Institute here in Chicago. Today we're going to talk about prehab PT for the hip arthroscopy. My objectives for today's presentation is to review the goals that I have for my patients preoperatively, discuss the treatment plan I use to try to meet those goals, as well as talk about some of the education that I give them prior to surgery to help them better understand what to expect after surgery. I have four goals that I'm looking to address during preoperative PT for the hip arthroscopy. First one being trying to improve any range of motion limitations the patient may have, reducing pain and symptoms as able, treating soft tissue deficits, and by using exercises, address poor activation patterns of the hip musculature. Improving all of these things help improve outcomes after surgery. Okay, so let's talk about our first goal. How do we improve hip range of motion with PT? Well, the first step really is looking at passive range of motion. It's part of our evaluation to really see what the patient's joints can do. When we start working into active range of motion, there's an involvement of the muscles, so it's nice just to start at the base level and start with passive range of motion. Once you have an assessment for what the patient is working with as far as range of motion, you can also use passive range of motion as treatment. The key is that we want to work within a symptom-free range so that we're not causing further irritation of the hip. We can also do some static stretching, kind of your more traditional stretching. I usually have a focus on external rotation and extension, knowing that those range of motions tend to be quite limited after surgery, so anything we can do beforehand to gain more range of motion, it'll help us after surgery. Again, same concept, trying to avoid any symptom aggravation. And then there's also functional mobility stretches slash exercises. So, getting a little more functional, having a little bit more involvement with the patient's muscles, but those can also be really good to help regain pretty much any range of motion you're looking for. Kind of the same process, avoid symptom aggravation. Alright, so a lot of different options and just depending on the patient, you want to pick and choose what works best for them. Our next goal is how do we reduce pain and symptoms? Honestly, everything that we do in physical therapy is really looking to help reduce the symptoms, but there are some more local symptom reduction options that we have, kind of using modalities. So, there's hot and cold therapy. Again, really a pre-surgical, I will let the patients use whatever feels better for them. So, if they like heat, great. If they like ice, awesome. I even find a nice little ice and cold, or excuse me, ice and heat combination can be really helpful as well. The joints usually like the ice, the muscles usually like the heat. There's also cold laser therapy treatments to help reduce tissue inflammation, electrical stimulation, kind of more along the TENS type to reduce that neural sensitivity, kind of working more on the nerve level to help reduce pain, and also ultrasound which, again, reduces pain, can promote blood flow to the area, helps reduce any inflammation within those tendons and tissue. So, again, a lot of different options to use and just depending on the patient, depending on the physical therapist and what they have available to them, can also use modalities to help reduce those symptoms. So, our third goal, how do we reduce soft tissue restrictions with physical therapy? This is where I get really passionate. I think as physical therapists, what we can do with our hands can really make or break an outcome for our patient, and there's so many different options of what to do. Picking and choosing which ones and where to do it is probably the hard part, but making sure that soft tissue manipulation is part of really an everyday treatment for your patient or an every session treatment for your patient, in my opinion, is really, really important. The amount that you do, the locations that you do, can definitely vary depending on what the patient needs, but this is where I get so passionate and I get a little frustrated when I hear therapists don't really work on the soft tissue as much. They're more exercise heavy, and exercisers are important, don't get me wrong, but what we can do with our hands really can just take it to that next level and really help our patients kind of buy into what we're doing and not just having that unfortunate stigma around PT that we're just gonna send you off and do some exercises and move along. And even especially in the pre-operative phase of things, even though they're gonna have to have surgery, anything we can do to the muscles to reduce that restriction, reduce that irritation, just helps make everything easier on the back end. So, when we're looking at the different options, these are kind of the main ones that I use, but again, kind of sky's the limit and just depending on the therapist, there's a lot of wiggle room here. So, we have our soft tissue mobilization, which is just our kind of basic what we do with our hands. You can also do manual trigger point release, active release therapy, which is kind of a combination of a trigger point release with a movement that the patient is restricted on. So, we can be, you