying case is also better option.

So ladies for those of you going against these recommendations its a good excuse to go shopping – happy bag hunting! 



If you suffer from shoulder pain or neck pain, it is advisable to start shoulder treatment straight away.  Your physiotherapist has numerous tricks that can help to quickly relieve your shoulder pain and muscle spasm.

If you have had shoulder pain or stiffness for a month or more, your GP may be able to refer you to a physiotherapist in Sydney as long-term shoulder stiffness can be treated effectively at any time.

If you are not sure what to do, please contact Sydney Physio Solutions for advice or to make an appointment with one of our shoulder physiotherapists.

Tendinopathy: What is it?

Tendinopathy is a term used to described pain or dysfunction in a tendon with structural changes that are often chronic in nature. It is frequently seen in clinical practice with the most commonly affected tendons being the Achilles, patella, rotator cuff and elbow. Tendinopathy is a complex condition that can often take many months to recover from. Often referred to as tendinitis, tendinopathy does not involve inflammation of the tendon. Therefore, traditional methods used to control inflammation, such as medication, rest and ice do not seem to improve a person’s long-term function.


Tendinopathy is largely a clinical diagnosis based on symptoms and patient history. Common symptoms include:

  • Pain with tendon loading (e.g. running, throwing, jumping)
  • Reduced exercise tolerance/impaired function
  • Pain with palpation over the tendon

Tendinopathy often develops due to a change in loading through the tendon. This can be due to a sudden increase in training load or due to having a long period off exercise, leading to a weak tendon. Unlike muscle, tendons take a long time to adapt to new stimuli and can easily get damaged if changes in load are to large.

Although imaging such as ultrasound and MRI is accurate for diagnosing tendinopathy, it often does not have a direct relationship to the amount of pain you may be experiencing. It is useful in determining if any structures near the tendon may be irritated that could be contributing to your pain. Structures such as bursa can often be inflamed and which may respond to medication or short periods of rest or ice. It is not uncommon to have inflammation in structures around the tendon in addition to tendinopathy.

A review by an experienced physiotherapist in addition to some imaging can help to be as specific with your diagnosis as possible and determine the best course of treatment and long-term management.


There are a few key points to consider when rehabilitating your tendinopathy. It is a complicated condition and will often take many months for your pain to settle and return to normal sporting activities pain free. The majority of this blog will focus on exercise, as this is the most evidence-based treatment for tendinopathy. Before discussing exercise options to improve tendon strength we will touch on a few common treatment options:

  • Rest: tendinopathy does not improve with rest as it does not improve the affected tendon’s response to load. Although pain may initially settle, it often returns with a return to activity
  • Anti-Inflammatories: these may help reduce pain levels but have no effect on tendon structure, as it is not considered an inflammatory condition.
  • Shockwave Therapy: Evidence on shockwave therapy is mixed, mostly due to the type of study conducted. The best evidence is in plantar heel pain (e.g. plantar fasciitis). It does seem to have a good short-term effect on pain and therefore is often a useful adjunct to exercise.
  • PRP Injections: Overall, there is poor evidence for any type of injection in tendinopathy. Currently one of the most common options is a PRP injection. PRP injections are derived from spinning a blood sample to separate the platelets that contain growth factors and promote healing. This is then injected into the tendon to stimulate healing. In good quality studies PRP does not perform better than placebo. In fact, it was removed from the Medicare rebate scheme due to lack of evidence and the high cost. It therefore should only be considered a last resort in stable tendon pain.

Tendons need to be loaded progressively so that they can adapt and develop a tolerance to each individual’s specific activity. In most cases, tendinopathy will not improve without this increase in loading. Although rest does not heal tendons, there is a need to modify some aggravating factors in order to allow the tendon time to adapt to the exercises. Exercise needs to be individualised based on your individual pain, function and goals. Current evidence supports a progressive exercise program that is progressed over months according to each person’s response. These programs can be broken down in to 4 key phases:

  1. Isometric Exercise (pain relief): recent evidence shows long sustained holds for 5×45-60sec may have a pain relieving effect in tendinopathy.
  2. Strength: once symptoms allow, progressing to specific heavy, slow exercises of 4×6 up to 3x per week allow for muscle growth.
  3. Power & Speed: reducing weight from phase 2 but increasing speed, up to a maximum of 3 sessions per week.
  4. Sport Specific: every 2-3 days while continuing strength exercises.

As you can see, tendinopathy is a complicated condition that requires a very clear and multifaceted approach to achieve the best possible outcomes. Unfortunately, there is no shortcut or quick fix to treating tendon pain. Exercise is the best medicine, with everything else being an adjunct to a well planned, personalised and progressive rehabilitation program. It is important to get a review by a therapist confident and experienced in treating tendinopathy as it can often be a debilitating condition that will hang around for months without appropriate treatment.

