Sample Intermediate Sports Risk Management Program: Fill & Download for Free

Weight training for fightersHere is an outline guide on weight training for fighters - this is part of strength training.The principles and guidelines are given first, followed by some sample skeds (sessions with the exercises and repetitions laid out).Skeds and the exercises that comprise them are not important for beginners - just get in the gym and use the weights. Get some coaching on technique. Value safety more than anything else.When you have had some basic tuition and know the gym layout, then start with basic light workouts using general exercises. Typically, this means an 8 to 10 exercise 3 x 8 sked. At this stage you need a notebook with your sked and weights in.All this is explained later.Please start out light, and don’t lift heavy until you know what you’re doing. Don’t risk your back.Do not train hard the first time you go in the weights gym - otherwise next day you won’t be able to move.The principles of weight training for fightersDiscussed here is strength training with weights, directed at improving strength and power in fighting. It should also help with speed and stamina, as long as balance is maintained between strength and speed work.This is not a complete guide to strength training, as there are other components - this section concerns the regular weight training part of strength training. In addition to this there will be other types of strength training such as that with a partner ( the squats, carries, twisters etc.), bodyweight strength work (dips, chins, etc.), heavy gear moves (the weight sled, giant tyre etc.) and so on.Weight training is an efficient way of increasing stress by measured amounts, which leads to measurable progress.Our goal is not increased size, but increased strength and power. Power is applied strength - it means harder hits, stronger throws, better grappling capability. Some size increase is likely if you have never trained with weights before. As contests take place in weight divisions you will need to watch your bodyweight carefully. A simple balance mechanism for strength vs bodyweight vs stamina is to run more and workout harder in the fight training gym if bodyweight is climbing too much with weight training.It doesn't usually, because it's hard to make big size gains if you are running and doing other gym work, without increasing nutritional input. If you do more weights than anything else, then it is likely your bodyweight will go up, assuming your fuel intake is sufficient.If you train hard on the weights but find that progress of any kind is slow or nonexistent (whatever your goals are, it doesn't matter), then your fuel intake is not adequate: eat better, eat more.Weights will not make you slow unless you go crazy on them and forget balance. Life is a question of balance and proportion, and if you go too far / too hard / too much in any one direction, then it is inevitable that everything else suffers. This is plain logic.Weights for fightersWe want to build:Increased power in all techniqueUsable strengthCore strength: powerful central body strengthStrength with speedStrength with staminaStrength that has a fast delivery characteristicWhat we don't want:To be slowerTo lose stamina: reduced performance later in the athlete's eventGreater bodyweight; or, greater bodyweight without all-round improvementsBulk without speed and fast powerMore stiffness or reduced range of movementWeights for novice fightersWeight training for fighters must be balanced with other training factors, so there is a correct balance overall. We should work on strength, speed, stamina and suppleness. Normally what happens is there is too much of the last three and not enough of the first - so you should be OK to hit the weights fairly hard.For complete beginners, the weight sked is not important at all. (The exercises, reps and sets.) It is a blind alley, a silly diversion, to worry about this aspect of it, as a beginner. Just get in the weights gym and lift. That's all there is to it. You'll soon learn how to go about it better. But: try to get some basic tuition.The first 3 months are just feeling your way and really of zero importance, in the long run. And training is all about affecting the outcome in the long run.Do's and Dont'sThere's only one thing to remember for beginners in the weights gym: DO NOT risk injuring yourself - especially your back - by going too hard. Just don't.Keep a notebook for skeds and weight used - this is important. Weight training is about progressive increase in stress. If you don't know what you started with or what you used last week, it's hard to make progress. Weight training is best treated as a process of measured progress, not a random affair.On the big lifts, write down your max lift in the first week of training. Then, after a year, you can see the progress you have made. As a beginner, it is not advisable to max out the deadlift or squat - just do a lift near to the max and add 10 or 20 pounds. For bench press you go to the max as it is almost impossible to be injured on this lift, assuming you have spotters (helpers).Check the collars before you lift anything, ever, anywhere. Always.Get a weightlifting belt, one that fits.Get spotters to help you if you're not sure about handling a weight safely.Think: safety. It is never wrong to play safe.Learn how to lift a heavy bar safely: the flat back technique. Hollow the lower back very slightly, keep the back flat not hunched, and lift with the legs as much as possible.……….Lifting too much weight is really, really dumb. Don't.There are a couple of exceptions to this: working pyramids on the bench for example, with capable spotters - it is very hard to injure yourself on this move, assuming the spotters are OK - big weights are just fine, and the bigger the better. You can safely lift to the fail, on the bench.Do cleans in preference to heavy deadlifts. What we need is explosive all-round power with a wide movement range - not ultimate leg/back strength. We want the ability to use the strength fast in a wide variety of use cases; not pure leg/back strength.Otherwise just be sensible, and watch your back. Back injuries tend to be persistent so DON'T risk one.Things to avoidNever risk the lower back. My advice is to avoid the 'good morning' type of lift: forward bends with the bar in the back squat position; also avoid Romanian deadlifts (a stiff-leg deadlift where the lift is done entirely with the lower back and back thighs) - unless you do these moves light.Don't add weight on a belt when doing dips. For some reason, parallel bar dips put an unusual stress on the shoulder joint, and loading them up makes this a frequent cause of shoulder joint problems. Do your dips free - no added weight.Important exercisesFighters need these core moves:cleansbench presssquatsbent rowingoverhead presstrunk twists with kettlebell / dumbbellPlus more forearm work than other athletes (more grip strength is needed).Don't miss out any of these moves.Weights for boxer/fightersThere are two exercises you can safely prioritise for:cleansbench pressCleans, because they are a basic part of Olympic lifting, which gives all-round strength gains and the ability to use the strength over a wide movement range.Bench press, because it is the puncher's move: it blasts all the bits you use most in a hard punch: the top strip of the pecs, the front delts and triceps.Lats, shoulders, legs, trunk twists: yes they are important - but they're all done plenty in other moves.Starting outDon't start weights within one month of a fight date, if you've never done weight training before.Never train hard at your first-ever weight training session. This results in soreness and stiffness that takes several days to get over.Don't train hard in your first ever weights session.Stop weight training one week before a fight.If you fight every month and want to start weights for the first time (this would be unusual - but anything is possible), then weight train only once per week in month 1; and start out very easy and light.DietYou will need more fuel when you add weights to your training sked. More protein and carbs will be needed, otherwise you will not see much in the way of strength gains, and energy will be depleted. Make sure to maintain a balanced diet.Don't eat junk like heavily processed food and snacks. Eat food. Food grows on trees and runs around, it doesn't come in a packet. Don't eat white bread, white sugar, and packet food. Garbage in, garbage out. If you want to take your training and results seriously, you can't run the machine on crap: it needs proper fuel.Probably the first sign a person is beginning to take their fights seriously is when they stop eating nutrition-free garbage like white bread.A meal consists of something like a glass of pressed fruit juice; a piece of steak or fresh fish with potato or brown rice, peas and broccoli, with sea salt on it*, with some wholemeal bread; a baked apple with clove and raisins, and a wholemeal muffin and some honey; and a glass of water. Preferably bottled if the alternative is urban tap water.* Sea salt has more minerals than just sodium choride - it can have up to 8 components, which means it is a far better electrolyte replacement than table salt.To get yourself drinking more water, try sparkling bottled water, chilled from the fridge.A meal does not consist of a white bread sandwich, something out of a packet, followed by a pop tart and a can or bottle of soda. How you expect to perform well on that is a mystery - indeed, you hope that's what your opponent is eating.TermsSkeds are training schedules: exercises, sets, reps, and how they are organised.In your workout notebook you have your sked written out. A sked for Mondays might for example feature 8 or 10 exercises of 3 sets of 8 reps. This is an intro sked for a beginner, which they will do weekly on a Monday (or whenever).Skeds are not important for complete beginners: just get in the gym and lift some weights, you'll soon understand how things are done.Exercises are the names of the individual moves on the weights - for example curls, or squats.Sets are the groups of reps on one exercise that collectively comprise a training session or sked. A set can be 8 reps on curls, for example. Rest for 1 minute between sets.Reps or repetitions are single iterations of a move repeated several times to make a set - for example 8 reps: 8 curls, to make 1 set, then rest. A rep is one curl. A set is 8 of them.Do your reps briskly, with no wait between each rep.A barbell curl, for example, is where you load a short bar up light - say a 10 pound disc each end - pick it up with palms facing forward so that you are standing, arms straight, with the bar in front of the hips (this is called clean to hang, palms forward) - 'curl' the bar up: without moving any other part of the body you will bend the arms to bring the bar up to shoulder height - relax and let it slowly return to hang. This is one rep of the curl exercise, of which you will do 8 one after the other briskly, which is called a set. Then replace the bar on the floor and rest 1 minute till the next set.The weight is increased whenever you think you can perform the full group of sets without failing or cheating. It’s OK to fail on the last rep of the last set; this is when you can ‘cheat it up’: get the bar up by using a cheat method not a strict move. It’s best to use a strict move routinely, then cheat the last rep if you need to. You weight is adjusted perfectly if you need to cheat the last rep of the last set - soon you will be able to add more weight. If you cannot do the bulk of the reps in strict form then you have too much weight - take some off.Don’t overload the lifts in your first 6 months of weight training: you are allowing the body to toughen up all the joints and connections, not just the muscles - this takes a little time.Collars are the screw clamps you put on the end of the bar outside of the weight discs, to stop them falling off. Whenever you get hold of a new bar, check the collars. It is common to see discs falling off the end of a bar where the lifter did not check the collars. Injuries and damage can occur.A bar or barbell is a long 1 inch thick steel bar, of 4 to 6 feet in length usually. The weight discs slide onto each end, and are secured with collars.A curling bar is a bar for arm exercises that can be used instead of the short 4 foot bar. It may be only 3 feet long (1 metre). It will either be in a W shape or be a parallel bar arrangement with angle grips. It is used for curls and tricep extensions, to provide an angle grip, which is more comfortable with heavier weights.A dumbbell is a short bar about 10 or 12 inches long with small weight discs at each end, for use in one hand. They are often used in pairs.An endbell is a dumbbell with weight discs at one end only. They are used for the forearm lever and twist moves that build strength in the hand. This item of equipment is important for fighters because grip strength is critical for harder punches and better throws.A wrist roller is a 2 or 3 foot stick, a wooden rod cut from a broomhandle or suchlike, with a thin rope about 4 or 5 feet long attached centrally, from which is suspended a 5 pound disc weight (typically). Along with an anti-cheat bar at chest height - this is an absolutely crucial part of the method and the wrist roller is virtually useless without it - the wrist roller is used to wind the weight up and stress the forearms. The wristroller and endbell together, used correctly, produce massive strength in the hands - far better than any barbell or dumbbell moves - useful for both boxers and wrestlers, as grip strength is critical for both.ConventionsA weight lift is assumed to be with a barbell unless otherwise stated (or if it is not possible with a bar). Example: curls - done with a bar, so the method is not stated. Dumbbell curls - done with two dumbbells, alternating. Single dumbbell curls - a set on the right arm, then a set on the left.Standing can be abbreviated to st.Lying can be abbreviated to ly.Dumbbell/s can be abbreviated to d.Extensions is abbreviated to ext.Free weights versus machinesFree weights are bars and dumbbells and the like, without any attachment to a machine.Machines or machine weights are mechanical devices that contain weights integrally, or assist with the mounting of bars or dumbbells.Both have a use, but free weights are of more benefit overall to the fighter, as the whole body has to be employed to manage the bars and dumbbells. Machines are useful for an alternative, or for targeted training.For example, a lat pull-down machine can be used when you do not have the strength required to execute a single rep on the back chin. It will allow you to build the strength required to do 1 rep on back chins. After that, the back chins move will be sufficient as it is much harder than the pull-downs. Negatives can be used too: do the return (falling) part of the move slowly.All free weights work the whole of the body, to a certain extent, as:You have to pick up the bar or dumbbells first.Although the moves target a certain limb or muscle group and its framework, other parts of the body have to work to stabilise the limbs and/or body when performing a lift with free weights.Machines are much easier to use, and provide less overall work for the whole body - but they are good for variation; to reduce boredom and maintain interest; to provide a different type of stress; and to provide a different action that varies the load on the origin and insertion of a muscle (varying the load type and direction).You cannot equate the weight used on a machine to that used on a barbell - the two are not related. Write them separately in your notebook.NegativesNegatives, or negative lifts, or reverse-direction lifts, are a way to increase low rep capability.For example on the back chin (chins / pull-ups, with hands wide spaced, palms forward, pulling up to the bar at the back of the neck), some find it hard to do one rep if they are unused to exercise. So we can start by just using the downward or negative part of the lift: get up to the high position at the chinning bar, with the bar touching the back of the neck, by standing on a stool; lower yourself very slowly to the start position; repeat several times.Soon you will be able to do 1 rep on the back chin move, as the muscles have received repeated stress on the negative or lowering part of the move, and have become stronger as a result.Negatives and machines can be used to get past sticking points, especially when early on in your strength program.Pyramid setsIf you want to