hip arthroscopy rehabilitation part two

The hip arthroscopy

rehabilitation guide for

patients and therapists

By Louise Grant MCSP

Hip Specialist Chartered Physiotherapist,

Hip-Physiocure, UK

Copyright August 2011

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LEVEL ONE

Week 4 exercises

Aim – early active hip circumduction/proprioception

46. Active assisted hip circumduction. Lie on your back with your knees and hips bent. Next, place an elastic exercise band around your lower thigh (note-health & safety warning). Place hip and knee at 90 degrees, pic 1. Tension up the band with your hands. Lumbo-pelvic neutral, T.Abs engaged. Now push your thigh away from you, pic 2, so you are activating your hamstrings. Your hip flexors should be relaxed as the band should be supporting your leg and hamstrings engaged. Next, imagine a pencil pointing from your knee up towards the ceiling. Draw a small circle with the pencil, very slowly and relaxed. 10 times in each direction, 2 times a day.

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Copyright-PHYSIOCURE

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LEVEL ONE

Week 4 exercises

Aim – early active hip control

47. Four point kneeling gluteal strengthening. This exercise uses the hip extensors without taking the hip past neutral extension. It can then be progressed to integrating hip abduction as an alternative to side lying (some hip patients find side lying a problem). Firstly, set up position on all fours as per exercise 17. Keeping lumbo-pelvic neutral, T.Abs engaged, shoulder blades wide and gently drawn down towards your lower ribs, neck lengthened. Next slide one leg back, extending it behind you, keeping your pelvis level. Repeat 5-10 times, 2 times a day. The progression from this (once mastered!) is to lift the leg in the extended position from the floor , not higher than hip level. Then, once the second stage is mastered…once you have lifted the leg, maintained lumbo-pelvic neutral and have correct body posture you can then take the leg out to the side into hip abduction.


If too difficult, try exercise 45 instead

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LEVEL ONE

Week 4 exercises

48. Double leg bridges. As per exercise 32

49. Hamstring stretch. As per exercise 36.

50. Calf stretch. As per exercise 37.

51. Iliotibial band stretch. As per exercise 38.

52. Faber stretch. As per exercise 39.

53. Hams curl/Quads stretch. As per exercise 22.

54. Exercise bike. As per exercise 10.

55. Calf raises. As per exercise 35.

56. Swiss ball exercises. As previously shown.

57. Hydrotherapy. Refer to separate handbook.

58. Prone hip internal rotation. As per exercise 19.

59. Heel slides in supine. As per exercise 16. Progress with opposite arm floats ie. left leg slides straight as right arm raises above head. Ensure good rib cage placement, do not lift the breastbone or extend in the thoracic spine. Please get your therapist to check you have correct technique and control.


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LEVEL ONE

Week 4 exercises

Aim- integrate into function.

60. Double small knee bend. Some guidelines suggest the controlled use of the leg press at this stage. Personally, I prefer a more functional based exercise that will also challenge body awareness/posture/alignment and integrate lumbo-pelvic-hip control (and you can fit into your day!).Stand with your feet hip distance apart. Weight bearing as allowed by consultant. Some will be full weight bearing (FWB). Those who are partial weight bearing (PWB), stand near an appropriate support to take some weight through your arms. Make sure your feet are pointing forward (or very slightly turned out if this is more comfortable). Stand up straight, good posture, lumbo-pelvic neutral , T.Abs engaged. Gently squeeze your bottom, but do not tuck your tail bone under, or rotate through the hip bones or pelvis. Place your hands on the sides of your hips to monitor their movement (not if PWB!). Bend at your hips and knees (about 30 degrees flexion), knees in alignment with the middle toe, do not let ankles/feet ‘roll in’, the rest of the body should be straight..you are only bending at the ankles/knees/hips. Keep gluts and T.Abs engaged throughout the WHOLE movement..contin on next page..


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LEVEL ONE

Week 4 exercises

60. Double small knee bend continued …. Palpate with your hands to check your hip flexors are relaxed, gluts are firing but not ‘gripping’, you should be able to feel the side hip bone glide backwards in a relaxed fashion as your hips bend. Hold the bent position for 5-10 seconds, repeat 5-10 times, 2 times a day. It is important that when you return from the bent position to the start position, that you keep your gluteals and T.Abs activated GENTLY and do not hyperextend your hips or knees at the end of the movement, or go into ‘sway back’ posture. It is important that you get your therapist to check this.

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LEVEL ONE

Week 4 exercises

Exercises –

It is still beneficial to be practicing weight transference exercises and the swiss ball exercises, even though they are mentioned specifically in week 3.

