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Exploring Advances In THA

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Rehabilitation of Total Hip Arthroplasty and Arthroscopy patients.

Rehabilitation of Total Hip Arthroplasty and Arthroscopy patients.

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  • We are in private practice, we are not owned by a hospital or any physicians. I want to try and take back our profession – when you work for yourself you have to become a better clinician. Look at the work that has come from Austrailia – Diane Lee, Maitland, McConnell, Jim MeadowsIt is my goal today to make you a better clinician, and I challenge you to use that knowledge to reclaim our profession.
  • The health care bill just passed. I got up the next morning and log on to APTA web site to gain more information. I also get emails from the OPTA listserve. APTA members – this is my other soap box today, if you are not a member you need to join. The APTA is fighting for our rights. You need to get active in the OPTA, the PAC. Things are changing and you can either get involved and fight for your profession or your profession may drastically change.
  • Research – read your journals. CE courses – Clinical Expertise – clinical skill and formulated educationWhen I graduated, we tried to selective isolate the VMO for improving patellar mechanics – the literature has proven this ineffective.
  • Increaseing at a rate of 10% a year.
  • Sensitivity was 86% and specificity was 75% with a LR+ of 3.44
  • This was a low friction arthroplasty. Smaller femoral head 7/8 inch which has a decreased wear rate. However, it had a poor stability. This prosetesis used cement.Stems are typically made of titanium alloys or chrome cobalt – very strong and most biocompatible. New heads are ceramic or cobalt-chromium alloy.
  • FDA issued a warning. Recalled ceramic hip parts.
  • Most patients are diagnosed with snapping hip or psoas muscle strain or bursitis
  • This is a non-specific test – internal hip pathology (intra-capsular).
  • Feel end-feel. Should be capsular, not empty or painful.
  • Used to assess FAI – exactally like the shoulder impingement test. Same ball and socket joint. Always test this prior to having a patient stretch the piriformis muscle
  • Mitchell et all reported that the presence of hip pain during the FABER test was 88% sensitive for intra-articular hip pathology.
  • JOSPT July 2006
  • College of Rheumatology has criteria – so why did Childs develop a CPR?
  • X-ray will show joint space narrowing, osteophytes.
  • Do the exercise. How to correctly stretch the psoas.
  • Surgical approach used is one of the main determinates to rehabilitation. The posterior lateral approach is the most common, although as new techniques of minimally invasive THA are evolving, the anterior-lateral approach is becoming more common for younger, active patients.Posterior lateral approach – cuts posterior capsule and gluteus maximus – posterior dislocation.Anterior-lateral approach involves take-down of the gluteus medius, which can limit post-op weight bearing.
  • Surgery done in Europe for over 17 years. Birmingham Hip Resurfacing device was approved by the FDA in May 2006
  • Fracture rate at about 4% compared to 1% in THA. Have preserved the bone in the femur.
  • 2009 returned to cycling after his ban and finished 17th overall in the Tour of New Zeland.
  • FDA approved in 1997 – hyaluronan acid – extracellular matrix, contributes to cell proliferation.Molicular goo. Syovial fluid – increase the viscosity. Lubrication. Using in wound healing.

Transcript

  • 1. Total Hip Rehabilitation:The latest advances
  • 2. Bridgit Finley, PT, DPT, M.Ed., OCSBoard Certified in Orthopaedicsbfinley@ptcentral.orgwww.ptcentral.orgFacebook
  • 3. Physical Therapy Central
    Choctaw Chickasha Newcastle Norman
    OKC Pauls Valley Stillwater
  • 4. Objectives
    Course Objective:
    The course participants will be able to:
    Understand the surgical procedures and contraindications with specific exercises.
    Describe normal biomechanics for the hip joint.
    Implement the use of outcome measures for patient’s that have had hip surgery.
    Utilize the internet to access information in regards to evidence based practice.
    Effectively progress patients through the rehabilitation protocol.
  • 5. Course Schedule
    Evidence Based Practice
    Anatomy
    Biomechanics
    Hip O-A & Surgery
    Manual Therapy
    Therapeutic Exercises
    Outcome Measures
  • 6. Vision 2020 The first, best choice in musculoskeletal care.
