When a PT Rehabs

You are at a loss. You have tried everything. After months or years of pain and appointments to all the doctors and other healthcare providers, your hip still hurts. In fact, it might even be worse!

Now the doctor wants to do hip arthroscopy surgery. You are willing to do whatever it takes to make the pain go away and get your life back. However, surgery is a big step! Should you really let the surgeon cut on your hip?

Hip arthroscopy can be a great option, but it’s a big decision and not for everyone. This guide will help you make the right decision for you.

What Is Hip Arthroscopy?

Hip arthroscopy is an effective way to see what damage and problems are going on in your hip as well as treat those problems.  The surgeon makes several small incisions (about the size of a buttonhole) and uses them to introduce a high definition camera and specialized instruments into your hip to be able to see and treat the injury.

Advantages of Hip Arthroscopy

The advantage of hip arthroscopy compared to a surgery where your entire hip is cut open is that it decreases the amount of tissue damage done to the hip. This decreases time in the hospital, pain from surgery, and time for recovery. Hip arthroscopy may help decrease how much or how quickly arthritis develops in the hip and may even decrease the chance of needing a hip replacement.

Challenges of Hip Arthroscopy

Arthroscopy procedures have been done since the early 1900’s, including hip arthroscopy in 1931. However, it didn’t start to gain popularity until the 1980’s and beyond, because the hip is challenging for arthroscopy for several reasons. 

First, the hip is a ball and socket joint, which means the bones of the joint fit very tightly together. This makes it difficult to access the joint and do the necessary work. In order to get into the joint, the surgeon has to use traction, which can increase the risk of injury to the nerves and blood vessels near the joint.

Second, the hip joint is very deep in the body, with layers of muscles around it. This makes it even harder to reach the joint and requires special instruments.

As new techniques and tools are being developed, this surgery is more effective and is used more often. Hip arthroscopy surgery increased 250% between 2007 and 2011. 

Is Hip Arthroscopy Major Surgery?

Although hip arthroscopy is less invasive than an open hip surgery, many of the techniques done in the surgery are significant. Hip arthroscopy is major surgery. 

Top 5 Reasons to Have Hip Arthroscopy 

No one wants to have surgery, but it may be a solution if you have the following problems:

Reason #1: Hip Labral Tear

The labrum is a ring of cartilage around the hip socket (acetabulum) that helps to keep the joint in place. When it is torn, it can cause pain with daily activities. This is one of the most common- if not the most common- reason people have hip arthroscopy surgery. 

Reason #2: Femoroacetabular Impingement (FAI)

When the bones of the hip joint are not shaped well and are rubbing against each other, that pinching and rubbing is called “impingement”. This is often the cause of a labral tear, so fixing a labral tear and correcting FAI are often done together in the same surgery. FAI itself is typically not painful, but can cause painful damage.

Reason #3: Capsular Insufficiency

If the ligaments of the capsule around the joint are too loose, it causes instability and pain in the hip. This may be due to naturally loose ligaments, like when someone has Ehlers-Danlos syndrome, or a previous surgery where the capsule wasn’t closed, or didn’t heal well.

Reason #4: Loose bodies

Sounds horrible, right? “Loose bodies” refer to something that is moving around the joint. Examples are a cartilage injury where a piece of cartilage broke off, or a loose anchor from a previous surgery. Loose bodies can cause painful “catching” in the hip and decreased range of motion. Hip arthroscopy can remove any of these loose bodies.

Reason #5: Pain on the Outside of the Hip

This can be caused by a number of reasons, from bursitis on the outside of the hip, to a tear of the gluteus medius tendon. The surgeon can repair or lengthen tendons as needed during hip arthroscopy.

What Could Go Wrong?

No one wants to think about the bad things that could happen, but it’s important to consider what can happen if things don’t go smoothly. Significant complications with hip arthroscopy are rare, but they can happen. Some of them are:

• Bleeding
• Infection
• Blood vessel damage
• Nerve damage (can be decreased with intermittent traction or post-less traction)
• Blood clots
• Fluid build up in the body
• Extra bone around the hip
• Scar tissue
• Failure of the surgery
• Loss of limb function
• Fracture
• Abandoned procedure
• Chondrolabral injuries
• Hip instability
• Anesthesia complications 

Who Should (and Shouldn’t!) Have Hip Arthroscopy? 

