15.2.1 - Postoperative Management of the Hip Monograph

8/19/2019 15.2.1 - Postoperative Management of the Hip Monograph

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Postoperative Management

of Orthopaedic Surgeries

Independent Study Course 15.2.1

Keelan R. Enseki, PT, MS, SCSCenters for Rehab Services

University of Pittsburgh Center for Sports Medicine

Pittsburgh, PennsylvaniaPete Draovitch, PT, MS, ATC, CSCS

Centers for Rehab ServicesUniversity of Pittsburgh Center for Sports Medicine

Pittsburgh, Pennsylvania

Bryan T. Kelly, MDUniversity of Pittsburgh Medical Center

University of Pittsburgh Center for Sports Medicine

Pittsburgh, PennsylvaniaMarc J. Philippon, MD

University of Pittsburgh Medical CenterUniversity of Pittsburgh Center for Sports Medicine

Pittsburgh, Pennsylvania

Postoperative Management of the Hip

An Independent Study CourseDesigned for IndividualContinuing Education

CONTINUING

PHYSICAL THERAPY

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2920 East Avenue South, Suite 200 La Crosse, WI 54601Office: 608/788-3982 Toll Free: 877/766-3452 FAX: 608/788-3965

April 2005

Dear Colleague,

I am pleased to welcome you to Postoperative Management of the Hip by Keelan R. Enseki, PT, MS, SCS; Pete Draovitch, PT,MS, ATC, CSCS; Bryan T. Kelly, MD; and Marc J. Philippon, MD.This is the first monograph in the Orthopaedic Section Indepen-dent Study Course series 15.2 entitled Postoperative Manage- ment of Orthopaedic Surgeries .

Keelan Enseki and Pete Draovitch both work at the Centers for Rehab Services at the University of Pittsburgh Cen-ter for Sports Medicine. Keelan Enseki is a physical therapist who is a sports certified specialist as well as a certi-fied strength and conditioning specialist. Pete Draovitch is an athletic trainer and physical therapist who special-izes in golf fitness and rehabilitation. Dr Kelly and Dr Philippon also work at the University of Pittsburgh Centerfor Sports Medicine. Dr Kelly is a specialist in sports medicine and arthroscopic surgery of the shoulder, hip, andknee. Dr Philippon is a clinical assistant professor of orthopaedic surgery at the University of Pittsburgh School of Medicine and director of sports-related hip disorders at the University of Pittsburgh Medical Center’s (UPMC) Cen-ter for Sports Medicine. He is one of the world’s leading orthopaedic hip surgeons. All authors have worked exten-sively with patients having hip dysfunction and bring a wealth of both clinical and academic experience with themin writing this monograph.

This monograph starts with a review of anatomical considerations of the hip and surrounding structures. It con-tinues with a discussion of general rehabilitation guidelines. The authors then go into detail regarding both soft tis-sue and bony injuries to the hip and adjoining structures, including the capsule, labrum, and bony and soft tissues.This is followed by applicable information concerning specific postoperative interventions.

The second half of the monograph includes 3 cases studies for patients with various hip dysfunctions. The casesare very clinically applicable and consist of the following: patient history; systems review; tests and measures; eval-uation, diagnosis, and prognosis; intervention; reexamination; and termination of physical therapy.

The authors do a great job of covering issues of postoperative management of the hip from start to finish in a veryuser-friendly manner. I believe that you will find this monograph to be an informative and useful reference forworking with your patients in any practice setting.

Best regards,

Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDTEditor

Postoperative Management ofOrthopaedic SurgeriesMary Ann Wilmarth, PT, DPT, MS,

OCS, MTC, Cert MDT—Editor

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TABLE OF CONTENTS

LEARNING OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

REVIEW OF ANATOMICAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Osseous Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Labrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Capsuloligamentous Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Other Significant Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

GENERAL REHABILITATION GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

SOFT TISSUE INJURIES AND INTERVENTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Labral Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Labral Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8


Capsular Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9


Soft Tissue Release Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

BONY INJURIES AND INTERVENTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Microfracture Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Tests and measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Evaluation, diagnosis, and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Termination of physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17


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Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18



Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19


Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20



Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21


REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

REVIEW QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Opinions expressed by the authors are their own and do not necessarily reflect the views of the Orthopaedic Section.

The publishers have made every effort to trace the copyright holders for borrowed material.If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.

© 2005, Orthopaedic Section, APTA, Inc.

Course content is not intended for use by participants outside the scope of their license or regulations. Subsequentuse of management is physical therapy only when performed by a PT or a PTA in accordance with Association policies,

positions, guidelines, standards, and ethical principals and standards.


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Postoperative Management of the Hip

Keelan R. Enseki, PT, MS, SCSCenters for Rehab ServicesUniversity of Pittsburgh Center for Sports MedicinePittsburgh, Pa

Pete Draovitch, PT, MS, ATC, CSCSCenters for Rehab Services

University of Pittsburgh Center for Sports MedicinePittsburgh, Pa

Bryan T. Kelly, MDUniversity of Pittsburgh Medical CenterUniversity of Pittsburgh Center for Sports MedicinePittsburgh, Pa

Marc J. Philippon, MDUniversity of Pittsburgh Medical CenterUniversity of Pittsburgh Center for Sports MedicinePittsburgh, Pa

LEARNING OBJECTIVESUpon completion of this monograph, the course par-

ticipant will be able to:1. Describe anatomical characteristics of the hip joint

as they relate to potential pathological conditions.2. Describe indications for surgical procedures of the

hip joint.3. Understand current surgical techniques used to treat

pathological conditions of the hip joint.4. Understand and apply concepts of tissue healing

during rehabilitation.5. Describe intervention techniques utilized during

rehabilitation after surgical procedures of the hipjoint.

6. Apply these techniques to clinical practice.

INTRODUCTIONThe surgical options available for management of

pathological conditions of the hip joint have evolved sig-nificantly in the last few years. There are a number of reasons for the advancement of surgical intervention.Improved diagnostic techniques such as gadolinium-enhanced magnetic resonance arthrography (MRA) haveallowed detection of intra-articular conditions that

would have previously gone unrecognized. Significantadvancement of arthroscopic techniques has contributedto the improvement of diagnostic capability and anincreased number of surgical options available for selectconditions. The development of flexible scopes andmore versatile instrumentation has been crucial in thisprogression (Figure 1). Hip arthroscopy offers a less inva-sive alternative for hip procedures that would otherwiserequire surgical dislocation of the hip. In addition, thisprocedure allows surgeons to address intra-articularderangements that were previously undiagnosed and

untreated. Utilization of minimally invasive interventiontechniques provides the potential for a shorter recoveryperiod and course of rehabilitation for individuals undergoing arthroscopic surgery or total hip arthroplasty.

Numerous indications for surgical intervention of thehip exist. Currently the most common indicator ipainful, functionally limiting degenerative changes of thearticulating joint surfaces. The most common treatmenfor this is a total hip arthroplasty procedure. Appropriatepatient selection is of paramount importance to a successful outcome after hip arthroscopy. Injuries to the hip

in athletes are often categorized as muscle strains or softissue contusions. However, the cause of hip pain mayarise from a number of soft tissue structures in andaround the hip joint. It is important to be able to differentiate extra-articular from intra-articular pathologyPotential indicators for arthroscopic intervention includebut are not limited to, symptomatic tears of the labrumcapsular laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, painfusnapping hip syndrome, and presence of loose bodies.Less common indicators also exist, but are beyond thescope of this monograph.

Due to the inherent anatomical characteristics of thehip, arthroscopy of the joint is a technically demandingprocedure. The femoral head is deeply recessed in theacetabulum. The joint is surrounded by a thickened capsule and a large amount of muscle tissue. The proximityof other structures such as the sciatic or lateral femoracutaneous nerves also presents potential complicationwhen attempting to perform arthroscopy of the hip jointThe development of improved visualization procedureand surgical tools such as flexible scopes has helpedimprove the effectiveness and safety of such intervention

Figure 1. Flexible instruments allow for greater accessto hip joint structures during arthroscopy. (A)Radiofrequency heating probe. (B) Close-up of flexibletip. Reprinted from Kelly BT, Williams RJ III, PhilipponMJ. Hip arthroscopy: current indications, treatmenoptions, and management issues. The American Jour-nal of Sports Medicine. 2003;31:1020–1037. Copyright

2003, by permission of Sage Publications Inc.


