Introduction
- John C. Clohisy, MD
Epidemiology
Age
- •
Average age 35 yrs (range, 16 to 91)
Sex
- •
57% male
- •
43% female
Sport
- •
Any sport with repetitive hip flexion, bending and squatting (soccer, hockey, football, baseball, basketball, etc.)
- •
One recent study indicated:
- •
59% participated in regular sporting activities.
- •
59% classified participation intensity as high.
- •
28% reported intensity as moderate.
- •
Average UCLA was 7.1 ± 2.8, consistent with patients participating in activities like fast walking, golfing, and bowling.
- •
29% participated in impact activities like jogging, tennis and ballet on regular basis.
- •
Position
- •
Athletic activities/positions with repetitive hip flexion are at highest risk.
Pathophysiology
Intrinsic Factors
- •
Hip pathomorphology—Acetabular overcoverage ( Figure 26-1 )
FIGURE 26-1
Acetabular overcoverage—deep socket, preoperative view.
- •
Hip pathomorphology—Femoral head-neck offset deformities ( Figure 26-2 )
FIGURE 26-2
Femoral head-neck offset deformity, preoperative frogleg view.
- •
Soft tissue laxity with excessive hip motion
Extrinsic Factors
- •
Repetitive hip flexion activities including occupational and athletic activities
- •
Athletics: hockey, soccer, basketball, football, and others that involve repetitive hip flexion activities
Traumatic Factors
- •
Forced hip flexion can result in acute labrochondral injury
- •
Forced hip flexion with combined adduction and internal rotation can result in subluxation or hip dislocation.
- •
Patients with femoroacetabular impingement (FAI) anatomy may be more susceptible to subluxation/dislocation episodes due to levering from anterior impingement.
Classic Pathological Findings
- •
Structural abnormalities of the acetabulum and proximal femur consistent with femoroacetabular impingement (FAI; see Figure 26-2 )
- •
Acetabular labral abnormalities including detachment, degeneration, and ossification
- •
Chondral abnormalities specifically of the acetabular rim including delamination, articular cartilage flap formation and full thickness defect ( Figure 26-3 ).
FIGURE 26-3
Chondral abnormality, labral disruption.
- •
The most common intraarticular abnormality includes injury to the acetabular labrochondral complex.
Clinical Presentation
History
- •
Groin pain
- •
Activity-related symptoms
- •
Activity limitation owing to hip symptoms
- •
Locking, catching of the hip
- •
Groin pain with prolonged sitting or hip flexion activities
- •
History of recurrent groin pulls, compensatory symptoms (low back pain, SI joint pain, trochanteric bursitis, adductor strain)
Physical Examination
Abnormal Findings
- •
Limited hip flexion
- •
Limited internal rotation in flexion
- •
Positive impingement test (sensitive but not specific for FAI).
- •
Positive flexion, abduction, external rotation (FABER) test
Pertinent Normal Findings
- •
Normal external rotation/motion
- •
Normal gait
- •
Athletes may have normal muscle strength and function
Imaging
- •
Plain radiographs including the anteroposterior (AP) pelvis, frog lateral, and 45° Dunn view
- •
Parameters consistent with acetabular overcoverage
- •
Femoral head-neck offset abnormalities are present.
- •
Magnetic resonance imaging (MRI) and magnetic resonance arthrography can demonstrate labrochondral disease, structural anatomy, and secondary articular cartilage changes.
- •
CT scan with three-dimensional images provides detailed information regarding deformity characteristics.
Differential Diagnosis
- •
Hip dysplasia
- •
Secondary hip osteoarthritis
- •
Lumbar spine dysfunction
- •
Sacral Iliac joint dysfunction
- •
Athletic hernia
- •
Muscle imbalance syndromes
- •
Stress fractures
- •
Adductor strain
- •
Symphysis pubalgia
- •
Comprehensive history, physical exam, and imaging evaluation of the patient distinguish the above conditions from a symptomatic femoroacetabular impingement. Compensatory disorders are common and many of the above diagnoses can occur simultaneously with femoroacetabular impingement.
