Get Started
Get Started

Several years ago, while hiking to the bottom of the Grand Canyon with my family, my wife Esther developed “canyon knee,” also known as “hiker’s knee” or in medical terms, “patellar tendonitis.” Regardless of the term, the end result was that she had severe pain in the tendon below her knee cap and was unable to walk up the trail to get out of the canyon. In addition to ice, rest, bracing, and non-steroidal anti inflammatory medications, the National Park Ranger insisted that she use two trekking poles on her ascent to the rim.

Prior to that experience, I always thought that “walking, hiking sticks or trekking poles” were for show or those in need of a walking aide. Well, I could not have been more incorrect. Needless to say, Esther made it out of the canyon safely and, with the use of our life saving trekking poles; we have lived “happily ever after!” Now, 15 years later, I rarely walk more than 5 miles without my poles.

As a result of this experience, I have been recommending walking or trekking poles to my patients. These poles are an essential part of hiking or distance walking gear, for the novice and expert alike. Specifically, for those over 50 who have degenerative arthritis and pain in their lower back, hips, knees, ankles or feet, these simple devices have been shown to improve the efficiency of the exercise and lessen the impact on the spine and lower extremities. Additionally, using poles reduces the likelihood of ankle sprains and falls during walking. Trekking poles are also a safe option for those with compromised balance. If you want to walk distances for exercise and need a little stability but don’t want the stigma of a cane, trekking poles are for you.

History of the Hiking Stick:

Early explorers, Europeans and Native Americans have been using walking sticks for centuries. More recently, in the 1968 classic hiker’s bible, “The Complete Walker,” Colin Fletcher praised his “walking staff” for its multipurpose use: for balance and assistance with walking and climbing, protection from rattlesnakes, and for use as a fishing rod. Today, these sticks are now versatile poles made from light-weight materials.

Trekking Pole Features:

Trekking poles are made of light-weight aluminum and vary in cost and quality. But, like most things, “you get what you pay for!” These hollow tubes can telescope to fit any person and collapse to pack in luggage for travel. Better poles offer multiple removable tips for various uses, conditions and terrains. For example, abasket to prevent sinking too deeply in snow, mud or sand; a blunt rubber tip for hard surfaces like asphalt or concrete, or the pointed metal tip to grip ice or hard dirt/gravel. Better quality poles offer an ergonomic hand grip and strap and a spring system to absorb shock through your hands, wrists and arms upon impact.

The poles should be properly adjusted to fit each individual. When your hand is griping the handle the elbow should be at a 90 degree angle. Proper use is simple; just walk with a normal gait pattern of opposite arm and leg swing. For example, left leg and right arm/pole swings forward to plant while the left arm/pole remain behind with the right leg .  

This pattern is reciprocated with as normal gait advances (opposite arm and leg). I have been very pleased with my moderately priced poles (Cascade Mountain Tech from Dick’s Sporting Goods ($34.99 per pole). Prices range from $19.99 to 79.95 per pole.;;; However, if you travel frequently to hike the State and National Parks, you may want to purchase more expensive poles that collapse and retighten more efficiently. (;;) 

Montem Trekking Poles - with close-up of easy adjustable locking clasp.


There are numerous studies to support the use of trekking poles, especially research that supports their use for health and safety. One study compared hikers in 3 different conditions; no backpack, a pack with 15% body weight and a pack with 30% body weight. Biomechanical analysis was performed blindly on the three groups and a significant reduction in forces on lower extremity joints (hip, knee, and ankle) was noted for all three groups when using poles compared to those not using poles.

Another study confirmed that trekking poles reduced the incidence of ankle fractures through improved balance and stability. Additional studies support the theory that trekking poles reduce exercise induced muscle soreness from hiking or walking steep terrain and another study found that while less energy is expended in the lower body muscles using poles, increase energy is used in the upper body; therefore, the net caloric expenditure is equal as it is simply transferred from the legs to the arms.

Reasons to Use Trekking Poles:

In conclusion, it is important to remember that trekking poles for hiking or distance walking are much more than a style statement. They are proven to be an invaluable tool for health, safety and wellness by reducing lower extremity joint stress, improving stability and balance, and enhancing efficiency for muscle recovery.    

Sources: Medicine and Science in Sports and Exercise. The Complete Walker, by Colin Fletcher

Model: Andrea Molitoris, PT, DPT at Mackarey Physical Therapy

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email:

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!

Part I of III

Total knee replacement surgery is one of the most commonly performed orthopedic surgeries in the U.S. for individuals older than 40. Given historical trends, these procedures are anticipated to increase in volume by an estimated 143% by 2050.

Knee replacement surgery is widely considered a safe and effective surgical option for patients with end-stage osteoarthritis or inflammatory arthritis of the knee. The surgery aims to maximize the quality of life for patients by reducing pain and improving joint functionality. Unfortunately, research estimates between 1 and 10 percent of patients may experience persistent pain, limited range of motion and loss of function after surgery. This rare but devastating outcome is thought to be associated with arthrofibrosis or scar tissue build-up around the joint which ultimately has a negative impact on an individual’s daily activities and affecting emotional well-being and satisfaction. Thankfully there are remediation treatment options to consider in this situation. One non-invasive, safe, and effective possibility is manipulation under anesthesia (MUA). 