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methods. The purpose of this monograph is to review anumber of currently utilized surgical techniques andrehabilitation considerations for such procedures.

Given the complex nature of the hip joint (27 musclescrossing the hip), and the significant weakness that canoccur after these procedures, the authors feel that super-vised therapy is essential for full return of function. Incomparing the outcomes of our patients who receive thefull rehabilitation protocol versus those who have short-

ened or less intense programs, the authors have foundsignificantly faster and more complete return to full func-tion with the comprehensive program. The duration of therapy may be lengthened or shortened based upon thesuccessful achievement of therapeutic goals. High-levelathletes are often able to have a return to full activitybetween 3 and 4 months (depending upon the procedureand the nature of the sport); however, in more sedentaryindividuals, full function may not return until 6 to 8months. Appropriate patient education regarding expec-tations is critical for complete patient satisfaction.

Due to the overlap of rehabilitation intervention tech-niques, common principles for various arthroscopic pro-cedures are described using the general rehabilitationguidelines section as the primary template. Discussion of rehabilitation following specific procedures is basedupon modifications of this template. The exception isrehabilitation of patients undergoing total hip arthroplas-ty procedures. Rehabilitation of patients undergoingtotal hip arthroplasty procedures is discussed indepen-dently of arthroscopic procedures. It is important toremember that rehabilitation techniques evolve in con-junction with surgical advancements. Many of the pro-cedures described in this monograph are relatively newand continue to evolve. The information in this mono-

graph is intended to reflect rehabilitation techniquesbased upon the most current surgical techniques beingutilized at the time of publication.

REVIEW OF ANATOMICAL CONSIDERATIONSIn order to understand the rationale behind specific

surgical intervention techniques and subsequent rehabil-itation, an appropriate level of anatomical knowledgeregarding the hip joint is necessary. The intention of thissection is to provide the reader with a review of struc-tures and function of the hip joint region. The implica-tions of these concepts will become apparent throughout

the remainder of the monograph.

Osseous StructuresThe hip joint is formed by the articulation of the con-

vex femoral head with the concave acetabulum of theinnominate. It is described as a ball and socket joint.Although it is classified as the same type of joint as theshoulder, the hip joint has numerous differing character-istics. This is secondary to the fact it is inherently muchmore stable and weight bearing in nature. Variations of femoral head geometry and acetabular depth can affectstability of the hip joint.1 The amount of coverage the

acetabulum provides over the femoral head will affectthe inherent stability of the hip joint. The center edgeangle is calculated to provide a measurement of acetab-ular overhang (Figure 2). The center edge angle isformed between a line extending vertically from the mid-dle of the femoral head and a line from the middle of thefemoral head to the edge of the acetabulum. An anglesignificantly less than 30° is considered abnormal and isassociated with decreased joint stability. The femoral

head normally forms two-thirds of a sphere with a flat-tened area where the acetabulum applies its greatestload.1 During normal function, rotation is the primarymotion occurring at the joint, with a minor and variableamount of translation.2 The angles created by the neck of the femur in both the frontal (angle of inclination) andtransverse (angle of declination) planes can affect stabil-ity of the joint.

LabrumThe labrum is a fibrocartilagenous horseshoe-shaped

structure attached to the periphery of the acetabulum(Figure 3). It is contiguous with the transverse acetabu-lar ligament across the acetabular notch. It attachesperipherally to the joint capsule at the base. The centralsurface is lined with articular cartilage continuous withthat of the acetabulum. The labrum has been found to

Figure 2. The center edge angle is represented by theangle between a line drawn vertically from the center of

the femoral head and a line drawn from the center of the femoral head to the edge of the acetabulum. A nor-mal angle is approximately 30° in the adult population.


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have sensory innervation with both proprioceptors andnociceptors in its superficial layers.3 The intact labrumcontributes to joint stability by deepening the concavityof the acetabulum and helping to create negative intra-articular pressure. Studies exist suggesting the labrumplays a role in cartilage consolidation and formation of alabral seal in hip joint mechanics.4,5 Ferguson et al5

found that absence of the labrum significantly increased

cartilage consolidation and contact pressure of thefemoral head against the acetabulum. They also foundthat the labrum had a sealing function in the hip that lim-ited fluid expression from the joint space and had a pro-tective effect on the cartilage layers of the hip. Consid-ering these findings, it can be suggested that labral com-promise or deviations from normal structural characteris-tics could result in a potentially altered load distributionof the joint surfaces, increasing the potential for dam-age.6 Much like the meniscus of the knee, the majority of the labrum in the hip is avascular, with vasculature onlyon the outermost layer. This suggests a poor healingpotential for many injuries of this structure.

Articular CartilageThe articular cartilage of the acetabulum and the

femoral head is situated to handle the weight-bearingcharacteristics of the joint. The articular cartilage liningthe periphery of the acetabulum is thickest superiorly.The articular cartilage of the femoral head is thickestsuperiorly and posteriorly. Found in the central area of the femoral head, the fovea capitis is devoid of cartilageand serves as the proximal attachment for the ligamen-tum teres. The articular cartilage is avascular and notinnervated.

Capsuloligamentous StructuresThe joint capsule of the hip is dense and relatively

inelastic, with reinforcement from 3 ligaments. It attaches proximally to the acetabular rim and distally to thebase of the femoral neck (Figure 4). Two-thirds of thefemoral neck is contained within the capsule. Ligamentous reinforcement consists of the iliofemoral, pubofemoral, and ischiofemoral ligaments (Figure 5). Theiliofemoral ligament, the strongest ligament of the hip

lends support to the anterior capsule. This ligament primarily serves to limit extension and external rotation. Thepubofemoral ligament reinforces inferior and anterioportions of the capsule. It resists extension and abduction. The ischiofemoral ligament reinforces the posterioportion of the capsule. This ligament has the potential tolimit extension and internal rotation. Because of their orientation around the joint, the capsular ligaments becomemost taut in a position of full extension.

The ligamentum teres originates proximally from theacetabular fossa and transverse acetabular ligament andinserts at the fovea of the femoral head (Figure 3)Although this ligament conducts vessels to the femorahead in most people,7 it has been thought to play a minorole in vascularity. It has been traditionally thought thathe ligamentum teres plays no significant role in stabilityStudies exist suggesting that the ligament does becometaut with hip adduction, flexion, and external rotation.Additionally, patients suspected of having a traumatictear have often been found to suffer from symptoms oinstability and pain.1 Assessing the ligamentum tereclinically and through diagnostic imaging can prove to

Figure 3. The labrum surrounds the rim of the acetabu-lum nearly circumferentially and is contiguous with thetransverse acetabular ligament across the acetabularnotch. The ligamentum teres arises from the margins of the acetabular notch and the transverse acetabular lig-ament. Reprinted from Kelly BT, Williams RJ III, Philip-pon MJ. Hip arthroscopy: current indications, treat-ment options, and management issues. The American

Journal of Sports Medicine. 2003;31:1020–1037.Copyright 2003, by permission of Sage Publications Inc.

Figure 4. Expanded view of the hip joint capsule. (ACapsular fibers. (B) Proximal insertion of the capsuleinto the acetabular rim. (C) Distal attachment of thecapsule along the trochanteric line. Reprinted withpermission from The Physiology of the Joints. Vol. 2:the lower limb . Kapandji IA, page 33. Copyright 1987with permission from Elsevier.


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be difficult. The suggested role of the ligamentum teresand subsequent treatment of injury to the structure may

change. Further research to define such changes is nec-essary at this time.

Other Significant StructuresA number of other structures in proximity to the hip

play significant roles in function of the joint. Muscles of particular interest include the gluteus medius and theiliopsoas. The gluteus medius provides the majority of force required to keep the pelvis stable in the frontalplane during single limb stance. Weakness of this mus-cle may result in significant functional impairment. Theiliopsoas is primarily a hip flexor. This muscle crosses

the anterior portion of the joint. Excessive tightness of this muscle may lead to several problems. In severe cas-es where less than 10° of extension is allowed, normalgait may be hindered. Excessive tightness may produce asnapping sensation as the tendon passes over the femoralhead or other bony structures. The iliotibial band is oftenfound to be the source or contributing factor to lateralthigh pain. The iliopsoas, greater trochanteric, andischial bursae structures can become inflamed andsymptomatic. The iliopsoas bursae is continuous withthe joint in approximately 20% of the adult population.9

Inflammatory conditions of the joint may result in symp-toms manifesting as iliopsoas bursitis.

