hip arthroscopy rehabilitation part one


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Hip arthroscopy rehabilitation exercise guide for patients and therapists written by Louise Grant, hip specialist chartered physiotherapist.

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hip arthroscopy rehabilitation part one

  1. 1. rosc opy hip arth T he ide f or atio n gu ilit istsre hab erap MCSP d th Grant t, tien ts an By Louise therapis K pa tered io Phys siocure hy ,U 1 ar Hip- P 01 ali st Ch ug ust 2 peci ri ght A Hip S Copy
  2. 2. •  About the author •  About this guide hip •  Anatomy of the hip •  What is a hip arthroscopy? •  What might the surgeon do in the hip? •  Labral repair or resection nts •  Pincer decompression •  CAM decompression eCont •  Other surgical techniques •  Possible complications of surgery •  Getting ready for your operation •  Pre-op assessment record •  Post-operative advice •  Post-operative range of movement advice •  Precautions and considerations following surgery •  Awareness of negative findings that may impact on rehab •  Rehabilitation exercises following hip arthroscopy •  Six week reassessment record •  Twelve week reassessment record •  Rehabilitation pathway •  Rehabilitation summary charts •  References •  Acknowledgements
  3. 3. hip INTRODUCTION Louise Grant is a Chartered Physiotherapist who qualified in 1992. Since the year 2000, she has jointly owned PHYSIOCURE, a private physiotherapy clinic. She is a r member of the Health Professions Council, The Society of o Orthopaedic Medicine, The Acupuncture Association of auth Chartered Physiotherapists, PhysioFirst and the Association of Chartered Physiotherapists in Sports Medicine. In 2005, Louise additionally qualified as a Modern Pilates Instructor. t the Louise is a private, independent hip specialist physiotherapist who works with patients undergoing hip arthroscopy, and in the management of femoral acetabular hip impingement (FAI). She also sees other types of hip surgery and conditions. She has written thisAbou guide to assist in patient’s rehabilitation. Copyright-PHYSIOCURE
  4. 4. hip This guide is not intended to replace your surgeon’s protocol, but to be used alongside it. Louise has gathered together various hip arthroscopy guides/ protocols from around the world, research papers and e books, her learning from attending international hip guid conferences and from individual teaching from top hip arthroscopy surgeons, to personally formulate this amalgamation of material. She has also collected data recording patient’s experiences of hip arthroscopy rehabilitation. Please note, this guide is general, and can not cover every eventuality. t this Louise has personal experience with living with femoral acetabular impingement (FAI) and has had a hip arthroscopy herself. Louise’s hip condition is in no means simple, and she understands fully the emotionalAbou rollercoaster some patients experience in recovery. Practical advice has been added into this guide from her Occupational Therapist mother who lived with hip dysplasia and had a early hip replacement, age 50. Louise has used this information to produce a useful guide aiming to aid patients and therapists in hip arthroscopy rehabilitation. Copyright-PHYSIOCURE
  5. 5. hip e guid Disclaimer – the author is not responsible for any person’s using this guide or for their interpretation t this of it. Hip arthroscopy rehabilitation should be done under the care of a suitably qualified CharteredAbou Physiotherapist or equivalent therapist. Copyright-PHYSIOCURE
  6. 6. hip It is important to note that any rehabilitation guide needs to be modified and adapted for the patient individually. Patient’s undergoing hip arthroscopy, vary. Has the surgery been complex or simple? Some are e sports people who have a sudden onset of hip pain. Some, patients have had pain for many years, before guid they are diagnosed with femoral acetabular impingement. Therefore, people using this guide will be at different levels of fitness, have different pain scenarios and disability. Hence, staging a guide that is time framed is not always realistic, and can cause some patients huge t this distress when they feel they are not meeting time bound goals, so please remember the ‘weeks’ are only meant as a guide. It is important to be realistic with patients, judge their fitness, capabilities and operation findings. Some patient’s goal will be getting to level two/three stageAbou exercises. If a non-athletic patient is painfree, with good symmetrical range of movement and power, is back at work/hobbies, and is happy with this recovery, do not push them to do exercises aimed at elite sports people. There are criteria to be met, and relevant tasks to be performed satisfactorily before moving onto a harder level in this guide. Copyright-PHYSIOCURE
  7. 7. ‘3D’ Normal hip joint. hip The labrum (red), forms a ‘skirt’ around the rim e h ip of th omy Rim of acetabulum Femoral headAnat Femoral Neck Greater trochanter Copyright-PHYSIOCURE
  8. 8. A hip arthroscopy is when the surgeon uses ‘keyhole’ hip surgery to enter the hip joint. Normally, this involves making two small incisions in the upper thigh area, but on some occasions, a surgeon may choose to use hip additional incisions (portals). One of the incisions is for py? the camera, and the other is for the operating tool. The operated leg is usually in traction throughout the procedure to enable access to the central t is a osco compartment of the joint. This is carefully controlled and monitored. The traction is gently released for when the surgeon accesses the peripheral compartment. The surgeon will then carefully move the leg with the camera in situ to check there is no impingement. Whaarthr Bruising and swelling are normal post-surgery. Side of thigh Front of Some people are thigh surprised to see where the incisions are, they presume they would Incisions be higher up. Copyright-PHYSIOCURE
  9. 9. hip You will have already been examined, xrayed and possibly had an arthrogram/scan by the the the surgeon; and a proposed treatment plan hip? discussed.(Ref 1).However, further examination of the joint takes place, when the surgeon lookssurg t might into the joint with their camera. They will then do in fully assess the joint and decide on the appropriate procedure. See the following pages for common surgical techniques.. eon Wha Copyright PHYSIOCURE
  10. 10. hip This is a picture of a labral tear. There are different ir o r debr ction/ classifications of tears (Ref 2). It will depend on the ent type of tear and quality of the labrum as to whether the surgeon repairs or resects /removes. (Ref 3) repa idem rese l abraHip L Copyright-PHYSIOCURE
  11. 11. hip Below is a picture of a pincer deformity. The extra bone can cause impingement in the hip. The surgeon may remove/resect this boney deformity to alleviate ity ‘pinching’ in the hip. ction f o rm pincer Red indicates labrum rese er de Copyright-PHYSIOCUREPinc Green indicates boney overcoverage around the rim. A local area =pincer, a global area = coxa profunda.
