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Old 03-23-2008, 07:59 AM   #1
Bryan Veis
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Rehab Help? Two Questions

I am 5 months out from a hip resurfacing operation. (For a WFS explanation, those who are interested can look at http://www.activejoints.com/resurfacing.html.) I have "graduated" from the normal course of physical therapy, but all of the supporting musculature in my hip is still weak. The PT at the surgical hospital described me as "beyond normal" and does not really have a good solution, since most of the patients he sees are older and less athletic. Once they are able to do strengthening exercises with 10 pounds of resistance in four directions (standing adduction, abduction, etc. using an ankle cuff on a cable machine), they are done. I am able to do all of them with 20-25 pounds of resistance, so strength is not an issue, at least for normal day-to-day activities.

Background: I've been involved in martial arts, mostly taekwondo, for 35+ years. About 20 years ago I felt a twinge in my hip that was ultimately diagnosed as arthritis. I managed to put up with that until the resurfacing option (as opposed to total hip replacement) became available. I actually ran a marathon after my diagnosis, and I've been pretty active in general conditioning and strengthening during all this time.

I continue to have two problems:

First, I tried some bodyweight lunges the other day, and the consequent DOMS is still killing me after more than a week. The sensation is primarily in the gluteus maximus and gluteus medius, but I'm sure that all the smaller muscles are hurting as well. Compensating for that causes pain to run up my back on the affected side as well. (Interestingly, I can still squat ***-to-ground with no problem.)

Second, I continue to have the same pain as I had before the operation. The surgeon has determined that I have inflammation around the origin of the vastus intermedius. It took a while to figure out, because it is, apparently, an unique complication -- I'm the first out of ~1400 resurfacings that this surgeon has done. We ended up with me under a fluoroscope pointing out the painful area as he traced it with a metal implement so he could see it on the screen.

There may have been a preexisting condition that coexisted with the arthritis, and/or the pain may be related to the use of a retractor to keep the muscle out of the way during surgery. Either way, it still hurts. A series of triamcinalone (like cortisone, but newer) injections really reduced the pain there, so it is likely that is the culprit. The prescribed follow-on therapy is phonophoresis (ultrasound over the affected area using a topical cortisone gel) plus some other things. The problem, as I understand it, is that this is an uncommon condition, and that it is very difficult to deal with problems that deep in the joint. In addition, they have to be very careful not to get too close to the implant when applying ultrasound.

First question: Can anyone suggest intermediate exercises can I do to work back up to being able to do a full lunge? At bodyweight alone, it's difficult and painful; I can't even conceive of using weight, let alone doing something like a split snatch. Under current conditions, I could probably do a couple sets of 10 or 12 lunges every 10 days or so and then suffer for a week before repeating. That doesn't seem like the best way to work this out, though.

Second question: How does one isolate and work on the vastus intermedius? I've done a pretty exhaustive search on line and found nothing helpful. Most of the article dealing with quadriceps rehab focus on the other three members of the quadriceps group.
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Old 03-23-2008, 12:27 PM   #2
Craig Snyder
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Re: Rehab Help? Two Questions

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Originally Posted by Bryan Veis View Post
First, I tried some bodyweight lunges the other day, and the consequent DOMS is still killing me after more than a week. The sensation is primarily in the gluteus maximus and gluteus medius, but I'm sure that all the smaller muscles are hurting as well. Compensating for that causes pain to run up my back on the affected side as well. (Interestingly, I can still squat ***-to-ground with no problem.)

Second, I continue to have the same pain as I had before the operation. The surgeon has determined that I have inflammation around the origin of the vastus intermedius. It took a while to figure out, because it is, apparently, an unique complication -- I'm the first out of ~1400 resurfacings that this surgeon has done. We ended up with me under a fluoroscope pointing out the painful area as he traced it with a metal implement so he could see it on the screen.