GENERAL REHABILITATION GUIDELINESAs a general guideline, the authors recommend 3

months of supervised therapy after arthroscopic hip pro-cedures. During month 1, the authors prescribe 1 day of therapy each week. During month 2, patients receivetherapy 2 days per week. During the final month, wherereturn of strength, coordination, and endurance areemphasized, patients have therapy 3 times per week.Month 1 is the tissue healing phase and focuses ondecreasing inflammation, allowing the tissue to heal

properly, and regaining full passive range of motion(ROM). Month 2 is the early strengthening phase.Month 3 focuses on return of full strength, endurance,and coordination.

The goal of immediate postoperative care for allarthroscopic procedures is to control inflammation,maintain ROM, and avoid muscle atrophy of the lowerextremities. A combination of modalities and non-steroidal anti-inflammatory drugs (NSAIDs) are often

used to control inflammation. Early ROM may beobtained and preserved through a number of approach-es. A continuous motion apparatus is often utilized for10 days to 6 weeks depending on the procedure. The useof a stationary bike immediately after surgery can helpobtain ROM without excessive compressive or shearforces acting at the joint. Excessive ROM may be avoid-ed through use of a brace that limits motion in the sagit-tal plane (Figure 6). A night immobilization system isoften prescribed to limit excessive external rotation dur-ing sleeping hours. Gentle isometric activities (eg,quadriceps sets, gluteal sets, and abduction and adduc-tion isometrics contraction) are initiated to help preventexcessive atrophy of lower-extremity musculature.

Figure 6. Postoperative brace to prevent movement of the hip joint in the sagittal plane.

Figure 5. Anatomical constraints of the hip. Reprintedfrom Kelly BT, Williams RJ III, Philippon MJ. Hiparthroscopy: current indications, treatment options,and management issues. The American Journal of Sports Medicine. 2003;31:1020–1037. Copyright 2003,by permission of Sage Publications Inc.


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Aquatic activities have proven to be an effective com-ponent of the rehabilitation process. Early ambulation inthe pool allows patients to focus on gait symmetry in adeweighted environment. Active ROM within pain-freelimits can also be initiated in the water. For those indi-viduals concerned with preservation of their cardiovas-cular fitness, such as distance runners, jogging in anaquatic vest can be initiated as tolerated. In the authors’experience, aquatic activities have proven to be an

excellent tool to aid in the transition from limited weightbearing to functional activities on dry land.

Initiation of ROM, strength, and weight-bearing activ-ities varies depending on the specific procedure per-formed. Though the first 2 weeks of therapy are standardfor most procedures, variations for these activities occurafter this time. Rehabilitation principles for specific pro-cedures are discussed under their respective sections inthe monograph and summarized in Table 1.

SOFT TISSUE INJURIES AND INTERVENTIONSLabral Resection

Arthroscopic procedures to address labral injurieshave gained popularity only in recent times. In our expe-rience, injuries to the labrum are the most commonsource of hip pain identified at the time of arthroscopy.The labrum deepens the acetabulum and effectivelyincreases the total contact surface area of the joint. Thesecharacteristics have a potential stabilization effect on thejoint. This effect may be compromised with injury to thelabrum. In the North American population, tears mostcommonly occur in the anterior-superior portion of the

labrum. Tears can be defined as midsubstance, frayeddegenerative, or flapped in nature. Partial labral detachment has also been observed.

Labral injuries may occur through several mechanisms. Common causes of labral tears are listed in Table2. Traumatic injuries are often observed in athletes andindividuals subject to high-amplitude, short-durationforces at the hip joint. Common mechanisms of injuryare those that consist of a rotary nature, often in a

weight-bearing position. The most common mechanismis application of an external force on a hyperextendedand externally rotated hip joint.1 An example of therotary mechanism may be noted by the relatively highincidence of symptomatic labral injuries in golfers. Thehip joint repetitively experiences forceful internal andexternal rotation in a weight-bearing position during theperformance of a golf swing. Other athletes at higher riskfor injuries of this nature are dancers, gymnasts, socceplayers, and hockey goaltenders. A portion of athletes

Activity Isolated Labral Procedure Capsular Procedure Microfracture

(isolated or with labralprocedure)

Stationary bike Immediately Immediately Immediately

Gentle quadriceps, Day 2 Day 2 Day 2hamstring, and glutealsetting

Passive range of motion Weeks 1 to 2: flexion from Weeks 1 to 2: flexion Weeks 1 to 2: flexion0° to 90° from 0° to 90° from 0° to 90°

After 2 weeks: motion as After 2 to 3 weeks: very After 2 weeks: variabletolerated gradual pain-free motion progression depending

on procedure

Active range of motion As tolerated after 2 weeks As tolerated after 3 weeks Variable

Stretching After 3 weeks After 3 to 4 weeks: hold After 3 to 4 weekship flexor stretch untilafter 4 weeks

Resistance exercise As tolerated after 2 to 4 weeks As tolerated after 4 weeks As tolerated after 4 to 6 weeks

Weight-bearing activities Initiate at 10 days to 4 weeks Typically 10 days to 4 Typically 4 to 8 weeksweeks

Functional activities As tolerated after full weight As tolerated after full As tolerated after fullbearing weight bearing weight bearing

Table 1. Rehabilitation Guidelines for Specific Arthroscopic Procedures of the Hip

• Traumatic injury• Joint laxity/hypermobility

• Bony impingement

• decreased femoral head neck junction offset

• overhang of the anterior superior acetabular rim

• retroverted acetabulum

• Dysplasia

• Degenerative changes

Table 2. Common Causes of Labral Tears


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with significant flexibility of the hip joint may demon-strate characteristics that result in decreased femoralhead containment.1 Because the labrum has an effect onoverall joint stability, injuries to this structure are oftenfound in combination with compromise to other jointstructures. Capsular laxity, articular cartilage lesions, andsubchondral cysts are among those conditions that maybe observed in conjunction with a labral tear.

Injuries to the labrum may also be atraumatic in

nature. Deviations of the hip joint’s bony architecturethat affect stability may potentially increase the likeli-hood of labral compromise. Such characteristics includedysplasia of the hip joint, femoral anteversion, and adecreased center edge angle. The presence of an osteo-phyte in the area of the head and neck junction may alsobe associated with labral tears. A proportion of individu-als have been observed to have a hypoplastic labrum.This condition results in a loss of the ball-valve effectaround the femoral head compromising joint stability.Conditions that result in increased generalized ligamen-tous laxity may also predispose an individual to labraltears. Such conditions include Ehlers-Danlos syndromeand Down syndrome. Excessive or constant exposure tothe previously described forces may result in a higherpotential for injury in these individuals.

Diagnosis of labral tears relies heavily on clinicalexamination, which then may be confirmed by diagnos-tic studies. The patient’s history may reveal a mechanismconsistent with that previously described. Potential clin-ical findings in patients with labral tears or hip instabili-ty are listed in Table 3. A cluster of potential symptomsshould be taken into account. Diagnosis can be compli-cated by the potential involvement of adjacent regionssuch as the lumbar spine and sacroiliac joint. Mechan-

ical symptoms such as an audible and painful pop aswell as an associated decrease in ROM may beobserved. The presence of a snapping sensation shouldbe interpreted with caution. The underlying mechanismof such symptoms could involve movement or hypermo-bility of the iliopsoas tendon or iliotibial band over bonyeminences. Many patients may have been previouslydiagnosed with a chronic groin-pull. There may also becurrent complaints or a history of low back pain andsymptoms consistent with sacroiliac joint involvement.

Individuals with labral compromise may also demon-strate or report specific functional limitations. Gaitasymmetry (eg, ambulation with an externally rotatedlower extremity) may be noted. Patients may report dif-ficulty with prolonged ambulation or sitting. Transition-al movements such as getting up from a chair or gettingin and out of a car may be difficult. Balance testing maydemonstrate asymmetry between the affected and unaf-fected extremity.

