hip arthroscopy rehabilitation part two

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LEVEL ONE hip Week 4 exercises Aim – early active hip circumduction/proprioception tion wing 46. Active assisted hip circumduction. Lie on your y back with your knees and hips bent. Next, place an scop elastic exercise band around your lower thigh bilita (note-health & safety warning). Place hip and knee at 90 degrees, pic 1. Tension up the band with your follo hands. Lumbo-pelvic neutral, T.Abs engaged. Now push your thigh away from you, pic 2, so you are rthro activating your hamstrings. Your hip flexors should Re h a be relaxed as the band should be supporting your leg and hamstrings engaged. Next, imagine a pencil cises pointing from your knee up towards the ceiling. hip a Draw a small circle with the pencil, very slowly and relaxed. 10 times in each direction, 2 times a day.exer 1 2 Copyright-PHYSIOCURE

LEVEL ONE Week 4 exercises hip Aim – early active hip control 47. Four point kneeling gluteal strengthening. tion wing This exercise uses the hip extensors without y taking the hip past neutral extension. It can then scop be progressed to integrating hip abduction as an bilita alternative to side lying (some hip patients find side lying a problem). Firstly, set up position on follo all fours as per exercise 17. Keeping lumbo- rthro pelvic neutral, T.Abs engaged, shoulder blades wide and gently drawn down towards your lower Re h a ribs, neck lengthened. Next slide one leg back, cises extending it behind you, keeping your pelvis level. Repeat 5-10 times, 2 times a day. The hip a progression from this (once mastered!) is to lift the leg in the extended position from the floor , not higher than hip level. Then, once the secondexer stage is mastered…once you have lifted the leg, maintained lumbo-pelvic neutral and have correct body posture you can then take the leg out to the side into hip abduction. If too difficult, try exercise 45 instead Copyright-PHYSIOCURE

LEVEL ONE hip Week 4 exercises 48. Double leg bridges. As per exercise 32 tion 49. Hamstring stretch. As per exercise 36. wing y 50. Calf stretch. As per exercise 37. scop 51. Iliotibial band stretch. As per exercise 38. bilita 52. Faber stretch. As per exercise 39. follo 53. Hams curl/Quads stretch. As per exercise 22. rthro 54. Exercise bike. As per exercise 10. Re h a 55. Calf raises. As per exercise 35. cises 56. Swiss ball exercises. As previously shown. hip a 57. Hydrotherapy. Refer to separate handbook. 58. Prone hip internal rotation. As per exercise 19.exer 59. Heel slides in supine. As per exercise 16. Progress with opposite arm floats ie. left leg slides straight as right arm raises above head. Ensure good rib cage placement, do not lift the breastbone or extend in the thoracic spine. Please get your therapist to check you have correct technique and control. Copyright-PHYSIOCURE

LEVEL ONE Week 4 exercises hip Aim- integrate into function. 60. Double small knee bend. Some guidelines suggest tion wing the controlled use of the leg press at this stage. y Personally, I prefer a more functional based exercise that scop will also challenge body awareness/posture/alignment bilita and integrate lumbo-pelvic-hip control (and you can fit into your day!).Stand with your feet hip distance apart. follo Weight bearing as allowed by consultant. Some will be rthro full weight bearing (FWB). Those who are partial weight bearing (PWB), stand near an appropriate support to Re h a take some weight through your arms. Make sure your cises feet are pointing forward (or very slightly turned out if this is more comfortable). Stand up straight, good hip a posture, lumbo-pelvic neutral , T.Abs engaged. Gently squeeze your bottom, but do not tuck your tail bone under, or rotate through the hip bones or pelvis. Placeexer your hands on the sides of your hips to monitor their movement (not if PWB!). Bend at your hips and knees (about 30 degrees flexion), knees in alignment with the middle toe, do not let ankles/feet ‘roll in’, the rest of the body should be straight..you are only bending at the ankles/knees/hips. Keep gluts and T.Abs engaged throughout the WHOLE movement..contin on next page.. Copyright-PHYSIOCURE

LEVEL ONE Week 4 exercises hip 60. Double small knee bend continued …. Palpate with your hands to check your hip flexors are relaxed, gluts are firing but not ‘gripping’, you should be able tion wing to feel the side hip bone glide backwards in a relaxed y fashion as your hips bend. Hold the bent position for scop 5-10 seconds, repeat 5-10 times, 2 times a day. It is bilita important that when you return from the bent position to the start position, that you keep your gluteals and follo T.Abs activated GENTLY and do not hyperextend your hips or knees at the end of the movement, or go into rthro ‘sway back’ posture. It is important that you get your therapist to check this. Re h a cises hip aexer Copyright-PHYSIOCURE

LEVEL ONE hip Week 4 exercises tion Exercises – wing y It is still beneficial to be practicing weight transference exercises and the swiss ball exercises, even though they scop are mentioned specifically in week 3. bilita follo Note to therapists – rthro In some of the guides I have reviewed, it is suggested that the use of the cross trainer is Re h a appropriate at week 3-4. There will be some patients that this maybe appropriate for , ie. they have had cises simple non-complex surgery / had good pre-op fitness with no long standing muscle imbalances / hip a the surgeon has advised this… In my experience, I have found that it is preferable for patients to have symmetry of movement andexer muscle power, good lumbo-pelvic control, satisfactory and symmetrical balance and proprioception…before adding in dynamic challenges. I test these things in my patients so I have a good idea if they are ready for the cross trainer. This is in order to prevent any compensations in movement patterns. Copyright-PHYSIOCURE