  12. 12. hip A CAM deformity can be found at the femoral neck, it can restrict hip movement and cause impingement. This can be resected during surgery and the area ‘decompressed’. Some CAM people have a ‘mixed’ CAM and pincer ssion deformity. (Ref 4,5) Red indicates CAM labrummpredeco Copyright-PHYSIOCURE Green indicates boney ‘bump’ on the femoral neck, this can vary in size and situation.
  13. 13. hip Removal of a loose body – These are free- l gica es floating catilage fragments usually originating from traumatic injury, degenerative conditions or synovial proliferative disorders. niqu Microfracture/chondroplasty – Holes are made r sur in the subchondral plate, in local contained areas , producing a marrow clot. The cells from this change into a fibrocartilaginous material. tech Psoas tendon releaseOthe Removal of adhesions Ligamentum Teres Reconstruction Labral Grafting (Ref 6,7,8,9,10,11)
  14. 14. With any surgery, there are complications and hip things to consider…. •  Infection, DVT, delayed wound healing, tions ible p swelling, bruising. y of hi •  Avascular necrosis of the femoral head, rger fracture, heterotopic ossifications, Poss adhesions. •  Failure to resolve pre-operative py su symptoms, increased pain, damage to labrum or cartilage, traction related pain. •  Sciatic and lateral cutaneous nerve injuries, pudendal nerve problems, plica osco impotence, pressure sores. •  Instrument breakage, extravasation of irrigation fluid. comarthr For more information visit www.isha.net Your surgeon will discuss complications in more detail.
  15. 15. hip f or Preparing yourself before surgery can help ation make your recovery easier. Your physiotherapist can help you with – eady •  Showing you pre-op exercises to maintain your muscle tone and overall function . oper •  Explanation of the post-op exercise routine and advice. Remember new exercises can in g r make you ache. •  Practice crutch walking. your •  Assessing and measuring your hip before surgery to establish pre-op function.Gett •  Record your pre-op pain and symptoms to be able to gauge appropriate post-op progress. Copyright-PHYSIOCURE
  16. 16. hip Shade in the areas on this body chart where you have your pre-op pain. Scale the pain from 0-10 (0 is no pain and 10 is the worst pain ent rd imaginable). Do this, as you may possibly forget what you actually did feel like before surgery ! reco essm p assPre-o
  17. 17. hip Diary page – write down here how you are feeling in yourself and the things you are currently finding a problem in day to day life. ent rd reco essm p assPre-o
  18. 18. hip Ask your physio to record these pre-op hip measurements for you, so you can monitor your progress. (ref 12) ent rd reco essm Hip Right Left Flexion Abduction p ass Adduction FaberPre-o Int rot (neutral) Ext rot (neutral) Trendelenberg test (ref 13)
  19. 19. Pre-op -Exercise record sheet (Your therapist can select exercises from this guide) 19
  20. 20. hip f or Items to help in your recovery – ation •  Elbow crutches (essential) . Check if your insurance company provides these. If not, eady these can be purchased at the hospital. •  Ice packs (essential). Ice is used to reduce oper swelling, bruising and provide pain relief. These can be bought on the internet or at in g r the hospital. Get two, so one is always ready. •  Non-slip shower mat (essential). You must your be careful that you do not jar your hip, so think of safety aspects.Gett •  Exercise bike (advisable). As this is recommended for daily use, and you can not drive to the gym for a couple of weeks, think about having a bike at home. Copyright-PHYSIOCURE
  21. 21. hip Items to help in your recovery – •  Shower stool, grab rails, raised toilet seat, f or easy reach grabber, and long handled shoe ation horn – although these items are not essential, they can eady really assist in making independence much easier and may help prevent you jarring or overstretching the hip. oper •  Swiss ball, wobble board, inflatable balance cushion. in g r •  Elastic resistance exercise band, ankle weight. your •  Soft football, pilates ‘circle’, foam roller.Gett •  Scar massage oil. •  Small rucksack and flask - useful as you can’t carry things in your hands. •  A couple of spare pillows – useful for supporting your leg in different positions. Copyright-PHYSIOCURE
  22. 22. hip f or ation Items to take with you to the hospital – •  Loose fitting jogging trousers (your leg may be swollen after the operation). eady •  Comfortable, flat, supportive non-slip shoes. oper •  Nightwear, spare underwear and toiletries. •  Phone and charger (headphones) in g r •  Medications, hip xray (if you have been given this by consultant), elbow crutches (if you are your having to provide your own). •  Book, magazines, (earplugs!!!eye mask!!) etc..Gett •  Avoid taking any valuables, jewelry. •  Glasses…you will be required to remove contact lenses. Copyright-PHYSIOCURE
  23. 23. For 2-6 weeks (6-8 weeks for a microfracture) you hip will be partial weight bearing on elbow crutches. You need to give the bone and soft tissues the best environment to heal in. The joint may be f or quite sore at first and it is important to let this ation settle. Therefore, no lifting, twisting, overstretching, jarring or movements/activities eady that provoke the pain. Look around your home to see what you can do now to make post-op recovery easier. Consider organizing your home oper so you can easily reach things, so you are not having to bend down to a low drawer or in g r overreach into a high cupboard. Check there are no trip hazards. When it comes to eating, if you at home alone, a high stool at the kitchen worktop your would mean you could safely prepare food and eat it in the same place as you can not carry aGett plate. Alternately, you could put food in a sealed plastic container and have a flask/drink container which could go in your rucksack…and thus your food and drink can be transportable. Consider stocking up on some easy freezer meals. Enlist help if you can with children/pets/ laundry/cleaning/gardening/shopping, etc… Copyright-PHYSIOCURE
  24. 24. hip Using elbow crutches – Walking – partial weight bearing is approximately half of your body weight tive ce going through the operated leg, whilst you take a step with the non-operated leg. Some surgeons specify less weight than advi pera this, some more…so check with the surgeon. Begin by standing straight, in a good posture, with weight fully through your non- operated leg and partial through the o operated leg. Place both crutches a shortPost- distance in front of you, then place the foot of your operated leg level with the crutches, keeping the foot flat on the floor. Next, putting your weight through the crutches and partially through the operated foot, step through with the non-operated foot. Take your weight fully through the non- operated leg as you position the crutches and operated leg for the next step..and so on. Copyright-PHYSIOCURE
