Rehabilitation of Hip Injuries in Athletes

Transcription

1 Rehabilitation of Hip Injuries in Athletes Kevin E Wilk, PT, DPT Hip injuries are somewhat common in sports & daily activities Hip injuries less common than other joints More difficult to identify than other lesions Didn t t have much to do for these disorders Numerous common lesions seen Martin, Kelly, Leunig, Phillippon: Arthroscopy 2010 Hip forces: x BW Injuries often occur due to excessive twisting, pivoting & extremes of motion Frequency: % 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: Hip Injuries are common in specific sports: Ballet Runners Soccer Golfers Contact sports Hip Injuries are common in specific sports: Baseball Hip Injuries are common in specific sports: Golf

2 Hip Injuries are common in specific sports: Hockey, Soccer, Ballet, Diagnostic Dilemma The Spine Hip Joint Other Causes Hip lesions Arthroscopy has defined numerous sources of disabling hip pain Athletes previously resigned to living within the constraints of their symptoms 60% of intraarticular hip disorders unrecognized during initial management (avg. 7 mos) Byrd & Jones: Clin Sports Med 01 Clinical Examination Martin et al: Arthroscopy 2010 Bryd et al: No Am J Spts PT 07 Classifications of Lesions Intraarticular Extraarticular Acetabular labral tears Hypermobile iliopsoas tendon Chondral injuries Snapping iliotibial tendon Osteoarthritis Muscle strain (iliopsoas( iliopsoas,, gluteus medius, Posttraumatic arthritis hamstring) Inflammatory arthritis Bursitis (greater trochanteric, iliopsoas, FAI (cam, pincer) ischial) Ligamentum teres tears Tendonitis (rectus femoris,, external Instability rotators) Capsular sprain Avulsion injuries Capsular tightness Stress fracture of the lesser trochanter Capsular tear Sacroiliac joint strain Developmental dysplastic hip Myositis ossificans Femoral neck stress fracture Hip pointer Osteonecrosis Lumbar radicular pain Loose bodies Inguinal/Femoral hernia SCFE Legg-Calve Calve-Perthes disease Phillippon et al: Op Tech Orthop 05 Transient synovitis Bryd et al: No Am J Sports PT 07 Infection Intraarticular Lesions Labral Tears Femoracetabular» Hypertrophic tears Impingement (dysplasia)» CAM» Hypotrophic tears» Pincer Chondral Injuries Synovitis» Focal defects Loose Bodies» AVN Tumors Ligamentum Teres Tears» Synovial chondromatosis» Partial» PVNS» complete

3 Extraarticular Lesions Capsular Problems» Instability» Hypomobility Snapping Hip» Internal» External Lateral Hip Pain» Trochanteric Bursitis» Glut Medius/Minimus Tears Pubic Pain» Osteitis Pubis» Chronic adductor strain» Sports Hernia Tendonitis/Avulsion Injuries Nerve Compressions» Performis syndrome» Meraigia paresthetica (LFCN)» Illioguinal n» Illiohpogastric n» Genitofemoral n 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 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 2-32 mos this to prevent set back Bryd et al: AJSM 10 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-variable Arthroscopic Debridement Week One:» Initiate light ROM & stretching» Glut sets, Quad sets, SLR» Bridges Week two:» Progress strengthening to ER/IR» Isotonics on hip machine» Balance drills, stepping drills, lunges

4 Arthroscopic Debridement Week Three:» Functional drills (light to moderate)» Balance, hip stabilization drills, single leg drills Week 4-6: 4» Functional drills (moderate to advanced)» Star drills, Bosu ball, Ellipical,, Alter G Week 7-9: 7» Advanced functional drills Progress WB AlterG Week 10-12: 12:» Sport Specific Drills & progression of sport drill Arthroscopic Femoroplasty FAI Crutch use for 4 weeks Vigorous impact loading avoided for 3 months to allow bone remodeling/ healing Progressive ROM, stretching program Progressive strengthening program» Pool program, Bike Initiate functional activities 3 months Return to sports: months Bryd et al: AJSM 11 Bryd et al: Arthroscopy 11 Intra-Articular Lesions Articular Trauma: Microfracture» Well circumscribed Grade IV lesions» 86% successful outcome (2-5 5 year f/u) Byrd & Jones AANA '04 Arthroscopic Microfracture Strict protection with WB for wks Crutches 8 weeks Emphasis on ROM, capsular mobility & flexibility Pool program Bicycle: low intensity long duration Initiate functional activities: 3-43 months Unloading treadmill Alter G, Pool

