hip arthroscopy rehabilitation part one

The hip arthroscopy

rehabilitation guide for

patients and therapists

By Louise Grant MCSP

Hip Specialist Chartered Physiotherapist,

Hip-Physiocure, UK

Copyright August 2011

Con

tent

s

•  About the author

•  About this guide

•  Anatomy of the hip

•  What is a hip arthroscopy?

•  What might the surgeon do in the hip?

•  Labral repair or resection

•  Pincer decompression

•  CAM decompression

•  Other surgical techniques

•  Possible complications of surgery

•  Getting ready for your operation

•  Pre-op assessment record

•  Post-operative advice

•  Post-operative range of movement advice

•  Precautions and considerations following surgery

•  Awareness of negative findings that may impact on rehab

•  Rehabilitation exercises following hip arthroscopy

•  Six week reassessment record

•  Twelve week reassessment record

•  Rehabilitation pathway

•  Rehabilitation summary charts

•  References

•  Acknowledgements

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INTRODUCTION

Louise Grant is a Chartered Physiotherapist who qualified in 1992. Since the year 2000, she has jointly owned PHYSIOCURE, a private physiotherapy clinic. She is a member of the Health Professions Council, The Society of Orthopaedic Medicine, The Acupuncture Association of Chartered Physiotherapists, PhysioFirst and the Association of Chartered Physiotherapists in Sports Medicine. In 2005, Louise additionally qualified as a Modern Pilates Instructor.

Louise is a private, independent hip specialist physiotherapist who works with patients undergoing hip arthroscopy, and in the management of femoral acetabular hip impingement (FAI). She also sees other types of hip surgery and conditions. She has written this guide to assist in patient’s rehabilitation.

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This guide is not intended to replace your surgeon’s protocol, but to be used alongside it. Louise has gathered together various hip arthroscopy guides/protocols from around the world, research papers and books, her learning from attending international hip conferences and from individual teaching from top hip arthroscopy surgeons, to personally formulate this amalgamation of material. She has also collected data recording patient’s experiences of hip arthroscopy rehabilitation. Please note, this guide is general, and can not cover every eventuality.

Louise has personal experience with living with femoral acetabular impingement (FAI) and has had a hip arthroscopy herself. Louise’s hip condition is in no means simple, and she understands fully the emotional rollercoaster some patients experience in recovery. Practical advice has been added into this guide from her Occupational Therapist mother who lived with hip dysplasia and had a early hip replacement, age 50. Louise has used this information to produce a useful guide aiming to aid patients and therapists in hip arthroscopy rehabilitation.

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Disclaimer – the author is not responsible for any person’s using this guide or for their interpretation of it. Hip arthroscopy rehabilitation should be done under the care of a suitably qualified Chartered Physiotherapist or equivalent therapist.

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It is important to note that any rehabilitation guide needs to be modified and adapted for the patient individually. Patient’s undergoing hip arthroscopy, vary. Has the surgery been complex or simple? Some are sports people who have a sudden onset of hip pain. Some, patients have had pain for many years, before they are diagnosed with femoral acetabular impingement. Therefore, people using this guide will be at different levels of fitness, have different pain scenarios and disability. Hence, staging a guide that is time framed is not always realistic, and can cause some patients huge distress when they feel they are not meeting time bound goals, so please remember the ‘weeks’ are only meant as a guide. It is important to be realistic with patients, judge their fitness, capabilities and operation findings. Some patient’s goal will be getting to level two/three stage exercises. If a non-athletic patient is painfree, with good symmetrical range of movement and power, is back at work/hobbies, and is happy with this recovery, do not push them to do exercises aimed at elite sports people. There are criteria to be met, and relevant tasks to be performed satisfactorily before moving onto a harder level in this guide.

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Ana

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Rim of acetabulum Femoral head Femoral Neck Greater trochanter

Normal hip joint. The labrum (red), forms a ‘skirt’ around the rim

‘3D’

Wha

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a hi

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A hip arthroscopy is when the surgeon uses ‘keyhole’ surgery to enter the hip joint. Normally, this involves making two small incisions in the upper thigh area, but on some occasions, a surgeon may choose to use additional incisions (portals). One of the incisions is for the camera, and the other is for the operating tool. The operated leg is usually in traction throughout the procedure to enable access to the central compartment of the joint. This is carefully controlled and monitored. The traction is gently released for when the surgeon accesses the peripheral compartment. The surgeon will then carefully move the leg with the camera in situ to check there is no impingement. Bruising and swelling are normal post-surgery.

Incisions

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Front of thigh

Side of thigh

Some people are surprised to see where the incisions are, they presume they would be higher up.

Wha

t mig

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e su

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o in

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You will have already been examined, xrayed and possibly had an arthrogram/scan by the surgeon; and a proposed treatment plan discussed.(Ref 1).However, further examination of the joint takes place, when the surgeon looks into the joint with their camera. They will then fully assess the joint and decide on the appropriate procedure. See the following pages for common surgical techniques..

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Lab

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This is a picture of a labral tear. There are different classifications of tears (Ref 2). It will depend on the type of tear and quality of the labrum as to whether the surgeon repairs or resects /removes. (Ref 3)

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Pinc

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Below is a picture of a pincer deformity. The extra bone can cause impingement in the hip. The surgeon may remove/resect this boney deformity to alleviate ‘pinching’ in the hip.


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Green indicates boney overcoverage around the rim. A local area =pincer, a global area = coxa profunda.

