Hip-Physiocure in collaboration with The Yorkshire Hip Clinic and Fitcure have produced their new evidence based 2021 Hip Arthroscopy Rehabilitation guide

1. THE HIP ARTHROSCOPY REHABILITATION
GUIDE 2021 - SUMMARY
FOR PATIENTS, SURGEONS AND THERAPISTS
Second Edition. March 2021©
Louise Grant MSc. MCSP. MHCPC
Hip Specialist Chartered Physiotherapist.
Hip-Physiocure, UK
Associate Member International Society For Hip Arthroscopy (ISHA)
In collaboration with The Yorkshire Hip Clinic and Fitcure

2. ! VISIT OUR WEBSITE FOR THE
FULL FREE GUIDES, WITH
PHOTOS AND DETAILS ON EACH
EXERCISE
WWW.PHYSIOCURE.ORG.UK
ALL REFERENCES CAN BE
FOUND AT THE END OF THE
PHASE FOUR FULL GUIDE
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3. DISCLAIMER
• Disclaimer – The author is not responsible for any person’s using this guide or for their interpretation of it.
• Hip arthroscopy rehabilitation should be done under the care of a suitably qualified Chartered Physiotherapist or
equivalent therapist, and any concerns raised immediately to your Hip Surgeon.
• DO NOT USE THIS GUIDE TO REPLACE ADVICE FROM YOUR SURGEON OR THERAPIST.
• DO NOT USE IT TO REPLACE GOING FOR FACE TO FACE INDIVIDUAL CARE
• This guide is not intended to replace your Surgeon’s protocol, but to be used alongside it. Louise has gathered together hip
arthroscopy guides/protocols from around the world, research papers and books, her learning from attending international hip
conferences, and from individual teaching from top hip arthroscopy surgeons, to personally formulate this amalgamation of
material. She has also collected data, recording her own patient’s experiences of hip arthroscopy rehabilitation over the last 10+
years that has helped mould this booklet and have a clinician’s perspective based a wide variety of cases rather than a research
study sample (these have age, health factors, sports and joint condition criteria and so make recommendations based on a certain
group of the population). This guide is general, and can not cover every eventuality. It also needs to be highlighted that some
patients having the surgery have suffered for a long time and maybe in a physically depleted state and they are going to be at a
different starting point to an athlete who is fit, strong and having immediate surgery on an acute labral tear.
• USE OF THIS GUIDE IS DONE SO AT YOUR OWN RISK.
• Louise Grant – Physiocure – March 2021
2

4. 3
THE ‘HAPI’ STUDY
PRE-OPERATIVE EXERCISES FOR
HIP ARTHROSCOPY SURGERY
• The HAPI program was designed in 2012 to address the specific muscle weakness in the hip flexors,
extensors, external rotators, adductors and abductors which have been identified in FAIS acetabular labral
tear subjects 26, 27, 28. As the study was a controlled research trial, all the patients had to do the same plan
so I could compare the effects of a set intervention.
• We also looked at the research in a wider sense to include calf strengthening, as Lewis et al 29 presented
findings to suggest increased ankle push-off could help decrease forces through the hip. We noted that
anecdotally many papers commonly reported hip flexor tightness; therefore gentle mobility work was
incorporated 30,31. Another very common feature we noticed in clinical practice was a weak, poorly controlled
single leg squat, so we thought it a good idea to try and improve that functional movement. This movement
was found to be a pre-operative indicator of post-operative function in total hip replacement patients in a study
published in 2011 32 . Since then there has been evidence published in 2016 stating 1 to 2 years after hip
arthroscopy, deficits in single-leg squat performance exist that have the potential to increase hip joint
impingement and perpetuate postoperative symptoms 33 .
3

