Post Surgical Rehabilitation

A bunionectomy is a surgical procedure that is performed to remove a bunion. A bunion is an enlargement of the joint at the base of the big toe, involving both extra bone and soft tissue, which usually occurs as a result of years of walking around with collapsed arches and/or poorly fitting shoes. The progression of the bunion can be slowed with proper fitting shoes and custom orthotics, but if conservative treatment along with anti-inflammatories is unsuccessful in treating the pain associated with the bunion, then a bunionectomy is performed. There are different ways to remove a bunion, and the type of surgical procedure performed depends upon the severity of the bunion, the age and general health of the individual, and the condition of the bones and soft tissue. Post op recovery may vary slightly depending on which procedure is performed, but most bunionectomies will require a period of walking with a post op boot and going through a course of physical therapy to restore toe range of motion, lower extremity strength, and balance.

Carpal tunnel is categorized by numbness in the hand which is typically worse with use of the hand with activities such as typing or prolonged positions such as sleep. Carpal tunnel may be diagnosed grossly in the office with Phalen’s test. Depending on a person’s symptoms, a doctor may require more imaging or tests such as a nerve conduction velocity test, electromyography or an MRI. Typical symptoms consist of pain, numbness, tingling, tenderness and decreased strength in the hands and wrists. Sometimes individuals will complain of referred pain, or pain that travels to another portion of the body such as the elbow or forearm.

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According to National Institute of Health, carpal tunnel release is one of the more common surgical procedures in the U.S. and is performed if signs and symptoms persist more than 6 months. Although symptoms may be relieved immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may have infection, nerve damage, stiffness, and pain at the scar. Occasionally the wrist had a loss of strength because the carpal ligament is cut. Patients should undergo physical therapy after surgery to restore wrist strength. Some patients may need to adjust job duties or even change jobs after recovery from surgery.

A joint replacement (joint arthroplasty) is a surgical procedure in which one or more parts of the joint are replaced with prosthetic parts. It is usually indicated when the joint is severely arthritic and no other treatment has been effective. Shoulders, knees, and hips can all be replaced but hips can also be resurfaced, which is slightly less invasive.

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All joint replacements will require a recovery period and then some work to regain normal joint range of motion (ROM), muscle strength, and function. Physical therapy can help restore premorbid function by utilizing manual therapy techniques, proper exercise instruction, and functional retraining. A partial or total knee replacement will most likely require a great deal of passive ROM as well as strength and balance training, whereas a partial or total hip replacement will require less passive ROM and more strength and balance training. A total shoulder replacement, on the other hand, involves a slightly different course of treatment because it is the only procedure that will require a period of immobilization and will not require balance or gait training.

A rotator cuff repair is a type of surgery to repair a torn tendon in the shoulder. The procedure can be done with a large (“open”) incision or with shoulder arthroscopy, which uses small button-hole sized incisions. Both types of procedures require a period of immobilization, so a sling will be worn for most likely 4-6 weeks depending on the severity of the rotator cuff tear. As a result of being immobilized for that period of time, the shoulder becomes stiff and weak compared to what it was before the surgery. This is why physical therapy is imperative to help restore the shoulder to its premorbid state following rotator cuff repair. Some doctors even recommend starting PT before the sling has been discharged to help prevent stiffness, because physical therapists can still passively move the shoulder outside the sling even though the patient is not allowed to actively move it themselves. When the rotator cuff tear has fully healed, which usually occurs at about ten weeks post op, the physical therapist will start the patient on a progressive strengthening program to maximize function. It is imperative to go through a course of physical therapy following rotator cuff repair in order to return to normal daily activities as well as sporting activities.

Degenerative disc disease (DDD) is a term used to describe the normal aging process of disc degenerating in the spine. The name is a misnomer and can be very confusing for some people who have been diagnosed with DDD. The term “degenerative” indicates a progressive disorder that will worsen when it actually is a natural part of aging. Ultimately, all people will exhibit changes in their discs consistent with a greater or lesser degree of degeneration. It is not strictly degenerative and it is not a disease, but rather a degenerative condition that can produce pain over time. The signs and symptoms can include neck or low back pain with possible radiating numbness, tingling, and muscle weakness in the legs. Signs and symptoms usually resolve within a few months, however if they persist, physical therapy intervention can help alleviate the problem. Sometimes a doctor can prescribe pain meds to alleviate the pain and reduce inflammation in the compressed nerves. It is important to note that disc degeneration can lead to other complications such as spinal stenosis, osteoarthritis or spondylolisthesis. A course of physical therapy for degenerative disc disease focuses on strengthening, stretching, posture, and body mechanic training.