WEEK 4 - Exercise record sheet Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 2846474849505152535455565758 85960

hip tion •  Minimal pain with level one wing exercises. y •  75% hip ROM restored scop •  Proper muscle firing of bilita initial exercises. follo •  Minimal pinching of hip flex to 100 degrees. rthro •  Full weight bearing achieved (ref 12,13 ). Progression Re h a cises criteria to •  Ability to maintain lumbo- hip a move on to pelvic and hip joint neutral. level two •  Equal weight bearing through ischial tuberositiesexer in sitting. •  Good control with double bridge, double calf raises and small knee bends. Copyright-PHYSIOCURE

hip •  Intermediate stage tion rehabilitation. wing y •  WEEK 5 scop •  (day 29 – 35) bilita •  WEEK 6 follo •  (day 36 – 42) rthro •  Aim to increase range of Level Re h a movement. •  Ensure good walking cises pattern. hip a two •  Progressive balance, posture, proprioceptive, strength and core stability work.exer •  Thoraco-lumbar, lumbar- pelvic and hip dissociation work. •  Use whole body and functional approach in rehab. Copyright-PHYSIOCURE

hip LEVEL TWO Week 5 + 6 exercises tion wing y 61. Single bent knee fall out. Lie on your back, knees scop and hips bent. Ankle bones together. Find lumbo-pelvic bilita neutral. Engage T.Abs. Gently float one knee out to the side, rotating at the hip outwards. The knee of the follo opposite leg should stay pointing to the the ceiling, and your pelvis should not rotate. Hold the position for a rthro breath in and then move back to the start on the breath out. Repeat 5-10 times, 2 times a day. Re h a Aim – to help rotation control at the hip/pelvis. cises hip aexer Copyright-PHYSIOCURE

LEVEL TWO Week 5 + 6 exercises hip 62. Hip internal rotation with band. Tie an elastic exercise resistance band around your ankles. Kneel on tion wing a stool but make sure you can hold on to a support. y Keeping your knees together, rotate one hip inwards, knees together, lower leg moves out, as in the photo. scop The other leg serves as an anchor. Hold 5-10 seconds, bilita repeat 5-10 times, 2 times a day. follo rthro Re h a cises hip aexer 63. Active assisted hip circumduction with band. As per exercise 46. Copyright-PHYSIOCURE

LEVEL TWO Week 5 + 6 exercises hip 64. Single leg balance. This exercise can then be progressed to single leg controlled knee bends. Firstly, tion set up your posture, as in exercise 33. Engage your T.Abs wing and gently take your weight through one leg. Try not to y hyperextend your knee or sway forward in the hip, keep scop good alignment of hips, pelvis, spine, lower limb….. You bilita may need to hold lightly onto a support at first. Practice for 5-30 seconds, little and often. Once you have good follo control of one leg standing, progress this to bending the rthro knee of the weight bearing leg very slowly and in a small range (ie.10-30 degrees). Use the alignment Re h a principles as in exercise 60, keep your knee cap cises pointing forwards, knee in line with 2nd toe . Repeat slowly 5-10 times, 2 times a day. hip a Also try single leg calf raises, see how manyexer reps you can do on your non-operated side and work on gaining equal Single ability. knee Aim – integrate into bend function. (ref 40) Copyright-PHYSIOCURE

LEVEL TWO hip Week 5 + 6 exercises 65. Adductor stretches. These can be done in sitting or standing as shown, make sure they feel comfortable to tion wing do. They can also be done in the pool. y Hold 10-30 seconds, repeat 5 times, 2 times a day. scop bilita follo rthro Re h a cises hip a Copyright-PHYSIOCUREexer 66. Isometric Adductors. As per exercise 27. 67. Exercise Bike. As per exercise 10. You can start gradually increasing the resistance on the bike now.

LEVEL TWO hip Week 5 + 6 exercises 68. Dynamic balance challenges. Equipment such as a tion wing wobble board, ‘sit-fit’, ‘dyno-cushion’, ‘Wii-fit’ can be y used after discussion and consent from your scop physiotherapist, to aid weight transference and bilita proprioception work. Begin with double leg work, progress in time to single leg. follo rthro Re h a cises hip a Top tip – Add in some upper body challengesexer as your balance improves Copyright-PHYSIOCURE

LEVEL TWO hip Week 5 + 6 exercises tion 69. Hip Abduction. This can be done in the pool or as in wing exercise 47. Alternately, if side lying is pain free you can y try hip abduction in side lying. Side lying exercises not scop favourable with trochanteric bursitis. bilita Set yourself as in the picture 1.Adopt Lumbo-pelvic follo neutral, T.Abs engaged. Waist and leg lengthened. Gently squeeze your bottom as you float the top leg to hip height rthro as you breathe out, see photo 2; keep waist lengthened. Re h a Hold for a breath in and then slowly lower the leg back down keeping the gluteals and T.Abs engaged. cises Repeat 5-10 times, 2 times a day. hip a This exercise can also be done so your body is against the wall. This is so you can push your heel into the wall to engage your gluts and keep that pressure as you slideexer your heel up and down the wall. (ref 27). 1 2 Copyright-PHYSIOCURE

LEVEL TWO hip Week 5 + 6 exercises tion 70. Double bridge with heel lifts. You can progress wing exercise 32 if you have good technique, control and it is y pain free. Once in the bridge position, raise the heel of scop one foot, lower, then repeat on the other foot. Then lower bilita your pelvis back to the start position. Repeat 10-20 times, 2 times a day. follo rthro Re h a cises hip a Copyright-PHYSIOCUREexer 71. Lower limb stretches. As per exercises 8, 19, 36, 37, 38, 39. 72. Hydrotherapy. As per exercise 34.

