Post-operative Rehabilitation Protocol following Arthroscopic Hip

Departments of Rehabilitation Services and

Orthopaedic Surgery

Post-operative Rehabilitation Protocol

following Arthroscopic Hip Surgery for

Femoroacetabular Impingement

Arthroscopic Hip Surgery for Femoroacetabular Impingement

2

Departments of Rehabilitation Services and Orthopaedic Surgery

Post-operative Rehabilitation Protocol following Arthroscopic

Hip Surgery for Femoroacetabular Impingement

Hip preservation surgery has become an increasingly common procedure to address a number of intra-

articular hip disorders including labral tears and femoroacetabular impingement. The number of hip

arthroscopies has increased greatly in the past decade. With this increase in number of surgeries have

come advancements and refinements in surgical techniques and increasingly complex considerations for

rehabilitation needs. Hip arthroscopies with labral repair and FAI correction are typically a successful

procedure with improvements in function (mHHS) and pain (VAS) typically seen in patients at 3, 6, and

12 months.

1

This rehabilitation protocol has been written with consideration of current surgical techniques and

avoidance of post-operative complications. Proper rehabilitation to avoid post-operative adhesions, and

appropriate weight bearing, along with manual therapy to manage post-operative impairments are all

important factors to consider in order to minimize the risk of adverse outcomes. The rationale for aspects

of this protocol is provided in the following paragraphs to increase clinician knowledge and

understanding. Since surgical techniques and procedures can vary for each patient, the clinician should

obtain and read the detailed operative report in order to gain a full understanding of what must be

considered in the post-operative period.

Consideration for tissue quality, bone quality, success of repair, and surgical technique should be assessed

and considered by the clinician. Avoidance of irritation and inflammation in the post-operative phase is

imperative. In the first phase of rehabilitation the focus is to protect the repair and avoid irritation. Gluteal

isometrics have been shown to be helpful in decreasing iliopsoas spasm and preventing anterior hip pain

and are therefore initiated in Phase I of the protocol.

2

One surgical technique that merits special consideration in post-operative rehabilitation is capsular

closure. Capsular closure is performed to restore the normal anatomy and minimize the risk of post-

operative issues with instability. With the capsular repair closure technique, it is necessary to protect and

limit hip external rotation and extension in the early healing phase to protect the integrity of the repair.

2

Capsular integrity has been correlated to improved outcomes after hip arthroscopy with FAI correction.

Additionally, the clinician should consider whether the labrum was repaired or reconstructed. If the labral

tissue is inadequate the surgeon may reconstruct the labrum using an autograft or allograft. This

information can be accessed in the operative note and will impact rehabilitation.

The evidence for manual therapy after hip arthroscopy is developing. It is thought that manual therapy to

the musculature and joints around the hip joint helps to decrease nociceptive input and address

impairments that develop in the pre and post-operative period, thereby decreasing abnormal forces to the

hip joint and improving patient outcome.

3

In order to protect the integrity of the labral repair or

reconstruction, capsular repair, and protect the fluid seal, long axis hip distraction should not be

performed until 8 weeks after labral repair and 12 weeks after labral reconstruction. Joint mobilizations of

grade III-IV should not be performed until 8 weeks postoperatively for the aforementioned reasons.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Intra-articular adhesions have been recognized as a cause of surgical complications and pain. In an

analysis of possible risk factors for adhesions following hip arthroscopy, the following factors were

identified: age under 30, Modified Harris Hip score under 50, no microfracture performed, and

rehabilitation without circumduction.

4

Passive range of motion circumduction is incorporated into

treatment to minimize the development of post-operative adhesions.

Appropriate progression of weightbearing and gait retraining are essential aspects of rehabilitation. With

respect to weightbearing, the patient is initially limited to 20 lb of foot flat weight bearing in the

immediate post-operative phase. This limitation is due to the concern for appropriate healing of the labral

repair or reconstruction, and the capsular repair. Foot flat weight bearing is indicated to avoid achilles

irritation or shortening, irritation or shortening of hip flexors and stressing the labral repair or

reconstruction.

2

Patients should be counseled that they should not self select a non-weightbearing pattern

due to increased compressive forces to the hip joint due to hip flexor overactivity.

5

It is expected that the

gluteus medius will be inhibited post-operatively, therefore special attention should be paid to gait

retraining and proper crutch use to avoid contralateral hip drop when weightbearing on the operative leg

to avoid irritation to hip joint or repair.

5

Patients should be advised to continue with use of assistive

device for 6 weeks following surgery, or until their gait without device is without deviation. Allowing

unassisted gait with deviations will cause intraarticular irritation and overuse of accessory muscles around

the hip, possibly delaying the healing process.