Treatment
Nonoperative Management
- •
Activity modification and patient education
- •
Nonsteroidal antiinflammatory medicines
- •
Physical therapy with muscle strengthening and balancing
- •
Intraarticular corticosteroid injection
Guidelines for Choosing Among Nonoperative Treatments
- •
A panel of nonsurgical treatment options to block the pain cycle and optimize function about the hip is preferred.
- •
Corticosteroid injections are mostly used in patients greater than 40 years of age with early osteoarthritis.
Surgical Indications
- •
Patients less than 50 years of age
- •
Symptomatic hip impingement disease
- •
Failure of nonsurgical treatment methods
- •
Defined hip impingement deformity
- •
Imaging studies demonstrate lack of moderate to advanced osteoarthritis of the hip.
- •
Body mass index (BMI) less than 35
- •
Positive response to intraarticular injection (with pain relief)
Aspects of History, Demographics, or Exam Findings that Affect Choice of Treatment
- •
Age
- •
Physical health
- •
Deformity characteristics
- •
Articular cartilage integrity
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Open versus closed surgical correction
- •
Treatment of the acetabular labrum (partial resection or repair)
- •
Correction of the impingement deformity (acetabuloplasty, femoral plasty or both) ( Figures 26-4 , 26-5 )
FIGURE 26-4
Deep socket, postoperative view.
FIGURE 26-5
Head-neck offset postoperative frogleg view.
- •
Treatment of acetabular articular cartilage disease including chondromalacia, delamination, articular cartilage flap and full thickness defects.
Evidence
Multiple-Choice Questions
- QUESTION 1.
What is the most common pain location of symptomatic hip impingement?
- A.
Groin
- B.
Lateral
- C.
Buttock
- D.
Thigh
- A.
- QUESTION 2.
What is the most common location of intraarticular damage in patients with femoroacetabular impingement?
- A.
Acetabular labrum
- B.
Acetabular labrochondral complex
- C.
Acetabular articular cartilage
- D.
Femoral head articular cartilage
- A.
- QUESTION 3.
Nonsurgical management of hip impingement should focus on the following combination of modalities:
- A.
Hip range of motion and activity modification
- B.
Hip strengthening and hip range of motion
- C.
Hip strengthening, muscle balancing, and activity modification
- D.
Nonsteroidal antiinflammatory medicines, hip strengthening and balancing, and range of motion.
- A.
- QUESTION 4.
What is the most common physical examination finding in patients with symptomatic hip impingement?
- A.
Reduced hip flexion and external rotation
- B.
Reduced hip abduction and external rotation
- C.
Reduced hip flexion and internal rotation
- D.
Limited extension and external rotation
- A.
- QUESTION 5.
Which of the following disease characteristics is a relative contraindication for hip preservation FAI surgery?
- A.
Severe deformity
- B.
History of injury to the joint
- C.
Symptoms of catching and locking
- D.
Moderate (50%) joint space narrowing
- A.
Answer Key (identify where in text the answer can be found)
- QUESTION 1.
Correct answer: A (see Pathophysiology: Clinical presentation )
- QUESTION 2.
Correct answer: B (see Pathological Findings )
- QUESTION 3.
Correct answer: C (see Nonoperative Management )
- QUESTION 4.
Correct answer: C (see Physical Exam Findings)
- QUESTION 5.
Correct answer: D (see Surgical Indications )
Nonoperative Rehabilitation of Hip Stiffness and Hip Impingement (Cam/Pincer Lesions)
- Erik P. Meira, PT, SCS, CSCS
- Mark B. Wagner, MD
- •
Avoid exacerbating the anterior hip pain associated with femoroacetabular impingement (FAI).
- •
Range of motion may be limited by bony deformity—DO NOT FORCE MOTION.
- •
Focus on increasing strength and coordination within pain-free range of motion.
- •
Specific attention should be made to controlling dynamic knee valgus.
- •
Activation of hip abductors should be reinforced during each phase of rehab.