The only person who can decide if you should have hip surgery is you. There are no definite answers, but there are some guidelines that can help.

Who Should Consider Surgery 

You may want to consider having surgery if:

• You have hip pain that is affecting your ability to live life normally AND you have tried other treatments without getting pain relief.
• You have stiffness or decreased range of motion in your hip that is not letting you do your normal activities.
• You have hip pain almost daily.

Who Should Think Twice Before Having Hip Arthroscopy

Even if hip arthroscopy can help, you may need to take extra care if any of the following apply to you:

• You have hip dysplasia. If your hip dysplasia is severe enough, you need to consider PAO surgery to correct the dysplasia. If you have a torn labrum fixed, but you still have dysplasia, you have a much higher likelihood of re-tearing the labrum.
• You don’t have much time for rehab. Physical therapy and rehabilitation require a lot of time after surgery and some people do not feel that they have the time. That’s understandable, but if you don’t have time to do rehab, you may not get the outcome you hoped to get from surgery. 
• You have had a previous hip arthroscopy. There are people who have revisions done very successfully, but it is an even harder surgery the second time around. It is even more important in this case to have a surgeon that specializes in hip arthroscopy.
• You are able to do most of your normal activities with little to no pain. If you don’t have surgery, your hip labral tear will not heal on its own. The damage may get worse without surgery. However, surgery is not something that makes the hip magically new again. If you are having a lot of problems, it can be a great option. If not, you may be better off waiting. Many people have labral tears and FAI without having many, if any, symptoms.

Who Should Not Have Hip Arthroscopy

Certain things make the surgery a lot less likely to succeed, and you may want to consider a different strategy, such as hip replacement if these are the case:

• Age over 60
• Use of tobacco products
• Obesity
• Moderate to severe arthritis
• Hip ankylosis
• Hip joint contracture
• A surgeon that doesn’t do many hip arthroscopies

What Are My Other Options?

Physical Therapy

Try physical therapy before surgery. Best case scenario, you will be able to manage the symptoms well enough that you won’t have to have surgery. Even if you end up having surgery, doing some strengthening and stretching ahead of time will often help make recovery more smooth. Besides, many insurance companies require that you do physical therapy before they will pay for the surgery.

Caveat: Find a physical therapist who works with this type of injury often and has a good understanding of it. Some hip exercises can actually make a hip labral tear MORE painful. Physical therapy should not be making your hip pain worse!

Platelet-Rich Plasma (PRP)

Some people have relief from platelet-rich plasma (PRP) therapy. However, the research is inconclusive as to how well it works or how long it lasts. Not only that, but PRP can be quite expensive and insurance rarely covers it.

Medication/Injections

Your doctor may have you try medications for pain relief, including anti-inflammatories. You may also try injections, including cortisone. Anti-inflammatories will not fix the tear, but they will sometimes calm the pain and inflammation down enough that you get relief from the pain.

Massage 

Massage can also be helpful for decreasing hip pain. When there are no good massage therapists available (or are not within your budget), you can use tools like foam roll, massage balls, and other specially designed tools to help release the muscles in and around the hip. Massage is rarely enough to fix the problem, but it can be a big help in managing the symptoms.

Rest

If you haven’t already done so, sometimes taking a couple weeks off from your normal activities can help decrease hip pain.

You’re Having Surgery. Now What? (Your Planning Guide)

If you have decided to have hip arthroscopy surgery, you need to prepare for surgery.

1. Find a Surgeon

For many of you, you already have one. Great! You’re all set! If you don’t have one, or you want a second opinion, keep these things in mind:

• How often does your surgeon do hip arthroscopy? This is a technically difficult surgery, and surgeons who specialize in hip arthroscopy tend to have better outcomes.
• Talk to your surgeon about their outcomes. The success rates of hip arthroscopy are hard to find because they vary so much between surgeons. You want to know your surgeon’s success rate with this surgery. 