increase the max weight you can lift on a particular move: do pyramids.A pyramid set is where you start light with high reps, and add weight through the set, dropping the reps, ending up with a single rep at max. It's not a lift type that should be used much for fighters as it puts a massive load on the body area being worked, and therefore has too much injury risk for the joints for us.However it is entirely appropriate for benching as it is almost impossible to overwork or damage the joints on the bench. Since the bench is best for punch power, pyramids on the bench are excellent.Let's say you are a lightweight, just starting out, and can bench 130 max. This is how your sets go. You need a spotter for this, at least on the last couple of reps in each set. There are (about) 16 reps in each set, and you do 4 sets.6 reps with 80 pounds4 reps: 1003 reps: 1102 reps: 1201 rep: 130Don’t do more than the fixed number of reps per weight. If you find the last rep easy, then add 5 pounds. If you make that easily, add another 5. Count the bar as 10 pounds unless it is a heavyweight bar - in that case allow 15 pounds. Next set (or next session) add that weight all the way through the set, so you are up by 5 pounds.It's OK to fail on the last rep, indeed you want to increase the weight so that at least the last rep on the last set fails: this is successful estimation. If you are failing on the rep, then make the lift by:Cheating it up: decline it (change it to a slight down angle) by raising the hips off the bench - this makes the angle better, the lift is easier.Or: decline it to the max - put your feet up on the bench and raise your hips high. This makes it a big decline lift which is much easier. This is a cheat - but if you have to make the final lift by this method, it's OK, because you've got the weight exactly right.Or: your spotter puts a finger of each hand under the bar and helps you lift it.Any of these will help you jack the weight up month on month.Follow with heavy flyes: 6 reps for 4 sets.We just do 4 sets on the pyramids.Grip strengthMost arm exercises, such as curls and tricep extensions, do not work the forearm (and therefore the grip) well; they are targeted at the upper arm, and any effect on the lower arm is subsidiary.To increase grip strength, all bar and dumbbell handling is good; heavy bar lifts (or simply hangs) are good; and best of all are the specific forearm exercises.You can think of these as an equivalent to calf raises: most leg moves work the upper leg 90% and the lower leg 10%, and it is much the same with arm work. To optimise the grip we need work that is optimised for the forearm.Alternating skedsNovices who can train twice a week on the weights can use a different sked on each day: if you can train on say Tuesday and Friday then you will use moves comprising sked A on Tuesday, and (mostly) different moves comprising sked B on Friday.Both will be general skeds, in order to cover plenty of ground without too heavy a stress factor.You build your own skeds for this purpose. It really does not matter what moves you use at this stage, as it is all building experience and knowledge. Try to cover all of the body regions; you can do a region light on one day and hard on the next session later in the week, for example.Experienced lifters who don't want to do split routines also build their own skeds like this. Typically one day will be a general sked, the other day will be for blasting one or two areas such as chest and legs. This way we can get everything done and also hit one or two areas hard - which could change monthly or as appropriate. There is some balance to it.Split routinesThese are heavy work skeds that blast limited body areas multiple times per week, typically Mon - Wed - Fri or similar.They are limited to one or two body regions per day. This approach is good for off-season power building, but too much on the weights for a fight lead-up program.TargetsThe goals and aims, and specific targets, come in various forms.For example we will probably want to be able eventually to lift some good weights on the bench and for squats.For fighters, a 6 x 6 sked has proven useful once per week: a sked with 6 moves lifted heavy for 6 reps. It takes a little while to build up to this as we do not want to introduce too much stress, too early. It's not just the muscles that are being made stronger, it is the entire structure of the body, from the skeleton onward: the bones become thicker and denser as a result of repeated progressive stress; the joints become stronger; the muscles become stronger. The whole structure is improved. This takes time.It takes some time to elapse before we reach the point where it is safe to apply extreme stress without risk of injury: we must allow time for the untrained body to respond to the new regime of hard work.Weights and targetsA weight to aim at is useful, especially in several of the lifts, as this tells you where the endpoint is and what you are aiming at.At this stage we will just address the bench press. An achievable target for fighters is 1.75 times bodyweight, and this is a good lift considering the athlete is not in a strength sport.So for 1.75x BW (one and three-quarter times bodyweight):For the 140 male: 245at 160: 280at 180: 315For females, a little lessAn example from life: a fighter X started at bodyweight 145 and his max on the bench was 125 pounds, in week 1 of weight training, never having used the weights before.So, he started out at 86% BW.After several years his BW is 175 and he maxes 306 on the bench. He made 1.75 BW. Or if you like, 211% start BW.Three-lift totalOne way to measure a person's overall strength is to add the total for three of the major lifts: bench press, squat, and deadlift.An average total for a strong athlete at intermediate lifting level (but very strong for a fighter) is 1,000 pounds - but of course this takes no account of BW and is therefore a pointless measure, much of the time. It applies at about 170 - 190 BW.For lighter people this number would be much lower (e.g. 800); and heavier for the bigger men (1,200 perhaps).For fighter X listed above on the bench total (a person starting at BW 145 and benching 125 in week 1), their eventual 3-lift was 1150.These kinds of measures are not relevant for fighters with less than three years on the weights. They are a way to take stock once you are several years in. Like your fight record, they give a guide to how things are going.ExercisesThere follows a selection of moves and the area of the body they work hardest. There are hundreds of these, so a good policy is to pick one or two to work an area then change to a different move after a short time.Note that most of these moves are pushes, pulls, or lifts. This means they utilise the chest and triceps (pushes - aka pressing - analogous to punching); the back and biceps (pulls - as in the rowing moves - like the pulling action in throws or punching arm returns); or combining the back/legs/shoulders/arms - mostly the biceps/forearm - (lifts: a major body move that misses out only the chest and triceps).A good policy for sked creation is to mix these fundamental types carefully, since otherwise you'll overload the triceps for example if you just do pressing, or miss out on other important moves.The moves below are separated by body region; by type: free weights or machine; and by gear needed: bar/dumbbell. Example: d. tricep ext = dumbbell single tricep extension - could be seated, standing, lying or standing bent over singles, if not specified.The formatting options on Quora are essentially nonexistent, therefore you will have to excuse the scruffy/random formatting of the following lists.……Big liftscleansdeadlift….Chestbench pressincline bench pressbench press racksmith machine benchpressdumbbell flyespec deck (machine flyes)….Backbent rowingpulloversdumbbell single-arm bent rowingfront chinsback chinslat pull-down machine….Shouldersoverhead pressneck pressrotary pressupright rowingd. lateral raises (aka standing flyes)….Midsectionkettlebell trunk twists (can also be done with a dumbbell)ab bench incline sit-ups with dumbbell….Legssquatscalf raisessquat rackleg press machinehack squat machineleg curl machineleg ext. machine….Armscurlscurling bar curlschins (basic type)ly. tricep ext.st. tricep extensionsd. curlsalt. d. twist curlsbending d. tricep ext.st. d. tricep ext.……SkedsIntro skeds: here we simply pick some moves to cover all areas and do them in a 3 x 8 format. So, we get 8 to 10 moves, with 3 sets on each, and 8 reps in each set. This is a good approach for learners.Intro sked 13 sets of each move, 8 reps in each set: 3 x 8Rest 1 minute between sets, and in the break between one exercise and the next - e.g. between cleans and bench press. Do each rep briskly, with little or no rest between reps.This sked takes about 1.25 hours in the gym on average; maybe quicker with unhindered access to all weights and equipment.Take a short break after the main weights - take a drink, rest 5 minutes - then do some midsection or forearm work.Forearm work must be done last, since the hands should be virtually paralysed at the end of this part of the session. If not, it was not done right.cleansbench pressdumbbell flyesbent rowingsquatsoverhead pressupright rowingcalf raisescurlslying tricep ext--wait 5-- --rehydrate--incline board sit-ups or forearm workIntro sked 2Now build your own.Do 8 to 10 moves at 3 x 8.Or, go to an area blaster such as chest and legs only, for your second weights session of the week. Next week do back and shoulders. The week after, do legs and arms. Or as you prefer.Forearm and gripA hand strength sked - do it anytime.It has to be done last if you’re doing it in the gym - the hands are unusable after this, assuming you do it right.1. endbell twists2. endbell front lever3. endbell back lever4. wristrollerThe endbell moves can be done as 3x8’s.The wristroller is ALWAYS used off an anti-cheat bar at chest height, and ALWAYS worked until the fail point.Always finish with wrist roller.The hands cannot be used after this for about 10 minutes, so it is not possible to do this move earlier in a sked.If you can still use the hands after this sked, you didn't do it properly. The forearms should be pumped up hard like bursting sausages, and the hands paralysed. If this does not apply, you probably didn't have an anti-cheat bar on the wrist roller. Mostly you just wasted your time, then.Next time do it right:get an anti-cheat bar to rest the arms on at chest height for wrist roller work……Split routinesSplit 16 x 6 split, chest / backThese are heavy lifts - do a weight that means you have to cheat the last rep or fail, on the final set.Warm-up: free squats, front bends1. cleans - 6 sets, 6 reps. Do the first set light, to warm up the back.2. bench press - 6 x 63. dumbbell flyes: 6 x 64. bent rowing: 6 x 65. back chins: 6 x 6 (add weight from the start, with a weight disc on a belt, if you think you will do more than 6 reps on the last set)6. reverse flyes (bent-over flyes): 6 x 6--wait 5-- --rehydrate--Finish with some light arm work - either upper arm or forearm:curls: any kind, 2 x 8 — tricep extensions: any kind, 2 x 8or:forearm work (endbell, wrist roller)….Split 2- build your own.…………………………Punch powerPunching power comes from total body strength and speed: drive from the legs, hard rotation, strong arm lock at the impact point. Breath control and movement contribute.Once you have done plenty of basic weights, you can try these weight gym moves for jacking up punch power:Landmine press. This uses a vertical endbell with its bottom end located in a hinge, or in the corner of a room. Work alternate sets using a right cross, then left cross, position (press out with rear hand, switch guard).Standing one-arm cable press. Stand back to a wall or the cable row machine, where the cables can be pressed outward from a shoulder height position: press the cable out one side for a set, then the other side.This concludes the intro to weight training for fighters.After 6 or 12 months you will know all this by heart, and will be able to build your own skeds.

Physiotherapy ManagementPrecautions and ContraindicationsPatients are at risk of hip dislocation after replacement as a result of the trauma to the hip stabilizers of the hip (capsule, ligaments and muscles) as well as due to the size difference of the prosthesis to the bones. Reduced size of the prosthetic femur head when compared to the average human femur head makes it easier to dislocate until the stabilizing tissues have healed and adapted to this smaller size[40]. This generally takes up to 6 weeks to heal.Posterior ApproachNo combination of the following hip movements on the operated side:Flexion > 90 degreesInternal rotation past neutralAdduction past midlineWeight bearing restrictions as per surgeon (mostly partial to full weight bearing for 6 weeks after surgery)Anterior ApproachHip replacements following this surgical approach is generally more stable. No specific ranges are currently linked to the precaution movements, as surgeon preference should also be taken into account.Patients are encouraged to avoid a) excessive ranges and b) combination of the following hip movements on the operated side:ExtensionAbductionExternal rotationWeight bearing restrictions as per surgeon (usually less strict than with posterior approach surgery and patients are able/allowed to mobilise unaided sooner)Pre-operativePrescribing preoperative exercise as soon as people are approved for hip surgery could play an important role towards improving preoperative quality of life, because people can wait many months for surgery and might experience further deterioration in health-related quality of life during long waits.[41] Level 2b evidence shows that physiotherapy and educational therapy may be useful for end-stage osteoarthritis.[42] A study on a 6 week education and exercise programme has shown significant and sustained improvements in pain and disability on patients wait-listed for joint replacement surgery. Further positive results included improvements in function, knowledge and psycho-social aspects.[43]A pre-operative assessment and treatment session is very helpful in the planning of the post-operative management of patients following a total hip replacement. Benefits include decreased length of stay[44],decreased anxiety levels[45], improved self-confidence[46] and establishing a relationship of trust between the physiotherapist and patient early on. Further benefits include improved quality of life and psychological health.[45] It also helps to develop a patient-specific rehabilitation programme to follow post-operative, taking assessment findings into consideration. The main factors defining the therapy management are the surgical approach and the general state of the patient. Whether the patient desires to gain physical fitness or wishes to recover for recreational activity should also be taken into account when establishing the rehabilitation programme.Research has shown that a combination of verbal explanation and written pamphlets is the best method for health education.[45] It is very important to incorporate this into the pre-operative physiotherapy management of patients prior to total hip replacements. Pre-operative education on precautions are liked to better post-operative adherence.[45]AssessmentSubjective historyRange of motionMuscle powerCirculationMobility and function[46]TreatmentEducation and advice:Patient information bookletPrecautions and contraindicationsRehabilitation processGoals & expectationsFunctional/ADL adaptionsSafety principlesEncourage to stop smoking if applicableDischarge planningTeach:Bed exercisesTransfers in and out of bed (within precautions)Gait re-education with mobility assestive device (crutches vs walking frame vs rollator)Stair climbingPost-operativeThe aim of post-operative rehabilitation is to address the functional needs of the patient (e.g. start mobilising) and to improve strength and range of motion. This starts off as an assisted process, but the aim is to get the patient as functional as possible prior to discharge. As a result of the underlying pre-operative pathology, patients may present with muscle atrophy and loss of strength, particularly in the gluteus medius and quadriceps muscles. The result of the loss of strength is that the elderly are less independent.[8] Although the surgery will correct the joint problems, any associated muscle weakness that was present before the surgery, will remain and require post-operative rehabilitation. Research has shown hip abductor weakness after surgery is a major risk associated with joint instability and prosthetic loosening.