6

Clinicians should have a good understanding of the expected progression and healing timeframes as

outlined in this protocol. If patient is not progressing appropriately, or if there is concern for post-

operative complications, the surgeon should be contacted and notified of the patient’s status.

Progression to the next phase of rehabilitation is based on achieving both Clinical Criteria

as well as Time Frames. Variance from this needs to be reviewed by surgeon.

The intent of this protocol is to provide clinicians with a guideline of the post-operative

rehabilitation for patients following arthroscopic hip surgery for femoroacetabular

impingement. This protocol is not intended to mandate the course of patient care. If there are

concerns regarding the patient’s clinical presentation. Please consult with the referring

physician prior to making adjustments to the protocol.

Procedures Performed:

☐

Acetabuloplasty

☐

Labral repair

☐

Labral debridement

☐

Labral reconstruction

☐

Chondroplasty

☐

Microfracture

☐

Fibrin glue repair

☐

Femoroplasty

☐

Capsular repair

☐

Iliopsoas Release

☐

Endoscopic Trochanteric Bursa Excision

☐

Endoscopic Abductor Repair

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Specific Case Complexity and Limitations:

☐Primary Procedure

☐Revision Procedure

Comments: ___________________________________________________________________

Pace of Protocol:

☐ROUTINE

☐LESS-AGGRESSIVE

Comments: ___________________________________________________________________

Weightbearing

Timeframe

Weightbearing

0-21 days

Partial weightbearing 20 lbs, step to pattern,

foot flat gait

3-6 weeks

Gradually increase weight bearing to WBAT

pain-free

6 weeks-8 weeks

Gradually wean from crutches, decrease to

single crutch, then without device as tolerated

Range of Motion

Hip

Motion

ROM Days 0-

21

ROM Week 3-6

ROM Week 6-12

ROM Week 12+

Flexion

0-90 degrees

Gradually increase

in pain free

manner

Gradually increase in

pain free manner

Gradually increase in

pain free manner

Extension

0 degrees, no

motion beyond

neutral

0-10 degrees

Gradually increase to

fully ROM as

tolerated

If full ROM not

attained, gradually

increase to full ROM

Abduction

0-30 degrees

0-45 degrees

Gradually increase to

full ROM as tolerated

If full ROM not

attained, gradually

increase to full ROM

External

Rotation

0-30 degrees

0-45 degrees

Gradually increase to

full ROM as tolerated

If full ROM not

attained, gradually

increase to full ROM

Internal

Rotation

0-30 degrees

0-45 degrees

Gradually increase to

full ROM as tolerated

Gradually increase to

full ROM as tolerated

Bracing: none

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Phase I – Immediate Post-Surgical Phase (Day 1-28):

Initial Physical Therapy Evaluation to be scheduled 2 weeks after surgery. Patient instructed on initial

exercise program by surgical team.

Goals:

• Minimize pain and inflammation

• Protect integrity of repair

• Avoid post-operative adhesions

• Improve pain-free AROM/PROM within stated parameters

• Attain non-antalgic gait with use of device and appropriate weight bearing

• Address muscle inhibition

• Patient demonstrates independence with initial home exercise program

Precautions/Guidelines:

• No active straight-leg raises throughout rehabilitation period

• Avoid ambulation to fatigue or pain

• No active hip flexion for days 0-21, hip flexion should be self-assisted for functional mobility

• No Gr III-IV hip joint mobilization for 1

st

8 weeks

• No long axis hip distraction for first 8 weeks for labral repair

• No long axis hip distraction for first 12 weeks for labral reconstruction

• At all times pain and pinching in the hip joint should be avoided.

Throughout rehabilitation period every effort should be made to avoid:

o Hip flexor tendinitis

o Synovitis of operative joint

o Trochanteric bursitis

o Lower back pain or sacroiliac pain

Criteria for progression to the next phase:

• Minimal pain with ambulation

• Non-antalgic gait with use of crutches

• Minimal pain at rest

• Patient able to perform exercise program without increase in baseline pain

Patient compliant with weight bearing, home exercise program, and activity precautions

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Treatment Strategies

Patient Education

Activity modification, bed mobility, positioning:

o No crossing of legs

o Avoid sitting for more than 30 minutes for first 2 weeks, vary position frequently

throughout the day. Gradually increase sitting time as tolerated after first 2 weeks.

o Sit with hip angle less than 90 degrees by sitting on a high chair or sit slightly reclined

o Prone lying 15 minutes 2-3 times per day to avoid hip flexor contracture

o Assist operative leg when getting in/out of bed, in/out of car and for all functional

mobility

o Consider obtaining raised toilet seat to avoid hip flexion greater than 90 degrees when

sitting on toilet

Manual Therapy

• Soft tissue mobilization as appropriate for quadriceps, hamstrings, TFL, gluteus medius, iliacus,

psoas, quadratus lumborum, lumbar paraspinals. Avoid suture sites until sutures removed and

incisions healed.