Note to therapists –

In some of the guides I have reviewed, it is suggested that the use of the cross trainer is appropriate at week 3-4. There will be some patients that this maybe appropriate for , ie. they have had simple non-complex surgery / had good pre-op fitness with no long standing muscle imbalances / the surgeon has advised this…

In my experience, I have found that it is preferable for patients to have symmetry of movement and muscle power, good lumbo-pelvic control, satisfactory and symmetrical balance and proprioception…before adding in dynamic challenges. I test these things in my patients so I have a good idea if they are ready for the cross trainer. This is in order to prevent any compensations in movement patterns.

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Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28

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WEEK 4 - Exercise record sheet

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Progression criteria to

move on to level two

•  Minimal pain with level one exercises.

•  75% hip ROM restored •  Proper muscle firing of

initial exercises. •  Minimal pinching of hip flex

to 100 degrees. •  Full weight bearing

achieved (ref 12,13 ).

•  Ability to maintain lumbo-pelvic and hip joint neutral.

•  Equal weight bearing through ischial tuberosities in sitting.

•  Good control with double bridge, double calf raises and small knee bends.


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Level two

•  Intermediate stage rehabilitation.

•  WEEK 5 •  (day 29 – 35) •  WEEK 6 •  (day 36 – 42)

•  Aim to increase range of movement.

•  Ensure good walking pattern.

•  Progressive balance, posture, proprioceptive, strength and core stability work.

•  Thoraco-lumbar, lumbar-pelvic and hip dissociation work.

•  Use whole body and functional approach in rehab.


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LEVEL TWO

Week 5 + 6 exercises

61. Single bent knee fall out. Lie on your back, knees and hips bent. Ankle bones together. Find lumbo-pelvic neutral. Engage T.Abs. Gently float one knee out to the side, rotating at the hip outwards. The knee of the opposite leg should stay pointing to the the ceiling, and your pelvis should not rotate. Hold the position for a breath in and then move back to the start on the breath out. Repeat 5-10 times, 2 times a day.

Aim – to help rotation control at the hip/pelvis.

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LEVEL TWO


62. Hip internal rotation with band. Tie an elastic exercise resistance band around your ankles. Kneel on a stool but make sure you can hold on to a support. Keeping your knees together, rotate one hip inwards, knees together, lower leg moves out, as in the photo. The other leg serves as an anchor. Hold 5-10 seconds, repeat 5-10 times, 2 times a day.

63. Active assisted hip circumduction with band. As per exercise 46.

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LEVEL TWO


64. Single leg balance. This exercise can then be progressed to single leg controlled knee bends. Firstly, set up your posture, as in exercise 33. Engage your T.Abs and gently take your weight through one leg. Try not to hyperextend your knee or sway forward in the hip, keep good alignment of hips, pelvis, spine, lower limb….. You may need to hold lightly onto a support at first. Practice for 5-30 seconds, little and often. Once you have good control of one leg standing, progress this to bending the knee of the weight bearing leg very slowly and in a small range (ie.10-30 degrees). Use the alignment principles as in exercise 60, keep your knee cap pointing forwards, knee in line with 2nd toe . Repeat slowly 5-10 times, 2 times a day.

Also try single leg calf raises, see how many reps you can do on your non-operated side and work on gaining equal ability.

Aim – integrate into function.

Single

knee bend (ref 40)


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LEVEL TWO


65. Adductor stretches. These can be done in sitting or standing as shown, make sure they feel comfortable to do. They can also be done in the pool. Hold 10-30 seconds, repeat 5 times, 2 times a day.

66. Isometric Adductors. As per exercise 27.

67. Exercise Bike. As per exercise 10. You can start gradually increasing the resistance on the bike now.


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LEVEL TWO


68. Dynamic balance challenges. Equipment such as a wobble board, ‘sit-fit’, ‘dyno-cushion’, ‘Wii-fit’ can be used after discussion and consent from your physiotherapist, to aid weight transference and proprioception work. Begin with double leg work, progress in time to single leg.

Top tip – Add in some upper body challenges as your balance improves


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LEVEL TWO


69. Hip Abduction. This can be done in the pool or as in exercise 47. Alternately, if side lying is pain free you can try hip abduction in side lying. Side lying exercises not favourable with trochanteric bursitis.

Set yourself as in the picture 1.Adopt Lumbo-pelvic neutral, T.Abs engaged. Waist and leg lengthened. Gently squeeze your bottom as you float the top leg to hip height as you breathe out, see photo 2; keep waist lengthened. Hold for a breath in and then slowly lower the leg back down keeping the gluteals and T.Abs engaged. Repeat 5-10 times, 2 times a day.

This exercise can also be done so your body is against the wall. This is so you can push your heel into the wall to engage your gluts and keep that pressure as you slide your heel up and down the wall. (ref 27).

