Rehabilitation After Hip Arthroscopy

Transcription

1 Research Reviews Rehabilitation After Hip Arthroscopy Karen M. Griffin, Cindy 0. Henry, and J. W. Thomas Byrd Objective: To explain the basic fundamentals of patient assessment after hip arthroscopy, formulation of a treatment plan, and detailed essentials of postoperative rehabilitation. Data Sources: Established literature and the evolution of a protocol developed in treating over 150 hip-hrthroscopy patients and numerous patients with symptomatic hip disease. Data Synthesis: Although the pathological process being addressed and the surgical technique employed in its management influence the protocol, the common goals of rehabilitation are to reduce discomfort and improve function. These common goals, first realized in the postoperative rehabilitation process, have been found to have similar application in the conservative management of patients with symptomatic hip disease. Conclusions: Arthroscopy has necessitated the development of a postoperative rehabilitation protocol. Principles previously employed in other joints are now finding application in the hip. Key Words: hip rehabilitation, hip arthroscopy Griffin KM, Henry CO, Byrd JWT. Rehabilitation after hip arthroscopy. J Sport Rehabil. 2000;9: O 2000 Human Kinetics Publishers, Inc. A variety of intra-articular sources have been defined that can result in disabling mechanical hip pain. This can be especially evident in active and athletic individuals. Arthroscopy has found a role in addressing many of these lesions, with potentially successful outcomes.' Consequently rehabilitation has taken on a new role in the postoperative recovery of patients undergoing arthroscopic surgery of the hip. Rehabilitation techniques often employed in other joints such as the knee, shoulder, elbow, and ankle are now finding application in the management of hip disorder^.^ Historically therapeutic principles applied to the hip focused on 3 areas: (1) gait training, maintaining protected weight-bearing status that is often necessary in managing hip fractures; (2) instruction in routine precautions that should be taken after hip arthroplasty, including protected weight bearing and preventing dislocation; and (3) teaching arthritic patients how to live within the limitations of their disease and how to mod* their environments. Karen Griffin and Cindy Henry are with Baptist Sports Rehabilitation, Nashville, TN Thomas Byrd is with Southern Sports Medicine & Orthopaedic Center, Nashville.

2 78 Griffin, Henry, and Byrd Arthroscopy has been effective in the management of elusive causes of hip pain, such as tearing of the acetabular labrum, chondral injuries, or rupture of the ligamentum teres?~~ In the past, these occult lesions usually went untreated, resigning the patient to live within the constraints of their symptoms. For conditions such as symptomatic loose bodies, arthroscopy now offers a much less invasive approach than the open arthrotomy previously employed in such cases. Occasionally, arthroscopy might have a place in the treatment of arthritic disorders, as an attempt to delay the necessity of joint replacement. Regardless of the indications for surgery, a successful result often depends on a properly constructed and implemented rehabilitation program. As the surgical technique of hip arthroscopy has evolved, so have the rehabilitative principles. The common goal of the postoperative program is to reduce discomfort and improve function. As we have developed our postoperative rehabilitation program, we have learned that many of the principles applied in the postoperative management of hip-arthroscopy patients might well be used in managing patients with a variety of painful hip disorders. The principles and phases of the rehabilitation program are constant, but the program for the postoperative patient is individualized to the pathology found and procedure performed. Similarly conservative treatment for a patient with a painful hip is individualized to the extent of disease and the patient's goals. Thus, rehabilitative measures are important not only in conservatively treating hip disease and in the postoperative recovery after arthroscopic surgery but also in the preoperative management ("prehab") of potential candidates for hip arthroscopy. Successful prehab can help avoid the necessity of surgical intervention. At the very least, it better prepares the individual, both mentally and physically, for postoperative recovery. This in itself can have a sigruficant positive influence on surgical results. Prehab can also help define patient motivation, occasionally idenbfymg patients that might not be good candidates for surgical intervention for various reasons. The information presented here highlights the basic fundamentals of assessing patients and formulating a treatment plan, as well as the detailed essentials of postoperative rehabilitation. This overview is based on the established literature and the evolution of a protocol developed in treating over 150 hip-arthroscopy patients and numerous patients with symptomatic hip disease. Note that the principles established in treating postarthroscopy patients usually apply in the management of common causes of intra-articular hip pain. Assessment Obtaining a history and performing a physical examination are the mainstays of clinical assessment. Assessment really begins, however, by asking about and then understanding the goals and expectations of the individual.