Knee Joint Cartilage Tears

 What is a Knee joint Cartilage Tear?

The two types of knee joint cartilage tears  include traumatic and degenerative tears.

Traumatic tears occur through twisting injuries of the knee and degenerative tears occur over time through wear and tear on the joint.

 Do Cartilage Tears heal?

It depends on the location and severity of the tear. The meniscus (cartilage) generally has poor blood supply. The outside one third portion of the meniscus had some blood supply, which may give tears in this location a chance to heal. However, the inside two thirds has no blood flow, therefore tears in this region have no chance to heal. These tend to require arthroscopic surgery.

How do you treat knee joint cartilage tears?

 Small meniscal tears, or tears in the area receiving good blood supply can respond well to physiotherapy.

Physiotherapy treatment for meniscal tears aims to decrease the pain and inflammation in the joint, restore normal movement around the joint and muscle length. Physiotherapy will improve the strength of the hamstrings and quadriceps and hip muscles. Physiotherapy will also correct any longstanding biomechanical issues surrounding the knee joint.

Overall, the knee joint will improve in function and will have a reduced chance of re-injury.

How long does a knee joint cartilage tear take to heal?

MeniscKnee painal tears generally take 6-8 weeks to heal, although some meniscal tears require surgery. Your physiotherapist is the best person to guide you on the most appropriate course of action to recover. Typically, avoiding high impact activities that stress the joint whilst seeing your physiotherapist is key to a optimal outcome.

If you suffer from knee pain or knee injurt, it is advisable to start treatment straight away.  Your physiotherapist has numerous tricks that can help to quickly relieve your knee pain and muscle spasm.

If you have suffered knee pain or stiffness for a month or more, your GP may be able to refer you to a physiotherapist in Sydney as the causes and treatment of knee stiffness can be treated effectively at any time.

If you are not sure what to do, please contact Sydney Physio Solutions for advice or to make an appointment with one of our knee physiotherapists.



Sleep Habits

Physios are often asked about the best position to sleep in, and what is the best mattress or pillow to use. Unsurprisingly, there is no one answer. However, sleep is obviously a crucial time to allow the body and mind to recuperate. Here are a couple of tips that I often advise.

dog upside down

In patients with low back pain, especially if it is one sided and referring into the leg, I advise them to sleep with their sore side up and a pillow/s between the knee to unload the spine. This also works very well for hip pain, particularly bursitis, as it removes the tension of the leg from the hip.

Mattresses are often a great source of contention. The main advice that I give to patients is to make sure they feel comfortable and supported and check that they are not waking up in a valley in the morning! This would indicate that it may be time for a new mattress. This is where you need to have a trade-off between feeling comfortable but also supported. When patients are deliberating between a slightly softer or firmer mattress I generally recommend the firmer mattress as they tend to soften over time anyway.


When it comes to neck pain and pillows, I advise patients to select a pillow that maintains a neutral neck position. If you are unsure of what a neutral position is then you may want to consult your physio. The pillow chosen will vary depending on whether the person is a stomach/back/side sleeper, but it will also vary based on the person’s size and natural spinal curvature.

In general, side sleepers will probably need a high profile pillow, whereas back sleepers will likely only need a low profile pillow or sometimes no pillow at all (or a rolled up towel behind the neck).

When a patient is suffering from acute neck pain and finding it difficult to find a position of comfort, I generally recommend lying on your back with a McKenzie cervical roll under the neck. This usually keeps the neck in a minimally stressful position. If the patient also has associated arm pain, then I may advise them to have a pillow under their arm to support it and take the weight of the arm off the neck.

Ligament injury of the knee: When to see someone.

Imaknee injurygine this scenario: You are playing sport on the weekend when you step hard to change direction and your knee buckles underneath you, leaving a sharp searing pain in your knee.  You hobble off to the sideline and ice the knee straight away.  The next day you go and visit ED who send you for an XRAY which shows no broken bones.  Great you think, though its pretty swollen so yo plan to give it a week or two to settle before getting back to sport.  But the knee doesn’t feel right, maybe the pain doesn’t go away, maybe it feels unstable, something is definitely wrong. But what?

The above scenario is common to most physiotherapists, and highlights the need to seek a definite diagnosis as early as possible in a knee injury.  Most of the time a knee injury will be minor and not result in any significant ongoing problem but sometimes that is not the case.

