Dominic S. Carreira, M.D. 300 SE 17 th St First Floor, Fort Lauderdale, FL (954)

Transcription

1 300 SE 17 th St First Floor, Fort Lauderdale, FL Phase I: Initial Hip Exercises A. Ankle Pumps - 20 repetitions, 2 times/day POST OPERATIVE HIP PROTOCOL B. Isometrics - 20 repetitions, 2 times/day 1. Gluteal sets - Tighten buttock muscles - hold 5 seconds. 2. Quad Sets - Tighten thigh muscles - hold 5 seconds. 3. Transverse abdominal Isometrics - Draw belly button in towards spine without moving pelvis or spine - hold while taking 5 breaths. This exercise is to be completed along with core stabilization exercises. 4. Hip adduction and abduction - No resistance should be added until week 5 or 6. C. Passive ROM (performed by therapist and caretaker) - 2 times/day for 6 weeks 1. Circumduction: A. In Flexion: Lying on your back and with hip in 70 flexion, move knee in a circular motion (pendulum rotation). Knee not rotating beyond the shoulder. 3 sets for 5 minutes. B. In Neutral: Lying on your back with hip und knees straight, move the leg in a circular motion (bring hip into abduction and slight flexion). May be uncomfortable for first few days. 30 reps in each direction. 2. Passive Supine Hip Roll (IR): Lying on your back with legs straight, have partner rotate thigh inward. 20 repetitions. 3. Flexion: Lying on your back have partner bend knee toward chest (90 limit for 10 days). Increase range as tolerated after 10 days. 20 repetitions. 4. Abduction: Lying on back with leg straight, have partner bring leg away from your midline (35 limit for 3 weeks). Increase range as tolerated after 3 weeks. 20 repetitions. 5. Prone Internal Rotation: Lying on stomach with knee bent to 90, have partner bring ankle away from your body. No external rotation in prone for 3 weeks. 20 repetitions. Start 6 and 7 at Week 4: 6. Extension: Lying on your stomach have partner grasp knee and lift leg up from the table 20 repetitions. 7. FABER for ER: Lying on back bring involved leg into figure four position with ankle resting on top of opposite knee. Gently lower bent knee towards the table. You may need to start with ankle resting on shin or inside of leg. It is normal to feel lateral hip discomfort. Do not push on knee. D. Passive Stretching - 5 repetitions, hold 20 seconds, 2 times/day 1. Piriformis Stretch: Lying on uninvolved side, bottom leg straight/pelvis stacked) bend involved hip to flexion, hook your top foot behind uninvolved knee. Stabilizing pelvis, lower the involved knee towards table. Stretch should be felt in buttock. Avoid pinch in groin.

2 2. Quadriceps Stretch: Lying on stomach, have partner bring ankle toward buttock, feeling a stretch in front of thigh. 3. Kneeling hip flexor stretch (Start Week 4) In a half kneeling position with the involved knee on the floor tighten stomach muscles. Shift weight forward while keeping trunk upright, feeling stretch in front of hip/thigh. (PT can start using Thomas stretch in therapy) 4. General Hip, Knee, Calf Stretching (Start 3rd 4th week): Stretching in all directions is acceptable from this point forward 5. Heel Slide to a March; perform heel slide then lift your heel off table so hip is bent to 90 keeping core stable, return leg to starting position. Alternate legs. (PT can advance to even more difficult exercises as long as you avoid hip flexor pain including alternating heel lifts and toe touch: both heels up tapping one heel down at a time) 6. At this point, progression dependent on patient / therapist discretion. Examples include dead bug exercises; planks; etc. E. Gluteal Progression - 3 sets, 10 repetitions, once a day 1. Glute Medius Firing: Attempt to initiate glute medius with assisted side lifts in muscle test position. Work on eccentrics (negatives) until patient can perform lift without pelvic compensation. 2. Side leg raises (glute medius focus): Start only when can properly perform without compensating. Focus on form. Lying on uninvolved side, raise top leg up and slightly back without moving your trunk (side leg raise) 3. Stomach leg raises (Glute Maximus focus): Lying on your stomach flex knee 90 degrees or further. Lift your knee off the table keeping the knee flexed. Raise your leg up 6 8 inches. 4. Rose Wall Slides (week 4): Lying on uninvolved side with shoulders, hips, and heels flush up against a wall. Slowly slide top involved heel along wall maintaining firm abdominal muscles. 5. Prone heel squeeze (week 5): Lie on your stomach. Slightly separate, then bend your knees about 45 degrees, place your heels together (froggie style). Draw abdominals in and squeeze heel together for 5 seconds. Increase difficulty by lifting your thighs off the mat with heel squeeze maintaining a stable pelvis. Do not arch your back. F. Water Progression minutes, 3 times/week. Start Week 4 1. Water Walking Walk forward, backward and lateral in chest deep water. Emphasize full weight shift to involved side. 2. Water Jogging In deep water using an aqua jogger, jog in place. Start Week 5 3. Swimming started at 5 wks. We prefer frog kick as in the breast stroke. G. Quadruped Racking - 3 sets, 20 repetitions, Once a day On your hands and knees, shift your body weight forward on your arms then back onto your legs. You may also shift side to side and in diagonal directions. H. Standing Hip IR - 3 sets, 20 repetitions, Once a day Place knee of involved leg on a stool. Rotate hip without moving trunk, so that the stool turns (moving foot outward from your body). Progress to using a resisted band when tolerated. 2