2 1


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LEVEL TWO


70. Double bridge with heel lifts. You can progress exercise 32 if you have good technique, control and it is pain free. Once in the bridge position, raise the heel of one foot, lower, then repeat on the other foot. Then lower your pelvis back to the start position. Repeat 10-20 times, 2 times a day.

71. Lower limb stretches. As per exercises 8, 19, 36, 37, 38, 39.

72. Hydrotherapy. As per exercise 34.


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LEVEL TWO


73. Swiss Ball Exercises. As previously shown.

74. Cross Trainer/Elliptical Trainer. Check this is done symmetrically and without any compensations. Start on an easy level and build up slowly. Stop if painful.

75. Kneeling Hip Flexor Stretch. Kneel on one knee and place the other leg in front of you with the knee/hip bent and foot flat on the floor. Adopt lumbo-pelvic neutral, engage T.Abs and now gently tuck your tail bone under and move your bent knee slightly forward, so you feel a gentle pain free stretch in the front thigh of the kneeling leg. Avoid straining the front of the hip of the kneeling leg, or pushing the hip into extension. Hold 10-30 seconds, 5-10 repetitions, 2 times a day.


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LEVEL TWO


Extra optional exercises –


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Hip side glide to the wall

Hip flexor stretch, avoid pushing into hip extension. Keep in hip joint and pelvic neutral.

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LEVEL TWO


Note to therapists – Re-measure the hip range of movement and record for the patient in this handbook.

Check the sacro-iliac joint and lumbar spine (Ref 36).

Expect new pains to occur as the body is adjusting to changes following surgery. It is normal that your patient may still feel quite tired, even at this stage, after surgery. Encourage them to get plenty of rest and not to overdo things.

Patients who have suffered a long time with pain and decreased function will need time, patience, understanding and information on realistic goals in their recovery. (Ref 41)

Recovery is not judged on a time basis but the overall long term satisfaction(Ref 20). It may take a year or longer, for some people who have had pain for a long time to reach their optimum recovery.


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Reassessment of pain after 6 weeks. Shade in the areas on this body chart where you have

your post-op pain. Scale the pain from 0-10 (0 is no pain and 10 is the worst pain imaginable).

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Diary page – write down here how you are feeling in yourself and the positive changes you

feel since your operation.

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Ask your physio to record these 6 week post-op hip measurements for you, so you can monitor

your progress. (ref 12)

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Hip Right Left

Flexion

Abduction

Adduction

Faber

Int rot (neutral)

Ext rot (neutral)

Trendelenberg test (ref 13)

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move on to level three

•  Hip has full range of movement.

•  Painfree normal gait •  Hip flexion muscle power

(MP) operated leg at least 60%.

•  Hip add/abd/ext rot/int rot/ext MP operated leg at least 70%.

•  No joint inflammation, muscle irritation or pain.

•  Good neuromuscular control •  Painfree functional exercises

(ref 19,20).

•  Good control of single knee bend, single leg calf raises and bridge with heel lift.


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Level

three

•  Advanced stage rehabilitation.

•  WEEK 7 •  (day 43 – 49) •  WEEK 8 •  (day 50 – 56)

•  Aim to gain whole body symmetry.

•  Increase general flexibility. •  Increase strength and

endurance with cardio vascular challenges.

•  Advanced proprioceptive and core stability work.

•  Recreational sports specific skills.


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LEVEL THREE


76. Exercise Bike. As per exercise 10.

77. Hydrotherapy.

78. Cross Trainer/Elliptical Trainer. Check this is done symmetrically and without any compensations. Start on an easy level and build up slowly. Stop if painful.

79. Lower limb and spinal flexibility stretches +/- foam roller. Adductors, ITB, Quads, Hip flexors, Hams, Calf, Spinal Mobility (eg. Exercises 8, 36, 37, 38, 39, 12, 19, 65, 75). Hold your stretches 10-30 seconds, 5-10 times, 2 times day. Please note, the hold times and the repetitions are set in this variable way, to point out that it can be different for each patient in what is suitable for them.

Top tip – Patients frequently report how important they find stretches in helping their recovery and notice they do not feel as good if they have forgotten or have been too busy to do them.


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LEVEL THREE


80. Walk-Jog-Run Program. (do not run/jog for 13 weeks following microfracture). Start by building up your walking distance outside and speed, making sure this is painfree. If this is painfree, there is no limp and you have passed tests with your physio to ensure symmetry and adequate dynamic stability you can start a walk/jog program ie. walk 1 min, jog 1 min….for 5-10 mins. Have a rest day after so you can observe if this has provoked any latent pain (delayed pain that occurs after an event).Gradually build up to running.

