Hip Arthroscopy - Post-Operative Care and Rehabilitation Franz Valenzuela, DPT, OCS Surgery corrects mechanical problems Rehabilitation corrects functional deficits Surgical Procedures Requires little biological healing Loose body removal Labral debridement Synovectomy Ligamentum teres debridement Requires more extensive biological healing Labral repair Thermal/suture capsulorrhapy Microfracture Osteoplasty Post-operative operative Rehab Communication of accurate surgical information is crucial Precautions and limitations during phase I are determined by which arthroscopic procedures were performed Voight et al., Sports Health, June 2010 Goals of Post-operative operative Rehab To reduce symptoms (pain and inflammation) Improve function ROM Strength Proprioception endurance Return to desired level of activity Phase 1 Maximum protection and Mobility (1-4 weeks) Protect surgical repair Diminish pain and inflammation Restore ROM within restrictions Reverse muscular inhibitions Achieve good gluteal recruitment Normalize gait
Protection of Surgical repair Use hip hinge brace for 3 weeks when walking. If patient was given a boot strap to use at night, this should be worn for 10 days Protection of surgical repair ROM within protected range No abduction > 45 for 2 weeks Capsular modifications - No ER and extension for 3 weeks Avoid sitting at 90 deg. Of hip flexion for 2 weeks Hip internal rotation: No restrictions, PAIN FREE Hip Adduction: No restrictions, PAIN FREE Weight bearing precautions Foot flat weight bearing for 2-32 3 weeks 50% WB on 3 rd week and gradually to WBAT in the 4 th week Add 4-54 5 weeks for microfracture Foot Flat weight bearing vs. NWB NWB requires significant muscle force to suspend the leg off the ground -- increase dynamic joint compression (Tackson et al, 1997) Neutralize by FFWB Application of Wolff s s Law Promoting relatively normal gait Decrease load on both UE ROM within protected range Stationary upright bike using good leg PROM instruct caregiver/trainer Emphasis on circumduction and IR CPM 4-66 hours/day for 3 weeks, then 2 hours week 4-64 ROM Phase 1 Pain Free ROM Phase 1 Day 3 Piriformis stretch in sidelying Cat and camel in quadruped Supine hip abduction/add
Post-operative operative muscle presentation Hip flexors facilitated and in spasm, erector spinae facilitated Gluteus medius/maximus and deep abdominals inhibited - altering normal patterns of movement (anterior pelvic tilt) Exercises to correct muscle imbalance Isometrics on 1 st day post-operative operative Stretch hip flexors (day 2-3) 2 Isometrics Day 7 Neuromuscular reeducation - Gluteals Active gluteal extension (to neutral) in quadruped Isometric hip extension in sidelying Isometric left hip abduction hold in sidelying Prone hip extension off edge of bed (2 nd week) Quadruped rocking to increase hip flexion AROM at 3rd week Standing Hip abduction with IR AROM at 3rd week FABER heel slides start once external restrictions are lifted Passive hip internal and external rotation with hip in neutral in prone lying
AROM (phase 1) at 3 rd week Increase weight bearing at week 3-4 Start 50% WB on the 3 rd week then wean off crutches Optimal gait is a must Wean off assistive device only when patient is pain free with weight bearing and without a limp. Trendelenburg gait Gluteus medius provides a level pelvis If gluteus medius are weak and or inhibited - contralateral hip drop during single limb support. Criteria to advance to Phase 2 Minimal pain with all phase I exercises Proper muscle (deep abdominals/gluteals) with all phase 1 exercises Normal gait Minimal complaints of pinching in the hip before 100 flexion Phase 2 (Intermediate exercise and stabilization) Begins at week 4 or 5 PROM Progress strengthening and stabilization exercises Precautions No treadmill use No ballistic stretching Avoid joint irritation: Too much volume, force or not enough rest Watch for hip flexor and adductor tendinopathy Avoid active SLR for 6 weeks Avoid active hip adduction in sidelying
Phase 2 Exercises Phase 2 Exercises Phase 2 Phase 2 core stabilization exercises Phase 2 Functional exercises Double knee bends Double knee bends to calf raise Weight shifting Lateral forward/backward Single leg stance Reverse lunges without resistive band Forward shift to Romanian dead lift Manual Interventions Start on the 7th week if needed to increase Hip ROM Manual long axis gentle distraction Manual A/P mobilization
Criteria to progress to Phase 3 Full PROM Normal gait Pain free with functional exercises and with good neuromuscular control Perform sidelying hip abduction lift with leg IR Phase 3 (Advance exercise and Strengthening) Week 8 or 9-12 Establish multi-directional strength, advance proprioceptive retraining and cardiovascular conditioning Precautions No treadmill use No ballistic stretching and strengthening Phase 3 exercises Phase 3 exercises Shuttle Double leg squats Single leg squats Heel raises Double leg squat on Bosu, band around knees Phase 3 Exercises Single leg step down Femoral adduction and internal rotation
Phase 4 (Sports Specific Training) Week 12 or 13 Phase 4 Exercises Increase duration before intensity Side to side lateral agility Forward/ backward running with bungy cord W Cuts Z Cuts Cariocas W Cuts Z Cuts Cariocas Running Progression Obtain clearance from orthopedic surgeon Can start if patient can do 3 minutes of single knee bends without pain
Running progression Involves four phases Progress to the next phase after completing for 20 minutes without pain Phase Walk/run ratio Time Frequency 1 4 min/ 1 min 10-20 3 X/week 2 3/2 10-20 3 X/week 3 2/3 10-20 3 X/week 4 1/4 10-20 3 X/week Continue Running Progression for 2 weeks, if no pain Can start Sports test exercises without resistance Return to Sport Case study reported by Dr. Marc Philippon et al Published Journal of Sport Rehabilitation, 2009 Criteria to begin Phase 5 (Return to sport) consisted of passing the Return to sport test Return to sport test Sport cord agility test Evaluates an athlete s s performance when fatigued and assess ability to accept load through the hip Consist of 4 tests 20 points possible with 17 considered a passing score Return to sport test 1- Cord resisted Single knee bend (70 ) One point for 30 seconds with good form Goal is 3 minutes Max points is 6 Return to sport test 2- Lateral agility with sport cord one point for each 20 seconds with good form Goal is 100 seconds Max points is 5
Return to sport test 3- Diagonal agility with sport cord One point for each 20 seconds Goal is 100 seconds Max points is 5 Return to sport test 4- Forward box lunge with sport cord One point for each 30 seconds Goal is 2 minutes Max points is 4 References Ekstrom R, Donatelli R, Carp K. Electromyographic analysis of core trunk, hip and thigh muscles during 9 rehabilitation exercises. J Orthop Sports Phys Ther. 2007;37:754-762 762 Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The Hip Joint: Arthroscopic Procedures and Postoperative Rehabilitation. J Orthop Sports Phys Ther.2006;36(7):516 2006;36(7):516-525525 Philippon MJ, Christensen JC, Wahoff MS. Rehabilitation after Arthroscopic Repair of Intr- articular Disorders of the Hip in a Professional Football Athlete. J Sports Rehab. 2009;18:118-134 References Stalzer S, Wahoff M, Scanlan M. Rehabilitation following Hip arthroscopy. Clin Sports Med. 2006;25(2):337-357 357 Voight ML, Robinson K, Gill L, Griffin K. Postoperative Rehabilitation Guidelines for Hip Arthroscopy in an Active Population. Sports Health: A Multidisciplinary Approach.. 2010;2:222-230 230