[Sarah Bosserman]

Katie, I agree with you in that I have been trying to emphasize the hip extensor moment. Tyler, she has already noticed that she is walking better than before her surgery and has worked up to walking over a mile. She did continue to experience intermittent anterior hip pain but her physician thought that at least some of it was irritation due to the hardware (and may need to be removed eventually) as she is very thin. I have been able to use a lot of this research/discussion with her in explaining expectations and helping her understand the surgery as well and the gait mechanics we are trying to promote.

[Sarah Bosserman]

1.Partial meniscectomy involving up to 50% of the width of the posterior horn of the medial meniscus does not increase contact pressures in the knee.
2. Vertical tears inc max contact pressures, but pressures can be restored to near normal levels with repair.
3. Horizontal cleavage tears have the least impact on contact pressure, thus resection should be reserved for those more symptomatic and should involve a single leaflet when possible.
4. Repair of a root tear may return contact pressures to near normal levels. Root avulsions can cause meniscal extrusion, loss of circumferential fibers which inhibit creation of hoop stresses (and thus prevent function of the meniscus) = act as a functional meniscectomy.
5. Early compensatory changes in gait to avoid or alleviate pain can cause long term changes: should pay attention to reduced ROM of the joint, subconscious gait adaptations developed early on, and muscular strength deficits in knee (isometric max voluntary contraction and rate of force development).
6. Partial meniscectomy has been shown to lead to inc KAM and inc stress to the ACL, predisposing them to OA.

-I thought this was an interesting review and reminded me of some of the points made during the running medicine conference after ACL-R. Quad strength and ability to recruit the muscle quickly, along with knee flexion angles were impacted for a more significant length of time (and to a greater extent) than I may have originally realized.
-Another good point: “Reductions in knee extensor moments may be an important indirect indicator of the presence of persistent pain and changes in joint loading” – this is seen in those with OA to decrease joint loading and may lead to development of a posterior capsule contracture due to prolonged knee flexion…In future patients, this is important to keep in mind, especially for those patient that have been dealing with pain for a long time before seeking treatment.

[Sarah Bosserman]

thanks for the input everyone! I was thinking of the some of the same, Katie, in terms of posterior capsule tightness and increased stress to the psoas. The MD we were able to contact lists quadruped rocking to address capsular hypomobility and muscular facilitation around the hip as well, with progressive loading to the hip joint in earlier phases (quadruped, tall kneeling) to help with CKC loading/proprioception before gait training as well. Thanks for the feedback everyone!

[Sarah Bosserman]

I posted the PAO survivorship article here where they found that risk factors for conversion into THA or progression of osteoarthritis, or a Merle d’Aubigne´Postel score <15 found at the 30- and 20-year followup were: preoperative age > 40 years, a preoperative Merle d’Aubigne´-Postel score < 15, preoperative limp, a preoperative positive anterior impingement test, and preoperative osteoarthritis > 1 Grade according to Tonnis. Additional factors found at the 30-year followup were a preoperative HHS < 70, a preoperative positive posterior impingement test, limited preoperative internal rotation < 20deg, postoperative anterior overcoverage, and postoperative acetabular retroversion.

-Lerch TD, Steppacher SD, Liechti EF, Tannast M, Siebenrock KA. One-third of Hips After Periacetabular Osteotomy Survive 30 Years With Good Clinical Results, No Progression of Arthritis, or Conversion to THA. Clin Orthop Relat Res. 2017 Apr;475(4):1154-1168.

[Sarah Bosserman]

To answer my first question, I found 2 articles (2014 and 2017) that address the questions of : in patient s/p PAO is it possible to return to normal gait mechanics?
1. Gahramanov A, İnanıcı F, Çağlar Ö, Aksoy C, Tokgözoğlu AM, Güner S, Baki A, Atilla B. Functional results in periacetabular osteotomy: is it possible to obtain a normal gait after the surgery? Hip Int. 2017 Sep 19;27(5):449-454.
2. Jacobsen JS, Nielsen DB, Sørensen H, Søballe K, Mechlenburg I. Joint kinematics and kinetics during walking and running in 32 patients with hip dysplasia 1 year after periacetabular osteotomy. Acta Orthop. 2014 Dec;85(6):592-9.

– jacobson article: They found that walking and running characteristics improved after PAO, with improved hip flexion moment at 6 and 12 months and at 6 months with running. peak hip extension angle during walking increased at 12 months. Basically there were no significant differences between patients and controls as 12 months. They hypothesized that the decreases found in hip, knee extensor moments may be due more to muscle inhibition.

-Gahramanov article: found similar findings in terms of improvement in gait parameters, though still found deficits in sagittal plane. The article points to a few factors that should be considered if you find decreased hip flexion or abductor strength including previous surgery, previous antalgic gait, reduced hip extension (more evident in those with degenerative changes). Surgical technique is also important to be considered (sartorial approach, ilioinguinal, minimally invasive).