    Resources
    APTA
    JOSPT
    Physiopedia
    Evidence in Motion
    AAOMPT
    PEDro
    NAIOMT
    Life Long Learners
    Patient Access
    Autonomous
    Experts
    Take our game to the next level
    Specialty Certifications
    Manual Therapy Certifications
    DPT
  • 7. Evidence Based Practice
    Integration of the best research evidence with clinical expertise and patient values.
    Levels of Evidence
    Systematic Reviews
    Case Series
    Expert Opinion
  • 8. American Physical Therapy Association
    Consumers
    Professional Development
    Advocacy
    Reimbursement
    Learning Center
    Hooked on Evidence
    Database current research
    Earn CEU’s
  • 9. JOSPT
    Journal of Orthopaedic & Sports Physical Therapy
    Searched
    Hip Arthritis
    20 Abstracts
    Full Text Articles
  • 10. NAJSPT
    Sports Physical Therapy Section
    Hip Arthritis
    North American Journal of Sports Physical Therapy
  • 11. Overview of the Hip
  • 12. OSTEOARTHRITIS
    In US, 100 Billion Health Care $ by 2020
    Progressive loss of articular cartilage with variable subchondral bone loss.
    Prevalence – 10 to 25% in adults age 55 and older.
    43 Million people in US
    Standard of care is THA
  • 13. Total Hip Arthroplasty
    The most common surgical procedure for end-stage hip osteoarthritis.
    Primary reason for surgery is pain which interferes with ambulation.
  • 14. American College of Rheumatology
    Classification Hip OA
    Cluster 1
    Pain in the hip
    < 115 hip flexion
    < 15 IR
    Cluster 2
    Pain with IR
    < 60 minutes morning stiffness
    > 50 yrs. old
    Current guidelines focus on pharmacological and surgical management
  • 15. X-Ray
    Demonstrate loss of joint space, osteophytes and sclerosis.
    Dysplasia
    tears are more common in individuals with acetabular dysplasia.
  • 16. In US, between 1990 and 2002, THA rose from 119,000 to 193,000 annually.
    62% increase
    600,000
    THA Procedures Performed Annually
  • 17. Total Hip Arthroplasty
    The first joint replacement, a total hip arthroplasty, was performed in 1936.
    Most widely performed orthopedic procedure performed on adults.
    In 2008, the average hospital and physician charge for a THA totaled $ 45,000.
  • 18. Prosthesis
    Materials
    Glass
    Pyrex
    Ivory
    Plastics
    Dr. Charnley in 1960 developed a low friction
    All new designs are adapted from his design.
  • 19. Artificial Joint
    Titanium hip prosthesis
    Ceramic head
    Polyethylene acetabular cup
  • 20. Zimmer
  • 21. Health Care Costs
    Physical Therapy
    12 visits
    Manual Therapy and exercise
    $1,200
    THR
    $45,000
    Surgery, hospitalization and rehabilitation
  • 22. Risks and Complications
    Medical Risks
    Heart Attack
    Stroke
    Venous Thromboembolism 1%
    Pneumonia
    UTI
    Infection 0.2 – 1%
    Intra-operative
    Mal-positioning
    Short/Long 1%
    Instability
    Loss of ROM
    Fracture 2-5%
    Nerve Damage 1%
    Dislocation 4-10%
  • 23. Long Term Risks
    Osteolysis
    Loosening of the components
    Cement breaks down
    Wear debris
    Inflammatory
    Pain
    Polyethylene wear rate is 0.3mm year
    Wear debris
    Body will absorb the metal
  • 24. Osteolysis
    Cascade starts from particles
    The body creates an inflammatory response.
    Re-absorbs the bone.
    12 months
  • 25. A Squeaking hip ?
    Stryker
    Highly durable ceramic hips in 2003.
    7% of patients from 2003-2005 developed squeaking
    Squeaky Walk
  • 26. Trendelenburg
    (+) for weakness in Abductor muscles
    Tendinous avulsion
    Sonography used to diagnosis
    Test
    Gait
  • 27. Glut Medius controls Adductor Moment
    Hip Abductor function in closed chain is to maintain a level pelvis.
  • 28. Trendelenburg Gait
    Have patient stand on one leg and assess if the pelvis drops.
