Post-op hip rehab: preparing the whole athlete for cutting

Welcome to the Performance Place Sports Care podcast, where you can learn about sports injury theory, rehab, diagnosis, and how to understand the doctor lingo you didn't understand at your appointment. And now, your host, Dr. Sebastian Gonzales. Hey, thanks for joining me on the podcast today. I am Sebastian Gonzales, your host. And today, we're going to actually digest through a comment that we had on a YouTube video. And this one's mainly about a hip, a post-op hip. And I thought I would share it with you guys because it seems like there is a disconnect sometimes of healing time for an actual injury versus being game ready.

And what I mean by that is when you have, say, an ACL tear, which is a knee ligament, by the way, and your ACL is ready, actually ready itself to do work and transfer load and so on, that doesn't mean the rest of your body is. And because we don't know what you've been doing during the time where you've been off and letting the structure heal. So again, the structure might be game ready, but are you game ready? So what this person was saying was, I'll read you verbatim the response they had. So they said, 16 weeks post-op, post-op in a hip scope on the right side. They tried cutting for the first time in PT and now have a sharp pain on the left hip, which is the other hip, that is consistent and resembles the pain I felt on the right side.

How likely is it that I have damaged the labrum on the left hip while rehabbing the right one? So hard to know because we actually, well, did they, did they damage the labrum? We have no idea because we don't have an image to support. And so let's digest this down. I'll try to take this thing apart in pieces to make sure that you guys understand the injury that's happening with this guy. And so you guys can learn about Dr. Lingo because that's part of what this podcast is about. So it sounds like 16 weeks ago, he had a surgery on the right side of his hip, on his right hip. And it's not uncommon to go to PT for a little bit of while, a little bit of time after you secured a structure back on or repaired a labrum or repaired something that was kind of torn up or frayed.

By the way, the labrum in the hip is a cartilaginous or cartilage cup, which goes between the ball or so you have a ball and socket. So it's between the ball and socket of the hip. It almost works like a little gasket, too, and it deepens the socket and it supports it and it keeps it so the hip stays together and the actually the labrum can be frayed or torn, which then changes not only the security of the hip or how stable it is, but also, too, it can catch and pop and click. And that is common symptoms of a labrum. So that is something that becomes painful, obviously. So labrums sometimes need surgery, and that's why this person ended up having surgery.

So we don't have the gray of the labrum or anything like that. But either way, the question is about his other side. So going into this first, we have to be considered, again, structural healing time. Yes, he was probably ready to start cutting, which sounds like he did it in PT, but perhaps did we do enough prep work? Before that, to make it safe for his other hip to assume that activity. What do I mean by this? You have to consider, like, say you've run, this actually happened to me a few times. So say I'm used to amount of doing about 10 miles in a given setting. So I can run 10 miles at a time.

I take a few weeks off. I've had miles really low, say, doing like two to three miles at a time just because I haven't had time, say. And then, say, three weeks later, I start to run again. But now I don't run from three miles to four miles to five miles to six miles all the way to 10. I just go 10 straight off the bat. And this could leave you really, really sore. My brain was ready to do 10 miles because it really wasn't that long ago that I did 10. But my body wasn't ready, okay? So we have to consider, was there a gradual increase to that cutting? And a lot of times, cutting or what we call change of direction drills, such as running cones and so on, or even jumping, landing and all that stuff, we have a precursor that we do before we get there.

And we have to make sure the person can balance on one leg and they can stack the joints and make sure that there's not any spinning of the knee inward or what we call internal femoral rotation. And there's a really strong correlation with trunk control. Can they hold position? And can they keep the ilium or the pelvis? The pelvis is, actually, probably a lot of you know what the pelvis is. The ilium is one side of the pelvis. So can we control that and make it so we're not crunching down on the labrum or the small parts of the hip while we're doing cutting drills? Okay, so that's really, really important.