There may have been a preexisting condition that coexisted with the arthritis, and/or the pain may be related to the use of a retractor to keep the muscle out of the way during surgery. Either way, it still hurts. A series of triamcinalone (like cortisone, but newer) injections really reduced the pain there, so it is likely that is the culprit. The prescribed follow-on therapy is phonophoresis (ultrasound over the affected area using a topical cortisone gel) plus some other things. The problem, as I understand it, is that this is an uncommon condition, and that it is very difficult to deal with problems that deep in the joint. In addition, they have to be very careful not to get too close to the implant when applying ultrasound.

First question: Can anyone suggest intermediate exercises can I do to work back up to being able to do a full lunge? At bodyweight alone, it's difficult and painful; I can't even conceive of using weight, let alone doing something like a split snatch. Under current conditions, I could probably do a couple sets of 10 or 12 lunges every 10 days or so and then suffer for a week before repeating. That doesn't seem like the best way to work this out, though.

Second question: How does one isolate and work on the vastus intermedius? I've done a pretty exhaustive search on line and found nothing helpful. Most of the article dealing with quadriceps rehab focus on the other three members of the quadriceps group.

Bryan:

For your first problem, is there a way you can lower your weight? Using bands looped over a pull up bar then under your arms. This way when you do lunges, you are lunging with less bodyweight. As far as dosing, in the clinic where I work, we start with high reps (up to 30 pain free reps) and slowly lower the reps and increase the resistance as tolerable.

Another way is partial lunges. I know partial reps sucks, but if you are injured and recovering from a surgical procedure, it might be a possible part-time alternative to build up to full lunges.

For your second question on isolation, I believe that you cannot isolate a specific muscle in the quad, ie VMO, lateralis, intermedius, etc. When the quad fires...it goes. If you want to isolate your quads to get them stronger...try any bodybuilding site on the net. I am sure you can find one....or a thousand. You cannot specifically isolate that muscle. But others may disagree with me as many PTs have been doing (and still try to do) that for many years.

If your hips are still weak, your quads could be taking a lot of the stress irritating it as well. If your thigh can handle it, side stepping with bands (around knees/ankles) is a great way to build them up. Just add them in to your warm up.

Hope this helps get you started.

Craig
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Old 03-25-2008, 04:49 AM   #3
Bryan Veis
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Re: Rehab Help? Two Questions

Thanks, Craig. I'm going to work on figuring a mechanism to lighten the load on lunges, probably just holding onto a rope afixed overhead and compensating as I do the movement.

Perhaps "isolate" wasn't the right word to use, as I don't think that the problem in the vastus intermedius is strength. I meant something more like "What modalities are there that can be directed at the source of the pain?"

The problem seems to be that the origin of the muscle is so deep that it is very hard to get to. The surgeon didn't seem to want to do another series of injections (for good medical reasons, I'm sure), but that's the only thing that has ever provided relief. My PT's are kind of throwing up their hands on this, as there doesn't seem to be any set regimen to deal with this problem.
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Old 03-25-2008, 11:38 AM   #4
Jerimiah Childress
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Re: Rehab Help? Two Questions

First question, your right on working partial reps gradually increasing the range. Also, think about using a Grease the Groove approach to working it. You said that 10 to 12 reps would kill you for 10 days, you might try doing 3-5 reps then resting a couple hours, then 3-5 more, and so on. It might seem like a tedious approach, but should be much quicker than kill yourself/ rest.

Second question, your right you can't isolate it and if you could you wouldn't want to. Your also right that the tissues are to deep for normal surface modalities to significantly affect you would need something along the lines of Ultrasound.
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Old 03-25-2008, 02:58 PM   #5
Bryan Veis
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Re: Rehab Help? Two Questions

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Originally Posted by Jerimiah Childress View Post
First question, your right on working partial reps gradually increasing the range. Also, think about using a Grease the Groove approach to working it. You said that 10 to 12 reps would kill you for 10 days, you might try doing 3-5 reps then resting a couple hours, then 3-5 more, and so on. It might seem like a tedious approach, but should be much quicker than kill yourself/ rest.