    (+) Trendelenburg Sign
  • 29. Subjective History
    DJD (> 50)
    Usually no specific mechanism of injury
    Groin pain; behind greater trochanter, anterior thigh to knee
    Stiffness in the morning
    Loss of ROM (Flexion, IR)
    Increased pain with WB (bony)
  • 30. Functional Limitations
    Walking
    Stair climbing
    Putting on shoes
    Shaving legs
    Rising from a chair
  • 31. Causes of Hip OA
    Congenital Dysplasia
    Genetics
    Disease Process
    Trauma
    Compensation
    Leg length, lumbar pathology
  • 32. X-Ray
    Gold Standard
    Joint Space Narrowing
    Osteophytes
    Subchondral Bony Change
  • 33. Femoroacetabular Impingement (FAI)
    Contact between the femoral head-neck junction and the acetabular rim.
    Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.
  • 34. Precursor to early hip O-A
    Acetabular labral pathology secondary to femoroacetabular impingement (FAI)
    Acetabular labral pathology is frequently present in highly active individuals 20-40 yo.
    Gradual on-set with repetitive microtrauma.
  • 35. Diagnosis of FAI
    Scour Test
    FADIR – anterior-superior labrum
    EABDER – posterior-inferior labrum
    Log Roll Test
  • 36. Scour Test
    The examiner moves the patient’s hip through a range of motion from hip flexion and adduction to hip extension and abduction, while adding a compressive force through the hip joint as well as movement into hip internal and external rotation. The test is considered positive if there is a reproduction in hip pain and/or intraarticular joint clicking.
  • 37. Log Roll Test
    The examiner passively moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B).
    Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity
  • 38. Impingement Test
    The examiner passively moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation.
    A positive test is reflected by increased hip or groin pain.
  • 39. FABER Test
    The examiner passively positions the testing limb in a position of hip flexion, abduction, and external rotation.
    The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table.
    A decrease in this distance or pain, when compared to the uninvolved side, is
    suggestive of intra-articular hip pathology.
  • 40. Hip Impingement
  • 41. Hip Special Tests
    Martin et al
    JOSPT July 2006
    Intra-articular Tests
    FABER Test
    Scour Test
    Resisted SLR
    Log Roll Test
    Distraction
    FAI
  • 42. Hip Arthroscopy
  • 43. Recent Developments
  • 44. Clinical Prediction RuleChilds September 2008
    Loss of IR
    < 15 degrees
    Loss of Flexion
    < 115 degrees
    (+) Scour Test
    (+) FABER Test
    (+) Hip Flexion Test
    Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA.
    A clinical prediction rule consisting of 5 examination variables was identified.
    If at least 4 of 5 variables were present, the positive LR was equal to 24.3
    95% confidence interval: 4.4-142.1, increasing the probability of hip OA to 91%.
  • 45. Diagnosis Hip O-A
    Made with certainty on the basis of history and physical exam.
    X-ray is definitive
    CPR – Child’s et al.
    Hip Guidelines – Cibukla
    Physiopedia
  • 46. 1975 Management THA
    Phase I – immobilization. If unstable will use hip spica cast x 3 weeks. (2-5 days)
    Phase II – mobilization. Isometric, isotonic (AAROM, AROM). Trochanter detached and transplanted distally. 2-3 week and D/C to home. Crutches x 8 weeks. Walk day 7 - WBAT
    ROM goals
    Flexion 90, ER 15, Abd 15, IR 0, Add 0
  • 47. 2010 THA Management
    Hospital 1-3 days/Out-patient
    Ambulate day 1 – FWB
    AROM day 1
    Isotonic week 1
    C-V by day 10
    ROM goals
    Flexion 125, Add. 30, ER 50, IR 30 by week 12
  • 48.
  • 49. Muscles
  • 50. Gluteus Medius
    Gluteus Medius – main hip abductor
    Primary stabilizer of hip and pelvis
    Trendelenburg sign
  • 51. Gluteus Maximus
    TFL envelops the muscles of the thigh
    Counteracts the backward pull of the gluteus maximums of the ITB.
    Hip extensors are 3 times as strong as the flexors
  • 52. Psoas
    Iliopsoas bursa – present in 98% of adults.