  25. 25. Using elbow crutches – Stairs – Hold onto the banister with one hand and the other should have hip your crutch (place your other crutch horizontally in the crutch hand, as shown in the photo). tive UP STAIRS - ce 1.  Non-operated leg steps up. 2.  advi Operated leg next onto the same step. pera 3.  Crutch goes last. DOWN STAIRS – 1.  Crutch first. o 2.  Operated leg.Post- 3.  Non-operated leg onto the same step. Copyright-PHYSIOCURE
  26. 26. hip Using elbow crutches – tive SITTING DOWN – ce Walk right up to the chair, turn carefully around advi so your bottom is facing the chair. Remove both pera crutches from your arms and place in one hand, so your hand is gripping the hand supports across the top and you can still support yourself safely. Next, with your other hand reach back and place hand on the chair arm. Slowly lower o yourself carefully down into the chair.Post- STANDING FROM SITTING- Move your bottom to the edge of the chair. Both feet on the floor. With one hand, place on top of the crutch handles, the other on the chair armrest. Push up from the armrest. Once in standing, put your crutches in the correct position. Copyright-PHYSIOCURE
  27. 27. hip PAIN – Pain, bruising, swelling and stiffness of the hip is normal tive ce after the operation. You will be given medication to take home following your surgery and repeat prescriptions can be organized via your GP. It is advisable to take your advi pera painkillers to keep any pain to a minimum to help your rehabilitation, ensure a good nights sleep and enable relaxation of the leg. The anti-inflammatories will help the joint settle, and it is usually advised that these are taken for at least two weeks. Be aware that some patients o can feel no pain straight after surgery and some feel likePost- they have ridden a horse! (due to the bolster used in the traction procedure). It is normal to feel muscle soreness in the leg from the traction, and sometimes knee or ankle pain. Remember, as your activity level increases, then there may be temporary increased soreness. So it may not be wise to be weaning off your painkillers at the same time as coming off your crutches/starting work/ increasing exercise levels, etc… Copyright-PHYSIOCURE
  28. 28. hip PAIN continued – Drink plenty of water and have a healthy diet, tive including fresh fruit and vegetables, as the medication ce can make your ‘insides’a bit sluggish! See your GP if constipation or stomach upset is a problem with the medication. Getting enough rest and relaxation is advi pera important in settling pain and ice is useful too(Ref 14,15,16). When using an ice pack, wrap it in a damp tea towel to protect the skin. Leave it on for 10-20 minutes but be cautious of numb areas after surgery, do not use ice on these areas. Keep checking the skin o to avoid ice burn/frost bite. Your physio can also helpPost- with the pain – they may offer acupuncture and gentle massage (avoid wound).Keep a diary, recording all the positive progress you are making…some days may be ‘bad’ days, this is normal. Listen to your body, there maybe a reason that the pain has increased. Maybe you overdid something the previous day, or have come off your painkillers too soon or too suddenly? Learn from this and make modifications, don’t try and battle through pain..take things slowly (Ref 17). Copyright-PHYSIOCURE
  29. 29. hip WOUND CARE – You will have dressings on your wounds after surgery and will be told if your stitches are dissolvable or not. tive With the latter, you will advised by the nurse on the ce ward when these need to be removed (usually 7-10 days post op). This can be arranged at your GP advi surgery. There may be a small amount of blood that pera stains the dressings. This is normal, however, if it is more than this, please contact the ward or the consultant to report this. It is very important to keep the wound dry until it has fully healed, to prevent o infection. You will be supplied with waterproof dressings from the ward to ensure this whenPost- showering. Alternatively, waterproof dressings can be purchased from your chemist. Do not have a bath or commence hydrotherapy until your wounds are fully healed. Scar massage must only be started once the wounds are fully healed and strong enough to cope with this. Check with your physiotherapist when this is suitable and ask them to show you the correct massage technique. Copyright-PHYSIOCURE
  30. 30. ADDITIONAL ADVICE – hip •  Do not run/jump or do high impact sport for 6 weeks (13 weeks for microfracture) post surgery. Some patients may be advised not to run at all, if tive they have a particular hip condition. ce •  Driving is at the discretion of the consultant. advi Clutch use may flare up symptoms in the early pera stages of recovery and it is essential that an emergency stop can be fully performed before driving is resumed. •  A lot of consultants ban the use of treadmills o forever post surgery –check this with yours.Post- •  Check the appropriateness of the use of the rower and breast stroke swimming post surgery with the consultant and physio with your particular hip problem – it may not be advisable. •  Pay attention to good posture, do not sit in low soft settees, do not cross your legs or sit with your legs up on the settee in a twisted position. An ‘open seat angle’, where the angle of the hips is more than 90 degrees is recommended. A good mattress is favourable, check yours isn’t sagging. Copyright-PHYSIOCURE
  31. 31. ADDITIONAL ADVICE hip continued - Take good care of your hip for the first 8-12 weeks following surgery, or longer if you have pain or tive degeneration, or have been told to take rehabilitation ce slower. These are some activities to be careful with – •  Getting in/out of bed - assist and support your leg advi when it is painful and weak initially following pera surgery. •  Keep your knees together when getting in/out of the car and bed. •  Limit stair climbing, prolonged walking, standing, o sitting.Post- •  Avoid heavy lifting and repetitive bending, twisting or sudden/uncontrolled movements. •  Caution with squatting, crouching and lying on your operated side. •  Take consideration with intercourse positions – see the medical website , Herman and Wallace – orthopaedic considerations for intercourse. •  Do not provoke pain, if any exercises are painful..STOP and report to your physio, who will modify your program. Copyright-PHYSIOCURE
