Day 35, Week 5 – Tough Tissue a Great Teacher (Post 10)

August 18th, 2017

Day 35, Week 5 – Tough Tissue a Great Teacher (Post 10)

If you haven’t been following the entire series, get it here:

Post 1: Day 1 Post-Op Recovery
Post 2: Day 2 Post-Op Recovery
Post 3: Days 4-5 Post-Op Recovery
Post 4: Day 6 HLI Rehab
Post 5: Day 7 HLI Rehab: Mantras and Edema Management
Post 6: Day 10 Slow & Steady: The Yoga of Hip Labral Rehab
Post 7: Days 11-19: A Turning Point Hip Preservation Post-Op
Post 8: Days 19-27: Hip Labrum Rehab Milestones
Post 9: Days 28-34: New Pain Leads to New Discovery (and Progress!)
Hip Arthroscopy: The First Month Review

At Day 35, week 5, I am ambulating (walking) with a single crutch. I’m not able to graduate to a cane yet, and there is still significant motor (strength and neurological) deficits as well as remarkable femoracetabular and external impingement-related pain. For those of you who follow outcome measures, I am testing at 18/80 on the Lower Extremity Functional Scale, and as a PT and patient, I’m okay with that. It is still very early in the journey.

My gait (walking) is antalgic (painful), and I demonstrate a short stride length (I’m taking baby steps) due to pain with hip extension. Heel strike and toe off, as well as weightbearing in general, are apprehensive, and rightfully so. If you have been in pain for 3 years before having surgery, your hip and related body parts just don’t get a “memo” to start acting normally. Not to mention you have a whole slew of post-surgical deficits (that aren’t written about in the “brochure” about surgery either). I’ll be talking more about “What Isn’t Included in the Brochure about Hip Arthroscopy” in an upcoming post.

Doing my aquatic therapy!

I have also made the decision, with my PT hat on, to remain in the brace to avoid accidental range of motion that is beyond my capability, especially since there are plenty of opportunities to fall, given I have three young boys who love to leave legos, cars, and dirty clothes strewn about the house AND on the stairs. I’ve already fallen trying to climb the stairs and slipped on a Hot Wheels car. My brace saved me, and I quickly learned that trying to get around in my house is probably more dangerous than outside in the community!

My motto is Better Safe than Sorry, and it has served me well with a household FULL of young children.

Surgical precautions are still preventing any manual muscle testing by myself or my colleagues in PT. Range of motion is progressing well as follows:

AROM (Active Range of Motion)

Flexion – 105, extension 15; external rotation 20, internal rotation 30

PROM (Passive Range of Motion)