    Lies under the psoas tendon
    Overuse and impingement syndromes
  • 53. SLR Exercises
    Must have excellent core strength
    This is a core exercise,
    If neutral pelvis is not maintained
  • 54. Hip External Rotators
    Hip capsule is cut and the ER are retracted so that the joint can be exposed.
    THA – now most repair the capsule
  • 55. Surgical Incisions
  • 56. Journal of Orthopedic Surgery
    Chung, et al.
    Smaller incision
    Operating time
    Blood loss
    Narcotic use
    Length of Stay
    Assistive device
    Harris Hip Score
    2004
    9.2 20
    49 55
    136 200
    2.2 2.64
    4.4 5.4
    21 25
    95 93
  • 57. Metal-on-Metal Hip Resurfacing Arthroplasty
  • 58. Resurfacing
    Main advantage is bone conservation for younger patients
    Early resurfacing failed because of polyethylene
    5 year follow-up excellent results
    Complication
    Femoral neck fracture
    Osteonecrosis
  • 59. High Failure Rate
    1970, materials available at the time had insufficient wear resistance
    Incorrect patient selection
    1999, re-introduced
    Same revision rate as THA at 4 years
    Women 2 x than men
    1-3%
  • 60. Design
    Metal on Metal
    Cause release of inflammatory cytokines
    Metal allergy
    Large ball – decrease wear rate
    Cemented
    THA - Cementless acetabular fixation – bony in growth
  • 61. Patient Selection
    Young and active
    Isolated hip disease
    Excellent bone quality
    Normal kidney function
    Contra-indicated
    Severe acetabular dysplasia
    Obesity
  • 62. Surgery
    High learning curve
    Posterior approach
    Capsulotomy – preserve lateral muscles but sacrifice medial circumflex artery
    Implant positioning
    Limited candidates
  • 63. Outcomes
    94-99% survival rates at 5 years
    446 hips, patients < 55 yrs old
    Primary diagnosis of OA
    No difference in ROM
    Gait analysis – no difference THA
    Hip impingement
  • 64. Birmingham Hip Resurfacing
  • 65. Traditional THA
  • 66. Floyd Landis
    Won the Tour de France in 2006
    Stripped of his title
    Road with Lance 2002-2004
    Osteonecrosis – crash in 2002
    Sept 2006 Surgery
  • 67. Tour de France
  • 68. Birmingham Hip Resurfacing
    Part 1
    Part 2
    Part 3
    Part 4
    Part 5
  • 69. Rehabilitation Considerations
    Surgical Approach
    Selection of appropriate hip precautions
    Cemented vs. non-cemented
    Weight bearing precautions
    Early mobilization (prevent DVT)
    Early rehab can improve short term outcomes.
  • 70. Bioengineering
  • 71. Viscosupplementation
    Injection of artificial lubricants into the joint.
    Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymaltem cells.
  • 72. Biomechanics
  • 73. Hip Dysplasia
    Displacement of femoral head in acetabulum
    Left hip is more often involved
    80 % Females
    Breech birth
    First born
  • 74. Hip Dysplasia
    Less degress of femoral head coverage
    Decreased joint surface area
    Normal 30-40%
    Angle of inclination >125 degrees
    Increased femoral anterversion
    Acetabular retroversion
    McCarthy & Lee found 72% of patients with dysplasia had labral tears
  • 75. Ball and Socket Joint
    Flexion to 110-120
    Extension 10-15
    Abduction 30-50
    Adduction 25-30
    ER 30-45
    IR 20-35
    Rolls anterior glides posterior
    Rolls posterior glides anterior
    Rolls laterally
    Rolls medially
    Spins anteriorly and laterally
    Spins posteriorly and medially
  • 76. Mobilization
    Flexion
    Extension
    Adduction
    Internal Rotation
    Posterior / Inferior Glide
    Anterior Glide
    Lateral Glide
    Lateral Glide
  • 77. Distraction
    General joint mobility
    Can be diagnostic
    Gentle let off
    Place in open packed position
    Don’t grab ankle
  • 78. Posterior
    Gain
    Flexion
    Adduction
    Be careful not to create impingement
  • 79. Exercise
    Posterior Mobilization
    Psoas & TFL Release
    Follow with psoas stretch
  • 80. Psoas Stretch
    Avoid lumbar extension
    Have patient posterior pelvic tile
    Can flex or extend the knee
  • 81. Lateral Mobilization
    Gain
    Adduction
    Internal Rotation
  • 82. Lateral Mobilization
    To gain adduction
    Can also work on ER
  • 83. Lateral Mobilization
    Patient self mob
    Must stretch lateral structures
    ITB
    Don’t let hip IR
  • 84. Inferior Mobilization
    Excellent technique to use with hip impingement
    Test – re-test
  • 85. Caudal/Inferior Mobilization
    Mulligan technique – mobilization with movement.