• Joint mobilizations to lumbar spine/sacrum to address lumbosacral dysfunction as indicated

• Gr I-II hip joint mobilizations for pain modulation as appropriate

• Initiate hip circumduction and passive IR as indicated below

PROM Hip Circumduction at 70° Hip Flexion

• Setup: The patient should begin lying on their

back. The provider should hold the patient's leg

just above the knee and under the heel, with the

patient's hip bent at a 70 degree angle.

• Movement: The provider should gently move

the patient's hip in a small clockwise motion,

then counterclockwise direction.

• Tip(s): The provider should only move the

patient's leg in a gentle, pain-free range of

motion.

PROM Hip Internal and External Rotation

• Setup: The patient should be lying on their

back with their legs straight. The provider

should grasp the patient's closest leg with one

hand on the thigh and the other on the shin.

• Movement: The provider should then gently

rotate the patient's leg inward approximately 30

degrees, then back to neutral, then outward

approximately 30 degrees keeping it on the bed

with the knee straight.

• Tip(s): The patient should stay as relaxed as

possible during the exercise.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Gait Training

• Gait training with B axillary crutches maintaining indicated weight bearing

• Stair training with step to pattern, maintaining indicated weight bearing with rail/assistive device

Modalities

• Cryotherapy as needed

• Electrical stimulation for pain management as needed

Therapeutic Exercise:

Note: Dosage of exercises to be prescribed by physical therapist as appropriate.

Recommendations have been made when appropriate. Exercise instructions are written in patient

friendly language.

Supine Ankle Pumps

• Setup: Begin lying on your back with your legs

straight.

• Movement: Slowly pump your ankles by

bending and straightening them.

• Tip(s): Try to keep the rest of your legs relaxed

while you move your ankles.

Supine Quad Set

• Setup: Begin lying on your back on a bed or

flat surface with your legs straight.

• Movement: Tighten the muscles in the thigh of

your surgical leg as you straighten your knee.

Hold, then relax and repeat.

• Tip: Make sure to keep your toes pointing

toward the ceiling during the exercise. Try to

flatten the back of your knee towards the bed.

Supine Glute Set

• Setup: Begin lying on your back with your

hands resting comfortably.

• Movement: Tighten your buttock muscles, then

release and repeat.

• Tip(s): Make sure not to arch your low back

during the exercise or hold your breath as you

tighten your muscles.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Transversus Abdominis Activation Hooklying

• Setup: Begin lying on your back with your

knees bent, feet resting on the floor, and your

fingers resting on your stomach just above your

hip bones.

• Movement: Tighten your abdominals, pulling

your navel in toward your spine and up. You

should feel your muscles contract under your

fingers. Hold this position, then relax and

repeat.

• Tip(s): Make sure to keep your back flat against

the floor and do not hold your breath as you

tighten your muscles

Prone Knee Flexion

• Setup: Begin lying face down with your legs

straight.

• Movement: Bend one knee, bringing your foot

as close as possible toward your body. Once a

gentle stretch is felt in the thigh, hold the

position for 10 seconds

• Tip: Make sure to keep your upper body

relaxed during the exercise and do not arch your

back as you bend your knee. This should not

cause pain.

Passive Supine Hip Flexor Stretch

• Setup: Lie flat on your back with one pillow

under your hips.

• Movement: relax all muscles and you will feel

a gentle stretch in the front of your operative

leg. Hold position for 10 minutes 3 x per day

Upright Stationary Bike

• Setup: Seat slightly elevated to minimize

excessive hip flexion

• Movement: Pedal with slow, controlled motion.

No resistance

• Tip(s): Start with 5 minutes, 2 x per day

gradually increase to 20 minutes 2 x per day

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Phase II – Protection Phase (day 21-week 6):

Goals:

Progress weight bearing as appropriate per timeline

Progress ROM as tolerated per protocol

Minimize pain and inflammation

Protect integrity of repair

Avoid post-operative adhesions

Improve pain-free AROM/PROM within stated parameters

Attain non-antalgic gait with use of device and appropriate weight bearing

Address muscle inhibition

Patient demonstrates independence with initial home exercise program

Precautions/Guidelines:

• No active straight-leg raises for 8 weeks

• No active hip flexion for days 0-21, hip flexion should be active assisted for functional mobility

• No Gr III-IV hip joint mobilization for 1

st

6 weeks

• No long axis hip distraction for first 8 weeks for labral repair

• No long axis hip distraction for first 12 weeks for labral reconstruction

• At all times pain and pinching in the hip joint should be avoided.

