Question from Taylor: I’m curious, should a patient meet with a PT before surgery? If yes, why? My doctor recommends it. Thx.
Thanks for the GREAT question Taylor! First, I need to say that without a doubt, “prehab,” that is, rehab before surgery, is a must. Second, a PT will do far more than prepare you for how to move post-operatively, including education on precautions, stair climbing, fitting and education about assistive device, and management of your prehab exercise program. A PT should also be screening for complicating factors, such as pelvic issues, that could affect or slow recovery, and can make recommendations for overall lifestyle changes that could improve surgical outcomes.
A critical part of choosing a PT is interviewing several – You want to make sure she/he has post-graduate training in specialized rehab of the hip. General orthopaedic PT’s are not necessarily prepared or trained to rehab hip scope patients. Standard PT education does NOT include hip preservation rehab and the science is very new on it. You may have to interview several before you find the right one. If you want to know what you should ask, let me know.
Third, you do need to know LOTS before surgery, including safe movement, muscular patterning, and prevention scarring, to name a few, plus – there are things you can do to expedite recovery if you “prehab” (rehab prior to surgery).
You may also want to check out my post on Top Five “Must-Have’s” Before Hip Labral Surgery. Hope this helps!
Question from Brooke: What should my PT evaluate for a nonoperative hip visit?
Hello everyone. My daughter (aged 12) has her first PT appointment today. Surgery has been recommended and her OS does not think PT will help, but we’d like to see what they have to say about her condition and possible pain management in the meantime. So, I’m looking for advice: What do I want them to test and/or examine her for? What should I make sure they measure or test for? Any help and advice would be GREATLY appreciated!
This is a fantastic question Brooke! If you are going for nonoperative PT or “prehab” – then I suggest asking the following of the examining PT:
- How do you screen for hip impingement? Meaning, what tests do you use (FADDIR and modified Thomas are 2 of the best)
- How do you check for femoral head centering? (squat is a great way to do this, along with palpation of the femoral head laterally)
- How do you check for neuromuscular patterning and timing of the glueals (Max, Min, and Med), deep hip rotators (there are 6), and the cylinder (transversus abdominis, pelvic floor, respiratory diaphragm, and mulitifidus) (I use a yoga-based therapeutic screen because it is more integrative and thorough, but there are many ways to screen these muscles).
- What about previous surgeries, abdominal scars, or any scar tissue that would affect PT.
- What about MMT all the muscles in the trunk and hip separately and as a group.
- What about my obturator internus (a deep hip rotator) and ask about any pelvic floor issues.
- What about nutritional habits (certain foods are inflammatory and can worsen orthopaedic conditions)?
- What about my pain patterns – could they be related to the hip, back, SIJ, or pelvis?
In addition, a PT should:
- Carefully evaluate her gait – both walking and running (if she can run or would like to return to running) and identify specific patterns of deficiency or impairment that can be modified to decrease abnormal load transfer or anterior joint loading.
- Carefully evaluate a sit to stand from a chair – you can tell LOTS about hip muscular patterning and deficiencies.
- Evaluate the fascia. Ask them what they do to evaluate the fascia. It’s that important. If they don’t immediately launch into an explanation of how important fascia is – I would be wary. 😉
- They should evaluate muscles in resting positions also – the tone of the psoas, iliacus, external obliques, pelvic floor, obturator internus, gluteus medius, and hamstrings. Many times these muscles are implicated in superficial stabilization of the unstable hip – so they will be painful and in varying states of tendinopathy.
Finally, a good hip PT should welcome questions and talk to you about strategies for hip preservation.
Hip PT is NOT:
- A PT handing you a list of “exercises” that focuses on “stretching” or “strengthening” to do at home. Assessing and treating a nonoperative hip is MUCH more complex than a home exercise handout and requires careful monitoring of neuromuscular patterning.
- Treating your nonoperative hip labral tear like a regular orthopaedic condition. Hip labral tear management should include a hefty dose of activity modification education and recommendations, as well as assessment of sport or activity specific task performance. It does not primarily base itself around strength or stretch of muscles. It must be approached from a systems-based assessment, one where all systems are considered, from urogynecologic to visceral to fascial to neuroendocrine, etc. Women with hip labral issues are at risk for many other pelvic pain and sexual dysfunction conditions. So it is very important that you are assessed by a PT trained in this area.
I hope this helps you – of course, this is all a mere suggestion – as I can’t legally give advice in a forum like this – I can only offer ‘good samaritan” suggestions. Best of luck to you – and I’m sure I could add a few more things, this is just me writing “off the cuff.”
Question: I have read on many forum related to FAI that the success rate of arthroscopic labrum repair is between 85 & 93%. Can anyone tell me the main causes of failure? Is it poor recovery protocol, physical implications or something else?
Any pre-existing OA, osteophytes, or chondral lesions markedly reduce satisfactory outcomes. That is one reason for the lack of 100%. Others include – post-op adhesions, poor surgical technique/outcome, poor PT, that is barring other systemic complications or comorbidities. I would say beyond these reasons, poor post-op rehab (poor care by the PT or poor adherence by the patient, which includes returning to work or activities too soon) is often a culprit. Again, another reason to search out a PT with lots of hip labral experience and post-graduate training.
Hope this helps!
Question: Before hip surgery…is it possible to ever have any pelvic issues that go along with the hip problem? I’m having some pretty severe pelvic floor issues and everything from my piriformis, pelvic floor, quadratus lumborum, and my psoas is very unhappy…BTW, I’m in therapy now with an awesome womens health PT.
First, oh no! I am so sorry to hear you are having such pelvic issues! But yes, your problem is not uncommon. Let me emphasize though that it is not normal. You can have severe pelvic problems – with the obturator internus especially – but everything in the area can also be implicated, such as the transverse perineal muscles, levator ani, etc. The good news is I am glad you are getting some relief with pelvic PT.
Question from Rebecca: I am interested to know whether you have any information or experience of FAI/labral tears co-existing with neuropathic pain within the sacral plexus distribution (e.g. pudendal & cluneal neuropathy/pelvic floor dysfunction).
I have had groin pain for 18 months (following an acute onset of left groin pain and inability to weight-bear during a gentle partial squatting movement) with additional episodes of buttock and SI joint pain. More recently, I have developed unpleasant (mainly posterior) neuropathic ‘pelvic’ pain. I have had one (superficial) pudendal nerve block which is going to need to be repeated. There is a concern that hip treatment such as pelvic PT, may flare up the chronic neuropathic pain situation. However, the hip pain is chronic too but fluctuates depending on activities, which have become pretty limited.
I am confused as to whether leaving the hip situation will cause more guarding and pelvic floor muscle imbalances etc, thereby creating another vicious cycle.
However I am also worried that hip arthroscopy in particular, may exacerbate the neuropathic situation due to traction on the hips. It seems very complicated (so apologies for a long question)!
I have seen that there appears to be a link between hip pain and pelvic pain. I would therefore be very grateful if you would be able to provide any further information regarding the two co-existing, if possible.
I was interested to have a good look around your website. I feel that traditional medicine focuses too much on individual body systems and agree that an integrated holistic approach can be beneficial.
First, I am sorry that you are struggling with such an injury Rebecca – it is a painful and debilitating one, no doubt.
To try and answer your questions –
- Yes, I find that the two – pudendal neuralgia and hip labral injury coexist and overlap with one another. That is not uncommon.
- As to whether or not to pursue surgery – do you have a confirmed tear and/or FAI?
- As to avoiding surgery due to neuropathic complications, that risk does exist, but it is low. So I would not recommend avoiding surgery for that reason alone.
Questions for consideration:
- What are ALL the symptoms you have (muscle guarding, which ones; fascial issues, where; GI, neuroendocrine/hormonal, sleep issues, patterns that go with them; pain that increases with menstrual cycle or eating, how?)
- How comfortable are you with the help you are currently receiving?
Hope this helps!
Question from Jesse: Will I be able to run again?
Dear Jesse, that’s a loaded question. The surgery is called hip preservation – but it should rightly be called hip reconstruction. It is a major event focused on saving the hip from being replaced in the future. Running easily disperses 4 times your body weight through that repaired hip. I will leave you with the courage of your convictions to decide what is best for you.
But let me say this also –
Please know that I feel your pain. I do. As a PT and patient. And it’s not that you can’t run, but to take it on as a primary mode of exercise may not be best for hip longevity. I can’t tell you, and would never say to someone, “you can’t do _______.” That is cruel and arrogant. But what I do is give them the best information and science on the condition, and let the patient decide. I can also help steer them toward activities that they can do for a lifetime.
Jesse: Thank you Ginger! I feel like my life has completely changed. The weight of this injury is hitting me. My heart is heavy. I’m a mother of 4, and a minister’s wife. I homeschool, I teach yoga, and I’m a CEO of a nonprofit. I’ve had many trials in my life. This injury and upcoming surgery has hit me heart harder than I thought it would. I feel vulnerable and weak. Weakness is not an emotion I’m ok to feel.
Ginger: Whoa Jesse, that story is familiar. If I could remind us of another phrase we both know, now that I have learned more about you – it is this: “In our weakness we are made strong.”
Jesse, followed up after her surgery: AMEN! I receive that Ginger Garner! Just took my first shower since surgery. Whew…feeling like a conqueror now. Lol. The shower is a place of solace and a place to reconnect with my creator. You’ve been great Ginger Garner. Wish I could hobble over to give you a big hug.
Question from Jane: Will I be able to teach yoga again?
This is an easy one to answer. Yes! No problem. But you must know what your precautions are based on your hip anatomy. I went back to teaching, on crutches and unable to transfer to the floor, at 7 weeks post op (I had no choice, I had to return to my job in medical education). That is an extreme example, but knowing what my permanent limitations are for returning to yoga – is paramount. For example, excessive anteversion is a contraindication for performing lotus or half lotus, and other similar postures that place the hip in an extreme of external rotation.
Hope this helps!
*Names have been changed to protect privacy.
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