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Tuesday, May 15, 2012 1
Greater Trochanteric Pain
Syndrome
Dr R. Presley Swann
Tuesday, May 15, 2012 2
About Surgery
Greater Trochanteric Pain Syndrome
- Surgical Intervention for GTPS o Proximal IT band release with
bursectomy o Debridement of calcium o Bursectomy o Gluteus Medius Repair
Involved structures:
- inflammation of the trochanteric bursa –
making sleeping on side difficult
- Lateral hip pain in a some patients with lateral hip pain have pathology of the
gluteal tendons
o Tendinosis
o Calcium deposits in the gluteals
o Tears (small group of patients)
Tuesday, May 15, 2012 3
Day of Surgery
Where do I report?
Report to the Surgery Desk when you first enter ___________________________
Have your packet completed 3 days prior to surgery
Phone Calls: Complete at least 14 days prior to surgery date
Pre-Registration for Surgery ______________ Monday – Friday 7:00 a.m. – 7:00 p.m. Sat 7:00 – 3:00
Pre-Admissions for surgery (after 9:00am) ______________ How long will I be here?
Estimation of surgery: 1-1.5 hours and in the facility about 4-5 hours
General reporting times: start at 6:30 am til noon.
o Call between 2-3 pm the DAY BEFORE SURGERY –___________________
General Anesthesia You will be under general anesthesia. You will need someone 18 yrs old or older to drive you
home and stay with you for the first 24 hours.
Medication check / Past medical history:
Do you have any history with the following?
o Sleep apnea, Blood clots / DVT’s, Pacemaker, Diabetes, Medication allergies, Cancer,
Stroke, Heart attack
o Allergies?
What will happen prior to discharge?
You will take your ice unit home with you/ bring cruthes to surgery or some will be provided before
you leave
Before you go home, you will receive your prescription for any medication
o Pain Medication / Anti-inflammatories:
Oxycodone for pain and Naprosyn for inflammation
o Stool Softner – take Colace AM and PM for constipation
At home if you are having any adverse reactions or need pain medication refills, please call Sarah
Tuesday, May 15, 2012 4
First week at home Showering:
48 hours after surgery – remove the surgical dressing. Water can run over however do not soak surgical incisions.
Pat dry and cover with dry Band-Aids if needed. No ointment. Leave steri-strips in place for 2-3 weeks
Assitive Device?
Crutches – o WBAT and use until you are not limping and no pain (Bursectomy and IT band release) o 20% weight bearing for 4 weeks and then 50% until 6 weeks with Gluteus Medius Repair
Signs of infection
Fever greater than 101 deg F, Redness beyond the incisions, Worsening / intolerable pain and possibly – nausea, pus or smelly discharge
How should I sleep/rest?
Icing for the first week home when you are not taking care of basic needs or doing your physical therapy).
o Put layer (pillow case) between your skin and ice pad o The white pad can be replaced with a pillow case at anytime
When do I begin my therapy program?
You should begin within the first 24-48 hours. You should have some general ache / soreness, however your exercises should not cause sharp pain. If your pain is increasing more than 2 points on pain scale, back off of your stretches by being less
aggressive or reducing the number of reps. o Before you stop them all together, call your physical therapist to discuss.
How much pain am I going to have after surgery? Pain is individual however; it is recommended you take your pain medication as prescribed as needed
for the first week. Pain medication is not as effective on spiked pain. Pain is common for the first several weeks but will decrease over the first 4-6 weeks Ice is a natural analgesic: ice for the first 7 days continuously to control pain and swelling
What are the side effects of general anesthesia and pain medication?
Some pain medications have side effects causing constipation. Take over-the-counter stool softeners (Colace am and pm while on pain medications as needed). Drink at least 8 glasses of water a day during the first couple weeks following surgery.
General anesthesia can cause nausea in some patients and difficulty with memory
Tuesday, May 15, 2012 5
Expectations from Physical Therapy
It is not uncommon for you to reach a couple plateau’s or flare up’s during your recovery and is associated with transitions phases in your rehabilitation, weaning off of crutches or increased daily activity. It will take you a year to “recover” despite the fact you will feel improved after 3-4 months. Your function prior to surgery will dictate the time line for your recovery. Post operative exercise:
It is recommended for an optimal outcome that you have access to a gym or gym equipment to include a pool. Pool will be very important in your recovery.
Restrictions for up to 4-6 weeks for IT band release/bursectomy
Hip active range of motion a. Do not cross your legs – in the first 3-4 months
Weightbearing: weight bearing as tolerated on crutches
Crutches – required until you can walk without a limp
Sleeping – do not sleep on your non-surgical side for the first 4-6 weeks. This causes your surgical hip to collapse to the other which provides a constant strain for 6-8 hours.