Therapists, please note, some consultants prefer to leave running until week 8-12…..therefore check!

Also practice walking backwards/sideways and along an imaginary tight rope.

Do not ever run on a treadmill as there are concerns about the damage this could cause to your hip (forever).

Make sure you wear supportive adequate running shoes and be aware that some patients report a difference in foot posture after theiir surgery. If you wear orthotics it would be wise to have yourself reassessed by a Podiatrist.


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LEVEL THREE


81. Lunges. Stand with one foot in front of the other, feet pointing forwards. Make sure your pelvis is straight. Imagine a ‘head light’ on each front boney prominence of your pelvis and that they are pointing straight ahead. Adopt lumbo-pelvic neutral, T.Abs engaged and maintain these throughout the movement. Now bend your back knee, bending at the foot/ankle so the heel lifts from the floor; at the same time as bending your front knee (see photo). Try and keep good alignment – get your therapist to check your technique. Keep your torso straight; imagine it to be a piece of toast going up and down in a toaster! Repeat the movement slowly and in a controlled fashion 5-10 times, 2 times a day. (Ref 42)


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LEVEL THREE


82. Single leg bridge. Adopt the double leg bridge position as in exercise 32. Check you are able to perform the heel lifts as in exercise 70 before you attempt removing one leg for the single bridge. Once in the double bridge, remove one foot off the floor. Make sure your pelvis stays level and it is a painfree position. Hold for 5-10 seconds. Repeat 10 times, 2 times a day. (Ref 43)

83. Hip Adbuction with internal rotation. If you have reached a satisfactory level with exercise 69, you can progress to performing it with the leg turned in. This must not provoke pain. Lift slowly, with good control 5-10 times, 2 times a day. Check the patient does not dominate with the ITB.


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LEVEL THREE


84. Prone heel squeeze. Lie on your front with your knees at a 70 degree bend, hips slightly abducted. Put the insides of the heels together, press together gently and slightly let the knees lift from the floor. Hold 5-10 seconds, repeat 5-10 times, 2 times a day. (ref 27)

85. Plank/Side plank/High kneeling swiss ball roll outs. Reetitions to be determined by therapist as dependent on ability and control of individual.


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LEVEL THREE


86. Single bent knee fall out with band. Once you are comfortable doing exercise 61, you can progress this with an elastic exercise resistance band tied around your lower thighs. (Please observe the health & safety warning for use of bands). Repeat slowly 5-10 times, 2 times a day.

Start

Finish


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LEVEL THREE


87. Long lever hip circumduction/proprioception with band. Once you are comfortable doing exercise 46, you can progess this with the leg straight and the band around the foot like a stirrup. (Remember eye goggles recommended with use of bands). Ensure the leg is supported by the band, the foot is pointed and imagine drawing small circles 10 times clockwise then anti-clockwise; as if your leg is a pencil, 2 times a day. Try to make your circles as smooth and circular as possible. The movement should be slow and controlled.


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LEVEL THREE


88. Single leg extension with band. This exercise is useful to compare the ability of each leg with control and alignment. Lie on your back, hips/knees bent, place the band like a stirrup under one foot (eye goggles). Slowly bring that leg up so the hip and knee are at a 90 degree bend. Tension up the band so you are holding it like reins, elbows tucked into sides. Adopt lumbo-pelvic neutral, engage T.Abs and slowly push your foot away as if to the wall (not ceiling). Try and observe what is happening to the leg, do not let it rotate/adduct/abduct, try and keep your knee cap pointing up towards the ceiling. Repeat 5-10 times each leg , 2 times a day.


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LEVEL THREE


89. Hip Adduction in side lying. Lie on your side as in the photo with supports for comfort. Adopt lumbo-pelvic neutral, engage T.Abs; lengthen through the bottom straight leg and gently hover off the ground. Hold 5-10 seconds, repeat 5-10 times, 2 times a day.

Therapists, check technique and look for signs of compensation with leg position. (Ref 44)

Make sure this exercise is painfree in the groin.

Start

Finish


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LEVEL THREE


90. Hip Flexion in supine. Stage 1- lie on the floor with both knees/hips bent, lumbo-pelvic neutral, T.Abs engaged. Breathe out and float one leg up so the knee is directly over the hip joint, hip/knee bent to 90 degrees, photo 1. Lumbo-pelvic neutral should be maintained. Hold as you breathe in, then slowly lower as you breathe out. Repeat 5-10 times, 2 times a day.

When this feels comfortable to do, progress to stage 2, floating one leg up. You will need to imprint your spine (flatten into the floor) for this. Keep it in that position and bring the other up to join it. Then straighten one knee, photo3 then bring it back to photo 2 position then repeat with other leg. Finally lower one leg to the floor, then the other leg.

