My name is Diana Silas and I practice out of Novi, Michigan. So disclosures, I am a striker consultant, but none of that pertains to today's talk. Today's talk I'm going to talk about, again, is the prehab and rehab pearls and controversies. So in 2019, the International Society of Hip Preservation Surgeons submitted a PT agreement and they discussed the assessment, the non-surgical management, the surgical management, and the pre, post-operative physical therapy, as well as return to sport. The group consisted of 11 physical therapists, eight surgeons, and it spanned across four countries. They did discuss six major topics of physical therapy, and we'll go into further detail on those six topics as I continue to discuss. So the six major topics, hip assessment, non-surgical PT, rehab, post-op PT, stages of post-op PT, as well as the return to sport criteria and guidelines after surgery. So they use this hip assessment, which I think is wonderful, and it goes through the diagnosis of hip pathology and hip pain. I'm not going to go into further detail today on the assessment because there are other talks that will talk about that, but basically we're going to be talking about patients who have FAI syndrome, hypermobility, hypomobility, labral and chondralabral lesions. In 2017, a study that was done by Grant, he did a study that did demonstrate positive results in post-op recovery for patients who exercised before hip arthroscopy for FAI syndrome. There is no specific protocol that I use in my practice for post-op for prehab as it's tailored to the patient's physical ability and specific needs. So the only thing that I'm careful of is what I write on the prescription. I want to make sure the therapist is aware of what they're treating. Are they treating a dysplastic hip that potentially needs a PAO? Are they treating FAI syndrome? Because that can better tailor their ability to form an exercise routine for the patient. When do I proceed with surgery after the patient is not improving with six weeks of formal physical therapy? In the state of Michigan, and I know many other states, if you do not improve after, or insurance actually requires a patient to either fail six weeks of formal physical therapy or have a well-documented note from the physical therapist that they are failing to progress and worsening with physical therapy. Initially doing this, not only do we know that it can help a patient in their post-op function, but also it's quite essential in even moving forward with care. Waiting longer than three to six months has actually shown that you can have inferior clinical outcomes. So there is kind of that sweet spot of when we want to treat a patient with FAI syndrome surgically. The 2019 ISHA study that was published does have a table that included approximately four to five post-op phases, which I will go into further detail, as well as spanned across 12 to 28 weeks. So going into the five phases, Dr. Giordano and a couple others, including his athletic trainer, published a study in 2016, which did also further define the four to five stages of recovery. So initially, maximum protection and pain control. Two, restore range of motion and prepare for full weight bearing. Three, normalize gait mechanics and improve strength. Four, advanced strengthening. And five, return to sport. So maximum protection and pain control. So maximum protection and pain control. Initially after surgery, I send my patients home with a small narcotic prescription, no more than 28 pills, usually Norco 5, Naproxen 500 BID. I have them take Naproxen for two weeks. I have been giving them a 30-day supply for a couple reasons. One, it's the same insurance cost. And two, if they still have pain after they run out of their narcotic prescription, I encourage them, or as quick as possible, I encourage them to just use Naproxen for pain. With a large bony resection, I have patients take endomethicin and Prilosec. Prilosec is used for gut protection. And then Colace. I do encourage patients to avoid sitting in low chairs, which will go into the precautions. No hip flexion greater than 90 degrees for seven days. Avoid active hip flexion and forceful external rotation. Consistent use of a night splint for one week, which I'll show you. And lay flat with minimal flexion to prevent hip flexion contracture. I do like them laying prone for two to four hours a day at minimum. And again, the weight bearing progression. Touchdown weight bearing initially post-op, which is approximately 20 pounds of weight on their foot. And at two weeks, they start to progress to 50% weight bearing. And they add 25% of their weight every two to three days thereafter until their full weight bearing, which is typically around three weeks. I give them the three to six week window so patients don't get discouraged who are progressing a little bit slower or having some difficulty with pain management. And full weight bearing with controlled pain, non-antelgic gait, and normal pelvis mechanics. It was, you know, the advice of the therapists and the trainers given to me was to avoid one crutch just because of the protection of back mechanics, lumbosacral mechanics. So this is the night splint that I use. It's basically half of an abduction pillow. I have patients use this for one week post-operatively at night. I do an interportal capsulotomy, which is the reason that I don't use a brace. There are some surgeons and I'm sure some surgeons who will be teaching at this course that are using a brace. I do find in the rare