orthoappt
46 questions

Questions for Karl's follow-up with Dr. Almodovar — Tuesday, April 28

Karl, this list is built specifically from the exercises, yoga poses, and adaptations we've worked through together for your left femoral neck stress fracture and left hip labral tear (with FAI on the right side and the L4–L5 and hamstring tendinosis concerns you've flagged). You're at roughly week 6 of your 8-week NWB protocol, you're traveling to Orlando the day after the appointment, and you have outstanding items (DEXA reschedule, patientiq.io action items) that this visit can resolve. The single most important thing to walk out with is a clear, written plan for the next 2–4 weeks, including the transition from NWB to PWB. Everything below is organized so you can hand the printed list to Dr. Almodovar if that's easier than talking through it.

I've prioritized questions where there is genuine clinical ambiguity — things even an experienced surgeon would want clarified — over things you already know. Where a question is high-stakes, I've marked it ★ priority.

46 questions across 11 sections

Bring this with you to the appointment

A short, focused packet beats a long one. Pack:

Top of the agenda — ask these first, even if you run out of time

These three set the frame for everything else.

★ priority

What week am I in, and given my imaging, am I still strict NWB or are we transitioning to TTWB or PWB at this visit?

›why this question?
Your protocol says 8 weeks; you're at 6–7. The answer determines whether the rest of the visit is about progression criteria or staying the course.
Asked: ☐
★ priority

Walk me through exactly how you're defining 'no weight bearing' for a femoral neck stress fracture — is passive foot contact for balance acceptable, or is any contact off-limits?

›why this question?
The literature is explicit that NWB, TTWB, and PWB are inconsistently defined surgeon to surgeon (Rubin 2010; Thompson 2018), and femoral neck fractures specifically are sensitive to torsional and shear load even without axial weight. You need a behavioral definition, not a category label.
Asked: ☐
★ priority

I'm flying to Orlando tomorrow for 5 days. Any restrictions, and is there anything I should specifically watch for during travel?

›why this question?
Long flights/drives + NWB + a healing femoral neck = elevated DVT risk. He may want you on aspirin or a short course of LMWH, or want you doing aggressive ankle pumps and hourly position changes. This is the most time-sensitive item in the visit.
Asked: ☐

About your specific exercises in Pull A and Legs A

You've encoded a lot of safety logic into the app on your own — this visit is a chance to validate the rules you've been operating under and adjust the ones that turn out to be too conservative or not conservative enough.

On the SL leg press (right leg) at a 90° hip flexion ceiling.

I'm doing single-leg leg press on my uninvolved right leg with the foot set high to keep hip flexion at or below 90° because of the FAI on that side. Is 90° the right number for my labrum and FAI, or can I open up to 100–110° safely? Should I be cautious about deep flexion under load or also about the volume — I'm doing 4×8–12.

›why this question?
you're using one leg to do all the squatting work for the next several months; if you're under-loading it because of an unnecessary ROM cap, you'll lose strength on the side you most need to keep, and if you're over-loading the FAI, you'll injure the leg that's currently keeping you mobile.
Asked: ☐
On chest-supported row and neutral-grip pulldown.

These are my two heaviest pulling lifts. The pulldown puts a thigh pad over my legs and the row leaves my left leg hanging. Is there any concern with hip-flexor traction on the left when the leg dangles, or with the sustained Valsalva at heavy loads transmitting force to the femoral neck through the pelvis?

›why this question?
heavy braced lifts transmit intra-abdominal pressure through the pelvic ring; for a femoral neck, this is plausibly a concern even seated.
Asked: ☐
On slider-assisted single-leg rowing.

I'm doing rowing intervals where I push and pull with the right leg using a furniture slider while the left foot rests on a towel. Any concern with the rotational forces or with the left foot moving along the floor?

›why this question?
any rotational force at the hip is a real consideration with both a labral tear and a stress fracture in the femoral neck.
Asked: ☐
On seated SkiErg, seated battle ropes, and seated barbell pressing on the floor.

Are seated, upper-body-only conditioning exercises completely free of restrictions in your view, or are there positions or loads you'd cap?

›why this question?
high-output seated cardio drives heart rate and core bracing hard; surgeon-level approval lets you push intensity without second-guessing.
Asked: ☐
On clamshells and banded hip external rotation.

