Posts tagged surgery
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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No Differences Found Between Surgery Or Physical Therapy For Tendon Injury
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Overuse tendon injuries can present as an acute inflammatory response (Tendinitis) or a chronic degeneration condition (tendinopathy).   These injuries result when an individual’s volume of activity (type, duration, frequency, and intensity) exceeds the strength and integrity of the tendon.  At MEND, we commonly see these injuries in the tendons of the rotator cuff, knee, ankle or elbow.  Recent studies summarized in our previous blog posts have highlighted the importance of a Physical Therapy exercise program.  Optimal, progressive loading of these injuries is critical to the healing process (remodeling) resulting in decreased pain and improved function.  Despite overwhelming evidence supporting exercise interventions patients may still be provided with a surgical treatment.

A recent study from the British Medical Journal reviewed the available medical evidence to determine the effectiveness of Physical Therapy compared to surgery or no treatment in patients with tendinopathy (Challoumas et al. 2019).  Authors included 12 studies of over 1000 patients to determine the impact of these treatments on a patient’s pain, function, range of motion, strength and quality of life.  Authors reported Physical Therapy was as effective as surgery in both the mid and long term for improving pain, function, and quality of life.  Authors report surgery should be reserved for patients who do not improve with 12 months of a loading program. 

Quad Weakness After ACL Surgery Associated With Decreased Cartilage Health
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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
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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
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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.

Physical Therapy Supported As First Line Treatment For Meniscal Tears
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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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