Red indicates labrum

pincer

CA

M

dec

omp

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A CAM deformity can be found at the femoral neck, it can restrict hip movement and cause impingement. This can be resected during surgery and the area ‘decompressed’. Some people have a ‘mixed’ CAM and pincer deformity. (Ref 4,5)

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Red indicates labrum CAM

Green indicates boney ‘bump’ on the femoral neck, this can vary in size and situation.

Oth

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s Removal of a loose body – These are free-floating catilage fragments usually originating from traumatic injury, degenerative conditions or synovial proliferative disorders.

Microfracture/chondroplasty – Holes are made in the subchondral plate, in local contained areas , producing a marrow clot. The cells from this change into a fibrocartilaginous material.

Psoas tendon release

Removal of adhesions

Ligamentum Teres Reconstruction

Labral Grafting

(Ref 6,7,8,9,10,11)

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Poss

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surg

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With any surgery, there are complications and things to consider….

•  Infection, DVT, delayed wound healing, swelling, bruising.

•  Avascular necrosis of the femoral head, fracture, heterotopic ossifications, adhesions.

•  Failure to resolve pre-operative symptoms, increased pain, damage to labrum or cartilage, traction related pain.

•  Sciatic and lateral cutaneous nerve injuries, pudendal nerve problems, impotence, pressure sores.

•  Instrument breakage, extravasation of irrigation fluid.

For more information visit www.isha.net

Your surgeon will discuss complications in more detail.

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n Preparing yourself before surgery can help make your recovery easier.

Your physiotherapist can help you with –

•  Showing you pre-op exercises to maintain your muscle tone and overall function .

•  Explanation of the post-op exercise routine and advice. Remember new exercises can make you ache.

•  Practice crutch walking.

•  Assessing and measuring your hip before surgery to establish pre-op function.

•  Record your pre-op pain and symptoms to be able to gauge appropriate post-op progress.

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Pre-

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Shade in the areas on this body chart where you have your pre-op pain. Scale the pain from 0-10

(0 is no pain and 10 is the worst pain imaginable). Do this, as you may possibly forget what you actually did feel like before surgery !

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Diary page – write down here how you are feeling in yourself and the things you are

currently finding a problem in day to day life.

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Ask your physio to record these pre-op hip measurements for you, so you can monitor your

progress. (ref 12)

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Hip Right Left

Flexion

Abduction

Adduction

Faber

Int rot (neutral)

Ext rot (neutral)

Trendelenberg test (ref 13)

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Pre-op -Exercise record sheet (Your therapist can select exercises from this guide)

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n Items to help in your recovery –

•  Elbow crutches (essential) . Check if your insurance company provides these. If not, these can be purchased at the hospital.

•  Ice packs (essential). Ice is used to reduce swelling, bruising and provide pain relief. These can be bought on the internet or at the hospital. Get two, so one is always ready.

•  Non-slip shower mat (essential). You must be careful that you do not jar your hip, so think of safety aspects.

•  Exercise bike (advisable). As this is recommended for daily use, and you can not drive to the gym for a couple of weeks, think about having a bike at home.

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Items to help in your recovery –

•  Shower stool, grab rails, raised toilet seat, easy reach grabber, and long handled shoe horn –

although these items are not essential, they can really assist in making independence much easier and may help prevent you jarring or overstretching the hip.

•  Swiss ball, wobble board, inflatable balance cushion.

•  Elastic resistance exercise band, ankle weight.

•  Soft football, pilates ‘circle’, foam roller.

•  Scar massage oil.

•  Small rucksack and flask - useful as you can’t carry things in your hands.

•  A couple of spare pillows – useful for supporting your leg in different positions.

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n Items to take with you to the hospital –

•  Loose fitting jogging trousers (your leg may be swollen after the operation).

•  Comfortable, flat, supportive non-slip shoes.

•  Nightwear, spare underwear and toiletries.

•  Phone and charger (headphones)

•  Medications, hip xray (if you have been given this by consultant), elbow crutches (if you are having to provide your own).

•  Book, magazines, (earplugs!!!eye mask!!) etc..

•  Avoid taking any valuables, jewelry.

•  Glasses…you will be required to remove contact lenses.

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For 2-6 weeks (6-8 weeks for a microfracture) you will be partial weight bearing on elbow crutches. You need to give the bone and soft tissues the best environment to heal in. The joint may be quite sore at first and it is important to let this settle. Therefore, no lifting, twisting, overstretching, jarring or movements/activities that provoke the pain. Look around your home to see what you can do now to make post-op recovery easier. Consider organizing your home so you can easily reach things, so you are not having to bend down to a low drawer or overreach into a high cupboard. Check there are no trip hazards. When it comes to eating, if you at home alone, a high stool at the kitchen worktop would mean you could safely prepare food and eat it in the same place as you can not carry a plate. Alternately, you could put food in a sealed plastic container and have a flask/drink container which could go in your rucksack…and thus your food and drink can be transportable. Consider stocking up on some easy freezer meals. Enlist help if you can with children/pets/laundry/cleaning/gardening/shopping, etc…

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Using elbow crutches –

Walking – partial weight bearing is approximately half of your body weight going through the operated leg, whilst you take a step with the non-operated leg. Some surgeons specify less weight than this, some more…so check with the surgeon.