    Measure flexion or IR and mobilize and re-measure
  • 86. Anterior Mobilization
    Assess gait
    Pelvic wink
    To gain extension and external rotation
    Stress the anterior labrum
    If had labral repair
  • 87. Anterior Mobilization
    Mobilize anterior capsule
    Self stretch and exercises – army crawl
  • 88. Anterior Self Stretch
    Kneeling Mobilization
    Psoas and TFL stretching
  • 89. Cyriax
    Capsular pattern – specific and proportional loss of movement
    Most common cause of capsular pattern is arthritis
  • 90. Capsular Pattern
    Cyriax
    IR
    Flexion
    Abduction
    If capsular pattern of restriction; joint is arthritic.
    If non capsular pattern; not joint.
    Cyriax listed in ascending order
    Loss of internal rotation
    More than flexion
    More than abduction
  • 91. Noncapsular Restrictions
    Fractures
    Osteomiylitis
    Labral tears
    Cancer
    Bursitis
    Capsular Irritation
    Synovitis
    Impingement
  • 92. Resting Closed Packed
    Flexion 30 degrees
    Abduction 30 degrees
    External Rotation 10-15 degrees
    Extension
    Adduction
    Internal Rotation
    Stable position of the joint
    Tighten capsule
  • 93. Muscle Imbalances
    Tightness
    Psoas
    Adductors
    Quadratus Lumborum
    TFL
    Piriformis
    Weakness
    Glut Maximus
    Glut Medius
    Quads
    Hip ER
    Core Muslces
    Abs
    Errector spinae
  • 94. FACILITATED MUSCLES
    Iliopsoas
    Rectus Femoris
    TFL
    QL
    Hip Adductors
    Piriformis
    Hamstring
    Lumbar Erector Spinae
  • 95. Medial Hip Mobilization
    Makofsky, et al.
    Journal of Manual and Manipulative Therapy 2007
    Increase in abductor muscle force
    Prior to exercise
  • 96. Abductor Strength
  • 97. Outcome
    Measures
  • 98. Lower Extremity Function Scale
    Ordinal Scale 0 “extreme difficulty” to 4 “no difficulty”
    Patient rate ability to perform 20 different activities
    0 to 80 scale, 80 no limitations.
    Minimum detectable change 9 scale points
  • 99. Harris Hip Score
    Scores on 10 different variables
    Pain
    ROM
    Gait
    ADLs
    Score range from 0 “worst” to 100 “best”.
    Harris Hip Score
  • 100. Hip Outcomes Measures
    Validity
    Reliability
    Includes
    Pain
    ROM
    Function
    Surgeon & Patient disagree on outcomes
    Harris Hip Score
    Charnley Score
    Oxford Hip Score
    The Hip Disability and Osteoarthritis Outcome Score
  • 101. Patient Based Scales
    Site Specific
    Oxford Hip Scale
    Health Status
    Designed for RA
    20 Tasks
    SF-12
    Disease-Specific
    Hip & Knee OA
    WOMAC
    Oxford
    12 item questionnaire
    THR
    Validated against SF-36
    Short, practical and valid
  • 102. Activity Limitation
    6 Minute Walk Test
    How far a person can walk in 6 minutes.
    Can use walking aids.
    Treadmill is good.
    Stair Measure
    Patients are instructed to ascend and descend 9 stairs (step height 20cm)
    Timed measure in seconds
  • 103. Rehabilitation Protocol
    Age
    Health Status
    Control pain and swelling
    Body Weight
    Body Build -
  • 104. Week 2-3
    Goals
    Patient Education
    Decrease Edema
    Incision Healing
    Independent HEP
    ROM: flexion 90, abduction 35, ER 35, IR 20, adduction 20
  • 105. Treatment
    Modalities
    MFR/ Massage
    PROM
    Transfer and gait training
    Rhythmic Stabilization
    MET / Manual Stretching
  • 106. Modalities
    US
    At incision and piriformis/ITB
    NMS
    Glut Medius with isometric ABD.