1

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3

Caution with Hip flexor


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LEVEL THREE


90. PROGRESSION - Hip Flexion in standing/balance. Adopt a good standing position as in exercise 33. Stand near an appropriate support, take your weight through one leg, avoid hyperextending the knee or gripping the floor with your toes. Slowly lift up the leg as in the photo, to hip height. Keep your pelvis level, and lumbo-pelvic neutral, upper body relaxed. Balance for 5-10 seconds, 5-10 times, 2 times a day.

Integrate in with dynamic balance challenges (exercise 68).

Caution that this does not irritate the hip flexor


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LEVEL THREE


Note to therapists – Use realistic timescales, be cautious.

Use common sense – players/patients will progress at different rates.

Assess each patient individually, you may need to modify rehabilitation/timescales/treatment.

Always liaise with the consultant, flagging up any problems you may have with the rehab so this can be dealt with promptly.

Certain exercises can be provocative and inflame the hip (ie.CLAM, straight leg raise and sit-ups).

Avoid aggressive hip extension at all times.


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move on to level four

•  All level three exercises painfree, and can demonstrate good lumbo-pelvic control.

•  Full range of hip and spinal movement.

•  Hip flexion MP of operated side at least 70%.

•  Hip Add/Abd/Int rot/Ext rot/Ext MP of operated side at least 80%.

•  Cardiovascular fitness level equal to pre-injury level (ref 19,20).

•  Good control with lunges, single leg bridge, rotation control with Lx/pelvic neutral, the plank, and hip flexion in standing.


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Level

four

•  Advanced ‘PLUS’ stage rehabilitation.

•  WEEK 9 •  (day 57 – 63) •  WEEK 10 •  (day 64 – 70) •  WEEK 11 •  (day 71 – 77) •  WEEK 12 •  (day 78 – 84)

•  Aim to advance cardio-vascular fitness and stamina.

•  Progress challenges with plyometrics, speed and agility.

•  Progress proprioceptive and ballistic challenges.

•  Focus on being appropriate to the patient, their sport and their goals in recovery.


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LEVEL FOUR

Week 9 – 12 exercises

The repetitions for these exercises should be dictated by your physiotherapist.

91. Side steps with elastic band. Secure an elastic resistance band around your ankles. (Note band warnings). Squat slightly, keeping good body alignment and T.Abs engaged. Side step against the resistance of the band.

92. Resistance band kicks. Tie the band around a secure unmovable object. Place one foot in the loop. Stand far enough away so the band is under tension. Balance on the other leg, as per balance set up in previous exercises. Perform reps in each direction of movement (forward/backward/out to side/across body) with the band resisted leg. You will need to change position for each of these. This will be a balance challenge for the stance leg and a resistance challenge for the band leg.

93. Single leg stance with pelvis/trunk rotation away. The stance leg must remain pointing forward. This is a good functional weight bearing rotation control exercise.

94. Agility running drills. Forward/back/side.

95. Dynamic lunges.

96. Bike/XTrainer/Hydrotherapy (see guide for swimming criteria).


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LEVEL FOUR


Appropriate for sports that involve running with changes of direction….

97. Z Cuts. Face the direction you are going to jog. Jog 1-2 metres in a Z pattern. At each change of direction, make sure your foot is firmly placed, stay low and push off in a new direction.

98. W Cuts. Jog 1-2 metres in a forwards direction. At the change of direction, keep low and push back on the right foot, thereby jogging backwards. After 1-2 metres, keep low and push off on the right foot, into a forward jog, forming a W shape. Continue for 8-12 cuts, then repeat using the left leg.

99. Cariocas. Face sideways to the direction you are jogging. Cross the right leg over the left, then bring the left foot from behind the right and step to the side. Cross the right leg behind the left and then bring the left foot from behind to the side, in a ‘grapevine’ pattern. 15-20 metres. Repeat in opposite direction.

100. Ghiardelli’s. Start by crossing the right leg over the left, then swing the left leg forward (from behind the right) and touching the ground with the left hand. Repeat with the right.

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LEVEL FOUR


101. Forward bow progressing to arabesque. Adopt correct stand posture, lumbo-pelvic neutral, T.Abs engaged. Bend forward at the hips keeping lumbo-pelvic neutral and slowly return. (Ref 44). Needs to be cued and supervised by physio and reps determined.

When forward bow has satisfactory control, repeat the action then raise one arm (like superman), return to stance, then repeat on other side.

Final stage is when combined arms and trunk are controlled, now lift the opposite leg from the floor, so your arm/trunk/leg are in perfect alignment.