3 Rehabilitation After Hip Arthroscopy 79 The clinician must first know the patient's goals. This step in the assessment can highlight early warning signs of unreasonable expectations. It might even prompt a quick call to the physician before proceeding. Over time, part of the strategy might be to help the individual formulate and accept more reasonable goals and expectations. The clinician's assessment is as important as the physician's assessment. The history the physician obtains and the examination he or she performs, combined with various diagnostic studies, determine a tentative diagnosis, but the clinician's evaluation is important in understanding the behavior of the athlete's symptoms and in determining how the symptoms respond to treatment. Reassessment provides the feedback necessary in determining a further plan of management. There is virtually no isolated movement in the hip. The hip uses several different planes of motion for each function and comes closest to being a true ball-and-socket joint. It allows a combination of movement for activities that do not occur in a straight plane. Sitting, walking, running, stair climbing, and squatting all require a combination of motions. For example, a normal walking pattern on average requires 15" of extension, 37" of flexion, 7" of abduction, 5" of adduction, 4" of internal rotation, and 9" of external r~tation.~ Ascending stairs requires the motion of a normal walking pattern with added flexion to 67". It is also important to be familiar with the forces imparted on the hip during the course of normal daily adivitie~.~ Standing on 1 leg creates a force of 2.5 times that of body weight. Ascending stairs creates a force of 3 times body weight, and running increases the force to approximately 5 times that of body weight. A normal healthy hip can tolerate times body weight. History Each athlete's history (subjective evaluation) provides the therapist with valuable information regarding the patient's signs and characteristic symptoms. For example, the hip predominantly receives innervation from the L2-S1 nerve roots of the lumbosacral ple~us.~ Pain in the hip usually involves the L3 root and might be referred to the L3 dermatome. Complaints of pain are most often reported in the midinguinal area and might be referred to the anterior and medial thigh and, occasionally, even the medial side of the knee. Pain laterally in the region of the greater trochanrer is more characteristic of trochanteric bursitis. Buttock pain spreading into the lateral or posterior thigh could suggest an underlying disorder of the lumbosacral spine. The onset and nature of symptoms are also important, along with questions of past history and previous treatment. Examination The physical examination (objective evaluation) includes observation; gait analysis; balance testing; clearance of the lumbar spine, sacroiliac joints,

4 80 Griffin, Henry, and Byrd and knee; testing active and passive range of motion (including accessory movement); manual muscle tests; palpation; and special tests for flexibility and stress to various structures. Careful attention to gait analysis helps identify weakness and compensatory movements, which can help one better understand the problem. Because of the mobile ball-and-socket configuration of the hip joint, few functional movements are uniplanar. For examination purposes, however, the 6 principal directions of movement are flexion, extension, abduction, adduction, and internal and external rotation. The typical capsular pattern of restriction is characterized by marked limitation of internal rotation and abduction, moderate limitation of flexion and extension, and some limitation of external rotation and addu~tion.~ Normal parameters of range of motion can vary greatly. It is always important to examine and compare the uninvolved extremity for normal limits. Typically, in the prone position, the hip can be extended 30". In the supine position, hip flexion averages 125". Recording hip flexion requires that the contralateral extremity be flat on the table to eliminate accessory or compensatory movement that can occur as a result of pelvic tilt. Recording abduction and adduction requires that the pelvis be stabilized to eliminate accessory movement that could falsely indicate greater range of motion. Abduction averages 45-50", and adduction 20-30". With the hip flexed 90, internal rotation averages 35", and external rotation, 45". A succinct, abbreviated examination can be used to quickly determine whether there is any gross restriction in range of motion of the hip: To test for abduction, have the athlete stand and spread his or her legs as far apart as possible. An individual should be able to abduct approximately 45" from the midline. For adduction, instruct the athlete to alternately cross his or her legs while standing. An individual should be able to achieve approximately 20" of adduction. For flexion, have the athlete draw each knee to the chest as far as possible without bending the back. For combined flexion and adduction, have the patient sit in a chair and alternately cross 1 thigh over the other. For extension, have the athlete sit in a chair with arms folded across the chest and then rise to a standing position. The Thomas test can alternatively be used to quantitate hip flexion or the presence of a hip-flexion contracture. For measuring flexion, the knee is brought toward the chest. The contralateral hip is maintained in extension, and the degree of flexion of the hip being examined is recorded. Conversely, for assessing a flexion contracture, the knee of the contralateral extremity is brought maximally to the chest. The hip being examined is