LEVEL TWO Week 5 + 6 exercises hip 73. Swiss Ball Exercises. As previously tion shown. wing y 74. Cross Trainer/Elliptical Trainer. scop Check this is done symmetrically and without any compensations. Start on an easy bilita level and build up slowly. Stop if painful. follo 75. Kneeling Hip Flexor Stretch. Kneel on one knee and place the other leg in front of rthro you with the knee/hip bent and foot flat on the floor. Adopt lumbo-pelvic neutral, Re h a engage T.Abs and now gently tuck your tail cises bone under and move your bent knee slightly forward, so you feel a gentle pain hip a free stretch in the front thigh of the kneeling leg. Avoid straining the front of the hip of the kneeling leg, or pushing the hip into extension. Hold 10-30 seconds, 5-10exer repetitions, 2 times a day. Copyright-PHYSIOCURE

LEVEL TWO hip Week 5 + 6 exercises tion wing Extra optional exercises – y scop bilita Hip side glide to the wall follo rthro Re h a cises hip a Hip flexorexer stretch, avoid pushing into hip extension. Keep in hip joint and Copyright-PHYSIOCURE pelvic neutral.

hip LEVEL TWO Week 5 + 6 exercises tion wing Note to therapists – Re-measure the hip range of y movement and record for the patient in this scop handbook. bilita Check the sacro-iliac joint and lumbar spine (Ref 36). follo Expect new pains to occur as the body is adjusting to rthro changes following surgery. It is normal that your patient may still feel quite tired, even at this stage, Re h a after surgery. Encourage them to get plenty of rest and not to overdo things. cises Patients who have suffered a long time with pain and hip a decreased function will need time, patience, understanding and information on realistic goals in their recovery. (Ref 41)exer Recovery is not judged on a time basis but the overall long term satisfaction(Ref 20). It may take a year or longer, for some people who have had pain for a long time to reach their optimum recovery. Copyright-PHYSIOCURE

hip Reassessment of pain after 6 weeks. Shade in the areas on this body chart where you have ent r eek your post-op pain. Scale the pain from 0-10 (0 is d no pain and 10 is the worst pain imaginable). ecoressmreass Six w

hip Diary page – write down here how you are feeling in yourself and the positive changes you feel since your operation. iary page ek d eSix w

hip Ask your physio to record these 6 week post-op hip measurements for you, so you can monitor your progress. (ref 12) ent r eek d ecor Six w Hip Right Left Flexion Abduction Adductionessm Faber Int rot (neutral)reass Ext rot (neutral) Trendelenberg test (ref 13)

hip •  Hip has full range of tion movement. wing y •  Painfree normal gait scop •  Hip flexion muscle power bilita (MP) operated leg at least 60%. follo •  Hip add/abd/ext rot/int rot/ ext MP operated leg at least rthro Progression 70%. Re h a •  No joint inflammation, criteria to muscle irritation or pain. cises •  Good neuromuscular control move on to hip a •  Painfree functional exercises level three (ref 19,20).exer •  Good control of single knee bend, single leg calf raises and bridge with heel lift. Copyright-PHYSIOCURE

hip •  Advanced stage tion wing rehabilitation. y •  WEEK 7 scop •  (day 43 – 49) bilita •  WEEK 8 •  (day 50 – 56) follo Level rthro •  Aim to gain whole body symmetry. Re h a •  Increase general flexibility. cises •  Increase strength and endurance with cardio three hip a vascular challenges. •  Advanced proprioceptive and core stability work.exer •  Recreational sports specific skills. Copyright-PHYSIOCURE

LEVEL THREE hip Week 7 + 8 exercises 76. Exercise Bike. As per exercise 10. tion wing 77. Hydrotherapy. y 78. Cross Trainer/Elliptical Trainer. Check this is scop done symmetrically and without any compensations. bilita Start on an easy level and build up slowly. Stop if painful. 79. Lower limb and spinal flexibility stretches +/- follo foam roller. Adductors, ITB, Quads, Hip flexors, Hams, Calf, Spinal Mobility (eg. Exercises 8, 36, 37, 38, 39, 12, rthro 19, 65, 75). Hold your stretches 10-30 seconds, 5-10 times, 2 times day. Please note, the hold times and the Re h a repetitions are set in this variable way, to point out that it cises can be different for each patient in what is suitable for them. hip a Top tip – Patients frequently report how important they find stretches in helping their recovery andexer notice they do not feel as good if they have forgotten or have been too busy to do them. Copyright-PHYSIOCURE