  32. 32. ADDITIONAL ADVICE continued – hip Returning to work – This subject needs to be discussed pre-operatively with your consultant/GP/physio and employer. It is tive ce important that the positions and tasks you need to carry out at work are analyzed realistically to avoid any set-backs in recovery. With the UK consultants I advi pera work with, their patients tend to have 2-6 weeks off work in sedentary jobs. A longer time off is usual in more manual jobs.It depends on the type of surgery you have had, the condition of the joint and other factors that indicate how long recovery might take. It o can vary.If you are in a sitting job, you need to makePost- sure you are going to be able to sit comfortably before returning to work. This means giving the hip adequate time to recover after surgery and rehabilitate. A workplace assessment may need to be done by your employer to check your desk and chair ensure a correct posture. A staged return is often a good idea. Feedback from my patients on this matter is that once you are back at work, it is hard to find time to do rehab exercises. This is why I have included sitting/ standing exercises in my guide that could be done ‘slottted’ in here and there in the day. Copyright-PHYSIOCURE
  33. 33. Labral repair and hip capsular plication/repair considerations – Some surgeons have a hip flexion up to 90’ limit for e 10 days then 120’ until 4 weeks post-op, and a hip e rang abduction 25’ limit for 3 weeks. Hip extension and dvic external rotation gentle or nil for first 3 weeks (to avoid stress on capsule and labrum) – check your surgeon’s guidelines…it will differ from surgeon to surgeon . ent a ative No isometric or loaded hip flexion for the first two weeks. After that period, avoid if painful and introduce only when safe to do so, to avoid hip flexor tendinitis. o pe r ovem Use night splints in internal rotation for capsular plication/repair for 4 weeks. All hip arthroscopies –Post- Do not push into painful movements, especially withof m arthritic hips and it is important to ALWAYS avoid aggressive hip extension. (ref 18,19,20,21) Copyright-PHYSIOCURE
  34. 34. •  Prevent hip flexor tendonitis. •  Be aware of ‘normal’ and ‘abnormal’ post-op pain. hip •  Check for trochanteric bursitis, sacroiliac joint d and lumbar spine dysfunction. tions •  ns an h ip Prevent, manage capsulitis / synovitis. py •  Manage scarring around portal sites. •  osco Adhere to instructions given by the surgeon on wing idera use of crutches – do not come off too soon. autio •  Adhere to instructions given by the surgeon regarding medication and rehabilitation plan and arthr any movement restrictions. follocons •  Attend post-operative appointments with yourPrec surgeon so they can monitor your recovery. •  Attend post-operative physiotherapy so they can address any rehabilitation problems and assist you in your recovery. •  Expect new pains and adjustments occurring in the rest of the body. •  Be mindful of the other hip, especially if it is possible that may also need surgery at a later date. Copyright-PHYSIOCURE
  35. 35. hip ss of impa gs ct on b Centre edge angle Presence of advanced indin below 20 degrees reha OA changes rene (dysplasia) tive f Awa Generalized hyperlaxity in patients Low pre-op modified may with instability harris hip score (MHHS) nega symptomsthat Pain and a negative hip arthroscopy Information courtesy of Prof Schilders
  36. 36. hip •  Early stage rehabilitation tion •  Patient on elbow crutches, wing partial weight bearing. y •  Aim to decrease pain and scop inflammation, promote bilita healing and protect repaired tissues. follo •  A whole body approach to rthro aid circulation, relaxation, Level early joint mobility, Re h a maintenance of muscle tone, correct posture and to cises prevent musculoskeletal one hip a compensatory issues in other parts of the body. •  Ensure hip joint neutralexer position is achieved in various postures and equal weight bearing through ischial tuberosities in sitting. Copyright-PHYSIOCURE
  37. 37. hip •  Week 1(day1-7) tion wing •  Week 2(day 8-14) y scop •  Week 3(day 15-21) bilita follo •  Week 4 (day 22-28) rthro Level •  Please note, some people Re h a may need to stay at week 1 cises for longer, or week 2, etc..It is important to progress at a one hip a speed that is appropriate to you. Pushing with exercises that are too hard or provokeexer pain is not advisable. The time frames in this handbook are meant as a general guide and may need to be modified to suit the individual. Copyright-PHYSIOCURE
  38. 38. LEVEL ONE hip Week 1 exercises 1. Circulatory exercises – ankle pumps. tion wing y Point one foot and at the same time flex the scop other foot back at the ankle, as shown below. Repeat 10 times hourly while immobile. bilita Aim – to pump blood to encourage circulatory follo flow whilst immobile. rthro Re h a cises hip aexer Copyright-PHYSIOCURE
  39. 39. LEVEL ONE Week 1 exercises hip Static contractions, hold 5 seconds, 10 reps, every 3 hours. Aim – to maintain muscle tone tion while immobile. wing y 2. Quadriceps - Straighten one knee and tighten / scop tense the muscles on the front of your thigh. bilita follo rthro Re h a Copyright-PHYSIOCURE cises hip a 3. Hamstrings – Bend one knee to approx 45 degrees. Push heel gently down into the bed to tense the muscle at the back of the thigh.exer
  40. 40. LEVEL ONE hip Week 1 exercises Static contractions, hold 5 seconds, 10 reps, 2 times tion a day. Aim – to maintain muscle tone while immobile. wing y 4. Transversus Abdominis (T.Abs) – Lie on your scop back with your hips and knees bent to approximately 45 degrees (as in exercise 5). Place a small pillow or bilita folded towel under your head if needed. It is important follo that you feel relaxed and comfortable. Next, keeping your bottom in contact with the bed/ rthro floor, tuck your tailbone under so you flatten your Re h a back against the bed/floor..then tilt the other way, arching your lower back gently..this is called a pelvic cises tilt. Do this a few times as it will help to gently mobilise your lower back. Now, position your pelvis so your hip a lower back is in what we call ‘neutral’, this is the position in between the two movements you have just done and your lower stomach should be level north-exer south, east-west. Finally… without losing this position, gently pull your lower tummy muscles (T.Abs) in, as if you are pulling your navel towards your spine. Your upper body should still be relaxed and you should try to breathe normally as you do so. As we go through this guide, we will exercise this muscle in various positions. (Ref 22). Copyright-PHYSIOCURE
