New York City—February 25, 2009
A treatment plan designed by a physical therapist after she connected a patient’s hip pain to a back injury suffered in high school helped the patient avoid the need for hip surgery. The unusual case study describing the patient's diagnosis and treatment experience was published in the February 2009 issue of the HSS Journal, the musculoskeletal journal of Hospital for Special Surgery in New York.
Joint pain can be insidious, slowly building up over time and often dismissed as a condition that comes with age. But joint pain is not something that just appears - it can usually be traced back to a defining moment that changes the way the body operates.
"It is not uncommon for surgeons at Hospital for Special Surgery to refer their patients to the Sports Rehabilitation and Performance Center at the hospital prior to surgery," explained Jaime Edelstein, a physical therapist at Hospital for Special Surgery and author of the case study.
"The moment the patient walks in the door we begin observing them," continued Edelstein. "From the way they stand, walk and go up and down stairs, everything tells us how the different parts of their body are working together or not. By observing the patients this way, we are looking at how the entire body acts collectively to understand why a patient is in pain. If there is some imbalance, if the muscles, joints and other soft tissues are not working together properly, we can re-educate them and this will help the patient respond better to surgery."
Kolette Annand, the patient profiled in the case study, had noted "popping" in her hips for years, but when she was 41 years old it began to be accompanied by a burning sensation. Annand visited several doctors but had no definitive diagnosis when she was finally referred for surgical treatment to Bryan T. Kelly, M.D., at Hospital for Special Surgery. An MRI showed that she had tears in the cartilage of both her hip sockets and a bone spur within the socket.
"From the MRI I could see that Ms. Annand would most likely need surgery to remove the damaged tissue from her hips," said Dr. Kelly, a specialist in sports medicine and arthroscopic surgery of the hip, shoulder and knee at Hospital for Special Surgery. "But I wasn’t completely sure that was the source of her pain, so I recommended physical therapy prior to the surgery."
In Annand's case, the physical therapy proved so successful she was able to avoid having surgery altogether. In Edelstein's analysis and talks with Annand, the physical therapist discovered that the patient had been a hurdler on the track team in her teens and had suffered a back injury. The injury most likely set off a series of events that changed the way the muscles in Annand’s body worked.
There is scientific evidence that after an injury the body can respond by re-patterning the way that its muscles interact. In Annand's case, instead of using her core abdominal muscles to hold herself upright, she was overusing her hip flexor muscles to assist them. The hip flexors run from the pelvis and lower back to the thigh bones and normally act as a group to bend, or flex, the hip to move the knee upward. This caused her to stand in a "sway back" posture with her hips tilted forward and her buttocks tilted back, putting a large amount of pressure on the front of her hips.
"Her hip flexors were not just overused, they were acting during motions that they weren’t supposed to," said Edelstein. "We first had to inhibit them and then reeducate them to act only at the proper times as well as reeducate her core muscles. I knew it was working when Ms. Annand came in after just the first session and said she already felt better."
Since working with Annand and publishing the case study, Edelstein has approached and collaborated with many of the surgeons at Special Surgery. She has examined and treated a number of different patients and has had success through conservative treatment plans, helping many of them avoid surgery. Though she stresses that not all patients are good candidates and not all patients will be able to avoid surgery. A patient who has had a traumatic accident or whose pain is stemming directly from an injury in the joint will not benefit as much. However, even patients who are undergoing surgery can work to correct underlying imbalances that will ultimately help them respond better to surgery.
"The surgeons I have collaborated with here are open to starting with conservative treatment," said Edelstein. "The bottom line is that they all want their patients to get better and some may not need surgery for that."