[9] Early postoperative rehabilitation after a total hip replacement focuses on resorting mobility, strength, flexibility and reducing pain.[10] It is found that patients can achieve significant improvements through a targeted strengthening programme following total hip replacement.[47]No specific general hip replacement protocol is currently in use, as small elements of the rehabilitation process is surgeon specific. For example, in some enhanced recovery after surgery protocols, patients are mobilised out of bed within the first 6 hours post surgery. Other settings may only start mobilising patients out of bed on day 1 or 2 post surgery. Accelerated rehabilitation programmes and early mobilisation have shown to give patients more confidence in their post-operative mobilization and activities of daily living, as well as being more comfortable with earlier discharge.[48]EvidencePhysiotherapy can improve strength and gait speed after total hip replacement and help prevent complications such as subluxation and thromboembolic disease. In addition, physiotherapy increases the patient’s mobility and offers education about the exercises and precautions that are necessary during hospitalization and after discharge.[49] (level of evidence 1a)Physiotherapy maximizes the patient’s function which is associated with a greater probability of earlier discharge, which is in turn associated with a lower total cost of care[50](level of evidence 2c).Physiotherapy provides pain relief, promotes rehabilitation and the reintegration of patients into ADLs. It also provides a better quality of life through the patients’ reintegration into social life [51] (level of evidence 1b).Level 1b evidence suggests that bed exercise following a total hip replacement does not seem to have an effect on the quality of life[52], but stays important for the effects on oedema, cardiac function and improving range of motion and muscle strength (level 4 evidence).[53]. It also allows an assessment of the physical and psychological condition of the patient right after surgery.Early weight bearing and physical activity has benefits for the quality of bone tissue[32] as it improves the fixation of the prosthesis and decreases the incidence of early loosening. The amount of activity is patient specific, and clinical reasoning should be used to make adaptions where needed. Certain specific sport movements have a higher risk of injury for unskilled individuals, and should be incorporated later in the rehabilitation process under supervision of a physiotherapist or biokinetisist.The following is a suggested protocol in the absence of complications. Surgeon preference should be taken into account, as well as any other factors that might hinder the following of the protocol. Adaptions should be made to make it more patient specific.[46][54]Day 1 Post-SurgeryEducation and adviceEducation of muscular relaxationRevision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).Bed exercises:Circulation drillsUpper limb exercises to stimulate the cardiac functionMaintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilisation on the operated hipIsometric quadriceps (progressing to consentric VMO) and gluteal contractionsActive-assisted (progressing to active) heel slides, hip abduction/adductionBed mobilisation using unilateral bridging on the unaffected legTransfer to sit over edge of bedSit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)Sitting out in chair for maximum 1 hourPostioning when transferred back to bedDay 2 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceIncorporate balance exercises if neededSitting in chairDay 3 Post-SurgeryBed exercises as described above, progressing repetitions and decreasing assistance given to patientProgression of distance mobilised and/or mobility assistive deviceStair climbing (at least 3, or as per home requirements)Sitting in chairRevision of precautions, contraindications and functional adaptionsGive 6 week progressive resistive strengthening home exercise to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)Discharge from hospitalAccelerated ProtocolCombination of day 2 & 3 to discharge patient day 2 post surgery.Only selected patients6 Weeks Post SurgeryPatients are normally followed up by orthopaedic surgeonSurgeon determine if the patient are allowed the following:Full range of motion at the hipFull weight bearing without mobility assistive deviceDrivingAfter 6 WeeksGain of initial ROM, stabilization, and proprioceptionEnduranceFlexibilityBalanceSpeed, precision, neurological coordinationFunctional exercisesOutcome MeasuresHarris Hip ScoreOxford Hip Score (OHS)6 Minute Walking TestTimed Get Up & Go TestWestern Ontario and McMaster universities osteoarthritis index (WOMAC)SF-36Fear Avoidance Belief ScoreHip Disability & Osteoarthritis Outcome Score (HOOS)International Hip Outcome ToolIbadan Knee/Hip Osteoarthritis Outcome MeasureTake Home MessageProper preoperative examination and early postoperative rehabilitation is crucial for successful outcome.ResourcesPre-operative patient workbook on "living with osteoarthritis"Related articlesTotal Knee Arthroplasty - PhysiopediaDefinition/Description Total knee arthoplasty (TKA) or total knee replacement (TKR) is a orthopaedic surgical procedure where the articular surfaces of the knee joint ( the femoral condyles and tibial plateau) are replaced. There is at least one polyethylene piece, placed between the tibia and the femur, as a shock absorber.[1] In 50% of the cases the patella is also replaced. Reasons for a patella replacement include: osteolysis, maltracking of the patella, failure of the implant. The aim of the patella reconstruction is to restore the extensor mechanism. The level of bone loss will dictate which kind of patella prosthesis is placed. [2] The main clinical reason for the operation is osteoarthritis with the goal of reducing an individuals pain and increasing function..[3] Clinically Relevant Anatomy The Knee is a modified hinge joint, allowing motion through flexion and extension, but also a slight amount of internal and external rotation. There are three bones that form the knee joint: the upper part of the Tibia , the lower part of the Femur and the Patella. The bones are covered with a thin layer of cartilage, which ensures that friction is limited. On both the lateral and medial sides of the tibial plateau, there is a meniscus, which adheres the tibia and has a role as a shock absorber. The three bones are kept together by the ligaments and are surrounded by a capsule. Epidemiology /Etiology When all the compartments of the knee are damaged, a total knee prosthesis may be necessary. The most common reason for a total knee prosthesis is Osteoarthritis [4]. Osteoarthritis causes the cartilage of the joint to become damaged and no longer able to absorb shock. There are a lot of external risk factors that can cause knee osteoarthritis. For example: being overweight; previous knee injuries; partial removal of a meniscus; [5] rheumatoid arthritis; fractures; congenital factors. There might also be some genetic factors the contribute to the development of osteoarthritis, but more research is necessary. Total knee arthroplasty is more commonly performed on women and incidence increases with age.[5] IN the US in 2008 63% of TKR operations were on women. Also a dramatic increase in TKR surgery is projected to occur with a 673% increase by 2030 in America..[6] Another trend for TKR surgery is the increasing rate of of recipients under 60, whilst initially designed as an operation for the >70 age bracket.[7] Characteristics/Clinical Presentation Pain is the main complaint of patients' with degenerated knee joints. At first, pain is felt only after rest periods ( this is also called ‘starting pain’) after a couple of minutes the pain slowly fades away. When the knee joint degeneration increases, the pain can also occur during rest periods and it can affect sleep at night. Individuals' can also complain of knee stiffness and crepitus. Due to pain and stiffness, function can decline and is manifests as reduced exercise tolerance, difficulty climbing stairs or slopes, reduced gait speed and increased risk of falls. Complications Stiffness is the most common complaint following primary total knee replacement, affecting approximately 6 to 7% of patients undergoing surgery.[8] *0 5 of patients have some degree of movement limitation.[6]In addition to stiffness, the following complications can impact on function following this surgery: Loosening or fracture of the prosthesis components Joint instability and dislocation Infection Component misalignment and breakdown Nerve damage Bone fracture (intra or post operatively) Swelling and joint pain Complications as above may require joint revision surgery to be performed. Diagnostic Procedures In order to assess the gravity of wear or injury the orthopedic surgeon carries out external tests, and the patient is likely to undergo imaging. Patients co-morbidities also need to be considered[9] Obesity is an important factor that needs to be considered prior to surgery as evidence suggests a correlation between higher body mass index (BMI) and poorer post-operative functional outcomes [10] These are the different stages of osteoarthritis that you can see at a MRI. Outcome Measures Knee disability and Osteoarthritis Outcome score (KOOS) The Timed Get Up and Go Test (TUG) Visual Analogue Scale (VAS) Range of motion (ROM) [11] Examination Subjective Assessment First the examiner should ask the patient about the history of complaints and also about expectations from surgery. The examiner should then perform a full objective examination. After this different tests could be carried out to determine whether the patient needs total knee arthroplasty: Active ROM Passive ROM Muscle power Functional tasks Post-operative Tests Inspection: of the wound/scar, redness, adhesion of the skin. When infection of the wound is suspected the patient must be referred to an Orthopedic Consultant or an emergency doctor. Palpation: post-operative swelling, hypertonia (adductors), pain and warmth. [12] Medical Management The purpose of the surgical procedure is to achieve pain free movement again, with full functionality of the joint, and to recreate a stable joint with a full range of motion. Total knee arthroplasty is chosen when the patient has serious complaints and functional limitations. Surgery takes some 60-90 minutes and involves putting into place a three-part prosthesis: a part for the femur, a part for the tibia, a polyethylene shock absorbing disc and sometimes a replacement patella. A high comfort insert design is chosen to achieve this. The perfect prosthesis doesn’t exist; every prosthesis must be different and the most appropriate size and shape is chosen on a patient by patient basis. During surgery a tourniquet is sometimes used; this will ensure that that there is less blood loss. However, when a tourniquet is not used, there will be less swelling and less pain.[13] Physical Therapy Management Pre-operative The physical therapist can choose to teach the patient the exercises before surgery in order that the patient might understand the procedures and, after surgery, be immediately ready to practice a correct version of the appropriate exercises. It is also important that the functional status of the patient before surgery is optimised to assist recovery. The focus of a pre-operative training program should be on postural control, functional lower limb exercises and strengthening exercises for both of lower extremities.[14] Unfortunately, there is limited evidence to support that pre-operative physiotherapy brings significant improvements in patient outcome scores, lower limb strength, pain, range of movement or hospital length of stay following total knee arthroplasty.[15] Post-operative Evidence indicates that physiotherapy is always beneficial to the patient post-operatively following total knee arthroplasty. Although specificity of intervention can vary, the benefits of the patient actively participating and moving under physiotherapists' direction are clear and supported by the evidence. There is also some low-level evidence that accelerated physiotherapy regimens can reduce acute hospital length of stay.[16] Perhaps the most important role of physiotherapists in the management of patients following TKA is facilitating mobilisation within 48 hours of surgery, sometimes as early as the same day as the operation (Day 0). The use of a continuous passive motion (CPM) may be utilised in this period. A 2011 report found that although clinical outcome measure showed no better results than traditional mobilisation techniques, subjectively patient outcomes of pain, joint stiffness and functional activity were better.[17] The optimal physical therapy protocol should also include strengthening and intensive functional exercises given through land-based or aquatic programs, that are progressed as the patient meets clinical and strength milestones. Due to the highly individualized characteristics of these exercises the therapy should be under supervision of of a trained physical therapist for best results. [18] [19] There is evidence that cryotherapy improves knee range of motion and pain in the short-term. With are relatively small sample size of low quality evidence, it is difficult to draw solid conclusions regarding the outcomes measured and specific recommendations cannot be made about the use of cryotherapy.” [20] Common Bed and Chair Exercises [21] Ankle plantarflexion/dorsiflexion Isometric knee extension in outer range Inner Range Quadriceps strengthening using a pillow or rolled towel behind the knee Knee and hip flexion/extension Isometric buttock contraction Hip abduction/adduction Straight leg raises BridgingPartial Knee Replacement - PhysiopediaDescription A partial knee replacement (PKR) is a surgical procedure to replace only one part of a damaged knee. It can replace either the inside (medial) part, the outside (lateral) part, or the kneecap (Patellofemoral) part of the knee. With PKR, only the damaged area of the knee joint is replaced, which may help to minimize trauma to healthy bone and tissue, and also helps relieve arthritis in on or two of the three compartments of the knee. Surgery to replace the whole knee joint is called total knee replacement. Indication Partial Knee Replacement is intended for use in individuals with joint disease resulting from Degenerative, Rheumatoid and post-traumatic arthritis, and for moderate deformity of the Knee. Clinical Presentation People with advanced osteoarthritis and conservative treatments have been exhausted.[1] Mild valgus or varus deformity. Pain is often noted when performing physical activities requiring a wide range of motion in the knee joint.[2] Diagnostic Tests X-ray and MRI of the joint will reveal the joint disease resulting from Degenerative, Rheumatoid or any Post traumatic arthritis, and also moderate deformity of the Knee. The x-ray indication for a knee replacement would be weightbearing x-rays of both knees- AP, Lateral, and 30 degrees of flexion. AP and lateral views may not show joint space narrowing, but the 30 degree flexion view is most sensitive for narrowing. If this view, however, does not show narrowing of the knee, then a knee replacement is not indicated. Surgical Procedure & Types of Partial Knee Replacement Types MEDIAL PATELLOFEMORAL LATERAL BICOMAPRMENTAL Unicondylar Knee Replacement is a procedure that replaces only the single affected compartment of the knee, either the medial or lateral compartment. Patellofemoral Knee Replacement is a procedure that replaces the worn patella (the kneecap) and the trochlea (the groove at the end of the thighbone). Bicompartmental Knee Replacement is a procedure that replaces two compartments of the knee, the medial and patellofemoral compartments. Pre-operative Preparation Pre-operative preparation begins immediately following surgical consultation and lasts approximately one month. The patient is to perform range of motion exercises and hip, knee and ankle strengthening (Isometrics) as directed by Therapist. Before the surgery is performed, pre-operative tests are done: usually a complete blood count, electrolytes, APTT and PT to measure blood clotting, chest X-rays, Electrocardiogram, and blood cross-matching for possible transfusion. About a month before the surgery, the patient may be prescribed supplemental iron to boost the hemoglobin in their blood system. Accurate X-rays of the affected knee are needed to measure the size of components which will be needed. Medications such as warfarin and aspirin will be stopped some days before surgery to reduce the amount of bleeding. Patients may be admitted on the day of surgery if the pre-op work-up is done in the pre-anesthetic clinic or may come into hospital one or more days before surgery. Some hospitals offer a pre-operative seminar[3] for this surgery. Currently there is insufficient quality evidence to support the use of pre-operative physiotherapy in older adults undergoing total knee arthroplasty[4] Preoperative education is currently an important part of patient care. There is some evidence that it may slightly reduce anxiety before knee replacement surgery, with low risk of detrimental effects.