hip LEVEL THREE Week 7 + 8 exercises tion 80. Walk-Jog-Run Program. (do not run/jog for 13 wing weeks following microfracture). Start by building up y your walking distance outside and speed, making sure scop this is painfree. If this is painfree, there is no limp and you have passed tests with your physio to ensure bilita symmetry and adequate dynamic stability you can start a walk/jog program ie. walk 1 min, jog 1 min….for 5-10 follo mins. Have a rest day after so you can observe if this has provoked any latent pain (delayed pain that occurs after rthro an event).Gradually build up to running. Re h a Therapists, please note, some consultants prefer to leave running until week 8-12…..therefore check! cises Also practice walking backwards/sideways and along hip a an imaginary tight rope. Do not ever run on a treadmill as there are concerns about the damage this could cause to your hipexer (forever). Make sure you wear supportive adequate running shoes and be aware that some patients report a difference in foot posture after theiir surgery. If you wear orthotics it would be wise to have yourself reassessed by a Podiatrist. Copyright-PHYSIOCURE

hip LEVEL THREE Week 7 + 8 exercises tion wing y 81. Lunges. Stand with one foot in front of the other, feet scop pointing forwards. Make sure your pelvis is straight. bilita Imagine a ‘head light’ on each front boney prominence of your pelvis and that they are pointing straight ahead. follo Adopt lumbo-pelvic neutral, T.Abs engaged and maintain these throughout the movement. Now bend your back rthro knee, bending at the foot/ankle so the heel lifts from the floor; at the same time as bending your front knee (see Re h a photo). Try and keep good alignment – get your therapist cises to check your technique. Keep your torso straight; imagine it to be a piece of toast going up and down in a hip a toaster! Repeat the movement slowly and in a controlled fashion 5-10 times, 2 times a day. (Ref 42)exer Copyright-PHYSIOCURE

LEVEL THREE Week 7 + 8 exercises hip 82. Single leg bridge. Adopt the double leg bridge position as in exercise 32. Check you are able to perform the heel lifts as in exercise 70 before you attempt tion wing removing one leg for the single bridge. Once in the y double bridge, remove one foot off the floor. Make sure your pelvis stays level and it is a painfree position. Hold scop for 5-10 seconds. Repeat 10 times, 2 times a day. bilita (Ref 43) follo rthro Re h a cises hip a Copyright-PHYSIOCUREexer 83. Hip Adbuction with internal rotation. If you have reached a satisfactory level with exercise 69, you can progress to performing it with the leg turned in. This must not provoke pain. Lift slowly, with good control 5-10 times, 2 times a day. Check the patient does not dominate with the ITB.

LEVEL THREE Week 7 + 8 exercises hip 84. Prone heel squeeze. Lie on your front with your knees tion at a 70 degree bend, hips slightly abducted. Put the wing insides of the heels together, press together gently and y slightly let the knees lift from the floor. scop Hold 5-10 seconds, repeat 5-10 times, 2 times a day. bilita (ref 27) follo rthro Re h a cises hip aexer Copyright-PHYSIOCURE 85. Plank/Side plank/High kneeling swiss ball roll outs. Reetitions to be determined by therapist as dependent on ability and control of individual.

hip LEVEL THREE Week 7 + 8 exercises tion wing y 86. Single bent knee fall out with band. Once you are scop comfortable doing exercise 61, you can progress this with bilita an elastic exercise resistance band tied around your lower thighs. (Please observe the health & safety warning for follo use of bands). Repeat slowly 5-10 times, 2 times a day. rthro Re h a cises Start hip aexer Finish Copyright-PHYSIOCURE

LEVEL THREE hip Week 7 + 8 exercises tion 87. Long lever hip circumduction/proprioception with wing band. Once you are comfortable doing exercise 46, you y can progess this with the leg straight and the band around scop the foot like a stirrup. (Remember eye goggles bilita recommended with use of bands). Ensure the leg is supported by the band, the foot is pointed and imagine follo drawing small circles 10 times clockwise then anti- clockwise; as if your leg is a pencil, 2 times a day. Try rthro to make your circles as smooth and circular as possible. The movement should be slow and controlled. Re h a cises hip aexer Copyright-PHYSIOCURE

LEVEL THREE hip Week 7 + 8 exercises tion 88. Single leg extension with band. This exercise is wing useful to compare the ability of each leg with control and y alignment. Lie on your back, hips/knees bent, place the scop band like a stirrup under one foot (eye goggles). Slowly bring that leg up so the hip and knee are at a 90 degree bilita bend. Tension up the band so you are holding it like reins, elbows tucked into sides. Adopt lumbo-pelvic follo neutral, engage T.Abs and slowly push your foot away as if to the wall (not ceiling). Try and observe what is rthro happening to the leg, do not let it rotate/adduct/abduct, try and keep your knee cap pointing up towards the Re h a ceiling. Repeat 5-10 times each leg , 2 times a day. cises hip aexer Copyright-PHYSIOCURE

LEVEL THREE hip Week 7 + 8 exercises tion wing 89. Hip Adduction in side lying. Lie on your side as in y the photo with supports for comfort. Adopt lumbo-pelvic neutral, engage T.Abs; lengthen through the bottom scop straight leg and gently hover off the ground. bilita Hold 5-10 seconds, repeat 5-10 times, 2 times a day. follo Therapists, check technique and look for signs of compensation with leg position. (Ref 44) rthro Make sure this exercise is painfree in the groin. Re h a cises hip a Startexer Finish Copyright-PHYSIOCURE