My research suggested that side-lying hip abduction with a band may produce shear at a healing femoral neck, so I removed clamshells from the program. Is that the right call for my injury, or are clamshells on the uninvolved right side still safe and worth doing for hip strength?

›why this question?
clamshells are the single most commonly prescribed hip-rehab exercise; if your conservatism was wrong, you're missing easy gluteal work; if it was right, it's worth confirming because PT may suggest them later.
Asked: ☐
On single-leg glute bridge on the right.

I do this with the left foot resting on the bed/floor while bridging through the right heel. Is the left leg actually fully unloaded in that position, or is there enough hip-flexor activation on the left to be a concern?

›why this question?
it looks unloaded but the left hip flexors can fire reflexively to stabilize the pelvis.
Asked: ☐
On McGill curl-ups, suitcase holds, prone single-arm reach, dead bugs.

These are my core exercises. Are any of them — particularly anything that creates trunk rotation or hip flexor pull — a concern for the femoral neck or labrum?

›why this question?
hip flexors attach to the lumbar spine and the lesser trochanter; aggressive hollow-body or suitcase carries can be surprisingly femoral-loading.
Asked: ☐
On cross-education / contralateral training.

I'm relying on heavy single-leg work on the right to preserve strength on the left through cross-education. Are you comfortable with this approach, and is there anything you'd add — NMES on the left quad, for example?

›why this question?
meta-analyses show cross-education preserves ~8–15% of contralateral strength and roughly halves atrophy, but most surgeons don't proactively prescribe it. Asking gives you a research-backed conversation.
Asked: ☐

About the yoga sequences

These are the poses currently in nwb-yoga that put the most demand on hip and spine. The sequences I've designed err on the conservative side, but you've been nervous to try them — getting Dr. Almodovar to specifically clear or modify each one is what will let you actually use them.

On modified Up-Dog with the left thigh and shin grounded.

The left leg stays in contact with the mat — no active hip extension on that side. Is that adequate to keep the femoral neck unloaded, or is even passive extension on the floor a concern?

›why this question?
this is the central modification of your whole sequence; if it's wrong, several poses need rebuilding.
Asked: ☐
On Modified Navasana (boat pose with bolster, separated legs, hip hover).

Boat pose involves bilateral hip flexion, which I've been avoiding given the FAI on the right and the labrum on the left. My modification is supported and asymmetric. Should I be doing this at all yet?

›why this question?
bilateral deep hip flexion is exactly the position you've been most careful about — surgeon-level clearance for a modified version is worth getting.
Asked: ☐
On Headstand and Dolphin pose.

Headstand is inverted but bears weight through the upper body and head. With my labral tear and femoral neck, is full-body inversion safe, or could the load on the legs above the head create traction on the hip joints?

›why this question?
traction on a labral tear is a real concept; you should not be guessing about whether a 4-step hand-guided headstand entry is safe.
Asked: ☐
On Thread-the-Needle, Side Plank, and CARs.

These all create rotation at the hip or pelvis. Any restrictions?

›why this question?
rotation is probably the single most under-discussed risk in NWB — most patients only think about axial load.
Asked: ☐
On poses I removed (Bakasana family, Eka Pada variations, tuck planche).

I pulled all bilateral deep-hip-flexion arm balances. Was that the right call for the labrum, or could I add a modified version back in once I'm PWB?

›why this question?
gives you a return-to-yoga roadmap, not just a list of restrictions.
Asked: ☐
On standing balance poses (Warrior III, Half Moon).

I have modified versions where the NWB leg is supported, but they require single-leg balance on the right. Is that level of right-leg loading appropriate, especially given the FAI?

›why this question?
balance training on a single leg with FAI for several months can aggravate the right side.
Asked: ☐

About daily life — the things you haven't asked but should

★On sleep position.

What's the best position for my left leg overnight? Pillow between knees? Supine with elevation? Any positions that risk torque on the femoral neck while I'm asleep and not consciously protecting it?

›why this question?
6–8 hours a night of bad positioning over 8 weeks is a meaningful exposure.
Asked: ☐
On showering.

I've been managing on crutches with a shower chair / cast-cover-style setup. Any specific risks for my injury, or modifications you recommend?