5. 4
HIP ARTHROSCOPY REHABILITATION
THE EVIDENCE
• What research is out there for us to base our protocol on?
• There are many papers with clinical commentaries on hip arthroscopy rehabilitation 46,47,48, case series studies 49,50,,
but only one randomized controlled trial (RCT) - the FAIR trial 51 .
• In a study published in 2018, 28 Surgeons and 62 Physios in Scandanavia both rated physiotherapy as an important
part in the rehab process and advocated a progression based on a combination of a criteria and time 52.
• Published in December 2020, a systematic review concluded phase based rehab protocols can help achieve
predictable improved outcomes 65 .
• In 2021 the International Society for Hip Arthroscopy Physiotherapy group published their consensus 93 statement on
how FAIS should be assessed and treated and guidelines for hip arthroscopy rehabilitation.
4

6. 5
HIP ARTHROSCOPY REHABILITATION - PHASES OF REHAB
• Staging a guide that is time framed is not always realistic, and can cause some patients huge distress when they
feel they are not meeting time bound goals, therefore we have set out four phases of post-op rehab, where there
may be an overlap of phases. The ‘weeks’ associated with each phase are not set in stone and only there as a
general guide.
• Each patient will have different goals. If a non-athletic patient is pain free, with good symmetrical range of
movement and power, is back at work/hobbies, and is happy with this recovery, it may not be appropriate to push
them to do exercises aimed at elite sports people, such as in Phase four. Thus, for these patients, their end point
may be Phase three exercises but possibly carried on for a longer period of time.
• In this guide there are criteria to be met, and relevant tasks to be performed satisfactorily before moving
onto the next phase.
5

7. 6
HIP ARTHROSCOPY REHABILITATION
CRITERIA FOR PROGRESSION SUMMARY
Phase one Phase two Phase three Phase four
Criteria to be reached before
commencing Phase two
37,50,60,65,96,98 –
• Minimal pain or inflammation
with Phase One exercises
• 10 degrees of hip extension
• Asymptomatic hip flexion at 90∘
• Full weight bearing achieved,
normal gait +/- aids
• Range of motion in all planes
>75% compared with opposite
hip
• Good control with mini squats,
double leg bridge, double leg
calf raises
• Ability to contract target muscle
without substitution muscle
dominance
Criteria to move onto Phase
three 37,50,60,65,93,98 –
• Phase two exercises are
pain free and have have
good control
• Range of motion is full in all
planes of motion compared
with opposite leg
• Pain free normal gait
• No joint inflammation,
muscle irritation or pain
• Good neuromuscular
control of functional
movement patterns
• Progressions should be
made based on objective
assessment and not on
time frames
Criteria to move onto Phase
four 37,50,65 –
• All Phase three exercises are
demonstrated with good
control, strength and are pain
free
• Full range of hip and spinal
movement
• Hip muscle testing 90% of the
uninvolved side with hand held
dynamometer
• Cardio-vascular fitness equal
to pre-injury level
• Good control shown with split
squats/lunges, single leg
bridge, hip rotation control,
single leg squat, the plank and
superman exercises
Criteria to move onto the
‘return to play/sport’ Phase –
At this stage we recommend
working one to one with your
rehab specialist trainer to
develop an individual plan and
goals required for your specific
sport100. You should be able to
carry out the exercises in Phase
four with no pain and good
technique and control. The Vail
Sports Hip Test103, Star
Excursion Balance Test88 and
the Copenhagen Adductor
Exercise 90,91 offer a way of
measuring progress but may not
reflect what is demanded of you
in your specific sport

8. 7
HIP ARTHROSCOPY REHABILITATION- A SUMMARY

9. 8
GENERAL WEIGHT BEARING
GUIDELINES
• Weight bearing guidelines are procedure related and may differ from surgeon to surgeon, the following are
based on a review of the literature and what Jon Conroy recommends 19,50,65,93,102 .
8
PROCEDURE
Labral resection PWB (partial weight bearing) to WBAT (weight bearing as tolerated)
up to 2 weeks
Labral repair PWB to WBAT, 2-4 weeks, dependent on location and extent of tear
Osteoplasty PWB to WBAT, up to 6 weeks
Microfracture PWB to WBAT, up to 8 weeks
Capsular modification Variable – depending on procedure
Tendon lengthening/release PWB to WBAT, up to 2 weeks