• Avoid functional activities that cause hip pain

Avoid:

• Hip flexor tendinitis

• Synovitis of operative joint

• Trochanteric bursitis

• Lower back pain or sacroiliac pain

Treatment Strategies:

Gait Training

• Increase to weightbearing as tolerated with B axillary crutches and normalize gait pattern. Avoid

contralateral pelvic drop.

• As tolerated decrease to single crutch and normalize gait pattern.

• Wean from crutches by 6-8 weeks as tolerated.

Manual Therapy

• Soft tissue mobilization as appropriate for quadriceps, hamstrings, TFL, gluteus medius,

iliopsoas, quadratus lumborum, lumbar paraspinals

• Joint mobilizations to lumbar spine/sacrum to address lumbosacral dysfunction as indicated

• Gr I-II hip joint mobilizations as appropriate

• Scar mobilization to portal scars as appropriate

• PROM small range hip circumduction at 70 degrees flexion

• PROM log rolls to internal rotation/external rotation

• PROM all motions within allowed ROM

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Modalities

• Cryotherapy as needed

• Electrical stimulation for pain management as needed

Therapeutic Exercise

Continue with Phase I exercises as deemed appropriate by treating physical therapist

Phase IIa Exercises, Initiate beginning week 3 as tolerated:

Quadruped Rocking

• Setup: begin on all fours, with your arms

positioned shoulder width apart and your knees

resting on a cushion.

• Movement: Slowly rock back and forth,

shifting your weight between your arms and

your legs.

• Tip: Make sure to keep your back straight and

chin tucked during the exercise. Maintain equal

weight distribution between both sides of your

body.

Hip rotations on stool IR/ER

• Setup: Begin in a standing upright position with

the knee of your affected leg resting on a

spinning stool or chair.

• Movement: Slowly turn your thigh inward so

your foot moves out to your side, then turn your

thigh outward so your foot moves in toward

your opposite leg, and repeat.

• Tip(s): Make sure to maintain an upright

posture and keep your balance during the

exercise.

Prone B hip IR

• Setup: Begin lying on your stomach.

• Movement: Bend both knees to a 90 degree

angle, tighten your abdominals, and let both of

your legs fall outward as far as you can. Bring

them back together, then repeat.

• Tip: Make sure to keep your abdominals tight

and do not let your low back arch during the

exercise

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Hook-lying Lumbar Rotation (small range)

• Setup: Begin lying on your back with your

knees bent and feet resting on the floor

• Movement: Keeping your back flat, slowly

rotate your knees slightly toward one side, then

back to the other side.

• Tip: Make sure that your back and shoulders

stay flat on the floor.

Hip ABD/ADD Isometrics Hook-lying

• Setup: Begin lying on your back with your

knees bent, a ball between your knees, and a

belt looped around your knees.

• Movement: Gently press your knees out into

the belt, hold briefly, then squeeze your knees

into the ball, and hold briefly. Continue

alternating these movements.

• Tip: Make sure to continue breathing evenly.

There should be little to no movement during

the exercise.

Hook-lying Gluteal Set

• Setup: Begin lying on your back with your

knees bent and heels on the floor.

• Movement: Tighten your buttock muscles,

digging your heels into the floor, then release

and repeat.

• Tip: Make sure to keep your low back flat on

the floor during the exercise.

Standing Knee Flexion

• Setup: Begin in a standing upright position with

your hands resting on the back of a chair in

front of you for support.

• Movement: Slowly bend your operative knee,

lifting your foot as far as possible.

• Tip: Make sure to maintain your balance, stand

up straight, and do not bend at your waist

during the exercise.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Quadruped Hip Extension Knee Slides for

Operative Leg w/TrA Activation

• Setup: Begin on all fours.

• Movement: Tighten your abdominal muscles,

pulling your navel in and up towards your spine.

Then slide the knee of your operative hip back

approximately 6 inches

• Tip: Your hips should stay level and your lower

leg should stay on the surface

Quadruped ‘Cat and Camel’ Exercise

• Setup: Begin on all fours with your arms

directly under your shoulders and knees bent 90

degrees.

• Movement: Slowly round your back up toward

the ceiling, then let it sag down to the floor

while looking up, and repeat.

• Tip: Make sure to use your entire back for the

motion and keep your movements slow and

controlled. You should not feel any pain in your

hip.

Supine Modified Thomas Stretch (operative leg

straight)

• Setup: Begin lying on your back with your legs

straight.

• Movement: Slowly lift your non-operative leg

and hug your knee toward your chest until you

feel a gentle stretch in the front of your hip of

the leg that is straight.

• Tip: Make sure to keep your abdominals

engaged and your opposite leg flat on the

surface.

Sidelying Piriformis Stretch

• Setup: Patient sidelying operative hip up, bend

knee of operative leg and support on 1-2

pillows.