If you know anyone that’s had the surgery, ask for recommendations of who to see!

2. Set up Pre-Op Appointments

Your surgeon’s office will let you know what appointments you need to make in preparation for surgery.

Your surgeon will require a pre-op check. They will test your blood work, urine, and possibly an EKG to be sure that you are healthy enough for surgery. This is done about 2 weeks before surgery. Your surgeon’s office will let you know when to make the appointment and whether it can be done at your regular doctor’s office. 

Because of the pandemic, you may also need to schedule a COVID test. Your surgeon’s office will help you get a prescription for the test and tell you where to schedule the testing. They will also let you know if you need to make any other appointments.

3. Prepare Your Home

You need to prepare your home for surgery.

First of all, do you have help at home? At the very least, you will need someone to help you for the first 24-48 hours after surgery. Some people struggle with getting in and out of bed or using the restroom or shower immediately after surgery and may need help for several days, perhaps up to a couple of weeks.

Next, you need to make sure that you have room to walk with crutches or a walker to any of the places that you need to go, such as between your bedroom, bathroom and kitchen. 

You also need to pick up any area rugs or other tripping hazards. If you have pets, you will need a plan to make sure they won’t trip you.

4. Get Equipment

Medical equipment: Your surgeon’s office will let you know what medical equipment you need and how to get it. Usually crutches or a walker are required for at least a short time, and many surgeons also want their patients in a protective brace for several weeks after surgery. Other possible equipment that they may order includes: an ice machine, a continuous passive motion (CPM)  machine, and some sort of compression device to help prevent blood clots.

Non-medical equipment: Things that are not required, but many people find helpful are a toilet riser, a shower chair, some extra pillows for positioning, a shoe horn, a sock aid, and a reacher. Some people like to have a belt or stretching strap to help them lift their leg in and out of bed. It’s also nice to have a small backpack to carry things in while you’re using crutches. 

5. Surgery Day Preparation

Your surgeon’s office will let you know how to prepare for the day of surgery. They will let you know whether to expect outpatient surgery or if you need to plan for an overnight stay. They will let you know where to go and when to be there, as well as when you should stop eating or drinking before surgery.

Make sure you have someone who can drive you home after surgery.

Hip Arthroscopy Surgery: What the Surgeon Is Doing 

Surgical Procedure 

During the surgery, the surgical team will put your leg in traction to open up the hip joint. The surgeon will make several small incisions to insert the camera and instruments into the joint. The surgeon uses fluid flowing into the joint to help keep the view clear. The surgeon will first check to confirm what injuries or problems are present and to what extent, and then perform whichever procedures are necessary. The length of the surgery will depend on what type of procedures your surgeon has to do. 

Hip arthroscopy is both diagnostic and therapeutic. Imaging doesn’t show everything, but during the surgery, the surgeon can see exactly what is going on and the extent of the damage. Then they are able to treat the problems that they find.

Types of Surgical Procedures That May Be Done During Hip Arthroscopy

Different treatments that may be done during your surgery, depending on what injuries you have.

Labral tear

Labral tears can be addressed in a few different ways during surgery. Each treatment has its pros and cons.

Debridement is when the surgeon trims or smooths the labrum, perhaps even removing part of the labrum. For some people, this significantly decreases their pain and has the advantage of a quicker recovery than some of the other options. Unfortunately, it can affect how well the joint works, and can accelerate the rate of arthritis.

Repair of the labrum is when the labrum has separated from the bone, and the surgeon anchors it back into the bone so that it can heal. This maintains the labrum so you don’t lose its function for the joint. However, the procedure interrupts some of the blood supply to the labrum, making healing more difficult. It also has a less satisfactory result if the labrum itself has become so damaged that it is larger or smaller than normal.