10. 9
MOVEMENT RESTRICTIONS
FOLLOWING SURGERY
• Range of motion guidelines are procedure related and may differ from surgeon to surgeon, so it is
important for the Physio to have the full operation details, and guidance from the surgeon this is a general
overview based on how our surgeon works and published literature 19,50,65,93 –
9
PROCEDURE
Labral resection As tolerated by the patient
Labral repair Anterior – limit external rotation and extension up to 4 weeks
Posterior – limit flexion and/or internal rotation up to 4 weeks
Osteoplasty As tolerated by the patient
Microfracture Varies with the procedure location
Capsular modification Anterior – limit external rotation and extension up to 4 weeks
Posterior – limit flexion and/or internal rotation up to 4 weeks
Tendon lengthening/release As tolerated by the patient

11. 10
HIP ARTHROSCOPY REHABILITATION
AVOID
10
Clam shell exercise
Straight leg raises
Avoid straight leg raises, the clam shell exercise, the rower and the treadmill

12. 11
HIP ARTHROSCOPY REHABILITATION
PHASE ONE – DAY1-3 – ON THE WARD
11
Key exercises -
1 Circulatory exercise – ankle pumps
2 Static quadriceps contraction
3 Static hamstrings
4 Pelvic tilts
5 Relaxation
And….
learning to walk, doing the stairs, sit to
stand, get in/out of bed, washing and
dressing.

13. 12
HIP ARTHROSCOPY REHABILITATION
PHASE ONE – WEEK ONE – AT HOME
Key exercises -
6 Active hip circumduction
7 Gluteal activation
8 Prone lying
9 Ice
10 Core activation and lateral breathing
11 Passive hip circumduction
Key exercises -
1 Circulatory exercise –
ankle pumps
2 Static quadriceps
contraction
3 Static hamstrings
4 Pelvic tilts
5 Relaxation
Additional exercises -
12 Quadriceps stretch
13 Spinal extension
14 Chest openings
15 Seated spinal mobility
16 Hip flexion slides

14. 13
HIP ARTHROSCOPY REHABILITATION
PHASE ONE – WEEK TWO, THREE & FOUR
13
Exercises from the previous week -
SPINAL & HIP MOBILITY 4 Pelvic tilts
REST 5 Relaxation
HIP MOBILITY 6 Active hip circumduction in supported standing
POSTERIOR HIP ACTIVATION 7 Gluteal activation in prone
ANTERIOR HIP MOBILITY 8 Prone lying
CALMING 9 Ice
CORE 10 Core activation and lateral breathing
SPINAL MOBILITY 13 Spinal extension in prone
SPINAL MOBILTY 15 Seated spinal mobility
HIP MOBILITY 16 Hip flexion slides in supported standing

15. 14
HIP ARTHROSCOPY REHABILITATION
PHASE ONE – WEEK TWO, THREE & FOUR
14
Your Physio will select which exercises you are to do -
EXTERNAL ROTATORS 17 Static contraction of deep hip external rotators
INTERNAL ROTATORS 18 Hip internal rotation in prone
FLEXORS 19 Four point kneeling pendulum hip flexion
EXTENSORS 20 Double leg bridge
ADDUCTORS 21 Static contraction of hip adductors in supine
ABDUCTORS 22 Hip abduction activation in supine lying
CORE 23 Arm floats in crook lying
CIRCUMDUCTION 24 Supported short lever hip circumduction in supine

16. 15
HIP ARTHROSCOPY REHABILITATION
PHASE ONE – WEEK TWO, THREE & FOUR
15
Your Physio will select which exercises you are to do -
FUNCTION 25 Double leg mini squats
HIP FLEXION MOBILITY 26 Four point kneeling hip rocks
QUADRICEPS 27 Seated knee extension +/- weights
HAMSTRINGS 28 Hamstring curls +/- weights
CALF 29 Double leg calf raises
WEIGHT TRANSFERENCE 30 Hip sways
BALANCE 31 Supported one leg balance
SOFT TISSUE MOBILITY 32 Foam rollers and spiky balls