• Movement: Should feel gentle stretch in gluteal

muscles without any pain or pinching in hip.

Cardiovascular Exercise:

Upright bike up to 20 minutes, 2 x per day with seat slightly elevated to minimize excessive hip

flexion, no resistance.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Phase IIb Exercises, Initiate week 4 as tolerated:

Bilateral Bridging

• Setup: Begin lying on your back with your

knees bent and feet resting flat on the floor.

• Movement: Lift up through your pelvis as you

exhale, inhale and slowly lower back down, and

repeat.

• Tip: Make sure to engage your core, maintain a

neutral spine, and keep your upper back on the

floor during the exercise.

Standing Hip Abduction

• Setup: Begin in a standing upright position

with your hands resting on a counter.

• Movement: Lift your operative leg out to the

side and back on a diagonal, then return to the

starting position and repeat.

• Tip: Make sure to keep your moving leg

straight and do not bend or rotate your trunk

during the exercise. Use the counter to help you

balance as needed

Quadruped Hip Extension for Operative Leg

• Setup: Begin on all fours with your arms under

your shoulders and knees under your hips.

• Movement: Extend your operative leg straight

back so that it is parallel with the ground and

your toes are pointing toward the floor. Hold 2-

3 seconds), then return to the starting position.

• Tip: Make sure to keep your back straight and

maintain a gentle chin tuck during the exercise.

Do not let your trunk rotate while moving your

leg.

Standing Hip Extension to Neutral

• Setup: Begin in a standing with a slightly

flexed trunk in front of a counter or stable

surface for support.

• Movement: Tighten your buttock muscles and

slowly lift your operative leg backward in a

small motion. Return to the starting position

and repeat.

• Tip: Make sure to keep your operative knee

straight and keep your shoulders and hips

facing forward during the exercise. Do not bend

forward at your hips.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Counter Plank

• Setup: Begin standing with your hands resting

on a table.

• Movement: Lean onto the table with both

hands as you keep your elbows straight and

walk your feet backward into a plank position.

Hold this position.

• Tip: Make sure to keep your back straight,

abdominals tight, and maintain a gentle chin

tuck throughout the exercise.

Single Leg Balance

• Setup: Begin in a standing upright position

with your feet together and arms resting at your

sides.

• Movement: Lift one non-operative foot off the

floor, balancing on your operative \leg.

Maintain your balance in this position.

• Tip: Try not to move your arms away from

your body or let your weight shift from side to

side.

Sidelying Clamshell in Neutral

• Setup: Begin lying on your side with your

knees bent at a 90 degree angle behind you.

• Movement: Lift your top knee upward. Hold

briefly, then slowly lower it back down and

repeat.

• Tip: Make sure not to let your hips fall

backward as you lift your leg.

Hip Internal Rotation Prone with Resistance

• Setup: Begin lying on your front with one knee

bent at a 90 degree angle and a resistance band

looped around that ankle, anchored on your

opposite side.

• Movement: Slowly rotate your bent leg

outward against the resistance, then bring it

back to the starting position and repeat.

• Tip: Make sure to keep your hips flat on the

ground during the exercise.

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Criteria for progression to the next phase:

• ROM within functional limits

• Ascend/descend 8-inch step with good pelvic control

• Good pelvic control during single-limb stance

• Normalized gait without an assistive device

• No joint inflammation, muscular irritation, or pain

• Good neuromuscular control and optimal muscle firing patterns

Phase III – Intermediate phase (week 6-12):

Goals:

• Performance of exercise program without hip pain

• Normalize hip ROM through appropriate ROM progression as outlined

• Good activation of hip musculature without evidence of muscle inhibition

• Normalized soft tissue of hip and lumbopelvic region

• Normal gait without evidence of gait deviations

Precautions:

• No extreme combined ROM (e.g. flexion/IR, flexion/ER)

• No plyometrics

• No running

• No squatting below 90 degrees

• Avoid painful ROM

• No pivoting on operative leg

• Avoid extreme combined hip ROM

• Avoid symptom provocation during ambulation, ADLs, or therapeutic exercise and avoid post-

activity soreness

• Avoid pinching in operative hip with range of motion exercises

Treatment Strategies:

Gait Training:

• Normalize gait without device.