The spine is made up of thirty three vertebrae, twenty four of which have a discs between them. A disc bulge or disc herniation may occur in the cervical (neck) or lumbar (low back) spine. The disc is a round shock absorber and is made up of an outer ring called the annulus and an inner jelly like material called the nucleus. A disc bulge is a deformation of the annulus (outer ring). This may put pressure on a nerve which can cause back and leg pain. A disc herniation is a failure of the annulus and the jelly like material on the inside of the disc escapes and may leak into the spine and around the nerve. The symptoms are also back and leg pain.

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For both the disc bulge and disc herniation, physical therapy would focus on core strength, posture, body mechanics, as well as stretching. Other treatments such as epidural injections for the disc bulge or disc herniation may be performed in conjunction with physical therapy. When conservative treatment has failed a discectomy may be warranted. This is a surgical procedure where a portion of the damaged disc is removed. Following a discectomy a patient would then undergo the above course of physical therapy.

Disc replacement is surgery that typically takes place in the cervical (neck) or lumbar (low back) spine. The disc replacement surgery is performed on patients that have a dysfunctional disc (either from a severe disc bulge or herniation). These patients typically present with low back or leg pain that has not responded to at least six months of conservative treatment. The surgery utilizes a prosthetic disc (much like a total knee or hip replacement) to simulate normal spine function. If the patient is a candidate, disc replacement may be the preferred surgery versus a spinal fusion because the normal spine function is preserved. Depending on the surgeon, the surgery may be performed either from the front or the back of the body.

Following a disc replacement surgery, a course of physical therapy will be prescribed. Physical therapy will focus on body mechanics, posture, strength, spinal alignment, and stretching. It is very important for each patient to follow the surgeon’s and physical therapists precautions after this type of surgery in order to preserve the integrity of the new prosthesis.

Osteoarthritis, also called OA, can be cause by multiple factors such age, injury or obesity. It is classified as joint and cartilage breakdown. The bones start to rub and wear down to the point of pain and limited function. Common symptoms of early osteoarthritis are stiffness in the joints or back that is alleviated with light movement or pain that is worse with increased activity and towards the end of the day. Some people never have their symptoms progress past this point, however others may have worsening signs and symptoms causing difficulty with walking, sleeping, climbing inclines or stairs, and other household tasks. Osteoarthritis cannot be reversed, however if the symptoms are mild, they can be treated with physical therapy. If symptoms are severe, surgery may be considered. It is recommended to speak with a medical professional about options regarding treatment since new research is showing decreased signs and symptoms after proper strengthening and stretching of key muscle groups versus surgical intervention.

Spinal fusion is a surgery to fuse the vertebra together in the neck, mid back, or the low back. Spinal fusions can be required if the spinal cord or nerve roots that exit the spinal canal are compressed. Compression of the nerve roots or spinal cord can be caused by multiple reasons such as degeneration or aging, trauma or injury, and herniated discs, or spinal stenosis. Researchers do not agree that surgical intervention would decrease pain as there are major risks following a spinal fusion. Sometimes intense physical therapy can alleviate pain or other signs and symptoms related to compression of the spinal cord and it important to exhaust all avenues of pain relief before considering surgery.

Spinal fusions in the spine can be approached through different directions and through different methods in the cervical, thoracic, or lumbar spine. Typically a cervical fusion is approached anteriorly, or through the front of the neck. A thoracic or lumbar fusion is usually approached posteriorly, or from the back. Either approach involves placement of a bone graft, usually taken from the pelvic bone or cadaver, and placed between the vertebra to take pressure off the compressed nerve root or spinal cord. Every surgery is different depending on the surgeon and levels of compression in the spine. Therefore there is no “typical” recovery process. Each individual will experience different results from a spinal fusion and depending on different factors, may go through a rehabilitative exercise program as early as 4 weeks post-op.

Spinal stenosis is used to describe the narrowing of the spaces between the vertebrae. This progression is part of the natural aging process that happens when the discs between the vertebrae in the spine start to degenerate. The narrowing of the gaps usually results in the compression of the spinal column or nerve roots that exit the spinal column and travel to the extremities. This compression can occur in the neck or the low back and cause complications depending on the severity of the stenosis. Signs and symptoms include but are not limited to numbness and tingling in the extremities, pain, and weakness. Severe compression can also cause loss of control in the bowel or bladder and sexual dysfunction.

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Spinal stenosis is typically diagnosed with an MRI or CT scan but can also be viewed with an x-ray. Typically, spinal stenosis can be treated with conservative methods such as NSAIDs for pain relief and physical therapy to increase flexibility and strength of the core muscles. Sometimes a stronger pain-reliever such as a corticosteroid will be recommended if the pain is severe along with surgery to correct any deformities contributing to loss of function or mobility.