  41. 41. LEVEL ONE hip Week 1 exercises Static contractions, hold 5-10 seconds, 10 reps, 2 tion times a day. Aim – to maintain muscle tone while wing immobile. y scop 5. Hip Abductors – Lie on back, hips and knees bilita bent to approx 45 degrees. Tie a belt around your lower thighs. Use the techniques in exercise 4 to follo find a neutral spine and to gently contract the T.Abds. Gently push out sideways against the belt. rthro Make sure this does not provoke pain. Keep a Re h a neutral pelvic position throughout. If you find getting down to the floor a problem with these cises following exercises, lie on the bed. Safety comes hip a first.exer Copyright-PHYSIOCURE Caution - with trochanteric bursitis
  42. 42. LEVEL ONE Week 1 exercises hip Static contractions, hold 5 seconds, 10 reps, every 3 hours. Aim – to maintain muscle tone while tion immobile. wing y 6.Gluteals – Gently squeeze together your buttock scop muscles. This can be done in the position shown in bilita exercise 5, or in sitting, or laid on your front, or in standing….whichever is the most comfortable. If follo lying on your front, place your feet in the position rthro shown in the picture, heels in neutral, ensure a neutral lumbar spine, and gently contract your T.Abs Re h a before squeezing your bottom. This exercise can be cises improved by palpating your side hip bones to give you feedback to check you are not gliding or rotating hip a around the hip joint or pelvis as you contract your gluts. The hip joint and pelvis should stay in neutral. Then progress to individual glut (buttock) squeezes.exer Therapists – please read Sahrmann’s work (ref 22) Copyright-PHYSIOCURE
  43. 43. LEVEL ONE hip Week 1 exercises Gentle stretches – Hold 10-20 seconds, 5 reps, 2 times a day. Aim- to maintain muscle length without tion wing provoking inflammation/pain. y 7. Quadriceps – Lie on your front with a folded towel scop under your forehead so your head is supported and bilita not in a twisted position. Engage your T.Abs in a follo neutral spine. Bend one knee bringing the heel of the foot towards the bottom. A stretch in the front of the rthro thigh should be felt. Your lower back should not Re h a hollow, your T.Abs and gluts should be maintaining neutral spinal and pelvic position. If you can not cises comfortably lie on your front, try a pillow under your hips and/or ankles. hip aexer Copyright-PHYSIOCURE
  44. 44. LEVEL ONE Week 1 exercises hip Gentle stretches – Hold 10-20 seconds, 5 reps, 2 times a day. Aim- to maintain muscle length without provoking tion inflammation/pain. wing y 8. Iliotibial band and hip abductor stretch – Lie on your scop non-operated side on the bed, near the edge, with the bilita underside knee/hip bent. Pillow under head. Straighten the top leg. If a gentle stretch is felt in this position, do follo not progress to the next stage. Hold in the gentle stretch position. To progress this exercise, gently let the foot of rthro the top leg hand over the side of the bed, as shown in the Re h a picture. cises hip aexer Warning – do not do if this causes any ‘nipping’/pain in the groin. Copyright-PHYSIOCURE
  45. 45. LEVEL ONE hip Week 1 exercises Gentle stretches – Hold 10-20 seconds, 5 reps, 2 tion wing times a day. Aim- to maintain muscle length without y provoking inflammation/pain. scop 9. Adductors – sit (not on a low seat), feet on the floor, bilita using your hands to support the operated leg, gently follo take it out to the side. DO NOT LET IT ROTATE OUTWARDS. Only a small careful movement should be rthro done at this early stage. A GENTLE stretch should be Re h a felt in the inner thigh. cises hip aexer Warning – do not do if this causes any soreness/pain in the groin. Copyright-PHYSIOCURE
  46. 46. LEVEL ONE hip Week 1 exercises 10. Exercise bike – the use of the bike post hip arthroscopy varies from surgeon to surgeon, some tion wing recommend immediately, some after 1 week, some y after 2, some after 4. Check your surgeon’s protocol. scop We advise our patients use the bike, with the seat high, bilita to encourage early ACTIVE ASSISTED range of movement of the hip, the day after surgery. The bike follo should be set to zero resistance and the non operated leg should do most of the work. Pedaling should be rthro done slowly, and the operated hip should not ‘hitch- up’, it should feel relaxed during movement. Start by Re h a doing the bike ‘little and often’ eg. 5-10 minutes 2-3 cises times a day, but you may increase this if it feels comfortable and pain free. Increase SLOWLY by 5 hip a minutes. Keep at the same time for a few days before increasing time. Maximum would be 45 mins, 2 x a day. No resistance until week 5-6.exer Warning – modify time used, if this causes any soreness/pain in the groin. Try pedaling backwards! Copyright-PHYSIOCURE
  47. 47. LEVEL ONE Week 1 exercises hip 10. Exercise bike – continued …… tion wing What do we do if for some reason the patient can not y go on an exercise bike? scop bilita Some surgeons recommend pendular hip movement rather than the bike at this stage. This exercise could be follo used for patients who can not use a bike . rthro •  Stand on a step with your non-operated leg, see Re h a photo on the next page. Holding on with both hands, to a secure support. Let the operated leg cises hang in a heavy, relaxed fashion. Imagine your leg to like a pendulum of a clock and gently swing it hip a forwards then back to neutral (no hip extension ). Repeat 10-20 times every 2 hours.exer •  This movement can also be done in the pool as long as the patient is safe to mobilise in this environment and has waterproof wound dressings. •  Water cycling can be done with floats assisting and supporting – see separate hydrotherapy guide. Copyright-PHYSIOCURE
  48. 48. hip LEVEL ONE Week 1 exercises tion wing y Pendular exercise – scop bilita follo rthro Re h a cises hip aexer Neutral Forward Copyright-PHYSIOCURE