102.Plie squats. Squats done with the feet turned out to work more rotation. Add in upper body resistance work to be done at the same time.

103. Diagonal arm and leg work. Hip abduction in standing with band and opposite arm abduction with band. Your physio can advise you further in retraining the global muscle/sling system.

104.Advanced plank/side plank. Plank position, then side step one foot, return, then repeat on other side. Side plank position, upper leg hip abduction.

105. Rehab equipment..such as pilates reformer or ski-fitter can be used under supervision.


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LEVEL FOUR


Notes for therapists and patients - The basic principles detailed overleaf are to work through with your physio, as there are so many different exercises, and it can depend on what kind of sport you do as to what is appropriate. A lot of rehab guides often bias towards running based sports….but if you are a ballet dancer, martial artist or dressage rider there will be different training exercises to consider. Your physio can write you a program to cover these principles. It is advised that you are supervised so any compensations and faulty movement patterns can be observed.

Therapists, you will need to keep monitoring your patient to pick up any rehab issues and faulty movement techniques.

Remember in some patients, recovery can take up to one year.


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LEVEL FOUR


BASIC HIP REHAB PRINCIPLES

IN RETURNING TO SPORT

•  Thoraco-lumbar-pelvic-hip dissociation work.

•  Ensure active equals passive movement – ability to control through the full range of movement and at inner and outer ranges.

•  Control of body with different speeds of movement.

•  Eccentric and concentric control of movements.

•  Pelvic stability work and balance, with arms above head to dissociate upper body fixation.

•  Diagonal upper body cable work combined with pelvic stability and lower limb challenges.

•  Rotation control work in different functional positions.

•  Dynamic balance, plyometric and ballistic work with upper and lower body combined challenges.

•  A comprehensive program of flexibility stretches with a whole body approach.

•  Movement pattern work involving the ‘kinetic chain/link theory’ (ref 45).


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Reassessment of pain after 12 weeks. Shade in the areas on this body chart where you have

your post-op pain. Scale the pain from 0-10 (0 is no pain and 10 is the worst pain imaginable).

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Diary page – write down here how you are feeling in yourself and the positive changes you

feel since your operation.

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Ask your physio to record these 12 week post-op hip measurements for you, so you can

monitor your progress. (ref 12)

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Hip Right Left

Flexion

Abduction

Adduction

Faber

Int rot (neutral)

Ext rot (neutral)

Trendelenberg test (ref 13)

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Progression criteria to move onto level five

•  Consent from surgeon to return to full sports training.

•  Good ability with level four exercises.

•  Full painfree hip range of movement and muscle power.

•  Ability to perform sports specific drills at full speed painfree.

•  see Wahoff ‘sports test’ (ref 12,13).

•  Star excursion balance test (ref 47).


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Level

five

•  Elite and professional sports skill training.

•  WEEK 13 +

•  Liaison between the consultant, hip arthroscopy rehab physio, the specific sport physio and personal trainers.

•  Aim to create rehab drills and exercises to replicate the specific sport with awareness of the hip surgery carried out and impact this can have on other parts of the body.

•  Look out for musculoskeletal compensations when athlete is performing high level tasks.


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Week 13+

Note to therapists – Most guides suggest jump lunges, lunges with resistance, hopping, box jumps, bounding can be done at this stage. In sports which involve kicking against resistance, jarring type movements and a lot of rotational challenges such as in martial arts/football/rugby/contact sports, build up slowly with lots of preparation work. Liaise closely with the consultant on appropriate time scales and safety considerations.

Racing cyclists may need certain pedals on their bike that allow some external rotation of the leg to lessen being in an impingement position. They also may need their position on their bike reassessing with a cycling specialist.

Horse riders need to consider the width of the horse, type of saddle and saddle position when rehabilitating back to riding. The leg and hip position is different with different saddles and disciplines of riding.

Keep on measuring range of movement even at late stage recovery.


Summary Week One Week Two

Ankle pumps *

Iso Quads/Hams *

Iso Gluts/Hip Abd * *

Trans Abs * *

Stretches Q/Add/ITB * *

Ex.Bike * *

Spinal ext * *

Chest openings * *

Prone lying * *

Calf with band *

Knee ext *

Hams curls *

Iso Adds *

Supp heel slides *

Stretches piri/int rot *

Hip rocks/glides *

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Summary Week Three Week Four

Double calf raise * *

Hams curls *

Iso Adds * *

Trans Abs/heel slides * *

Stretches Q/Add/ITB * *

Stretches H/C/int rot * *

Stretches faber * *

Chest openings * *

Spinal ext * *

Ex.Bike * *

Double Bridge * *

Hip Rocks/Glides *

Stand Hip Abd *

Hydro * *

Swiss Ball * *

Wgt Transference *

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Summary Week Four Week Five/Six