Reconstruction is when the person’s labrum is removed and a new one is created from donor tissue. This can lead to less pain because the new tissue has no nerve sensitivity. Furthermore, being able to make the graft the correct size can help the labrum perform its gasket function and seal the head of the femur in the socket. This has shown promise in some studies, but reconstruction is a very new procedure, and long term outcomes are not known. The surgeon needs a lot of expertise in order to perform the surgery well, and outcomes may depend on how the graft is done (all one piece vs. being done in sections, for example).  Finally, it is more complicated to do a revision after reconstruction if the surgery fails. 

Femoroacetabular Impingement (FAI)

To correct bony impingement, the surgeon shaves down the bone and reshapes it. This makes the joint more smooth and able to move through the full range of motion. When this is done for a CAM lesion, which is on the femur, it is referred to as a femoroplasty. When the procedure is done for a pincer lesion on the socket of the joint (the acetabulum), it is called an acetabuloplasty.

General

Tendons. During surgery, the surgeon may repair or lengthen a tendon. To repair a torn tendon, like the gluteus medius, the surgeon will use anchors to reattach the tendons to the bone.

To lengthen a muscle or tendon, the surgeon will cut small incisions in the muscle or tendon. This can relieve pain, but should be used with caution. Some evidence suggests that even if the tendon is causing pain, releasing it in someone with a lot of anteversion (femur bone rotating in) causes the hip to be more unstable. Moreover, the muscle will atrophy and not work as well after surgical release.

Loose bodies that may be present in the joint can be removed during the surgery.

Hip capsule insufficiency can be fixed by tightening the capsule, or repairing a capsule that wasn’t closed or didn’t heal well during a previous surgery. 

Post Op: What to Expect After Hip Arthroscopy

Finally, what to expect during recovery from hip arthroscopy.

Is Arthroscopic Hip Surgery Painful? (Managing Pain and Discomfort)

Everyone’s experience is different after this surgery. Some people can manage their pain with over the counter medications, but most people require stronger medications at first. Often the pain is significantly less within a few weeks after surgery, though you could have some soreness for several months after surgery.

The doctor will be sure that you have appropriate pain medications prescribed. You can also use ice to help decrease pain and inflammation after the surgery.

Do’s and Don’ts After Hip Arthroscopy

Your specific limitations may vary depending on what you have done. Always follow your surgeon’s protocol. However, here are the common do’s and don’ts.  

After hip arthroscopy surgery, you should: 

• Follow your surgeon’s recommendations for weight bearing.
• Use crutches or a walker for as long as is recommended by your doctor
• Use your brace if one has been ordered for you by your surgeon.
• Change positions often and avoid sitting in one position for hours at a time.
• For the first 4-6 weeks, you should help your leg when lifting it in and out of bed or in and out of the car to avoid aggravating the hip flexors.
• Spend time lying on your stomach to help keep the hip flexors gently lengthened.
• Use ice as directed by your surgeon.
• Be patient. This recovery takes time, and nothing can speed up tissue healing.

After hip arthroscopy surgery, you should not:

• Over do.
• Do excessive rotation or flexion movements. (Some surgeons will have very strict range of motion restrictions for the first few weeks. Be sure to follow them!)
• Stand or walk prolonged amounts for the first 8 weeks.
• Crouch or squat for at least several months (you may always need to avoid these movements).
• Do heavy lifting for at least 2-3 months.
• Sleep on your side for 6-8 weeks (especially the post op side, but often you should avoid either side).

Rehabilitation After Surgery

You will need to do physical therapy after your surgery. The surgeon will let you know when they want you to start, and your physical therapist will be able to follow the protocol set by your surgeon. In general, you want to make sure that you are not doing activities that are causing increased pain in your hip. This is a surgery that will heal faster in the long run if you give it time.

Early physical therapy will focus on range of motion to keep things mobile. You will also need to work on protecting the hip flexors from overuse. Keep in mind that recovery from hip arthroscopy is a marathon, not a sprint. It takes a lot of time and patience, and many patients who have had this surgery describe the recovery as a “roller coaster”.

Even if you are feeling great, those tissues in your hip need time to heal. DON’T try to rush and do more even if you have very little pain. Keep in mind that if you overdo, your hip will often not feel flared up until a day or two after you overdo, so progress slowly!