Restrictions for 6 weeks following Gluteus Medius Repair
No leaning forward past 90 degrees / no picking objects up off the floor, socks and shoes
Weightbearing – 20% for the first 4 weeks then 50% until 6 weeks post op o Use crutches or walker
Home therapy in the first week home
Activity Expectations for It band release and bursectomy 0-4 weeks: activities for grooming, bathing and general light activity in the home / desk job. Do not clean the house, walk the dog, mow the lawn, lift objects etc. Even if you feel good.. 4-6 weeks: light activities in the community with crutch lasting no more than 30 mins / light house work without lifting / light duty at work without lifting ( 6-10 weeks: moderate activity in the community (2 hours walking and may still be weaning from crutch), at work (up to 5 lbs carrying or lifting , and at home moderate house work. Light gym activity with guidance 10 - 16 weeks: ramping of activities / hobbies as pain dictates. Begin uneven ground activities.
Tuesday, May 15, 2012 6
Home Exercise Program
Begin the day you go home from surgery and complete for the 1st week 3-6 times per day
Quad Sets Place towel under back of the knee. Push knee into the towel contracting the quadriceps. Hold for 5 seconds. Complete 10-15 reps 4 times per day Ankle Pumps Laying on your back, move the ankle through full range of motion. Complete 10-15 reps 6 times per day. START THESE WHEN YOU WAKE UP FROM SURGERY Glut sets ( Not for gluteus medius repairs) Laying on your back, contract your gluteals. Hold for 10 seconds. Complete 10-15 reps 4 times per day
Tuesday, May 15, 2012 7
Ice machine- ice 24/7 first week home
You will go home with a ice unit for your hip.
The placement of the pad
Lateral / side of the thigh. The straps go around your waist and lower thigh as the
picture shows.
The Velcro should be snug but not restrictive
Place either the white pad or a pillow case between the pad and your skin
Precautions
Make sure a barrier is between you and the pad. Burning from the cold is possible if
you do not have enough of a barrier.
Take off to walk
Buy ice every 1-2 days to supplement your ice maker
Purpose
To help control soft tissue edema and joing swelling
To help knock down pain 1-2 points on a pain scale
Important after 1st week to manage increased evening and night time pain
*** Lay on stomach for 20 mins 2 times per day. Increase you time if you are sitting more to
prevent hip flexion contractures. – (Not for gluteus medius repairs)
Tuesday, May 15, 2012 8
APPOINTMENTS
Surgery Date: _________________________ / Therapist Name: _________________________
1st week PT: Day: ________ DATE: _____/____/____ TIME: __________AM/PM 2nd week PT: Day: ________ DATE: _____/____/____ TIME: __________AM/PM 3rd week PT: Day: ________ DATE: _____/____/____ TIME: __________AM/PM 4th week: Day: ________ DATE: _____/____/____ TIME: __________AM/PM MD POST OP Follow up: at your ___ week PT appointment
Visits to physical therapy and physician follow ups
Post op’s week 1,2, 3 and 4.
o You will see Dr. Swann around your 2 week visit, as needed until 12 weeks and at 1 year.
o If you are workmans comp or has disability insurance, you will have to see him every 30 days.
You are responsible for making sure you are scheduled.
Post op’s after 4 weeks - is every 2-3 weeks depending upon status
If you are having therapy outside of MSM, we need to see you in physical therapy at 1 week, 2 week,
6 weeks and 12 weeks to ensure you are progressing at the expected rate
Program Design
We are an integrated Physician / Physical Therapy model.
Dr. Swann works closely with the physical therapy “team” to allow for maximal therapy effectiveness and efficiency of care.
Visit frequency
Dr Swann and Therapy have developed a highly independent program that uses critical but limited therapy sessions. Your compliance to each therapy session is vital to your recovery.
Rescheduling:
If you experience scheduling conflicts with a set appointment, be sure to contact your therapy team immediately for rescheduling.
Research Team
We are a “Research Team” by going beyond typical orthopedic rehabilitation programs by collecting outcomes to
improve patient care.
We will complete a hip subject outcome at each clinic visit as well as after discharge from treatment that
enable us to understand the long term outcomes of our treatment protocols.
Tuesday, May 15, 2012 9
Phone Numbers
Dr Swann’s Office Contact MD office if you go to the emergency department post operatively, need medication refills, have problems with your pain medications or other post operative concerns **** Reaches the Dr on call*******
Office Hours: Monday – Friday 8:00 am – 5:00 pm Hip Coordinator Physical Therapy Department: Contact your therapist / therapy staff if you have questions about your post operative rehabilitation. Call the scheduling number if you need to reschedule your appointment or need your post operative rehabilitation question answered before end of day
Paperwork
If your insurance is workmans comp or you are filing FMLA / time off paperwork / disability
forms
If you need paperwork filled out, please get these documents as soon as possible. The paper work can
take a couple days to be completed.
You need to provide all the name’s and phone numbers to where the documentation needs to be faxed.
o She does not store the information therefore you will need to provide the name’s and fax number
for any paper work you bring in throughout your care.
