1. health and fitness
2. exercise

Rehabilitation following
Hip arthroscopy
Prof. Ernest Schilders
Leeds Metropolitan University
Bradford Teaching Hospitals
Start
Which
procedure?
Operative
Findings
Pain
Orginal pain
Procedure
specific
Rehab related
Hip
arthroscopy
Rehab
Progress of the
rehab
Patient
orientated
Use assessment
criteria
Return to sport?
Type of sport
Fitness
Type of
procedure
Questions to answer before we start
our rehab program
 What is the exact procedure and operative findings?
Faster rehab program for simple and longer for complex
procedures.
 How long was the patient injured before his surgery?
Conditioning is a very important element of the rehab.
Incidence of pathology in athletes
n=120
80%
70%
60%
50%
40%
30%
20%
10%
0%
FAI
Instability
Ligamentum
Teres Tear
Incidence of intraarticular pathology
80%
70%
60%
50%
40%
30%
20%
10%
0%
Labral tear
cartilage
lesion
adhesions
ligamentum
teres tear
Type of articular cartilage lesion
generalized cartilage
degeneration
wave sign
Partial thickness
full thickness
0%
5%
10%
15%
20%
25%
30%
Femoroacetabular Impingement
simple
Diagnostic,
Removal loose body
Labral debridement
Ligamentum Teres debridement
Intermediate
CAM decompression
Iliotibial band release
Iliopsoas release
complex
Acetabular rim trimming + labral
repair + CAM decompression
Microfracture (prolonged crutches)
Very complex
Acetabular rim trimming+ labral
repair+ CAM decompression + capsular
plication
Procedures in athletes
Microfracture
ligamentum teres debridement
resection cartilage flaps
capsular plication
acetabular rimtrimming
CAM decompression
labral repair
0%
10% 20% 30% 40% 50% 60%
Procedure specific rehab advice
 FAI surgery (1-4 week crutches PWB)
 Microfracture (prolonged use of crutches 6-8 weeks)
 Capsular Plication (use of night splints in internal
rotation for 4 weeks)
Clinical and operative findings that
might have a negative impact on the
rehab
 Pain and a negative hip arthroscopy
 Presence of extensive grade 4 cartilage lesions.
 Generalised hyperlaxity in patients with instability
symptoms.
 Centre edge angle below 20 degrees.
 Low preop outcome score.
20y old
professional
football player
• CE angle= 20
• vertical
sloping
weightbearing
surface.
•Perthes
disease
•Generalized
hyperlaxity
Perioperative pain management
 Muscle relaxant at induction (Atracurium 0,6mg/kg)
 Remifentanyl infusion during surgery for blood pressure
control, muscle relaxation and analgesia.
 Multimodal analgesia at the end of the surgery. NSAID/
paracetamal and morphine.
 Postoperative pain relief consists of codeine,
paracetamol and NSAID
 Antibiotics administration at induction.
Rehabilitation ladders
Process whereby patient/player progresses through
rehabilitation, achieving goals within specific timescales.
Easy to follow.
Based on evidence and agreed with consultant involved.
Other considerations
 Use realistic timescales (Always err on the side of
caution).
 Use common sense, as injured patients/players will
progress at different rates.
Frank Gilroy
Post surgical
general rehabilitation
ladder
Increased shearing activities,
agility, sports specific rehab
Advanced strengthening and
proprioception
Regain full ROM
Increased strengthening and proprioception
Regain ROM
Early strengthening
Surgery
Pre-op preparation
Timescales depend on
consultant involved
Playing again!
8-12 week ladder
Phase 4
Short sprints and shuttle runs, increasing core
stability work. Gradual return to sports
specific training
Phase 3
Straight line running, strengthening exercises, increased
pool work and full stretches
Phase 2
Jogging 20-30 minutes, light
stretching and pool exercises
Phase 1
Gentle walking and light stretching
Surgery
Pre-op preparation
Timescales depend on consultant
involved
Week 1
 Ankle pumps
Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
Isometrics

These are static exercises. When you do
the exercise you should feel the muscles
tighten without movement of the joints.
Try to do twenty repetitions of each
exercise, 2 times a day.

 Gluteal sets: tighten your buttock
muscles – hold for 5 seconds.
 Quads sets: tighten the front thigh
muscles – hold for 5 seconds.
 Transversus Abdominus:
Draw belly button in towards spine without
moving pelvis/spine – hold while taking 5
breaths.
 Hip abduction: Lying on your
back with hip and knees bent, place a belt
around your thighs near your knees and push
out against the belt – hold 5 seconds
Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily
 Stationary Biking with high
seat and minimal
resistance.
 As soon as you are
comfortable enough to get
onto a bike, cycle for 20
minutes 2 times a day.