[5] Weight loss surgery before a knee replacement does not appear to change outcomes.[6] Post-operative Rehabilitation The length of post-operative hospitalization is 5 days on average depending on the health status of the patient and the amount of support available outside the hospital setting.[7] Protected weight bearing on crutches or a walker is required until specified by the surgeon [8] because of weakness in the quadriceps muscle[9] To increase the likelihood of a good outcome after surgery, multiple weeks of physical therapy is necessary. In these weeks, the therapist will help the patient return to normal activities, as well as prevent blood clots,improve circulation,increase range of motion,and eventually strengthen the surrounding muscles through specific exercises. Week 1 Goals Decrease pain/swelling. Passive range of motion <90 degrees (secondary to stitches) x 2 weeks. Full weight bearing. Week 2 - 4 Goals Decrease pain/swelling. Tolerate bilateral stationary cycling. Active range of motion 0-90 degrees. Week 4 - 6 Goals Normal gait pattern. Week 6 - 8 Goals Active range of motion 0 to 110 degrees. Passive range of motion 120 degrees. Week 8 - 12 Goals Road cycling. Walk downstairs with reciprocal gait. Full range of motion.[10] Treatment includes encouraging patients to move early after the surgery. [11] Often range of motion (to the limits of the prosthesis) is recovered over the first two weeks (the earlier the better). Over time, patients are able to increase the amount of weight bearing on the operated leg, and eventually are able to tolerate full weight bearing with the guidance of the physical therapist. After about ten months, the patient should be able to return to normal daily activities, although the operated leg may be significantly weaker than the non-operated leg.[12] For knee replacement without complications, continuous passive motion (CPM) can improve recovery. [13]Additionally, CPM is inexpensive, convenient, and assists patients in therapeutic compliance. However, CPM should be used in conjunction with traditional physical therapy. In unusual cases where the person has a problem which prevents standard mobilization treatment, then CPM may be useful. Contra-indications & Common Side-Effects Key Evidence Some physicians and patients may consider having lower limbs venous ultrasonography to screen for deep vein thrombosis after knee replacement.However, this kind of screening should be done only when indicated. If a medical condition exists that could cause deep vein thrombosis, a physician can choose to treat patients with cryotherapy and intermittent pneumatic compression as a preventive measure.[14] Partial Knee EReplacement surgery is not appropriate for patienst with certain types of Infections, any mental or Nueromuscular disorder which would create an unacceptable risk of prosthesis instability, prosthesis fixation failure or complication in postoperative care, skeletal immaturity, severe instability of the knee or Excessive body weight. Comom side effects:as with any surgery, PKR has its risks which may be Implant related risks which may lead to a revision include dislocation, loosening, fracture, nerve damage, heterotropic ossification, wear of the implant, metal sensitivity, soft tissue imbalance, osteolysis(localized progressive bone loss) and reaction to particle debris. Knee implants may not provide the same feel or performance characteristics experienced with a normal healthy joint.Partial Hip Replacement - PhysiopediaDescription Partial Hip Replacement is a surgical procedure used to replace half of the hip joint. The operation involves replacing the ball of the femur that has worn from arthritis, degeneration, or a serious fracture involving the ball of the hip joint. Normal motion becomes restricted and painful with advanced wear of the hip joint.[1] Indication A fractured neck femur, where the fracture occurs just below the ball-and-socket hip joint causing the ball to get disconnected from the rest of the thigh bone or femur. Blood supply to the fractured portion of bone is often disrupted at the time of injury and is at high risk of not healing when the fracture is badly displaced. Osteoarthritis: the degeneration of cartilages located at the end of the hip bones. Rheumatoid arthritis: the inflammation of the synovial membrane in the hip joints causing abnormal production of synovial fluid. Traumatic arthritis, from hip fracture or severe hip injury. Avascular necrosis where the head of the femoral bone dies due to lack of blood supply, and many other degenerative diseases are also factors that lead to broken the head of femur.[2] Note: [Partial hip replacement is only recommended on occasion and generally when the patient is elderly and in poor health, because metal prosthesis bearing against bone is not the optimal solution. It can result in wear on the bone and possibly even to the point of wearing away the base of the socket. For this reason, certain patients (young and very able and active older patients) may have a total hip replacement.][3] Clinical Presentation add text here relating to the clinical presentation of the condition Diagnostic Tests add text here relating to diagnostic tests for the condition Pre-Op add text here relating to the pre-operative advice Post-Op add text here relating to post-operative rehabilitation Key Evidence add text here relating to key evidence with regards to any of the above headings Resources add appropriate resources here Case Studies add links to case studies here (case studies should be added on new pages using the case study template)Total Ankle Arthroplasty - PhysiopediaWhat is an Ankle Arthroplasty? Ankle arthroplasty is when the ankle joint (Talocrural Joint) is replace with prosthetic components comprised of polyethylene and metal and is preferred to ankle arthrodesis (fusion) as range of movement and function an not compromised. Main objectives of the arthroplasty are to Replicate ROM of the talocrural joint Function well under weight bearing Be wear resistent Maintain alignment and stability History of Total Ankle Arthroplasty Ankle replacement surgery has been available for over two decades however it is a far less common procedure than hip or knee arthroplasty owing to the less frequent incidence of osteoarthritis ankle pathology. The majority of ankle osteoarthritis is secondary to trauma.[1] Until relatively recently, ankle joint arthrodesis (fusion) was the gold standard of treatment, but this was not without its complications, e.g. non-union, osteoarthritis in the other mid/hind foot joints and stiffness and loss of proprioception[2] Total ankle replacement was developed in the 1970's but initially was plagued with high long term failure rates. The older prosthesis loosened or malfunctioned and frequently needed to be removed[3]. In the late 70's Dr. Frank G. Alvine an orthopedic surgeon from Sioux Falls, SD developed the Agility Ankle which was the first FDA approved total ankle implant in use in the United States[4]. Since its introduction the Agility Ankle System has gone through several modifications. Currently the Agility Ankle System is the most widely used ankle prosthesis. With more than 20 years of experience it has the longest followup of any fixed bearing device[5]. On May 29, 2009 the medical news today announced the FDA approved the first mobile bearing device called the Scandinavian Total Ankle Replacement System (STAR). As a condition of FDA approval the company (Small Bone Innovations Inc.) must evaluate the safety and effectiveness of the device during the next eight years[6]. In a systematic review of the literature published in the Journal of Bone and Joint Surgery in 2007, the intermediate outcome of total ankle arthroplasty appears to be similiar to that of ankle arthrodesis however data was sparse[7]. In a study comparing reoperation rates following ankle arthrodesis and total ankle arthroplasty SooHoo, Zingmond and Ko confirmed that ankle replacement is associated with a higher risk of complications as compared with ankle fusion, but also has potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion[8]. In a seven to sixteen year follow up on the Agility Total Ankle Arthroplasty, Knecht, Estin, Callagham et al concluded that the relatively low rates of radiographic hindfoot arthritis and revision procedures at an average of nine years after the arthroplasty are encouraging[9]. Although interest in total ankle replacements is increasing, midterm clinical results to date are few and often have not been validated by independent pratitioners. In addition no level I or II studies have been published[10]. Poor patient satisfaction, high rates of revision due to loosening, and high wound complications rates were all very problematic when total ankle arthroplasty (TAA) surgeries were first introduced in the 1970’s.[11] In 1990, noncemented prostheses were shown to allow for bony ingrowth and less bone removal as compared to cemented.[11] Beyond the transition to cementless, further advances in technology over the years has led to new surgical arthroplasty techniques, primarily moving from a two-component design to a 3-component model. An observational study analyzed advantages of arthroplasty over arthrodesis stating individuals with monoarticular or polyarticular disease who undergo arthroplasty have less gait abnormalities and fewer adverse effects to other joints in the lower extremity.[12] A systematic review provided that in 852 individuals undergoing TAA's, there was a 78% implant survival 5 years post-op and 77% at 10 years post-op and overall only had a 7% revision rate. This provides evidence that the procedure yields satisfactory results and should be considered for potential candidates that are appropriate for surgical corrections.[13] The Arthroplasty Indication for Procedure There is no well-defined indication for a Total Ankle Arthroplasty. Surgery is considered only when conservative treatment has been attempted with no improvement. The operation is mainly being executed in patients who suffer from different types of arthrides. This cause advanced arthritic changes of disabling pain and loss of ankle motion. The ankle is most frequently affected by post-traumatic arthritis.[14] Total ankle joint replacement is also indicated following unsuccessful ankle arthrodesis [15] the ‘ideal’ patient for ankle joint replacement is an elderly person with the low physical demands who has good bone stock, normal vascular status, no immune-suppression, and excellent hind foot-ankle alignment.[16] Generally here are common indications for arthroplasty: Primary or post-traumatic osteoarthritis Severe rheumatoid arthritis Rejected arthrodesis Indications: According to Saltzman, there are no exact indications for receiving a total ankle arthroplasty.[17] The “ideal” patient who would typically undergo this intervention is one who is elderly with a healthy immunity, normal vascular status, good bone density, and a proper hindfoot-ankle alignment who has not had success with conservative treatment measures. Individuals with debilitating ankle arthritis, unresponsive to nonoperative approaches, or have failures with the outcome of their ankle arthroplasty are typically treated with an arthrodesis procedure to fuse the joint. Contraindications: Arthroplasty is contraindicated for those with neuroarthropathic degenerative joint disease, infection, avascular necrosis of the talus, osteochondritis dessicans, malalignment of the hindfoot-ankle, severe benign joint hypermobility syndromes or soft tissue problems, or decreased sensation or motion in the lower extremities.[11] In individuals with rheumatoid arthritis (RA), inflammatory processes may occur before signs of swelling, tissue reaction, and joint destruction are seen. In the first and second year of this disease process, structural damage (ie. joint erosion) can be seen with X-ray imaging.[18] Diabetic patients may develop gouty arthritis in their ankle joint. This is caused by uric acid changing into urate crystals, which is deposited into the joint.[18] Thus, RA and diabetic individuals may or may not be candidates for ankle arthroplasty depending on the severity of joint degeneration found with radiographic imaging. Common contraindications are: Severe talus subluxation, severe valgus or varus deformity Substantial osteoporosis Neurological disorders or recurrent infection Pre-operative Procedure and Definitive Diagnosis Weight bearing A-P and lateral mortise views of bilateral ankles is required to make effective preparation and anticipation of that will be required in the surgery. The rearfoot alignment (Cobey/Saltzman) view is essential to evaluate the ankle joint and identify any calcaneal-totibial deformities. This is performed by getting the patient to stand, elevated with a cassette positioned at 15 degres anteriorly inclined with the x-ray bemed perpendicular to the film. This position is altered if deformities are present, after this has been taken anterior distal tibial angle (ADTA) is measured. The ADTA is formed by the mechanical axis of the tibia and the joint orientation line of the ankle in the sagittal plane and measures 80° ± 3° in the normal lower extremity. In the coronal plane, the lateral distal tibial angle (LDTA), the tibial-talar angle and the calcaneal tibial alignment should be measured. The LDTA is formed by the distal tibial articular surface and the anatomical axis of the tibia and measures 89° ± 3°.29, if this is decreased this represents a varus deformity. The tibial-talar angle (Figure 3C) is defined by the tibial and talar articular surfaces in the ankle joint. When the tibialtalar angle is >10° the joint is defined as incongruent (unstable)[19]. "If an abnormal ADTA or LDTA is present (sagittal or coronal deformity), the center of rotation of angulation (CORA) is measured. The CORA is the intersection of the mid-diaphyseal line and the line starting from the middle of the joint and perpendicular to the abnormal ADTA or LDTA (Figure 4). The CORA can be located at the joint line level (usually due to anatomical joint line malalignment or to ankle degeneration) or proximally (usually due to tibial deformities/fractures)"[19]. So as you can see there are many consideration to be taken, and multiple angles to be analysed and this is important and any instability and malalignment of the new prosthesis can be excessively worn or may even fail[19]. Medical Management First generation: Early ankle prosthesis attempts involved cementing a stemmed metal ball into the tibia and a polyethylene cup cemented into the talus. Throughout the 1970’s, prosthesis evolved into using a vitallium component cemented into the talus. All designs used methylmethacrylate cement, which became the defining element of first generation prosthesis.[11] Types: Constrained - Increased stability due to only allowing dorsiflexion and plantarflexion. Loosening of the prosthesis was common from increased torque at the joint.[11] Nonconstrained - Allows full ROM, resulting in decreased stability that commonly caused impingement against the medial and/or lateral malleoli. Semiconstrained - A combination of contrained and nonconstrained models, allowing greater ROM and medial-lateral stability. The Imperial College, London Hospital prosthesis uses a concave polyethylene in the tibia and a stainless steel component on the talus.[11] Unfortunately, by the early 1980’s, first generation ankle arthroplasties were not recommended by the majority of orthaepedic surgeons. Numerous studies showed loosening of the cement fixation, wound issues, and low patient satisfaction [17][11]. As a result of the poor outcomes and high complication rate, surgeons began to recommended ankle arthrodesis. Second generation: Second generation arthroplasties are cementless, using bony ingrowth to stabilize the implant. Compared to cement, bony ingrowth prosthesis have less bone resection, damage to soft tissue and complications of the cement such as cement displacement[17]. Surgical Factors: Fixation: Ingrowth implants tend to have either a beaded surface along the bony interface, hydroxyapatite layer or a combination of both. Current surgical designs tend to use the combination fixation technique.