17. 16
HIP ARTHROSCOPY REHABILITATION
CRITERIA FOR PROGRESSION SUMMARY
Phase one Phase two Phase three Phase four
Criteria to be reached before
commencing Phase two
37,50,60,65,96,98 –
• Minimal pain or inflammation
with Phase One exercises
• 10 degrees of hip extension
• Asymptomatic hip flexion at 90∘
• Full weight bearing achieved,
normal gait +/- aids
• Range of motion in all planes
>75% compared with opposite
hip
• Good control with mini squats,
double leg bridge, double leg
calf raises
• Ability to contract target muscle
without substitution muscle
dominance
Criteria to move onto Phase
three 37,50,60,65,93,98 –
• Phase two exercises are
pain free and have have
good control
• Range of motion is full in all
planes of motion compared
with opposite leg
• Pain free normal gait
• No joint inflammation,
muscle irritation or pain
• Good neuromuscular
control of functional
movement patterns
• Progressions should be
made based on objective
assessment and not on
time frames
Criteria to move onto Phase
four 37,50,65 –
• All Phase three exercises are
demonstrated with good
control, strength and are pain
free
• Full range of hip and spinal
movement
• Hip muscle testing 90% of the
uninvolved side with hand held
dynamometer
• Cardio-vascular fitness equal
to pre-injury level
• Good control shown with split
squats/lunges, single leg
bridge, hip rotation control,
single leg squat, the plank and
superman exercises
Criteria to move onto the
‘return to play/sport’ Phase –
At this stage we recommend
working one to one with your
rehab specialist trainer to
develop an individual plan and
goals required for your specific
sport100. You should be able to
carry out the exercises in Phase
four with no pain and good
technique and control. The Vail
Sports Hip Test103, Star
Excursion Balance Test88 and
the Copenhagen Adductor
Exercise 90,91 offer a way of
measuring progress but may not
reflect what is demanded of you
in your specific sport

18. 17
HIP ARTHROSCOPY REHABILITATION
PHASE TWO – WEEKS FOUR TO EIGHT
17
Your Physio will select which exercises you are to do -
ROTATORS 33 Active deep external and internal rotation
FLEXORS 34 Supine heel slides
EXTENSORS 35 Prone hip extension
ADDUCTORS 36 Double leg bridge with adductor squeeze
ABDUCTORS 37 Hip abduction in side lying
CORE 38 Double leg hamstring bridge with arm pullovers
CIRCUMDUCTION 39 Long lever circumduction with hamstring stretch
FUNCTION 40 Gluteal activation gait integration

19. 18
HIP ARTHROSCOPY REHABILITATION
PHASE TWO – WEEKS FOUR TO EIGHT
18
Your Physio will select which exercises you are to do -
QUADS AND HAMS 41 Wall squat/leg press
SINGLE LEG STABILITY 42 Hip hitches off a step
CALF 43 Split stance calf raises
BALANCE 44 Half moon one leg balance
ANTERIOR HIP STRETCH 45 Anterior hip stretch
POSTERIOR HIP STRETCH 46 Posterior hip stretch
CALF STRETCH 47 Calf stretch
SOLEUS STRETCH 48 Soleus stretch
SPINAL MOBILTY 49 Side lying open door
CARDIO 50 Cross trainer/ swim with flutter kick/ bike