If labral compromise is suspected, then further imag-ing may be performed. To obtain an accurate impressionof the capsulolabral structures or articular surfaces of thejoint, gadolinium-enhanced MRA may be utilized (Figure7). Magnetic resonance arthrography has been found tobe more sensitive than magnetic resonance imagingalone.1 Plain radiographs will likely be performed to ruleout fractures, dislocation and subluxation, osteitis pubis,and degenerative conditions.1

The results of both clinical examination and diagnos-tic tests should be utilized to determine candidates forarthroscopic labral procedures. Patients who have per-sistent hip pain for longer than 4 weeks, clinical signs,and radiographic findings consistent with a labral tearare candidates for hip arthroscopy.1 Arthroscopy pro-vides a definitive diagnosis of a labral tear (Figure 8). Anunstable portion of the labrum may be debrided in anattempt to eliminate the observed symptoms. An attemptis made to spare as much viable tissue as possible inorder to preserve mechanical properties of the joint. Incases where removal of a portion of the labrum isthought to pose a significant threat to the mechanics of the joint, a repair of the structure may be attempted.

The presence of a symptomatic labral tear does notguarantee a patient is a suitable candidate for hip

• Reports of groin pain

• Accompanying low back or sacroiliac joint pain

• Difficulty with activities requiring hip rotation

• Subjective report of weakness and decreasedstability

• Restricted range of motion

• Painful clicking sensation

• Difficulty and pain transitioning from sit to stand

• Difficulty with prolonged sitting

Table 3. Potential Findings of Patients With Labral Tearsor Hip Instability

Figure 7. Gadolinium-enhanced magnetic resonancearthrogram of the hip joint. Arrow indicates a lesion of the labrum.


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arthroscopy. Patients with signs of advanced degenera-tive changes are not generally considered as good candi-dates. Studies report a direct correlation betweenadvanced cartilage degeneration and poor outcomes fol-lowing arthroscopy.10,11 Patients with advanced cases of osteoarthritis are usually considered more appropriatecandidates for total hip arthroplasty. Patients who areunable to comply with an extended course of postoper-ative rehabilitation are not generally considered strongcandidates for arthroscopic hip procedures.

Although isolated debridement of a torn labrum isoften performed, other conditions may be addressed as

well. These conditions are often thought to contribute tothe underlying cause of the observed labral tear. Proce-dures to address capsular laxity and chondral lesions, aswell as soft tissue release procedures, will be discussedin separate sections of this monograph. The presence of osteophytes in the region of the head and neck junctionhas been reported in a number of patients with labraltears. When it is suspected that bony impingement maybe occurring, a cheilectomy (removal of the osteophyte)may be performed.1

Specific rehabilitation principlesRehabilitation following arthroscopic surgery to

address labral compromise should take into considera-tion all those tissues involved during the procedure. Therehabilitation principles discussed in this section of themonograph assume an individual undergoing an isolateddebridement or repair of the labrum. The principles dis-cussed in the general rehabilitation guidelines sectionapply in these cases. Rehabilitation considerations forother procedures, including those that may be combinedwith labral procedures, are discussed in following sec-tions. When procedures are performed in combination,utilization of the most conservative approach for each

aspect of rehabilitation (ROM, strength, and weight bearing) is chosen based on tissue healing properties.

In patients who have had an isolated labral resectionprocedure performed, the main factors that affect regaining ROM and strength are soft tissue damage created bythe surgical instrumentation when entering the joint andthe effects of immobility. After the soft tissue healingprocess has initiated, a progression from passive ROM tostretching can proceed. A major concern during thi

phase of rehabilitation is to not initiate an inflammatoryresponse in the joint. Avoidance of excessive flexion oabduction is a concern. These motions are limited inorder to avoid impingement of capsular and soft tissuethat has not yet healed. Excessive motion in these planeis indicated by an uncomfortable pinching sensation. Theauthors generally recommend beginning stretching astolerated around 3 weeks after surgery. In cases whereother procedures have been performed in combinationwith a labral resection procedure, specific limitationmay exist. These specific limitations will be discussed ina later section of the monograph.

The weight-bearing progression during rehabilitationdepends on several issues. The area of the tear and subsequent debridement or repair must be taken into consideration. Most tears in the North American populationof these patients occur in the anterior-superior region othe labrum. This area represents the weight-bearing portion of the structure. A short period of limited weightbearing is usually recommended. We generally recommend a range from 10 to 28 days of foot flat (approximately 20 pounds) weight bearing. Completenon–weight-bearing precautions in patients undergoingisolated labral procedures are usually not suggestedGentle compression aids in providing an environment o

optimal loading to promote healing. Weight-shiftingactivities early in rehabilitation help to create this com-pression without the risks of damage that may occur withthe shear forces that are created with ambulation.

Active ROM and open chain resistive exercises areutilized after the appropriate ROM and control of baseline symptoms have been established. We recommendan early emphasis on gluteus medius muscle-strengthening activities. Open chain knee extension and flexionactivities should be progressed as tolerated. Thosepatients undergoing additional soft tissue release procedures may have precautions regarding specific motionsThese procedures will be addressed in a later section othis monograph.

After full weight-bearing status has been achievedfunctional progression is primarily dictated by symptoms. Gait training is often required to ensure symmetrical weight bearing and terminal extension of the affected hip. Careful attention should be given to ensure thaevidence of a Trendelenburg gait does not exist. Weightbearing exercises should be progressed to closed chainprogressive resistance exercises as tolerated. Movemenin all planes of motion should be addressed. Rotary stability is of particular concern. The authors often utilize

Figure 8. Arthroscopic view of a tear in the anterior-superior region of the acetabular labrum (indicated bythe arrow).


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weight-bearing hip rotation activities and will applyresistance through elastic tubing to increase difficulty(Figure 9). Open and closed chain proprioceptionshould be addressed. As mentioned, the superficial lay-ers of the labrum are innervated. Therefore, compromiseof this tissue could be implicated in proprioceptivedeficits. Additional studies are necessary to determinethe potential role the labrum may play in proprioception.In patients undergoing isolated labral resection, the

authors will initiate single leg stance activities approxi-mately 10 days to 3 weeks after surgery. Perturbationand functional activities are added and progressed in dif-ficulty as tolerated.

The progression to running varies significantly amongindividuals. Factors such as preoperative condition,extent of injury, and body composition affect return torunning activities. Using devices such as the ellipticaltrainer or step trainer may be useful in providing a transi-tional period to running. The authors typically initiatethese activities 4 to 6 weeks after surgery as tolerated. Inour experience running may be initiated as early as 6weeks, but more often is initiated closer to 10 weeks after

surgery. During the running progression, an individualmay develop those conditions of the hip joint regioncommon to runners. Such conditions include tendonitisand bursitis, and if evident, these should be addressedpromptly to optimize the running progression. The con-cept of relative rest should be emphasized to the patient.

Particular attention should be given to patient symp-toms during any phase of transition. Such phasesinclude the transition from crutches to full ambulation

and from normal activity to higher level activity or returnto training in athletes. The authors have observed thatindividuals who have made attempts to push excessivelythrough discomfort often develop tendonitis (iliopsoas,rectus femoris, and iliotibial band), bursitis, or synovitis.In these cases activity must be significantly decreaseduntil symptoms have subsided to baseline. Avoidingsuch situations is a primary concern as a significantamount of rehabilitation time may be lost in the case of their occurrence.

Many patients who have had labral tears may report ahistory of low back pain or symptoms consistent withsacroiliac dysfunction. Such problems should beaddressed as indicated by physical examination. Stabi-lization techniques to enhance lumbopelvic stability canbe utilized as per patient tolerance. Manual techniquesas indicated for the lumbar spine and sacroiliac regionsare frequently useful in addressing symptoms of thesacroiliac and low back regions. Leg length discrepan-cies may also exist. Orthotic intervention should be con-sidered as indicated in these cases.

Labral RepairProcedures to repair a tear of the labrum are relative-

ly new. These may be performed on patients with

detachment of the labrum from the bony acetabular rimor intrasubstance tears. In these cases it is believed thatdebridement of the labrum would potentially have a neg-ative effect on the mechanics of the hip joint.1 The repairmay be performed through use of sutures to reattach thelabrum to the bony surface of the acetabulum. Generalresults for this procedure were previously described for12 patients, with early results being favorable (S. Bharamet al, unpublished data, 2003). Patients subjectivelyreported being able to return to their previous level of function with minimal discomfort.