Second question, your right you can't isolate it and if you could you wouldn't want to. Your also right that the tissues are to deep for normal surface modalities to significantly affect you would need something along the lines of Ultrasound.
Thanks for the GTG suggestion -- I'll work on that.

As to ultrasound, that is, as I understand it, somewhat tricky in my case because the affected area is very close to my metal implant. I am told that ultrasound and metal implants don't mix very well. I have a metal cap over the femoral head and a thin spike running down into the femoral neck to secure it. The origin of the vastus intermedius is on the anterior surface of the femoral neck. They are going to try phonophoresis next month, but everyone seems to be a bit nervous about doing it so close to the implant . . . and when they are nervous, so am I. (Not to mention that I am dubious about the efficacy of phonophoresis; I had iontophoresis a while back for a shoulder injury, and the concept that the electric current was going to push molecules of topical medication an inch or two into my body just didn't make a lot of sense to me. Maybe I'm inappropriately skeptical, but that didn't seem very likely to me. I feel the same way about phonophoresis.)
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Old 03-26-2008, 04:59 AM   #6
Jerimiah Childress
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Re: Rehab Help? Two Questions

I understand the caution around implants, but i believe with the right settings it would be perfectly safe. As to the efficacy of phono, i understand it seems a little weird, but the science says it works and from my experience it works.
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Old 03-26-2008, 07:30 AM   #7
Craig Snyder
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Re: Rehab Help? Two Questions

For the phono, you will know if it is causing a problem with the implant, it will hurt. The sound wave from the US will bounce off the implant and you will get pain pretty immediately. The good news is that when they pull it away, it will stop. No harm, no foul. This can also happen over bone, called perioteal pain as the sound waves bounce off the bone.

If you are really concerned, I would try Ionto. I have seen very good results, sometimes better than phono. It works on magnetics/electric currents as opposed to sound waves and that won't bother the implant as they aren't magnetic (usually titianim based). Ask about the patches if they have them. You can put them on and leave them on for up to 24 hours for a good long dose to get deep into the tissue. If you do a seach for 'ionto patch' you should be able to find some info for yourself.

Craig
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Old 04-02-2008, 05:05 AM   #8
Bryan Veis
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Re: Rehab Help? Two Questions

A quick update:

I seem to be having pretty good luck with assisted reps on lunges. Thanks, that was a good suggestion. I loop a yoga strap over my pullup bar and assist as necessary. For now, I'm only doing 1 set of 10 reps every couple days, but I have been relatively DOMS-free. With assistance, I can go full range. I'll probably raise the sets and reps next week.

Interestingly, at least to me, I can do full range bodyweight squats with only minor discomfort, and can hold the "third-world squat" position until I get bored and decide to stand up again.

I start physical therapy for the vastus intermedius issue next week. I had an amusing conversation with my podiatrist a couple days ago. He mentioned that in some circles, they talk about "phony-phoresis." He said the science is there, but, even so, there are a lot of skeptics. His take was, "It can't hurt, so why not give it a try."
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Old 04-02-2008, 06:48 PM   #9
Steven Low
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Re: Rehab Help? Two Questions

Ever considered just resting with massage/foam rolling/ART/etc. to let the inflammation go down and let the area heal?
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Old 04-03-2008, 04:36 AM   #10
Bryan Veis
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Re: Rehab Help? Two Questions

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Ever considered just resting with massage/foam rolling/ART/etc. to let the inflammation go down and let the area heal?
I took it pretty easy for several months after surgery. I didn't do anything other than hobble around on crutches and then a cane -- that didn't seem to do anything for the pain. I'n still using a cane to walk.

The problem with massage, etc., the PT's tell me, is that it is extremely difficult to get to this particular muscle. The vastus intermedius is under other muscle tissue. Everybody is throwing up their hands on this. From the research I have done, this seems to be a pretty rare condition. Most physical therapy relating to the hip seems to focus on the iliopsoas, which, until recently, was what everyone assumed was the problem.
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