The Process of Returning from Labrum Surgery
Taylor Byers, PT, DPT, ART-Cert. (Left)
Gina Pongetti, MPT, MA, CSCS, ART-Cert. (Right)
Hip arthroscopic procedures are one the most common surgeries we see at Achieve Sports Medicine. We see patients ranging in age from as young as 11 to mid-60’s who undergo surgery to repair labral tears and/or impingement syndromes. While most of these patients are athletes that involve repetition, such as runners, gymnasts, and dancers, their activity levels can range from weekend warrior and recreation to elite/professionals. We find that hip arthroscopy procedures are most successful when done as a team approach. As therapists, we play a role in the pre-surgical (AKA: prehab) and post-surgical periods.
There is a lot of conversation being had within the medical community about the necessity of such surgeries, including factors such as age-appropriateness, high sport demand and its safety, likelihood of reinjury, and accuracy of primary diagnosis (i.e. will it really fix the problem and symptoms that the patient is reporting, or is it simply fixing something found on an MRI or X-ray). This is a hot topic due to the increase in sport specialization for kids and young adults, as well as some skepticism of the medical community with regards to overusing surgical techniques.
Often Physical Therapists, in combination with communicating with the patient, parents (if an adolescent patient is being treated), athletic trainers, strength staff, and coaches, have the best ability to put the puzzle pieces together with regards to cause, biomechanics issues, strength and flexibility deficits and more. Making sure that the patient is evaluated and treated based on symptoms and physical assessment, and not simply MRI results, matters. Physical issues are often not fully resolved with surgical techniques, as there is a great deal of compensation that develops as the pain has increased, or as techniques have skewed
When surgery is decided, evaluation should be done pre-surgically to evaluate for muscle strength imbalances, joint mobility deficits and flexibility challenges. These should be addressed with a comprehensive and specific home program and manual treatment. Manual treatment can include soft tissue techniques such as: A.R.T. (Active Release Technique), Graston Technique, joint mobilizations, myofascial release, soft tissue mobilization (STM), passive stretching, Trigger Point Dry Needling, and more. Crutch training and precaution instruction is also done pre-surgically to address patients' specific home, work and school environments and address the challenges the patient may encounter. We have found by addressing these challenges pre-surgically it takes some stress away from patients knowing they will be able to handle ambulating in their home and work place. "Prehab" will help set the patient up for the best possible surgical outcome. Getting to and from therapy is one of the main facets that needs to be addressed (pain medicine, driving leg, mobility, getting a driver, etc.) Especially in the case of adolescents, it is imperative that the family understands the needs at home and in ambulation after, as well as pain management. In the case of adults, often daily living activities are impaired, such as driving, caring for children, and work. Addressing these in advance leads to a planned and smooth recovery!
As assessment is often done within 1-2 weeks of the surgery to observe gait, mobility, pain, and posture, as well as assess incisions and any other concerns. Typically we see patients in clinic shortly there after to start therapy. Early on, gentle range of motion and soft tissue mobilization is done to reduce pain, swelling and help regain mobility. A new home exercise program is given to start core and gluteal strength while avoiding excessive stress to the hip flexors, specifically the Iliopsoas, which often is lengthened surgically during the procedure and must be rested for 6 weeks. Weight bearing status and ROM restrictions are again discussed as often additional or changes are made to protocol after the hip is examined closely during surgery.
As precautions are lifted between 3-6 weeks post-op, strength and ROM is progressed in therapy and at home. The variation in aggressiveness of return-to-walk without crutches is always pending severity of tear/surgery, anchors in the bones that were used as well as MD release to activate hip flexors, which are needed for walking! Non-impact and pain-free activities are encouraged to help patients regain both cardiovascular endurance and mobility. Strength and ROM progression can vary in time but typically impact activities can be initiated in clinic 12-16 weeks post-op as strength and motion returns to normal levels.
The final phase of treatment is “sport specific training” in clinic to return patients back safely to their activity or sport. For example, dancers and skaters need excellent balance and hip rotator strength to return to receptive jumping, twisting and extreme ranges of motion required for these sports. Running athletes need good hip flexor/ITB flexibility and abdominal/gluteal strength to return to pre-injury training and avoid re-injury. A specific plan needs to be in place with the athlete, coaching staff, and taking into consideration the season/training plan to ensure proper time is allowed to ramp up intensity even after being released from therapy.
Once the physician, therapist, and patient agree that goals have been met, a final home program will be prescribed. This program will be done independently but with the options for patients to return for consults to update or change programs if needed. The goal being our patient will be back to living their desired healthy lifestyle.
Patients with hip labral surgeries have returned to full elite-level athletics, weekend warrior basketball, yoga, bearing children, running and more! Understanding the fragility of the human body, and what repetitive stress can do to joints, is a concept that every post-surgical patient needs to understand. The risk/reward in training will forever be a point of focus (i.e. do I ‘need’ to do deep squats, can I take an extra day to rest, etc.). Once the motion and biomechanics are restored, patients are as good as new, but with a few small scars to keep!