Specific rehabilitation principlesThe rehabilitation process following repair of the

labrum does not vary significantly from that following aresection procedure. A limited weight-bearing statusmay be prolonged depending on the extent of the repair.Large tears requiring an extensive repair may have a par-tial weight-bearing status for 4 to 6 weeks. This may holdparticularly true for individuals who had tears on theanterior-superior (weight-bearing) portion of the labrum.After the repair is believed to be stable, functional pro-gression should parallel the process described for labralresection procedures.

Figure 9. Resisted external rotation of the hip in a

weight-bearing position using elastic tubing resistance.


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Capsular ProceduresAlthough the hip joint is inherently stable, cases of

instability exist and can be a significant source of painand functional limitation. In comparison to the shoulder,the hip joint relies much less on adjacent soft tissue forstability. In a normal hip this is secondary to the inher-ent osseous stability of the joint.1 The labrum and cap-sule act together to provide joint stability. In the casewhere one structure is compromised, a disproportionate

load may be placed on the other structure. Injuries or softtissue abnormalities such as labral tears or iliofemoralligament insufficiency can disturb the complex buffermechanism in the hip and result in increased tension inthe joint capsule and its ligament and decreased abilityto absorb stress or overstress. During arthroscopic exam-ination, labral tears and capsular laxity are often concur-rent findings. In many cases, deficiency of theiliofemoral ligament is also observed. There may be aproportionately higher load on the soft tissue structuresin joints with deviations of bony architecture (eg, thepresence of dysplasia). Several authors have described

the presence of capsular redundancy following recurrentdislocation.12,13 Dall et al12 have suggested that when thesuction effect of the labrum is lost due to a tear, the cap-sular labral relationship is compromised and subtle insta-bility may develop causing capsular elongation andattenuation. Furthermore, this subtle instability can bean important factor in the development of hip pain.1,6,12

Currently, biomechanical studies are being performed todetermine the effects of capsular and labral compromiseon movement characteristics of the femoral head.1

Hip instability can be a difficult condition to diag-nose. Injury can occur through traumatic or atraumaticmechanisms. A thorough history combined with clinicalexamination is required to make an accurate diagnosis of instability. Dynamic fluoroscopy may be used to furtherstrengthen the hypothesis of joint laxity.6 A sense of instability may be reported as opposed to the joint phys-ically giving away. Athletes commonly report a traumat-ic onset or specific symptom provoking maneuvers.Common examples include throwing a football to thesideline or swinging a golf club.6 A subset of this popu-lation may be able to voluntarily sublux the hip. Theseare often individuals with an atraumatic onset of symp-toms. These patients often show signs of generalized lig-amentous laxity. Patients that fall into this category may

include those with disorders that affect connective tissuesuch as Ehlers-Danlos syndrome, Down syndrome, andMarfan syndrome. Careful attention should be paid dur-ing the physical examination to ensure that patients whoseemingly can sublux the hip through rotational move-ments are not actually snapping the iliopsoas or iliotibialband over a bony landmark. The latter is a much morecommon clinical finding and not a direct indicator of joint instability.

Even less common than hypermobility of the hip isglobal capsular tightness. These patients present with a

capsular pattern of decreased motion and closely resemble the clinical findings associated with adhesive capsulitis of the shoulder. They typically have significansynovitis associated with their decreased motion. Nonoperative management should be the mainstay of treatment for these patients, focusing on physical therapy toregain motion and anti-inflammatory medications todecrease the inflammation. Fluoroscopically guidedcorticosteroid injections directly into the hip joint may

help decrease the local inflammation. If patients areunresponsive to nonoperative treatment, they may beconsidered for arthroscopic capsular release. Mixedresults have been observed in these cases.

Options to treat capsular laxity include thermal capsulorrhaphy, plication, or a combination of these procedures. One author (MJP)9 has had extensive experiencetreating hip instability with capsular thermal modification. This is achieved using a monopolar radiofrequencyheating probe. A probe with a flexible tip allows greateaccess to areas of the joint that are more constrained.The goal of the procedure is to achieve a volumetric contraction of the capsule to reduce capsular redundancythereby enhancing joint stability.6 Capsular plication is arelatively newer procedure. Capsular tension iachieved through the use of sutures. Short-term resultfor these procedures appear to be promising; howeveradditional research is required to determine the longterm effectiveness of this approach.1

Labral resection or repair procedures are often com-bined with capsular modification procedures. As previously mentioned, labral tears and capsuloligamentouscompromise are often found concurrently. Assuming aninteractive nature regarding the role these structures playin providing stability of the hip joint, addressing com

promise of only one structure could potentially compromise the long-term results of surgery. Once injury to thelabrum is addressed, restoration of normal capsular tension should be considered to achieve the balance of contribution to joint stability that these structures normallyprovide.

Specific rehabilitation principlesThe most significant issue of rehabilitation for those

patients undergoing capsular modification procedures isearly limitation of ROM to allow appropriate healing andreestablishment of capsular tension characteristicsGlobal and focal cases of synovitis have been noted during arthroscopy. In such cases, avoiding additionainflammation is of significant concern. Weight bearingand strength progression are typically similar to the protocol described for labral procedures. Often capsulamodification is performed in conjunction with a labraprocedure. Depending on the extent of the procedure, apartial weight-bearing status may be assigned for 10 dayto 4 weeks after surgery. Protected early ROM is imperative. There are particular concerns with excessive external rotation, flexion, and abduction. Excessive externarotation can potentially place an inappropriate amoun


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of tension through the anterior portion of the capsule.Excessive flexion or abduction may cause impingementof unhealed tissue into the joint, creating discomfort andpotentially encouraging the inflammatory response.

The authors typically limit movement from neutral to90° of flexion in the sagittal plane, with minimal move-ment in other planes for the first 7 to14 days of treatment.Approximately 7 to 14 days after surgery, rotation is gen-tly initiated through active rotation with the affected

knee resting on the exam stool or floor in a quadrupedposition. The patient is instructed to rotate the hip usingthe knee as an axis only within an ROM that is comfort-able. A gradual increase of motion in the sagittal planeis typically initiated at approximately 7 to 14 days aftersurgery. The authors have observed most patients cantolerate greater flexion without discomfort using a rock-ing to heel method in quadruped compared to supineflexion-based activities. Stretching may be initiated astolerated around 21 to 28 days after the surgery. Gentlejoint distraction techniques for the purpose of relievingpain can be initiated around 21 days postoperatively.Direction-specific mobilization techniques may be uti-lized as indicated after approximately 28 days. Cautionshould be exercised when utilizing these procedures.Full ROM as tolerated is typically recommended atapproximately 4 to 5 weeks after surgery.

After a patient has reached full weight-bearing status,the rehabilitation process for an isolated capsular proce-dure or combined labral-capsular procedure typicallyfollows the same course as an isolated labral procedure.Functional progression is based primarily on sympto-matic reaction to activity. For example, when a patientcan ambulate a mile without residual pain or limping,the authors will begin a gentle jogging progression.

Soft Tissue Release ProceduresIn rare cases, surgical release of soft tissue structures

may be indicated. The most common indications forsuch procedures are painful and functionally limitingcases of snapping hip syndrome (coxa saltans) that havenot responded favorably to conservative treatment.1 Softtissue release procedures may be performed in isolationor may be combined with other procedures (eg, labraldebridement).

Allen and Cope14 described 3 types of snapping hip.External snapping hip is caused by snapping of the pos-terior iliotibial band or anterior portion of the gluteusmaximus over the greater trochanter.14,15 The snappingsensation usually occurs when the hip moves from anextended to flexed position.14,15 Internal snapping hipoccurs when the iliopsoas tendon is displaced over thebony landmarks of the iliopectineal eminence or femoralhead.1,15,16 The intra-articular case of snapping hip syn-drome is often caused by a loose body in the joint. 15,16

This could include a fragmented piece of bone, a portionof torn labrum, a chondral flap, or synovial chondro-matosis.1 Individuals with external and internal snappinghip may be candidates for a soft tissue release procedure.

Intra-articular cases may be candidates for surgicalremoval of loose bodies or debridement of displaced tis-sue.