know, releasing the piriformis as patients going into a pain-free range of motion of a clam. Dry needling, I love dry needling. I think it's a great benefit to treatment options that I have for soft tissue. It works really well on releasing those tight restrictive muscles. It can also help work on promoting improved activation of soft tissue by releasing trigger points, especially in the glutes, to help improve the efficiency with which that muscle activates. We also have instrument-assisted soft tissue mobilization. Those would be considered the scraping tools that you hear about. They help stimulate blood flow, help reduce soft tissue restrictions, but more along the lines of maybe adhesion, some scar tissue that had developed from compensatory activation or strain that's happened to the muscles pre-surgery, as well as cupping, which is more of a distractive force to help stretch out those tissues and release. All of these options have the same end goal. So, whatever works best for the therapist, whatever works best for the patients, that's what matters, but we just have a lot of tools in our toolbox to be able to use to help them. So, let's talk about that fourth goal. How do we properly and efficiently prescribe exercises for a patient to reduce muscle compensations and help them try to get a little bit more active prior to surgery, if that's a limitation that they have? In the world of PT, there are so many different exercises and so many different activities and stretches and things we can give to patients that it truly is challenging to give a generic exercise program to all of our patients before surgery. In the next slide, we're going to talk about kind of a basic exercise program that could be effective, but I highly encourage if you're looking for a more specific and specialized home program for your patients, I would refer them to PT, either for just a home exercise program or get them to PT to help with reducing all of the things that we've just talked about. Pain, mobility restrictions, soft tissue restrictions, to give them the best chance of having a really good outcome after surgery. So, when I'm seeing my patients before surgery and even after surgery, I kind of, you know, block these different exercise kind of categories. So, we have the strengthening, which is more about just muscle activation, more in kind of a linear plane, little single plane, neuromuscular and stability, a little more dynamic, and then endurance. Okay, so it's still nice to kind of work those endurance muscles, make sure that they can, whether it's elliptical or walking or biking, whatever feels best to them. Usually, we want to stay away from impact activities, so non-impactor is a better choice, but that's important if the patient can tolerate it. Most of the time, though, I will say my exercise prescription is focusing on strengthening and neuromuscular, and then to go even a little bit deeper on that, I really probably focus more on the neuromuscular part of things, which involves strengthening, but at another kind of a little bit of a higher level. It's not just, hey, let's go through these movement patterns and add some resistance onto the leg press. Let's actually make sure the muscles are activating the way they were meant to activate and improving the efficiency and the effectiveness with which they activate by reducing pain, by reducing compensations and tightness, improving range of motion. So my focus, especially with prehab, is in that kind of neuromuscular and stability component. Again, what exercise I prescribe really depends on the patient and what level that they are at. I want to meet the patient at their level and try to take them a little higher. I don't want to under-prescribe and I don't want to over-prescribe exercises. So a good thorough evaluation from a PT is very important to get the most bang out of our buck, if you will, with our home exercise program. So we're gonna get ready to talk a little bit about maybe more of a generic home exercise program, but I would highly encourage you to take this into consideration, that an assessment by a PT will give the patients a really a better program and a more effective prehab experience. So when I was talking about that kind of generic home exercise program, this is probably some of my favorites, if you will, some of my go-to's when it comes to glute activation, some stability. I will definitely say this is a little bit more lower-end, more basic muscle activation patterns. And honestly, if you're gonna give out a generic exercise program from a PT standpoint, I would prefer something less than more. I'd rather have a patient maybe not doing as much as they should, but still getting good muscle activation, than giving a patient something that's just too much and they cause more irritation. So you'll see if you really look at these exercises, I'm really focusing on that posterior chain, the glutes, and then stretching out the front of the hip and getting some nice kind of more of that neural read. We talked about balance, stability with your abdominal bracing, bird dogs, and the staggered stance trunk rotation. So again, a lot of different options that you can do in the world of PT, but these would be my go-to's. So I understand, and you may be thinking that I didn't give you very many specific exercises on what to do