Posts tagged hip impingement
Only 1/3 Of Patients Are Satisfied With Activity Level Following Surgery For Hip Impingement
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Hip impingement (FAI) is one of the fastest growing orthopedic surgeries, but much of this growth has outpaced our current understanding of this condition. A key question involves the additional bone development (cam and pincer lesions) found among athletes. Many of these athletes remain asymptomatic despite having positive findings of impingement on x ray and other imaging techniques. Other athletes with FAI who are symptomatic often return to sport and high function after undergoing Physical Therapy indicating some individuals are able to compensate and adapt for these structural changes or they may be a natural response to the sport itself.

Previous research has found equivocal long term outcomes between Physical Therapy and surgery for hip impingement. This data indicates a significant duration (8-12 weeks) of Physical Therapy should be attempted before surgical interventions. The majority of athletes undergoing hip impingement surgery will return to sport around 6-10 months post surgery, but many will be unable to return to their pre injury levels of activity. Prior studies have found only half are able to return to their previous sports and 1 in 5 will be able to return to the same sport with the same level of performance. A recent study sought to understand how these individuals function 6-10 months after surgery.

The Orthopedic Journal of Sports Medicine followed 33 patients who underwent hip arthroscopy for conditions involving hip impingement (Worner et al. 2019). On average, patients were reassessed at 8 months post op and their subjective history and objective testing were compared to their age matched peers. Authors reported decreased subjective function and ability to return to sport in the surgical group. Specifically, 46% and 18% were able to return the same sport at a lower or similar level, respectively. Consistent with prior research these individuals regained strength and range of motion after post operative Physical Therapy except continued to experience decreased hip flexion strength and range of motion compared to their peers.

This study adds to our existing knowledge on the recovery following hip arthroscopy for hip impingement. Despite being cleared to return to sport many athletes will require additional recovery time to regain participation in sporting activities.

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Majority of Patients With Hip Impingement Did Not Receive Physical Therapy Prior To Surgery
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Hip impingement or femoroacetabular impingement (FAI) is common hip condition causing pain in the front of the hip and groin. This condition has received considerable attention in the medical research and our clinical practice because of the sky rocketing rates of advanced imaging including MRI and surgical procedures to “correct” the condition. Of greatest concern are the high rates of hip impingement and labral tears found on imaging in asymptomatic (pain free) individuals. Thus, are the structural changes associated with FAI natural adaptations to activity or do they require surgical intervention? The lack of a clear cause and effect between structural FAI and a patient’s symptoms supports the utilization of conservative interventions including Physical Therapy prior to any surgical intervention. Consistent with other musculoskeletal conditions, one of the main indications for surgery remains failure of conservative care, but a new research study reported the majority of patients with FAI did not receive Physical Therapy before surgical interventions.

In the Journal of Sports and Orthopedic Physical Therapy authors reported on health care utilization of patients undergoing hip arthroscopy between 2004 and 2013 (Young et al. 2019). They reviewed the charts of 1870 participants who underwent this procedure to determine what interventions they were offered prior to their surgery. Surprisingly, 60% (n=1106) did not receive any Physical Therapy prior to surgery and for those who did receive Physical Therapy they averaged only 2 visits, well below the standard of care for this condition. Further, only 12% of patients undergoing PT received 6 or more visits including exercise. Surgery is reserved for patients with persistent functional limitations (disability) not pathology (hip impingement on imaging), but without an evidence based course of Physical Therapy surgical decision making will be remain unclear.

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Pre Operative Expenses Linked To Post Operative Expenses After Hip Surgery
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Arthroscopic hip surgery is one of the fastest growing orthopedic surgical procedures today. This procedure is commonly utilized to treat hip impingement and hip labral tears. The rapid growth of surgery for this condition is thought to result from both an increase in surgeons trained in hip arthroscopic surgery, as well as, the increased utilization of MRI scans. Experts have expressed concern over these increases in surgical rates due to the large numbers of pain free athletes and patients who show impingement and labral tears on MRI, but remain asymptomatic. One of the key indications for surgery remains failure of conservative treatments including high level, evidence based Physical Therapy. Patients who are unable to return to a desired level of activity or play may opt for the surgery after completion of this Physical Therapy program. A recent study reports on the pre and post operative costs associated with this procedure.

Clewley and colleagues performed a retrospective analysis of pre and post operative costs in 1850 patients who elected for hip arthroscopic surgery over a 12 year period (JOSPT. 2018). Authors found significant differences in costs and health care use between high and low health care utilization groups. In addition, authors found patients who utilized greater amounts of care before the procedure were more likely to use greater amounts of healthcare after the procedure. As expected, the higher utilization group spent significantly greater amounts of money for their associated care compared to their lower utilization peers. Future research is needed to determine the psychosocial and behavioral traits associated with higher health care expenditures.

