Posts in surgery
Arthroscopic Surgery for Knee Pain

Last year over 500,000 thousand arthroscopic knee surgeries (scopes) were performed in the Unites States making it one of the most common orthopedic surgical procedures.  In a previous post we highlighted some of the evidence behind this surgery showing it is not superior to a sham or placebo surgery for degenerative meniscal tears.  In addition, many literature reviews and analyses have shown the procedure offers little to benefit to patients with knee pain (Thorlund et al. BMJ. 2015).  

A recent article in the British Medical Journal compared Physical Therapy exercises to surgery for middle aged patients with degenerative medial meniscal tears (Kise et al. 2016).  The authors found no difference in self reported knee function at long term follow up, but reported greater strength and muscle performance in the exercise group.  Patients with knee pain are encouraged to utilize Physical Therapy over surgery for painful knee conditions.   

Return to Play after Achilles Tendon Rupture

Achilles tendon ruptures mainly occurs in middle aged adults, males > females, participating in sports with high levels of jumping or high force activity.  The repair and recovery time of these tendon ruptures is lengthy due to the post operative immobilization, weight bearing, and exercise restrictions.  Prior research has shown only 1 in 2 athletes returns to play at 1 year post op.  Among these athletes who do not return some may either choose not to return to their previous sport due to fear of reinjury while others have placed themselves at greater risk of injury due to not restoring their leg's strength, balance, agility, and coordination to pre injury levels.  

A recent article in the British Journal of Sports Medicine reviewed the available evidence to determine an athlete's ability to return to play after achilles tendon repair.  (Zellers et al. 2016).  The authors reviewed 108 studies of over 6500 patients and found on average 80% of athletes return to play at pre injury levels.  The average time to return to sport after a course of Physical Therapy was 6 months.

Athletes are encouraged to use Physical Therapy following an Achilles Tendon injury to accelerate their healing and improve their chances of recovery.  

Reducing ACL Reinjury Risk

Athletes often return to sports around 6-9 months after ACL reconstruction and Physical Therapy.  In a previous ACL post we described how important these Physical Therapy sessions are to an athlete's recovery.  Each session after surgery is designed to move the athlete closer to the all important return to play.  New research is showing how instrumental this path to recovery is to reduce the risk of ACL re injury.  

Grindem and colleagues studies 106 pivoting sports athletes who underwent ACL reconstruction and Physical Therapy.  The athletes were followed for 2 years to document their rehabilitation, functional performance, and finally return to play.  The authors reported athletes who returned to high level sports had 4 times the risk of re injury compared to lower and mid level sports participation.  Among all athletes, those who did not pass their functional testing before returning were 8 times more likely to re injure their ACL.   Importantly, this re injury rate was cut in half for each month the athlete stayed in rehabilitation and delayed their return to sport up until 9 months.  In short, having athletes who complete 9 months of Physical Therapy and pass their functional tests can reduce their reinjury risk by 84%.

Athletes are advised to work with a local Physical Therapist for 9 months to allow a safe return to competitive sports.  

Does Physical Activity Improve after a Total Knee or Hip Replacement?

Total knee and hip replacements are among the fastest growing surgeries in our country.  Physical Therapy remains the first line treatment for patients with knee and hip arthritis, but in patients with severe osteoarthritic pain and loss of function joint replacement remains a good surgical option.  In prior research among patients undergoing these procedures there is often a disconnect between subjective reporting of pain and function and the objective testing of a patient's function.  For example, a patient may report great outcomes and an ability to walk long distances without fatigue or pain, but objective testing in Physical Therapy often reveals residual endurance, strength, and balance impairments.  

In addition to severe pain, one of the most important indications for a total joint procedure is loss of function.   After the surgery patients are expected to increase their activity levels due to reduced pain, but new research is questioning this assumption.  A recent review article in the Journal of Orthopedic and Sports Physical Therapy examined if physical activity levels increased after these procedures (Arnold et al. 2016).  Authors reviewed the available data and found 8 studies of 373 patients who underwent a total joint replacement.  

These studies objectively tracked a patients physical activity levels up to 1 year after the procedure to see if levels had increased compared to pre operative levels.  The authors reported negligible improvements at 6 months and limited evidence to support increases in activity levels at 1 year.  At one year, patients with total joint replacements were significantly less active than their peers.  This study indicates the importance of post operative Physical Therapy to effectively improve strength, endurance, and balance allowing patients to resume an active lifestyle.  

Physical Therapy Reduces Need for Total Hip Replacement
physical-therapy-hip-pain-arthritis

Over 200,000 Americans undergo a total hip replacement often as a result of severe hip osteoarthritis.  Patients who enter the surgery in a weakened, less functional state have worse outcomes up to 2 years post operatively compared to their higher functioning peers (Fortin et al. 1999, 2002).  This is concerning because the most rapid recovery after surgery occurs in the first 3 months with slower recovery up to 1 year.  A patient with more difficulty entering surgery would have limited success in this crucial window in their recovery.  Conversely, pre operative Physical Therapy for patients with limited flexibility, strength, balance, and endurance can improve surgical outcomes, but similar to research in knee osteoarthritis may delay or prevent the need for the surgery.  

A recent study was conducted to determine the long term impact of PT interventions on patients with hip osteoarthritis (Svege et al. Ann Rheum Dis. 2015).  Patients were randomized to either an education or PT group and followed up to 6 years after the treatment.  The authors reported the average time to a total hip replacement was 5 and a half years in the Physical Therapy group compared to 3 and a half years in the education group.  In addition, twice as many patients in the Physical Therapy group did not require surgery reducing the need for surgery by 44%.  

This evidence adds to our knowledge on the beneficial effects of Physical Therapy on patients with hip osteoarthritis.  Patients with hip pain are advised to see a Physical Therapist to postpone or prevent the need for a total hip replacement. 

Return to Professional Basketball after Surgery

“In life there are no guarantees” and this is certainly the case with return to sport after surgical procedures.  Unfortunately, the commonly held belief is surgical repairs of muscles, tendons, ligaments, etc. guarantees a return to sport at prior levels of play and competition.  The odds of returning to competitive levels of sport can be improved dramatically through pre and post operative Physical Therapy.   A new review article highlights the lower than expected odds of returning to high level basketball competition after orthopedic surgery.  

We assume professional athletes have a greater likelihood of returning to sports following surgery given their athletic gifts and high levels of resources directed at their care including money, time, and medical staffs.  A recent review article of close to 350 NBA basketball players was conducted to determine the likelihood of these athletes returning to high level play after surgery (Minhas et al. Am J Sp Med. 2016).  The return to sport ranged from 70% in achilles repairs to 98% after hand/wrist surgeries.  Across all procedures older (>30 years old) and heavier (BMI >27) athletes were 3 times less likely to return to sport.  In addition, those undergoing arthroscopic knee surgery or achilles tendon repairs suffered the greatest reduction in performance at both a 1 and 3 year follow up.    Athletes at greatest risk of decreased performance should work closely with a Physical Therapist to facilitate an optimal return to sport.