20. 19
HIP ARTHROSCOPY REHABILITATION
CRITERIA FOR PROGRESSION SUMMARY
Phase one Phase two Phase three Phase four
Criteria to be reached before
commencing Phase two
37,50,60,65,96,98 –
• Minimal pain or inflammation
with Phase One exercises
• 10 degrees of hip extension
• Asymptomatic hip flexion at 90∘
• Full weight bearing achieved,
normal gait +/- aids
• Range of motion in all planes
>75% compared with opposite
hip
• Good control with mini squats,
double leg bridge, double leg
calf raises
• Ability to contract target muscle
without substitution muscle
dominance
Criteria to move onto Phase
three 37,50,60,65,93,98 –
• Phase two exercises are
pain free and have have
good control
• Range of motion is full in all
planes of motion compared
with opposite leg
• Pain free normal gait
• No joint inflammation,
muscle irritation or pain
• Good neuromuscular
control of functional
movement patterns
• Progressions should be
made based on objective
assessment and not on
time frames
Criteria to move onto Phase
four 37,50,65 –
• All Phase three exercises are
demonstrated with good
control, strength and are pain
free
• Full range of hip and spinal
movement
• Hip muscle testing 90% of the
uninvolved side with hand held
dynamometer
• Cardio-vascular fitness equal
to pre-injury level
• Good control shown with split
squats/lunges, single leg
bridge, hip rotation control,
single leg squat, the plank and
superman exercises
Criteria to move onto the
‘return to play/sport’ Phase –
At this stage we recommend
working one to one with your
rehab specialist trainer to
develop an individual plan and
goals required for your specific
sport100. You should be able to
carry out the exercises in Phase
four with no pain and good
technique and control. The Vail
Sports Hip Test103, Star
Excursion Balance Test88 and
the Copenhagen Adductor
Exercise 90,91 offer a way of
measuring progress but may not
reflect what is demanded of you
in your specific sport

21. 20
HIP ARTHROSCOPY REHABILITATION
PHASE THREE - WEEKS EIGHT TO TWELVE
20
Your Physio will select which exercises you are to do -
EXTERNAL ROTATORS 51 Hip external rotation with resistance
INTERNAL ROTATORS 52 Hip internal rotation with resistance
FLEXORS 53 Supine knee lifts
EXTENSORS 54 Single leg bridge
EXTENSORS 55 Superman/Bird dog
ADDUCTORS 56 Hip adduction in side lying
ABDUCTORS 57 Clock face sliding discs
CORE 58 Plank and side plank
CORE 59 Double bridge with loaded pullovers
FUNCTION 60 Step ups and step downs

22. 21
HIP ARTHROSCOPY REHABILITATION
PHASE THREE - WEEKS EIGHT TO TWELVE
21
Your Physio will select which exercises you are to do -
QUADS AND HAMS 61 Forward lunges
SINGLE LEG STABILITY 62 Single leg mini squat
CALF 63 Single leg calf raise
BALANCE 64 Single leg with self controlled perturbations
LATERAL HIP STRETCH 65 Lateral hip stretch
ANTERIOR HIP STRETCH 66 Hip flexor stretch
ADDUCTOR STRETCH 67 Adductor stretch
SPINAL MOBILITY 68 Standing bow and arrow
POWER WALK 69 Power walk
CARDIO 70 Bike/swim/cross trainer

23. 22
NOTE ON PHASE THREE
• Phase three may be the final stage of rehab for
some patients
• The exercises in Phase Four may be not appropriate or necessary for what level of
recovery they are aiming for.
• If your level is getting back to Pilates, walking, swimming and a bit of cycling, then
achieving the goals for Phase Three may be enough and it may be that you need to
spend longer than 4 weeks at this level. It can be a good idea to continue with a
maintenance set of exercises you do 2-3 times a week once recovered.
• However, for running, football, tennis, martial arts which involve speed, quick changes
of direction and explosive movements, Phase Four is necessary.
22
Phase four is not for
everyone – discuss
with your physio

