Whether you are looking to manage your hip dysplasia conservatively or surgically, a physical therapist (PT)/physiotherapist can be an extremely valuable member of your medical care team. Here are answers to common questions and some tips to get the most out of your physical therapy experience. **Please note, this information is related to physical therapy in the United States. Physical therapy practice and services may vary depending on what part of the world you are in.

How can a physical therapist help me?

Most doctors and surgeons will recommend that patients complete a course of physical therapy before deciding to manage hip dysplasia surgically. Some people argue that hip dysplasia is a structural issue and that conservative management cannot “fix” the structural issue. This is true. But hip dysplasia pain is also poorly understood, and a course of conservative management can help determine what pain is related to the actual structure (primary) and what is secondary (likely caused by compensations).

There is some research starting to be published that shows the potential benefits of physical therapy for improving pain and function for people with hip dysplasia. This may be done through core and hip strengthening, posture re-education, and movement training. In some cases, physical therapy may be enough to improve symptoms and function to allow people with hip dysplasia to continue to lead active lives without surgery or to delay the need for surgery.

Even if a patient is planning on surgery, some hip dysplasia research shows that patient outcomes may be better if a patient has lower pain levels and higher function before surgery. A PT can help get your body the strongest and readiest it can be going into surgery and can help you meet your physical goals after surgery.

Are all physical therapists the same?

All physical therapists must graduate from a credentialed physical therapy program and must pass the National Physical Therapy Examination and be licensed in the state they practice in (you can visit this link to find your PT’s licensure information: https://www.fsbpt.org/Secondary-Pages/The-Public/Verify-a-PT-PTA-License). While all PTs receive the same basic coursework through their physical therapy education, PTs often develop specialty areas of practice based on their interests, continuing education, mentorship, advanced training, and experiences. Similar to how medical doctors and surgeons often become highly specialized in their specific area of practice, many PTs are also becoming and more and more specialized. Patients often seek second opinions from medical doctors, but it is important to understand that PTs also vary greatly in their skills, training, and experience and that it may be important to seek a second or even third PT opinion depending on your needs.

What do all those letters mean after my physical therapist’s name?

Physical therapy credentials (all those letters after the name) can be confusing. Physical therapy education has progressed over the years. Entry-level physical therapy practice (meaning the degree you have when you finish school) has changed over the years from a certificate to a Bachelor’s degree (“PT”) to a Master’s degree (MSPT) and currently to a doctoral degree (DPT). These changes have been made over time to support the autonomy of physical therapists as specialist medical providers with a unique skill set.

Patients often ask if it is better to see a PT who is a DPT versus one who is a MSPT. This is a complicated question since there are many more factors than just the credentials. More than anything, the credentials often are more reflective of when a therapist graduated from school. For example, therapists with a DPT are more likely to have graduated in the past 10-15 years unless they returned to school to get their tDPT (transitional DPT). The DPT training programs include more formal coursework on things like differential diagnosis (determining what is the underlying cause of a patient’s symptoms), imaging (like reviewing X-rays, MRIs, etc.), business education, and may also include a more formal research or capstone project and more hours of clinical training. All physical therapy training programs transitioned to being DPT programs in 2015, so all PTs who have graduated since then have a DPT.

In spite of this formal education and training, however, it is also important to recognize that PTs also gain a lot of skill, knowledge, and expertise through their patient care experiences, their mentors, and their continuing education, and a PT who graduated from a Bachelor’s degree program with 30 years of clinical experience and who has completed much specialized training and continuing education in a specific area may be way more knowledgeable about a patient’s condition than a DPT who graduated more recently. If you have questions about your PT’s education, certifications, training, and experience treating your condition, feel free to ask them. Many PTs will be happy to discuss the qualifications with you.

I sometimes see other letters after a physical therapist’s name. What do those letters mean?

As the field of physical therapy has become more specialized, many therapists have decided to become recognized in their area of expertise by becoming board certified. PTs may become board certified in orthopedics (“OCS”), sports (“SCS”), pediatrics (“PCS”), women’s health (“WCS”) and several other areas. To become board certified, a PT has to either complete a residency program (these are optional mentored training programs that may be done in the first few years after graduation to allow a PT to develop specialization in an area) or prove that they have over 2000 hours of direct patient care experience in their specialty area. They must also pass a specialty examination that often takes many months to prepare for. Since board certification is optional, there are many exceptional PTs who are not board certified, however finding a PT with these credentials is a way for patients to know that their PT is committed to this level of specialization.