- •
Modify lifestyle to accommodate FAI as able.
Phase I (weeks 0 to 2)
Protection
- •
Weight bearing as tolerated.
- •
Limit motion to pain-free range.
- •
Minimize activation of the iliopsoas.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) | PHASE IV (weeks 8+) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Nonsteroidal antiinflammatory drugs (NSAIDs)
- •
Cryotherapy with compression to the joint
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Long axis traction and gentle lateral glides in supine for pain control
Soft Tissue Techniques
- •
Gentle massage to anterior hip with the focus on relaxation of regional musculature, specifically pectineus and iliopsoas
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Gentle stretching to the iliopsoas ( Figure 26-6 ) and lumbar extensors
FIGURE 26-6
Iliopsoas stretch. Maintain posterior pelvic tilt during the stretch.
Other Therapeutic Exercises
- •
Upright exercise bike with elevated seat to minimize hip flexion
- •
Total leg strength (TLS) may be initiated as tolerated.
Activation of Primary Muscles Involved
- •
Hip abductors
- •
Gluteus medius
- •
Gluteus minimus
- •
- •
Hip external rotators
- •
Gluteus maximus
- •
Piriformis
- •
Gemellus superior
- •
Gemellus inferior
- •
Obturator internus
- •
Obturator externus
- •
Quadratus femoris
- •
- •
Hip extensors
- •
Gluteus maximus
- •
- •
Hip adductors
- •
Adductor magnus
- •
Adductor longus
- •
Adductor brevis
- •
Pectineus
- •
Gracilis
- •
Sensorimotor Exercises
- •
Single leg stance as tolerated
Open and Closed Kinetic Chain Exercises
- •
Clamshells in pain-free range (OKC)
- •
Bridging (CKC)
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Prone heel squeeze
- •
Isometric adductor squeeze
Neuromuscular Dynamic Stability Exercises
- •
Manual resistance hip stability (rhythmic stabilization) in side lying ( Figure 26-7 )
FIGURE 26-7
Rhythmic stabilization in side-lying. Be cautious applying resistance to flexion during Phase I.
Milestones for Progression to the Next Phase
- •
No pain at rest
- •
Pain free with all rehab activities
- •
Able to perform one straight leg raise without pain
Phase II (weeks 2 to 4)
Protection
- •
Limit motion to pain-free range.
Management of Pain and Swelling
- •
Continue with nonsteroidal antiinflammatory drugs (NSAIDs), and cryotherapy with compression to the joint as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue long axis traction and gentle lateral glides in supine for pain control.
Soft Tissue Techniques
- •
Continue gentle massage to anterior hip with the focus on relaxation of regional musculature as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Progress iliopsoas and low back extensor stretching as tolerated.
- •
Gentle stretching into combined flexion abduction external rotation as tolerated
Other Therapeutic Exercises
- •
May progress to elliptical trainer as tolerated.
- •
Continue to progress TLS.
- •
May begin core stability training being cautious of excessive load to the iliopsoas.
Activation of Primary Muscles Involved
- •
Hip abductors
- •
Gluteus medius
- •
Gluteus minimus
- •
- •
Hip external rotators
- •
Gluteus maximus
- •
Piriformis
- •
Gemellus superior
- •
Gemellus inferior
- •
Obturator internus
- •
Obturator externus
- •
Quadratus femoris
- •
- •
Hip extensors
- •
Gluteus maximus
- •
Biceps femoris
- •
Semitendinosus
- •
Semimembranosus
- •
- •
Hip adductors
- •
Adductor magnus
- •
Adductor longus
- •
Adductor brevis
- •
Pectineus
- •
Gracilis
- •
Sensorimotor Exercises
- •
Single leg stance on uneven surface
Open and Closed Kinetic Chain Exercises
- •
Clamshells in pain-free range against resistance (OKC)
- •
Standing hip abduction, adduction, and extension against resistance (OKC)
- •
Bridging with marching (CKC)
- •
Double and single leg press in pain-free range (CKC)
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Begin Romanian Deadlift (RDL) with focus on lumbopelvic coordination.
