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

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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.

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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

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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.

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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

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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

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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

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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

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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