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 second
exer

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

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.

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. Place
exer

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..

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 a
exer


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 and
exer

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.


WEEK 4 - Exercise record sheet
Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28
46
47
48
49
50
51
52
53
54
55
56
57
58
8
59
60

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 tuberosities
exer

in sitting.
•  Good control with double
bridge, double calf raises
and small knee bends.


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.

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 a
exer


LEVEL TWO
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 a
exer

63. Active assisted hip circumduction with band. As
per exercise 46.


LEVEL TWO
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 many
exer

reps you can do on your
non-operated side and
work on gaining equal
Single
ability.
knee
Aim – integrate into bend
function. (ref 40)

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

exer

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
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 challenges
exer

as your balance
improves


LEVEL TWO

hip

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 slide
exer

your heel up and down the wall. (ref 27).

1 2


LEVEL TWO

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

exer

71. Lower limb stretches.
As per exercises 8, 19, 36, 37, 38, 39.
72. Hydrotherapy. As per exercise 34.

LEVEL TWO
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, 5-10
exer

repetitions, 2 times a day.


LEVEL TWO
hip

tion
wing
Extra optional exercises –

y
scop
bilita
Hip side glide
to the wall
follo
rthro
Re h a
cises
hip a

Hip flexor
exer

stretch, avoid
pushing into
hip extension.
Keep in
hip joint and
Copyright-PHYSIOCURE pelvic neutral.

hip LEVEL TWO

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.


61
62
63
64
65
66
67
68
69
70
71
72
73
21
74
75

61
62
63
64
65
66
67
68
69
70
71
72
73
22
74
75

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).

ecor
essm
reass 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
e
Six 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

Adduction
essm

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.


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.


LEVEL THREE
hip
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 and
exer

notice they do not feel as good if they have forgotten
or have been too busy to do them.


hip LEVEL THREE

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 hip
exer

(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.


hip LEVEL THREE

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


LEVEL THREE
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

exer

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
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 a
exer


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

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 a
exer

Finish


LEVEL THREE

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 a
exer


LEVEL THREE

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 a
exer


LEVEL THREE
hip

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

Start
exer

Finish

LEVEL THREE
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

3
exer

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.

LEVEL THREE
hip

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 not
exer

irritate the hip flexor


hip
LEVEL THREE

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 the
exer

hip (ie.CLAM, straight leg raise and sit-ups).
Avoid aggressive hip extension at all times.


76
77
78
79
80
81
82
83
84
85
86
87
88
40
89
90

76
77
78
79
80
81
82
83
84
85
86
87
88
41
89
90

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, rotation
exer

control with Lx/pelvic
neutral, the plank, and hip
flexion in standing.


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 cardio-
vascular 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.

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).


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 foot
exer

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
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.


LEVEL FOUR
hip

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.


LEVEL FOUR
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).



49


50


51


52

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 w
Twel

hip Ask your physio to record these 12 week post-
op hip measurements for you, so you can
monitor your progress. (ref 12)

k
d
essm 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


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.


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 when
exer

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.


Summary Week One Week Two
Ankle 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 * 59
Stretches piri/int rot *
Hip rocks/glides *

Summary Week Three Week Four
Double 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 * * 60
Swiss Ball * *
Wgt Transference *

Summary Week Four Week Five/Six
Assisted 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 * 61
Iso Adds *
Side hip Abd *

Summary Week Seven/Eight
Long 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 * 62
Side 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 * 63
Box 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 early
Refe
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 recreational
Refe

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 Orthopaedic
Refe
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’. Clinical
Refe

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. The
Refe
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.


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 is
Ackn

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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