"Physical Therapy Can't Help This!" These are the exact words my post-surgical patient was told following a unilateral subtalar fusion. My patient had to self-advocate and almost beg for a PT referral for six months before his surgeon finally gave in. I don't encounter many surgeons who don't recommend PT after a procedure, so this was very surprising, to say the least.
My initial shock was followed by irritation. WHY wouldn't a surgeon recommend PT after this procedure? I knew the benefits of PT after a subtalar fusion. I've seen it in my own clinics. Why didn't the surgeon believe it was beneficial? This led me down the rabbit hole of trying to think of orthopedic procedures that absolutely would not benefit form therapy. Let's just say, I'm still thinking.
Surgery is a big deal. There's a physical recovery process, emotional healing and psychological confidence that all need to be addressed. For some procedures, such as a rotator cuff repair, a return to prior level of function can be eight months, even a year. It should not be taken lightly - not before nor after. In terms of a subtalar fusion, our goal does not include return to full prior ranges of motion (hence the fusion), but there are plenty of other things that need to be addressed.
Healing the foot/ankle in a boot leads to a wide range of compensatory mechanisms to accommodate walking in something heavy that completely restricts (intentionally) movement of the joints in the foot. We often see things like low back pain and hip pain from lateral leaning, and vaulting from walking with one limb "longer" than the other. This can also increase forces on the contralateral, unaffected, non-surgical side which may also result in new pain. One of the biggest compensations I see is significant external rotation at the hip of the affected side to allow for easier ground clearance of the affected limb. Even weeks after the patient is cleared from using the boot, you can clearly see most are still walking with external rotation of the affected lower extremity.
We must also remember, surgery is usually elected after of a long history of injury and or symptoms and because of this, there are frequently compensatory mechanisms that were years in the making. Many times a patient has "lived" with pain for at least 1-2 years before moving escalating treatment to involve surgical interventions. This can make the correction of such mechanics all the more difficult and necessitate the keen eye and prescriptive direction of a trained professional.
With this particular patient, we focused on the entire lower extremity chains of BOTH legs - activating and improving the mechanics and eccentric control of everything from hips and glute to ankle, even foot intrinsics. I followed with soft tissue mobilization and PROM of the lower extremity. On his second visit, the patient reported feeling sore for about an hour following the his first session, but was very pleased because as soon as that first night he began to feel better than he had since the surgery. He said the improvement continued over the next few days. He thanked me several times for the help, knowledge and clear communication and said being persistent with his surgeon about his desire to attend physical therapy was a decision he was happy he made. I'm happy too. #choosePT
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