Q&A with Lucie Gosling, Consultant Physiotherapist

Lucie is a consultant physiotherapist at the Royal Orthopaedic Hospital in Birmingham in the Young Adult Hip Clinic

Question one: Tell us a little bit about yourself, your role, and the services available at your hospital

I work as a consultant physiotherapist at the Royal Orthopaedic Hospital in Birmingham in the Young Adult Hip Clinic. I’ve been at the hospital for over 20 years now, specialising in musculoskeletal and orthopaedic problems. In 2012, I started working with a Young Adult Hip surgeon called Callum McBryde, who had started doing hip arthroscopy, which was quite a new operation at the time. We realised that quite a few patients were coming back after their operations and were tight in their range of movement and struggling, so we developed a physiotherapy protocol together. This evolved and we subsequently developed the Young Adult Hip Service. My role has changed quite a bit, I’m now mainly based in young adult hip clinics where I assess and look at management options for patients with hip pain. I also continue to treat patients in physiotherapy. We now have three Consultant Surgeons in the clinic and two other Advanced Physiotherapy Practitioners who are also seeing patients with complex hip problems, and we’ve got a team of specialist physiotherapists who are also involved with the clinic. In the young adult hip clinic, we see anyone with hip pain under the age of 45, including patients with hip dysplasia, osteoarthritis, hip impingement, and other hip problems that might be congenital or may have developed during childhood.

Question 2: What is your favourite part about your job?

My favourite part of my job is still treating patients in physiotherapy and being able to make a real difference in patient outcomes. I also really like being a part of the diagnosis process, particularly for patients that have spent years in pain seeking a diagnosis and not really getting anywhere; being able to provide this diagnosis and creating a management plan for them is really rewarding.

Question 3: Regarding general conservative management for hip dysplasia, what do you focus on?

There is a primary focus on education and strengthening for this patient group. The education aspect is really important, particularly regarding managing the pain and instability. The increased range of movement of the hip, which goes hand in hand with dysplasia, can exacerbate pain, so we really try to encourage people not to stretch the hip to the extreme ranges of movement, but instead to work on more local strengthening.  At the Royal Orthopaedic Hospital, we have a hip dysplasia class which we set up about 18 months ago, this focuses on education in each session and a progressive strengthening program. The dysplasia class is in a group setting, so there is peer support and patients can share their experiences. We are collecting outcomes on the class and the results look really promising. 

Question 4: What advice would you give patients who are awaiting surgery?

One of the best things patients can do before any operation is to read up about it and inform themselves about the surgery. We have seen good results when patients can practice the exercises preoperatively and trial using crutches. In addition, we often advise continuing to exercise and stay active whilst awaiting surgery. If pain is a big issue, we encourage ‘closed chain exercises’ whereby the hip isn’t subject to lots of extremes of force or twisting: cycling, cross training and Pilates can be very beneficial.

Question 5: Could you give a brief overview of the Birmingham Interlocking Triple Pelvic Osteotomy surgery (BIPO)?

BIPO is the Birmingham interlocking pelvic osteotomy which is used at The Royal Orthopaedic Hospital.  The BIPO differs from a Pelvic Acetabular Osteotomy (PAO) in that is cuts through the back of the hip whereas the PAO doesn’t. There are pros and cons of both approaches. There is good fixation of the bone with metalwork and patients can weight-bear quickly after surgery.

Question 6: Could you give a rough overview of the post-operative protocols and the anticipated timeline for return to activities ( eg return to work )

We don’t have a set protocol for the BIPO, as it’s really dependent on the individual patient. Rehabilitation and progress are affected by things like bone healing, and the healing times can vary between patients; it is quicker in some patients than others, so we found that trying to adhere to strict timelines doesn’t work for this group, it’s more a case of progressing as the patient is able to, which is really dependent on pain and what they can tolerate. We generally find that patients can take between six weeks and sometimes up to three months to get back to full weight bearing, and that’s not because it’s not stable but more because of pain. Patients are normally back to reasonably normal daily activities by around four months, sometimes it’s sooner and sometimes it can take longer, particularly if there’s a complication from surgery.

Question 7: Do any patient characteristics impact these guidelines?

Yes, there are a lot of patient characteristics that could affect how someone heals and their ability to progress. If you think about bone healing, things like age, smoking, diet and other comorbidities can play a part – optimising the factors that patients can influence is very important. Other factors such as a patient’s motivation and adherence to exercise preoperatively are generally good predictors of how someone will do.

Question 8: Do you find many patients return to sport following BIPO surgery, if so, is there a general timeline for return to sport?

I would say from my experience working in the NHS, that less than half of patients go back to high level sports, and it can take up to 12 months dependent on the individual sporting demands. A lot of patients that we see have had hip pain for a long time and therefore have struggled to participate in sports. Often their aims are to get back to normal activities with less pain and so sports may be lower on their priority list. Saying that, a lot of patients do get back to a very good level of activity.

There are a number of rehab phases that a patient will need to go through in order to return to sport. After getting back to normal daily living activities such as shopping/ driving/ walking short distances, a patient would then need to progress to activities such as loading the operated leg and controlling twisting movements/ managing unstable surfaces, improving balance and increasing cardiovascular fitness. The next phase would include controlling landing/ jumping/ propelling off that one leg, moving then on to doing those in multiple directions and then more sports specific activities.

Question 9: What are common issues experienced after BIPO and how do you approach this with physiotherapy?

The most common issues after BIPO are probably pain and muscle weakness, and that’s mainly because there’s been a change in the joint alignment and as a result, the muscles struggle to activate as easily as they did before the operation – in essence they have to re-learn how to function. Another factor is that the bones are healing so the muscles are pulling on bone that is very sore. The first six weeks can be very painful and quite frustrating for patients. We tend to progress patients individually in terms of what they can tolerate. The pain does eventually settle and therefore it’s not worth pushing patients too quickly or judging them against milestones because this can be quite negative for the patient, instead we gently progress patients as they are able to. We encourage patients to attend hydrotherapy in the first six weeks but this does depend on how local they are to the Hospital. Hydrotherapy is really helpful because it helps patients regain their range of movement, confidence in weightbearing and the heat helps the muscle soreness. After around six weeks, patients normally move on to land-based physiotherapy and start working with exercises against gravity, against resistance, and then on to more functional strengthening.

 Question 10: What area would you like to see further developed through research?

I think there’s a real need to develop research into the conservative management options for dysplasia. Some research is coming out that strengthening is beneficial and we are definitely seeing that in the classes that we’re running at the Royal Orthopaedic Hospital, but I think there are lots of different patient groups, some that benefit from coming to a class environment and some, where travel or time is an issue, we need to look at what might benefit them too and other ways we can deliver Physiotherapy and education. Alongside this, research into understanding patients’ perceptions of their condition and what they actually want from conservative treatment would be very helpful.

Junior Board Member Bronagh Walsh interviewed Lucie for this Q&A.

Disclaimer: 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.