Neuromuscular Dynamic Stability Exercises
- •
Single leg lunge on wall with physioball ( Figure 26-8 ) with focus on controlling knee valgus and hip adduction
FIGURE 26-8
Wall lunge with physioball. Avoid knee valgus and Trendelenburg position.
Plyometrics
- •
Submaximal jumps on shuttle
- •
Double leg bouncing while maintaining contact on mini-trampoline
Functional Exercises
- •
Hip band ambulation
- •
Forward/backward
- •
Side-to-side
- •
“Monster walking” ( Figure 26-9 )
FIGURE 26-9
“Monster walking.”
- •
Milestones for Progression to the Next Phase
- •
No pain with activity of daily living (ADL)
- •
Pain free with all rehab activities
- •
Able to hold straight leg raise at 45° hip flexion in supine against minimal manual resistance without pain.
- •
Able to maintain hip height within 2 cm of uninvolved side during single leg stance phase test.
Phase III (weeks 4 to 8)
Protection
- •
Continue to limit motion to pain-free range.
Management of Pain and Swelling
- •
Continue with nonsteroidal antiinflammatory drugs (NSAIDs) and cryotherapy with compression to the joint as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Long traction with progressive range of motion in all directions as tolerated
Soft Tissue Techniques
- •
Continue gentle massage to anterior hip with the focus on relaxation of regional musculature as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Progress iliopsoas and low back extensor stretching as tolerated. Continue gentle stretching into combined flexion abduction external rotation as tolerated.
Other Therapeutic Exercises
- •
Continue elliptical trainer as tolerated.
- •
Continue to progress TLS.
- •
Progress core stability training, being cautious as tolerated.
Activation of Primary Muscles Involved
- •
Hip abductors
- •
Gluteus medius
- •
Gluteus minimus
- •
- •
Hip external rotators
- •
Gluteus maximus
- •
Piriformis
- •
Gemellus superior
- •
Gemellus inferior
- •
Obturator internus
- •
Obturator externus
- •
Quadratus femoris
- •
- •
Hip extensors
- •
Gluteus maximus
- •
Biceps femoris
- •
Semitendinosus
- •
Semimembranosus
- •
- •
Hip adductors
- •
Adductor magnus
- •
Adductor longus
- •
Adductor brevis
- •
Pectineus
- •
Gracilis
- •
Sensorimotor Exercises
- •
Single leg stance on uneven surface
- •
Lunges in multiple planes with focus on maintaining proper knee position
Open and Closed Kinetic Chain Exercises
- •
Continue clamshells in pain-free range against resistance (OKC).
- •
Continue standing hip abduction, adduction, and extension against resistance (OKC).
- •
Continue bridging with marching (CKC).
- •
Side plank (CKC)
- •
Progress double and single leg press in pain-free range (CKC).
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progress Romanian Deadlift (RDL) with focus on lumbopelvic coordination.
- •
Squatting, first in Smith machine progressing to back squats in pain-free range (CKC)
- •
Begin deadlifts from floor with focus on proper form (CKC).
- •
Begin single leg squats in Smith machine with focus on maintaining proper knee position (CKC).
Neuromuscular Dynamic Stability Exercises
- •
Continue single leg lunge on wall with physioball ( Figure 26-8 ) with focus on controlling knee valgus and hip adduction.
Plyometrics
- •
Double leg jumps on stable surface in pain-free range
- •
Single leg bouncing while maintaining contact on mini-trampoline
Functional Exercises
- •
Continue hip band ambulation
- •
Forward/backward
- •
Side-to-side
- •
“Monster walking”
- •
- •
Resisted sit-to-stand with hips abducted and externally rotated (sumo squat) with dumbbell or kettle bell weight ( Figure 26-10 )
FIGURE 26-10
Resisted sit-to-stand with hips abducted and externally rotated (sumo squat) with dumbbell or kettle bell weight.