3 I. Active Prone IR/ER - 20 repetitions, Once a day Lying on your stomach with knee bent to 90, allow foot to drop out so that the hip is in full IR. Actively rotate hip back to neutral only. Partner gradually adds resistance to this motion in both direction. May go beyond neutral after 3 weeks. J. Lower Abdominal/Short Lever Hip Flexor Progression - 20 repetitions, Once a day For each stage, progress when no pulling is felt in hip flexor 1. Heel Slides with Strap: Lying on your back place strap around foot and use arms to pull heel towards your buttocks keeping heels on mat and core stable. 2. Heel Slides without strap: Gradually reduce the use of your arms and strap and increase the use of hip muscles to slide heel until you do not need the strap (monitor for hip flexor pain). K. Bridging Series - 3 sets, 20 repetitions, 1-2 times/day 1. Double leg bridge: Lying on your back place rubber tubing around knees with hip and knees bent. Raise buttocks while keeping core stable slowly lower. 0 Progress to single leg bridging 2. Bridge on Swiss Ball: Lying on your back place feet up on swiss ball. Keep knees straight and core stable as you raise your buttocks, hold 5 seconds then lower. 0 Progress to laying with shoulders on ball and feet on floor then lowering and raising your buttocks. 0 Add arm rotations in this position or perform with single leg bridge L. Leg press (limited weight) - 3 sets, 30 repetitions, Once a day Using light weight (20-30 lbs), perform leg press. Increase weight in Phase II. M. Gait Progression: "Crutch weaning" - USE TWO CRUTCHES as you increase weight bearing. 1. Weight shifting exercises: Focus on avoiding Trendelenburg/compensated Trendelenburg 2. Increase weight-bearing tolerance. 3. Gradually add 25% weight on surgical leg every 1-3 days until 100%, continuing to use both crutches during this period, Return to crutches avoiding early fatigue. Avoid limping and focus on correct walking, weight shift, and mechanics. Make sure patient is getting full hip extension. Phase II: Intermediate Exercises Close Chain, Single Plane For specific questions about running, dance, skating and golf, please review Phase III progressions for potential start times. A. Balance Progression - 3 sets, hold 30 seconds, Once a day 1. Single Leg Stance 2. Dyna disc: Start with poles for support. Progress by touching the opposite foot to the 9, 10.5, 12, 1.5 and 3 o'clock positions. Add Dynamic Balance activities as tolerated. B. Stationary biking with resistance minutes Increase resistance slowly while maintaining RPM. Reduce time on bike when initiating resistance. For Cyclists: Due to the correct pedaling motion and the great amount of hip flexor use: 1st three weeks: use flats on trainer 3