  49. 49. LEVEL ONE Week 1 exercises hip Aim – maintain upper body flexibility. 11. Supine chest openings – Lie on your back with tion wing your knees and hips bent to approx 45 degrees. Ensure y good symmetrical alignment of the legs and a neutral scop spine (see exercise 4). Bring your hands together in bilita front of you, in a prayer position. Connect your T.Abds and as you breathe out, open out your arms as in the follo picture below. Only go as far as comfortable. It is important to keep a neutral spine and not let your rib rthro cage lift up or your spine hollow. Hold as you breathe in. Re h a Then return to the start position as you breathe out. cises Repeat 5-10 times, 1-2 times a day, as required. Can be progressed to lying on a fit roll (not in week 1-3). hip a Top tip – good for tightnessexer caused from crutch use Early stage Advanced stage
  50. 50. LEVEL ONE hip Week 1 exercises Aim – maintain upper body flexibility. 12. Spinal extension – Lie on your front, prop yourself tion wing up on your forearms. Slide your shoulder blades gently y down your back, gently tuck in your chin so you are scop lengthening down the back of your neck (do not allow bilita chin poke). Connect through your T.Abds, keep your lumbar spine and pelvis neutral. Gently push your follo breastbone forwards as you breathe out so your thoracic spine hollows(the bit between your lower neck and rthro lumbar spine). Hold the position as you breathe in, then relax to the start position as you breathe out. Repeat Re h a 5-10 times, as required, 1-2 times a day. cises hip a Top tip – this part ofexer spine can become very stiff due to body compensations and use of crutches. Incorrect this exercise also gently -’hinging’ stretches the hip flexors Copyright-PHYSIOCURE
  51. 51. LEVEL ONE Week 1 exercises hip 13. PRONE LYING – try and spend one hour laid on tion your front in the morning and one hour in the afternoon. wing y This is to prevent the front of your hip becoming tight. scop 14. ICE – Use an ice gel pack wrapped in a damp tea bilita towel (to protect your skin). 20 minutes every 3 hours. Do not use on numb skin and keep checking the area follo and moving the ice pack to different parts of the leg/ hip/pelvis to avoid ice burns. rthro 15. RELAXATION – Plenty of sleep and rest is needed Re h a in recovery. Take things slow, be realistic, do not try and rush recovery. Keep positive and keep stress to a cises minimum. ‘Self Care – the seed of recovery. It is nearly hip a impossible to use your body well and treat it wisely when you feel hostile, fearful or harshly demanding toward some part of yourself’ (ref 23).exer Note to therapists – Acupuncture (Ref 24,25,26) and gentle massage techniques for pain relief, muscle spasm and swelling are helpful at this stage. Some consultants advise hydrotherapy at this early stage. Health and safety criteria must be met. See ‘Hydrotherapy exercises following hip arthroscopy guide’, by Louise Grant (HIP-PHYSIOCURE). Copyright-PHYSIOCURE
  52. 52. WEEK 1 -Exercise record sheet Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 712345678910111213 521415
  53. 53. LEVEL ONE hip Week 2 exercises Aim – Gentle transversus abdominis/hip/pelvic control tion 16. Supported heel sides in supine. Lie on your back, wing y knees and hips bent to approx 45 degrees, ideally on a scop ‘slidey’ surface that your heel can glide along. Use a strong strap or belt to secure around your operated leg bilita foot, hold with both hands – as shown in the photo. follo With relaxed breathing, a neutral pelvis and lumbar rthro spine and T.Abs engaged….and using the strap to assist the movement of the operated leg, gently slide Re h a the leg out straight, keeping the heel in contact with the cises floor. Then assist the leg to bend. You are aiming to go from 0-70 degrees hip flexion, keeping the heel in hip a contact (no lifting) with the floor and the leg supported at all times, to avoid activation of the hip flexor (ref 27). Repeat 5-10 times, 2 times a day..SLOWLYexer Copyright-PHYSIOCURE
  54. 54. LEVEL ONE hip Week 2 exercises Aim – hip flexion mobility with lumbo-pelvic control and tion early dissociation. wing y 17. Four point kneeling hip rocks. Set yourself up as in scop the first picture. Hands directly under shoulders, knees bilita under hips. Perform some pelvic tilts initially in the position to mobilise the lumbar spine and eventually follo find neutral. Gently draw your navel towards your spine, rthro activating the T.Abs but keeping the lumbar spine in neutral. Now, gently ‘rock’ your bottom backwards Re h a towards your heels, but do not bend in the back, keep cises the spine neutral and T.Abs engaged. Do not rotate the pelvis and aim for symmetry of movement. Hold for 5 hip a seconds, then ‘rock’ forward as in the last photo . Hold 5 seconds. Repeat 10 times, 2 times a day. (ref 22)exer Copyright-PHYSIOCURE
  55. 55. hip LEVEL ONE Week 2 exercises tion Aim – early hip abduction/adduction mobility with wing y lumbo-pelvic control and early dissociation. scop 18. Four point kneeling hip glides. Set yourself up as bilita in the first picture. Hands directly under shoulders, knees under hips. Perform some pelvic tilts initially in follo the position to mobilise the lumbar spine and eventually rthro find neutral. Gently draw your navel towards your spine, activating the T.Abs but keeping the lumbar spine in Re h a neutral. Now, gently and slowly, ‘glide’ your hips to the cises side. Do not rotate the pelvis. Aim for symmetry of movement. Avoid painful ranges. Hold for 5 seconds, hip a then ‘glide’ to the other side. Repeat 10 times, 2 times a day. (ref 22)exer Copyright-PHYSIOCURE
  56. 56. LEVEL ONE hip Week 2 exercises Aim – Gentle hip mobility tion wing 19. Hip internal rotation. Lie on your front, neutral y lumbo-pelvic spine, T.Abs engaged. Bend your knees scop up to 90 degrees bend, keeping them together. Slowly bilita and gently make a ‘V’ shape, separating your feet but follo keep your knees together. Hold 5 seconds, repeat 5-10 times, 2 times a day. rthro Re h a cises hip aexer Copyright-PHYSIOCURE 20. Exercise bike (as per description in ex. 10)
  57. 57. LEVEL ONE hip Week 2 exercises Aim – maintain calf muscle strength tion 21. Ankle plantar flexion with resistance band. Secure wing y a resistance band like a stirrup around the ball of the foot. scop Hold with both hands. Firstly pull the foot back towards you, pull the band tight so it under tension, then flex your bilita foot at the ankle pushing against the resistance of the follo band. Hold 5 seconds, repeat 10 times, 2 times a day. rthro Re h a cises hip aexer SAFETY WARNING – ALWAYS CHECK YOUR ELASTIC EXERCISE BAND BEFORE USE, THERE IS A DANGER THAT IT COULD SNAP. EYE GOGGLES ARE ADVISED TO BE WORN WITH THESE PRODUCTS.