5 Rehabilitation After Hip Arthroscopy 81 then brought toward extension. Inability to lay the leg flat on the table reflects a hip-flexion contracture. Inordinate tightness of the iliotibial band can most easily be detected using the Ober test. The patient is positioned on his or her side with the suspect hip placed up. With the hip extended and knee flexed, limitation of passive adduction indicates a tight iliotibial band. There are wide variations of normal; the examination should compare the involved with the uninvolved extremity. Formulating the Treatment Plan From the therapist's subjective and objective assessment and the information provided by the physician, specific problem areas will be identified. A plan of care and management is then outlined. This plan might be multifaceted. Simple devices such as insoles might help relieve compressive stress. A program of generalized water-conditioning exercises in a reducedweight environment can have a very positive influence on the hip. Treatment via therapeutic modalities for pain and inflammation control might be indicated. Joint distraction mobilization techniques, specific stretching and strengthening exercises, and other functional routines might also be recommended. Postarthroscopy Rehabilitation The rehabilitative treatment plan after arthroscopic hip surgery depends on the pathology identified at the time of surgery and the methods of surgical intervention used to address it. For example, the recovery after removal of symptomatic loose bodies or excision of an isolated displaced labral tear can be quite prompt. Conversely, debridement for arthritic disorders, whether posttraumatic, degenerative, or inflammatory, can be much slower, respective of the patient's symptoms. Abrasion arthroplasty for focal articular-surface deficits can require an even longer, more deliberate period of recuperation, despite how well the patient might be feeling. The level of discomfort associated with arthroscopic hip surgery is often remarkably low. Each patient responds differently, however. Individuals with identical-appearing lesions might rehabilitate at completely different rates. Although this can sometimes be attributed to an athlete's personality or "pain tolerance," it is often difficult to predict or explain why one individual experiences a greater level of discomfort and slower progress than another does. Postoperative recovery begins with the preoperative educational process. This might have been a formal prehab program or, at least, a comprehensive opportunity for preoperative instruction. Preoperative instructions should not be cursory and, thus, cannot be effectively relayed on the day