4 3rd to 4th weeks: clip-less with no resistance. C. Double 1/3 knee bends - 3 sets, 20 repetitions, Once a day Start standing with feet shoulder width apart, bend at the knees to 60. Do not allow knees to go past toes. Progress by using a sport cord for resistance. D. Advanced Core Progression - 3 sets, 20 repetitions, Once a day 1. Planks: Lie on either side with your knees bent resting on your elbow. Lift your hips up to a straight line, and then slowly lower. Progress by performing with legs straight. Progress to performing on back and stomach positions 2. Pilates: With an instructor: Footwork series, Skater series, hip extensions E. Manual mobilization: (Therapist as needed). Address posterior or medial capsule tightness. Refer to photos for the preferred mobilizations. F. Side Stepping - 3 sets, 20 repetitions, Once a day Place rubber tubing around ankles. Bend at the knee and sidestep in each direction while maintaining the bent knee position and chest upright. G. Elliptical trainer/stair climber minutes, 3 times/week Begin with minimal resistance and progress in intensity over time as tolerated. TREADMILL USE IS PROHIBITED H. Single 1/3 Knee Bends - 3 sets, 20 repetitions, Once a day Same starting position as double knee bends but with only surgical leg. Bend knee to 60 flexion while maintaining a level pelvis and not letting the knee fall in (corkscrew). Progress by adding cord for resistance (sport test exercise) Other single-leg closed kinetic chain exercises: 1. Lateral Step Downs 2. Balance Squats: With one leg behind you on a chair, squat with your opposite leg to 70 degrees. Perform with opposite leg on chair. 3. Lunges 4. Reverse Lunges Following hip surgery by Dominic Carreira, the patient can NEVER use the treadmill. Concern is with the secondary force of the moving tread being dissipated through the hip! Phase III: Advanced exercises multi directional & plyometric A. Plyometrics: water to dry land progression - 10 sets, 1-2 minutes, 3-5 times/week Begin with water: in chest deep water, perform forward bounding. Focus on absorption when landing, Progress to dry land plyos. B. Side to side lateral agility with cord - 3 sets, 50 reps, 3 times/week Attach the sport cord from the side with the surgical leg facing the cord. Step sideways to create tension on the cord. From a single knee bend position on the surgical side, explode off laterally, touching momentarily with the opposite leg before the tension pulls you back. Emphasize the absorption back onto the surgical leg. C. Forward/ Backward running with cord - 3 sets, 1-2 minute intervals, 1 time/day Shift from one leg to the other while running in place without exaggerating the absorption and push off motion. Face the cord for backwards running. 4

5 D. Running/ Skating/Golf progression. NEVER USE TREADMILL RUNNING: Expect to have mild limping/discomfort/awkwardness this should go away gradually. Common sense dictates that if limp worsens or there is pain, running should stop. Progress to the next phase each week. No Treadmill Use Walk/Run Ratio Sets/Total Time Frequency R 1 4 minutes/ 1 minute 4 sets 20 min 4-5 times/week R 2 3 minutes/ 2 minutes 4 sets 20 min 4-5 times/week R 3 2 minutes/3 minutes 4 sets 20 min 4-5 times/week R 4 1 minute/ 4 minutes 4 sets 20 min 4-5 times/week R 5 15 minute Jog 2 sets 10 min 4-5 times/week From 10 min jogging, increase as tolerated. SKATING: Goalie: hold back pads an extra week. Progress to the next phase each week S1 S2 SKATING PROGRESSION Time Frequency Skate no pads forward and back with crossover Skate Use of Pads with change of direction, stop/start min 4-5 times/week min 4-5 times/week S3 Sport-Specific Drills 2-4 times/week S4 S5 Sports Test (to be cleared) Full Contact Practice with Team Week 10 + of protocol After passing sports test GOLF: Begin after 3 weeks of walking. Don't carry bag and do not pull cart. GOLF PROGRESSION Volume Frequency G1 Put, chip, ½ swing only 1 bucket For 1-2 weeks G2 8-9 Irons, ¾ swing only 1 bucket For 2 weeks G3 All Irons, Use cart, full swing 9 holes For 2 weeks G4 Full play, walking 18 holes 18 holes E. Initial agility drills - Straight Plane Agility, Chop Downs/Back Pedaling jog forward, stutter step to a stop, absorb and push off smoothly into a back pedal. Side Shuffles Start with feet shoulder width apart, maintain an athletic stance and shuffle to the right, then back to the left. 5

6 Phase IV: High Level Activities Functional Sport Test Passing the Sport Test = you are cleared A. Multi Plane Agility 1. Z Cuts 2. W Cuts 3. Cariocas 4. Ghiardelli's Start by crossing the right leg over iliac crest, swing the left leg out from behind the right absorbing and touching the ground with your left hand in one fluid motion. Repeat to the right side. B. Sport Specific Training 6