4+ Weeks Post-Op: New Pain Leads to New Discovery (and Progress!)
Hip Labrum Rehab
- Post 1: Day 1 Post-Op Recovery
- Post 2: Day 2 Post-Op Recovery
- Post 3: Days 4-5 Post-Op Recovery
- Post 4: Day 6 HLI Rehab
- Post 5: Day 7 HLI Rehab: Mantras and Edema Management
- Post 6: Day 10 Slow & Steady: The Yoga of Hip Labral Rehab
- Post 7: Days 11-19: A Turning Point Hip Preservation Post-Op
- Post 8: Days 19-27: Hip Labrum Rehab Milestones
At more than four weeks postoperative hip labrum repair (see post 1 for all surgical details), I should be returning to full weight-bearing and able to ditch my crutches, per the protocol. However, as a PT, I know I am far from ready to do that. Trendelenburg gait and immediate groin pain with attempted increased weight bearing are key signs I am not quite ready to wean from both crutches. I should also be able to resume trying to regain full ROM (range of motion) in all planes, however, no strength testing (MMT) or special tests can really be performed yet. So my conclusion this week is therapy must be functionally driven – i.e. helping me return to painfree ambulation and working to improve neuromuscular function in the hip and lumbopelvic region(s). This means not pushing myself to stick with protocol beyond honoring weight-bearing and ROM precautions.
Being nonambulatory with hip precautions, including limits on daytime upright sitting (no more than 30’ daily) with no active work of the psoas and no extension (yet), create cause global atrophy and debilitation. Aquatic therapy is a lifesaver, but ambulation is strictly functional only – with a three story home to ambulate through, it’s all I can do to just get in/out of the house and through it to complete ADL’s (activities of daily living).
Clinical Pearls from Week 4+:
- Caretake the nonoperative leg: The left (nonoperative) hip and foot significantly hurt from bearing all weight, with remarkable external snapping hip of the iliotibial band (ITB over the greater trochanter that mimics a hip labral tear (I talk quite a bit about categorization and diagnosis of “Hip Mimickers” in my HLI (Hip Labral Injury) course), with mechanical giving way, clicking, and popping. As a PT I have quickly isolated it to coxa sultans (snapping hip); but it doesn’t change the pain or instability that it causes. It still must be dealt with as a secondary diagnosis. Caution with ambulation is critical, especially up/down stairs. I have already fallen from kid toy and water mishaps, and thank goodness I had my brace on to stop collapsing into my newly repaired hip.
- Monitor (read: differentially diagnose) operative hip knee pain: My right knee still is unable to fully flex secondary edema and pain, perhaps from the traction required to sublux (partially dislocate) the hip during surgery.
- Address fascial response and old and new scars that may inhibit restoration of ROM: The right knee medial joint line gaps with attempted hip ER (external rotation) at 90 degrees of hip flexion, which tells me this “new” right hip is stiffer than a board of sheet rock with little resilience or response from the surrounding fascia.
- Look for “back-door” solutions to regain ROM: Right hip ER ROM increases with prone-lying with decreased pain (ER is easiest in prone). This is good information, so I spend longer amounts of time in simple prone-lying. Thank goodness I can read and do a bit of work in this position if I position an ottoman in front of my massage table as a workspace.
- Don’t force hip flexion without looking for the root cause(s) of the limitation: My right hip absolutely refuses to purely flex. This is a common finding in retrospect, as the only motion I can accomplish is FABER (flexion, abduction, and external rotation) in order to flex without impingement. The causes could be many, from post-operative edema in the joint and surrounding tissues (which I still have), nonresponsive fascia (yep, have that too), false femoracetabular or subspinal impingement from SIJ (sacroiliac joint) woes or to other murkier and more troublesome issues, such as postoperative heterotopic ossification or intra-articular issue.
- Be patient. It takes time to tame the “Snarky Psoas”: The psoas continues to be a major pain in the you-know-what. However, some taping for inhibition is helping, while also knowing (read: being patient) it will take months to downtrain the psoas properly.
- Attend to scar tissue some more. The GMAX (gluteus maximus), GMED (gluteus medius), or other deep gluteals may be suffering from scar tissue issues. See below for more details.