Injuries to the knee

The knee is a large stable joint that is actually made up of two joints: the tibiofemoral and the patellafemoral components (three if we include the proximal tibiofibular joint.)  The stability of the joint is largely created by strong ligaments, large congruent articular surfaces and powerful muscles.  The stable structure of the knee allows it to perform its role whilst subject to large amounts of load during physical activity.  Accordingly, traumatic injury to the structures within the knee can lead to loss of stability and function.

the knee anatomy

Ligaments – There are 4 main structural ligaments of the knee that are usually considered during knee injury (remember though there are many more ligaments in and around the knee that have important functions and can get injured too)

  • Anterior cruciate ligament
  • Posterior cruciate ligament
  • Medial (or tibial) collateral ligament
  • Lateral (or Fibula) collateral ligament

These ligaments provide resistance to force in almost all directions and are injured when the force exceeds their capacity to respond.  For example, the medial collateral ligament is often injured by a force applied to the outside of the knee, forcing the knee open on the inside (a valgus force.)  Ligament injuries that are missed or poorly managed can result in:

  • Increased instability of the knee.
  • Ongoing pain.
  • Reduced function.
  • Risk of further injury including meniscal and cartilage injury.
  • Accelerated degeneration of the joint leading to osteoarthritis.

Meniscus and cartilage – The cartilage of the knee has a role in reducing friction and to act as a shock absorber within the knee.  It is particularly vulnerable to traumatic injuries, often in conjunction with ligamentous injuries.  Healing is variable and can be poor due to a number of factors including poor vascularisation (blood flow.)  Appropriate conservative management early can improve the chances of a good outcome.knee injury mechanicsSource: Anatomy & Physiology, Connexions Web site., Jun 19, 2013.

When to see someone 

Always!  It is always in your best interest to make an appointment for assessment by a practitioner who is experienced in diagnosing and treating musculoskeletal injuries as soon as practical after a knee injury.  Commonly used diagnostic tests including XRAY and ultrasound are often not adequate for diagnosing common knee injuries.  Clinical suspicion of a major knee injury can be followed by MRI imaging and referral to a specialist as necessary.  When an injury calls for conservative management, early diagnosis and correct treatment allows for improved management and outcomes.

Clinical example: Medial collateral ligament injury

MCL injury can be split into three grades:

  • Grade I – Involves a tear in a small proportion of ligament fibres
  • Grade II – Involves partial disruption to the ligament
  • Grade III –  Complete disruption to the ligament often resulting in instability of the knee and possible injury to other structures.

Whilst all are usually managed conservatively (with the exception of some grade III injuries) grade II-III injuries that are managed poorly can result in ongoing instability and pain in the knee.  Most Grade II and III injuries will be treated for a period of time in a range of motion brace that limits valgus stress to the knee, as well as physiotherapy intervention including swelling management, range of motion exercises, strengthening of the muscles of the core and lower limb, proprioception and walking and/or running retraining.  Recovery is dependent upon unloading and protecting the ligament while it heals, so early accurate diagnosis is crucial.  In the event that the knee remains unstable following immobilisation, surgery may be required.

So always see your physiotherapist or sports specialist after a knee injury.  They can help guide you on the path to recovery as soon as possible.

Wrist and Hand Arthritis

Do you have pain in your hands typing on the keyboard at work?

Do you have pain in your hand or wrist when opening and closing jars?

 Do you feel you have less strength in your hands when performing everyday manual tasks?

Hand and wrist arthritis may be the cause of your problem.

What is arthritis?? I hear you ask…

Arthritis is a very common degenerative condition that can form in the joints of your body as you get older.

It causes wearing away of the cartilage in the joint, which is the shock absorbing material between the bones. This can result in inflammation of the synovial lining in the joint. This is significant as this lining is responsible for producing synovial fluid, which helps protect and lubricate the joint.



What are the common signs and symptoms of hand and wrist arthritis?

If you have arthritis in the wrist and hands you may experience some of the following signs and symptoms:

  • Loss of movement in the joints of the wrist and hand.
  • You might notice grinding or cracking noises with joint movement.
  • Pain in the joint may come and go. It can become worse with gripping objects or repetitive wrist and finger movement. As the arthritis progresses it may develop into a constant ache, even at rest.
  • The joints may swell and can become tender to touch.
  • The joints may appear to be misshaped or deformed.


How can we solve the problem?

Mild symptoms associated with arthritis can be treated effectively by oral anti-inflammatories and physiotherapy. Physiotherapy would involve soft tissue massage to relieve muscle tightness around arthritic joints. Specific exercises can be prescribed for the joints to help improve and maintain range of motion and strength. Additionally, a physiotherapist could provide a splint or support to help protect the joints whilst performing everyday tasks.

In more severe cases of wrist and hand cortisone injections or surgery may be indicated. Surgery is considered when conservative management, no longer eases the pain, or when deformity prevents normal use of the hand. Surgery is also recommended in some patients with inflammatory arthritis. In these patients, the surgery stabilizes joints and prevents tendon damage. Deformity, loss of motion and pain that is not adequately controlled are the main reasons for surgery.