What is Manipulation Under Anesthesia (MUA)?

Manipulating the knee joint under anesthesia aims to forcefully release fibrous adhesions formed after surgery. It is considered a simple and effective medical procedure performed under general or regional anesthesia, ensuring complete muscle relaxation without any pain experienced. The procedure uses force to overcome adhesions in a controlled manner. While lying on their back, the patient's hip is flexed to a 90-degree angle, and the lower leg is used as a lever to bend the knee until a firm endpoint is reached. Force is also applied to the kneecap to free adhesions found there. These movements are repeated several times until the best range of joint motion is achieved.

A Patient's Experience: Pre-MUA

Sam, a 44-year old mother and second-grade school teacher suffers from painful osteoarthritis. She underwent knee replacement surgery for both knees. However, 3 months after her surgery, she continued to experience intractable pain, swelling, and an inability to fully bend her knee. She was using a walker to assist her and could not tolerate long periods of standing. She struggled with basic daily activities and became increasingly despondent. Clinical evaluation showed that Sam was not able to bend either knee to 90 degrees. At this point, the healthcare team suggested Sam consider the MUA procedure to release the scar tissue to help move her recovery forward.

When is the Best Time to Consider MUA?

Over time, we know that adhesive tissue tends to increase in quantity and maturity. This leads to progressively worsening pain and loss of joint mobility. Literature suggests that earlier MUA intervention provides better outcomes and is more effective. Still, there is no clear consensus on the timing, and MUA may still be effective when performed later. Because clinical improvement after replacement surgery should occur between 6-12 weeks — orthopedic practices often apply a generic 90 by 90 rule of thumb. The rule signifies the ability to bend your knee to 90 degrees within 90 days after surgery. If unable to attain the 90 by 90 goal, MUA is often recommended. This is not a hard and fast rule, and each patient is individually assessed throughout the recovery period.

Risks Associated with MUA

Not everyone will be a candidate for MUA, and there are risks involved. Since force is being applied to the joint during the procedure, there is a possibility of bone fracture. Patients with osteoporosis or any other bone-weakening illness might be cautioned against the procedure. Other risks include bleeding into the joint and wound rupture. It is also important to recognize that any procedure involving anesthesia is taxing on the body and carries additional risks. It is prudent to discuss all risks and benefits with your surgeon and healthcare team fully.

Expected MUA Outcomes

MUA intends to relieve pain and discomfort and help further increase the functional range of motion in the knee joint. Biomechanically we require a knee to flex or bend, ranging from 67 degrees for walking through to 105 degrees to rise from a low chair; and 115 degrees to squat or kneel. Immediately following the procedure, joint mobility is notably improved. Research studies have recorded an average increase in flexion of 29 degrees immediately after MUA, with continued improvements over time. Individual outcomes do vary. Current literature indicates having had two or more prior knee surgeries or injury to the joint, or a stiffer knee with less than a 70-degree bend 90 days after your replacement surgery, might yield less favorable outcomes.

A Patient's Experience: Post-MUA

Sam underwent her MUA 4 months after her initial knee replacement surgery. Physical therapy is started immediately following the MUA to ensure the best outcomes. During her initial evaluation less than 24 hours after the procedure, Sam could bend both knees by herself to 90-95 degrees, something she could not do before. Less than a month after her MUA, and with continued physical therapy, she reached a 115/120 degree bend. Sam had several risk factors; early-onset osteoarthritis, high body mass index (BMI) and previous knee surgeries. These factors complicate Sam's recovery and may have lead to her failure to attain the 90 by 90 goal. Still, she told me if given a choice again; she would make the same decision. Sam smiled and told me she no longer relies on her cane to walk, can walk up and down stairs almost normally and she is eager to start driving again.

Final Thoughts

The American poet Sheldon Silverstein wrote in his poem "Stop Thief!", "...Help me please. Someone went and stole my knees. I'd chase him down but I suspect my feet and legs just won't connect." Our knee forms such an integral part of daily life and activities— yet we seldom appreciate that it is one of our most stressed and complex joints, needing 10 muscles for movement and stability, and requires varying degrees of flexibility to get us through the day.

Next Monday, in part 2 of this article, we examine factors that might predispose a patient to scar tissue induced persistent pain and limited functionality after knee replacement surgery; and possible steps to avoid this.

This column is a monthly feature of “Health & Exercise Forum” in association with the students and faculty of Geisinger Commonwealth School of Medicine.

Author: Hendrik Marais, MD, MS

Hendrik Marais, MD, MS, received his Doctor of Medicine degree from Geisinger Commonwealth School of Medicine in 2015 and his Master of Science degree in Global Medicine from Keck School of Medicine at USC in 2019. He is passionate about creating positive and empowered patient health outcomes. He grew up in South Africa and currently calls Scranton, PA home – where he enjoys cycling, swimming, and discovering the beauty of NEPA. He is a member of the American Medical Association, American Public Health Association, and the International Society of Physical and Rehabilitation Medicine. He plans to pursue a clinical career in physiatry.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” Part II of III on Recovery From Knee Surgery

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email:

For all of Dr. Mackarey's articles visit:

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine.