If you haven’t been following the entire series, get it here:
- Post 1 – https://gingergarner.com/resurfacing-hip-labral-surgery-post-1/
- Post 2 – https://gingergarner.com/hip-labrum-postsurgical-musings-post-2-2/
- Post 3 – https://gingergarner.com/post-surgical-musings-days-4-5-post-3/
- Post 4 – https://gingergarner.com/hip-labrum-postoperative-rehab-day-6-post-4/
- Post 5 – https://gingergarner.com/hip-labrum-postop-integrated-rehab-day-7-mantras-edema/
- Post 6 – https://gingergarner.com/yoga-hip-labral-rehab/
- Post 7 – https://gingergarner.com/days-11-18-a-turning-point-hip-preservation-post-op/
- Post 8 – https://gingergarner.com/post-op-days-19-27-hip-labrum-rehab-milestones/
- Post 9 – https://gingergarner.com/5470/
- Post 10 – Day 35, Week 5 – Tough Tissue a Great Teacher
- Post 11 – https://gingergarner.com/day-40-5-weeks-sharp-shooting-dry-needling-begins/
- The First Month – https://gingergarner.com/hip-arthroscopy-post-op-rehab-the-first-month/
- Post 12 – https://gingergarner.com/day-47-week-6-snarky-psoas-shutdown-the-importance-of-social-support-post-12/
- Post 13 – https://gingergarner.com/week-6-first-time-1-crutch-walk/
- Post 14 – https://gingergarner.com/hitting-my-new-stride-day-50-week-7-post-14/
At the 8 week mark, I have new pain.
This week I stepped out into the regular community again for the first time by attending church. I needed some spiritual nourishment, as well as a new challenge. But my brave outing also caused new pain! Or did it?
After the 3 floor stair climb and an extended bit of walking to get to church, as well as sitting upright on a hard bench for an hour with repeated sit to stands (hello psoas!), I had a new knee pain.
Fortunately, I didn’t panic. Being a PT I had some pretty good ideas what was causing it. A little backstory goes a long way when you are trying to figure out what new groin and knee pain mean after having a hip scope. For me, there were two big causative factors.
- Prolonged immobilization that was required for a successful surgery, and,
- The injury happened during my third childbirth, which meant I couldn’t fully recover my core or any of my body after giving birth due to the hip injury.
Short story: The odds were TOTALLY stacked against me. Besides the double whammy of being freshly postpartum, freshly injured, and unable to rehab either issue completely, there was more. The other compounding troubles were:
- The hip is unstable and had to be subluxed (partially dislocated) during the surgery, which means the knee joint was likely gapped as well, which can create secondary issues; and,
- Weakness and atrophy due to the post surgical impairments that arise from the surgery itself.
This knee and groin pain is not uncommon. It leaves anyone in a similar situation who, like me, has little stability or balance in the quadriceps and hamstrings and little to no neuromotor patterning in the hip external rotators.
So, if you are post-op hip scope and have some knee or groin pain, don’t panic. There are likely many factors to address in therapy to help with the issue.
Is it A Retorn Labrum? Or Not?
At 2 months out I had a strong resurgence of groin pain. Ah! That’s the sign of a torn labrum, right? Not so fast.
Let’s discuss the details –
- Research tells us that mechanical symptoms (clicking, popping,
and snapping or giving way) are the most reliable measure for determining if
there is a hip labral tear. Even diagnostic tests aren’t that good at
predicting tears. The gold standard though, is arthroscopic surgery (not
exactly a cheap “test”). I had none of those symptoms. So before you worry
if you’ve retorn, ask yourself if you have any of those symptoms. If not,
chances are, you haven’t retorn.
- Groin pain returned with flexion (bending my hip) past 127
degrees (toward the chest), as well as a sharp feeling of impingement with
attempted hip flexion, adduction, and internal rotation (FADDIR). Ironically, this is the test that
would be positive if you have impingement or possibly a labral tear. However,
it didn’t hurt with other activities. Chances are more likely with a retear
that your hip will ache and hurt more often than only in specific
- Attempted walking even for short distances indoors over even terrain resulted in knee and groin pain, but I know as a PT that is to be expected at only 8 weeks post-op. So again, I had classic groin pain, which is the most common place for pain with a hip labral tear, but it isn’t the most common symptom. If you are wondering if you have retorn, visit your PT and let them strength and motion test you. Chances are, your muscles are still weak and too imbalanced to allow for proper mechanics to take place. This leads me to the next question, which is:
If I Didn’t Retear, then What is It?
For all of you out there that are scared that you’ve retorn post-op, please don’t jump to conclusions. I did not re-tear and you likely haven’t either.
There are a lot of reasons I can be fairly certain:
- I am a longtime orthopaedic and manual therapist. The hip is my wheelhouse. I have seen lots of folks with hip and pelvic pain and am used to doing differential diagnosis. See the figure on the 6 phases of differential diagnosis that I use as a physical therapist. There are many other issues groin pain could be without it being a retear. And there are many great PT’s who specialize in the hip. Find one. A good PT can very likely help you differentially diagnose it without having to order tests. A surgeon will order tests to diagnose but those are expensive and often unreliable. Your best bet is to see your PT.
- Because of the prolonged immobilization and double whammy of being postpartum without being able to fully rehab, I know I have low endurance and strength in the lower quarter (lower body). You may have similar issues (without being postpartum, of course). Good strength and motion testing by a PT can determine if it is inside the hip or outside in the muscles and soft tissue.
- The sacroiliac joint, in addition to the strength and motor patterning issues I mentioned, can MIMIC HIP IMPINGEMENT. I call these things “HIP MIMICKERS,” and there are LOTS more MIMICKERS than the sacroiliac joint that can fake a hip labral tear. A rotated ilia (one side of the pelvis) in an anterior (forward) direction (which can lend itself to sacroiliac joint woes) can also create what is called “FALSE IMPINGEMENT,” which is when the femur prematurely impacts the acetabulum and creates pain due to a changeable mechanical barrier (like a rotated pelvis). Again, have your PT check this out.
- Do you have increased groin or hip pain just before your cycle begins or during ovulation? I’ve asked thousands of women this question, to which the overwhelming majority said yes. (see the figure below) Period pain or PMS can also be a HIP MIMICKER. So if you are having a resurgence of groin pain that feels like your torn labrum did before surgery, don’t panic. Ask yourself if you are in this late luteal phase of your cycle, or if you are ovulating. If so, it may be hormonally driven groin pain. It should subside after that part of your cycle passes.
Hip Hacks for Tackling False Impingement (Hip Mimickers)
In my case, as is may be with yours if you are having new groin pain that feels like a re-tear, consider these Hip Hacks:
- Range of Motion (ROM) via Aquatic Therapy – Address flexion and internal rotation (the aggravating direction) in the hot tub in a seated position to a comfortable end range. I also add gentle posterior and lateral glides with the opposite hand (see photo and 2.). I also work the opposite movement, which is flexion, abduction, and external rotation (FABER) seated in the hot tub as well.
- Manual Therapy Aquatic Therapy (Joint Mobilizations) – You can self-mobilize, but you’ll need instruction and clearance from your PT to do so. I work on self-guided posterior inferior glides in hip flexion seated in the hot tub (see photo).
- Pilates Reformer – I call the Pilates Reformer “The Joint Saver!” I used it for the first time at 8 weeks. I successfully did foot work, arm work, rowing in seated, RTC (rotator cuff) work, frog, and leg circles, the latter two of which I needed assistance of my hand helping to control the rope. The key here is to NOT overdo the psoas recruitment, because you can cheat your way through Pilates work abusing the poor psoas by forcing it to work instead of integrating core work.
Success! I was able to achieve the ROM of desired without pain and improve my walking/gait pattern. Hip impingement and groin and knee pain – GONE. Below I’ll share more Hip Hacks!
Back for the Post-Op Recheck
This is where insurance gets dicey and the continuity of care suffers as a result. I only qualified for a single follow up visit in 6 weeks because my insurance won’t pay for follow up after 90 days (I know, it’s ridiculous).
In addition, because the surgeon was so stretched for time I ended up seeing a PA, and a new one at that, who had less experience than me in caring for a post-op hip. I drove 6 hours for this visit, and I left feeling utterly cheated.
This is not unusual. I know I’m not alone in being frustrated with being our healthcare system.
The surgeon was and is absolutely wonderful truly, but the care that they are allowed to deliver post-op is severely lacking. The only benefit to me was getting X-rays taken, which showed nothing remarkable.
After the visit my conclusion was “I’m done here.” There’s nothing else they can do to help me recover.
My conclusion as a PT and patient? If you aren’t a PT, recovery can be really challenging. And that is not fair. We need better post-op follow up care covered by insurance and better post-op physical therapy coverage, which is why I started this blog series in the first place!
I started this blog to help you be your own best advocate for getting the best rehab and care before and after hip surgery. So here are a few easy Hip (Recovery) Hacks and Tips to Consider at 8+ Weeks Post-Op.
More Easy Hip (Recovery) Hacks
I have learned quite a bit as a PT recovering from a hip scope. Here are a few Hip Hacks I’ve discovered along the way:
- Know your insurance coverage before you agree to surgery and before you go to PT. A full recovery with support from the healthcare system is nearly impossible due to the US having the most expensive healthcare in the world (with the worst outcomes). Insurance companies lord over people’s lives and overworked healthcare providers and underattended-to patients pay the price. One thing you can do is make sure you know what your physical therapy and post-operative coverage is BEFORE you have surgery. And if you have questions about how to recover if you don’t have good insurance, please CONTACT ME.
- Join my Hip Labrum PT Network CLOSED PAGE on FB. It’s entirely free with no strings attached. Why? Because I want to help you get the right care without going broke. The careless and cavalier authority of greedy insurance companies to dictate someone’s health and life has gone far enough. It is a good damn thing I’m a PT. And yes, this is the first time I’ve ever cursed on my blog. Ever. But there’s a reason. I believe it is morally wrong for healthcare to remain as it is, and to allow insurance companies and business people to decide our fate. So until we can change this you can join my HIP LABRUM PHYSICAL THERAPY NETWORK page on Facebook. It’s where you can go to find safe, solid advice on what to do when you are recovering. You can also sign up for my blog. I write new hip posts on a regular basis.
- Don’t be afraid to ask for help. Enlist the support of friends and family. You need a strong social support system to get through this recovery period. I don’t know what I would have done without my strong spouse, his parents, and loads of friends and family who checked in on my regularly to make sure I was in a good place mentally, spiritually, and physically.
- Keep reading this post and my past posts. I include critical Clinical Pearls for recovery at every stage of the post-operative process. The goal of this series and blog is to help you recover fully, and to seek the right resources and know the right questions to ask of your healthcare providers.
I Get By With A Little Help From My Friends
Speaking of leaning on friends and family, I get your frustration. There’s a certain fatigue that happens when you are trying to recovery from an injury. Here is an email I penned to a friend after the follow up visit.
The follow up appointment as the surgeon’s office was a huge waste of time. I drove 6 hours for a 15’ visit and never saw the surgeon. I saw a PA – when I specifically asked to see the surgeon. He was not attentive and was cavalier about my recovery. I knew more than he did about the rehab. So, I’m taking over my own post-op follow up care. I have no choice. I cannot afford to take an entire day off work for a 15′ appointment that isn’t helpful (and is expensive).
What’s frustrating is – what if I wasn’t a PT? What kind of care would I be getting? We have a VERY broken health care system, especially in smaller or rural areas in states like North Carolina. Folks just don’t have the access that they should. I would LOVE to change that.
Good news is – I can give you the medical update. 😉 I’m walking with a quad cane. I attended church for the first time on Sunday. I’m trying to walk without an assistive device on flat surfaces only and only inside the house. That is going well but I walk with a limp. I can’t go far on my own. 😉 I’m back to driving and within the next month I should be walking without an assistive device altogether, per my therapy prognosis. I still have pain in the hip and knee – but those are related to range of motion problems and strength deficits. I do know how to self-treat those, so all is well. 🙂
Vent, Find a Shoulder to Lean On, and Check In Often
I encourage you to vent when you need to, find a shoulder to lean on, and know it’s okay to do that. You can’t get through this on your own. To quote the old proverb, It takes a village.
Also know I don’t fault the surgeon or other providers at the clinic for my frustrations at the follow up visit. I fault the insurance companies who dictate what healthcare providers can do and how much time they can spend with patients. Insurance companies, not healthcare providers, have made our healthcare system unhealthy. Healthcare providers are working as hard as they can, are strapped for time and often burned out; all the while they watch insurance reimbursements dwindle. This forces them to have to see more patients in less time. And you know the results, healthcare becomes unhealthy for everyone.
But Yoga is My Best Friend. It Can Be Yours Too!
Good news for this week! Despite the lackluster recheck, yoga combined with physical therapy (medical therapeutic yoga, or MTY for short) is the foundational piece helping me recover. MTY helped me:
- I successfully resolved FALSE IMPINGEMENT. There was no retear.
- I conquered my first sun salutation (this means you can too!). I’m so proud of myself. It’s such a small thing, but to be able to get up and down off the floor is a major accomplishment afteer not being able to do it without pain for 3 years.
What else is possible at 8 weeks+?
- Sitting in wide angle pose with spinal neutral. A major accomplishment at this stage.
- Do a pelvic clock in the same wide angle position without impingement. Another VERY big deal.
- Do a tree pose on the surgical leg but on even ground.
- Do cobbler’s pose (see photo at right).
- Sit in modified hero onto inside of heels without a problem or modification.
- Practice pain-free in all these poses and positions!
What stands out that I need to work on? And what may YOU need to work on at 2 months post-op?
- The adductors (inner thigh muscles) are still VERY reactive. They are being appropriately cautious as I increase my freedom of movement.
- The psoas is also still reactive. But after all, with dysplasia and a fresh repair after 3 years of utter instability, that is the job of the psoas, to be snarky (I’ll share in upcoming posts how to tame it). So take home message here – don’t try to stretch the psoas quite yet. It may be protecting the labrum, and if you stretch it you could be increasing the compression across the hip labral repair (if you had an anterior tear, which most do).
- Protect the gluteus medius. My gluteus medius (GMED), which was torn away from the iliac crest to the point of showing marrow changes on the MRI, is doing well with no sign of return of tendinopathy. A HUGE deal.
- Work on balance and kneeling on the nonoperative side (a safe place to work instead of standing) in order to wean off crutches. I I worked on tree pose, 4 point pose, and tall kneeling, as well as step downs from an uneven surface in order to walk again without an assistive device. The video below shows me working on the unaffected side, which had become stressed and weak due to surgical precautions and prolonged crutch use.
A few things to consider with your PT at 8 weeks whether or not you have a return of groin pain:
- Work on the delay and integration issues you will likely have with transversus abdominis (TA) recruitment and gluteal firing. You need to normalize gait and this can be an entryway to do that.
- Fire the pelvic floor with the gluteals and the TA using a bottom up strategy.
My Bottom Up TA Strategy – Fire the pelvic floor first and allow the TA to naturally engage after. If the gluts join in, that is fine for now. See the video below to practice TATD Breathing “Power Breath.”
- If you have GROIN PAIN – muscle energy work for correcting any ilia rotation may not work; a manual adjustment may be necessary. Talk to your PT to see if this is right for you.
- Have your PT check your trunk synergists for weakness. That can contribute to abnormal and painful gait.
- In physical therapy check for ROM (knee to chest and knee across chest movement) limitations. That can also be a sign of FALSE IMPINGEMENT that needs to be addressed.