  58. 58. LEVEL ONE Week 2 exercises hip Aim – maintain quadriceps and hamstring strength and flexibility tion wing 22. Prone lying hamstring curls/Quads stretch. y Position yourself as in exercise 7 but with a small ankle scop weight around your ankle. Perform the exercise as in bilita exercise 7, slowly. Hold 10 seconds, 10 repetitions, 2 times a day. follo This exercise aims to gently work your hamstrings and at the same time stretch your quadriceps muscles. (ref rthro 27) Re h a 23. Seated knee quads extension/Hams stretch. Sit up cises straight on a firm chair. Feet should be on the floor and hips/knees at 90 degrees, or hips at more of an open hip a angle if required. Gently draw in your lower stomach muscles (T.Abs), lumbar spine in neutral. Straighten one knee, tensing up the muscle on the front of the thigh…exer try to keep your back straight. Hold 10 seconds, 10 repetitions, 2 times a day. Top tip- place one hand in the area between your incisions and try and ‘tense’ contract that area as you do exercise 23. This area may be inhibited with muscular activity after surgery. Copyright-PHYSIOCURE
  59. 59. hip LEVEL ONE Week 2 exercises tion Aim – maintain hip abductor and adductor length wing and strength y scop 24. Isometric hip abduction (as per exercise 5). bilita 25. Hip Abductor/ITB stretch (as per exercise 8). follo 26. Hip Adductor stretch (as per exercise 9). rthro 27. Isometric hip adduction. Gentle squeeze with a soft Re h a football or pilates ‘magic-circle’. Try in sitting/lying/ standing, which ever is comfortable. Do not do if it cises increase any adductor soreness. hip a Squeeze for 5-10 seconds, 5-10 times, 2 times a day.exer sitting standing lying Copyright-PHYSIOCURE
  60. 60. LEVEL ONE Week 2 exercises hip Aim – maintain gluteal strength and length 28. Isometric hip gluteals (as per exercise 6). tion wing 29. Gluteal/piriformis stretch. Lie in the position y shown with your operated leg on top. Place a pillow under the knee of your operated leg for comfort (if scop required). You should feel a stretch in your bottom bilita muscles. If uncomfortable, try having your top foot tucked behind the underneath foot, rather than behind follo the knee. To increase the stretch, rotate upper body backwards, or lie near the edge of a bed so you can drop rthro the knee of the top leg over. BE AWARE THAT THIS EXERCISE CAN CAUSE NIPPING IN THE GROIN…if you Re h a feel this, please do not do. Hold the stretch 5-10 seconds, as comfort allows, repeat 5-10 times, 2 cises times a day. hip a Copyright-PHYSIOCUREexer 30. Upper body stretches (as per exercises 11 and 12).
  61. 61. LEVEL ONE hip Week 2 exercises tion wing Continue with as in week 1 – y scop Prone lying, rest, relaxation and ice (exercises 13-15) bilita follo Note to therapists – Early passive gentle hip circumduction is recommended (Wahoff & Ryan, ref rthro 20). Done passively with hip in 70 degrees flexion. Re h a Gentle passive ‘log rolling’ of the leg in neutral is also useful. cises Appropriate joint mobilisations and soft tissue hip a techniques, such as myofascial release (Ref 28,29,30,31,32,33,34) , positional release and active release techniques can be beneficial. Emphasis isexer placed on the iliopsoas, iliotibial band, adductors, gluteus medius, quadratus lumborum and quadriceps(Ref 20). Acupuncture and electro- acupuncture can be helpful throughout rehabilitation (Ref 24,25,26). Copyright-PHYSIOCURE
  62. 62. WEEK 2 - Exercise record sheet Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 1416171819202122232425262728 622930
  63. 63. LEVEL ONE hip Week 3 exercises Aim – improve hip/lumbo-pelvic control tion wing 31.Heel slides in supine. Progress exercise 16, to be y done without a strap, if adequate control is displayed scop and it is pain free. Still keep heel in contact with the bilita floor at all times. Repeat slide 5-10 times slowly, 1-2 times a day. follo Aim – activation of gluteus medius with low iliopsoas rthro activation (exercise 32) (ref 27) Re h a 32. Double leg bridges. Lie on your back with your feet flat on floor, knees and hips bent. Lumbo-pelvic neutral, cises T.Abs engaged. Squeezing your bottom gently lift up hip a your pelvis to bring your hips up into a neutral position. Hold 5-10 seconds, 5-10 repetitions, 1-2 times a day.exer Copyright-PHYSIOCURE
  64. 64. LEVEL ONE hip Week 3 exercises Aim – weight transference to prepare for independent tion walking wing y 33.Weight transference exercises.If your consultant scop has given you consent to wean off crutches at the end of two weeks, then you will need to do exercises so bilita you are balanced and do not have a limp. follo DO NOT DO THIS EXERCISE IF YOU STILL HAVE WEIGHT BEARING RESTRICTIONS rthro Stand near an appropriate support that you can Re h a comfortably hold onto. Try and make sure your weight cises is distributed equally between your feet. Imagine each foot to be a tripod of weight bearing, (heel, the hip a base of the big toe and the little toe) and try to evenly distribute your weight through these three points. Now, position your body alignment imagining a lineexer dissecting through your side ankle bone up to the boney prominence of your lateral hip (greater trochanter), the middle of the lateral aspect of your shoulder, and finally your ear. Next, put your hands on top of your pelvis and imagine this to be rim of a bucket, tilt your pelvis anterior/posterior so the ‘rim’ is level. Engage your T.Abs and now you are ready to do weight transference!...see next page…. Copyright-PHYSIOCURE
  65. 65. LEVEL ONE Week 3 exercises hip Continued …. In the position detailed in exercise 33. slowly and gently sway your body weight forwards over your feet and then back into your heels. Keep your Trans tion wing Abs engaged (Ref 35) and you should feel your gluteals y ‘switch on’ at certain points. Do this 20 times. Then try scop side sways 20 times, get your physiotherapist to check bilita your technique with these. Progress standing posture work with the ‘tight rope’ stance. One foot in front of the follo other and gaining hip joint neutral (Ref 36)and lumbo- rthro pelvic neutral. Re h a 34. Hydrotherapy. (see separate hip arthroscopy hydrotherapy guide). cises Aim – as a medium to practice walking, weight hip a transference, early hip mobility , early lumbo-pelvic stability challenges and a ‘whole body’ approach. (ref 37,38) Health and safety criteria must be met beforeexer commencing hydrotherapy – see separate hydro guide. Copyright-PHYSIOCURE
  66. 66. LEVEL ONE Week 3 exercises hip Aim – to develop calf muscle strength to aid gait re- education tion 35. Bilateral calf raises. Stand, facing an appropriate wing y support that you can hold onto. Modify weight bearing scop on operated side as per surgeon’s instructions. Ensure bilita a good posture as you raise your heels so you are standing on the balls of your feet. Keep your ankles follo strong, do not let them rotate or twist. Repeat 10-20 times, 2 times a day. rthro Note – Progression to alternate calf raising and Re h a single leg calf raises will all depend on how much cises weight limit you have been instructed by your surgeon to put through your leg. You must comply hip a with this advice.exer Copyright-PHYSIOCURE
  67. 67. hip LEVEL ONE Week 3 exercises tion Aim – to improve lower limb flexibility wing y 36. Hamstring stretch. Lie on your back with head scop supported. Place an elastic resistance band (note bilita health & safety warning ex.21) like a stirrup around your foot. Start position, knee and hip bent to 90 follo degrees. Shoulders relaxed, lumbo-pelvic neutral, rthro T.Abs engaged, band under tension. Use band to assist straightening of the knee so a stretch in the back of Re h a your thigh is felt. Hold 10-30 seconds, 5-10 times, 2 cises times a day. hip aexer Copyright-PHYSIOCURE
  68. 68. hip LEVEL ONE Week 3 exercises tion Aim – to improve lower limb flexibility wing y 37. Calf stretch. Stand as in the picture. If still scop partial weight bearing, use an appropriate bilita support to hold onto so you can take some weight through your arms. Put one leg behind you, one in follo front, feet pointing forwards. Slowly bend the knee rthro of the front leg, keep the heel of the back leg on the floor and the knee straight. A stretch should be Re h a felt in the back of the rear calf muscle. Hold 10-30 cises seconds, 5-10 times, 2 times a day. hip aexer Try and maintain a good posture, do not twist in the pelvis;… use T.Abs to control. Copyright-PHYSIOCURE
  69. 69. hip LEVEL ONE tion Week 3 exercises wing y Aim – to improve lower limb flexibility scop bilita 38. Iliotibial band stretch. Sit on the floor, one leg straight and the other crossed over it, as follo shown in the photo. Pull your bent knee towards your opposite shoulder and turn your body rthro slightly away so you feel a stretch in your lateral Re h a thigh/buttock. Hold 10-30 seconds, 5-10 times, 2 times a day. cises hip aexer Please check this exercise does not pinch in the groin. Try exercise 8 if that Copyright-PHYSIOCURE is more comfortable.