[11][17] Between types of prosthesis the number of articulating surfaces and components both need to be considered.[17][11][20]. Components: Articulating surfaces: Current designs vary on the articulations that need to be resurfaced. Resurfacing may occur at the superior tibiotalar joint, superior and medial articulations, or medial, lateral, and superior joints.[11] Determining which patients would benefit the most from each type of surgery is ongoing.[17] Design components: 2 component implants include a tibial and talar articulating component. Implants may also incorporate syndesmosis fusion to resurface the medial and lateral recesses of ankle and converting the ankle from a 3-bone joint to a 2-bone joint. Known designs: Agility, Salto Talaris, Eclipse, INBONE Advantages: decreased shear and torsion on prosthesis[21], syndesmosis decreases shear force and increase the bony support for the tibial component[17] Disadvantages: increased bony resection, likelihood of soft tissue compromise, accelerated polyethylene wear, and possibility of syndesmosis fusion failure.[17] 2 Component Ankle Replacement Examples Salto Talaris Agility 3 component implants include a “mobile bearing” of polyethylene between the tibial plate and talar component. Known designs: Buechel-Pappas, Scandinavian Total Ankle Replacement (STAR), Mobility, HINTEGRA Advantages: low polyethylene wear rates, allow multiplanar motion[11], increased congruency, minimal bony resection[17][21] Disadvantages: mobile bearing segment may dislocate, more involved surgery, abnormal ligamentous stress due to malalignment of axis of rotation[17][11] 3 Component Ankle Replacement Examples STAR Buechel Pappas Both component designs permit semiconstrained motion, specifically allowing some inversion and eversion during sagittal plane ankle movement. The four 2 component designs have been approved by the U.S. Food and Drug Administration (FDA). The STAR was recommended for approval by the FDA in 2008.[22][21] There is insufficient evidence determining the life expectancy of current prosthesis designs.[21] Surgical Procedure To perfrom the procedure the patient is positioned supine with the hip slightly elevated and a tourniquet on the proximal thigh to restrict blood flow during the procedure. Next a 10 cm incision is made over the centre of the joint line to expose the relevent anatomical structures. Once the structures have been exposed the crucial nerves and tendons are identified as to protect and ensure their integrity to minimise operative complications, these include; peroneal nerves, tibialis anterior and extensor hallucis longus. This is also to achieve correct talocrural alignment and soft tissue balance to ensure the prosthesis can achieve plantar grade in standing. It is also important to debride and correct any osteophytes or any other structures that can contribute to malalignment. Depending on the natural angle of the talocrural joint (varus or valgus) more bone medially or laterally may have ot be removed, this also may occur if the joint is deep or shallow as it may need to be reduced or elevated[19]. Once the joints have been corrected and bones properly aligned the new components are trialed making sure rull ROM and stability is achieved. If dorsiflexion is limited and not due to malalignment then achilles tendon lengthening is required, the same goes for if there is instability in inversion or eversion the ligaments are reconstructed. Persistent malalignment can occure and may need separate procedures to correct such as subtalar fusion depending on severity and correctability[19]. Alternate Option: Ankle Arthrodesis Ankle arthrodesis or fusion was the recommended surgical option after the failure of the first generation ankle arthroplasty. The procedure includes resecting the articular surfaces of the joint, realignment the talus and tibia and fusing the bones together. As a result, the ankle joint doesn’t allow any motion. The goal of ankle arthrodesis is pain relief.[23][20] Unfortunately, the lack of ankle motion can cause elevated stress on the knee and hindfoot and in addition, increases motion at the hindfoot that may become arthritic.[11] Other complications of fusion include accelerated degeneration of adjacent joint and limitations in activity.[21] [24] Outcome Measures Foot and Ankle Disability Index Foot Function Index (FFI) Foot and Ankle Ability Measure (FAAM) Physical Therapy Management As it will be explained in the pre-operation and post-operation phase the multi-disciplinary team involved with the patient have a big role in making the arrangements before and after the surgery, this may involve physiotherapists, occupational therapists, discharge nurses, staff nurses, healthcare assistants as well as doctors. Both pre and post operative phases are integral to the progress of the patient and the pre-op should not be overlooked as important as it can be easy to focus on post-op. Pre-Operative Phase Before the surgery one of the main job for the team is to educate the patient about what will happen before, during and after the surgery as this will give the patient the opportunity to prepare, mentally rehearse, ensure smooth transition through short-term to long-term goals but also help control and reduce post-operative pain[25] (level of evidence 3B) ROM, muscle strength, gait and deviations will all be recorded as to compared before and after arthroplasty and ensure the patient is as optimal strength prior to operation if possible. For safety and ease of transition is can be important that the patient learns how to walk with crutches so they can perform ADL’s as soon as possible post arthroplasty but also understand that they will be non-weight bearing after the arthroplasty[26].(Level of evidence 4) As will all procedures under general anesthetic there are common pulmonary postoperative complications (PPC's) which need to be controlled and risk reduced and this can be explained at this stage as well. Post-Operative Phase It is important to ensure the risk of PPC's are reduced and respiratory physiotherapy may be used at this early stage, cough, deep breathing exercises and early mobility are essential here to reduce atelectasis and reinstate the muscoscilliary elevator as soon as possible. Atelecatsis occurs in 90% of anesthetized patients which leads to a 16-20% reduction in functional residual capacity which is why the alveoli tend collapse resulting in increased work of breathing, hypoxia, reduced compliance, V/Q mismatch and risk of pneumonia[27][28].(Level of evidence 5)T(Level of evidence 5)here is a 9% chance of developing pneumonia and this is where physiotherapy intervention is crucial at reducing the rate of all of these complications[29].(Level of evidence 5) IT IS IMPORTANT TO KNOW YOUR OWN HOSPITALS/SURGEONS GUIDELINES FOLLOWING ARTHROPLASTY OR ANY OPERATION AND THE FOLLOWING SHOULD ONLY BE USED TO EDUCATE AND CONSIDER SOME BASIC/COMMON PROTOCOLS THIS SHOULD NOT BE USED IN REPLACEMENT OF THE SURGEONS PROTOCOL THIS IS A PROTOCOL BY THE ROYAL NATIONAL ORTHOPAEDIC HOSPITAL NHS TRUST[30], utilising the best available evidence[31][32][33][34][35][36] As can be expected after any type of surgery, pain and inflammation must be controlled. This is the case especially after ankle replacement because pain and inflammation can last up to 12 months after surgery.[37] Surrounding muscles can be damaged during surgery and can result in decreased range of motion and strength.[38][39][40] Damage to joint proprioceptors during excision of the capsule may cause deficits in both static and dynamic balance.[41][42] These components can lead to gait disability and decreased efficiency of locomotion.[43] Correction of gait posture and ambulation deficiencies will be a target of therapy once the patient is ambulating independently. Physical Therapy Goals: Decrease pain Decrease inflammation Increase strength Increase range of motion Improve dynamic and static balance Improve proprioception Proper independent ambulation Assessment Mechanism of injury or etiology of illness Date of surgery and type of implant Use of assistive device with weight bearing status Use of controlled ankle motion (CAM) walker/walking boot Functional deficits/assistance with ADLs/adaptive equipment Pain/ Symptom history: Location, duration, type, intensity (VAS), aggravating and relieving factors, 24 hour symptom behavior Relevant Current/Past Medical history: Other lower extremity arthritis or injuries,upper extremity issues that may limit ability to ambulate with an AD and comorbid diagnoses Medications for current/previous diagnoses Diagnostic tests Sleep disturbance Barriers to learning Social/occupational history Patient’s goals Vocation/avocation and associated repetitive behaviors Living environment Relevant Tests & Measures: Observation/inspection/palpation: Skin and incision assessment, edema, muscle atrophy Circulation: Dorsal pedal pulse Sensory and proprioception testing Range of motion and Muscle length: Average postoperative arc of motion (dorsifexion and plantarfexion) is 23°[44][45] Muscle strength Posture: Increased pronation/supination in standing, ability to maintain wait bearing status Assess assistive and adaptive devices for need and proper fit Balance: Static and dynamic standing balance, unilateral balance of the unaffected extremity (especially if patient is still non-weight bearing).[44] Patient may demonstrate dynamic postural imbalance, less reliance on ankle strategy and deficit of motor control ability[41] Functional mobility American Orthopaedic Foot and Ankle Society ankle-hindfoot score[46], Outcome measures Self-selected normal walking speed[47] Assess safety in mobility Gait Assessment[44] Initial Rehab 0-4 Weeks Restrictions: Non-weight bearing 2/52 with a back slab Below knee POP at 2/52 and begin full weight bearing in this POP POP removed at 4/52 and aircast boot is considered Elevation If sedentary employment, return to work at 4/52 as long as elevated and protected Goals: Safe and independent mobility with walking aid Independent with exercise programme Know monitoring and protection Treatment: POP Pain-relief POLICE Basic circulatory exercises Mobility Progress when: Out of POP, fully weight bearing, no complications and then refer to physiotherapy out patients Recovery Rehab 4 weeks - 3 months Restrictions: No strengthening against resistance until 3 months if any tendon transfers No stretching tendons if transferred Goals: Independent from aircast boot Achieve full ROM Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Full ROM, independently mobile, neutral foot position in standing Intermediate Rehab 12 weeks - 6 months Restrictions: None Goals: Independent with no aids Normal footwear Grade 5 strength Grade 4 strength in tendons transferred Treatment: Pain relief, swelling management Advice, education, postural advice, monitoring complications, pacing Gait re-education Exercises --> PROM,AAROM, AROM, light strengthening, core stability, balance/proprioception, stretching Hydrotherapy Orthotics Manual therapy --> SSTM's, mobilisations Progress when: Normal footwear, independent with no aids, pain controlled, strength 5/5 (4/5 if tendon transferred) Final Rehab 6 months - 1 year Goals: Return to gentle no-impact/low impact sports Grade 5 strength in transferred tendons Treatment: Maximise function End stage exercises, balance and proprioception and sport specific Manual therapy Muscles to Consider Here is a unfinished list of some of the major muscles of the lower leg and foot, consider these in your rehabilitation and mechanism of pathology. Some may have had tendons moved or stretched and now need to be specifically rehabilitated as the proprioceptive function may now have changed. Posterior Compartment - Superficial Gastrocnemius Plantaris Soleus Posterior Compartment - Deep Popliteus Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Posterior Lateral Compartment Peroneus Longus Peroneus Brevis Anterior Compartment Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Tertius Sample Exercises Balance c perturbation Ball toss Standing reach Standing reach Seated rocker board DF theraband Ankle eversion DF stretch Ankle PF Additional Information After the surgery it is important that the patient keeps moving and performing his daily activities. However there is still discussion between physicians about when the patient should start again with exercising. There are some that allow exercise immediately after surgery. But some say it is considered best to wait until there is a satisfactory bony in growth as shown radio graphically. However it’s the job of the physician to try to improve: the patient’s ROM of the ankle, maintain the ROM in the hip and knee, increase the muscle strength with exercise for the Gluteus Maximus, Quadriceps femoris muscles and the muscles that are responsible for dorsal flexion and the plantar flexion of the ankle[48]. Postoperative mobilization begins early, with rapid progression to resumption of normal activities.[49] The goal is to obtain 10° of dorsal flexion and 30° of plantar flexion. For patients who have almost no motion in their ankle is any motion an improvement.[50] In early postoperative period it is important that the incision heals and the implant becomes solidly fixed to the bony bed to do this they will use a below knee non-weight bearing immobilization. This is maintained until there is satisfactory bony in growth. [51]. Another goal is to increase the ROM of the ankle and maintain the hip and the knee ROM. After a few months the patient needs to make an appointment with the doctor. Here they will take X-ray scans to see if there are no complications like: joint debridement for osseous impingement; the next most common procedures were extra-articular procedures for axial misalignments and component replacements.[52] Prognosis & Outcome Outcome of ankle arthroplasty includes pain, function implant survival and complications. There are numerous studies looking at survival rate of implants and rates are reported around 67-94% at 5 years[53][54][55] and 75% at ten years[53] which is reasonably reliable. A systematic review of intermediate and long term outcomes of arthrolplasty and arthrodesis performed by Haddal et al[56] had interesting results. It reviewed 49 primary studies of 1262 patients and utilised the AOFAS score (Americal Orthopaedic Foot and Ankle Society). This score is out of 100 (0=worst outcome, 100=best outcome) broken into 8 sections of pain, function walking distance, walking surface, gait abnormality, sagittal mobility, hindfoot mobility, ankle hindfoot mobility and alignment. The score has mixed reviews and the objective aspect of the score is hard to make reliable between therapists[57]. The mean AOFAS score was 78.2 points for the patients treated with total ankle arthroplasty and 75.6 points for those treated with arthrodesis. Meta-analytic mean results showed 38% of the patients treated with total ankle arthroplasty had an excellent result, 30.5% had a good result, 5.5% had a fair result, and 24% had a poor result. In the arthrodesis group, the corresponding values were 31%, 37%, 13%, and 13%. The five-year implant survival rate was 78% and the ten-year survival rate was 77%. The revision rate following total ankle arthroplasty was 7% with the primary reason for the revisions being loosening and/or subsidence (28%). The revision rate following ankle arthrodesis was 9% , with the main reason for the revisions being nonunion (65%). One percent of the patients who had undergone total ankle arthroplasty required a below-the-knee amputation compared with 5% in the ankle arthrodesis group. Their conclusion was that on the basis of these findings, "the intermediate outcome of total ankle arthroplasty appears to be similar to that of ankle arthrodesis; however, data were sparse. Comparative studies are needed to strengthen this conclusion"[56]. Resources [58] [59] [60] [61]Physical Activity Pre and Post Surgery - PhysiopediaBenefits of Exercise Pre and Post Surgery The effect of exercise on outcomes after surgery has been extensively studied in a number of populations. The most common populations studied are Those post- hip replacement Those post- knee replacement Those post- cardiac surgery Those post- abdominal surgery Other surgical groups such as colorectal, thoracic, post- cancer resection, vascular