 Increase the time by 5
minutes after 3-4 days until
you have reached a
maximum of 45 minutes
twice a day.
 No resistance should be
added until week 5-6.
Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily
 Passive stretching, Piriformis stretch (side lying),
Quads stretch (prone), Adductor stretch (sitting)
Passive stretching exercises
 Lying on your good side
(bottom leg straight and
pelvis stacked) bend your
involved hip to between
50° to 70° flexion and hook
top foot behind uninvolved
knee. Steadying the pelvis,
lower the involved knee
towards bed. Stretch
should be felt in buttock,
avoiding a pinch in groin.
Piriformis stretch
Quadriceps stretch
 Do 5 repetitions, hold for
20 seconds, and twice a
day.
 Lie on your stomach with
your hips flat on the bed.
Ask a partner bring ankle
toward buttock, feeling
stretch in the front of the
thigh.
 If it is too painful to lie on
your front, you can do this
stretch lying on your good
side.
Adductor stretch
 Do 5 repetitions, hold for
20 seconds, and twice a
day.
 Sit in a chair with the feet
on the floor. Carefully
move the knee of the
affected leg out to the side
so the hip is opening out
(abducting). Do the stretch
as comfort allows and feel
the stretch on the inside of
the thigh.
Week 1
 Ankle pumps,
 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
 Stationary bike – start 20 mins x 2 daily
 Passive stretching, Piriformis stretch (side lying), Quads
stretch (prone), Adductor stretch (sitting)
 Price
Week 2
 Week 1 exercises (including)
 Quadruped rocking
Quadruped rocking
 3 sets, 20 repetitions, once
a day.
 On your hands and knees
shift your body weight
forward on your arms, and
then back onto your legs.
Also shift your weight side
to side and in diagonal
directions.
Week 2
 Week 1 exercises (including)
 Quadruped rocking
 Standing Hip IR
Standing hip internal rotation
 3 sets, 20 repetitions, once
a day.
 Place knee of the operated
leg on a chair. Rotate the
hip by
moving your
foot outward from the
body. Progress the exercise
by using a resisted band
when tolerated.
Internal rotation strengthening with
thera bands
Start position
Finishing position
Week 2
 Week 1 exercises (including)
 Quadruped rocking
 Standing Hip IR
 Heel slides with/without strap
 Cons r/v
Weeks 3-4
 Pain relief – Price, electrotherapy or mobilisation
 Gait re-education
 ROM exercises (Cont week 1 & 2 exercises)
 Stretching (piriformis and quads) include Faber, calf, hamstring
and ITB
 Gym work (if appropriate) Bike – no resistance but increase time
(aim to build for 45 mins x 2 daily), Leg press – low weights and
repetitions, Cross trainer – min resistance monitor time, Swiss
ball
 Core stability
 Hydrotherapy
Faber
lying on your back bring
involved leg into a figure
four position with the ankle
resting above the opposite
knee. Gently lower the
bent knee towards the
floor. You may need to
start with ankle resting on
the shin or inside of the
leg. It is normal to feel
some hip discomfort
underneath the thigh. DO
NOT PUSH ON THE KNEE.
Weeks 3-4
 Pain relief – Price, electrotherapy or mobilisation
 Gait re-education
 ROM exercises (Cont week 1 & 2 exercises)
 Stretching (piriformis and quads) include Faber, calf, hamstring
and ITB
 Gym work (if appropriate) Bike – no resistance but increase time
(aim to build for 45 mins x 2 daily), Leg press – low weights and
repetitions, Cross trainer – min resistance monitor time, Swiss
ball
 Core stability
 Hydrotherapy
Weeks 5-6
 Cont weeks 1-2 and 3-4
(include the follwing)
 Gym work within capabilities
( inc resistance on bike alter
time)
 Balance work – wobble
board, trampette
 Core stability – progress as
able
 HEP – lunges, lateral side
steps, knee bends, fartlek
(jog/walk)
Weeks 7+
 Week 1-2 exercises can be stopped
 Cont with weeks 3-4 and 5-6
 Increase hydrotherapy exercises (squats, step
ups/downs, ¼ - ½ lunges.
 Running – progress from straight line to multi-directional
 Sports specific
Advanced hydrotherapy
Advanced hydrotherapie
Which questions do we have to ask
ourselves?
 How do we know that our rehab is progressing steadily,
what is normal and what is abnormal?
 What are the standards we can realistically aim for?
(measurements of outcomes)
 Can we separate the built up of fitness from a hip
arthroscopy specific rehab program?
Which assessment criteria can we use
during rehab?