6 82 Griffin, Henry, and Byrd of surgery. On that day the patient is likely to remember as little of what he or she is told before the surgery as of what he or she is told afterward. Patient satisfaction and comfort are predicated on advance knowledge of corning events. Resumption of supervised rehabilitation is delayed until the second postoperative day. At this point, the patient is usually more comfortable and better prepared to face the demands of physical therapy. The lingering effects of anesthesia have passed, and the patient is mentally better collected. At this stage, the instructions given preoperatively are reinforced and refined. Phase Progression As noted, certain restrictions are dictated by the physician, based on the pathology addressed at the time of arthroscopic surgery. Accounting for these limitations, the rehabilitative process will progress based on the patient's ability to perfonn the previous maneuvers in a relatively pain-free fashion. Consequently progression is largely dictated by the patient's symptoms. Typical time references for progression can be noted, but this is a functionally based progression scheme, not a chronologically based progression. Although each individual goes through the same basic phases, which are outlined in Figure 1, some might accomplish rehabilitation within a matter of weeks, and others within a matter of months. Gait Training A patient's weight-bearing status can vary depending on the surgeon's findings. Typically, weight bearing is allowed as tolerated, and crutches are discontinued within the first week. Although the discomfort associated with arthroscopy might be surprisingly little, there can still be a sigruficant amount of reflex inhibition and poor muscle firing as a result of the combination of penetration with the arthroscopic portals and the traction applied during the course of arthroscopy. Consequently, assistive devices are helpful to reestablish a normal gait pattern and synchronous muscle activity. Abrasion arthroplasty represents the most challenging and perhaps most individualized circumstance in the arthroscopy patient. Ideally, unloading the joint and performing only passive range of motion for at least 2 months is ~ptimal.'~,~~ However, this is probably impossible to achieve in clinical settings and usually impractical. With this as an ideal goal, recommendations are usually modified to meet the patient's individual circumstances. It should be noted that the most effective method of neutralizing compressive forces across the hip is to allow the patient to apply the equivalent weight of the leg on the ground. Maintaining a true non-weight-bearing status requires signrficant muscle force to suspend the extremity off the ground and, thus, generates considerable dynamic compression across the joint as a result of muscle contraction. Resting the weight of the leg on the ground neutralizes this dynamic compressive effect of the muscles.

7 Rehabilitation After Hip Arthroscopy 83 I. Initial Phase Goals: Regain range of motion within tolerance, decrease swelling and pain, retard muscle atrophy A. Day of surge y 1. Begin isometric glut sets and ankle pumps. B. Postoperative days Remove bulky dressing. 2. Weight bearing to tolerance, crutch ambulation on flat and stairs. 3. Immediate postoperative exercises. a. Isometric quad, glut, hamstring, adductor, and abductor sets b. Active assisted range of motion in all planes c. Hip mobilization if beneficial in decreasing pain and increasing range of motion with straight-plane distraction, inferior glide, and posterior glide d. Closed chain bridging, weight shifts, balancing drills e. Open chain standing abduction, adduction, flexion, extension without resistance 11. Intermediate Phase Goals: Regain and improve muscular strength and normalize joint arthrokinematics A. Postoperative weeks Progress off crutches and normalize gait. 2. Continue to progress range of motion with gradual end-range stretch within tolerance. 3. Begin progressive resistive exercises as tolerated. a. Closed chain single leg bridging b. Open chain above knee resistive Theraband or pulley exercise in flexion, extension, adduction, abduction, hamstring curl as tolerated c. Bike if tolerated d. Pool exercises 111. Advanced Phase Goals: Improve functional strength and endurance A. Postoperative weeks Continue flexibility exercises. 2. Continue to progress resistive strengthening and functional strengthening exercises. a. Closed chain exercises as tolerated: multihip strengthening, hamstring curls, knee extensions B. Gradual progression tofullfunctional activities Figure 1 Postoperative rehabilitation for hip-arthroscopy patients.