In addition to board certification, some PTs have advanced training in a specific technique or area of specialty practice through fellowship programs. For example, patients with orthopedic conditions who are interested in a provider who has advanced training in hands-on manual therapy treatments, might look for a PT who has FAAOMPT (Fellow of the American Academy of Orthopedic Manual Physical Therapy) or COMT (Certification in Manual Physical Therapy) after their name.

A few other credentials that patients may include post-graduate level degrees such as PhD (Doctor of Philosophy), DHSc or DHS (Doctor of Health Science), or EdD (Doctor of Education). These degrees indicate that your PT has even more specialized training, but these degrees are more academic or research-based and not based on clinical training or specialization.

Do I need a referral to go to physical therapy?

The answer to this question will vary depending on the state you live in. Many states have a provision called “direct access.” In a state with direct access, patients can be seen by a PT without a doctor’s referral. Sometimes there are limits on how long a patient can be treated for before needing a referral and sometimes this is unlimited.

To find out what the direct access laws are in your state you can visit this link: http://www.apta.org/StateIssues/DirectAccess/FAQs/. Keep in mind that even in a state with direct access, specific physical therapy practices may still require a referral or your insurance may still require a referral for reimbursement, so this is important to know when you schedule an appointment. It is also important to have open communication with all of your medical providers, so even if you don’t need a referral, it would be good to let your physician or surgeon know that you are planning on scheduling an appointment with a PT in case there is anything important for the team to share.

What is important to consider when finding a physical therapist?

Location and Office Hours

This may be more or less important to you depending on where you are at in your treatment. Patients may go to PT as much as 2-3 times a week for a course of time, so it may be important to find a facility that is convenient for you to get to and that has office hours that work with your schedule.

Insurance

It is important to understand your insurance benefits if you plan on getting your visits covered through insurance. When you schedule an appointment it is important to verify that your insurance is in-network. Many PT practices will help verify your benefits, but it is also good for patients to double check their coverage. Some practices are “cash-based” only. If you go to a cash-based practice you may be able to submit receipts for reimbursement if you have out-of-network benefits. If you plan on doing this, it will be important to ask the PT practice if they can help by providing receipts with diagnosis and treatment codes.

Session Structure

Depending on the clinic type and model, patients may have varying amounts of contact with a physical therapist. In some clinics patients spend 100% of their time in the clinic directly with the physical therapist or physical therapist assistant. In other clinics patients may spend half or even less than half of their time in the clinic working directly with the physical therapist and may be doing a lot of their exercise program with distant supervision of the therapist or under the supervision of a physical therapy aide. Although therapy aides may have extensive training in movement and exercise, certification or licensure are not necessary for these roles and the level of supervision and expertise provided may not be optimal for patients who need a lot of guidance to perform exercises correctly. There is not a “right” or “wrong” for choosing a clinic model, but it is important for patients to be aware of their options and have an understanding of what your therapy program might look like in the clinic and under what level of direction so that you can choose a practice that will work for you.

Connection

Although not necessary, there is a lot to be said for finding a PT who you can “connect with.” Rehabilitation can be an extremely worthwhile investment both in the conservative and surgical management of hip dysplasia but it can take a lot of time. Since you will be spending a lot of time with your physical therapist (way more than with your surgeon!), many patients who have very positive experiences describe having good relationships with their PT. Your PT should want to get to know you and understand what your values and priorities are, as well as what your goals are for therapy. You should feel comfortable talking with your PT openly about questions and concerns you might have. A good PT will listen to your questions and concerns, respond openly and honestly, problem solve with you, have patience, and will help empower you to have the best outcome possible for YOU.

How do I begin to find a physical therapist?

Finding a PT can be an overwhelming process, but taking the time to do some research may help you find the provider who is right for you. Here are some places to begin:

1. Ask your primary care physician or surgeon for recommendations. If you are having surgery locally, your PCP or surgeon may already have relationships with PTs in the area who have treated other patients.
2. Visit the American Physical Therapy Association (APTA) website for therapists who are members of the APTA (professional membership is voluntary and does not have anything to do with a therapist’s skill level). https://aptaapps.apta.org/APTAPTDirectory/FindAPTDirectory.aspx
3. Search for board certified specialists in your area. For adolescent and adult patients with hip dysplasia, generally a PT who specializes in orthopedics and has an “OCS” might be most appropriate, but in some cases a therapist who specializes in sports, women’s health, or pediatrics might be equally appropriate. https://aptaapps.apta.org//APTAPtDirectory/CertifiedSpecialistDirectory.aspx
4. Ask family members, friends, or other hip dysplasia patients for recommendations. Keep in mind that the best PT for one patient and their diagnosis may not be the best for you, but sometimes “word of mouth” can be a great way to find a PT.
5. Contact local hospitals. Hospitals often have out-patient PT clinics associated with them or may be able to tell you where they tend to refer patients to.

