More and more surgeons are embracing the idea that physical therapy after bunion surgery can improve range of motion and other functional outcomes. But some practitioners still aren’t sure it’s right for everyone.
By Linda Weber
Most surgeons will tell you outcomes of hallux valgus surgery are very good, often quoting a 90% to 100% percent success rate. A survey-based study published in the December 2001 issue of Foot and Ankle International is typically cited as evidence.
But consensus is harder to come by in determining to what degree post-operative physical therapy contributes to functional outcomes. Some doctors send patients home with a self-administered exercise and self-massage routine and nothing more. Others prescribe an extensive, twice-weekly supervised physical therapy protocol that lasts from four to eight weeks on top of home-based exercises. To complicate matters, patients start PT at various times after surgery, depending on the rate of healing and the type of procedure.
Not all practitioners are ready to accept the idea that physical therapy, and not just surgical technique, can have a substantial impact on the success of hallux valgus procedures.
“Some physicians may think if they send a patient for physical therapy after surgery, it reflects poorly on their surgical procedure,” said Juan J. Rivera, DPM, a private practice podiatrist with the Ankle + Foot Center of Tampa Bay, who views physical therapy as complementary. “In actuality, you are helping your patient optimize their ultimate results and overall post-surgical experience.”
In the last year, two studies, one published and one presented at the American College of Foot and Ankle Surgeons’ annual meeting, have revived the debate. They suggest that post-operative physical therapy can significantly improve range of motion and weightbearing outcomes.
Enter new evidence
In the September 2009 issue of Physical Therapy, investigators from the Foot and Ankle Center in Vienna, Austria, analyzed 30 patients who underwent surgical correction of mild to moderate hallux valgus deformity, including 20 Austin osteotomies and 10 Scarf osteotomies. Prior to initiating the study, the researchers had observed that despite favorable clinical results, including pain relief, the ability to wear a wider variety of shoes, and the ability to participate in recreational activities, gait patterns did not spontaneously alter after surgery.
“We noticed that patients who underwent hallux valgus surgery didn’t use their great toe for push off, even though the deformity was corrected sufficiently,” said Reinhard Schuh, MD, a first-year resident in the department of orthopaedic surgery at Innsbruck Medical University and lead author of the study.
“To achieve bony union of the osteotomy, we had to avoid loading for four weeks,” Schuh said. “But we instructed patients to perform passive ROM exercises starting two days after surgery.”
At four weeks, patients began a comprehensive, 45-minute rehabilitation program once a week for four to six weeks. The standard protocol included elevation of the leg, lymphatic drainage, activation of the muscle pump, and cryotherapy in the first session to reduce swelling. Other modalities, such as scar tissue massage, mobilization, manual therapy, soft tissue techniques, proprioceptive training for the lower leg, strengthening exercises, and gait training, were added progressively over the next four weeks.
Although the researchers did not use a control group, they found that at six months after surgery patients experienced significant improvements in first metatarsophalangeal joint range of motion and function. Weight bearing at the great toe and first metatarsal head, specifically related to maximum force levels and force-time integral, also improved significantly. Participants’ mean functional score on the American Orthopaedic Foot & Ankle Society forefoot scale improved from 60.7 out of 100 before surgery to 94.5 out of 100 at six months. By comparison, previous plantar pressure studies have documented a lack of weight bearing in the medial forefoot and first ray after hallux valgus surgery not followed by physical therapy.
Believe it or not
In the second study, which has been submitted for publication, researchers studied 55 patients who had undergone Scarf procedures at the Weil Foot and Ankle Institute in Des Plaines, IL. The large, 16-office practice in the Chicago area handles 500 bunion surgeries a year. According to Lowell Weil, Jr., DPM, MBA, senior investigator of the study, surgeons in his practice fall into two camps.
“The advent of screws and proper screw fixation eliminated the need for complete immobilization. Patients are able to return to activities and start physical therapy earlier, which has tremendous benefits. We developed physical therapy protocols for patients undergoing these types of procedures,” he said. “Despite that, some doctors in our practice weren’t prescribing physical therapy; they didn’t believe it made a difference.”
So Weil and a few colleagues set out to investigate. Their nonbelieving colleagues’ patients, who did not receive PT, served as a control group.
They studied 44 patients (65 feet) who underwent Scarf osteotomy procedures between 2006 and 2008, followed by a program of once- or twice-weekly physical therapy sessions. The 30 to 45 minute sessions continued for one to six weeks. Another group of 11 patients (14 feet) received no post-operative therapy.
Follow up occurred between November 2009 and January 2010. The physical therapy group significantly outperformed the control group on the Foot Function Index (FFI) and the ACFAS Universal Foot and Ankle Scoring System (see table).
Opinions about post-operative physical therapy in hallux valgus cases are as varied as surgical procedures. For PT proponents, like Michael Loshigian, DPM, a podiatric foot and ankle surgeon in private practice with the Metropolitan Foot Group in New York City, the benefits are indisputable.
“My own experience is fairly clear. Patients who have some sort of formal or informal physical therapy after hallux valgus surgery have better overall results and the progression of healing is more consistent and reliable,” Loshigian said.
Getting a head start
“In a joint fusion case, there should not be any attempt to move the joint, obviously. But in the majority of cases, we’re reorienting the MTP joint, restoring normal range of motion and alignment and function of that joint. In those cases, I have patients start their own range of motion exercises the day after surgery,” he said.
A primary objective is to prevent the soft tissue contracture and joint stiffening that can result from cutting and repositioning of bone.