case that I necessitate a T-capsulotomy, I will use the night splint for two weeks instead of one week. It does prevent unexpected or undesirable motions at night, and it maintains the hip in a optimal position. CPM. I do begin formal physical therapy on post-op day one. And if I'm able to do that, I actually do not use a CPM routinely in my practice. CPMs are not routinely covered by most healthcare insurance providers in the state of Michigan. So it does become an out-of-pocket expense for patients. If they can get a CPM or they can't get into PT, whether it's because they live in a rural area or there's a lot of patients that I have socioeconomic factors that prevent them from actually getting to a physical therapy location or no access to an upright stationary bike, they will use a CPM four hours per day for the first two weeks after surgery. If they are able to use an upright stationary bike for 20 minutes, 15 to 20 minutes, it's equal to one hour of CPM use. Settings are important to know because patients will ask, start at 70 degrees of flexion to 30 degrees of extension, increase flexion and decrease extension by eight degrees each day for up to the two-week window that the CPM is in use. The second phase is restoring range of motion and preparing for full weight bearing. These exercises that I have provided on my physical therapy protocol, they should be performed one to two times a day, six to seven days a week. So their initial therapy, that's only a couple times a week, will teach them what they can do when they're not in physical therapy because most patients do not have the ability to be in a physical therapy facility for six to seven times a week because they're limited by their sessions. The third stage, normalizing gait and improving strength. So this is weeks five to seven. These exercises should be divided into two days, performed three times a week. Range of motion is tolerated and the biggest thing that you have to be careful for around this five to seven week window is hip flexor overuse and iliopsoas tendon irritation. Sometimes those hip flexors get irritated and we have to use other options such as steroid injections into the iliopsoas tendon. But in order to try to avoid those modalities, the best option is to be very careful around this time frame with physical therapy and not progress patients too quickly. So I often tell patients it's the structures around the joint that I'm protecting more so than even say the femoroplasty itself. Avoid prolonged sitting. So patients who have a desk job and are eager to get back to work, you know, a lot of my work from home people, you know, I still encourage them to move around because they are eager to return to work. I am doing surgery on patients on Thursday and if they work from home, they're able to return on Monday. I just caution them for sitting for a prolonged amount of time in one position. The elliptical is kind of touchy because some patients have a different definition of how they want to use the elliptical. But once the patient is full weight bearing without complaints, they can progress to an elliptical. I really give patients caution because a lot of patients will hike up the resistance quite quickly, which can lead to hip flexor irritation. So if a patient comes in and they're having hip flexor irritation, I typically, you know, discuss how much elliptical they're using. And then advanced strengthening, weeks 8 to 11, you know, going into leg press, T band, step up, step down, unilateral bridges. And finally, the return to sport, which is what, you know, all of our patients are looking for in our young hip preservation population. Return to sport depends on several factors, including a patient's preoperative status. But weeks 12 to 24 are our gradual return to sport. 12 to 14, prepare for functional return. 14 to 16, return to sport progression. Weeks 14 to 16 typically is when you start jogging for a couple of weeks, and then graduated return to sport. There are some studies on return to sports that, you know, recently I've seen 92 to 97% return to sport for high-level athletes. This study, level four study done by a few of our colleagues, demonstrated that high-level athletes were found to have 83 to 93% after treatment of FAI surgery. Another study for high-level endurance athletes did have a lower return to sport, which to me does make sense as, you know, running tends to place a high load on our hip joint. And then, but the same similar for all other athletes, just the endurance athletes were shown to have a little bit of a lower return to sport. And again, a study that was published in 2020 returned to sport after hip impingement or hip arthroscopy for FAI syndrome returned to sport at 87 to 93%, which is consistent with all of the literature. So in conclusion, like many areas of physical therapy, the clinical treatment is years ahead of the scientific research as was discussed in the 2019 paper, the consensus paper that was put out by ISHA. So, you know, if you have any questions, if you are interested in any of my physical therapy protocols, please don't hesitate to text me, email me, and I can share anything with you that you'd need. Having defined physical therapy, especially if you are one of the early hip preservation surgeons in an area, will definitely help you in practice. And please don't hesitate to reach out with any questions. Thank you very much and everyone have a good day.

hip injuries

prehab

rehab protocols

physical therapy plans

return-to-sport timelines