(in the same order) 132, 20, 32, 35 (add 10), all painful

Clinical Pearls

“No Pain, No Pain” does NOT apply to hip arthroscopy rehabilitation! Be gentle and easy on the surgical leg. No forceful passive or active range of motion. Follow surgical precautions, and if you feel as I did, coming into surgery with other comorbidities (like being postpartum and dealing with several injuries there, not to mention being completely out of shape!) you’ll want to gradually work your way off crutches. It’s an illusion (and a rather cinematic one) to think you can just ditch crutches after having used them for the better part of a month. PT’s worth their salt will all tell you that you need to wean off of assistive devices. Two crutches to single crutch. Single crutch to quad cane. Quad cane to stick/straight cane. You get my drift. Slow and steady is the way to win the race.
You may still have occurrences of rather terrific involuntary muscle spasms and strange tonic contractions in and around the hip and pelvic floor and spine. I did, especially in the psoas area, and they were just that, terrifically painful. Why? Because you are still healing, and the psoas runs directly over most all anterior labrum repairs and the anterior joint capsule. In my case, both were repaired, in addition to other repairs, and the last thing you want is for muscle spams to impair your rehab process or worse, damage the repair. So stay hydrated (in case the spams are due to dehydration), do your PROM (to diminish active spasms and prevent future ones), use the CPM if you have one, use compression/ice as indicated (to minimize inflammation), eat a well-balanced anti-inflammatory diet (to assist in healing and reduce inflammation), and learn some deep breathing techniques to help manage the pain and cut down on the spasm frequency. The muscles that will likely be most involved are the TFL (tensor fascia lata), sartorious, rectus femoris, and adductors, not just the psoas or iliacus. Keep in mind the pelvic floor and low back, including quadratus lumborum, may be involved as well due to all the “splinting” that occurs in the muscles of the nonoperative leg and back during ambulation with assistive devices.
Physical therapy WILL seem slow at first but don’t lose hope. Keep in mind scar mobilization (once the wounds are healed) with knee and hip flexion may allow for better gains on range of motion, now and for a long time to come. For example, there could be a rectus femoris connection with the scope scars, which, when addressed, could tie into proximal iliacus and psoas functioning. For example, I found a point at the junction of the iliacus and psoas that excruciatingly (but joyfully, as that’s GREAT news to find a solution) recreated the pain (which was anterosuperior moreso than in the groin). After doing deep yogic breathing with deep mobilization and manual therapy of the iliopsoas junction and related fascia (deep and superior to ASIS [anterior superior iliac spine]), my ROM was instantly better and I could flex more in the hip without anterosuperior impingement and pain. This progress allowed me to sit back on my heels without knee pain for the first time, which deserves to be celebrated!
You don’t have to believe in trigger points to suffer from them. Keep in mind that iliacus and/or psoas trigger points (or whatever you choose to call them) may trigger “sparks” of pain or tugging into the pelvic floor muscles. Please keep a close watch on this when working with someone or if you are the patient, when working with your physical therapist. This may be a clear indicator that internal pelvic floor and/or hip and/or gluteal sling work may need to be done.
Joint mobilizations can be super helpful (when delivered by a skilled and licensed physical therapist who knows your surgical protocol). General focal posterior glides and traction of the surgical leg may increase focal anterosuperior joint pain over the biceps femoris and closest scars to that area. Take care when having any joint mobilization work done and pay attention to whether or not this arises. Learn more about physical therapy and hip labral tears
Kinesiotape can help, whether or not you consider it a placebo effect. Kinesiotape for the gluteus medius (where the tape runs from origin to insertion to facilitate muscular action) and psoas (tape runs from insertion to origin to inhibit psoas action) is working. The psoas responds in “anger” rather than relaxing, so it will take repeated applications of tape before this begins to fully respond.
You may still be affected by side effects of having had anesthesia. PLEASE BE AWARE that at this point you may or still be experiencing a few symptoms from anesthesia. Not necessarily full blown POCD (post-operative cognitive disorder), which requires a diagnosis, some typical symptoms may include problems with memory and concentration. Additionally, unusual or excessive stress leading up to surgery can exacerbate this phenomenon. Read Scientific American: The Hidden Dangers of Anesthesia
Discuss the benefits of adding Dry Needling (DN) to your regimen at this stage with your physical therapist and surgeon. I added DN to my PT regimen, which I had a second physical therapy colleague perform. Together, we came up with a new protocol, individualized for my specific needs, that included combining DN with yoga postures from the MTY (Medical Therapeutic Yoga) Method. DN can include addressing myofascial, scar tissue-related, or long standing trigger points (pre-operative or post-operative) noted by areas of increased or persistent tone (rather than just from spasm or muscle recruitment alone), and can be especially effective for the hip, back, gluteal, and pelvic floor areas. For example, my primary PT and myself found an iliopsoas point that literally brought me off the table during palpation and manual therapy work. But afterward addressing the point with manual therapy I had less impingement pain and increased flexion and adduction/internal rotation. Prior to the manual therapy, I was stuck at 95 degrees hip flexion with zero adduction and internal rotation. And, after the addition of DN, my progress began to accelerate significantly. My next post will be dedicated to the addition of DN into rehabilitation. Learn more about Dry Needling
Manual therapy and DN can be a winning combination. The combination allowed me, as a PT, to hone in on specific muscles that were adhered to the new surgical scars, such as the rectus femoris, psoas, gluteal muscles, and pelvic floor muscles. When I palpated the scars during performing my own scar mobilization (in and outside of warm water), I was able to pinpoint the exact fibers involved with scarring and adhesions. This is incredibly valuable information that influences choices in physical therapy prescription and treatment.

The Yogic Lesson & Keeping Spiritual Joy

At week 5, all in all, this injury and surgery has been an incredible clinical and personal experience. It has allowed me more than enough opportunities to practice yoga breathwork and meditation and imagery for acute, surgical, and sub-acute, post-surgical pain. I have begun to include some basic yoga postures also as part of the physical rehab routine.

I often find myself saying to colleagues and students, “This would be a really cool case to study, if it wasn’t on my own body.”, but all jokes aside, I am seriously and fully embracing this journey with gratitude. There are so many pearls of wisdom and clinical findings that are making me an infinitely better and more “in tune” PT and person. Finding the “diamond in the rough,” in other words, being content whether I’m struggling or making progress, is the yogic lesson that emboldens my own personal spiritual faith and beliefs through this entire process. Yes, I am thankful for the struggle. “In this weakness, I am made strong.”

Resources

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