What Is the Recovery Timeline for Hip Arthroscopy?

Recovery is different for everyone. Often, progression is based on meeting certain milestones. Depending on your situation, that may be longer or shorter than other people in a similar situation.

How Long Is Recovery After Hip Arthroscopy?

While you will be able to return to most of your activities sooner, full healing takes 12-18 months. While you may be able to do many normal activities by 6 months after surgery, more strengthening and healing needs to take place after that time.

When Can I Drive After Hip Arthroscopy?

As long as you are off pain medications, your surgeon will typically allow you to drive after 4 weeks for your right hip, and 2 weeks for your left (unless you drive a stick shift). 

How Long Will I Be on Crutches After Hip Arthroscopy?

This varies widely, and depends on how much work is done on your hip. Some surgeons say a week or two, others require 4-6 weeks using the crutches. Your surgeon will also let you know how much weight you are able to put on your leg while using your crutches. Some require no weight on that leg, while others will say 20-30%, and others up to as much weight as feels okay.

Many people will be walking fairly normally with minimal pain within 6-8 weeks, but this depends on a number of different factors. When you see your surgeon for the pre-surgery consultation, ask them what their protocol is for crutches after surgery.

When Can I Go Back to Work After Hip Arthroscopy?

It depends on the surgery that you had as well as the type of job that you do. If you work in an office, your surgeon may let you go back to work as early as a couple of weeks after surgery. People who have more physical jobs may not be able to work for 2-4 months.

When Can I Start Running and Return to Sports After Hip Arthroscopy?

This also varies depending on your surgeon and the type of surgery you’ve had. Often, having enough strength in the healing tissues takes up to 5 months for light running and 6 for returning to sports activities, provided that your strengthening is going well. Some surgeons will let you go back sooner, but be cautious. If you do too much too soon, you are at a greater risk of re-injuring your hip, because those tissues have not had enough time to fully heal. 

Life After Hip Arthroscopy

What Is the Success Rate of Hip Arthroscopy? 

These numbers vary a lot depending on how much experience your surgeon has, as well as what kind of surgery they are doing. However, success rates are said to be as high as 85-90% after hip arthroscopy.

You need to find out the success rate of your particular surgeon, as well as how “success” is defined. Often this means that the patient’s pain and dysfunction improved; it doesn’t always mean that the patient is satisfied with how much it improved. 

Long term outcomes

Many people are very glad that they had hip arthroscopy surgery done, and are able to return to most, if not all, their previous activities. However, long term outcomes are not fully known at this time. Many of the studies currently show outcomes from 2-5 years after surgery, but it is difficult to find studies for outcomes longer than 5 years.

Long term precautions

Your surgeon will let you know if you should avoid certain activities after your surgery. Some people will always have to be careful due to structural issues or damage in their hips. For example, if your hip socket is more shallow than it should be, your surgeon may recommend that you not return to running after surgery.

What If Hip Arthroscopy Fails?

Surgery doesn’t guarantee success. The first hip arthroscopy has about a 15% chance of failing, and that number increases if you are having a revision of the surgery (fifteen percent was listed in a study, but as mentioned, the number varies widely between surgeons).

Symptoms of a Failed Hip Arthroscopy

Persistent pain after surgery is often one of the signs of a failed surgery. This can be difficult to determine at first, because pain after surgery is normal, and fluctuates a lot, especially at first.

After a failed surgery, people will usually work with conservative treatments such as physical therapy first. People may try a revision surgery with another arthroscopy, or they may have a total hip replacement. 

What Does This All Mean for You? 

Hip arthroscopy is not an easy decision to make. Only you can decide if you should try it. Do the research, talk to the surgeon about your specific situation, talk to people that have had the surgery (try discussion groups online if you don’t know anyone personally), and be prepared to put in the work.

If you do decide to have the surgery, be sure that you have an experienced surgeon, and have patience during the recovery. Give your hip time to heal. None of this is easy, but you can do it!