• If patient has pain with ambulation continue to use 1 crutch and wean as tolerated.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Manual Therapy:

• Soft tissue mobilization as appropriate for quadriceps, hamstrings, TFL, gluteus medius,

piriformis, quadratus lumborum, lumbar paraspinals

• Joint mobilizations to lumbar spine/sacrum to address lumbosacral dysfunction as indicated

• Gr III-IV hip joint mobilization as needed to address joint hypomobility

• Long axis hip distraction if needed beginning at 8 weeks for labral repair

• No long axis hip distraction for first 12 weeks for labral reconstruction

• PROM small range hip circumduction at 70 degrees flexion

• PROM log rolls to external and internal rotation

• PROM all motions within allowed ROM

Modalities

• Cryotherapy as needed

• Electrical stimulation for pain management as needed

Therapeutic Exercise:

Continue with Phase I and II exercises as deemed appropriate by therapist

Sidelying Hip Abduction

• Setup: Begin lying on your non-operative side

with your bottom knee bent and your operative

knee lstraight.

• Movement: Raise your operative leg toward the

ceiling , keeping your knee straight.

• Tip: Make sure that your hips do not roll

forward or backward during the exercise.

Bridge with Alternating Leg Extension

Setup

• Setup: Begin lying on your back with your

arms resting at your sides, your knees bent, and

your feet flat on the ground.

• Movement: Tighten your abdominals and

slowly lift your hips off the floor into a bridge

position. Keeping your trunk stiff, straighten

your operative knee and hold.

• Tip: Make sure to maintain your balance during

the exercise and do not let your hips fall

towards the ground.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Side Plank- modified (knees/forearm)

• Setup: Begin lying on yourwith your knees

bent, propped up on your forearm. Your elbow

should be directly under your shoulder.

• Movement: Engage your abdominal muscles

and raise your hips up into a side plank position,

keeping your knees on the ground. Hold this

position, then return to the starting position and

repeat on opposite side

• Tip: Make sure to keep your core engaged

during the exercise. Do not hold your breath or

let your hips roll forward, backward, or drop

towards the floor.

Modified Plank (knees/forearms)

• Setup: Begin lying on your stomach with your

elbows on the ground.

• Movement: Press yourself up into a plank

position, keeping your knees on the ground.

Return to the starting position and repeat.

• Tip: Make sure to keep your back straight in the

plank and look straight down between your

hands during the exercise.

Quadruped Alternating Leg Extension (progress

to opposite arm/leg as tolerated)

• Setup: Begin on all fours with your arms under

your shoulders and knees under your hips.

• Movement: Extend your operative leg straight

back so that it is parallel with the ground and

your toes are pointing toward the floor. Hold

briefly, then return to the starting position and

repeat with the opposite leg.

• Tip: Make sure to keep your back straight and

maintain a gentle chin tuck during the exercise.

Do not let your trunk rotate while moving your

leg

Partial Range Squats (gradually increase to 90

degree squats)

• Setup: Begin in a standing upright position,

with your feet slightly wider than shoulder

width apart.

• Movement: Bend your knees and hips into a

mini squat position, then straighten your legs

and repeat.

• Tip: Make sure to keep your back straight and

do not let your knees bend forward past your

toes.

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Prone Hip Extension

Setup

• Setup: Begin lying on your stomach with your

forehead resting on a towel roll. Position a

pillow under your lower abdomen and hips.

• Movement: Slowly lift your operative leg,

hold, then return to the starting position and

repeat with opposite leg

• Tip: Make sure to keep your leg straight and

focus on engaging your buttock muscles during

the exercise. Do not let your back arch or your

hips rotate side to side.

Single Leg Forward Weight Shifts (progressing

to Romanian dead lift)

• Setup: Begin in a standing position balancing

on your operative leg with your hands resting

on your waist.

• Movement: Lean forward by bending at your

hips and knee.

• Tip: Make sure to keep your back straight and

chin tucked

Lateral Band Walk

• Setup: Begin standing upright with a resistance

band looped around your thighs, just above your

knees. Bend your knees slightly so you are in a

mini squat position.

• Movement: Slowly step sideways, maintaining

tension in the band.

• Tip: Make sure to keep your feet pointing

straight forward and do not let your knees

collapse inward during the exercise.

Backwards Monster Walk With Band

• Setup: Begin in a standing upright position with

a resistance band looped around your ankles.

• Movement: Slightly bend your knees into a

mini squat position. Step diagonally backward

with one foot, then slowly bring your feet

together. Repeat in the opposite direction.

• Tip: Make sure to keep your chest upright and

do not bend your knees forward past your toes.

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Banded Hip Clamshell

• Setup: Begin by lying on your non-operative

side with your knees bent 90 degrees, hips and

shoulders stacked, and a resistance loop secured

around your legs.

• Movement: Raise your operative knee away

from the bottom one, then slowly return to the

starting position.

• Tip: Make sure not to roll your hips forward or

backward during the exercise.

Single Leg Balance with Clock Taps

• Setup: Begin in a standing upright position.

Imagine you are standing in the middle of a

clock.

• Movement: Bend your legs slightly, then reach

forward with non-operative(?) foot toward 12

o'clock, then bring it back to the starting

position and reach toward 3 or 9 o'clock.