  70. 70. LEVEL ONE hip Week 3 exercises tion Aim – to improve flexibility wing y 39. Faber stretch. Lie on your back. Cross one leg, so scop the foot is on the top of the opposite ankle, top leg is bilita turned slightly out (figure 4 position). You can place some pillows under the knee of the top leg for support. follo For an increased stretch, slide the top foot up the shin towards the knee and let the top knee lower towards the rthro floor. Do not push on the knee or force the stretch. Re h a An alternate position is to lie on your front in the cises position shown below. hip a Hold 10-30 seconds, 5-10 times, 2 times a day.exer Check the limit of external rotation in surgeon’s protocol. Some will prefer this movement Copyright-PHYSIOCURE to be done later on.
  71. 71. LEVEL ONE hip Week 3 exercises 40. Exercise Bike. As per exercise 10. tion wing y 41. Hip rocks and glides. As per exercises 17 and 18. scop bilita 42. Hip internal rotation. As per exercise 19. follo 43. Isometric hip adduction with ball. As per exercise 27. rthro 44. Resisted hamstring curls. As per exercise Re h a 22. cises 45.Standing hip abduction of operated side. hip a Stand near an appropriate support to hold on to. Assume correct stand posture as in exercise 33. Take your weight on to your un-operated side,exer engaging T.Abs and gluteals. Slowly glide your operated leg out sideways, a short distance so the foot is clear of the floor, squeezing your bottom gently. Hold 5-10 seconds, repeat 5-10 times, 2 times a day. Copyright-PHYSIOCURE
  72. 72. LEVEL ONE hip Week 3 exercises (additional suggestions) Aim – lumbo-pelvic control and mobility tion Swiss Ball exercises. Sit on the swiss ball feet flat on wing y the floor, seated so your hips are NOT lower than your scop knees, pic 1. Ensure you have equal weight through the bilita ‘sit bones’ (ischial tuberosities) by putting your hands under your bottom. Adopt a good posture, engage your follo T.Abs gently and engage pelvic floor, ref 39 (ask your physio how to do this). Now tuck your ‘tailbone’ under, rthro pic 2 (posterior pelvic tilt), your ‘sit bones’ should feel Re h a more flat, then roll back the other way, sticking your bottom out so your lumbar spine has a hollow, pic 3, cises (anterior pelvic tilt)…your ‘sit bones’ will feel more hip a pointed. Repeat 10-20 times, 2 times a day.exer 1 2 3 Copyright-PHYSIOCURE
  73. 73. hip LEVEL ONE tion Week 3 exercises (additional suggestions) wing y Aim – lumbo-pelvic control and mobility scop Swiss Ball exercises. ..continued. Assume the bilita position as before. Lumbo-pelvic neutral, T.Abs follo engaged, good overall posture. Glide your hips laterally to the side, and then to the other side. Place rthro your hands under your ‘sit bones’ to monitor weight Re h a bearing and weight transference being equal as you go to one side and then another. cises Repeat 10-20 times, 2 times day. hip aexer Copyright-PHYSIOCURE
  74. 74. hip LEVEL ONE tion Week 3 exercises (additional suggestions) wing y Aim – lumbo-pelvic control and mobility scop Swiss Ball exercises. ..continued. These are bilita optional other exercises that may be useful… follo rthro Re h a Alternate heel raises cises hip aexer Progressing to alternate foot lifts…. Copyright-PHYSIOCURE
  75. 75. hip LEVEL ONE tion Week 3 exercises (additional suggestions) wing y Aim – lumbo-pelvic control and mobility scop Swiss Ball exercises. ..continued. These are bilita optional other exercises that may be useful… follo rthro Re h a Upper body rotations cises – early dissociation work of Tx/pelvis hip aexer Upper body side bends Copyright-PHYSIOCURE
  76. 76. hip LEVEL ONE Week 3 exercises (additional suggestions) tion wing Aim – lumbo-pelvic control and mobility y scop Swiss Ball exercises. ..continued. These are bilita optional other exercises that may be useful… follo rthro Re h a Seated chest openings cises start position hip aexer Seated chest openings finish position Copyright-PHYSIOCURE
  77. 77. LEVEL ONE hip Week 3 exercises Note to therapists – Encourage your patient to still get adequate rest and to use ice on areas that are tion wing sore. Teach patient self-massage AROUND but not y on scars. scop Some patients may be planning to returning to work bilita at this stage. If you have any concerns about this, follo you must discuss with the patient/surgeon. rthro Pushing rehab/manual therapy to extremes of movement will not enhance function, and will Re h a increase soreness, inflammation and potentially cises prolong recovery. Do not provoke hip flexor tendinitis or bursitis, monitor exercises and modify hip a if necessary. Gentle hip gliding mobilizations and caudadexer longitudinal distraction in neutral can be performed if appropriate with the type of surgery and type of protocol. Some surgeons do not allow hip distraction manual techniques until a later stage – check. (Ref 9 Chapter 25, and ref 6 Chapter 17). Copyright-PHYSIOCURE
  78. 78. WEEK 3 - Exercise record sheet Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 2131323334353637383940414243 784445