and urological Whilst the evidence is good in general terms, unfortunately, as yet there is no clear consensus on the specifics of exercise prescription pre-surgery[1]. Studies can be divided into those that look at the effect of interventions pre-operatively on post- surgical outcomes and those that look at the effect of different exercise interventions post- surgery. What Are the General Benefits of Preoperative Exercise? The evidence that if cardiorespiratory fitness (CRF) is measured preoperatively, it is predictive of complications in the postoperative period is compelling, with several studies demonstrating this across different types of surgeries[2][3][4][5][6][7] The measure of CRF also offers significant advantage when compared to age alone in predicting mortality after major surgery[5]. CRF is a significant independent predictor of length of stay in hospital with patients older than 75 A low CRF is associated with an average of 11 days longer in hospital and 2 days longer in critical care Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. It also exerts beneficial effects on physical fitness and postoperative outcomes measures across various surgical fields.including cardiac surgery, orthopedic surgery, abdominal surgery, thoracic surgery, vascular surgery and urologic surgery[9]. In their scoping study, Pouwels et al (2016) conclude that more research is needed to focus on heterogeneous outcome measures, patient populations and guidelines for exercise regimes[9]. What Are the Benefits of Preoperative Exercise in Specific Populations? Hip Replacement In patients undergoing this surgery, significant improvements (small to moderate effect sizes) have been observed in pain, function, and length of stay with exercise interventions preoperatively. [10] Knee Replacement A 2014 systematic review (Chesham and Shanmugham) concluded that there is minimal evidence so far supporting education and exercise interventions pre-operatively, compared with no physiotherapy or usual care. Interventions reviewed in the 10 RCTs were preoperative exercise; combined exercise and education; combined exercise and acupuncture; neuromuscular electrical stimulation; and acupuncture versus exercise. Outcomes assessed were knee strength, ambulation, and pain. Good quality research into this is ongoing[11]. However Moyer et al (2017) in their systematic review and meta analysis found small to moderate effect sizes for pre-rehabilitation in this population. Significant improvements were made in function, quadriceps strength and length of stay.[10] Cardiac Surgery A Cochrane review in 2012 found that evidence from small trials suggests that preoperative physical therapy, with an exercise component, for elective cardiac surgery patients reduces postoperative pulmonary complications and length of hospital stay. They concluded that there is a lack of evidence to effect changes to postoperative pneumothorax, or prolonged mechanical ventilation[12]. It has been known for some years that inspiratory muscle training provided pre-operatively reduces the risk of anaesthetic complications as well as reducing post-operative complications[13] as well as length of postoperative hospital stay and pulmonary function[14]. Pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. Abdominal Surgery O'Doherty et al (2013) in their systematic review conclude that pre-operative exercise reduces the length of stay both in Intensive Care facilities and in hospital[8][1]. A meta-analysis and systematic review done in 2016 (Moran et al) concluded that more research was needed, but 'prehabilitation' consisting of inspiratory muscle training, aerobic exercise, and/or resistance training can decrease postoperative complications after intra-abdominal operations.[15] Other Mixed Populations A systematic review in 2010 found that preoperative exercise therapy is effective for reducing both postoperative complication rates and length of hospital stay after cardiac or abdominal surgery[16]. A Cochrane review in 2015 concluded that preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications (such as actelectasis and pneumonia) and length of hospital stay compared with usual care in adults undergoing cardiac and major abdominal surgery[17]. Colorectal Surgery A study on patients undergoing colorectal surgery found benefits from exercise programmes pre-operatively: improved physical function, peak exercise capacity, mental health and self-perceived health[18] Cancer-resection surgery A Cochrane review in 2017 found low quality evidence that preoperative exercise training may reduce some risks in those having lung resection surgery for early stage non-small cell lung cancer (NSCLC).[19]. These were- developing postoperative pulmonary complications, duration of intercostal catheter use, a reduced postoperative length of stay and improved exercise capacity and FVC post-operatively. [19] What Are the Benefits of Post-Operative Exercise? There is clear evidence for the following surgeries: Spinal surgery - improved spinal mobility[20] Total Hip and Knee Replacement surgery - earlier discharge[21] Colorectal surgery - increased cardiovascular fitness[22] Breast surgery - fewer side-effects[23] In many surgeries: reduced risk of blood clots[24] Cardiac surgery - inspiratory muscle training on length of postoperative hospital stay and pulmonary function [14] Contraindications to Exercise Pre/Post Surgery In addition to the absolute contraindications (see the Exercise Physiology page), specific precautions will apply depending on the surgery. The treating team ( Doctors, Nurses, Physiotherapists) will give the patient specific advice on this. Resources The Motivate2Move website, created by Wales Deanery, has a comprehensive section on surgery and exercise.ReferencesLevine BR, Klein GR, Cesare PE. Surgical approaches in total hip arthroplasty: A review of the mini-incision and MIS literature. Bulletin of the NYU Hospital for Joint Diseases 2007;65(1):5-18.Learnmouth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007; 370: 1508–19.University of Stellenbosch, Advanced orthopaedic training center. Orthopaedic referral guidelines, Tygerberg Hospital 2013 - Arthroplasty unit. http://www0.sun.ac.za/aotc/referrals/guidelines/Arthroplasty.pdf (accessed 26/06/2018).Iglesias SL, Gentile L, Mangupli MM, Pioli I, Nomides RE, Allende BL. Femoral neck fractures in the elderly: from risk factors to pronostic features for survival. Journal of Trauma and Critical Care. 2017;1(1).Meyers HM. Fractures of the hip, Chicago: Year of the book medical publishers Inc.,1985Trudelle-Jackson E, Smith SS. Effects of a late-phase exercise program after total hip arthroplasty: a randomized controlled trial. Archives of physical medicine and rehabilitation 2004;85(7):1056-62.Meyers HM. Fractures of the hip. Chicago: Year of the book medical publishers Inc., 1985Gremeaux V, Renault J, Pardon L, Deley G, Lepers R, Casillas JM. Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial. Archives of physical medicine and rehabilitation 2008;89(12):2265-73.Jan MH, Hung JY, Lin JC, Wang SF, Liu TK, Tang PF. Effects of a home program on strength, walking speed, and function after total hip replacement. Archives of physical medicine and rehabilitation 2004 ;85(12):1943-51.Stockton KA, Mengersen KA. Effect of multiple physiotherapy sessions on functional outcomes in the initial postoperative period after primary total hip replacement: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(10):1652-7.Rahmann AE, Brauer SG, Nitz JC. A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial. Archives of physical medicine and rehabilitation 2009;90(5):745-55.Crawford AJ, Hamblen DL. Outline of Orthopaedics , thirteenth edition, London: Churchill Livingstone, 2001Batra S, Batra M, McMurtrie A, Sinha AK. Rapidly destructive osteoarthritis of the hip joint: a case series. Journal of orthopaedic surgery and research 2008;3(1):3.Brandt CD. Diagnosis and non-surgical management of osteoarthritis. USA: Professional Communications, Inc. 2010Walters J, editor. Orthopaedics - A guide for practitioners. 4th Edition. Cape Town: University of Cape Town, 2010.Brunner LC, Eshilian-Oates L, Kuo TY. Hip fractures in adults. American family physician 2003;67(3):537-42.Kingma MJ, Koekenberg LJL, Van Linge B, Van Rens THJG, Sijbrandij S. Letsels van het steun en bewegingsapparaat, Utrecht/Antwerpen: Scheltema; Holkema BV,1983Chan G, Bezuidenhout L, Walker L, Rowan R. The Impact on Life questionnaire: validation for elective surgery prioritisation in New Zealand prioritisation criteria in orthopaedic surgery. The New Zealand Medical Journal 2016;129:1432Affatato S. Perspectives in total hip arthroplasty: Advances in biomaterials and their tribological interactions. London: Woodhead Publishing, 2014.Brotzman B. Clinical Orthopedic Rehabilitation (2003)-S. Brotzman, KE Wilk.Kelmanovich D, Parks ML, Sinha R, MD, Macaulay W. Surgical Approaches to total hip arthroplasty. Journal of the Southern Orthopaedic Association 2003;12:90-94.Chechik O, Khashan M, Lador R, Salai M, Amar E. Surgical approach and prosthesis fixation in hip arthroplasty world wide. Arch Orthop Trauma Surg. 2013;133(11):1595-600.Hoppenfeld S, DeBoer P, Buckley R. Surgical exposures in orthopaedics: the anatomic approach. Philidelphia, PA: Lippincott Williams and Wilkins, 2009.Oldenrijk JV, Hoogland PV, Tuijthof GJ, Corveleijn R, Noordenbos TW, Schafroth MU. Soft tissue damage after minimally invasive THA. Acta Orthopaedica 2010; 81 (6): 696-702Zhang XL, Shen H, Qin XL, Wang Q. Anterolateral muscle sparing approach total hip arthroplasty: an anatomic and clinical study. Chinese medical journal. 2008 Aug;121(15):1358-63.Röttinger H. Minimally invasive anterolateral surgical approach for total hip arthroplasty: early clinical results. Hip International 2006;16(4):42-7.Sköldenberg O, Ekman A, Salemyr M, Bodén H. Reduced dislocation rate after hip arthroplasty for femoral neck fractures when changing from posterolateral to anterolateral approach: a prospective study of 372 hips. Acta orthopaedica 2010;81(5):583-7.Alecci V, Valente M, Crucil M, Minerva M, Pellegrino C, Sabbadini DD. Comparison of primary total hip replacements performed with a direct anterior approach versus the standard lateral approach: perioperative findings. J Orthopaed Traumatol 2011;12:123-129.Verywell Health. Orthopedics - hip and knee - replacement http://implants.http://orthopedics.about.com/od/hipkneereplacement/a/implants.htm (accessed 23/07/2018).Bader R, Steinhauser E, Zimmermann S, Mittelmeier W, Scholz R, Busch R. Differences between the wear couples metal-on-polyethylene and ceramic-on-ceramic in the stability against dislocation of total hip replacement. Journal of materials science: materials in medicine 2004;15(6):711-8.Garcia-Rey E, Cruz-Pardos A, Garcia-Cimbrelo E. Alumina-on-alumina total hip arthroplasty in young patients: diagnosis is more important than age. Clinical Orthopaedics and Related Research 2009;467(9):2281-9.Mahendra G, Pandit H, Kliskey K, Murray D, Gill HS, Athanasou N. Necrotic and inflammatory changes in metal-on-metal resurfacing hip arthroplasties: relation to implant failure and pseudotumor formation. Acta orthopaedica 2009;80(6):653-9.Zimmer Biomet. The E1™ Antioxidant Infused Technology Process. E1- Vitamin E infused polyethylene for hip and knee replacement bearings (accessed 2506/2018).Lindalen L, Nordsletten L, Høvik Ø, Röhrl SM. E-Vitamin Infused Highly Cross-Linked Polyethylene: RSA Results from a Randomised Controlled Trial Using 32 mm and 36 mm Ceramic Heads. Hip International 2015;25(1):50 - 55Dargel J, Oppermann J, Brüggemann G, Eysel P. Dislocation Following Total Hip Replacement. Dtsch Arztebl Int 2014;111:51-52.Petis S, Howard JL, Lanting BL, Vasarhelyi EM. Surgical approach in primary total hip arthroplasty: anatomy, technique and clinical outcomes. Can J Surg 2015;58(2):128–139.Oliveira CA, Candelária IS, Oliveira PB, Figueiredo A, Caseiro-Alves F. Metallosis: A diagnosis not only in patients with metal-on-metal prostheses. European journal of radiology open. 2015 Jan 1;2:3-6. Available from: Metallosis: A diagnosis not only in patients with metal-on-metal prostheses (last accessed 24.2.2019)American Association of Orthopaedic Surgeons. Total hip replacement. Total Hip Replacement - OrthoInfo - AAOS (accessed 25/06/2018).Partridge T, Jameson S, Baker P, MBBS, Deehan D, Mason M, Reed MR. Ten-Year Trends in Medical Complications Following 540,623 Primary Total Hip Replacements from a National Database. J Bone Joint Surg Am 2018;100(5):360–367.Mirza S, Dunlop D G, Panesar S, Syed G N, Shafat G, Saif S. Basic Science Considerations in Primary Total Hip Replacement Arthroplasty. The Open Orthopaedics Journal. 2010;4,169-180Gill SD, McBurney H. Does Exercise Reduce Pain and Improve Physical Function Before Hip or Knee Replacement Surgery? A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Archives of physical medicine and rehabilitation. 2013;94(1):164-76.Ferrara PE, Rabini AL, Maggi LO, Piazzini DB, Logroscino G, Magliocchetti G, Amabile E, Tancredi G, Aulisa AG, Padua L, Gnocchi DC. Effect of pre-operative physiotherapy in patients with end-stage osteoarthritis undergoing hip arthroplasty. Clinical rehabilitation 2008;22(10-11):977-86.Saw MM. The effects of a six-week physiotherapist-led exercise and education intervention in patients with osteoarthritis, awaiting an arthroplasty in the South Africa [dissertation]. Cape Town: University of Cape Town. 2015.Crowe J,Henderson J. Pre-arthroplasty rehabilitation is effective in reducing length of hospital stay. Canadian Journal of Occupational Therapy 2003;70:88-96.Barnes RY, Bodenstein, K, Human N. Raubenheimer J, Dawkins J, Seesink C, Jacobs J, van der Linde J, Venter R. Preoperative education in hip and knee arthroplasty patients in Bloemfontein. South African Journal of Physiotherapy 2018;74(1).Raymond Sohier, Kinesitherapie de la hanche ; La Hestre : Sohier, 1974Galea MP, Levinger P, Lythgo N, Cimoli C, Weller R, Tully E, McMeeken J, Westh R. A targeted home-and center-based exercise program for people after total hip replacement: a randomized clinical trial. Archives of physical medicine and rehabilitation 2008;89(8):1442-7.Robertson NB, Warganich T, Ghazarossian J, Khatod M. Implementation of an accelerated rehabilitation protocol for total joint arthroplasty in the managed care setting: the experience of one institution. Advances in Orthopedic Surgery. 2015;387197.Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. Journal of physiotherapy. 2013;59(4):219-26.Freburger J. An analysis of the relationship between the utilization of physical therapy services and outcomes of care for patients after total hip arthroplasty. Physical therapy 2000;80(5):448-458.Umpierres CS, Ribeiro TA, Marchisio ÂE, Galvão L, Borges ÍN, Macedo CA, Galia CR. Rehabilitation following total hip arthroplasty evaluation over short follow-up time: Randomized clinical trial. Journal of rehabilitation research and development. 2014;51(10):1567-78.Smith TO, Mann CJ, Clark A, Donell ST. Bed exercises following total hip replacement: a randomised controlled trial. Physiotherapy 2008;94(4):286-91.Perhonen MA, Franco F, Lane LD, Buckey JC, Blomqvist CG, Zerwekh JE, Peshock RM, Weatherall PT, Levine BD. Cardiac atrophy after bed rest and spaceflight. Journal of applied physiology 2001;91(2):645-53.Suetta C, Aagaard P, Rosted A, Jakobsen AK, Duus B, Kjaer M, Magnusson SP. Training-induced changes in muscle CSA, muscle strength, EMG, and rate of force development in elderly subjects after long-term unilateral disuse. Journal of Applied Physiology 2004;97(5):1954-61.