Begin by standing straight, in a good posture, with weight fully through your non-operated leg and partial through the operated leg. Place both crutches a short distance in front of you, then place the foot of your operated leg level with the crutches, keeping the foot flat on the floor. Next, putting your weight through the crutches and partially through the operated foot, step through with the non-operated foot. Take your weight fully through the non-operated leg as you position the crutches and operated leg for the next step..and so on.

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Using elbow crutches – Stairs – Hold onto the banister with one hand and the other should have your crutch (place your other crutch horizontally in the crutch hand, as shown in the photo).

UP STAIRS -

1.  Non-operated leg steps up.

2.  Operated leg next onto the same step.

3.  Crutch goes last.

DOWN STAIRS –

1.  Crutch first.

2.  Operated leg.

3.  Non-operated leg onto the same step.

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ce Using elbow crutches –

SITTING DOWN –

Walk right up to the chair, turn carefully around so your bottom is facing the chair. Remove both crutches from your arms and place in one hand, so your hand is gripping the hand supports across the top and you can still support yourself safely. Next, with your other hand reach back and place hand on the chair arm. Slowly lower yourself carefully down into the chair.

STANDING FROM SITTING-

Move your bottom to the edge of the chair. Both feet on the floor. With one hand, place on top of the crutch handles, the other on the chair armrest. Push up from the armrest. Once in standing, put your crutches in the correct position.

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PAIN –

Pain, bruising, swelling and stiffness of the hip is normal after the operation. You will be given medication to take home following your surgery and repeat prescriptions can be organized via your GP. It is advisable to take your painkillers to keep any pain to a minimum to help your rehabilitation, ensure a good nights sleep and enable relaxation of the leg. The anti-inflammatories will help the joint settle, and it is usually advised that these are taken for at least two weeks. Be aware that some patients can feel no pain straight after surgery and some feel like they have ridden a horse! (due to the bolster used in the traction procedure). It is normal to feel muscle soreness in the leg from the traction, and sometimes knee or ankle pain. Remember, as your activity level increases, then there may be temporary increased soreness. So it may not be wise to be weaning off your painkillers at the same time as coming off your crutches/starting work/increasing exercise levels, etc…

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PAIN continued –

Drink plenty of water and have a healthy diet, including fresh fruit and vegetables, as the medication can make your ‘insides’a bit sluggish! See your GP if constipation or stomach upset is a problem with the medication. Getting enough rest and relaxation is important in settling pain and ice is useful too(Ref 14,15,16). When using an ice pack, wrap it in a damp tea towel to protect the skin. Leave it on for 10-20 minutes but be cautious of numb areas after surgery, do not use ice on these areas. Keep checking the skin to avoid ice burn/frost bite. Your physio can also help with the pain – they may offer acupuncture and gentle massage (avoid wound).Keep a diary, recording all the positive progress you are making…some days may be ‘bad’ days, this is normal. Listen to your body, there maybe a reason that the pain has increased. Maybe you overdid something the previous day, or have come off your painkillers too soon or too suddenly? Learn from this and make modifications, don’t try and battle through pain..take things slowly (Ref 17).

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WOUND CARE –

You will have dressings on your wounds after surgery and will be told if your stitches are dissolvable or not. With the latter, you will advised by the nurse on the ward when these need to be removed (usually 7-10 days post op). This can be arranged at your GP surgery. There may be a small amount of blood that stains the dressings. This is normal, however, if it is more than this, please contact the ward or the consultant to report this. It is very important to keep the wound dry until it has fully healed, to prevent infection. You will be supplied with waterproof dressings from the ward to ensure this when showering. Alternatively, waterproof dressings can be purchased from your chemist. Do not have a bath or commence hydrotherapy until your wounds are fully healed. Scar massage must only be started once the wounds are fully healed and strong enough to cope with this. Check with your physiotherapist when this is suitable and ask them to show you the correct massage technique.

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ADDITIONAL ADVICE –

•  Do not run/jump or do high impact sport for 6 weeks (13 weeks for microfracture) post surgery. Some patients may be advised not to run at all, if they have a particular hip condition.

•  Driving is at the discretion of the consultant. Clutch use may flare up symptoms in the early stages of recovery and it is essential that an emergency stop can be fully performed before driving is resumed.

•  A lot of consultants ban the use of treadmills forever post surgery –check this with yours.

•  Check the appropriateness of the use of the rower and breast stroke swimming post surgery with the consultant and physio with your particular hip problem – it may not be advisable.

•  Pay attention to good posture, do not sit in low soft settees, do not cross your legs or sit with your legs up on the settee in a twisted position. An ‘open seat angle’, where the angle of the hips is more than 90 degrees is recommended. A good mattress is favourable, check yours isn’t sagging.

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ADDITIONAL ADVICE

continued -

Take good care of your hip for the first 8-12 weeks following surgery, or longer if you have pain or

degeneration, or have been told to take rehabilitation slower. These are some activities to be careful with –

•  Getting in/out of bed - assist and support your leg when it is painful and weak initially following surgery.

•  Keep your knees together when getting in/out of the car and bed.

•  Limit stair climbing, prolonged walking, standing, sitting.

•  Avoid heavy lifting and repetitive bending, twisting or sudden/uncontrolled movements.

•  Caution with squatting, crouching and lying on your operated side.

•  Take consideration with intercourse positions – see the medical website , Herman and Wallace – orthopaedic considerations for intercourse.

•  Do not provoke pain, if any exercises are painful..STOP and report to your physio, who will modify your program.