What do I do if I have a limited number of insurance visits?

This can be a tricky situation. However, with some foresight, creativity, communication, partnership, and determination it is possible to make a situation of limited insurance visits work.

Here are a few ideas:

• Plan ahead and schedule surgery at the later end of your insurance year (keep in mind when you might be allowed to start PT after surgery. For surgeries like hip arthroscopy and total joint replacement you might be allowed to start PT right away. For a periacetabular osteotomy surgery (“PAO”) your surgeon may not want you to start PT for 6-8 weeks). For example, if you have 20 insurance visits per year and you are having a PAO a potential therapy schedule could look like this:
  • 4-6 visits to focus on “pre hab” (4-6 visits)
  • Surgery late September/early October
  • Start PT 6 weeks post-op and attend PT 2x/week for 6-8 weeks (16 visits)
  • New Insurance Year (by this time you are about 12-14 weeks post-op)
  • Continue PT 1-2x/week as needed to return to baseline level of daily function.
  • If you have athletic or high-level vocational or recreational goals, consider focusing on home programming for a few months and saving some insurance visits for months 6-12 to focus more intensively on higher level skills once you are further into healing and fully cleared for all activities.
• Discuss private pay/cash-based options with your physical therapist/clinic. Some cash-based therapists and standard clinics will be willing to work out special deals with patients who are post-operative to make frequent therapy services more affordable if insurance won’t cover the cost. If you will be paying out-of-pocket for therapy services and cost is a major consideration, you might even consider doing some therapy practice “shopping” to find out what these rates might look like when you choose your therapist/practice.
• Have an open conversation with your therapist about your therapy visits and how you can partner together to best plan how to use those visits. While most PTs do try to make the effort to pay attention to the insurance plan and have a sense of how many visits their patients have, it can be difficult for a busy PT to keep track of insurance information. Ultimately it is up to you as the patient to understand your insurance plan and to make sure that your medical providers are also aware of any limitations (although if you have questions, your insurance company can help and many clinics also have non-clinical staff who have knowledge in this area). Some variables that you might discuss with your therapist that may impact your plan of care include:
  • How many therapy visits you have?
  • What resources do you have beyond those? For example, can you afford out-of-pocket therapy visits? Do you belong to a gym or can you afford to get some therapy equipment to carry out the majority of your therapy program more independently?
  • What is your surgeon’s therapy protocol/expectations for therapy? How can this be modified to best-meet your needs?
  • What is the projected course of your recovery? Do you have unique health-related comorbidities that could slow your recovery process (ex. decreased bone density/at risk for slow bone healing, at risk for slow tissue or wound healing, chronic pain, connective tissue disorder, psychiatric conditions that might limit recovery?) If you are likely to require a prolonged course of rehab, it will be especially important to talk about how to best-use insurance visits. Spreading therapy visits out and focusing on home programming in between might be beneficial. It might even be beneficial to have a close family member or friend attend sessions with you so that they also can learn basic therapy techniques and movements to look for while you are doing your exercises so that they can help reinforce these at home or in the gym setting.
  • Do you have athletic goals or require high levels of physical function for work or life/recreational activities? If so, you might want to be especially thoughtful about how you use your insurance visits. Full recovery from hip surgery can take 6-12 months, if not longer. If you are in this situation and have limited visits you might talk about spreading therapy visits out earlier on to save some for a more intensive episode of care in the 6-12-month range when you can focus on higher level activities.

In addition to discussing these with your PT, it is also important to discuss them with your surgeon, especially before surgery. Sometimes it is possible for a surgeon to negotiate more visits with an insurance company. Other times there are “hard limits” on the number of visits. Regardless, it is important for your surgeon to understand any limitations you may have around post-operative PT. He/she and your PT may also be able to communicate and collaborate around your plan of care to make sure that you are set up for success!

What do I do if my physical therapist has never heard of hip dysplasia or the surgery I had?

Don’t freak out! The hip is a very complex structure and there have a been a lot of advancements in diagnosis and treatment in the past few decades. The rehabilitation world is working hard to keep up!

It is going to be easier to find a therapist who has experience with patients undergoing total joint replacements and hip arthroscopy (“scopes”) than some of the less common osteotomy procedures like PAOs (especially in areas of the country where there isn’t a local surgeon doing high volumes of complex hip surgeries). Finding a therapist who treats a lot of patients with hip pathologies and understands the complex biomechanics and need for proper muscle function and movement retraining can be key.

