Rehabilitation following Hip arthroscopy Prof. Ernest Schilders
Leeds Metropolitan University Bradford Teaching Hospitals
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Hip arthroscopy Rehab Start Which procedure? Operative Findings
Return to sport? Type of sport Fitness Type of procedure Progress
of the rehab Patient orientated Use assessment criteria Pain
Orginal pain Procedure specific Rehab related
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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.
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Incidence of pathology in athletes n=120
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Incidence of intraarticular pathology
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Type of articular cartilage lesion
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Femoroacetabular Impingement simpleDiagnostic, Removal loose
body Labral debridement Ligamentum Teres debridement
IntermediateCAM decompression Iliotibial band release Iliopsoas
release complexAcetabular rim trimming + labral repair + CAM
decompression Microfracture (prolonged crutches) Very
complexAcetabular rim trimming+ labral repair+ CAM decompression +
capsular plication
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Procedures in athletes
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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)
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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.
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20y old professional football player CE angle= 20 vertical
sloping weightbearing surface. Perthes disease Generalized
hyperlaxity
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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.
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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.
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Other considerations Use realistic timescales (Always err on
the side of caution). Use common sense, as injured patients/players
will progress at different rates.
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Frank Gilroy Post surgical general rehabilitation ladder
Timescales depend on consultant involved Regain full ROM Increased
strengthening and proprioception MEDIUM STRESS Pre-op preparation
Surgery Regain ROM Early strengthening LOW STRESS Increased
shearing activities, agility, sports specific rehab Advanced
strengthening and proprioception HIGH STRESS
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8-12 week ladder Timescales depend on consultant involved Phase
3 Straight line running, strengthening exercises, increased pool
work and full stretches MEDIUM STRESS Pre-op preparation Surgery
Phase 1 Gentle walking and light stretching LOW STRESS Playing
again! Phase 4 Short sprints and shuttle runs, increasing core
stability work. Gradual return to sports specific training HIGH
STRESS Phase 2 Jogging 20-30 minutes, light stretching and pool
exercises
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Week 1 Ankle pumps
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Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip
abduction
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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
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Week 1 Ankle pumps, Isometrics Gluteal, Quads, Trans Abs, Hip
abduction Stationary bike start 20 mins x 2 daily
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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.
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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)
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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
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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.
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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.
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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
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.
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Week 2 Week 1 exercises (including) Quadruped rocking Standing
Hip IR
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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.
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Internal rotation strengthening with thera bands Start
positionFinishing position
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Week 2 Week 1 exercises (including) Quadruped rocking Standing
Hip IR Heel slides with/without strap Cons r/v
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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
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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.
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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
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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)
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Weeks 7+ Week 1-2 exercises can be stopped Cont with weeks 3-4
and 5-6 Increase hydrotherapy exercises (squats, step ups/downs, -
lunges. Running progress from straight line to multi-directional
Sports specific
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Advanced hydrotherapy
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Advanced hydrotherapie
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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?
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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
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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.
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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
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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.
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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.
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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
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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
Slide 53
Modified Harris Hip score Preoperatively39-96 2 months
postop58-100 6 months postop74-100 Minimum of 12 months
postop.70-100
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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
Sports test M Philippon Scoring criteriasubsets Time20-30
seconds Endurance Form Pain Total1 point Passed > or = 17 points
Failed < 17 points
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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.
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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.
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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.
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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.
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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
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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.
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Return to sports following impingement surgery Soccer2-4 month
Rugby2-3 month Basket ball5 month Hockey3-4 month Dance 3 month
Martial arts3 month Tennis2 month sports involving twisting and
turning
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Return to sports following impingement surgery Golf2-3month
Cycling6week-2 month Running2 month Rowing2 month Rockclimbing3
month Sports not involving twisting and turning
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Hip arthroscopy Rehab Start Which procedure? Operative Findings
Return to sport? Type of sport Fitness Type of procedure Progress
of the rehab Patient orientated Use assessment criteria Pain
Orginal pain Procedure specific Rehab related