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ADDITIONAL ADVICE continued –

Returning to work –

This subject needs to be discussed pre-operatively with your consultant/GP/physio and employer. It is important that the positions and tasks you need to carry out at work are analyzed realistically to avoid any set-backs in recovery. With the UK consultants I work with, their patients tend to have 2-6 weeks off work in sedentary jobs. A longer time off is usual in more manual jobs.It depends on the type of surgery you have had, the condition of the joint and other factors that indicate how long recovery might take. It can vary.If you are in a sitting job, you need to make sure you are going to be able to sit comfortably before returning to work. This means giving the hip adequate time to recover after surgery and rehabilitate. A workplace assessment may need to be done by your employer to check your desk and chair ensure a correct posture. A staged return is often a good idea. Feedback from my patients on this matter is that once you are back at work, it is hard to find time to do rehab exercises. This is why I have included sitting/ standing exercises in my guide that could be done ‘slottted’ in here and there in the day.

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Labral repair and

capsular plication/repair considerations –

Some surgeons have a hip flexion up to 90’ limit for 10 days then 120’ until 4 weeks post-op, and a hip abduction 25’ limit for 3 weeks. Hip extension and external rotation gentle or nil for first 3 weeks (to avoid stress on capsule and labrum) – check your surgeon’s guidelines…it will differ from surgeon to surgeon .

No isometric or loaded hip flexion for the first two weeks. After that period, avoid if painful and introduce only when safe to do so, to avoid hip flexor tendinitis.

Use night splints in internal rotation for capsular plication/repair for 4 weeks.

All hip arthroscopies –

Do not push into painful movements, especially with arthritic hips and it is important to ALWAYS avoid aggressive hip extension.

(ref 18,19,20,21)

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•  Prevent hip flexor tendonitis.

•  Be aware of ‘normal’ and ‘abnormal’ post-op pain.

•  Check for trochanteric bursitis, sacroiliac joint and lumbar spine dysfunction.

•  Prevent, manage capsulitis / synovitis.

•  Manage scarring around portal sites.

•  Adhere to instructions given by the surgeon on use of crutches – do not come off too soon.

•  Adhere to instructions given by the surgeon regarding medication and rehabilitation plan and any movement restrictions.

•  Attend post-operative appointments with your surgeon so they can monitor your recovery.

•  Attend post-operative physiotherapy so they can address any rehabilitation problems and assist you in your recovery.

•  Expect new pains and adjustments occurring in the rest of the body.

•  Be mindful of the other hip, especially if it is possible that may also need surgery at a later date.

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Aw

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Centre edge angle below 20 degrees

(dysplasia)

Presence of advanced OA changes

Generalized hyperlaxity in patients

with instability symptoms

Low pre-op modified harris hip score (MHHS)

Pain and a negative hip arthroscopy

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Information courtesy of Prof Schilders

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Level one

•  Early stage rehabilitation •  Patient on elbow crutches,

partial weight bearing. •  Aim to decrease pain and

inflammation, promote healing and protect repaired tissues.

•  A whole body approach to aid circulation, relaxation, early joint mobility, maintenance of muscle tone, correct posture and to prevent musculoskeletal compensatory issues in other parts of the body.

•  Ensure hip joint neutral position is achieved in various postures and equal weight bearing through ischial tuberosities in sitting.


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Level one

•  Week 1(day1-7)

•  Week 2(day 8-14)

•  Week 3(day 15-21)

•  Week 4 (day 22-28)

•  Please note, some people may need to stay at week 1 for longer, or week 2, etc..It is important to progress at a speed that is appropriate to you. Pushing with exercises that are too hard or provoke pain is not advisable. The time frames in this handbook are meant as a general guide and may need to be modified to suit the individual.

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LEVEL ONE

Week 1 exercises

1. Circulatory exercises – ankle pumps.

Point one foot and at the same time flex the other foot back at the ankle, as shown below. Repeat 10 times hourly while immobile.

Aim – to pump blood to encourage circulatory flow whilst immobile.

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LEVEL ONE

Week 1 exercises

Static contractions, hold 5 seconds, 10 reps, every 3 hours. Aim – to maintain muscle tone while immobile.

2. Quadriceps - Straighten one knee and tighten /tense the muscles on the front of your thigh.

3. Hamstrings – Bend one knee to approx 45 degrees. Push heel gently down into the bed to tense the muscle at the back of the thigh.

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LEVEL ONE

Week 1 exercises

Static contractions, hold 5 seconds, 10 reps, 2 times a day. Aim – to maintain muscle tone while immobile.

4. Transversus Abdominis (T.Abs) – Lie on your back with your hips and knees bent to approximately 45 degrees (as in exercise 5). Place a small pillow or folded towel under your head if needed. It is important that you feel relaxed and comfortable.

Next, keeping your bottom in contact with the bed/floor, tuck your tailbone under so you flatten your back against the bed/floor..then tilt the other way, arching your lower back gently..this is called a pelvic tilt. Do this a few times as it will help to gently mobilise your lower back. Now, position your pelvis so your lower back is in what we call ‘neutral’, this is the position in between the two movements you have just done and your lower stomach should be level north-south, east-west. Finally… without losing this position, gently pull your lower tummy muscles (T.Abs) in, as if you are pulling your navel towards your spine. Your upper body should still be relaxed and you should try to breathe normally as you do so.

As we go through this guide, we will exercise this muscle in various positions. (Ref 22).

