Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: Letter to the Editor.

Dear Editor:

We recently read the article by Naessig et al entitled “Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: A Comprehensive 5-Phase Patient-Guided Program.” This retrospective study attempts to advance on the inconclusiveness of optimal rehabilitation treatment programs for patients undergoing hip arthroscopy for labral tears as a consequence of femoroacetabular impingement. The authors also qualify the effectiveness of a 5-phase physical therapy (PT) program by reporting patient outcomes.

This publication is a welcome addition to the current knowledge base, which is variable throughout the literature overall; however, we feel it important to highlight some methodological issues to avoid misinterpretation of the conclusion as it is reported.

Phase 1 of this protocol (prehabilitation) is 2-fold: (1) “to potentially resolve the issue” and (2) to “aid the recovery process if the patient progresses to surgery.” We appreciate that the major focus of this study is to evaluate the authors’ current PT protocols after hip arthroscopy specifically; however, the effectiveness of this prehabilitation phase in avoiding patient progression to surgery is not reported. Further, it is unclear how long patients were symptomatic upon initial presentation and whether the patients included in this study had undergone PT before the 3 months of prehabilitation PT in this protocol. As much as prehabilitation may have a positive impact on postoperative outcomes, if failed nonoperative management has already been attempted before referral, then the literature would suggest that delaying surgery may in fact result in poorer long-term outcomes for surgical patients.

Phases 2 to 5 are focused wholly on rehabilitation after arthroscopy and cumulates to a 6-month follow-up. The protocol states it is only at this stage that the physician gauges the patient’s recovery performance and decides whether the patient can return to his or her sport. Based on our own clinical practice, we feel this may be a very conservative approach. Our typical rehabilitation follows the patient utilizing a stationary bicycle from postoperative day 1, crutches for 5 days, initiation of hydrotherapy once the wounds have healed (at approximately day 10), resumption of running from 6 to 8 weeks, straight-line sprinting at 10 weeks, and, for athletes, a return to full training at 12 weeks, with significant improvements in patient-reported outcomes reported longitudinally. For a symptomatic athlete in particular, we fear the duration of this program may not be feasible or warranted. Moreover, the rationale for the phased approach seems disconnected to the description of the arthroscopic technique reported by the authors—minimally invasive puncture capsulotomy that “does not require postoperative [range of motion] limitations; thus, it should theoretically allow faster recovery.”

Perhaps most importantly, the analysis and presentation of the results are not supportive of the conclusion in their abstract that “a structured, patient-guided PT protocol after arthroscopic acetabular labral repair can significantly improve postoperative outcomes.” First, this study lacks a comparison control group of patients undergoing hip arthroscopy alone (ie, those not complemented by this structured patient-guided PT protocol). As such, there is no definitive evidence that improvement in outcomes is a result of the PT protocol or whether the improvements reported are as a result of direct surgical correction of the primary pathology. Second, this is a self-guided PT program, and compliance will undoubtedly vary between patients, the results of which have not been provided. This limits any causal inference of the additional component of PT, as outlined, influencing the observed postoperative outcomes.

In conclusion, we commend the authors for providing details of their phased PT program and agree with the premise that structured and tailored physical therapy after hip arthroscopy may result in improved outcomes and satisfaction. However, we wanted to point out our opinion that the conclusions made by the authors in their study are not supported completely by the results presented and that we do not want the reader to be misinformed.