 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST
Pain following the procedure
 Procedure related
Adhesions, microfracture, labral repair, decompression CAM or
pincer. INFECTION
 Traction related
adductor pain
Pectineus
Sciatic pain
Ankle pain
 Rehab related
Iliotibial band and trochanteric bursitis
Psoas
Hip flexors
Synovitis
 Sacro iliac joint pain.
Pain and Stiffness
 Pain:
Reintroduce analgesia, NSAID rarely steroid injection.
Limited rest
Concentrate on Deep Rotators of the hip.
 Stiffness:
ROM stuck (very rarely) ; check X rays or CT scan to
investigate for residual impingement
Risk factors for adhesions
 More complex arthroscopic procedures.
 Pre-operative sensations of stiffness that limits
function.
Possible risk factors
Longer time on crutches
Grade 4 articular cartilage lesions treated with
microfracture.
Iliotibial band
 Compression of the trochanteric bursa due to iliotibial
band tightness.
*Weakness of the hip abductors causing increased hip
adduction.
*Swelling bursa due to fluid extravasation.
*swelling and insufficiency muscles due to portal
trauma.
 Osteopathic technique to reduce the tightness,
myofascial release. “ counterstrain a positional release
technique”.
Research in progress, Iliotibial band
tightness
 Weakness of the hip abductors and imbalance between
adductor/abductor strength.
 Reduced hip mobility compared to controlateral side
an issue to address early in the rehab, before athletes
have increased their activities to significantly
Which assessment criteria can we use
during rehab?
 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST
Modified Harris Hip score
 Preoperatively
39-96
 2 months postop
58-100
 6 months postop
74-100
 Minimum of 12 months postop.
70-100
 Overall the average pre-op MHHS was
62.1 (95% CI 57.8-66.4)
and the average post-op MHHS, after
minimum 1 year, had statistically
significantly increased to 94.8 (95% CI
92.8-96.9) (p<0.001).
 Average return to sport was 2.4
months.
Which assessment criteria can we use
during rehab?
 Pain
 Functional scores
Modified Harris Hip Score
Hip outcome osteoarthritis score (HOOS)
SF 36
 Subjective assessment?
 Objective Static information
Range of motion
Strength test
Log roll test
 Objective dynamic evaluation
SPORTS TEST
Sports Test M Phillipon
Test Components
Maximum score
1.Single knee squat (single knee
bend)
6 points
2 Lateral agility test
5 points
3. Diagonal agility test
5 points
4. Forward single leg lunges
4 points
Total 20 points
Sports test M Philippon
Scoring criteria subsets
Time
 Passed
> or = 17 points
20-30 seconds
Endurance
Form
 Failed
< 17 points
Pain
Total
1 point
Timing to sport
 Difficult to predict.
 Should be athlete orientated rather the rehab
orientated.
 Need for objective measurements before allowing
athletes to go back to sports.
Risk factors for reinjury
 History of injuries and low level of off-season sport
specific training.
 Consider the time an athlete has been out with an
injury, before having surgery.
Risks of early return
 Persistent Pain
 Prolonged rehabilitation time.
 Low performance
 Re-Injury( new labral tear, articular cartilage lesion)
 New Injuries.
Emery et al. Med SciSports Exerc, 2001.
When would I stop an athlete from
returning?
 Lack of endurance in sports
specific tasks.
 Pain in sports specific
positions.
Progressive adaptations can
be feasible. Dressage: start
with small horses before
wide horse, stirrups higher,
to sit in a flexed more
abducted position.
 Endurance muscles fibers are the first to be lost after hip
surgery and take longer to recover.
Suaetta et al. J ApplPhysiol, 2008.
Deschenes et al. Am J Physiol, 2002.
Ferrettiet al. J ApplPhysiol, 2001
Principles
 If possible see patient/player pre-operatively
to prepare joint involved, and explain process
and timescales involved.
 Always work closely with the surgeon involved.
 Whenever possible follow evidence based
guidelines.
rockclimbing
netbal
martial arts
rowing
dance
cycling
hockey
tennis
basketball
running
horse riding
golf
rugby
soccer
0
2
4
6
8
10
12
14
Return to sports following
impingement surgery
 Soccer
2-4 month
 Rugby
2-3 month
 Basket ball
5 month
 Hockey
3-4 month
 Dance
3 month
 Martial arts
3 month
 Tennis
2 month
sports involving twisting and turning
Return to sports following
impingement surgery
 Golf
2-3month
 Cycling
6week-2 month
 Running
2 month
 Rowing
2 month
 Rockclimbing
3 month
Sports not involving twisting and turning
Start
Which
procedure?
Operative
Findings
Pain
Orginal pain
Procedure
specific
Rehab related
Hip
arthroscopy
Rehab
Progress of the
rehab
Patient
orientated
Use assessment
criteria
Return to sport?
Type of sport
Fitness
Type of
procedure
Thank you for your
attention