Now, when I strengthen hips, I usually don't do a lot of post-op cases, by the way. I do a lot of overuse conditions as well as ones that have been much longer past post-op. But 16 weeks post-op is a little bit soon for me. So I'm talking a little bit out of my realm here because I don't have a lot of experience with these people. But I know what we're looking at, roughly. So we have to consider that we have to have stabilization within the joints before the prime movers work. And the ball and socket of the hip is almost like the ball and socket of the shoulder. And the shoulder, actually, and we'll go into this in a different podcast because I did have a question on this as well, is the shoulder really has three types of muscles.

And this was coined by Dr. Joe back in, I think, in the early 90s. So there are stabilizers for the ball and socket. There are ones that stabilize, or they, sorry, they position the blade in the shoulder, which in this case would be the ilium or the pelvis of the hip. And then there's prime movers. And prime movers are the ones that do a lot of the work. In this case of the hip, we'll bring all these parts back. The stabilizers of the hip, or what we consider the rotator cuff of the hip, are the ligaments. And the external rotators are small movers, or sorry, small muscles of the hip. And they're the ones you really don't think about much of.

Probably one you have heard of is the piriformis. And all of these muscles drive the hip, ball, and socket together so it's centralized. Now the next muscles we have to consider are the ones which position the dish of the socket, not the ball. And those are everything attaching to the pelvis. And they are the rectus abdominis, or the six-pack muscles. They are the internal, the external obliques, which are the muscles on the side of the trunk. The transverse abdominis, there's also the adductors, or the muscles of the leg. There's a lot of muscles that attach in the area. And all of these ones can create stabilization within that dish, or the socket.

Other ones, which we won't go too much into, are pelvic floor muscles, which are, there's a whole subspecialty of this. Now the major movers of the hip are the ones that most people think about when they think about training of the legs, or the hip. They think about the glute max, or the big butt muscle. They think about the hamstrings, the rectus femoris, which is one of the quad muscles. They think a lot about those, or even the adductors. The adductor magnus is a huge muscle, which does a lot of work in the hip, ball, and socket area. And the fact of the matter is, the small muscles have to be stabilizing and compacting that ball and socket together.

And the muscles that control the dish, or the ilium or pelvis, have to be stabilizing it in the right way before the prime movers can do their work. And considering that we're talking about cutting drills now, cutting is much faster. Change of direction drills are much, much faster than strength moves, such as a very slow squat. A clean, or even a jerk are much, much quicker. And these are ones that I think would have a much higher injury potential. And although cutting and change of direction, and cone drills, and running backwards, and all these are very, they're light in weight, they're body weight.

It doesn't matter. The body's moving very quickly through a range of motion, and if it cannot control how that ball and socket and the dish are working, then you're going to shred some things up. So, what else could he have added? And again, this is assuming that he didn't do anything, or this is assuming, I have no idea what he did for PT. But probably we should have stabilized the trunk. And this is stuff that he could have done probably even without even dealing with the hip. And that would be isometric trunk control from multiple planes. So, there's three planes of motion. So, let's just say he could have done side planks, front planks, supermans.

He could have done rotational drills. He could have done pow-off press from a weighted or half-weighted or loaded position. There's lots of things he could have done. But something that's important, too, is to realize that the upper body could have been trained. The shoulder girdle could have been trained. Extension movements that would keep better posture through even plyometric training or cutting could have been trained. So, we have no idea what he was doing. But it's not uncommon in settings like this that if he's going to a place that's specifically working on that region of the body or, say, the hip, some of the other spots can be ignored.

And this isn't because they don't care or they don't know what they're doing. And a lot of times it's because if you're using an insurance, and this is a whole other thing we're talking about with one issue with medical today, is that a lot of medical insurgents will pay for you to get something worked on which is broken or injured. But they won't pay for the other regions. And this is why, even like with diagnostic codes, we have a specific to an area, we have a specific to a diagnosis, and we have a specific to a side. So, let's just say if this person had the right hip injured, their therapy is really only allowed to be catered towards that hip.