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LEVEL ONE

Week 1 exercises

Static contractions, hold 5-10 seconds, 10 reps, 2 times a day. Aim – to maintain muscle tone while immobile.

5. Hip Abductors – Lie on back, hips and knees bent to approx 45 degrees. Tie a belt around your lower thighs. Use the techniques in exercise 4 to find a neutral spine and to gently contract the T.Abds. Gently push out sideways against the belt. Make sure this does not provoke pain. Keep a neutral pelvic position throughout. If you find getting down to the floor a problem with these following exercises, lie on the bed. Safety comes first.

Caution - with trochanteric bursitis

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LEVEL ONE

Week 1 exercises

Static contractions, hold 5 seconds, 10 reps, every 3 hours. Aim – to maintain muscle tone while immobile.

6.Gluteals – Gently squeeze together your buttock muscles. This can be done in the position shown in exercise 5, or in sitting, or laid on your front, or in standing….whichever is the most comfortable. If lying on your front, place your feet in the position shown in the picture, heels in neutral, ensure a neutral lumbar spine, and gently contract your T.Abs before squeezing your bottom. This exercise can be improved by palpating your side hip bones to give you feedback to check you are not gliding or rotating around the hip joint or pelvis as you contract your gluts. The hip joint and pelvis should stay in neutral. Then progress to individual glut (buttock) squeezes.

Therapists – please read Sahrmann’s work (ref 22)

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LEVEL ONE

Week 1 exercises

Gentle stretches – Hold 10-20 seconds, 5 reps, 2 times a day. Aim- to maintain muscle length without provoking inflammation/pain.

7. Quadriceps – Lie on your front with a folded towel under your forehead so your head is supported and not in a twisted position. Engage your T.Abs in a neutral spine. Bend one knee bringing the heel of the foot towards the bottom. A stretch in the front of the thigh should be felt. Your lower back should not hollow, your T.Abs and gluts should be maintaining neutral spinal and pelvic position. If you can not comfortably lie on your front, try a pillow under your hips and/or ankles.

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LEVEL ONE

Week 1 exercises


8. Iliotibial band and hip abductor stretch – Lie on your non-operated side on the bed, near the edge, with the underside knee/hip bent. Pillow under head. Straighten the top leg. If a gentle stretch is felt in this position, do not progress to the next stage. Hold in the gentle stretch position. To progress this exercise, gently let the foot of the top leg hand over the side of the bed, as shown in the picture.

Warning – do not do if this causes any ‘nipping’/pain in the groin.

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LEVEL ONE

Week 1 exercises


9. Adductors – sit (not on a low seat), feet on the floor, using your hands to support the operated leg, gently take it out to the side. DO NOT LET IT ROTATE OUTWARDS. Only a small careful movement should be done at this early stage. A GENTLE stretch should be felt in the inner thigh.

Warning – do not do if this causes any soreness/pain in the groin.

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LEVEL ONE

Week 1 exercises

10. Exercise bike – the use of the bike post hip arthroscopy varies from surgeon to surgeon, some recommend immediately, some after 1 week, some after 2, some after 4. Check your surgeon’s protocol. We advise our patients use the bike, with the seat high, to encourage early ACTIVE ASSISTED range of movement of the hip, the day after surgery. The bike should be set to zero resistance and the non operated leg should do most of the work. Pedaling should be done slowly, and the operated hip should not ‘hitch-up’, it should feel relaxed during movement. Start by doing the bike ‘little and often’ eg. 5-10 minutes 2-3 times a day, but you may increase this if it feels comfortable and pain free. Increase SLOWLY by 5 minutes. Keep at the same time for a few days before increasing time. Maximum would be 45 mins, 2 x a day.

No resistance until week 5-6.

Warning – modify time used, if this causes any soreness/pain in the groin. Try pedaling backwards!

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Week 1 exercises

10. Exercise bike – continued ……

What do we do if for some reason the patient can not go on an exercise bike?

Some surgeons recommend pendular hip movement rather than the bike at this stage. This exercise could be used for patients who can not use a bike .

•  Stand on a step with your non-operated leg, see photo on the next page. Holding on with both hands, to a secure support. Let the operated leg hang in a heavy, relaxed fashion. Imagine your leg to like a pendulum of a clock and gently swing it forwards then back to neutral (no hip extension ). Repeat 10-20 times every 2 hours.

•  This movement can also be done in the pool as long as the patient is safe to mobilise in this environment and has waterproof wound dressings.

•  Water cycling can be done with floats assisting and supporting – see separate hydrotherapy guide.

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Week 1 exercises

Pendular exercise –

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Neutral Forward

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Week 1 exercises

Aim – maintain upper body flexibility.

11. Supine chest openings – Lie on your back with your knees and hips bent to approx 45 degrees. Ensure good symmetrical alignment of the legs and a neutral spine (see exercise 4). Bring your hands together in front of you, in a prayer position. Connect your T.Abds and as you breathe out, open out your arms as in the picture below. Only go as far as comfortable. It is important to keep a neutral spine and not let your rib cage lift up or your spine hollow. Hold as you breathe in. Then return to the start position as you breathe out. Repeat 5-10 times, 1-2 times a day, as required. Can be progressed to lying on a fit roll (not in week 1-3).

Top tip – good for tightness caused from crutch use

Early stage Advanced stage

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Week 1 exercises

Aim – maintain upper body flexibility.