How to Start a BusinessStarting a business involves a whole lot of moving pieces, some more exciting than others. Brainstorming business names? Fun! Filing taxes? ... Not so fun. The trick to successfully getting your business off the ground is to meticulously plan and organize your materials, prioritize properly, and stay on top of the status and performance of each and every one of these moving parts.From registering with the government to getting the word out about your business to making key financial decisions, here’s an overview of what you'll need to do to start a successful business.At its core, a business plan helps you prove to yourself and others whether or not your business idea is worth pursuing. It's the best way to take a step back, look at your idea holistically, and solve for issues years down the road before you start getting into the weeds.This post covers tips for writing a business plan, followed by an outline of what to include and business plan examples. Let's start with some basic, overarching tips before we dive in to the details. Grab yourfree business plan template here and apply the practices below.Narrow down what makes you different.Before you start whipping up a business plan, think carefully about what makes your business unique first. If you're planning to start a new athletic clothing business, for example, then you'll need to differentiate yourself from the numerous other athletic clothing brands out there.What makes yours stand out from the others? Are you planning to make clothing for specific sports or athletic activities, like yoga or hiking or tennis? Do you use environmentally friendly material? Does a certain percentage of your proceeds go to charity? Does your brand promote positive body image?Remember: You're not just selling your product or service -- you're selling a combination of product, value, and brand experience. Think through these big questions and outline them before you dive in to the nitty-gritty of your business plan research.Keep it shortBusiness plans are more short and concise nowadays than they used to be. While it might be tempting to include all the results of your market research, flesh out every single product you plan to sell, and outline exactly what your website will look like, that's actually not helpful in the format of a business plan.Know these details and keep them elsewhere, but exclude everything but the meat and potatoes from the business plan itself. Your business plan shouldn't just be a quick(ish) read -- it should be easy to skim, too.You can (and should) change it as you goKeep in mind that your business plan is a living, breathing document. That means you can update your business plan as things change. For example, you might want to update it a year or two down the road if you're about to apply for a new round of funding.Here are the key elements in a business plan template , what goes into each of them, and a sample business plan section at each step in the process.Business Plan TemplateStep 1. Executive SummaryThe purpose of the executive summary is to give readers a high-level view of the company and the market before delving in to the details. (Pro Tip: Sometimes it's helpful to write the executive summary after you've put together the rest of the plan so you can draw out the key takeaways more easily.)The executive summary should be about a page long, and should cover (in 1–2 paragraphs each):Example of an "Overview" section of the Executive Summary (fromBplans ):Jolly's Java and Bakery (JJB) is a start-up coffee and bakery retail establishment located in southwest Washington. JJB expects to catch the interest of a regular loyal customer base with its broad variety of coffee and pastry products. The company plans to build a strong market position in the town, due to the partners' industry experience and mild competitive climate in the area.JJB aims to offer its products at a competitive price to meet the demand of the middle-to higher-income local market area residents and tourists.Step 2. Company DescriptionNext, you'll have your company description. Here's where you have the chance to give a summary of what your company does, your mission statement, business structure and business owner details, location details, the marketplace needs that your business is trying to meet, and how your products or services actually meet those needs.Example of a "Company Summary" section (from Bplans ):NALB Creative Center is a startup, to go into business in the summer of this year. We will offer a large variety of art and craft supplies, focusing on those items that are currently unavailable on this island. The Internet will continue to be a competitor, as artists use websites to buy familiar products. We will stock products that artists don't necessarily have experience with. We will maintain our price comparisons to include those available online.We will offer classes in the use of new materials and techniques.We will build an Artist's Oasis tour program. We will book local Bed and Breakfasts; provide maps and guides for appropriate plein-air sites; rent easels and materials; sell paint and other supplies and ship completed work to the clients when dry.We will expand the store into an art center including: A fine art gallery, offering original art at, or near, wholesale prices; Musical instruments/studio space; Classrooms for art/music lessons; Art/Music books; Live music/coffee bar; Do-it-Yourself crafts such as specialty T-Shirts, signs, cards, ceramics for the tourist trade.Step 3. Market AnalysisOne of the first questions to ask yourself when you're testing your business idea is whether it has a place in the market. The market will ultimately dictate how successful your business will be. What's your target market, and why would they be interested in buying from you?Get specific here. For example, if you're selling bedding, you can't just include everyone who sleeps in a bed in your target market. You need to target a smaller group of customers first, like teenagers from middle-income families.From there, you might answer questions like: How many teenagers from middle-income families are currently in your country? What bedding do they typically need? Is the market growing or stagnant?Include both an analysis of research that others have done, as well as primary research that you've collected yourself -- whether by customer surveys, interviews, or other methods.This is also where you'll include a competitive analysis. In our example, we'd be answering the question: how many other bedding companies already have a share of the market, and who are they?Outline the strengths and weaknesses of your potential competitors, as well as strategies that will give you a competitive advantage.Example of a "Market Analysis" summary section (from Bplans ):Green Investments has identified two distinct groups of target customers. These two groups of customers are distinguished by their household wealth. They have been grouped as customers with <$1 million and >$1 million in household wealth. The main characteristic that makes both of these groups so attractive is their desire to make a difference in the world by making investment decisions that take into account environmental factors.The financial services industry has many different niches. Some advisors provide general investment services. Others will only offer one type of investments, maybe just mutual funds or might concentrate on bonds. Other service providers will concentrate on a specific niche like technology or socially responsible companies.Market SegmentationGreen Investments has segmented the target market into two distinct groups. The groups can be differentiated by their difference in household wealth, households of <$1 million and >$1 million.Step 4. Products and/or ServicesHere's where you can go into detail about what you're selling and how it benefits your customers. If you aren't able to articulate how you'll help your customers, then your business idea may not be a good one.Start by describing the problem you're solving. Then, go into how you plan to solve it and where your product or service fits into the mix. Finally, talk about the competitive landscape: What other companies are providing solutions to this particular problem, and what sets your solution apart from theirs?Example of a "Products and Services" section (from Bplans ):AMT provides both computer products and services to make them useful to small business. We are especially focused on providing network systems and services to small and medium business. The systems include both PC-based LAN systems and minicomputer server-based systems. Our services include design and installation of network systems, training, and support.Product and Service DescriptionIn personal computers, we support three main lines:1. The Super Home is our smallest and least expensive line, initially positioned by its manufacturer as a home computer. We use it mainly as a cheap workstation for small business installations. Its specifications include ...[additional specifics omitted]2. The Power User is our main up-scale line. It is our most important system for high-end home and small business main workstations, because of .... Its key strengths are .... Its specifications include ....[additional specifics omitted]3. The Business Special is an intermediate system, used to fill the gap in the positioning. Its specifications include ... [additional specifics omitted]In peripherals, accessories and other hardware, we carry a complete line of necessary items from cables to forms to mousepads ... [additional specifics omitted]In service and support, we offer a range of walk-in or depot service, maintenance contracts and on-site guarantees. We have not had much success selling service contracts. Our networking capabilities ...[additional specifics omitted]Competitive ComparisonThe only way we can hope to differentiate well is to define the vision of the company to be an information technology ally to our clients. We will not be able to compete in any effective way with the chains using boxes or products as appliances. We need to offer a real alliance.The benefits we sell include many intangibles: confidence, reliability, knowing that somebody will be there to answer questions and help at the important times.These are complex products, products that require serious knowledge and experience to use, and our competitors sell only the products themselves.Unfortunately, we cannot sell the products at a higher price just because we offer services; the market has shown that it will not support that concept. We have to also sell the service and charge for it separately.Step 5. Operations & ManagementUse this section to outline your business' unique organization and management structure (keeping in mind that you may change it later). Who will be responsible for what? How will tasks and responsibilities be assigned to each person or each team?Includes brief bios of each team member and highlight any relevant experience and education to help make the case for why they're the right person for the job. If you haven't hired people for the planned roles yet, that's OK -- just make sure you identify those gaps and explain what the people in those roles will be responsible for.Example of an "Personnel Plan" section of the Operations & Management section (from Bplans ):The labor force for DIY Wash N' Fix will be small. It will consist of a part-time general manager to handle inter-business relationships and corporate responsibilities. In addition, DIY Wash N' Fix will employ three certified mechanics/managers; their duties will consist of the day-to-day operation of the firm. These duties fall into two categories: managerial and operational. Managerial tasks include: scheduling, inventory control and basic bookkeeping. Safety, regulatory issues, customer service and repair advice are the operational tasks they will be responsible for.Additionally, customer service clerks will be hired to perform the most basic tasks: customer service and custodial. DIY Wash N' Fix will have a single general manager to coordinate all outside business activities and partnerships. The business relationships would include accounting services, legal counsel, vendors and suppliers, maintenance providers, banking services, advertising and marketing services, and investment services. Laurie Snyder will fill this general management position. She will be receiving an MBA from the University of Notre Dame in May 2001.The daily management of the business will be left to the lead mechanic. Even though DIY Wash N' Fix is not a full service repair shop it can be expected that some customers will attempt repairs they are not familiar with and need advice. Therefore, we intend to hire three fully certified mechanics. The mechanics will not be authorized to perform any work on a customer's car, but they will be able to take a look at the car to evaluate the problem. To reduce our liability for repairs done incorrectly we feel only professional mechanics should give advice to customers. The primary function of the mechanics will be customer service and managerial responsibilities.Step 6. Marketing & Sales PlanThis is where you can plan out your comprehensive marketing and sales strategies that'll cover how you actually plan to sell your product. Before you work on your marketing and sales plan, you'll need to have your market analysis completely fleshed out, and choose your target buyer personas, i.e., your ideal customers. (Learn how to create buyer personas here .)On the marketing side, you'll want to cover answers to questions like: How do you plan to penetrate the market? How will you grow your business? Which channels will you focus on for distribution? How will you communicate with your customers?On the sales side, you'll need to cover answers to questions like: what's your sales strategy? What will your sales team look like, and how do you plan to grow it over time?How many sales calls will you need to make to make a sale? What's the average price per sale? Speaking of average price per sale, here's where you can go into your pricing strategy.Example of a "Marketing Plan" section (from Bplans ):The Skate Zone plans to be the first amateur inline hockey facility in Miami, Florida. Due to the overwhelming growth of inline hockey throughout the United States, the company's promotional plans are open to various media and a range of marketing communications. The following is a list of those available presently.Public relations. Press releases are issued to both technical trade journals and major business publications such as USAHockey Inline, INLINE the skate magazine, PowerPlay, and others.Tournaments. The Skate Zone will represent its services at championship tournaments that are held annually across the United States.Print advertising and article publishing. The company's print advertising program includes advertisements in The Yellow Pages, Miami Express News, The Skate Zone Mailing, school flyers, and inline hockey trade magazines.Internet. The Skate Zone currently has a website and has received several inquiries from it. Plans are underway to upgrade it to a more professional and effective site. In the future, this is expected to be one of the company's primary marketing channels.Step 7. Financial PlanFinally, outline your financial model in detail, including your start-up cost, financial projections, and a funding request if you're pitching to investors.Your start-up cost refers to the resources you'll need to get your business started -- and an estimate of how much each of those resources will cost. Are you leasing an office space? Do you need a computer? A phone? List out these needs and how much they'll cost, and be honest and conservative in your estimates. The last thing you want to do is run out of money.Once you've outlined your costs, you'll need to justify them by detailing your financial projections. This is especially important if you're looking for funding for your business (which you’ll learn more about below). Make sure your financial model is 100% accurate for the best chance of convincing investors and loan sources to support your business.The following table is the projected Profit and Loss statement for Markam. (fromBplans ):Image source: BplansStep 8. AppendixFinally, consider closing out your business plan with an appendix. The appendix is optional, but it's a helpful place to include your resume and the resume(s) of your co-founder(s), as well as any permits, leases, and other legal information you want to include.Making Your Business LegalOnce the business plan is in place, you get to move on to the even less romantic part -- the paperwork and legal activities. This includes things like determining the legal structure of your business, nailing down your business name, registering with the government, and -- depending on your business structure and industry -- getting a tax code, a business license, and/or a seller’s permit.Furthermore, businesses are regulated on the federal, the state, and sometimes even local level. It’s important to check what’s required on all three of those levels. When you register your business with the government, be sure you’re covering registration on all the levels required for your business’ location. Your business won’t be a legal entity without checking these boxes, so stay on top of it.Below, you’ll find a brief explanation of what goes into each one of these steps, along with links to helpful resources where you can dig in to the details. (Note: These steps are for starting a business in the U.S. only.)Determining the Legal Structure of Your