24. 23
HIP ARTHROSCOPY REHABILITATION
CRITERIA FOR PROGRESSION SUMMARY
Phase one Phase two Phase three Phase four
Criteria to be reached before
commencing Phase two
37,50,60,65,96,98 –
• Minimal pain or inflammation
with Phase One exercises
• 10 degrees of hip extension
• Asymptomatic hip flexion at 90∘
• Full weight bearing achieved,
normal gait +/- aids
• Range of motion in all planes
>75% compared with opposite
hip
• Good control with mini squats,
double leg bridge, double leg
calf raises
• Ability to contract target muscle
without substitution muscle
dominance
Criteria to move onto Phase
three 37,50,60,65,93,98 –
• Phase two exercises are
pain free and have have
good control
• Range of motion is full in all
planes of motion compared
with opposite leg
• Pain free normal gait
• No joint inflammation,
muscle irritation or pain
• Good neuromuscular
control of functional
movement patterns
• Progressions should be
made based on objective
assessment and not on
time frames
Criteria to move onto Phase
four 37,50,65 –
• All Phase three exercises are
demonstrated with good
control, strength and are pain
free
• Full range of hip and spinal
movement
• Hip muscle testing 90% of the
uninvolved side with hand held
dynamometer
• Cardio-vascular fitness equal
to pre-injury level
• Good control shown with split
squats/lunges, single leg
bridge, hip rotation control,
single leg squat, the plank and
superman exercises
Criteria to move onto the
‘return to play/sport’ Phase –
At this stage we recommend
working one to one with your
rehab specialist trainer to
develop an individual plan and
goals required for your specific
sport100. You should be able to
carry out the exercises in Phase
four with no pain and good
technique and control. The Vail
Sports Hip Test103, Star
Excursion Balance Test88 and
the Copenhagen Adductor
Exercise 90,91 offer a way of
measuring progress but may not
reflect what is demanded of you
in your specific sport

25. 24
HIP ARTHROSCOPY REHABILITATION
PHASE FOUR – WEEK TWELVE ONWARDS
24
Your Physio will select which exercises you are to do -
FLEXORS 71 High knee marching → Mountain climbers
EXTENSORS 72 Romanian Dead Lift → Single leg Romanian Dead Lift
ADDUCTORS 73 Copenhagen adductor protocol
ABDUCTORS 74 Side steps with resistance band
ROTATORS 75 Single leg stance trunk rotation
ROTATORS 76 Arabesque → Aeroplanes
HAMSTRINGS 77 Supine hamstrings on swiss ball
QUADRICEPS 78 Star excursion balance test

26. 25
HIP ARTHROSCOPY REHABILITATION
PHASE FOUR – WEEK TWELVE ONWARDS
25
Your Physio will select which exercises you are to do -
CORE 79 Deadbug
DIAGONAL 80 Kneeling chop and lift
TRUNK 81 Side bridge/plank with hip abduction
BALANCE 82 Perturbations in single leg stance
FUNCTION 83 Multi-directional lunges +/- load
PLYOMETRICS 84 Bounding, jumping, hopping, plyometrics
RUN 85 Walk → Jog → Run program
CARDIO 86 Cardio – Boxing/Cycle/Swim/Cross trainer

27. 26
HIP ARTHROSCOPY REHABILITATION
A FINAL WORD
It is not unusual to have a rehab journey that has ups and downs. If you were to draw a graph of recovery, it is often not linear
but more resembling a roller coaster. If you have a flare-up, the key is to assess why you may have had a backward step and
to trouble shoot it and maybe seek help from your Physio or Surgeon.
Sometimes the cause can be doing exercises that are too advanced – mastery of the basics are essential, so they may need
re-visiting. Sometimes it can be neglecting specific maintenance exercises or not having a balance of a variety of exercises.
Are you overdoing one particular activity? Repeating the same movement too much? Or have you been sat or stood in a way
your hip doesn’t like.
Know your hip, and understand that although hip arthroscopy aims to repair the cartilage (where possible) and change the
boney architecture to reduce impingement problems, there are some things it can not change. Speak to your Surgeon and
Physio about what are realistic expectations with your individual, unique hip.
And finally, try not to compare yourself to others. We are all different. Be kind to yourself and your own special hip !
26
Best wishes
Louise Grant
Hip Physio
March 2021