Assisted Hip Circum * *

4 pt kneel leg lift * *

Double knee bends * *

Lower limb stretches *

Ex Bike + XTrainer *

Bent knee fall out *

Hip int rot + band *

Single leg balance *

Dynamic balance *

Add stretches *

Kneel hip flex stretch *

Swiss Ball *

Hydro *

Double Br + h/lift *

Iso Adds *

Side hip Abd *

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Summary Week Seven/Eight

Long lever Hip Circum *

Lunges *

Single leg bridge *

L. Limb + spine stretches *

Ex Bike + XTrainer *

Bent kn fall out + band *

Hip int rot + band *

S.Leg + dynamic balance *

Leg ext + band *

Walk-Jog-Run *

Prone Heel Squeeze *

Plank/side pk/sw.ball *

Hydro *

Hip flex supine-stand *

Side Hip Adds *

Side Hip Abd +int rot *

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Summary Week Nine-Twelve Week Thirteen +

Side steps + band *

Resistance band kicks *

Pelvic rot in stand *

Agility run drills *

Ex Bike/ Xtrainer/Hydro *

Ski-fitter/reformer *

Dynamic lunges *

Z cuts/W cuts *

Cariocas/Ghiardellis *

Fwd bow - arabesque *

Plie squats + up. body *

Adv. plank/side pk *

Diag up/lower body *

Hopping/jumping *

Box jumps/bounding *

Sports specific training *

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Pre-op

• Pre-op preparation. • Surgery.

Early

• Protect surgical area, reduce pain, muscle spasm, inflammation. • Gain control of joint neutral, control of local stabilizer muscles and correct muscle

firing. • Early mobility noting surgeon’s restrictions.

Intermediate

• Regain flexibility and strength. • Dynamic control of movement through range, concentrically and eccentrically. • Sensory- motor, posture, balance and proprioceptive work. •  Integrate into function.

Advanced

• Advanced strengthening, dynamic, proprioception, ballistic and plyometric work. •  Increased shearing activities, agility and sports specific rehab.

Rehabilitation pathway

Based on Frank Gilroy-post surgical general rehabilitation ladder

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References –

1.Tibor & Sekiya.’ Differential diagnosis of pain around the hip joint’. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 12 (Dec), 2008, 1407-1421.

2. Beck et al.’Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip’. JBJS (Br) 2005, 87-B, 1012-1018.

3.Schilders et al. ‘Arthroscopic treatment of labral tears in femoral acetabular impingement’. JBJS 2011, vol 93-B,8.

4. Wenger et al. ‘Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orth 2004. Vol 426, 145-150.

5.Byrd & Jones. ‘Arthroscopic Femoroplasty in the management of cam-type femoroacetabular impingement’. Clin Orthop Rel Res, 2009, 476:739-746.

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6.Byrd. Operative hip arthroscopy. Springer. Second Edition. 2004.

7. Kelly et al. ‘Hip arthroscopy:current indications, treatment options and management issues’. AJSM 2003. Vol 36,6.

8.Anderson et al.’Results of arthroscopic iliopsoas tendon release in competitive and recreational athletes’. AJSM 2008. Vol 36,12.

9. Guanche. Hip and pelvis injuries in sports medicine. Lippincott Williams & Williams. 2010.

10. Haviv et al. ‘Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular damage’. JBJS, May 2010. Vol 92-B, No 5.

11. Bardakos & Villar. ‘The Ligamentum teres of the adult hip’. British JBJS, 2009. 91-B:8-15.

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References –

12. American Academy of Orthopaedic Surgeons. Joint Motion: Method of Measuring and Recording. Churchill Livingstone.

13. Hattam & Smeatham. ‘Special tests in musculoskeletal examination – an evidence based guide for clinicians’. Churchill Livingstone 2010.

14. McDowell et al. ‘Cryotherapy in the Orthopaedic Patient’. Ortho Nurs 1994, 13(5),21-30.

15.Oliveira et al. ‘Three intermittent sessions of cryotherapy reduce the secondary muscle injury in skeletal muscle of rat’. JSSM 2006. 5, 228-234.

16. Kennet et al. ‘Cooling efficiency of 4 common cryotherapy agents’. Journal of Athletic Training 2007. 42(3), 343-348.

17. Butler & Moseley. Explain Pain. Noigroup publications 2003.

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18. Enseki et al. ‘The Hip Joint: Arthroscopic Procedures and Postoperative Rehabilitation’. Journal of Ortho & Sports Surg 2006. Vol 36.No.7.

