Specific PT for cut muscles?

[rboehmer]

Hello, all. I'm 7 weeks PO and my doc has cleared me to return to full activities in the gym.

I've returned to my pre-op routine of stationary bike, leg press, calf raise, hamstring curl and leg extension. I'm using low weight for now; I'll move up in weight very slowly.

My doctor told me that he cut certain muscles during the operation, although I don't remember which ones. So my question is this. I didn't feel any spectacular weakness during my normal routine. So I must not be doing any exercises that target the cut muscles, or I would surely feel it.

So, does anyone know more about the muscles that were cut? I had a typical birmingham procedure; posterior approach with glued femur, unglued cup. Will those cut muscles heal and be strengthen-able, and how long should that take? Or will I have to compensate by building surrounding muscles? In either case, what exercises should I add to my routine and when?

Thanks for any insight..!

- Ray

[sroberts]

Hey Ray,

Usually the surgeon will "release" the gluteus maximus at the insertion point (tendon attaching to femur). Most surgeons will reattach the glute and it'll be good as new in about six weeks.
PT can start immediately and after six weeks you won't have to worry about "ripping it from the bone". My surgoen, Dr Rogerson uses a barb or "fly" to reattach the tendon "no chance of coming loose". On my x-rays you can see the "fly" on my femur.

When rehabbing you want to make sure you are working the posterior chain muscles. Many folks just focus on leg lifts and develop a nasty case of tendinitis in the psoas because they haven't been activating the glutes (medius and maximus to be specific).

Let me know if you need some exercises which will give you the greatest benefit.


take care,

spencer

[rboehmer]

Yes! I could use the exercises! And thanks for the info!

- Ray

[sroberts]

Hey Ray,


I would recommend incorporating hip mobility and core stabilizing exercises.  For example great hip mobilities exercises are Roman Deadlifts, lunges with rotations, and deep (body weight) squats.  For core stabilization exercises I recommend abdominal bridges (planks), bird/dogs (aka quadrupeds), and glute bridges with core activation (pelvic tilts). 
For general workouts, the more weight bearing exercises you are able to do the better.  Think about more body weight exercises and less machines. Keep in mind that you are only 7 weeks post op. Take it easy at first and ramp up your rom and intensity of exercise gradually.

I also recommend massage and gentle stretching after exercise. Never stretch a "cold" muscle. Also keep in mind static stretching before exercise can reduce muscle power by up to 30%. Save the stretches for post exercise and have your warm up consist of dynamic movement like the bike, rower or treadmill.


take care,

spencer

[Bionic]

Usually the surgeon will "release" the gluteus maximus at the insertion point (tendon attaching to femur). Most surgeons will reattach the glute and it'll be good as new in about six weeks.

I found this prospect to be a bit alarming.  I know that different doctors have different techniques, but I wanted to check Dr. Gross's procedure, because he's doing my surgery next week and I have an irrational fear of having my a** removed.

You can see Dr. Gross's surgery video here: http://www.grossortho.com/video4.htm
This is an old video, which shows his cemented femur technique.  He has since moved on to mostly using an uncemented femur.

Unless he skipped that part in the video, he didn't appear to release the gluteus maximus at all.  I think he said he "divides the gluteus muscle in line with its fibers."  But I don't think that's the same thing as cutting it.  More like pulling the different fibers away from each other laterally.

He said that he does "divide and elevate" the gluteus minimus (not maximus) from the joint capsule to mobilize the femur.  He sews it back later when he's done.  He also divides and elevates the gluteus minimus near its origin in the illium, to create a space for the femur to sit when he works on the acetabulum.  It is only partially divided, however (only about 1-2 cm are cut, just to keep the minimus from ripping when the femur is tucked up into the pocket). 

He does cut the hip rotators, i.e., the piriformis, obturator internus, and obturator externus.  He also cuts the quadratus femoris.  All of these are deep muscles that appear to control internal and external rotation of the hip (pidgeon or duck-toed).  They are all repaired before closing.

Here's a nice picture showing where the muscles are: http://en.wikipedia.org/wiki/File:Posterior_Hip_Muscles_1.PNG

[dw]

yup, my doc "separates" the muscle fibers (says they're like a broom, and he pushed them aside), and they unattach ligaments and whatever else directly from the pelvic bone. They then re-attach to the bone, leading to no "cut" muscle.

[rboehmer]

I would recommend incorporating hip mobility and core stabilizing exercises.  For example great hip mobilities exercises are Roman Deadlifts, lunges with rotations, and deep (body weight) squats.  For core stabilization exercises I recommend abdominal bridges (planks), bird/dogs (aka quadrupeds), and glute bridges with core activation (pelvic tilts). 
For general workouts, the more weight bearing exercises you are able to do the better.  Think about more body weight exercises and less machines. Keep in mind that you are only 7 weeks post op. Take it easy at first and ramp up your rom and intensity of exercise gradually.

I also recommend massage and gentle stretching after exercise. Never stretch a "cold" muscle. Also keep in mind static stretching before exercise can reduce muscle power by up to 30%. Save the stretches for post exercise and have your warm up consist of dynamic movement like the bike, rower or treadmill.