8 84 Griffin, Henry, and Byrd Active Assisted Range-of Motion Exercises Active assisted range-of-motion exercises are initiated early in the postoperative recovery. Exercises are directed in all planes of hip motion. End ranges are determined by the patient's level of discomfort. Stretching is typically pushed only to tolerance, and the patient is educated as to these parameters, as well. The adage of "no pain, no gain" does not apply. As noted previously, the principal role is to reduce discomfort. Pushing the extremes of range of motion does little to enhance function and might only serve to exacerbate discomfort. One exception to this is after excision of large bony osteophytes that might have created a prominent bony block to motion. Under these circumstances, aggressive early stretching can regain the previously blocked motion and might indeed improve function when there was a significant mechanical block. Distraction Mobilization Techniques Distraction mobilization techniques can be very useful. Distraction reduces compressive forces across the articular surfaces, which can reduce discomfort and, over time, enhance cartilage healing.12 Range-of-motion exercises address only rotational motion of the joint. Distraction mobilization techniques address axial motion (joint separation/compression) and translational motion (horizontal movement of the articular surfaces in relation to each other), as well as rotational motion. Both require a clinician skilled in performing these techniques. Additionally, it requires patient compliance and cooperation for effective results. Whether because of cognitive or motor skills or apprehension, some patients might not be good candidates for these techniques. Distraction mobilization is performed by 3 methods: straight-plane distraction, inferior glide, and posterior glide. The simplest method is straightplane distraction. This is performed with the patient supine on a mat. The patient is coached to remain relaxed while the clinician, grasping the lower leg above the ankle, applies a manual traction force. This distracts the femoral head from the acetabulum. It might be necessary to have an assistant stabilize the torso. Beneficial results require sustained distraction of 5-10 seconds. Consequently, the clinician must be in a position that facilitates attaining as much leverage and mechanical advantage as possible. Usually 5 repetitions in each plane are performed. Inferior glide is performed supine with the hip and knee flexed 90". The therapist rests the patient's lower leg on the therapist's shoulder. Amanual distraction force is then applied to the proximal anterior thigh. This is achieved by interlocking both hands and then applying pressure, distracting in a distal direction. The posterior glide is similarly performed supine with the hip and knee flexed 90". For this method, however, the force is applied downward on the knee, creating posterior translation of the femoral head relative to the

9 Rehabilitation After Hip Arthroscopy 85 acetabulum. This is most effectively performed with the clinician positioned over the patient and using the clinician's body weight to apply the posteriorly directed force. Straight-leg-raise exercises are avoided early in the postoperative phase of recovery. For some patients, it might remain contraindicated. An active straight-leg raise, even without applied resistance, generates a force of several times body weight across the hip joint.13 This is more than the force generated by standing or walking. The consequences of this type of force applied across the joint must be considered relative to the forces and purpose of other early-phase rehabilitative maneuvers. Isometric Exercises Muscle-toning exercises are gradually introduced, often in the first week after surgery. However, it requires that the patient be comfortable and cooperative and then remain relatively pain-free throughout the performance of these exercises. Progression then depends on the patient's tolerance. Isometric exercises are the first muscle-toning techniques to be introduced. They are the simplest, easiest to perform, and least likely to aggravate underlying joint symptoms. These include isometric sets for the quads, hamstrings, gluteal, adductor, and abductor muscle groups. Closed Chain, Proprioceptive, and Balancing Exercises Closed kinetic chain exercises are initiated as the patient accomplishes painfree isometric exercises. Closed chain methods allow progressive weightbearing transference to the lower extremity in a manner that lessens the shear and translational forces across the joint surfaces.14 The simplest closed chain exercise is progression of carefully controlled single-leg-stance maneuvers, which are helpful in pelvic toning. It is especially helpful, however, in stimulating proprioceptive and balance responses, which are important long-term protective features for the joint. Double-leg bridging drills are a more advanced form of closed chain exercise. Supine, with both feet planted on the mat, the back is arched, raising the buttocks off the surface. Initially, well-leg support is used. This can be progressed to single-leg bridges with full support carried on the involved extremity as symptoms allow. Basic Functional Exercises As the patient successfully goes through the preliminary rehabilitative phases, remedial functional exercises are introduced. These are then progressed within the tolerance of the patient's symptoms. A stationary bicycle can enhance smooth, fluid motion of the hip joint. Resistance on the bicycle is kept low. Initially, the seat is raised; it is gradually lowered as mobility improves. Patients who have a stationary bicycle