12. Spinal extension – Lie on your front, prop yourself up on your forearms. Slide your shoulder blades gently down your back, gently tuck in your chin so you are lengthening down the back of your neck (do not allow chin poke). Connect through your T.Abds, keep your lumbar spine and pelvis neutral. Gently push your breastbone forwards as you breathe out so your thoracic spine hollows(the bit between your lower neck and lumbar spine). Hold the position as you breathe in, then relax to the start position as you breathe out. Repeat 5-10 times, as required, 1-2 times a day.

Top tip – this part of spine can become very stiff due to body compensations and use of crutches. this exercise also gently stretches the hip flexors

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Incorrect -’hinging’


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Week 1 exercises

13. PRONE LYING – try and spend one hour laid on your front in the morning and one hour in the afternoon. This is to prevent the front of your hip becoming tight.

14. ICE – Use an ice gel pack wrapped in a damp tea towel (to protect your skin). 20 minutes every 3 hours. Do not use on numb skin and keep checking the area and moving the ice pack to different parts of the leg/hip/pelvis to avoid ice burns.

15. RELAXATION – Plenty of sleep and rest is needed in recovery. Take things slow, be realistic, do not try and rush recovery. Keep positive and keep stress to a minimum. ‘Self Care – the seed of recovery. It is nearly impossible to use your body well and treat it wisely when you feel hostile, fearful or harshly demanding toward some part of yourself’ (ref 23).

Note to therapists – Acupuncture (Ref 24,25,26) and gentle massage techniques for pain relief, muscle spasm and swelling are helpful at this stage. Some consultants advise hydrotherapy at this early stage. Health and safety criteria must be met. See ‘Hydrotherapy exercises following hip arthroscopy guide’, by Louise Grant (HIP-PHYSIOCURE).

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WEEK 1 -Exercise record sheet

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Week 2 exercises

Aim – Gentle transversus abdominis/hip/pelvic control

16. Supported heel sides in supine. Lie on your back, knees and hips bent to approx 45 degrees, ideally on a ‘slidey’ surface that your heel can glide along. Use a strong strap or belt to secure around your operated leg foot, hold with both hands – as shown in the photo.

With relaxed breathing, a neutral pelvis and lumbar spine and T.Abs engaged….and using the strap to assist the movement of the operated leg, gently slide the leg out straight, keeping the heel in contact with the floor. Then assist the leg to bend. You are aiming to go from 0-70 degrees hip flexion, keeping the heel in contact (no lifting) with the floor and the leg supported at all times, to avoid activation of the hip flexor (ref 27). Repeat 5-10 times, 2 times a day..SLOWLY

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Week 2 exercises

Aim – hip flexion mobility with lumbo-pelvic control and early dissociation.

17. Four point kneeling hip rocks. Set yourself up as in the first picture. Hands directly under shoulders, knees under hips. Perform some pelvic tilts initially in the position to mobilise the lumbar spine and eventually find neutral. Gently draw your navel towards your spine, activating the T.Abs but keeping the lumbar spine in neutral. Now, gently ‘rock’ your bottom backwards towards your heels, but do not bend in the back, keep the spine neutral and T.Abs engaged. Do not rotate the pelvis and aim for symmetry of movement. Hold for 5 seconds, then ‘rock’ forward as in the last photo . Hold 5 seconds. Repeat 10 times, 2 times a day. (ref 22)

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Week 2 exercises

Aim – early hip abduction/adduction mobility with lumbo-pelvic control and early dissociation.

18. Four point kneeling hip glides. Set yourself up as in the first picture. Hands directly under shoulders, knees under hips. Perform some pelvic tilts initially in the position to mobilise the lumbar spine and eventually find neutral. Gently draw your navel towards your spine, activating the T.Abs but keeping the lumbar spine in neutral. Now, gently and slowly, ‘glide’ your hips to the side. Do not rotate the pelvis. Aim for symmetry of movement. Avoid painful ranges. Hold for 5 seconds, then ‘glide’ to the other side. Repeat 10 times, 2 times a day. (ref 22)

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Week 2 exercises

Aim – Gentle hip mobility

19. Hip internal rotation. Lie on your front, neutral lumbo-pelvic spine, T.Abs engaged. Bend your knees up to 90 degrees bend, keeping them together. Slowly and gently make a ‘V’ shape, separating your feet but keep your knees together. Hold 5 seconds, repeat 5-10 times, 2 times a day.

20. Exercise bike (as per description in ex. 10)

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Week 2 exercises

Aim – maintain calf muscle strength

21. Ankle plantar flexion with resistance band. Secure a resistance band like a stirrup around the ball of the foot. Hold with both hands. Firstly pull the foot back towards you, pull the band tight so it under tension, then flex your foot at the ankle pushing against the resistance of the band. Hold 5 seconds, repeat 10 times, 2 times a day.

SAFETY WARNING – ALWAYS CHECK YOUR ELASTIC EXERCISE BAND BEFORE USE, THERE IS A DANGER THAT IT COULD SNAP. EYE GOGGLES ARE ADVISED TO BE WORN WITH THESE PRODUCTS.