LEVEL THREE Week 7 + 8 exercises hip 90. Hip Flexion in supine. Stage 1- lie on the floor with both knees/hips bent, lumbo-pelvic neutral, T.Abs engaged. Breathe out and float one leg up so the knee tion is directly over the hip joint, hip/knee bent to 90 wing y degrees, photo 1. Lumbo-pelvic neutral should be maintained. Hold as you breathe in, then slowly lower as scop you breathe out. Repeat 5-10 times, 2 times a day. bilita follo 1 rthro Re h a Caution with cises Hip flexor 2 hip a 3exer When this feels comfortable to do, progress to stage 2, floating one leg up. You will need to imprint your spine (flatten into the floor) for this. Keep it in that position and bring the other up to join it. Then straighten one knee, photo3 then bring it back to photo 2 position then repeat with other leg. Finally lower one leg to the floor, then the other leg. Copyright-PHYSIOCURE

LEVEL THREE hip Week 7 + 8 exercises tion wing 90. PROGRESSION - Hip Flexion in standing/ y balance. Adopt a good standing position as in exercise 33. Stand near an appropriate support, take your weight scop through one leg, avoid hyperextending the knee or bilita gripping the floor with your toes. Slowly lift up the leg as in the photo, to hip height. Keep your pelvis level, follo and lumbo-pelvic neutral, upper body relaxed. Balance for 5-10 seconds, 5-10 times, 2 times a day. rthro Integrate in with dynamic balance challenges (exercise Re h a 68). cises hip a Caution that this does notexer irritate the hip flexor Copyright-PHYSIOCURE

hip LEVEL THREE Week 7 + 8 exercises tion wing y scop bilita Note to therapists – Use realistic timescales, be follo cautious. rthro Use common sense – players/patients will progress at different rates. Re h a Assess each patient individually, you may need to cises modify rehabilitation/timescales/treatment. Always liaise with the consultant, flagging up any hip a problems you may have with the rehab so this can be dealt with promptly. Certain exercises can be provocative and inflame theexer hip (ie.CLAM, straight leg raise and sit-ups). Avoid aggressive hip extension at all times. Copyright-PHYSIOCURE

hip •  All level three exercises painfree, and can tion wing demonstrate good lumbo- y pelvic control. scop •  Full range of hip and spinal bilita movement. •  Hip flexion MP of operated follo side at least 70%. •  Hip Add/Abd/Int rot/Ext rot/ rthro Progression Ext MP of operated side at Re h a least 80%. criteria to •  Cardiovascular fitness level cises equal to pre-injury level move on to (ref 19,20). hip a level four •  Good control with lunges, single leg bridge, rotationexer control with Lx/pelvic neutral, the plank, and hip flexion in standing. Copyright-PHYSIOCURE

hip •  Advanced ‘PLUS’ stage rehabilitation. •  WEEK 9 tion •  (day 57 – 63) wing y •  WEEK 10 scop •  (day 64 – 70) bilita •  WEEK 11 •  (day 71 – 77) follo •  WEEK 12 Level •  (day 78 – 84) rthro Re h a cises •  Aim to advance cardiovascular fitness and stamina. four hip a •  Progress challenges with plyometrics, speed and agility.exer •  Progress proprioceptive and ballistic challenges. •  Focus on being appropriate to the patient, their sport and their goals in recovery. Copyright-PHYSIOCURE

LEVEL FOUR hip Week 9 – 12 exercises The repetitions for these exercises should be dictated by your physiotherapist. tion 91. Side steps with elastic band. Secure an elastic wing resistance band around your ankles. (Note band y warnings). Squat slightly, keeping good body alignment scop and T.Abs engaged. Side step against the resistance of the bilita band. 92. Resistance band kicks. Tie the band around a secure follo unmovable object. Place one foot in the loop. Stand far enough away so the band is under tension. Balance on the rthro other leg, as per balance set up in previous exercises. Perform reps in each direction of movement (forward/ Re h a backward/out to side/across body) with the band resisted leg. You will need to change position for each of these. cises This will be a balance challenge for the stance leg and a resistance challenge for the band leg. hip a 93. Single leg stance with pelvis/trunk rotation away. The stance leg must remain pointing forward. This is a good functional weight bearing rotation control exercise.exer 94. Agility running drills. Forward/back/side. 95. Dynamic lunges. 96. Bike/XTrainer/Hydrotherapy (see guide for swimming criteria). Copyright-PHYSIOCURE

LEVEL FOUR hip Week 9 – 12 exercises Appropriate for sports that involve running with changes of direction…. tion wing y scop 97. Z Cuts. Face the direction you are going to jog. Jog 1-2 metres in a Z pattern. At each change of direction, make bilita sure your foot is firmly placed, stay low and push off in a new direction. follo 98. W Cuts. Jog 1-2 metres in a forwards direction. At the rthro change of direction, keep low and push back on the right foot, thereby jogging backwards. After 1-2 metres, keep Re h a low and push off on the right foot, into a forward jog, forming a W shape. Continue for 8-12 cuts, then repeat cises using the left leg. hip a 99. Cariocas. Face sideways to the direction you are jogging. Cross the right leg over the left, then bring the left foot from behind the right and step to the side. Cross the right leg behind the left and then bring the left footexer from behind to the side, in a ‘grapevine’ pattern. 15-20 metres. Repeat in opposite direction. 100. Ghiardelli’s. Start by crossing the right leg over the left, then swing the left leg forward (from behind the right) and touching the ground with the left hand. Repeat with the right.