While it would be great if everyone could find a therapist with experience in their specific diagnosis and surgery, it is important to remember that post-operative protocols can vary between patients and surgeons and there are many individual patient differences including comorbidities, chronicity of pain and muscle/movement dysfunction, psychosocial factors, and patient goals vary greatly. So unless a PT works in an area where they have high-volume exposure to a certain surgeon and patient population, it probably doesn’t matter too much. What WILL matter is that you find a therapist who is smart, thoughtful, creative, dedicated, and good with problem-solving and who is willing to work with you through your unique situation.

If your PT isn’t familiar with your specific surgeon or surgery, it will be important that they communicate or collaborate with your medical team. You can help by getting copies of your surgeon’s clinic and/or operative reports to share with your PT as well as your surgeon’s post-op rehab protocol (or ask your PT to get them). If your surgeon does not have a specific protocol, there are some articles that can also be shared with your PT if her or she is interested in more information about hip preservation concepts, surgery, and rehabilitation. It is extremely important, however, that you and your PT communicate with your medical team to make sure that these guidelines are appropriate for your case.

How do I know if physical therapy is helping me?

In general, the best way to know if physical therapy is working is that you will see a gradual improvement in symptoms and function over time.

It is important to keep in mind that many patients with hip dysplasia have lived for decades with hip instability and that this can cause a lot of muscle and movement compensations over time. Re-training muscles to fire properly and teaching your body how to maintain postures and move in new patterns can take a lot of time. Be patient with the process and discuss strategies with your PT to help know if you are progressing in the right direction.

As a patient it is easy to get impatient with the process of recovery and feel like it takes forever.  You may go through phases or rapid improvement and other phases of slower improvement during the treatment or recovery process.  Keeping a diary or calendar of your symptoms or rehab progress can be helpful.  Your PT can also be a great resource for maintaining perspective on recovery since he or she will be documenting your session activities and progress towards your goals on a regular basis.  It’s important to keep your focus on the “big picture” goals and outcomes, but don’t forget to appreciate and celebrate the smaller milestones along the way!

What do I do if I feel like physical therapy isn’t helping me?

Make sure your therapist is aware of how you are feeling about your progress in therapy. It is common to experience occasional “flares” and “setbacks” when managing hip dysplasia conservatively or post-operatively.  This is completely normal!  However, it is very important to make sure to openly share your symptoms with your therapist to make sure that you are progressing properly.

Sometimes an increase in symptoms can be due to the body trying to learn new ways of moving. Sometimes an increase in symptoms means that muscles are not firing in the correct pattern or that there is some weakness or decreased motion in your chain that is causing improper compensations.  In these cases, it might be that you still need more time to focus on basic muscle activation and postural/movement re-training before advancing to higher level activities.  Sometimes your body is still healing and needing more time to recover from a bone or soft-tissue healing perspective.  In these cases, time and patience may be the greatest variables.  Usually reassessing your overall therapy plan of care in these situations and some problem-solving between you and your PT is enough to get past the “flare” or “set-back” and then you will be able to progress again.

Occasionally an increase in symptoms can mean a bigger problem, so it is especially important for you and your PT to be communicating openly and that you communicate with your surgeon to determine if additional medical work-up is necessary before continuing to progress your PT program.

If you have worked through all of these situations and still feel like you are not making the progress in therapy that you are hoping for, it might be appropriate to consider a second PT opinion. All physical therapists, just like surgeons, assess problems through different lenses based on their training, mentors, previous experiences, and clinical biases.  This doesn’t make any one PT less “good” of a PT than another, but sometimes patients need a different “lens” on their case if progress has really stalled.  Even if it feels uncomfortable, it might be worth having the conversation with your PT about getting a second opinion.  A good PT might even recommend getting a second opinion from a PT with a different skill-set and may be able to help facilitate this.  If you do end up seeking a second opinion and perhaps even establishing care with another PT, transparency with your providers will help make sure that you all know what your overall rehab program looks like so that you can determine what is working and what is not working.

Author: Nancy Muir, PT, DPT, PCS, DHSc

Disclaimer: All of the information on this site is peer reviewed, as well as reviewed by our current medical advisor. The information on the Miles4Hips website is meant for informational purposes only. While our goals are to promote understanding and knowledge of hip dysplasia and to empower patients and their families in healthcare decision making, we cannot guarantee accuracy or appropriateness of the information for your specific condition or circumstances. The information on this site is not meant to take the place of the professional judgment of your medical providers. Individuals should always seek the advice of your physician/surgeon, physical therapists, and other qualified health care provider with any questions you may have regarding a medical condition or treatment. Individuals should never disregard the advice of your medical providers or delay in seeking it because of something you have read on this website.