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Week 2 exercises

Aim – maintain quadriceps and hamstring strength and flexibility

22. Prone lying hamstring curls/Quads stretch. Position yourself as in exercise 7 but with a small ankle weight around your ankle. Perform the exercise as in exercise 7, slowly. Hold 10 seconds, 10 repetitions, 2 times a day. This exercise aims to gently work your hamstrings and at the same time stretch your quadriceps muscles. (ref 27)

23. Seated knee quads extension/Hams stretch. Sit up straight on a firm chair. Feet should be on the floor and hips/knees at 90 degrees, or hips at more of an open angle if required. Gently draw in your lower stomach muscles (T.Abs), lumbar spine in neutral. Straighten one knee, tensing up the muscle on the front of the thigh…try to keep your back straight. Hold 10 seconds, 10 repetitions, 2 times a day.

Top tip- place one hand in the area between your incisions and try and ‘tense’ contract that area as you do exercise 23. This area may be inhibited with muscular activity after surgery.

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Week 2 exercises

Aim – maintain hip abductor and adductor length and strength

24. Isometric hip abduction (as per exercise 5).

25. Hip Abductor/ITB stretch (as per exercise 8).

26. Hip Adductor stretch (as per exercise 9).

27. Isometric hip adduction. Gentle squeeze with a soft football or pilates ‘magic-circle’. Try in sitting/lying/standing, which ever is comfortable. Do not do if it increase any adductor soreness. Squeeze for 5-10 seconds, 5-10 times, 2 times a day.

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sitting standing lying

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Week 2 exercises

Aim – maintain gluteal strength and length

28. Isometric hip gluteals (as per exercise 6).

29. Gluteal/piriformis stretch. Lie in the position shown with your operated leg on top. Place a pillow under the knee of your operated leg for comfort (if required). You should feel a stretch in your bottom muscles. If uncomfortable, try having your top foot tucked behind the underneath foot, rather than behind the knee. To increase the stretch, rotate upper body backwards, or lie near the edge of a bed so you can drop the knee of the top leg over. BE AWARE THAT THIS EXERCISE CAN CAUSE NIPPING IN THE GROIN…if you feel this, please do not do. Hold the stretch 5-10 seconds, as comfort allows, repeat 5-10 times, 2 times a day.

30. Upper body stretches (as per exercises 11 and 12).

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Week 2 exercises

Continue with as in week 1 –

Prone lying, rest, relaxation and ice (exercises 13-15)

Note to therapists – Early passive gentle hip circumduction is recommended (Wahoff & Ryan, ref 20). Done passively with hip in 70 degrees flexion. Gentle passive ‘log rolling’ of the leg in neutral is also useful.

Appropriate joint mobilisations and soft tissue techniques, such as myofascial release (Ref 28,29,30,31,32,33,34) , positional release and active release techniques can be beneficial. Emphasis is placed on the iliopsoas, iliotibial band, adductors, gluteus medius, quadratus lumborum and quadriceps(Ref 20). Acupuncture and electro-acupuncture can be helpful throughout rehabilitation (Ref 24,25,26).

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WEEK 2 - Exercise record sheet

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Week 3 exercises

Aim – improve hip/lumbo-pelvic control

31.Heel slides in supine. Progress exercise 16, to be done without a strap, if adequate control is displayed and it is pain free. Still keep heel in contact with the floor at all times. Repeat slide 5-10 times slowly, 1-2 times a day.

Aim – activation of gluteus medius with low iliopsoas activation (exercise 32) (ref 27)

32. Double leg bridges. Lie on your back with your feet flat on floor, knees and hips bent. Lumbo-pelvic neutral, T.Abs engaged. Squeezing your bottom gently lift up your pelvis to bring your hips up into a neutral position. Hold 5-10 seconds, 5-10 repetitions, 1-2 times a day.

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Week 3 exercises

Aim – weight transference to prepare for independent walking

33.Weight transference exercises.If your consultant has given you consent to wean off crutches at the end of two weeks, then you will need to do exercises so you are balanced and do not have a limp.

DO NOT DO THIS EXERCISE IF YOU STILL HAVE WEIGHT BEARING RESTRICTIONS

Stand near an appropriate support that you can comfortably hold onto. Try and make sure your weight is distributed equally between your feet. Imagine each foot to be a tripod of weight bearing, (heel, the base of the big toe and the little toe) and try to evenly distribute your weight through these three points. Now, position your body alignment imagining a line dissecting through your side ankle bone up to the boney prominence of your lateral hip (greater trochanter), the middle of the lateral aspect of your shoulder, and finally your ear. Next, put your hands on top of your pelvis and imagine this to be rim of a bucket, tilt your pelvis anterior/posterior so the ‘rim’ is level. Engage your T.Abs and now you are ready to do weight transference!...see next page….

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Week 3 exercises

Continued …. In the position detailed in exercise 33. slowly and gently sway your body weight forwards over your feet and then back into your heels. Keep your Trans Abs engaged (Ref 35) and you should feel your gluteals ‘switch on’ at certain points. Do this 20 times. Then try side sways 20 times, get your physiotherapist to check your technique with these. Progress standing posture work with the ‘tight rope’ stance. One foot in front of the other and gaining hip joint neutral (Ref 36)and lumbo-pelvic neutral.

34. Hydrotherapy. (see separate hip arthroscopy hydrotherapy guide).

Aim – as a medium to practice walking, weight transference, early hip mobility , early lumbo-pelvic stability challenges and a ‘whole body’ approach. (ref 37,38) Health and safety criteria must be met before

commencing hydrotherapy – see

separate hydro guide.