A detailed history and physical examination arerequired in determining the source of snapping hip syn-drome.1 A patient will often be able to voluntarily elicitthe snapping or clicking sensation during physical exam-ination. Patients who are experiencing intra-articularsnapping hip syndrome may describe a painful clicking

sensation as opposed to the snapping sensation moreoften associated with those of a musculotendinousmechanism. Description of location is the most obviousfactor in determining the source of symptoms. Internalsnapping is generally localized over the anterior portionof the groin, whereas external snapping is localized overthe greater trochanter.1 Intra-articular clicking may beobserved when initiating rotational motion.1

Most cases of internal and external snapping hiprespond well to conservative treatment. Such treatmentincludes utilization of NSAIDs, injection, and physicaltherapy intervention. However, there are refractory cas-es that are suitable to be addressed surgically.16 Untilrecently, tissue release or lengthening procedures had tobe performed in an open fashion.16–19 Recent advances inarthroscopic technology have expanded the optionsavailable for such procedures.1 Early results are promis-ing; however, further study is necessary.

Specific rehabilitation principlesThe primary concerns following tissue release and

lengthening procedures are controlling the postoperativeinflammatory response and allowing appropriate healingtime for those tissues being released. When performedwith other procedures such as labral resection or repair

and capsular modification, the previously mentionedpostoperative concerns regarding ROM and weight bear-ing that occur with such procedures apply. Non–weight-bearing limitations, partial weight-bearing limitations,and ROM limitations may apply in these cases. Earlypain-free ROM is indicated. In order to allow appropri-ate healing and to avoid initiating an exaggerated inflam-matory response, early stretching is usually avoided.Stretching is typically initiated as tolerated approximate-ly 4 weeks after surgery. An attempt is made to initiatestretching in a manner and time frame that promotesmaintenance of the appropriate muscle tissue lengthwhile avoiding an inflammatory response. The primarymuscles of interest are the iliopsoas, rectus femoris, ili-otibial tract, and hamstrings. Isometric exercise for thosemuscle groups not directly affected by the surgical pro-cedure can be initiated immediately. This usuallyincludes exercises for the quadriceps, hamstrings, andgluteal muscle groups. Submaximal isometric exercisesfor the involved structures are typically initiated 3 weeksafter surgery. This includes isometric flexion for an iliop-soas lengthening procedure and abduction for an iliotib-ial band lengthening procedure. Straight leg raise activ-ities in the plane of action for the involved musculo-


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tendinous structures are usually avoided for a minimumof 4 weeks. The authors’ experience has been that earlyinitiation of such activities is associated with an inflam-matory-type response resembling tendonitis. Once tol-erance of gentle isometrics and active ROM has beenestablished, a progression of weight-bearing strengthen-ing exercises and functional activities should be initiated.

BONY INJURIES AND INTERVENTIONS

Microfracture ProceduresPatients with focal osteochondral pathology may be

candidates for a microfracture procedure. Diagnosis of such pathology can be difficult.20,21 Results from clinicalexamination will most likely have to be supported byimaging studies to confirm a chondral lesion diagnosis.When symptoms do not respond to treatment and teststhat suggest intra-articular pathology are positive, a moreextensive diagnostic work-up should be considered.1

Although gadolinium-enhanced MRA and cartilage-sen-sitive magnetic resonance imaging are the suggestedimaging techniques in suspected cases of chondrallesions, there are limitations in reliability.1,22

The mechanism of osteochondral injury can be diffi-cult to diagnose. The patient will often recall a traumaticevent with an immediate onset of symptoms.1 However,the injury may be preceded by a seemingly trivial eventor no discernable cause, which is often the case in degen-erative conditions. An increased incidence of this injurytype has been noted in young, physically active men whoexperience impact loading over the greater trochanterduring athletic or other strenuous activities.1 The typicaldescription of the lateral impact injury is a direct blow tothe greater trochanters, such as during a fall. The highbone density of this area allows transfer of energy from

the external force to the joint surface. The final result is achondral lesion of the femoral head or acetabulum with-out osseous injury.1 Arthroscopic findings have helped tosupport the logic behind the lateral impact mechanism.21

The progression of chondral lesions can lead toextremely disabling consequences, the most significantbeing global degeneration of the articulating surfaces.The difficulty in diagnosing these lesions and the limitedsuccess of nonoperative treatment provide a reasonablerationale for the use of hip arthroscopy in the treatmentof chondral injuries.1

The stage and size of a chondral lesion play an impor-tant role in determining if an individual is a potentialcandidate for a microfracture procedure. Microfractureof medium-sized defects has been performed in manypatients with full-thickness lesions.1 The presence of alarger lesion may limit the available treatment options.Individuals with such lesions may be candidates for aresurfacing procedure. A limited number of resurfacingprocedures have been performed. In the authors’ expe-rience, early results appear favorable; however, furtheroutcome studies are necessary. A limited number of autologous chondral transplantations from the lateralfemoral condyle have been performed.1

McCarthy et al10 found a high association of chondrainjuries and labral tears. They found 73% of patientwith fraying or tearing of the labrum had chondral damage.10 Such patients may be candidates for procedureswhere the labrum is resected or repaired along with amicrofracture procedure or unstable flap resectionFuture studies are necessary to determine the long-termsuccess of microfracture procedures of the hip joint.

Specific rehabilitation principlesRehabilitation of patients undergoing microfracture

procedures carries particular concerns. The primaryconcern is to allow healing of the affected articular surfaces. An attempt should be made to create an environment that minimizes compressive and particularly sheaforces. Articular damage is often on the weight-bearingsurface of the femur or acetabulum. A non–weight-bearing or partial weight-bearing status for 4 to 8 weeks isusually assigned to the patient. This may vary dependingon the extent and location of the chondral lesionWeight-shifting activities may be initiated earlier, bucaution should be exercised with early ambulatory activities. The combination of weight bearing and rotationamotion can create potentially damaging shear forces athe joint surfaces. When transitioning from a limitedweight-bearing status to ambulating independently, thepatient should be monitored for any symptoms indicativeof joint inflammation. If allowed to persist without aperiod of relative rest, this condition can becomeextremely difficult to control. In the case such symptomdo occur, it is recommended that the patient temporarilyresumes a partial weight-bearing status, utilizes prescribed anti-inflammatories, and uses modalities such asice, compression, and electrical stimulation application

as indicated. A therapeutic pool can be utilized to beginearly gait training and weight-bearing activities. Rangeof-motion progression for microfracture procedures isusually similar to those guidelines followed for a labraresection or repair. If performed in conjunction with acapsular modification procedure, additional ROMrestrictions may be recommended.

Total Hip ArthroplastyTotal hip arthroplasty is the most common recon

structive hip procedure performed in the adult popula-tion.23 Hip arthroplasty techniques have dynamicallyevolved since their initiation. Innovations in biomechanical knowledge, materials, prosthetic componendesign, surgical approach, and rehabilitation concepthave allowed continued improvement of surgical outcomes. The intention of this section of the monograph ito review indications, surgical techniques, and rehabilitation principles as they apply to total hip arthroplastyprocedures.

Indications for total hip arthroplasty are based uponmedical diagnosis and degree of symptomatic functionalimitation. As with many surgical procedures, there areindications that are not completely agreed upon. Specif


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acetabulum. In order to avoid anterior dislocation of thehip joint, caution should be exercised to avoid positionsof extreme external rotation, extension, and abduction.There is no universal agreement on how long hip ROMprecautions should be followed. Recommendationsrange from 4 weeks to life.26 Recommendations mayvary depending on the patient’s age, condition of sur-rounding bone, the type of prosthetic utilized, presenceof other medical conditions, and other factors deemed

important by the surgeon performing the procedure.In select situations, a trochanteric osteotomy and lat-

eral reattachment may be performed in conjunction withan arthroplasty procedure. This was originally advocat-ed to increase the lever arm of the abductor mechanismat the hip joint. In order to obtain the beneficial trade-offs of bone preservation, and avoid problems related toreattachment of the greater trochanter, trochantericosteotomy and lateral reattachment procedures are notroutinely emphasized at this time.23 For these proce-dures, a prolonged limit of weight-bearing status andavoidance of active hip abduction for 8 to 12 weeks is

often recommended.The method of prosthetic fixation influences howaggressively activity can be initiated. This holds particu-larly true in the early phase of rehabilitation. Compo-nents can be classified as cemented or noncemented.This classification can be applied to femoral and acetab-ular components. A combination of 1 cemented and 1cementless component may also be utilized. All femoralcomponents consist of a metal stem that is inserted intothe medullary canal.23 A primary concern regarding thefemoral component is improving fixation within thefemoral canal in order to improve longevity.23 No singlesystem appears superior to others. Rather, selection is

based upon a multitude of individual factors. Factorsthat influence component selection include the patient’sindividual needs, expected level of activity, bone qualityand dimensions, availability of implants, and experienceof the surgeon.23

The early standard for femoral component fixationwas implantation with acrylic-based cement. Utilizationof cemented femoral components remains a popularchoice in many cases today. A primary concern regard-ing the cemented technique is the potential for mechan-ical loosening of the prosthetic component within thefemoral canal.

