I. A thorough physical examination and knowledge of anatomy are key to directing physical therapy (PT) for the painful hip.

1. 
   

   Discrete evaluation of the hip actions and their involved muscle groups is a necessary starting point:

   
   
   
   
   1. 
      

      Flexors: psoas, iliacus, pectineus, and rectus femoris.

      
      
   2. 
      

      Extensors: gluteus maximus and hamstrings.

      
      
   3. 
      

      Abductors: gluteus medius and gluteus minimus.

      
      
   4. 
      

      Adductors: adductor magnus, longus, and brevis.

      
      
   5. 
      

      External rotators: gluteus maximus, superior/inferior gemellus, obturator internus/externus, and quadratus femoris.

      
      
   6. 
      

      Internal rotators: tensor fascia lata, gluteus minimus, and gracilis.

II. Gait anomalies can arise from the following:

1. 
   

   Pain.

   
   
2. 
   

   Weakness.

   
   
3. 
   

   Structural abnormalities.

   
   
4. 
   

   Loss of motion.

   
   
5. 
   

   Combinations of the above.

III. Observation of gait and single leg stance provides important dynamic information regarding function of the hip and potential pathology.

1. 
   

   Key gait features include foot progression angle, pelvic motion, stance phase, stride length, truncal motion, and arm swing.

   
   
2. 
   

   Gait anomalies and their associated anatomic correlates are described in Table 22.1 .

I. Requires appropriate diagnosis and differentiating spinal etiology, referred pain, extra-articular muscle injury, intra-articular pathology, muscle imbalance, and stiffness.

1. 
   

   The hip is part of the kinetic chain extending from the lumbar spine to the feet.

   
   
   
   
   1. 
      

      Dysfunction at any point along this chain can impact hip function.

      
      
   2. 
      

      As the hip becomes more stiff, increased mobility demands are placed at the lumbar spine, knees, ankles, and/or feet, and can lead to secondary injuries.

      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      

      Table 22.1 Gait assessment

      Description	Clinical Correlate
      Trendelenburg gait: contralateral pelvic drop in stance phase	Abductor weakness
      Antalgic gait: shortened stance phase, lengthened swing time	Lower extremity pain
      Coxalgic gait: truncal shift over painful side, contralateral pelvic elevation	Intra-articular hip pain
      Externally rotated foot progression angle	Femoral retroversion, torsional anomaly, hip effusion
      Internally rotated foot progression angle	Excess femoral anteversion, torsional anomaly
      Quadriceps avoidance: increased knee extension	Quad weakness, knee pain, anterior cruciate ligament injury
      Drop foot or steppage gait: increased hip and knee flexion with loss of ankle dorsiflexion	Sciatic nerve injury, ankle dorsiflexion weakness

II. Goals of therapy include the following:

1. 
   

   Improving range of motion (ROM):

   
   
   
   
   1. 
      

      Manual techniques to mobilize the joint with manipulation and distraction can stretch the capsule and surrounding muscles, and can help maintain mobility. ¹

   
   
2. 
   

   Decreasing pain:

   
   
   
   
   1. 
      

      Modalities for muscle relaxation, pain relief, and anti-inflammation.

   
   
3. 
   

   Improving muscle strength:

   
   
   
   
   1. 
      

      Strengthening the muscles around the hip, including core abdominal muscles and hip abductors, can be particularly useful to normalize gait. ²

   
   
4. 
   

   Minimizing detrimental effects of immobility or activity restriction:

   
   
   
   
   1. 
      

      Cane can be used in the contralateral hand.

      
      
      
      
      • 
        

        i. Allows for reciprocal arm swing.

        
        
      • 
        

        ii. Widens base of support.

        
        
      • 
        

        iii. Reduces joint reaction force on the affected side by up to 30%, with longer lever arm for abductor function.

   
   
5. 
   

   Maintaining general fitness:

   
   
   
   
   1. 
      

      Weight reduction can significantly improve patient’s symptoms and increase functional status, while decreasing the force on all joints.

      
      
   2. 
      

      Recreations such as swimming or cycling can provide fitness while minimizing forces across the hip.

   
   
6. 
   

   Teaching home exercise program:

   
   
   
   
   1. 
      

      Education and empowerment can guide patients in activities, exercise programs, and footwear to reduce pain and optimize function.

I. Comprehensive education to set patient expectations for surgery and rehabilitation course.

1. 
   

   Tailored to patient’s baseline functional status, comorbidities, and postoperative goals.

   
   
2. 
   

   Preoperative education shows modest beneficial effect on anxiety before and after surgery.

   
   
   
   
   1. 
      

      Effect on pain, functional outcome, and length of stay is inconclusive. ³

   
   
3. 
   

   Address patient and family questions or concerns.

   
   
   
   
   1. 
      

      Create realistic expectations.

II. Organize the home environment:

1. 
   

   Remove throw rugs.

   
   
2. 
   

   Address bathroom—toilet seats, shower bars, chairs.

   
   
3. 
   

   Stair management.

   
   
4. 
   

   Minimize obstacles that may cause injury or difficulty with recovery.

III. Arrange social support:

1. 
   

   Meals.

   
   
2. 
   

   Rides to PT or other doctor visits.

IV. A preoperative rehabilitation or “prehab” program of strengthening and gait training can improve postoperative pain control and function in the first few weeks after surgery. ⁴

1. 
   

   Best evidence is to focus on patients with impaired mobility for preoperative strengthening, balance, and gait training. ⁵

   
   
2. 
   

   Train patients on use of relevant durable medical equipment, including walking assistive devices.

V. Set a hospital discharge plan, which may be subject to change after surgery.

1. 
   

   A prehab program before total hip arthroplasty (THA) has been shown to reduce rates of discharge to skilled nursing facilities and improve rates of discharge to home. ⁶

I. Protocols for PT and return to activity vary by the arthroscopy procedure performed.

1. 
   

   A hip abduction brace is frequently employed to limit postoperative hip motion.

   
   
2. 
   

   CPM (continuous passive motion) machine may be used to encourage ROM.

   
   
3. 
   

   Lying prone can help prevent the development of a flexion contracture.

   
   
4. 
   

   Protected weight bearing may be employed for a range of hip arthroscopy procedures.

II. Although there is no consensus rehabilitation protocol, specific precautions are based on the procedures performed. ⁷

1. 
   

   Labral repair requires a period of restricted weight bearing, limited hip abduction, and no external rotation beyond neutral to protect the repair as it heals.

   
   
2. 
   

   Labral resection typically is followed by a 10- to 14-day period of partial weight bearing, and avoidance of excess flexion and abduction.

   
   
3. 
   

   Cheilectomy/osteoplasty requires a period of restricted weight bearing given risk of femoral neck fracture in the early postoperative period.

   
   
4. 
   

   Microfracture necessitates up to 6 weeks of restricted weight bearing.

   
   
5. 
   

   Capsular plication patients should have limited hip flexion, extension, and external rotation in the first 3 to 4 weeks after surgery to protect the anterior capsule.

III. Progressive ROM and strengthening is encouraged among all postoperative hip arthroscopy patients. ⁷

1. 
   

   Gentle isometrics typically start around postoperative day 2, with gradual progression of active ROM (AROM) starting around the third week after surgery.

   
   
2. 
   

   It is important to avoid initiating activities that may lead to joint inflammation or tendinitis.