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Week 3 exercises

Aim – to develop calf muscle strength to aid gait re-education

35. Bilateral calf raises. Stand, facing an appropriate support that you can hold onto. Modify weight bearing on operated side as per surgeon’s instructions. Ensure a good posture as you raise your heels so you are standing on the balls of your feet. Keep your ankles strong, do not let them rotate or twist. Repeat 10-20 times, 2 times a day.

Note – Progression to alternate calf raising and single leg calf raises will all depend on how much weight limit you have been instructed by your surgeon to put through your leg. You must comply with this advice.

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Week 3 exercises

Aim – to improve lower limb flexibility

36. Hamstring stretch. Lie on your back with head supported. Place an elastic resistance band (note health & safety warning ex.21) like a stirrup around your foot. Start position, knee and hip bent to 90 degrees. Shoulders relaxed, lumbo-pelvic neutral, T.Abs engaged, band under tension. Use band to assist straightening of the knee so a stretch in the back of your thigh is felt. Hold 10-30 seconds, 5-10 times, 2 times a day.


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Week 3 exercises


37. Calf stretch. Stand as in the picture. If still partial weight bearing, use an appropriate support to hold onto so you can take some weight through your arms. Put one leg behind you, one in front, feet pointing forwards. Slowly bend the knee of the front leg, keep the heel of the back leg on the floor and the knee straight. A stretch should be felt in the back of the rear calf muscle. Hold 10-30 seconds, 5-10 times, 2 times a day.


Try and maintain a good posture, do not twist in the pelvis;… use T.Abs to control.

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Week 3 exercises


38. Iliotibial band stretch. Sit on the floor, one leg straight and the other crossed over it, as shown in the photo. Pull your bent knee towards your opposite shoulder and turn your body slightly away so you feel a stretch in your lateral thigh/buttock. Hold 10-30 seconds, 5-10 times, 2 times a day.

Please check this exercise does not pinch in the groin. Try exercise 8 if that is more comfortable. Copyright-PHYSIOCURE

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Week 3 exercises

Aim – to improve flexibility

39. Faber stretch. Lie on your back. Cross one leg, so the foot is on the top of the opposite ankle, top leg is turned slightly out (figure 4 position). You can place some pillows under the knee of the top leg for support. For an increased stretch, slide the top foot up the shin towards the knee and let the top knee lower towards the floor. Do not push on the knee or force the stretch.

An alternate position is to lie on your front in the position shown below.

Hold 10-30 seconds, 5-10 times, 2 times a day.

Check the limit of external rotation in surgeon’s protocol. Some will prefer this movement to be done later on.


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Week 3 exercises

40. Exercise Bike. As per exercise 10.

41. Hip rocks and glides. As per exercises 17 and 18.

42. Hip internal rotation. As per exercise 19.

43. Isometric hip adduction with ball. As per exercise 27.

44. Resisted hamstring curls. As per exercise 22.

45.Standing hip abduction of operated side. Stand near an appropriate support to hold on to. Assume correct stand posture as in exercise 33. Take your weight on to your un-operated side, engaging T.Abs and gluteals. Slowly glide your operated leg out sideways, a short distance so the foot is clear of the floor, squeezing your bottom gently. Hold 5-10 seconds, repeat 5-10 times, 2 times a day.


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Week 3 exercises (additional suggestions)

Aim – lumbo-pelvic control and mobility

Swiss Ball exercises. Sit on the swiss ball feet flat on the floor, seated so your hips are NOT lower than your knees, pic 1. Ensure you have equal weight through the ‘sit bones’ (ischial tuberosities) by putting your hands under your bottom. Adopt a good posture, engage your T.Abs gently and engage pelvic floor, ref 39 (ask your physio how to do this). Now tuck your ‘tailbone’ under, pic 2 (posterior pelvic tilt), your ‘sit bones’ should feel more flat, then roll back the other way, sticking your bottom out so your lumbar spine has a hollow, pic 3, (anterior pelvic tilt)…your ‘sit bones’ will feel more pointed. Repeat 10-20 times, 2 times a day.

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Swiss Ball exercises. ..continued. Assume the position as before. Lumbo-pelvic neutral, T.Abs engaged, good overall posture. Glide your hips laterally to the side, and then to the other side. Place your hands under your ‘sit bones’ to monitor weight bearing and weight transference being equal as you go to one side and then another. Repeat 10-20 times, 2 times day.


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Swiss Ball exercises. ..continued. These are optional other exercises that may be useful…

Alternate heel raises

Progressing to alternate foot lifts….


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Upper body side

bends

Upper body rotations – early dissociation work of Tx/pelvis


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Seated chest openings

finish position

Seated chest openings start position


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Week 3 exercises

Note to therapists – Encourage your patient to still get adequate rest and to use ice on areas that are sore. Teach patient self-massage AROUND but not on scars.

Some patients may be planning to returning to work at this stage. If you have any concerns about this, you must discuss with the patient/surgeon.

Pushing rehab/manual therapy to extremes of movement will not enhance function, and will increase soreness, inflammation and potentially prolong recovery. Do not provoke hip flexor tendinitis or bursitis, monitor exercises and modify if necessary.

Gentle hip gliding mobilizations and caudad longitudinal distraction in neutral can be performed if appropriate with the type of surgery and type of protocol. Some surgeons do not allow hip distraction manual techniques until a later stage – check. (Ref 9 Chapter 25, and ref 6 Chapter 17).


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hip arthroscopy rehabilitation part one

Health & Medicine

Transcript of hip arthroscopy rehabilitation part one