Thanks for those exercises. They are exactly what I need, and I can do them at home with dumbells, except for the roman lifts. I think these are the missing ingredient that will get me back onto the tennis court at 6 months!

Despite 2 calls leaving messages, I still haven't heard back from my Doc (Yes, that is unfortunately typical of him and his office) about which muscles he cut. But I don't think it was "gluteus" anything, or I would have recognized it. I looked at the chart in the link posted by 'Bionic' and it could have been any of the other muscles listed- I just can't remember.

I do remember that he said the muscles he cut wouldn't adversely affect anyone except soccer players. He bent his knee, pulled his foot off the floor in front of himself and pushed his knee to the outside, like a hacky-sacker might do to volley a sack repeatedly directly in front.

For my part, the only time I feel any pain is when I bend forward at the waist, balance on the foot on the resurfaced side and lift my OPPOSITE leg to put my pants on. And I don't feel the pain until after I place my foot back on the floor! Curiously, I can left either leg and balance fine when I'm not bent over. This would suggest that it is the stablization muscles in front of the hip that only come into play when bent forward, but what do I know??

Thanks again for your help and advice! I'll post again if I hear anything more in my case that varies from the excellent information already provided in this thread!

- Ray

[Todd]

Ray,

You described my pain and currnet limitation exactly!  I can stand fine on the new hip except for lifting my opposite leg to get my pants on (bending forward).  My lateral stability is what is suffering and my hip doesn't have the strength to maintain balance in that position.  Duing my PT sessions we've worked to isolate these muscles for strengthening.  It is common to use other strong muscles to compensate, so isolating and working on these specific muscles has been very important.  Otherwise I would be getting by without fixing the root cause.  For instance, on a mini trampoline she has me balance on the new hip, and focus on stabilizing balance with my ankle and lower body rather than using my arms spread wide to do the same.  Also doing some other core exercises with the same focus in mind.  Hope this resonates with you too.  Good luck.
todd

[sroberts]

Anytime Ray. That's what I do for a living.



spencer

[nwugrad]

Spencer,

I am a bi lat 17 days post op.  Dr. Su  performed my surgery. I am a 54 y.o. male.  I am still on crutches and will be so until at least next week when I have my follow up visit with Dr. Su. 

 I've been going to PT since the 7th day post op.  Mostly I ride a bike  20 - 30 minutes.  Do mat exercises, i.e., heal slides, abductor slides, single leg lifts, quad extensions, glute bridges on a PT ball and hip extensions on my stomach and abduction leg lifts on my side.  Then I do bar exercises:  knee lifts, hip extensions (backward), abductor leg lifts to the side, squats, leg curls, toe raises.  Lately I've used a yellow therband for most of the bar exercises.  To minimize weight bearing on one leg I alternate legs after each rep and stand b/t the bars so I can use both arms to bear some weight. 

I have some outward rotation of my feet unless I concentrate on keeping them turned forward.  My hamstrings are very tight.

Would you recommend the same that you recommended above?  In addition to or in lieu of some of those I am doing.

[sroberts]

Hey nwu,

Congrats on your bi lat. Dr Su is a great surgeon. A friend of mine here in Tucson had his rt hip resurfaced by Dr Su last spring and is doing everything from running to ice climbing.

It sounds like your PT program is very sound. This early in recovery you really need to listen to your body so you don't overdo it. Whenever you squat make sure your knees don't collapse inward, push out with you abductors.

I wouldn't recommend the deadlifts, lunges, or deep squats so soon. Work on range of motion and go slow. If you can incorporate the core stabilization exercises they will help but again, go easy and slow.

Get Dr Su's approval on everything you do for now. The neck capsule is still healing.

 Keep in touch.


take care,

spencer

[nwugrad]

Spencer,

Thanks you!  I am finding that I do need to run  things by Dr. Su b/c as experienced at the PTs are at Bryn Mawr Rehab they are not that experienced with resurfacings.  I think they think of them like replacements, where there are stricter ROM restrictions but not capsule or weight bearing issues. 

I am looking forward to getting into the pool.  I need Dr. Su's approval, i.e. agreement that incisions are completely healed, before they will let me in the pool.  Do you like pool therapy?  If so, is there anything I should or shouldn't do in the pool?

[rboehmer]

For me, the pool was HUGE, both physically and psychologically.

It made me realize that the limitations on what I was able to do were purely related to muscle weakness, not any kind of injury or damage.

I'd say to get in as soon as you are allowed.

- Ray

[nwugrad]

rboehmer,

What did type of exercises did you do when you first went into the pool?

[rboehmer]

I did a lot of stretching and leg lifts in all directions. I did several wide martial arts stances and movements that I couldn't do on dry land yet.

I was in a lap pool so I was able to do some power walking and sideways shuffle-walking which made my thighs very tired- which I assume is a good thing.

Now, at 2 months Post-Op, I'm swimming slowly, although I'm very cautious with the leg kicks; very slow and smooth.

[nwugrad]

rboehmer,

Sounds like a good routine.  The buoyancy coupled with additional resistance are a great combination.  Best of Luck!

Thanks,