Continue, reaching toward 6 o'clock, and repeat.

• Tip: Make sure to keep your hips level as you

reach with your leg, and do not let your

standing knee collapse inward

Single Leg Balance with Hip ABD and Band

Resistance

• Setup: Begin in a standing upright position,

holding onto a chair for support, with a

resistance loop around your ankles.

• Movement: Lift your operative leg off the

ground and pulse leg a small mount straight out

to your side. Continue this motion this motion

without letting your foot touch the ground.

• Tip: Make sure to keep your abdominals tight

and hips level during the exercise.

Single Leg Balance with Hip Ext and Band

Resistance

• Setup: Begin in a standing upright position,

holding onto a chair for support, with a

resistance loop around your ankles.

• Movement: Lift your operative leg off the

ground and move it straight backward a small

motion. Continue this pulsing the leg without

letting your foot touch the ground.

• Tip(s): Make sure to keep your abdominals

tight and hips level during the exercise.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Paloff Press

• Setup: Begin in a standing upright position

holding a resistance band in both hands that is

anchored at your side.

• Movement: Press your arms straight forward.

Hold briefly, then bring your arms back in and

repeat. Repeat for opposite side.

• Tip(s): Do not allow trunk to rotate

Standing IT Band Stretch

• Setup: Begin in a standing upright position with

one leg crossed over the other.

• Movement: Move the hip of your operative leg

to be stretched out to the side and reach your

arm overhead to the opposite side. Repeat on

opposite side.

• Tip: Make sure to avoid twisting or rotating

your body during the exercise.

Lower extremity stretching as indicated by patient impairments.

Cardiovascular Exercise:

• Upright stationary bicycle: gradually increase time and resistance as tolerated

• Elliptical training: pedaling forward and backward if pain-free, gradually increase time and

resistance as tolerated

• Swimming: initiate flutter kick as tolerated, avoid frog kicking

Criteria for progression to the next phase:

• ROM within normal limits pain-free

• Alternate Ascend/Descend 8-inch step with good pelvic control no UE support

• Good pelvic control during single-limb stance and dynamic balance

• Normalized gait pain-free without an assistive device

• No Pain at rest, ADL/IADL nor walking

• Strength of operative hip 75% of contralateral hip

• No joint inflammation, muscular irritation, or pain

• Good neuromuscular control and optimal muscle firing patterns

Phase IV – Advanced strengthening phase (week 12-16):

Goals:

• Independent home exercise program

• Optimize ROM

• >=4/5 LE strength, >=4/5 trunk strength

• Improved dynamic balance

• Pain-free ADL

• Pain-free hip flexion with ADLs and functional mobility

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Precautions:

• No extreme combined ROM (e.g. flexion/IR, flexion/ER)

• No plyometrics

• No running

• No squatting below 90 degrees

• Avoid painful ROM

• Avoid extreme combined hip ROM

• No symptom provocation during ambulation, ADLs, or therapeutic exercise

• Avoid pinching in operative hip with range of motion exercises

Treatment Strategies:

Manual Therapy:

• Soft tissue mobilization as appropriate for quadriceps, hamstrings, TFL, gluteus medius,

piriformis, quadratus lumborum, lumbar paraspinals

• Joint mobilizations to lumbar spine/sacrum to address lumbosacral dysfunction as

indicated

• Gr III-IV hip joint mobilization as needed to address joint hypomobility

• Long axis hip distraction if needed beginning at 8 weeks for labral repair

• Long axis hip distraction if needed beginning at 12 week for labral reconstruction

Modalities

• Cryotherapy as needed

• Electrical stimulation for pain management as needed

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Therapeutic Exercise:

Progressive LE and core exercises-

progress exercises from prior phases by

increasing challenge and resistance

Advanced balance exercises as

appropriate for sport or desired recreation

Sport specific plyometrics and agility

exercises as appropriate

Progress core strengthening as deemed

appropriate by therapist

Cardiovascular Exercise:

• Upright stationary bicycle: gradually increase time and resistance as tolerated

• Elliptical training: pedaling forward and backward if pain-free, gradually increase time and

resistance as tolerated

• Swimming: initiate flutter kick as tolerated, avoid frog kicking

Criteria for progression to the next phase:

• Y Balance Test Limb symmetry index 80% of uninvolved side

• Strength of operative hip 90% of uninvolved side

• Perform progressed exercise program without pain

• No joint inflammation, muscular irritation, or pain

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Phase V – Return to activity phase (week 16+):

Please note: Individuals who do not engage in higher level activities may not need to progress to

advanced and sport specific activities.

