Rehabilitation Following Hip Arthroscopy: Is It Guesswork?

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1 Rehabilitation Following Hip Arthroscopy: Is It Guesswork? Kevin E Wilk, PT, DPT Kevin E Wilk, PT, DPT,FAPTA 2015 Orthopaedic Summit Faculty Disclosure: Theralase Laser Medical Advisory Board LiteCure Laser Consultant AlterG Medical Advisory Board Intelliskin USA Medical Advisory Board Zetroz Medical Medical Advisory Board Throw Like A Pro Co-Owner Dr PRP Rehab Advisor Educational Grants:» Empi Medical» Joint Active System»ERMI» Bauerfeind Brace Book Royalties:» CV Mosby, Lippincott, Human Kinetics Presentations Goals: Post-operative rehab guidelines specific guidelines & not guess work Exercises for the hip region Exercises for the Gluteal Muscles Link the hip Joint to LE & UE Non-operative rehabilitation guidelines & programs tricks of the trade Limited Time!! Hip injuries are somewhat common in sports & daily activities Hip injuries less common than other joints Often more difficult to identify than other lesions often difficult to rehab Didn t have much to do for these disorders in the past today Numerous common lesions seen Martin, Kelly, Leunig, Philippon: Arthroscopy 2010 Hip forces: can reach up to 8-9 x BW Injuries often occur due to excessive twisting, pivoting & extremes of motion Frequency: 5-6 % in adult athletes % in child athletes Boyd et al: Sports Med 97 Hip not recognized as the source of symptoms in 60% of cases Length of time from initial onset to diagnosis 21 months Burnett: JBJS 06 Hip Joint Forces During Specific Exercises

2 Hip Joint Forces Bilateral stance: 0.5x BW Single leg stance: 2.5x BW Cane decreases forces by ~ 1x BW Running: x BW Supine SLR flexion: 1.5x BW Hip Abduction: 1.0x BW* Rydell et al: Clin Orthop 73 SLR Abd % higher than bilateral standing Addition of 5kg (#11) increased load by 250% Reizebos et al: Phys Ther 02 During walking forces on hip peak forces occur during stance phase higher than expected during swing phase (abductor muscle activity) Walking upstairs: 3x BW Running: x BW Jumping & landing 8-10 x BW Normally femoral head can be loaded up to 12-15x BW before neck Fx Rydell et al: Clin Orthop x BW Hip Injuries are common in specific sports: Ballet Runners Soccer Golfers Hockey Basketball Football Baseball Contact sports Hip Injuries are common in specific sports: Baseball Hip Injuries are common in specific sports: Golf

3 Hip Injuries are common in specific sports: Hockey, Soccer, Ballet, Hip Injuries are common in specific sports: Performers & artists RDLs Single Leg Deadlift Gluteus Maximus: Tri-Planar Muscle Extensor Abductor ER Gluteus Medius Functions: Abduction Anterior fibers: IR & flexor Posterior fibers: ER & ext Screening Glut Med Exercise Glut Med RDLs Single Leg Deadlift RDLs Single Leg Deadlift Modification Hip Extensors Screening Glut Med Exercise Glut Med Exercise Gluteus Med but also Extensors

4 Plank with Hip Abduction

5 Philippon:AJSM 11 #1 #2 #3 #4 Philippon et al: AJSM 11 Distefano:JOSPT 09 #5 #6 #7 #8 Philippon et al: AJSM 11

6 Distefano:JOSPT 09 Boren,Conrey,LeCoguic,Paprocki, Voight, Robinson: IJSPT healthy subjects SEMG placed on gluteus medius & gluteus maximus 18 exercises 5 exercises produced 70%> MVIC Gluteus medius: Side plank abduction (103% MVIC) bottom Side plank abduction (89% MVIC) top Single leg squat (82% MVICC) Clam shell #4 (77% MVIC) Front plank w/ hip extension (75% MVIC) Boren,Conrey,LeCoguic,Paprocki, Voight, Robinson: IJSPT healthy subjects SEMG placed on gluteus medius & gluteus maximus 18 exercises 5 exercises produced 70%> MVIC Gluteus maximus: front plank extension(106% MVIC) Glut squeeze (81% MVIC) Side plank hip abduction (73% MVICC) top Side plank hip abduction (71% MVIC) bottom Single leg squat (71% MVIC)