10 86 Griffin, Henry, and Byrd Table 1 Pool Exercises for Generalized Water Conditioning Water-resisted cuff weights, all directions Flutter-kick swimming Fast walking drills Weight shifts Minisquats Toe walking Heel walking Bounding and bouncing Deep-water running at home can initially use it for 5 min twice a day, gradually progressing to a maximum of 20 min twice a day. More prolonged periods of use are of minimal added benefit. The NordicTrac is an excellent device for gradually enhancing endurance and strength with low impact. Pool exercises (Table 1) are an excellent method of allowing early compression drills while reducing body weight. A variety of routines and sportspecific or activity-specific programs can be developed for this environment. As the athlete demonstrates tolerance to these methods, further closed kinetic drills can be introduced. The StairMaster and leg-press machine are methods that should be judiciously used. Open Chain and Advanced Functional Exercises Ultimate progression of rehabilitative exercises that stress and test the hip must be very individualized. Open chain exercises have recognized benefits in the course of muscle ~onditioning.'~ They are also known, however, to generate higher compressive and shear forces across the joint surfaces during the course of exercise. When it is felt that the healing joint can tolerate this, open chain exercises are introduced. These can include advanced use of Theraband and, ultimately, various weight machines. Functional exercises are similarly individualized to the patient's goals. These must be kept within the constraints dictated by the hip pathology addressed. Functional drills in a controlled environment are progressed to simulate activity-specific or sport-specific demands. Conclusions Rehabilitative principles long used in other joints are now finding application in the management of a variety of hip disorders. The principles presented

11 Rehabilitation After Hip Arthroscopy 87 here, initially developed for postoperative rehabilitation after arthroscopic hip surgery, also have application in conservative treatment of hip disease and injury. A unique feature of the hip is that limitation of motion often does not represent a significant functional problem. Although this can be considered in the course of management, it must be kept in perspective, because the common goals of hip rehabilitation are to reduce discomfort and improve function. The comprehensive nature of the rehabilitation program serves many purposes. The therapist's hands-on approach provides the opportunity to assess and interpret the patient's expectations. The therapist can then assist a patient in formulating reasonable goals. The rehabilitation team must ensure that the athlete's expectations and rehabilitation goals coincide by stressing education for current and future hip management. The athlete's compliance with a continued management program should include maintaining muscle balance (strength and flexibility) and improving overall function. References 1. Byrd JWT. Indications and contraindications. In: Byrd JWT, ed. Operative Hip Arthroscopy [videotape]. New York, NY. Thieme; 1998: Henry C, Middleton K, Byrd JWT. Hip Rehabilitation Following Arthroscopy [videotape]. 101 Theater. AAOS Annual Meeting; February 1995; Orlando, K. Chicago: American Academy of Orthopaedic Surgeons; Byrd JWT. Hip arthroscopy utilizing the supine position. Arthroscupy. 1994; 10(3): Byrd JWT. Arthroscopy of select hip lesions. In: Byrd JWT, ed. Operative Hip Arthroscopy [videotape]. New York, NY: Thieme; 1998: Byrd JWT. Operative Hip Arthroscopy [videotape]. New York, NY: Thieme; McCarthy JC, Day B, Busconi B. Hip arthroscopy: applications and technique. J Am Acad Orthop Surg. 1995;3(3): Gould JA, Davies GJ. Orthopaedic Sports Physical Therapy. St. Louis, Mo: Mosby; Kessler RM, Hestling D. Management of Common Musculoskeletal Disorders. Philadelphia, Pa: Harper & Row; 1983: Maitland GD. Peripheral Manipulation. Boston, Mass: Butterworth; Johnson LL. Arthroscopic abrasion arthroplasty. In: McGinty JB, Caspari RB, Jackson RW, Poehling GG, eds. Operative Arthroscopy. Philadelphia, Pa: Lippincott-Raven; 1996: Rodrigo JJ, Steadman JR, Silliman JF, Fulstone HA. lmprovement of fullthickness chondral defect healing in the human knee after debridement and microfracture using continuous passive motion. Am 1 Knee Surg. 1994;7(3):

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