[Sarah Bosserman]

Justin, she definitely still has compensations and have used a mirror to help with visual feedback but taking a video is a great idea and a way to also monitor her progress. I like the idea of giving her a benchmark goal so she does not feel like I am holding her back, but instead giving her more to work towards. Thanks for your feedback! I know it is a more rare post op patient, but appreciate the feedback based on your experience with any post op hips!

[Sarah Bosserman]

I agree with the above statements, the gait analysis presentations gave me a lot of perspective as to what I am actually able to confidently assess and how I should be setting up my camera for consistency. The impact of foot intrinsics and how we should strive to make our runners better athletes was also great and I was able to immediately incorporate into my program for some of the high school runners I have.

[Sarah Bosserman]

-Would want to rule out UMN, vascular causes. neuro exam would be high on my list.
-Lateral thigh numbness: could be lateral cutaneous nerve? (L2-L3, courses through lateral border of the psoas major and iliacus, h/o anterior hip THA)
-Lumbar radiculopathy L4-S1 (leg pain), stenosis…seems load sensitive.
-Would want to continue to assess hamstrings, glutes, deep hip rotators, iliopsoas, etc…curious what his hip mobility looks like for sure as it could affect mechanics (with walking/steps/transfers)/peripheral nerve entrapment.
-Curious a little more about the nature of his leg symptoms…is one side different from the other (did the pain start first on one side, earlier onset with activity R vs L, intensity?)
-Yellow flags due to patient reporting he has stopped walking program and has few ways to decrease his pain. Surgeries have lead to decreased quality of life.
-Definitely curious to hear more about his objective exam!

[Sarah Bosserman]

Definitely agree that I would look at her foot posture. Sounds like you have found some impairments at the hip and some good functional re tests. The difference in knee extension side to side and functional hip weakness seems like a good starting point. Sounds like running was the original aggravating factor (and something she continues to do) so I think I would also like to assess her running mechanics along with treating the other functional limitations. Looking forward to hearing more about her case this weekend!

[Sarah Bosserman]

Hi Tyler! Great case, I think we have all have patient’s with similar presentations. I agree with what Jen and Katie discussed when trying to explain recurrent low back pain to patients. I definitely do not want to make them more fearful of movement and I think using an example relevant to them/their goals helps with understanding. I agree that I would not likely use manipulation with this patient as he would benefit more from treatments focused on neuro re-education. I definitely think moving towards functional exercises as soon as possible also helps with patient buy in, especially with someone with low irritability. The more task specific (lifting, running, etc), the more likely he is to continue his HEP beyond the end of therapy and hopefully prevent future injury.

[Sarah Bosserman]

Hi Katie! interesting case. Pudendal or obturator nerves came to mind with pain patterns and symptoms (pudendal worsens with sitting and obturator with hip abduction and extension). Thinking about differentials of SIJ, FAI, iliopsoas/adductor tendinopathy. Did you find any significant muscle weakness? 2 years is a long time, has the pain been intermittent with more recent exacerbation or consistent and did the groin or LBP come first (or at the same time)? Was just curious about the quality of his motion if he has had pain for that long, seems like he has some significant hypomobility in lumbar spine and hip and how they may affect how he bends and lifts.

[Sarah Bosserman]

Hi AJ,

Thanks for the article. I thought this was a really interesting read. I think in terms of dosage this study showed that “normal” tendons respond differently than those with pathology, citing immediate supraspinatus tendon thickening following shoulder exercises and acromiohumeral distance decreasing post exercise that was maintained for 6 hours in the pain group. One of the main takeaways for me was to not further overload the tendon, we want to restore homeostasis without loading to fatigue and feeding into the cycle of intrinsic and extrinsic factors that create pain in the shoulder. Depending to the irritability and stage of the patient, limiting cuff strengthening to once per day or every other day may be more appropriate.

[Sarah Bosserman]

Sorry, guys. Katie told me today that my article did not post. Thanks!

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[Sarah Bosserman]

I agree with tyler in that a thorough neuro assessment would be high on my list and I would be monitoring frequently to ensure that symptoms were not further deteriorating. Similar questions also come to mind in terms of if you were able to centralize her symptoms, how irritable she was with nerve tension testing, and your thought process when using OP with someone who is more irritable.

[Sarah Bosserman]

Hey Tyler, a lot of questions come to mind with post ACL patients. I think it’s important to consider graft type (allograft, autograft), is this a revision or primary ACL reconstruction? how long after their injury did they wait to have surgery and were there associated injuries (meniscus, MCL, LCL, PCL, PLC)? Have they had prior injuries to the knee? I like to see them get full extension pretty quickly over the first month, while managing edema and pain levels to help facilitate quad. If they are not getting full extension, then I really start to question why and may give the doctor a call (is it associated with high pain levels? how is patellar mobility? edema?). Just curious – what type of graft did he have? The last pediatric ACLR I treated was a iliotibial band autograft.

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