In response to the concern for mechanical looseningof the femoral component and other complications asso-ciated with cement fragmenting, numerous cementlesssystems that rely on biological fixation have been devel-oped. Most of these systems attempt to initiate bonyingrowth upon a porous prosthetic surface. Thisapproach is often advocated for relatively younger, moreactive individuals.

A newer development is the nonporous, cementlessfemoral component. These devices may utilize an arrayof surface modifications to create a macrointerlock with

the adjacent bone.23 A bioactive compound may beapplied to the stem in order to improve osseous integration. Further research is necessary to determine theeffectiveness of nonporous, cementless femoral prosthetic components.

As with femoral components, the original method ofixation for the acetabular component was cementbased. Loosening is a particular problem with theacetabular component. Despite improvements in design

and technique, long-term survival of cemented acetabular components has not significantly improved.23 Currently, this option tends to be exercised in elderly andless active individuals.

In more active and younger individuals, a cementlesacetabular component is often the device of choiceMost cementless components are porous over the entiresurface that makes bony contact.23 These componentutilize various methods of initial fixation, but all rely oningrowth of bone to establish long-term stability.

In select cases, a bipolar endoprosthesis may be uti-lized. These systems are compromised of a metallic

acetabular cup and a polyethylene liner that contains asocket for a femoral prosthesis. The proposed advantageof such a system is the presence of 2 locations of move-ment. Inner movement occurs at the interface betweenthe femoral prosthesis and the polyethylene liner. Outemovement occurs between the metallic cup and theacetabulum. The amount and proportion of movementhat occurs at each interface is not completely agreedupon.23,27–29 The amount of motion appears to depend onmultiple factors including prosthetic design, inner headsize, and articular cartilage status.23

As with other surgical procedures, technologicaadvances have allowed the initiation of total hip arthro

plasty through a minimally invasive method. The overalgoal of this method is utilization of smaller incisions topermit joint replacement with minimal damage to adjacent tissue. This can be accomplished through various 1incision or 2-incision techniques utilizing an anterior oposterior approach. Computer-aided models are alsobeing developed in an attempt to improve the effective-ness and decrease complications associated with totahip arthroplasty. It can be suggested that minimally invasive joint replacement should allow for an acceleratedcourse of rehabilitation in comparison to conventionatechniques. Research comparing conventional and min

imally invasive procedures in terms of technical demandof the surgery, complication rate, functional outcomescost effectiveness, and subsequent course of rehabilitation is ongoing at this time. Further data regarding thesefactors will determine the usefulness of this technique infuture practice.

Patients undergoing total hip arthroplasty are at riskfor numerous complications. A number of complicationare inherent to the specific procedure, while others arereflective of the population on which the surgery is performed.23 The most severe complications usually occu


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within a short time period after the procedure. As withany surgical procedure, the patient should be monitoredfor signs consistent with the development of a deep veinthrombosis. Nerve injury has been estimated to occur inup to 3% of those individuals undergoing primary arthro-plasty. The sciatic nerve, particularly the peroneal divi-sion, is most often affected. The femoral and obturatornerves are compromised less often. Dislocation mayoccur at any time, but the risk is greatest for the first 3

months after surgery.23

The majority of dislocations are ina posterior direction, secondary to the dominance of theposterior and posterior lateral approach. The rate of dis-location increases following revision procedures. Sud-den pain and apparent shortening of the limb are poten-tial indicators of dislocation. Other postsurgical compli-cations include infection, vascular compromise, limblength discrepancy, bladder and urinary tract complica-tions, heterotopic ossification, femoral or acetabularfractures, component loosening, and osteolysis.23

Specific rehabilitation principlesThough no universal postoperative protocol for total

hip arthroplasty exists, common principles exist. A com-plete approach to rehabilitation can be divided into pre-operative, early postoperative, and long-term rehabilita-tion stages. The time spent at each stage varies amongindividuals.

Preoperative therapy should focus on patient educa-tion and optimizing the strength and flexibility. Thepatient should have realistic expectations regarding thegoals of the procedure and the progression of rehabilita-tion. The importance of adhering to postoperative pre-cautions should be emphasized. Time should be allottedto review transfer techniques, ambulation with assistive

devices, and modified performance of ADLs. Exerciseactivities to preserve ROM and optimize strength whilenot exacerbating symptoms should be established.

Postoperative rehabilitation usually begins the dayafter the surgery. Avoiding excessive adduction can beachieved through use of an abduction pillow. Sitting atbedside is typically allowed 1 or 2 days postoperatively,as long as ROM precautions are consistently followed.Unless stability issues exist, gentle bed exercises are usu-ally initiated at this time. Activities include active plan-tarflexion and dorsiflexion ROM for the ankle, isometricsfor the quadriceps and gluteal muscles, and limited heelslide exercises for hip flexion. Rotation can be addressedwithin tolerable limits, with internal rotation being limit-ed to the neutral position. Transfers to and from the bed,chair, and toilet should be reviewed.

Gait training may begin as soon as the second dayafter surgery. The surgeon will determine the weight-bearing status of the patient. The weight-bearing statuswill vary depending on means of component fixation,presence of structural bone grafts, stress risers in thefemur, and presence of a trochanteric osteotomy.23

Cemented components typically allow for a moreaggressive approach to ambulation. If cementless com-

ponents were utilized, weight bearing may be limited for4 to 8 weeks, depending on the presence of other limit-ing factors. A walker is most often utilized for early gaittraining. Younger or generally healthier patients mayprogress to crutches as appropriate. Stair and curb nego-tiation, as well as car transfers should be covered asappropriate for the patient’s living situation. Before dis-charge, ROM precautions should be reviewed and thepatient should be able to apply these to ADLs. Unless

limited by the surgeon, exercises emphasizing extensionshould be addressed. This can be addressed early bylying in a supine position without pillows underneath thelegs and progressing to time spent in the prone position.A short-term goal of at least 10° of extension will berequired for most individuals to achieve a normal gaitpattern.

Long-term rehabilitation in the outpatient setting isusually initiated 4 to 6 weeks after surgery. Goals of rehabilitation at this time should include: continuedstrength improvement, improvement in flexibility, ambu-latory progression, return to ADLs, and return to recre-

ational activity as appropriate. As determined by theassigned weight-bearing status, a progression from walk-er or crutches to a cane can be initiated. The caneshould be utilized until the patient can ambulate withouta limp. Particular emphasis should be placed on improv-ing the strength of hip abductor musculature. The patientshould be monitored for signs of functional weakness of the gluteus medius muscle (Trendelenburg sign or gait).The patient should be instructed to carry loads on theside of the surgical procedure. Neumann and Cook30

found that loads carried on the contralateral side signifi-cantly increase the loads placed on the surgical side,while loads up to 20% of an individual’s body weightcarried on the same side as the arthroplasty produced nomore abductor electromyographic activity than ambula-tion alone. Stretching activities emphasizing the ham-strings and hip flexor muscle groups should be empha-sized. Tightness of these muscle groups can significant-ly affect an individual’s ability to ambulate and performother ADLs such as stair negotiation.