    IFC & CP
    Control swelling and pain
    At the end of treatment
  • 107. Manual Therapy
    MFR
    ITB
    Piriformis
    Psoas
  • 108. Hip PROM
    Watch for compensation at the pelvis.
    Capsular pattern?
    End-feel?
    Pain?
  • 109. PROM
  • 110. Hip Rotation
    PROM of left hip
    Loss of IR > loss of hip ER
    End-feel usually empty and painful.
  • 111. MET – manual stretching
    Soft tissue and capsular tightness
    Have not moved hip though this motion in years
  • 112. Gait
    Hip extension
    15-20 degrees
    Pelvic
    Rotation
    Side bending
    Most patients will have LBP
  • 113. Rhythmic Stabilization
    Neutral Position
    Manual resistance in ER and IR
  • 114. Muscle Energy Technique
    Hamstrings
    Psoas
    Lumbar Spine
  • 115. Hamstring Stretch
    Lumabr spine is protected
    Increase stretch with APT
    Contract quads will inhibit hamstrings
  • 116. Exercises
    Exercise Pro Handout Week 2-3
  • 117. Week 5-6
    Hip Flexion 100-110, add. 40, ER 40, IR 30
    Quad/Ham strength 70%
    (-) Trendelenburg
    Initiate Hip PRE
    Neutral alignment lumbar spine
  • 118. Treatment
    Myofascial Release
    Psoas
    Posterior Hip Capsule
    PROM/Jt. Mobilization
    Core Stabilization
  • 119. Thomas Test
    Psoas Stretch
    Thigh off the table
    Tight iliopsoas and rectus femoris muscle (knee flexion)
  • 120. Mobilization
    Leg traction – inferior glide
    Distraction – inferior or caudal glide.
    Mobilization with movement
    Belt
    MET to restore IR/ER or hip flexion
  • 121. Joint Mobilization
  • 122. Whitman & ClelandSeptember 2007
    Hip OA when treated with manual therapy (mobilization)
    5 PT sessions
    Total PROM increases 82 degrees
    Harris Hip Score 25 points
  • 123. Case Report JOSPT Dec. 2007Vol. 37, Num. 12
    73 yo female with THA revision
    2 yrs s/p revision admitted to hospital 10/10 hip pain after lifting her foot to put on her shoe
    X-ray normal d/c
    PT – manual therapy – 4 PT visits
    4 year follow up
  • 124. Proprioception
    Arthritic hips lose input secondary to loss of articular cartilage.
    THR – no input from the hip joint. Must retrain neuromuscular system.
    Balance activities.
  • 125. Airplane
    Balance
    Hip Strength
    Functional
  • 126. Therapeutic Exercise
    THA Protocol Exercise Pro Handout
    Week 5-6
  • 127. Week 6-12
    Walk 1 mile
    C-V Endurance 20-40 minutes
    Pain Free
    Equal strength between legs
    Flexion 130, ER 45, IR 35
  • 128. S.E.R.F. Strap
    Pulls the hip into ER
    JOSPT September 2008 Vol 38, N 9
    50% self report decrease pain
    Decreases hip impingement
  • 129. Treatment
    D/C all modalities
    Manual techniques if necessary
    Exercise Pro Week 6-12
  • 130. 10 days S/P 12 Weeks
  • 131. Contraindications
    Home exercises. Exercises were commenced following manual physical therapy in the clinic
    Upright bicycle: 10 – 20 min
    Gluteus medius clamshell exercises: 3 sets of 12
    Hip abduction in sidelying: 3 sets of 12
    Core transverse abdominus: 2 sets of 20 in supine with hips flexed to 45°
    Bridge with straight leg raise: 3 sets of 10
    Hip flexor stretch kneeling or sidelying: 30 sec × 3
    Single leg balance: up to 60 sec
    Tandem stance eyes open or closed: up to 60 sec
    • Recumbent Bike
    • 132. SLR
    • 133. Aggressive Glut Medius Strengthening
  • Questions