How to Use Crutches
The patient will be allowed to weight bear as tolerated on the surgical leg. Crutches are to be used as
needed to ensure safety.
The patient can “wean” around 2-4 weeks - as long as no limp and no pain when weight bearing
Tuesday, May 15, 2012 10
Walking with Crutches
1. You should bear the weight on your hands and not lean on the crutch pads at the armpits when walking.
2. Place crutches forward first. 3. Move your injured leg forward and place heel down landing in
line with crutches. 4. Shift as much weight as tolerated onto surgical leg and push
down on crutches to “unload” weight as needed 5. Step through with healthy leg. 6. Roll over toe and bend knee to move your injured leg forward
again. 7. Go slowly at first.
Going Up Stairs
1. Approach step closely. 2. Place your health leg up on the step – keep your injured leg and crutches on the ground. 3. Place your weight on your healthy – step up. 4. Bring the crutches and surgical leg up to same step.
Going Down Stairs
1. Approach edge of stair closely, and place weight on healthy leg. 2. Lower crutches and step down leading with the involved leg. 3. Shift your weight to the crutches and injured leg. 4. Carefully place your healthy down on the step. REMEMBER: UP WITH THE GOOD…DOWN WITH THE BAD
FOR THERAPISTS
Tuesday, May 15, 2012 11
Hip Surgery: Glut Med Repair
Surgical post op: 0-1 weeks
Hospital: 23 hour stay
Medication: Percocet (narcotic) and Naprosyn
Weight bearing: 20%weight bearing first week
ROM: ankle pumps, quad setting, glut setting, log rolling
Wound Care: maintain dressing for 48 hours. May shower after 48 hours
Follow up: 1 week combo and physical therapy
First post op (6-10 days):
Location: in physical therapy clinic, combo
Treatment: physical therapy
Physical therapy o Weight bearing: 20% for first 4 weeks o Exercises: o Icing: 20-30 mins 3-4 times per day
Wound Care: cover with dry band aids only. Do not need coverage to shower
Motion: < flexion 90 degrees
Second post op (12-14 days / 2 weeks):
Location: in physical therapy clinic, combo
Treatment: xrays in clinic / physical therapy in PT clinic
Physical therapy o Weight bearing: 20% for 4 weeks o Exercises: ROM, bike, o Icing: continue 20 mins 4 times / day
Wound Care: cover with dry band aids only. Do not need coverage to shower
Medication: wean off narcotic and continue anti-inflammatory
Motion: 90 degrees, ER 20 degrees
Third post op ( 3 weeks):
Location: PT only
Treatment: physical therapy in PT clinic
Physical therapy o Weight bearing: 20% 4 weeks o Exercises: ROM, bike, pool
Wound Care: should be closed and submersion allowed
Medications: anti-inflammatories as needed
Motion : o Hip flexion
Tuesday, May 15, 2012 12
o Hold active Hip Internal rotation and abduction o Hold passive Hip external rotation and adduction
Fourth post op (4 weeks):
Location: PT clinic
Treatment: physical therapy in PT clinic
Physical therapy o Weight bearing: 50 % 4- 6 weeks o Exercises: ROM, bike, pool
Wound Care: can submerge
Medications: anti-inflammatories as needed
Motion : o Hip flexion o Hold active Hip Internal rotation and abduction o Hold passive Hip external rotation and adduction
Fifth post op (6-7 weeks):
Location: PT clinic
Treatment: physical therapy in PT clinic, combo
Physical therapy o Weight bearing: progress off crutches 25% each week o Assistive device: wean off in 4 weeks o Exercises: ROM, bike, pool, strengthening, motor control
Wound Care: can submerge
Medications: anti-inflammatories as needed
Motion: o Flexion and IR 90%, all others full motion o Intervention: oral steroid if needed for pain and/or limited motion from pain
Sixth post op (9-12 weeks):
Location: PT combo with HSW
Treatment: physical therapy in PT clinic
Physical therapy o Weight bearing: full normal gait mechanics o Exercises: ROM, bike, pool, full ADL function
Motion: full motion all directions
o Intervention: oral steroid if needed for pain and/or limited motion from pain o No limitations in motion
Tuesday, May 15, 2012 13
Seventh post op (12-16 weeks):
Location: PT clinic
Treatment: physical therapy in PT clinic
Physical therapy o Weight bearing: full normal gait mechanics o Exercises: ROM, bike, pool, full ADL function, Sport training o Sport testing
Motion: full motion all directions o Intervention: oral steroid if needed for pain and/or limited motion from pain o No limitations in motion
Work Implications:
Return to desk work: 1-2 weeks post operatively
Return to physical Labor: 6 months.
Return to Sport: 4-6 months.
Swimming/Soaking affected limb: 2 weeks or as soon as incisions are completely closed.
Moderate ADL’s: 3 months
Goals:
Full hip motion without impingement
Return to Sport after four to six months.
Physical Therapy visits - 10