Recommendations for return to normal activities varyby surgeon preference and are affected by individual fac-tors. Independent ambulation may range from approxi-mately 6 weeks to 3 months in cases of revision or struc-tural bone grafting.23 When arthroplasty is performed on

the left hip, patients may be allowed to resume driving asearly as 6 weeks. When the right hip is involved, theindividual must be functionally tested to determine theability to operate a vehicle safely. Time for return tooccupational duties is affected by individual factors andoccupational demand. Some patients can return tooccupations requiring limited lifting and bending around3 months postoperatively.23 Sexual activity may beresumed as tolerated, given the patient adheres to ROMprecautions. Stern et al31 found that patients usuallyresume sexual activity 4 to 6 weeks postoperatively.


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There is considerable debate regarding the level of athletic activity that is advisable for individuals undergo-ing total hip arthroplasty. In general, any activity thatsubjects the prosthetic components to an extremeamount, or a prolonged period, of impact loadingincreases the chances of prosthetic failure. Of particularconcern is the increased stress that occurs at the bone-cement interface with high-impact loading activities.Recommended activities include: swimming, golfing,

walking, bowling, and limited dancing.26

In our clinicalpractice, the authors have noted particular success withgolfers returning to regular frequency of play withoutmajor complication. Patients should be advised regard-ing the amount of potential stress during particular activ-ities as well as the potential consequences of excessiveloads across the prosthetic components.

CASE STUDIESCase Study 1Patient history

A 28-year-old woman physical therapist and graduatestudent was referred to physical therapy with a primary

complaint of right hip pain. The patient reported a 2-month history of groin pain that gradually progressed tothe point that it was limiting the majority of her ADLs.The pain was often accompanied by a popping or click-ing sensation that had not been present until the onset of the primary complaint. Symptoms had been particularlyaggravated by walking on inclined surfaces, running,prolonged sitting, prolonged standing, and crossing herlegs (particularly right over left). Prior to the onset of symptoms, she was completely independent with ADLsand participated in various general fitness activities on aregular basis. In the last 3 weeks she reported develop-ment of discomfort in the lumbar spine and right sacroil-

iac region. These symptoms typically occurred in con-junction with the onset of the primary complaint of righthip pain. Pain levels ranged from 2/10 at rest to 8/10with symptom-provoking activities. The patient had pri-marily addressed the discomfort with periods of relativerest and over-the-counter NSAIDs. This method of treat-ment had produced minimal change in her symptoms.She had an appointment with an orthopaedic physicianspecializing in hip disorders in 14 days.

The patient could not state a specific mechanism of onset. She did fall off a horse onto the lateral portion of the affected limb 2 years prior to the current episode.

The patient recalled experiencing a brief period of later-al thigh soreness and low back stiffness. These symptomsresolved without treatment and did not cause furthercomplications.

Systems reviewObservation yielded a 110-pound woman experienc-

ing minimal distress at the time of evaluation. Thepatient’s gait pattern appeared antalgic, with accompa-nying reports of pain. Gross assessment of lower-extrem-ity alignment and the lumbar spine appeared within nor-mal limits.

Tests and measuresSelective tension tissue testing produced asymmetry

of results when comparing the involved to the unin-volved side. Active ROM, passive ROM, and resistedtesting did not yield deficits on the uninvolved sideActive ROM and passive ROM were equal on the affected side. Side-to-side comparison yielded a 20° flexiondeficit and a 10° abduction deficit. End-feels for flexionand abduction were empty and painful for the involved

hip joint. Although all other motions were symmetricato the uninvolved side, internal and external rotationmotions were painful at the end ROM. With the exception of internal rotation, manual muscle testing (MMTyielded global weakness of muscle groups crossing thehip joint. Strength was assessed via MMT at 4/5 for flexion, extension, external rotation, and abduction. Alresistive testing elicited soreness with maximal exertionThis was particularly evident when testing hip flexionwith an emphasis on the iliopsoas MMT position.32 Thediscomfort was not as severe as the pain described as theprimary complaint. Hand-held dynamometer testing o

the gluteus medius muscle yielded 18 kilograms of forceon the right (involved) extremity, compared to 24 kilograms of force on the left (uninvolved) extremity.

Special testing for the sacroiliac joint resulted in findings listed below indicative of potential dysfunction. Palpatory assessment of pelvic landmarks in standingdemonstrated a relatively higher posterior superior iliacspine, with lower anterior superior iliac spine and iliaccrest on the right (involved) side in comparison to the lef(uninvolved) side. Assessment in the seated positiongave the same results for posterior superior iliac spineand iliac crest position characteristics. Increased craniamovement of the right posterior superior iliac spine waobserved during standing and seated flexion tests. Lumbar ROM was within normal limits with an increase ocentral local soreness at end-range flexion.

Special tests for the hip joint produced asymmetricafindings between the involved and uninvolved sides thasuggested potential articular pathology. During theThomas test, the patient was able to fully extend the posterior aspect of the involved thigh to the table, with theknee flexed to approximately 75° and no appreciabledeviation in the frontal or transverse planes. Howeverpain was noted with overpressure at the end of theThomas test maneuver. The FABER test showed symmet

rical motion with right groin pain and stiffness in theregion of the right sacral sulcus. The Scour test producedgroin pain accompanied by a pinching sensation. Apainful clicking sensation was also elicited when thepatient’s hip was brought from extension and neutrarotation to a position of combined flexion, internal rotation, and horizontal adduction. In the authors’ experience this position often produces groin pain in individuals with symptomatic tears of the acetabular labrum.1 Inaddition, the patient acknowledged groin pain occurringat the end range of descent when performing a deep


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squatting motion. The amount of movement during long-axis distraction of the hip joints was deemed symmetri-cal with no change of symptoms noted.

Evaluation, diagnosis, and prognosisBased on the patient’s history, observation, and phys-

ical examination, it was determined there was a highlikelihood of hip joint involvement accompanied bysacroiliac dysfunction. Treatment of the hip region

would focus on addressing the strength impairmentsobserved during physical examination. A collectivedecision was made with the patient to attempt manualtreatment of the sacroiliac region and conservative treat-ment of the hip region. Because special tests for hip jointinvolvement (Scour, FABER, and combined flexion, inter-nal rotation, with horizontal adduction) were positive, itwas agreed that the patient should consult with anorthopaedic physician specializing in hip disorders.Therapy would be adjusted as advised by theorthopaedic physician after the patient’s office appoint-ment in 14 days.

InterventionA mobilization technique for the presence of an ante-

rior rotation of the right innominate was performed. Thepatient was placed in a supine position with the therapiststanding opposite to the side being mobilized. Thepatient was then placed in a position of side-bendingtoward the restricted side by moving her legs and trunk.The patient was asked to clasp her hands behind herneck. The therapist then rotated the patient’s trunktoward him without losing the side-bending position.The therapist then placed his free hand on the anteriorsuperior iliac spine of the restricted side and delivered a

thrust in a downward direction. Quadruped rockingactivities and gentle lumbopelvic stabilization exerciseswere recommended as part of the initial home exerciseprogram. The patient tolerated the technique well, butdid not report an immediate change of symptoms.

Gentle isometrics and ROM activities for the hip wererecommended. Activities included gluteal, quadriceps,abductor, and adductor isometrics within a tolerablerange. Unresisted stationary bike riding and heel slideswere recommended as tolerated for ROM in the sagittalplane. Closed chain activities were deferred taking intoaccount patient apprehension and the tendency forsymptoms to increase with weight bearing.

The patient followed up in therapy 2 times prior to thephysician office appointment. She reported the symp-toms occurring in the right sacroiliac region haddecreased slightly, then remained steady at a lower levelthan previously reported (5/10 with symptom-provokingactivities, compared to 8/10 before intervention). Thesymptoms occurring in the right groin region graduallyincreased up to the time that the patient had her consul-tation with the orthopaedic physician. During this time,activities were diminished in an attempt to minimize anyfurther inflammatory response. The patient was ambu-

lating with crutches for moderate distances at the time of her physician office visit.

During the consultation, the physician performed aclinical evaluation and ordered diagnostic tests for thepatient. Magnetic resonance arthrogram results con-firmed the clinical suspicion of a labral tear. A decisionwas made to perform arthroscopic examination andsurgery as indicated.

Intra-articular pathology was discovered during

arthroscopic evaluation of the hip joint. A tear of theanterior superior portion of the labrum was confirmed. A

15.2.1 - Postoperative Management of the Hip Monograph

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Transcript of 15.2.1 - Postoperative Management of the Hip Monograph