LEVEL FOUR Week 9 – 12 exercises hip 101. Forward bow progressing to arabesque. Adopt correct stand posture, lumbo-pelvic neutral, T.Abs engaged. Bend forward at the hips keeping lumbo- tion pelvic neutral and slowly return. (Ref 44). Needs to be wing y cued and supervised by physio and reps determined. scop When forward bow has satisfactory control, repeat the action then raise one arm (like superman), return to bilita stance, then repeat on other side. follo Final stage is when combined arms and trunk are controlled, now lift the opposite leg from the floor, so rthro your arm/trunk/leg are in perfect alignment. Re h a 102.Plie squats. Squats done with the feet turned out to work more rotation. Add in upper body resistance work cises to be done at the same time. hip a 103. Diagonal arm and leg work. Hip abduction in standing with band and opposite arm abduction with band. Your physio can advise you further in retraining the global muscle/sling system.exer 104.Advanced plank/side plank. Plank position, then side step one foot, return, then repeat on other side. Side plank position, upper leg hip abduction. 105. Rehab equipment..such as pilates reformer or ski- fitter can be used under supervision. Copyright-PHYSIOCURE

LEVEL FOUR hip Week 9 – 12 exercises tion wing y scop Notes for therapists and patients - The basic principles detailed overleaf are to work through with bilita your physio, as there are so many different exercises, and it can depend on what kind of sport you do as to follo what is appropriate. A lot of rehab guides often bias towards running based sports….but if you are a ballet rthro dancer, martial artist or dressage rider there will be different training exercises to consider. Your physio Re h a can write you a program to cover these principles. It is advised that you are supervised so any compensations cises and faulty movement patterns can be observed. hip a Therapists, you will need to keep monitoring your patient to pick up any rehab issues and faulty movement techniques.exer Remember in some patients, recovery can take up to one year. Copyright-PHYSIOCURE

LEVEL FOUR Week 9 – 12 exercises hip BASIC HIP REHAB PRINCIPLES IN RETURNING TO SPORT tion •  Thoraco-lumbar-pelvic-hip dissociation work. wing y •  Ensure active equals passive movement – ability to scop control through the full range of movement and at inner and outer ranges. bilita •  Control of body with different speeds of follo movement. •  rthro Eccentric and concentric control of movements. •  Pelvic stability work and balance, with arms Re h a above head to dissociate upper body fixation. cises •  Diagonal upper body cable work combined with pelvic stability and lower limb challenges. hip a •  Rotation control work in different functional positions. • exer Dynamic balance, plyometric and ballistic work with upper and lower body combined challenges. •  A comprehensive program of flexibility stretches with a whole body approach. •  Movement pattern work involving the ‘kinetic chain/link theory’ (ref 45). Copyright-PHYSIOCURE

WEEK 9 - Exercise record sheetDay 57 Day 58 Day 59 Day 60 Day 61 Day 62 Day 63 49

hip Reassessment of pain after 12 weeks. Shade in the areas on this body chart where you have k your post-op pain. Scale the pain from 0-10 (0 is d no pain and 10 is the worst pain imaginable).essm ve wee ecor ent r Twel reass

hip Diary page – write down here how you are feeling in yourself and the positive changes you feel since your operation. iary page ek d e ve wTwel

hip Ask your physio to record these 12 week post- op hip measurements for you, so you can monitor your progress. (ref 12) k dessm ve wee ecor Hip Right Left ent r Flexion Twel Abduction Adduction Faber Int rot (neutral) reass Ext rot (neutral) Trendelenberg test (ref 13)

hip tion wing •  Consent from surgeon to y return to full sports training. scop •  Good ability with level four bilita exercises. •  Full painfree hip range of follo movement and muscle power. rthro Progression •  Ability to perform sports Re h a specific drills at full speed criteria to painfree. cises move onto •  see Wahoff ‘sports test’ (ref hip a 12,13). level five •  Star excursion balance test (ref 47).exer Copyright-PHYSIOCURE

hip •  Elite and professional sports skill training. tion wing y •  WEEK 13 + scop bilita •  Liaison between the consultant, hip arthroscopy follo rehab physio, the specific Level sport physio and personal rthro trainers. •  Aim to create rehab drills Re h a and exercises to replicate cises the specific sport with awareness of the hip surgery five hip a carried out and impact this can have on other parts of the body.exer •  Look out for musculoskeletal compensations when athlete is performing high level tasks. Copyright-PHYSIOCURE

Week 13+ hip Note to therapists – Most guides suggest jump lunges, lunges with resistance, hopping, box jumps, bounding tion wing can be done at this stage. In sports which involve y kicking against resistance, jarring type movements scop and a lot of rotational challenges such as in martial arts/football/rugby/contact sports, build up slowly bilita with lots of preparation work. Liaise closely with the follo consultant on appropriate time scales and safety considerations. rthro Racing cyclists may need certain pedals on their Re h a bike that allow some external rotation of the leg to lessen being in an impingement position. They also cises may need their position on their bike reassessing with a cycling specialist. hip a Horse riders need to consider the width of the horse, type of saddle and saddle position whenexer rehabilitating back to riding. The leg and hip position is different with different saddles and disciplines of riding. Keep on measuring range of movement even at late stage recovery. Copyright-PHYSIOCURE