on preoperative PT, but honestly, it's really hard to do that. And really, you need to think about what you want to get out of the exercises and what you want the patient to get out of the prehab portion of things, and then fill in the blanks with exercises based on them. So I would say it's more important to kind of think about these key points that I'm going to talk about, and then picking exercises that that kind of check these off, okay? And again, depending on the level of the patient, it could be something as simple as they're just getting glute squeezes, TA bracing, calf raises, and symptom management, all the way up to they could still be doing, you know, limited range squats, higher level balance activities. There's, again, just a big range for what patients can do preoperatively, so it truly is hard to give specific exercises. But if you keep these kind of ideas in mind, then you're really giving all the patients the same treatment, just specific to them. So a couple of things that I like to kind of focus on when I'm prescribing my exercises in my home exercise program. I want to avoid any symptom aggravating exercises, movement patterns, stretches, modalities, you know, if the heat causes more inflammation, well, guess what, you're not going to heat. Also, the exercises really should be focused on proper muscle activation and movement patterns, not range of motion. You have something going on inside the hip that could be limiting your range of motion, and you're having surgery to fix that. PT is there to help the muscles adapt to what's going on, not to regain things. We're going to regain things after the surgery. We're trying to improve what we have to work with, okay? So it shouldn't be about, you know, how high can you get your leg on a side-lying hip abduction. It should be, are you firing your glute mede? Are you avoiding any compensations in your trunk? And are you getting, like, the right muscles to activate and the wrong muscles to relax, okay? I usually go along kind of focusing on activating posterior hip musculature and working with that with, like, the strengthening exercises, and then decreasing compensations and guarding from the anterior hip muscles. We tend to be tighter in the front, weaker in the back. So my exercise program tends to focus on activating the posterior chain muscles and decreasing compensations, helping to stretch out modalities, symptom reduction through the front, the irritated hip flexor, the irritated quad, and TFL muscle. And then it's important to acknowledge that there can be a ceiling effect to patients preoperatively, right? We might keep working, and we're progressing, and we're a month in, and every time we try to go to that next level, the body says, no, thank you. We need to respect that and understand, like, great, I can work with all of this. We have to wait for all of this till after surgery. So just as a PT, as a doctor, as any part of the medical kind of group and team with these hip arthroscopies, it's important to know that the patient will have a limit pre-surgery, but that's okay because we're gonna reach those goals and sky's the limit after surgery. So just make sure you're acknowledging that and the patient understands that clearly. So again, take all these into consideration. You find exercises that check off these boxes, and your patient's going to have a very successful prehab of PT, and all of that is just going to make their post-operative recovery that much easier for them. Okay, our last objective was to talk about what kind of preoperative education we can give our hip arthroscopy patients. Now this can vary a lot depending on the doctors and what their protocol looks like, and I kind of base off what I educate our patients on and what we do at the American Hip, but if you have a patient and you're expecting them to walk with crutches, if you're going to use a brace after surgery, I highly recommend that the patient has some sort of education on how to use that before surgery. After surgery, they're going to be focused on trying to heal, there's a lot of stuff going on, their movement may be limited. If they can practice beforehand, everything is so much smoother afterwards. So I highly recommend that you teach your patients how to use crutches, how to use a walker, whatever they're gonna choose, how to use them on stairs, and how to walk with them. What is your weight-bearing status? What kind of gait pattern do you want them to use? I promise it makes a huge impact in the patient and they just feel like they're very prepared to know what to do after surgery. Instead of having surgery, get crutches thrown at them, anesthesia is affecting them, how do I get up my stairs, how am I supposed to move around with my house? So we will teach the patient how to use that and then they can go home and practice. I like the saying, practice makes perfect. If you're gonna use a brace, it's really much easier to fit a brace on the patient before surgery, so I recommend getting that brace fitted, showing the patient how to take it off, take it on. Again, practice a little bit so there's less that they have to mess with. We also educate on some different home modifications that can reduce the stress to the hip. So depending on if you're gonna have range of motion limitations after your surgery and the protocol, things