BusinessThe 4 most common business structures1. Sole proprietorship2. Partnership3. Limited liability company (LLC)Example: A small design firm.4. CorporationThe corporation does not get a tax deduction when it distributes dividends to shareholders. Shareholders cannot deduct any loss of the corporation, but they are also not responsible directly for taxes on their earnings – just on the dividends they give to shareholders.S corporations, on the other hand have only one level of taxation. Learn more about the difference between "C corporations" and "S corporations" here , and find IRS tax forms here .Choosing & Registering Your Business NameEstablishing a business name is a little more complicated than making a list and picking your favorite. If you’re using a name other than your personal name, then you need to register it with your state government so they know you’re doing business with a name other than your given name.Before you register, you need to make sure the name you want is available in your state. Business names are registered on a state-by-state basis, so it’s possible that a company in another state could have the same name as yours.This is only concerning if there’s a trademark on the name. Do a Trademark search of your desired name to avoid expensive issues down the road.For new corporations and LLCs: Your business name is automatically registered with your state when you register your business -- so you don’t have to go through a separate process. There are rules for naming a corporation and LLC, which you can read about here .For sole proprietorships, partnerships, and existing corporations and LLCs (if you want to do business with a name other than their registered name), you’ll need to register what’s called a “Doing Business As” (DBA) name. You can do so either by going to your county clerk office or with your state government, depending which state you’re in. Learn how to do that here .Want to trademark your business name? A trademark protects words, names, symbols, and logos that distinguish goods and services. Filing for a trademark costs less than $300, and you can learn how to do ithere .What is it and do you need one?The seller’s permit allows you to collect sales tax from buyers. You’ll then pay that sales tax to the state each quarter by putting the sales tax permit number on the state’s tax payment form.You can register for a seller's permit through your state's Board of Equalization, Sales Tax Commission, or Franchise Tax Board. To help you find the appropriate offices, find your state on this IRS website .Small Business TaxBusiness owners are obligated to pay specific federal taxes, and the amount of those taxes is determined by the form of business entity that you establish. All businesses except for partnerships need to file an annual income tax return. Partnerships file what’s called an information return .Any business that’s owned and operated in the United States needs an Employer Identification Number (EIN), which you can apply for on the IRS’ website here . Once you’re registered, it’s time to figure out which taxes you’ll be responsible for. Here are the three types:Marketing, Sales, and Services TipsHow to get customers and keep them happyOnce you’ve registered your new business with the government and gotten the legal paperwork squared away, how do you go about, you know ... acquiring customers?Before you can receive any significant funding for your business (which we'll talk about in the next section), you need to start building an online presence and marketing your business, as well as getting a sales process together and beginning to sell your product or service.Turns out that generating demand and earning customers needs to come before you can viably ask for funding from an external source. And once you start generating customers, you’ll need to retain them – which is where customer service comes in. Learn more about customer service here .Customer Code: Creating a Company Customers Love from HubSpotMarketing Your Small BusinessA new company needs to start drumming up interest for its product or service even before it’s ready to ship. But there are a million different platforms and avenues you can use to drive awareness … so where on earth do you start?Narrow down your target customerIt all comes down to your target customer. You won't be able to position what you're selling to meet customers' needs without knowing who they are. One of the very first questions you need to ask yourself is: Who wants what I’m selling? Who would find it useful? Who would love it?Then, you need to dig in to who that person is or those people are, and what kind of messaging would resonate with them. That includes their backgrounds, interests, goals, and challenges, in addition to how old they are, what they do every day, which social platforms they use, and so on.Creating very specific buyer personas can dramatically improve your business results.Read this step-by-step guide on how to create buyer personas , which includes buyer persona templates you can customize yourself. Once you’ve picked a buyer persona or two, print them out, tack them onto your wall, and think about their interests and needs before making every business decision.Develop a brand identityIn addition to researching your target customer, when you’re first starting a business, you’ll need to build the foundation for a strong brand identity. Your brand identity is about your values, how you communicate concepts, and which emotions you want your customers to feel when they interact with your business. Having a consistent brand identity to promote your business will make you look more professional and help you attract new customers.Build your online presenceWith your target customer and your brand identity under your belt, you can begin building the core marketing elements of your small business, which includes your website, your blog, your email tool, your conversion tool, and your social media accounts. To dive deeper into these topics, read our beginner’s guide to small business marketing here .Generate and nurture leadsOnce you've started building an online presence and creating awareness for your business, you need to generate the leads that will close into customers. Lead generation is the process of attracting and converting strangers and prospects into leads, and if you build a successful lead generation engine, you'll be able to keep your funnel full of sales prospects while you sleep.What does a successful lead generation process look like? Learn more about lead generation here , and click the button below to try HubSpot's free marketing tools , our free lead generation tool that lets you track your website visitors and leads in a single contact database.Free Marketing Tools & ResourcesHere are some helpful resources to help you spread awareness, build your online presence, and get the leads you need for free.Selling Your Products or ServicesSet up your sales infrastructure.By taking the time to set up your sales process from the get-go, you’ll avoid painful headaches that come with lost data down the line. Start with a CRM, which is a central database where you can keep track of all your clients and prospective clients in one place. There are loads of options out there, and you’ll want to evaluate the CRMs that cater to small businesses . (Excel doesn’t count!)Identify your sales goals.Don’t get intimidated by sales lingo such as KPIs and ROI. All this means is that you need to figure out what you need coming into your business to make ends meet and grow: how much revenue do you need, and how many products do you need to sell to hit that target?Hire a sales repWhen you’re starting your business, it’s tempting to do everything yourself, including taking on sales. However, making that first sales hire is crucial to scaling – you need someone dedicated to understanding your buyer and selling to them full-time. When looking for that first sales hire, seniority should be less of a priority than how much sales experience they have on the front lines and whether they understand your business’s target buyer.Get more out of your sales activities.Efficiency is key. Put together a sales process, such as this helpful 7-step sales process framework , which works regardless of your business size. You'll also want to automate sales tasks (such as data entry), or set up notifications when a prospective customer takes an action. That way, you spend less time poring through records and calling the wrong prospects and more on strategy and actual selling.Free Sales Tools & ResourcesHere are some helpful templates tools to help you build an efficient sales engine, reach prospects, and close customers for free.Enroll in HubSpot Academy to learn everything you need to know about digital marketing and sales. Train your whole team for free! Sign Up For FreeKeeping Your Customers HappyGetting net new customers in the door is important, but retaining them is just as important. You can’t ignore customers once you’ve closed them – you have to take care of them, give them stellar customer service, and nurture them to become fans of (and even evangelists for) your business.While inbound marketing and sales are both critical to your funnel, the funnel doesn’t end there: The reality is that the amount of time and effort that you spend perfecting your strategy in those areas will amount to very little if you’re unable to retain happy customers.This means that building a model for customer success should be central to your organization. Think for a second about all the different ways reviews, social media, and online aggregators spread information about your products.They’re all quick and effective, for better or for worse. While your marketing and sales playbooks are within your control and yours to perfect, a large chunk of your prospects are evaluating your company based on the content and materials that other people are circulating about your brand.Here are some tips for how to keep your customers happy and stand out as a stellar business:React quicklyPeople expect fast resolution times (some faster than others depending on the channel), so it’s essential to be nimble and efficiently keep up with requests so that you’re consistently providing excellent service to avoid losing trust with your customers.Pay attention to the volume of your company mentions on different channels. Identify where your customers spend the most time and are asking the most questions, and then meet them there, whether it’s on a social network, on Yelp, or somewhere else.Keep track of touchpoints with individual customers.Interactions with your customers are best informed by context. Keep track of all the touchpoints you’ve had with individual customers because having a view into their experience with your company will pay dividends in the long run.How long have they been a customer? What was their experience in the sales process? How many purchases have they made? Have they given positive/critical feedback about your support experience or products? Knowing the answers to these questions will give you a more complete picture when you respond to inquiries and will help you have more productive conversations with customers.Create feedback loops.From the moment you have your first customer, you should be actively seeking out insights from them. As your business grows, this will become harder -- but remember that your customer-facing employees are a valuable source of information because they are most in tune with your buyers and potential buyers.Create a FAQ page for your website.Give customers the tools to help themselves, and scale this program as you grow. When you’re starting out, this might take the form of a simple FAQ page. Over time, as your customer base grows, turn your website into a resource for your customers and enable them to self-service – such as evolving that FAQ page into a knowledge base or library that answers common questions and/or gives customers instructions.From the day you start building your business until the point where you can make a consistent profit, you need to finance your operation and growth with start-up capital. Some founders can finance their business entirely on their own dime or through friends and family, which is called “bootstrapping.”This obviously gives the business owners a ton of flexibility for running the business, although it means taking on a larger financial risk -- and when family’s involved, can lead to awkward holiday dinner conversations if things go wrong.Many founders need external start-up capital to get their business off the ground. If that sounds like you, keep on reading to learn about the most common kinds of external capital you can raise.Seed FinancingIf you’re looking for a relatively small amount of money, say, the investigation of a market opportunity or the development of the initial version of a product or service, then Seed financing might be for you.There are many different kinds of seed financing, but the one you’ve probably heard of most is called Seed-round financing. In this case, someone will invest in your company in exchange for preferred stock. If your company gets sold or liquidated, then investors who hold preferred stock often have the right to get their investment back -- and, in most cases, an additional return, called “preferred dividends” or “liquidation preferences” -- before holders of common stock are paid.AcceleratorAccelerators are highly competitive programs that typically involve applying and then competing against other startups in a public pitch event or demo day. In addition to winning funding and seed capital, winners of these programs are also rewarded with mentorship and educational programs.Although accelerators were originally mostly tech companies and centered around Silicon Valley, you can now find them all over the country and in all different industries. If this sounds like something you’d be interested in, here’s a list of the top accelerators in the United States to get you started.Small Business LoanIf you have a really rock-solid plan for how you’ll spend the money in place, then you might be able to convince a bank, a lender, a community development organization, or a micro-lending institution to grant you a loan.There are many different types of loans, including loans with the bank, real estate loans, equipment loans, and more. To successfully get one, you’re going to need to articulate exactly how you’ll spend every single penny -- so make sure you have a solid business plan in place before you apply. You can learn more about Small Business Administration’s loan programs here .CrowdfundingYou might ask yourself, what about companies that get funding through platforms like Kickstarter and Indiegogo? That’s called crowdfunding, which is a newer way of funding a business.More importantly, it typically doesn’t entail giving partial ownership of the business away. Instead, it’s a way of getting funding not from potential co-owners, but from potential fans and customers who want to support the business idea, but not necessarily own it.What you give donors in exchange is entirely up to you -- and typically, people will come away with early access to a product, or a special version of a product, or a meet-and-greet with the founders.Learn more about crowdfunding here .Venture Capital FinancingOnly a very small percentage of businesses are either fit for venture capital or have access to it. All the other methods described earlier are available to the vast majority of new businesses.If you’re looking for a significant amount of money to start your company and can prove you can quickly grow its value, then venture capital financing is probably the right move for you.Venture capital financing usually means one or more venture capital firms make large investments in your company in exchange for preferred stock of the company -- but, in addition to getting that preferred return like they would in series seed financing, venture capital investors also usually get governance rights, like a seat on the Board of Directors or approval rights on certain transactions.VC financing typically occurs when a company can demonstrate a significant business opportunity to quickly grow the value of the company but requires significant capital to do so.A business plan is a living document that maps out the details of your business. It covers what your business will sell, how it will be structured, what the market looks like, how you plan to sell your product or service, what funding you'll need, what your financial projections are, and which permits, leases, and other documentation will be required.