Summary Week One Week TwoAnkle pumps *Iso Quads/Hams *Iso Gluts/Hip Abd * *Trans Abs * *Stretches Q/Add/ITB * *Ex.Bike * *Spinal ext * *Chest openings * *Prone lying * *Calf with band *Knee ext *Hams curls *Iso Adds *Supp heel slides * 59Stretches piri/int rot *Hip rocks/glides *

Summary Week Three Week FourDouble calf raise * *Hams curls *Iso Adds * *Trans Abs/heel slides * *Stretches Q/Add/ITB * *Stretches H/C/int rot * *Stretches faber * *Chest openings * *Spinal ext * *Ex.Bike * *Double Bridge * *Hip Rocks/Glides *Stand Hip Abd *Hydro * * 60Swiss Ball * *Wgt Transference *

Summary Week Four Week Five/SixAssisted Hip Circum * *4 pt kneel leg lift * *Double knee bends * *Lower limb stretches *Ex Bike + XTrainer *Bent knee fall out *Hip int rot + band *Single leg balance *Dynamic balance *Add stretches *Kneel hip flex stretch *Swiss Ball *Hydro *Double Br + h/lift * 61Iso Adds *Side hip Abd *

Summary Week Seven/EightLong lever Hip Circum *Lunges *Single leg bridge *L. Limb + spine stretches *Ex Bike + XTrainer *Bent kn fall out + band *Hip int rot + band *S.Leg + dynamic balance *Leg ext + band *Walk-Jog-Run *Prone Heel Squeeze *Plank/side pk/sw.ball *Hydro *Hip flex supine-stand * 62Side Hip Adds *Side Hip Abd +int rot *

Summary Week Nine-Twelve Week Thirteen +Side steps + band *Resistance band kicks *Pelvic rot in stand *Agility run drills *Ex Bike/ Xtrainer/Hydro *Ski-fitter/reformer *Dynamic lunges *Z cuts/W cuts *Cariocas/Ghiardellis *Fwd bow - arabesque *Plie squats + up. body *Adv. plank/side pk *Diag up/lower body *Hopping/jumping * 63Box jumps/bounding *Sports specific training *

Rehabilitation pathway •  Pre-op preparation. •  Surgery. Pre-op •  Protect surgical area, reduce pain, muscle spasm, inflammation. •  Gain control of joint neutral, control of local stabilizer muscles and correct muscle firing. Early •  Early mobility noting surgeon’s restrictions. •  Regain flexibility and strength. •  Dynamic control of movement through range, concentrically and eccentrically. •  Sensory- motor, posture, balance and proprioceptive work.Intermediate •  Integrate into function. •  Advanced strengthening, dynamic, proprioception, ballistic and plyometric work. •  Increased shearing activities, agility and sports specific rehab. 64 Advanced Based on Frank Gilroy-post surgical general rehabilitation ladder

hip References – 1.Tibor & Sekiya.’ Differential diagnosis of pain s around the hip joint’. Arthroscopy: The Journal of e Arthroscopic and Related Surgery, Vol 24, No 12 renc (Dec), 2008, 1407-1421. 2. Beck et al.’Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of earlyRefe osteoarthritis of the hip’. JBJS (Br) 2005, 87-B, 1012-1018. 3.Schilders et al. ‘Arthroscopic treatment of labral tears in femoral acetabular impingement’. JBJS 2011, vol 93-B,8. 4. Wenger et al. ‘Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orth 2004. Vol 426, 145-150. 5.Byrd & Jones. ‘Arthroscopic Femoroplasty in the management of cam-type femoroacetabular impingement’. Clin Orthop Rel Res, 2009, 476:739-746.

hip References – 6.Byrd. Operative hip arthroscopy. Springer. Second s Edition. 2004. e 7. Kelly et al. ‘Hip arthroscopy:current indications, renc treatment options and management issues’. AJSM 2003. Vol 36,6. 8.Anderson et al.’Results of arthroscopic iliopsoas tendon release in competitive and recreationalRefe athletes’. AJSM 2008. Vol 36,12. 9. Guanche. Hip and pelvis injuries in sports medicine. Lippincott Williams & Williams. 2010. 10. Haviv et al. ‘Arthroscopic femoral osteochondroplasty for cam lesions with isolated acetabular damage’. JBJS, May 2010. Vol 92-B, No 5. 11. Bardakos & Villar. ‘The Ligamentum teres of the adult hip’. British JBJS, 2009. 91-B:8-15.

hip References – 12. American Academy of Orthopaedic Surgeons. Joint s Motion: Method of Measuring and Recording. e Churchill Livingstone. renc 13. Hattam & Smeatham. ‘Special tests in musculoskeletal examination – an evidence based guide for clinicians’. Churchill Livingstone 2010. 14. McDowell et al. ‘Cryotherapy in the OrthopaedicRefe Patient’. Ortho Nurs 1994, 13(5),21-30. 15.Oliveira et al. ‘Three intermittent sessions of cryotherapy reduce the secondary muscle injury in skeletal muscle of rat’. JSSM 2006. 5, 228-234. 16. Kennet et al. ‘Cooling efficiency of 4 common cryotherapy agents’. Journal of Athletic Training 2007. 42(3), 343-348. 17. Butler & Moseley. Explain Pain. Noigroup publications 2003.