“It’s easier to maintain good range of motion from the beginning than to attempt to restore it after it has been lost,” he said. “If we give those soft tissues an opportunity to tighten up, movement becomes difficult.”
Loshigian usually starts patients on formal twice-weekly physical therapy two to three weeks after surgery, once he removes the stitches. For most patients, the complete course of therapy lasts six to eight weeks.
At three or four weeks after surgery, patients can start weight bearing without the protection of a post-op shoe; at that point, Loshigian recommends strengthening the muscles and tendons that control the great toe along with continuing ROM exercises and techniques to reduce swelling. The final stage involves strengthening the lower legs and improving patterns of gait, agility, and balance.
Rivera says many factors influence his decisions about the timing and course of therapy.
“Surgical procedures —MTP joint fusion, arthroplasty, chevron, opening base wedge, closing base wedge, first metatarsal-cuneiform joint fusion—all have various timeframes to stay offloaded, which can lead to disuse atrophy,” he said. “Many patients have such low pain tolerance, they need gait retraining to overcome post-operative pain and swelling and regain joint flexibility. Older patients need more help with loss of balance and proprioception.”
Another issue is the amount of time a patient with an operable deformity has postponed surgery; long delays can lead to compensatory gait patterns that are difficult to unlearn without additional physical therapy.
“A common example for me is the patient who undergoes hallux limitus correction surgery,” he said. “The biomechanical compensation for a painful arthritic great toe joint is to ambulate with the foot in an inverted position. Post surgery, the patient continues to ambulate in that position out of habit, delaying the healing of the foot.”
Not for everyone
Donald R. Bohay, MD, a professor of orthopedic surgery at Michigan State University who is also in private practice at Orthopaedic Associates of Michigan in Grand Rapids, views hallux valgus surgery and its aftermath from a slightly different perspective.
“I’m a believer in physical therapy that can help your patient get better faster,” Bohay said. “But I don’t think we know for sure that the patient who gets physical therapy versus the patient who doesn’t is necessarily better after a year.”
Bohay, who favors tarsometatarsal arthrodesis with a modified McBride procedure, says that his patients wear a post-op splint for two weeks. They then wear a short leg cast with heel weightbearing for six weeks, followed by a weightbearing boot for two to four weeks.
Most of the surgeons interviewed for this article would prescribe supervised physical therapy for a procedure requiring so much healing time and immobilization. However, Bohay instructs most of his patients to do home-based range-of-motion exercises and soft self-massage with vitamin E oil to desensitize the foot. When he considers it necessary, he does prescribe formal physical therapy.
“You get a sense that some patients aren’t going to do the program. Those patients do well by going to PT,” he said. “Then there are patients who have a lot more done, who are very swollen, very stiff. For them, physical therapy helps reestablish control, range of motion, and desensitization.”
The therapist’s perspective
Despite the general consensus among surgeons that PT is a useful tool after bunion correction, at least in certain cases, physical therapists express frustration that surgeons don’t take full advantage of their expertise.
“It’s a misconception that physical therapy is cookie cutter,” said Clarke Brown, PT, DPT, OCS, ATC, who is in private practice in Rochester, NY, and president of the American Physical Therapy Association’s foot and ankle special interest group. “We study these procedures. We develop separate protocols for them, and adapt them for each patient.”
Physical therapy following bunion surgery, Brown said, should extend well above the ankle.
“The most challenging thing about feet is that they radically change what happens all the way up the kinetic chain. The good practitioner looks at the whole system, all the way up to the knee, the hip, and the back. We look at the range of motion in all the joints and the strength of the entire leg,” he said. “Most chronic bunion patients can’t effectively lift the bunion leg in side-lying. The hip muscles atrophy.”
Brown notes that the foot and ankle subspecialty in physical therapy is just developing. Even though it’s not something surgeons have clamored for, those who witness the benefits of specialized therapy are sold, he said.
“We found that the faster we started to move the patient’s foot and toes, the more quickly the swelling went down,” he said. “One podiatrist used to take his sutures out after two weeks. But when we moved aggressively, the incisions would sometimes open up. Now he takes the stitches out at 21 days, saying ‘I’ll leave these in longer so you guys can do more.’ The more we communicate with each other, the better.”
A proactive approach
Stephen Paulseth, PT, DPT, SCS, ATC, who runs a private practice in West Los Angeles, often sees patients who have complications or problems that he believes could have been avoided by introducing physical therapy earlier.
“If doctors would send their patients for prehab, they would be doing so much better,” said Paulseth, who preceded Brown as president of the foot and ankle SIG. “I sometimes see patients six weeks in who haven’t really done much. They’ve been told to ice, strengthen, and do some gentle motion, but they just can’t tolerate it.”
He believes proper therapy and patient training can reduce the progression of bunion surgeries.
“Calf length is number one. Inadequate dorsiflexion of the ankle leads to all kinds of distal forefoot issues, including hallux valgus. Patients should begin calf stretching as soon as possible, and they have to continue calf stretching after they’ve healed,” Paulseth said.
Surgeons contend that most patients who undergo hallux valgus surgeries are happy with the results.
“From my experience, the vast majority of patients who have gone through this procedure are very satisfied with the results and in retrospect would choose to undergo the same procedure again,” Loshigian said. “As for their initial post-op experience, the feedback I get from most patients is that it is less stressful and painful than they anticipated.”
In Brown’s estimation, that already good patient experience could be even better if the relationship between patient, doctor, and physical therapist were more collaborative.
“When patients do better quicker, the word of mouth is more positive for the doctor,” he said. “Everybody wins.”
Linda Weber is a freelance writer based in Clemmons, NC.