7 Selkowitz, Beneck,Powers: JOSPT 13 JOSPT healthy asymptomatic subjects Fine wire EMG Glut Med, Glut Max & TFL 11 different hip exercises: Glut Med & Max to TFL ratio best exercises Unilateral & bilateral bridging Quadruped hip extension Clams Side stepping Squatting JOSPT 2013 JOSPT 2013

8 My Favorite Hip Exercises Lateral slides Sidelying clams with manual resistance Seated theraband ER RDLs Single leg front step downs Star drill Single leg bosu ball catches Instant replay Unilateral plank into hip abduction Femoroacetabular Impingement Rehabilitation Following Selected Operative Procedures Rehabilitation Following Selected Operative Procedures Arthroscopy procedure» Loose bodies, labral debridement, chondroplasty, synovectomy, lig teres debridement Microfracture Labrum Repair Femoroplasty Iliopsoas release Arthroscopic Debridement Weight bearing as tolerated normalize gait Light rehab for first 4-6 weeks then functional progression» 2 months.- loose fragment, simple labral tear, ruptured ligamentum teres» 3months.- tenuous preserved labrum, extensive articular damage Delay functional activities for 2-3 mos this to prevent set back

9 Arthroscopic Debridement Normalize hip joint ROM Improve hip muscular flexibility Enhance muscular strength» Restore hip muscular balance Progress functional activities» Bicycle, pool, ellipical, treadmill Gradually increase WB forces Gradual return to sports Arthroscopic Femoroplasty FAI Crutch use for 4 weeks (sometimes 6 wks) Vigorous impact loading avoided for 3 months to allow bone remodeling/ healing Progressive ROM, stretching program Progressive strengthening program Pool program, Bike Hip dynamic stabilization exercises!!! Initiate functional activities 3 months Return to sports: 4-6 months Intra-Articular Lesions Articular Trauma: Microfracture» Well circumscribed Grade IV lesions» 86% successful outcome (2-5 year f/u) Byrd & Jones AANA '04 Intra-Articular Lesions Articular Trauma: Ligamentum Teres Traumatic rupture» Increasingly recognized (especially among athletes)» Twisting injury in absence of dislocation/subluxation» Mean improvement 47 pts.» 96% significantly better Byrd & Jones Arthroscopy '04 Precautions: Partial WB (50% BW) initially» Progress to FWB at 3-4 weeks Limit ROM» Flexion to 90 degrees 2-4 wks then increase» Extension to neutral» Avoid ER» Restoration of full ROM 8-10 weeks (6-8 wks athletes) Ejnisman, Philippon: Clin Spts Med 11 No supine SLR flexion rather hip abd into Flex Exercises:

10 Exercises: Exercises: Gravity E Pool, Unloader treadmill, Bicycle No early SLR flexion for 2-4 weeks Emphasize hip abduction, ER, extension Initiate WB exercises at 4 weeks with ROM restrictions Progressive strengthening program at 8-12 weeks Initiate running unloading first then gradually increase to full WB (3-4 mos) Exercises emphasize gluteal muscles hip abd/adduction & extension gravity eliminated hip flexion (first 2 wks) ¼ squats Hip ER/IR (limited ROM) prone heel digs bridging, clams, prone plank hip extension week 6-8: advance exercises Clams, RDLs, lateral slides, leg press, wall squats

11 Clams Progression Hip Abduction Progression Sport specific training: Alter G running: 6-8 weeks (50% BW) gradually increase BW forces Straight line running weeks Lateral movements weeks 12> Sport specific training: weeks 14-16> Return to sports: 5 months

12 Conclusions Numerous types of hip joint & hip region lesions Proper & accurate evaluation of hip & groin disorders is the key to successful treatment Requires understanding of anatomy and pathomechanics Different problems may have similar appearances; and may coexist Team approach to treatment Many can be treated non-operatively Well designed, progressive, & sequential rehab program is vital