Posts tagged surgery
Quad Weakness After ACL Surgery Associated With Decreased Cartilage Health

ACL injury is one of the most common traumatic sports medicine injuries seen in Boulder Physical Therapy practice. For patients who elect for surgical repair post operative Physical Therapy is key to facilitating a safe return to activity and sports. Common limitations for individuals returning to activity after ACL repair include: a loss of range of motion, balance and agility impairments, as well as, hip and quadricep weakness. The quadriceps are key muscles in maintaining strength and stability of the knee joint and when healthy improve weight bearing across the knee joint surfaces. Abnormal weight bearing in the knee joint leads to a decrease in joint space and increases the likelihood of knee osteoarthritis development. When undergoing surgical procedures of the knee, any effort to decrease progression of post-traumatic osteoarthritis should be taken.

Previous research has shown patients who sustain an ACL tear, treated either with PT or surgery, have an increased risk of knee arthritis. A recent study examined the cartilage and joint health of patients who had undergone ACL surgery (Pietrosimone et al. 2017). Consistent with prior research, authors found a decrease in quadricep strength in individuals 6 months after ACL repair. Concurrently, the authors found a greater T1p relaxation time within the joint which is a key marker of articular cartilage health. Thus, patients with quadricep weakness demonstrated decreased joint health compared to their stronger post operative peers. This emphasizes the importance of restoring quadricep strength after ACL surgery in order to optimize cartilage and joint health.

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Physical Therapy Offers Equivalent Outcomes To Surgery For Carpal Tunnel

Carpal tunnel syndrome or the entrapment of the medial nerve at the wrist is a condition leading to pain, numbness, and pins and needles sensations along the palm side of thumb, index, and middle fingers. If the entrapment continues weakness can be experienced in the wrist and hand. Contributing factors include loss of nerve and wrist mobility, muscle imbalance, and work ergonomics. Although surgery remains a common intervention, previous research has shown no difference in long term outcomes between surgery and Physical Therapy for patients with carpal tunnel surgery (Fenandez de las Penas et al. J Pain. 2015.). A recent research study compared the cost of these Physical Therapy interventions for patients with carpal tunnel syndrome.

Journal of Orthopedic and Sports Physical Therapy published a recent article on the cost effectiveness of either Physical Therapy or surgery for the treatment of carpal tunnel (Fernandez de las Penas et al. 2018). Authors randomized 118 patients with carpal tunnel to either a surgical intervention or Physical Therapy consisting of 3 sessions of manual therapy, nerve mobilizations, and home exercises. As expected, patients in the surgical group required greater numbers of additional treatments, days lost from work, and greater costs compared to patients in the Physical Therapy group. In addition, this study supported previous research findings on equivalent outcomes found between surgery and conservative care treatments for patients with carpal tunnel.

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Pre Operative Expenses Linked To Post Operative Expenses After Hip Surgery

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.

Physical Therapy Supported As First Line Treatment For Meniscal Tears

Meniscal tears are a common knee diagnosis and can occur either traumatically or gradually over time. This latter type of meniscal tear, degenerative, was previously treated with arthroscopic surgery and post operative physical therapy but more recent research has changed our practice patterns with this patient population. Specifically, research shows no benefit of surgery over placebo surgery or surgery over conservative care including Physical Therapy. The equivalent outcomes of arthroscopic surgery and Physical Therapy has let many medical groups to advocate against the use of surgery for this condition.

A recent article in the Journal of the American Medical Association supports these previous findings on the management of patients with meniscal tears (van de Graaf et al. 2018). Three hundred twenty one (321) patients were randomized to either a knee arthroscopic menisectomy (meniscal tear removal) or Physical Therapy consisting of 16 sessions over 8 weeks. These sessions primarily consisted of strengthening exercises of the lower quarter. Authors found Physical Therapy was equivalent to surgery for improving knee function at 2 year follow up and stated Physical Therapy may be considered as an alternate to surgery for patients with meniscal tears. Although some patients may eventually require surgery the vast majority of patients will benefit from Physical Therapy first for their meniscal tears.

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Increased Medical Risks of Chronic Pain and Mental Health Disorders Found After Elective Hip Surgery

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.

No Difference Between Surgery and Placebo Surgery For Tennis Elbow

Tennis elbow or lateral epicondylalgia is a painful condition affecting the wrist and finger extensor tendons as they attach into the arm.  Breakdown of the tendon at its' insertion and weakness in the forearm muscles lead to pain and reduced tolerance for gripping and hand movements.  Physical Therapy treatments including manual therapy to the spine and extremity joints has been shown to accelerate recovery and lead to reduced healthcare utilization over the long term.  Importantly, manual therapy improves a patient's tolerance for strength training exercises which allow for long term relief.  Patient's who do not improve with conservative treatments may opt for surgical debridement of the injured tendon and muscle.  

A recent double blinded, randomized controlled trial compared the effectiveness of surgery to a sham or placebo surgery in patients with chronic tennis elbow pain (Krosiak et al. Am J Sports Med. 2018).  Patients were randomized to either a sham/placebo group (skin excision and exposure of the tendon) or a surgical debridement and excision of the affected tissue.  Interestingly, both groups improved pain and function at 6 month follow up but there were no significant differences between groups.  Authors stopped the study early due to the lack of differences between the surgical and placebo groups.  The authors reported no additional benefit of surgery over placebo for patients with chronic elbow pain.

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