Increased Medical Risks of Chronic Pain and Mental Health Disorders Found After Elective Hip Surgery
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Inherent risks, such as infection and blood clots, are associated with orthopedic surgeries and should be considered in decision making between surgical and conservative treatments for musculoskeletal diagnoses. In addition to these inherent risks, patients should also consider other hidden or less common risks after surgery including increased healthcare costs (office visits, additional surgeries, hospitalization) and changes in disability after surgery. A recent study examined additional risks found in patients who elected for arthroscopic hip surgery.

Rhon and colleagues followed 1870 patients treated in the military health system up to 2 years after elective arthroscopic hip surgery to determine their subsequent healthcare utilization (Br J Sp Med. 2018). Specifically, the authors assessed for seven co morbidities (mental health, chronic pain, substance abuse, cardiovascular disoders, metabolic syndrome, systemic arthropathy, and sleep disorders) associated with poor outcomes in the management of musculoskeletal disorders. The incidence of these seven co morbidities at 1 and 2 year follow up was compared to each patient’s pre operative status. Authors reported a statistically significant increase in all seven co morbidities following the surgical procedure. Specifically, authors found significant increases in the following

Chronic Pain - 166%

Systemic Arthropathy - 132%

Sleep Disorders - 111%

Metabolic Syndrome - 86%

Mental Health Disorders - 84%

Cardiovascular Disorders - 71%

Authors concluded, “major clinical co morbidities increased substantially after elective hip surgery compared to preoperative status”.

Previous studies have not shown significant differences in outcomes between Physical Therapy and arthroscopic hip surgery. Thus, patient’s must consider surgical risks in their decision making.

Physical Therapy Reduces Healthcare Costs and Opioid Utilization After Hip Surgery
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Arthroscopic hip surgery rates have dramatically increased in the last decade due in part to increased MRI imaging.  MRIs are very sensitive, but lack specificity in many musculoskeletal disorders with high rates of false positives among asymptomatic populations.  Hip pathologies such as impingement (cam or pincer) and labral tears can be found in up to 68% of patients without hip pain.  As we described in our previous blog posts, many patients with these pathologies are able to improve pain and function with Physical Therapy alone.  Further, authors report no differences in long term outcomes between surgery and Physical Therapy.  A new study highlights the importance of post operative Physical Therapy in patients who do not respond to conservative treatments.  

Rhon and colleagues followed patients who underwent hip arthroscopic surgery between 2004 and 2013 to determine their outcomes and healthcare utilization (Physical Therapy. 2018).  The authors reported on 1870 patients of which 83% received Physical Therapy alone, 72% received opioid medication, and 56% received both Physical Therapy and opioid medication.  Authors reported a $5000 savings on healthcare expenditure, a reduction in subsequent hip surgeries, and opiod utilization among patients receiving Physical Therapy first.  Not surprisingly, patients receiving opioids first utilization more medication, over a longer period of time compared to patients receiving Physical Therapy.

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Should I choose PT or surgery for my hip impingement or labral tear?
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The labrum is a dense connective and fibrocartilage tissue lining the socket of the hip joint.  It functions to deepen the hip socket and improve stability and weight bearing during functional activities.  The labrum is highly innervated on top and front portions of the joint and often refers to the front of the hip when symptomatic.  Labral tear diagnosis is on the rise due to more surgeons being trained in hip arthroscopic surgery and increased utilization of MRI scans.  Experts note caution is warranted when interpreting these findings because up to 68% of pain free individuals will have a labral tear after MRI testing.

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Hip labral tears  and femoral acetabular impingement are common diagnoses among < 40 year old patients especially those involved in rotational sports such as hockey and tennis.  As stated previously, many of the positive MRI findings are also present in pain free athletes.  Researchers are still determining which of these findings indicate pathology vs. a natural adaptation to the sport similar to what we see in pitcher's shoulders. 

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Physical Therapy treatments including manual therapy and exercise are very effective for both hip impingement and labral tears.  Goals of treatment include pain reduction and improving patient function including return to sport and activity.  Interventions are designed to increase space and avoid abnormal contact at the hip joint.  Most importantly, patients are trained to re establish hip strength and coordination to allow a safe return to sport without the classic hip pinch or catch.  Two studies have compared the effectiveness of Physical Therapy to surgical interventions and both have found significant patient improvement, but no significant differences between groups.  Thus, patients are encouraged to utilize Physical Therapy first for their hip symptoms.  Early Physical Therapy may also help identify patients who require surgical intervention after conservative treatment.  

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