- Check for hip scar tissue. My psoas had become scarred to previous abdominal scars and created what presented like chronic hypomobility of the right ilia. Regardless, scar tissue could have been the driver that contributed to the original hip labrum tear. It could have also made the hip impingement and damage to the joint worse.
- Consider using McConnell taping for right medial knee pain at the joint line and MCL. It didn’t work for me, but either the tape wasn’t tight enough or it didn’t get close enough to the joint to help with kneecap tracking.
- Gait training – Work on slow and deliberate return of hip extension. This is required to return to normal, painfree walking.
- If you are unable to squat without medial (inside) knee pain – work on this: Prefire the hip external rotators and gluteus medius (your PT can show you how to do this). It will help but won’t eliminate pain. That will take time.
- Find a pelvic PT who can help release the obturator internus and pelvic floor from any trigger points. That will help you have less pain and can normalize your ability to return to sexual activity.
- Work on normalizing your pelvic floor activity from right to left and left to right. One side may not fire as strongly or relax as fully as the other side.
- Be open to dry needling if your surgeon agrees. You need to be fully healed with incisions before you can try it. But it can work miracles. I worked on needling the calf muscles (gastrocnemius and soleus), the rectus femoris, the iliopsoas (a feathering approach) just below the hip point this week followed by self-massage to each of those points. It improved gait, range of motion, and diminished pain.
- Important note – Practice deep, yogic breathing during all these techniques, especially needling!
- Don’t be afraid to add manual therapy. I used a lateral glide with a belt with PNF (proprioceptive neuromuscular facilitation) for the gluteus maximus through the whole arc of motion. Your PT can help you do this.
- After manual therapy glides I fired the iliopsoas in 90 degrees of hip flexion which gave me new information! I found out that the iliopsoas was weak close to the core but displayed tendinitis symptoms at the mid-belly point and pain in the obturator internus. At that point I returned to hook-lying (feet flat and knees bent lying on my back) and did bent-knee fall-out PNF to recruit the OI, which helped.
- The gluteus maximus is overall delayed and weak with all PNF. I need voluntary input to fire it. You may too.
- Future physical therapy goals – I am going to continue to treat trigger points in the pelvic floor, obturator internus, gluteus maximum, and gluteus medius with the help of a colleague via dry needling and soft tissue work. The goal? To see if treating trigger points decreases joint compression in the hip and see if also treating the rectus femoris increases the vastus medialis oblique (inside quad muscle) strength. My guess – it will.
Patient Question: Why do I still have pinching post-surgically?
My response: I have discussed at length with other colleagues, as well as considered for some time in my own practice, the causes of anterior impingement in the hip. These are the conclusions:
You have to consider multiple variables including but not limited to the following. Ask your PT, they should be able to address all of these issues. If not, you may need to find a PT who specializes in hip and pelvic health.
- Posteriorly rotated innominate,
- Old or new scar tissue or adhesions,
- Psoas tendinopathy or thickening of the tendon or muscle,
- Sacroiliac joint dysfunction,
- Posterior hip capsule restriction,
- Unresolved or chronic inflammation,
- Central sensitization or other biospychosocial factor(s)
This list will get you started on things to explore, and this list of course bars that there is a reinjury, tear, or unaddressed bony impingement. Hope this helps!
Need help finding a hip/pelvic PT?
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About the Author
Ginger has spent 20+ years helping people (mostly moms!) with chronic pain as a physical therapist, athletic trainer, and professional yoga therapist. Ginger is the author of Medical Therapeutic Yoga, now in its 4th foreign translation, founder of ProYogaTherapy Institute, codirector of Living Well Yoga in Healthcare, and most recently ran for State Senate in NC.
This and all blog posts related to yoga and/or physical therapy on www.gingergarner.com are not a substitute for medical advice and are not a prescription or program for individualized physical therapy. You must seek the advice of your health care provider and, only after a thorough physical examination and clearance, participate in any movement or exercise program.