19.Stalzer et al. ‘Rehabilitation following Hip Arthroscopy’. Clinics in Sports Med. Elsevier 2006.

20. Wahoff et al. ’Rehabilitation After Hip Femoral Acetabular Impingement Arthroscopy’. Clinical Sports Med 2011. 30, 463-482.

21.Garrison et al. ‘Rehabilitation after Arthroscopy of an Acetabular Labral Tear’. NAJSPT 2007. 2(4), 241-250.

22. Sahrman. Diagnosis and treatment of movement impairment syndromes. Mosby 2002, Chapter 4, 176-244.

23. O’Shea. Healing hip, joint and knee pain. North Atlantic Books 1998.

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References –

24. Longbottom. Acupuncture in manual therapy. Churchill Livingstone 2010.

25. Hopwood et al. Acupuncture and related techniques in physical therapy. Churchill Livingstone 1997.

26. Joseph Wong. A manual of neuro-anatomical acupuncture, vol 1:musculo-skeletal disorders. The Toronto Pain and Stress Clinic 1999.

27. Phillipon et al. ‘Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis’. AJSM 2011. Vol 39. No 8.

28. Myers. Anatomy trains: myofascial meridians for manual and movement therapists. Churchill Livingstone, second edition 2009.

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References –

29. Chaitow. Soft tissue manipulation. Healing Arts Press 1988.

30. Chaitow. Positional release techniques. Churchill Livingstone 1998.

31. Schultz et al. The endless web: fascial anatomy and physical reality. North Atlantic Books 1996.

32. Hengeveld & Banks. Maitland’s peripheral manipulation. Butterworth-Heinemann, 4th Edition 2005.

33. Mulligan. Manual therapy: NAGs/SNAGs/MWM.. OPTP, 5th Edition 2004.

34. Travell & Simons. Myofascial pain and dysfunction: the trigger point manual. Williams & Wilkins 1999.

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35. Rosie Mew.’Activation of the deep abdominals, is it more effective in standing or crook lying?’. Sportex Medicine 2011.49,12-18.

36. Lee. The Pelvic Girdle – an approach to the examination and treatment of the lumbo-pelvic hip region. Third Edition. Churchill Livingstone 2004. 101-102.

37. McIlveen & Robertson.’A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain’. Physiotherapy. Jan 1998, vol 84, no 1.

38. Harrison et al.’Loading of the lower limb when walking partially immersed:implications for clinical practice’. Physiotherapy. March 1992, vol 78, 164-166.

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References –

39. Critchley. ‘Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low abdominal hollowing’. Physiotherapy Research International. 2002. 7:65-75.

40. Crossley et al.’Performance on the single-leg squat task indicates hip abductor muscle function.’ AJSM 2011.

41. Ernest Rossi.’The Psychobiology of mind-body healing.Norton 1986.

42. Stuart McGill. Low back disorders- evidence based prevention and rehabilitation. Human Kinetics 2002.

43. Ricardson, Jull, Hodges, Hides. Therapeutic exercise for spinal segmental stabilization in low back pain. Churchill Livingstone 1999.

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References –

44. Comerford. Kinetic control:dynamic balance of the sensory motor system. Course manuals, Kinetic Control Ltd 2000.

45. Seidenberg & Bowen. The Hip and Pelvis in Sports Medicine and Primary Care. Springer 2010. Chapter 10.

46. Binningsley.’Femoro-acetabular impingement’. Sportex Medicine 2009;40 (Apr):10-15.

47. Kinzey et al.’The reliability of the star excursion tests in assessing dynamic balance’. Journal of Orthopaedic Sports Phys. Ther. 27:356-360.


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The author, Louise Grant MCSP accepts no responsibility for persons using this guide. The guide should be used under the instruction and guidance of your chartered physiotherapist. For further information on hip arthroscopy physiotherapy, pilates and hydrotherapy, log onto www.physiocure.org.uk.

Acknowledgements –Thank you to my family and all my hip arthroscopy patients who have assisted and inspired me to publish this guide. To my wonderful business partner, Anna Nelson who specializes in hip problems in horse riders. Thank you to Julie Reynolds, specialist hip pilates instructor and Louisa Weeks Browning; founder of an internet based hip arthroscopy/FAI support group. My deepest gratitude to the surgeons who have helped me, in particular, Prof Ernest Schilders and Mr Jon Conroy who continually support, teach and guide me.

Published by PHYSIOCURE Aug 2011. PHYSIOCURE is a registered trademark. Copyright Aug 2011 registered with O’Garras Solicitors. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, or otherwise, without the prior permission of the author/copyright owner. Printed by PH Print.

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hip arthroscopy rehabilitation part two

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