Goals:

• Progress to sport specific training without pain

• Progress to jogging pain free when cleared by surgeon

• Independent home exercise program

• Optimize ROM

• 5/5 LE strength, >=4/5 trunk strength

• Normal Muscle Length of B LE

• Good, dynamic unilateral balance of operative extremity

• Pain-free with all activities

Precautions:

• Avoid pain in hip joint with functional activities or exercises

• If post-exercise joint pain or limping occurs, activity level should be decreased

• Avoid joint inflammation

• Focus on quality of movement and exercise

Treatment Strategies:

Manual Therapy:

• Soft tissue mobilization as appropriate for quadriceps, hamstrings, TFL, gluteus medius,

piriformis, quadratus lumborum, lumbar paraspinals

• Joint mobilizations to lumbar spine/sacrum to address lumbosacral dysfunction as

indicated

• Gr III-IV hip joint mobilization as needed to address joint hypomobility

• Long axis hip distraction as needed for labral repair or reconstruction

Modalities

• Cryotherapy as needed

• Electrical stimulation for pain management as needed

Therapeutic Exercises:

Progress strength, proprioception, dynamic balance, agility, and power to address sport specific

demands. Sport specific retraining as tolerated.

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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Cardiovascular Exercise:

• Upright stationary bicycle: gradually increase time and resistance as tolerated

• Elliptical training: pedaling forward and backward if pain-free, gradually increase time

and resistance as tolerated

• Swimming: gradually progress time and swimming strokes at tolerated

• Jogging: initiate at 16-18 weeks as indicated by referring surgeon and patient status

Outcome Measures:

• Hip Outcome Score (HOS) has been validated in the hip arthroscopy population and is an

appropriate outcome measure. (Enseki)

• If unavailable Lower Extremity Functional Scale (LEFS) may be used.

Criteria for discharge from skilled therapy:

• Cross over triple hop for distance 90% of uninvolved side

• Y Balance Test Limb symmetry index 80% of uninvolved side

• Patient able to jog 30 minutes

• Patient able to perform sport specific drills without pain

• Good neuromuscular control and optimal muscle firing patterns

Arthroscopic Hip Surgery for Femoroacetabular Impingement

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This protocol has been written utilizing the available literature, clinical experience of physical

therapists, and surgeon experience and preference. The Department of Rehabilitation Services at

Brigham & Women’s Hospital has accepted this protocol as our standard protocol for the

management of patients following arthroscopic hip surgery for femoroacetabular impingement.

If you have any questions regarding this protocol, please contact:

Dawn Rogers-Hyde, PT, OCS

[email protected]

or

Clare Safran-Norton, PT, PhD, OCS

[email protected]

If you have any concerns regarding your patient, please contact:

Richard M. Wilk, MD, FAAOS

Chief, Hip Preservation Service

Sports Medicine, Shoulder & Knee Surgery

Brigham and Women’s Hospital

Clinical Instructor

Harvard Medical School

Office: 617-732-5352 | Mobile: 781-504-9191

[email protected]u

brighamandwomens.org

Authors: Reviewers:

Dawn Rogers-Hyde, PT, OCS Richard M. Wilk, MD, FAAOS

Clare Safran-Norton, PT, PhD, OCS Madhuri Kale, PT, OCS

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References

1. Dippmann, C., Thorborg, K., Kraemer, O., Winge, S., Palm, H., & Hölmich, P. (2014). Hip

arthroscopy with labral repair for femoroacetabular impingement: short-term outcomes. Knee Surgery,

Sports Traumatology, Arthroscopy, 22(4), 744-749.

2. Kuhns, B. D., Weber, A. E., Batko, B., Nho, S. J., & Stegemann, C. (2017). A four-phase physical

therapy regimen for returning athletes to sport following hip arthroscopy for femoroacetabular

impingement with routine capsular closure. International journal of sports physical therapy, 12(4), 683.

3. Heerey, J., Risberg, M. A., Magnus, J., Moksnes, H., Ødegaard, T., Crossley, K., & Kemp, J. L.

(2018). Impairment-based rehabilitation following hip arthroscopy: postoperative protocol for the HIP

ARThroscopy International Randomized Controlled Trial. journal of orthopaedic & sports physical

therapy, 48(4), 336-342.

4. Willimon, S. C., Briggs, K. K., & Philippon, M. J. (2014). Intra-articular adhesions following hip

arthroscopy: a risk factor analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 22(4), 822-825.

5. Enseki, K. R., & Kohlrieser, D. (2014). Rehabilitation following hip arthroscopy: an evolving

process. International journal of sports physical therapy, 9(6), 765.

6. Enseki, K. R., Martin, R., & Kelly, B. T. (2010). Rehabilitation after arthroscopic decompression for

femoroacetabular impingement. Clinics in sports medicine, 29(2), 247-255.