​Clinical Pearl #17: Importance of Progressions after Hip Surgery

There are many pieces of information you will hear, be informed about and learn through the process of preparing and undergoing surgery.  Regardless if you are going through, or have been through, a hip scope, PAO, combination, or a Derotational Femoral Osteotomy (DFO), there will be anticipated progressions throughout the post operative recovery.

It is easy to look at the surgeon’s protocol and see what activities to expect over the weeks during recovery.  One VERY IMPORTANT consideration is whether or not goals for certain stages of recovery are met, not necessarily the timeline in which activities are set.  

In the rehab world, protocols are similar to recipes.  For some therapists, following the protocol to the “T” will be the anticipated care given post operatively. Nothing more, nothing less.  I compare this to a young chef not knowing a new recipe, thus will adhere to the recipe to the Nth degree. It is a safe zone, and one which should get to the anticipated end result.  

For other, more experienced or specialized therapists, the protocol will be followed in the initial stages of healing and monitored throughout recovery to comply with the expectations of the surgeon and progressions.  These more experienced therapists may also expand the experience and recovery by including more activities not necessarily in the protocol.  For example:  Not only is the hip a primary concern following surgery, but so is the trunk and back, the entire lower extremity, including the foot and ankle complex. Upper body conditioning should not be ignored.  Balance, progressing passive range of motion into active motion, then increasing upon this with controlled mobility surrounding the hip.  Looking at and improving compensation patterns with walking or other activities, such as return to running, symmetry with use of the extremity with daily activities all are things which a protocol may not specifically address.  If the goal is to return to a sport, working into activities supervised by your physical therapist is important including jump training to improve impact capability of the extremity, multidirectional strength and stability, changing directions with symmetry and appropriate form to help minimize overuse or potential for injury, to name a few.

Progressions are a part of life.  As we age and go through our learning process with school, we progress through grades.  When we learn a new skill set, we start with a small number of skills and gradually build with more skills or increase the complexity as we progress.  We progress through various stages of life, and can reflect on life lessons learned, experience gained, or reflect on the change of hair color reflecting this progression in life!  Skipping progressions aren’t encouraged.  It is rare that a student will skip more than one progression of school grades during one’s career.  Trying to learn how to ski, one isn’t encouraged to put skis on and start on a black diamond run.  And, many times life lessons teach us that had we followed the steps, the progression, instead of skipping steps, the final result would have been achieved in a more timely manner, or perhaps with less strain.  With this in mind, I ask if time and time again progressions are followed for a reason, why should these principles be altered during recovery after surgery?  

Timelines are a part of every protocol, from rotator cuff surgery at the shoulder, to ACL reconstructions of the knee, protocols give safe timelines in which certain exercises or activities could be initiated and performed. The hip is no different.  Timelines will be present.  Just because a timeline has been met, however, it does not mean that you will be able to do certain activities.  For example, after a microfracture procedure, it is common to see that walking will be initiated at 6 weeks.  Many people think this means that they will be walking without crutches at that 6 week anniversary.  That is incorrect.  The majority of people will go through the process of weaning weight onto the surgical side using crutches at 6 weeks.  On average, it is encouraged to use 2 weeks to fully integrate walking without crutches by following the process.  Skipping the process results in greater pain, or discomfort, more limping and compensatory patterns with walking.  And, many times returning to using crutches and taking longer to fully discontinue them.  Again, why would you want to skip steps and work out of progressions?

Progressions are there for safety.  Goals of stages are to help identify important functional objectives, and once met, the next stage may be initiated.  Some people will work through these progressions sooner than established guidelines, and many times this is fine. If there are any concerns, contact your surgeon.  Others will be right on track, and there will be some who are slower to achieve these objectives.  Not every person heals at the same rate, in the same fashion.  While I know this can be frustrating if you fall into the slower category initially, do not let this get you down!  Remember to be kind to yourself!  Others may rush through initial stages, then get stuck on a stage for longer than anticipated.  Again, this can be frustrating. We all heal differently, and it will not be linear!  Working with a physical therapist who appreciates this will keep you grounded and supported through these times!  Because why?  Physical therapists follow processes!

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