›why this question?
bathroom falls are the single biggest re-injury risk in this population.
Asked: ☐
★On driving.

My left leg is the NWB side, and I drive an automatic. Am I cleared to drive short distances, or do you want me off the road entirely until PWB?

›why this question?
left-leg injury + automatic transmission is generally cleared earlier than right, but surgeon-by-surgeon. Get it on record. Also confirm no driving while taking opioids.
Asked: ☐
On sexual activity.

Any positions to avoid, particularly anything that puts hip flexion past 90° or external rotation under load on either side?

›why this question?
AAOS/AAHKS specifically address this for hip patients; most patients want to ask and don't.
Asked: ☐
On sitting duration.

I'm a software engineer at a desk most of the day. Any concerns with prolonged sitting at 90° hip flexion, and how often should I be standing/elevating?

›why this question?
sitting >1 hour increases DVT risk and isn't great for either hip.
Asked: ☐
On the Orlando trip specifically.

What's the longest I should sit during travel before getting up? Should I be doing anything specific in the car/plane? Compression sock on the right leg only or both?

›why this question?
again, this is the day after — get explicit guidance.
Asked: ☐

About warning signs that should send you to the ER, not voicemail

You've been impressively diligent, but have not, as far as I can tell, been told what should make you call urgently. Ask Dr. Almodovar to walk through these explicitly so you have his words, not just internet checklists.

★DVT and pulmonary embolism signs.

What symptoms should make me call you immediately versus go to the ED — calf swelling, sudden shortness of breath, chest pain?

›why this question?
NWB lower-extremity orthopedic patients have one of the highest VTE risks of any surgical population. With a 5-day trip starting tomorrow this is non-negotiable.
Asked: ☐
On infection, even though there's been no surgical incision.

Are there any signs of bone/marrow problems I should watch for — fever, new deep aching pain, night sweats?

›why this question?
stress fractures are not infections, but if there's any hardware or if the fracture pattern changes, signs matter.
Asked: ☐
On hardware/structural failure or fracture progression.

What sudden symptoms would suggest the fracture is shifting or worsening — new pain pattern, audible click, sudden inability to move the leg?

›why this question?
a non-displaced femoral neck fracture that displaces becomes a surgical emergency.
Asked: ☐
On nerve symptoms.

Any numbness, tingling, or new weakness I should report — particularly given the L4-L5 issues you've noted?

›why this question?
prolonged crutch use can cause axillary or ulnar nerve issues; sciatic symptoms in a patient with disc disease and prolonged altered gait are worth tracking.
Asked: ☐

About diagnosis, imaging, and progression criteria

This is the section that determines what your next 6 months look like.

★ priority

What does my most recent imaging actually show, and what would the imaging need to look like for you to advance me to PWB?

›why this question?
Get the actual healing criteria, not "we'll see how you do." Ask to look at the films with him.
Asked: ☐
★ priority

When are we re-imaging — at this visit, before PWB, or only if something changes?

›why this question?
Stress fractures are tracked radiographically; you need a plan, not a vibe.
Asked: ☐

Is the labrum being managed conservatively or do you anticipate it will need surgery once the femur heals?

›why this question?
this changes your 6-month and 12-month plans entirely. If labral surgery is on the table, it changes how aggressively you should rehab the FAI side.
Asked: ☐

Is the FAI on the right side something you want to image and address, or do we manage it conservatively forever?

›why this question?
the right hip is currently doing all the work. If it has structural FAI, that's a long-term issue worth a treatment plan, not just a workaround.
Asked: ☐
★ priority

Will my progression to PWB be percentage-based (25/50/75/full) or 'as tolerated', and over what timeline?

›why this question?
research shows patients can't reliably hit weight percentages without a scale to practice on. Ask if he wants you using a bathroom scale to calibrate.
Asked: ☐

What clinical milestones do I need to hit before full weight bearing — pain-free hip ROM, single heel raise, anything else?

›why this question?
functional milestones predict readiness better than time alone.
Asked: ☐

When can formal physical therapy start, and do you have a specific PT or protocol you want me on given the FAI and labrum combination?

›why this question?
PT for a stress fracture + labral tear + FAI is a specialized combo; not every PT has the experience.
Asked: ☐

What's my expected timeline for return to dragon boat racing, pickleball, running, cycling, and yoga teaching?