And maybe we can get to the trunk because it's important, or it's been shown to be important in research. But to get to a shoulder girdle, it probably would not even happen because it would really, really be questioned whether it's going to be productive for that hip. But it's not questioned if it's productive for the athlete. Because I think every strength coach in the probably of the world can agree with me that we need to train the whole body. We need to train the whole athlete. It's not just the one section. So, there's a possibility that some of that was left out because the clinic was not allowed to do it for him.

And that's not to the fault of the clinic or the therapist. That's something that possibly you could be co-managed for. And there are some strength coaches that I co-manage athletes with because I'm specifically working on a region and I can't work on the whole athlete. And I actually had a person come in recently that they, the amount of time that I spent with them in the office, it was about 30, 45 minutes or so. And a lot of our treatment blocks are around that amount of time. And they could have done a lot more. But that 15 to 20 minutes initially that we were working on, we were teaching technique.

We were teaching technique for a hip-related condition. And we were troubleshooting it because they couldn't hold their hip into flexion, which is like knee to the chest position. But they could do it with a little bit of a flare. And in order to do that, we had to test things or to find that we had to test things to be able to find that that is what this person's injury can tolerate. Now, considering it took about 20 minutes to get to that point, there's nowhere we're going to be able to have them do single arm dumbbell rows or some type of extension movement for posture even so that we can train the entire athlete.

There was just more, there was more important things that we had to get to, which was specific to that one condition. But that doesn't mean the athlete can't go immediately after the strength coach that we've been talking to, that we co-manage with, and work on all these other things. And it doesn't mean they go home and do complete bed rest because there's a lot of other things you can possibly do. Now, this is all I really have for this case. But for the most part, did they damage the other side? We have no idea. We don't know if it's a tendon issue, a college one. We don't know if it's a ligamentous issue.

Maybe it is something even much, much smaller. We have no idea. But if you want your question featured on our podcast, we do have a button that we have on the P2 Sports Care website page. It is called Speak Pipe. So you just go in, click it. You don't need a phone or anything like that. You just go straight through your computer and you talk to the microphone or talk straight to your computer and you can ask the question. Now, we can't give medical advice directly to you, obviously, because we have not done any exam. But we can definitely go through stuff like this because I think this really helps out other people understand what's going on with other types of conditions.

And I strongly, strongly believe the more you guys know about your body and the theory about how to rehab something, the better off you're going to be. Because I know that when I have injuries, I almost go through this emotional lull and just kind of sit down and get depressed about it and eat a couple Doritos here and there and watch some TV. And, you know, all of a sudden a month goes by and you're like, oh, shoot, like I could have done so many things if I would have just wrote down what hurts, what doesn't hurt, what we know about this type of injury. You know, is it something we have to rest?

Is it something that we have to have surgery on? Is it something that only takes maybe a couple days rest? And what else can we do beyond that? It's really, really important to know what you can do for your body because no one's going to care about your injury more than you will. And I can't stress that enough. Although you're going to a PT, a chiro, a doctor for help, they have a lot of other cases they're managing. I do the same thing. I love helping people with their cases, but I really, really am grateful when they learn more about their case so they can help me manage it as well. So if you guys are looking for courses as well, we have courses on our website.

Currently, they're on the Performance Place HB site, but they will be added to the P2 Sports Care site as well. This is where I really want people to learn more in depth about certain types of conditions. I know right now we have hip conditions. We have rotator cuff for baseball pitchers, but there's going to be a lot more. We're going to focus on some distance running ones, strength training for around the knees for runners, as well as other parts of the body. So take care, guys, and thank you for listening, as always, and I appreciate you sharing this podcast and rating it for me. Rate it on iTunes.

This is the only way I get good feedback that I know that you guys are enjoying what I'm doing. So take care.