hip References – 18. Enseki et al. ‘The Hip Joint: Arthroscopic s Procedures and Postoperative Rehabilitation’. e Journal of Ortho & Sports Surg 2006. Vol 36.No.7. renc 19.Stalzer et al. ‘Rehabilitation following Hip Arthroscopy’. Clinics in Sports Med. Elsevier 2006. 20. Wahoff et al. ’Rehabilitation After Hip Femoral Acetabular Impingement Arthroscopy’. ClinicalRefe Sports Med 2011. 30, 463-482. 21.Garrison et al. ‘Rehabilitation after Arthroscopy of an Acetabular Labral Tear’. NAJSPT 2007. 2(4), 241-250. 22. Sahrman. Diagnosis and treatment of movement impairment syndromes. Mosby 2002, Chapter 4, 176-244. 23. O’Shea. Healing hip, joint and knee pain. North Atlantic Books 1998.

hip References – 24. Longbottom. Acupuncture in manual therapy. Churchill Livingstone 2010. s e 25. Hopwood et al. Acupuncture and related renc techniques in physical therapy. Churchill Livingstone 1997. 26. Joseph Wong. A manual of neuro-anatomical acupuncture, vol 1:musculo-skeletal disorders. TheRefe Toronto Pain and Stress Clinic 1999. 27. Phillipon et al. ‘Rehabilitation exercise progression for the gluteus medius muscle with consideration for iliopsoas tendinitis’. AJSM 2011. Vol 39. No 8. 28. Myers. Anatomy trains: myofascial meridians for manual and movement therapists. Churchill Livingstone, second edition 2009.

hip References – 29. Chaitow. Soft tissue manipulation. Healing Arts s Press 1988. e 30. Chaitow. Positional release techniques. Churchill renc Livingstone 1998. 31. Schultz et al. The endless web: fascial anatomy and physical reality. North Atlantic Books 1996.Refe 32. Hengeveld & Banks. Maitland’s peripheral manipulation. Butterworth-Heinemann, 4th Edition 2005. 33. Mulligan. Manual therapy: NAGs/SNAGs/MWM.. OPTP, 5th Edition 2004. 34. Travell & Simons. Myofascial pain and dysfunction: the trigger point manual. Williams & Wilkins 1999.

hip References – 35. Rosie Mew.’Activation of the deep abdominals, s is it more effective in standing or crook lying?’. e Sportex Medicine 2011.49,12-18. renc 36. Lee. The Pelvic Girdle – an approach to the examination and treatment of the lumbo-pelvic hip region. Third Edition. Churchill Livingstone 2004. 101-102.Refe 37. McIlveen & Robertson.’A randomised controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain’. Physiotherapy. Jan 1998, vol 84, no 1. 38. Harrison et al.’Loading of the lower limb when walking partially immersed:implications for clinical practice’. Physiotherapy. March 1992, vol 78, 164-166.

hip References – 39. Critchley. ‘Instructing pelvic floor contraction s facilitates transversus abdominis thickness increase e during low abdominal hollowing’. Physiotherapy Research International. 2002. 7:65-75. renc 40. Crossley et al.’Performance on the single-leg squat task indicates hip abductor muscle function.’ AJSM 2011.Refe 41. Ernest Rossi.’The Psychobiology of mind-body healing.Norton 1986. 42. Stuart McGill. Low back disorders- evidence based prevention and rehabilitation. Human Kinetics 2002. 43. Ricardson, Jull, Hodges, Hides. Therapeutic exercise for spinal segmental stabilization in low back pain. Churchill Livingstone 1999.

hip References – 44. Comerford. Kinetic control:dynamic balance of the sensory motor system. Course manuals, Kinetic Control Ltd 2000. s e 45. Seidenberg & Bowen. The Hip and Pelvis in Sports Medicine and Primary Care. Springer 2010. renc Chapter 10. 46. Binningsley.’Femoro-acetabular impingement’. Sportex Medicine 2009;40 (Apr):10-15.Refe 47. Kinzey et al.’The reliability of the star excursion tests in assessing dynamic balance’. Journal of Orthopaedic Sports Phys. Ther. 27:356-360. Copyright-PHYSIOCURE

The author, Louise Grant MCSP accepts no responsibility for persons using this guide. The guide hip should be used under the instruction and guidance of your chartered physiotherapist. For further information on hip arthroscopy physiotherapy, pilates and hydrotherapy, log onto www.physiocure.org.uk. nts Acknowledgements –Thank you to my family and all my hip arthroscopy patients who have assisted and e inspired me to publish this guide. To my wonderful gem business partner, Anna Nelson who specializes in hip problems in horse riders. Thank you to Julie Reynolds, specialist hip pilates instructor and Louisa Weeks Browning; founder of an internet based hip d arthroscopy/FAI support group. My deepest gratitude to the surgeons who have helped me, in particular, Prof owle Ernest Schilders and Mr Jon Conroy who continually support, teach and guide me. Published by PHYSIOCURE Aug 2011. PHYSIOCURE isAckn a registered trademark. Copyright Aug 2011 registered with O’Garras Solicitors. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, or otherwise, without the prior permission of the author/copyright owner. Printed by PH Print. Copyright PHYSIOCURE

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hip arthroscopy rehabilitation part two

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