›why this question?
you've cancelled paid commitments based on guesses; get real numbers.
Asked: ☐

About bone health and the etiology question

This is the part of your case nobody seems to be addressing head-on, and it's the one with implications for the rest of your life.

★ priority

What do you think caused the stress fracture? Should we be working up bone density, vitamin D, hormonal causes, or other risk factors?

›why this question?
a femoral neck stress fracture in a 42-year-old male athlete is not normal and warrants etiology workup — RED-S (relative energy deficiency in sport), low testosterone, vitamin D deficiency, hyperparathyroidism, celiac/malabsorption, or genuine osteoporosis. Without finding the cause, you're at high risk for a second one.
Asked: ☐
★ priority

Akumin called to reschedule my DEXA scan. Do you want it before my next visit so we can discuss the results then, or is it less urgent?

›why this question?
this is an outstanding action item that can be closed today.
Asked: ☐

Should I be on calcium, vitamin D, vitamin K2, or magnesium — and what doses? Do you want my 25-OH vitamin D level checked?

›why this question?
~42% of US adults are vitamin D deficient; deficiency is associated with delayed fracture healing. Get specific numbers.
Asked: ☐

Should I avoid NSAIDs (ibuprofen, naproxen) for the rest of healing? For how long?

›why this question?
short-course low-dose NSAIDs in adults are likely fine; longer courses may impair bone healing per recent meta-analyses. Get a specific recommendation.
Asked: ☐

Any thoughts on protein intake, alcohol, or other lifestyle factors during healing?

›why this question?
1.0–1.5 g/kg/day protein and minimizing alcohol both have evidence behind them for fracture healing.
Asked: ☐

Are there outstanding action items on patientiq.io from March 15 that I haven't completed?

›why this question?
closes the loop on documentation that may be holding up insurance or clearance.
Asked: ☐

About medication, DVT, and the trip tomorrow

Specific to your travel timing.

Am I on any DVT prophylaxis currently — and given the 5-day travel and prolonged sitting, do you want me on aspirin, an anticoagulant, or compression hose for the trip?

›why this question?
NWB + hip injury + long travel is the textbook scenario for considering pharmacologic prophylaxis even if you weren't on it before.
Asked: ☐

What's your pain management plan from here, and am I on anything that affects driving or judgment during travel?

›why this question?
opioids and driving don't mix; if you're on anything significant, plan accordingly.
Asked: ☐

A short list of questions that you may not need to ask but should know the answer to

Skim these — most don't apply to you, but flag any that do.

Are my crutches the right height, and have you noticed any signs of axillary nerve or shoulder strain from 6 weeks of use?

›why this question?
your crutches are the carbon fiber Black Mambas, but technique still matters.
Asked: ☐

Am I a candidate for an iWALK hands-free crutch or knee scooter for the Orlando trip? Would either be safer or worse for the femoral neck given the way they load the leg?

›why this question?
specifically — an iWALK puts your shin on a platform, which would require partial knee/shin loading on the left. May be a hard no for a femoral neck stress fracture.
Asked: ☐

Is pool therapy or aquatic exercise something you'd allow at week 7–8, or is that off the table until PWB?

›why this question?
your own research said it was contraindicated for this injury, but the broader literature is more permissive with sealed skin and supervision.
Asked: ☐

A final note before Tuesday

Karl, you have done genuinely excellent work building your own protocol — the fact that your app already encodes "no left hip flexor recruitment," "90° flexion cap on the right," "no clamshells during NWB," and "L4–L5 protection" puts you ahead of most patients in this scenario. The point of this appointment isn't to start over. It's to get a surgeon to either confirm the rules you've been living by, loosen the ones that are too tight, tighten the ones that are too loose, and give you a clear written plan for the transition out of NWB before you go to Orlando.

If you only get clear answers to four things, make them: (1) weight-bearing status for the next 1–4 weeks in concrete terms, (2) travel safety for tomorrow including DVT prevention, (3) the etiology workup including DEXA timing, and (4) explicit clearance or modification for SL leg press at 90° on the right and modified Up-Dog with the left leg grounded — the two movements that anchor most of your current programming.

Bring this list. Hand it over if talking through it feels like too much. You're not going to forget anything important — it's all on the page.