- My “Best Fit” for Self-Scar Mobilization: I am finding that the BEST SCAR MOB (mobilization) is done in hot water (hot tub, spa, or bathtub) after a 10’ soak. The skin is very responsive and pliable and you can address deep mobility with less pain. However, be gentle. It is SAFEST for a professional trained in scar mobilization and myofascial release to teach you how to do this first before trying it on yourself.
Let’s Celebrate! Functional Milestones Met
- FIRST TIME – Today is the first time I can lie on my side without a pillow between my legs, albeit only for a short amount of time before impingement pain makes me move.
- FIRST TIME – I can transfer to prone-lying in bed safely and without pain!
- FIRST TIME – GMAX and GMED pain are both decreased with better scar mobility and response. This is a key point to attend to during rehabilitation. Scar tissue does not just settle in the hip and surrounding visceral structures (such as the psoas area). It can spread pervasively and unknowingly into the GMED, GMAX, and deep gluteal area. To know if this may be affecting your rehab, palpate your hip scars and gently draw them, one at a time, in a single direction. Find the first point of resistance (a barrier) and hold the tension. Find your deep yogic breath and hold the tension for 2-5 minutes. Note whether you feel any referred pain (could feel like strings pulling, dull aching, sharp stinging, or other sensation) to another area. If so, have your PT or health care provider carefully check for scar tissue and treat accordingly.
Biopsychosocial Yoga Lessons
- Self-care is paramount. Slow self-care. Comorbidities will slow typical protocol progress. I am trying, but unable, to bear any more than the 20# FFWB recommended during acute post-op, without significant pain (if try to do more than 3-4 times). As a result, PT is slower than I (as a PT and patient) would like. I am having to consider cutting out more responsibilities at work in order to truly heal and rehab properly. Lesson (re)Learned: Put your own O2 mask on first. You have unique pre-surgical + a new set of post-surgical deficits. Recovery will take longer.
- Be patient with yourself. I started aquatic therapy walking (in water) today. Guess what? I did too much. What I did was incredibly mild (chest deep water walking, A/P leg swings, bicycling, very easy treading water and dog paddling; hip extension), however, it was still too much too soon. Lesson (re)Learned: Just because you can doesn’t mean you should. Although I can technically pursue this rehab within my hip precautions, I am obviously not ready for it. And if as a PT, who monitors her progress hourly and knows the ins/outs of hip rehab, is not ready to progress yet, then the average patient should definitely pace his/herself slowly and listen carefully to his/her body. Don’t be pushed by a protocol or a therapist.
- Always attend to your stress response first. Pain kept me up last night, and this is coming from someone who has a very high pain tolerance. I could have done too much in PT or aquatic therapy, so I spent the day in resting, literally in bed. I worked on yogic breathing and meditation until the end of the day when my husband helped me down the two floors to the outdoor hot tub. Note that once on the main floor I went back to using my walker out of caution. I don’t want to ambulate independently until I can do it properly and with a healthy stress response. Once in the spa, and with a day of rest and yoga to inspire me and manage my pain, I created a new aquatic therapy program (see below)!
My MEDICAL THERAPEUTIC YOGA AQUATIC PROGRAM
This program is not generalizable to the broad population of hip preservation surgery recovery. Individualized therapy should be prescribed for you if you are recovering from this surgery. This is a program that I created for myself based on my physical therapy evaluation and customized prescription.
- Forward fold DFD (downward facing dog). I was unable to get to 90 degrees but I could move from a wall downward facing dog holding the side of the spa into:
- Standing cobra/updog for hip and trunk extension
- Tree pose (very mild) left leg WB only (shin slides seated and standing); had to lean back in seated secondary to impingement pain but it was manageable.
- Standing weight shift (water covering hip)
- Twice – Gentle D1/D2 LE PNF patterns from reclined supine. The pain was sharp with FABER and mild ADDIR (no hip flexion).
- Prone right hip extension (floating)
- Unable to right knee flex today – too much anterior superior pain and knee pain
- Scar mobs in hot tub definitely work best – but today felt rectus femoris fibers lift up when trying to mobilize the most proximal scar (that increased pain quite a lot after the mobilization).
- Spent 1 hour in aquatic therapy then followed up with compressive icing (Game Ready)
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