5 Arthroscopic Microfracture Toe Touch WB day1 post-op op Gradually increase WB till 8 wks NWB exercises for wks Bicycle week 2 Pool program week 3-43 WB type exercises week Light running week 16* Gradual return to sport specific training week 20> Intra-Articular Lesions Articular Trauma: Ligamentum Teres Traumatic rupture» Increasingly recognized (especially among athletes)» Twisting injury in absence of dislocation/subluxation subluxation» Mean improvement 47 pts.» 96% significantly better (>20 pt.) Byrd & Jones Arthroscopy '04 Ligamentum Teres Rupture Limited WB on crutches as demanded by Physician Gradual ROM & stretching program Light strengthening program progressing to more advanced isotonics in 4-6 weeks Functional drills 4-6 weeks Sport Specific training Physician determines (week 8 week 16) Intra-Articular Lesions Articular Trauma: Fracture/Dislocation Thoughtful recovery strategy» Uncertain long-term prognosis Most develop subchondral edema femoral head» Not necessarily poor prognostic indicator of return to play Return to 8 weeks 12 wks> Minimal alterations with posterior lip fx» For persistent sx s look for other source Arthroscopic Labral Repair Precautions: Partial WB (50% BW) for 6 weeks Limit ROM» Flexion to 90 degrees» Extension to neutral» Avoid ER for 6 wks» Caution w excessive ROM Arthroscopic Labral Repair Rehabilitation Guidelines:» Immediate limited ROM (PROM)» Isometrics immediately post-op op» Pool walking, etc week 2-32» Stationary bicycle week 4-54» Isotonics hip week 6-86» Ellipical week 6-8, 6 Unloading treadmill wk6-8» Pool running week » Sport Specific training: week » Return to sports: week 16> (Physician decision)

6 Arthroscopic Iliopsoas Release Weight bearing as tolerated Crutches used to normalize gait (2-4 4 weeks) Gentle emphasis on hip extension Aggressive hip strengthening delayed for 6 weeks Functional activities/progression when appropriate Return to sports:3 months Arthroscopic Femoroplasty Rehabilitation: Precautions:» WBAT for weeks» Protect against excessive forces onto hip 8 wks» Protect against twisting or torsional forces» Limit aggressive activities for 12 weeks Immediate Post-Op» Limit & light PROM, stretches» Glut sets, abdominal, LE isometrics» Bridges, progress isometrics Arthroscopic Femoroplasty Rehabilitation:» Stationary bicycle: week 2» Pool program: week 3» Mini-squats, lunges, hip ER/IR» Isotonics hip week 4» Elliptical week 5-65» Advanced strengthening exercises week 12» Functional activities: initiate week 14-16> 16> * Criteria to Return to Sports Full ROM & flexibility Satisfactory clinical exam Single leg pick up with level pelvis RDLs Approval by Physician Strength within 80-85% 85% opposite side Ability to perform functional activities w/o pain Hip Flexor Stretches TFL/ITB Stretches Self Stretch Thomas Stretch Ober Stretch Supine Stretch

7 Hamstring Stretches Joint Mobilization Techniques Multi-Planar Stretches Lateral Distraction Joint Mobilization Techniques Hip ER/IR Anterior Glide Hip Rotation Strengthening Instant Replay Hip ER/IR

8 Hip Flexors Hip Extensors

9 Plank Progression Bilateral stable surface Bilateral unstable Bilateral unstable RS Bilateral rubber band resist Unilateral stability RS Unilateral unstable Alternating unilateral

10 Functional Drills 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 operatively Well designed, progressive, & sequential rehab program is vital

11 Thank You!!!