like a raised toilet seat, shower chair, tub transfer bench, all of those things can just reduce the chance that they're putting more strain onto the tissues or the labrum that you've just repaired. Increasing the risk for possibly falling if they don't have this assistive device and they're trying to somehow get over that that tub and then they slip and they fall. As well as we usually educate, make life convenient. If you're really reaching up high, if you're trying to bend down lower to things, again, you're just you're shifting your weight, you're throwing your balance off, which could increase the risk of falling, as well as you're putting more strain through the hip. So I tell my patients, the analogy I use is it's like poking a bruise, all right? You get a bruise on your arm, you don't touch it, you don't mess with it, heals nice and clean. Maybe you bump it once, does it feel good? No, it hurts, but you probably haven't interrupted any of that healing. If every day you wake up and you hit that bruise again, the timeline with which it's going to heal or even the chance that maybe it doesn't heal a hundred percent is increased. So all of these things that we do to help kind of modify the home can help reduce the risk that we irritate the healing structures and hopefully increase the ability of that healing tissue and and just get us kick-started off onto the right foot. And then I also think it's important that the patients know their expectation for physical therapy. When do you want them to start? How often do you want? Where do they get the PT script? Where should they go? It's a lot of things that patients don't always think about because in the moment before surgery, it's all about the surgery. But there's an after part. There's an after PT, which we'll talk about. And if they've just come out of surgery and have to figure all that out the next day, it can be stressful to the patient. So that pre-planning and that pre-setup before surgery can just make the patient feel so much more comfortable going in and maybe it doesn't make or break the surgery itself, but I promise you it makes a difference to the patient. And they're usually very appreciative of, as much as it's a lot of knowledge, of having that knowledge beforehand. And then there's just less surprises afterwards. Okay, so let's wrap it all up. There are three kind of main points that I hope you guys can take out of this presentation and transition it into your own program. But physical therapy is a little bit more open-ended than some of the other medical professions. There's a lot of well ands or what ifs and buts, and it really comes down to us PTs meeting the patient where they're at, okay? And because of that, there's a lot of different options for what we can do before surgery for the patient. But there is some main goals. The first one, the main one that I would say is the main purpose of preoperative PT is to reduce those symptoms and help improve kind of range of motion and functional ability as tolerated for the patient of that hip to help with our outcomes after surgery. We know something needs to be fixed, okay? So we don't have these high-level functional goals in preoperative PT. We kind of just roll with what the body is going to give us, all right? So we have to be knowledgeable and we have to appreciate that as PTs that we do what the body can gives back to us and we don't overdo it if it says it doesn't like it, all right? So I always tell my patients we need to listen to your body. We know where we want it to go, but if it's not having it, well, I'll see you after surgery and we'll make sure it does it then, okay? Again, I would highly recommend that if you are wanting something a little bit more for your patient when it comes to prehab, when it comes to exercises, symptom management, there really should be a referral to a physical therapist so they can assess the patient and meet them where they're at, okay? We don't want to under prescribe, we don't want to over prescribe, so that assessment with the PT is very important. And that being said, PTs kind of like amaze when it comes to prescription, there's a lot of different ways that you can go. So whatever your patient needs, you can ask the therapist for that. If you only want them to have a one-time visit for a home program, great. If you think three sessions, six sessions would be enough, the patient's a little highly irritable when it comes to their symptoms, then fine. And what we give the PT, as much as we have all these different options, it's going to be different. You might have some patients that it's much higher stretching and symptom management, their exercises are minimum. Some patients may have more exercises. Whatever the patient needs, the therapist is there to meet them. So just know that it's not just, PT just doesn't have to be two times a week for six weeks, all right? We're here to give the patient what they need, give them a positive outcome from prehab PT, and we will help you give your patients an even better outcome before surgery, and then we'll also see them after surgery. So I really appreciate your time. I hope you guys got some stuff out of this and it was informative, and take care. Thank you so much.

preoperative physical therapy

hip arthroscopy

range of motion

therapeutic modalities

muscle activation

prehab