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
No pain with ADL
- •
Pain free with all rehab activities
- •
Able to consistently perform single leg squat into full functional range without pain while controlling dynamic knee valgus without verbal cues
- •
Able to consistently perform vertical drop jump from 18 inches without pain while controlling dynamic knee valgus without verbal cues
Phase IV (weeks 8+)
Protection
- •
Continue to limit motion to pain-free range.
Management of Pain and Swelling
- •
Continue with nonsteroidal antiinflammatory drugs (NSAIDs) and cryotherapy with compression to the joint as needed.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Continue for pain relief if indicated.
Soft Tissue Techniques
- •
Continue gentle massage to anterior hip with the focus on relaxation of regional musculature as needed.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Progress iliopsoas and low back extensor stretching as tolerated.
- •
Continue gentle stretching into combined flexion abduction external rotation as tolerated.
Other Therapeutic Exercises
- •
Progressive running program as tolerated
- •
Begin with 10 minute jog, stopping if painful.
- •
If pain free during run and over next 24 hours, progress by 5 minutes the next day; if not, stay at 10 minutes.
- •
Continue to monitor and progress as above.
- •
- •
Continue to progress TLS.
- •
Progress core stability training as tolerated.
Activation of Primary Muscles Involved
- •
Hip abductors
- •
Gluteus medius
- •
Gluteus minimus
- •
- •
Hip external rotators
- •
Gluteus maximus
- •
Piriformis
- •
Gemellus superior
- •
Gemellus inferior
- •
Obturator internus
- •
Obturator externus
- •
Quadratus femoris
- •
- •
Hip extensors
- •
Gluteus maximus
- •
Biceps femoris
- •
Semitendinosus
- •
Semimembranosus
- •
- •
Hip adductors
- •
Adductor magnus
- •
Adductor longus
- •
Adductor brevis
- •
Pectineus
- •
Gracilis
- •
Sensorimotor Exercises
- •
Progress single leg stance on uneven surface to incorporate perturbations.
- •
Lunges in multiple planes with focus on maintaining proper knee position while adding dynamic component such as twisting
Open and Closed Kinetic Chain Exercises
- •
Continue clamshells in pain-free range against resistance (OKC).
- •
Continue standing hip abduction, adduction, and extension against resistance (OKC).
- •
Continue bridging with marching (CKC).
- •
Continue side plank (CKC).
- •
Progress double and single leg press in pain-free range (CKC).
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Progress resistance during RDL with focus on lumbopelvic coordination.
- •
Free squats in pain-free range with higher intensity (CKC).
- •
Continue deadlifts from floor with higher intensity and focus on proper form (CKC).
- •
Progress single leg squats in Smith machine with focus on maintaining proper knee position (CKC).
- •
Power lifts such as clean, jerk, snatch as indicated for specific sports
Neuromuscular Dynamic Stability Exercises
- •
Continue single leg lunge on wall with physioball with focus on controlling knee valgus and hip adduction, adding dumbbell resistance as needed.
Plyometrics
- •
Double and single leg jumps on stable and unstable surfaces in pain-free range
Functional Exercises
- •
Continue hip band ambulation.
- •
Forward/backward
- •
Side-to-side
- •
“Monster walking”
- •
- •
Squat to run medicine ball throws ( Figure 26-11 )
FIGURE 26-11
Squat to run medicine ball throws. Squat ( A ) then throw ( B ) as initiating run.
Sport-Specific Exercises
- •
Begin sport-specific drills as indicated including:
- •
Running
- •
Cutting
- •
Jumping
- •
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Has full, functional, and pain-free range of motion as necessary for the athlete’s particular sport during training activities
- •
Lower body strength is within 90% of the involved side during single leg squats in Smith machine.
- •
Lower body power is within 90% of the uninvolved side.
- •
Single hop
- •
Triple hop
- •
Crossover hop
- •
6-minute timed hop
- •
- •
Athlete has achieved proper scores in validated functional tests that challenge range of motion, strength, and coordination as appropriate for his or her sport such as the Lower Extremity Functional Test.
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Pain-free ROM does not improve to within functional limits of the athlete’s particular sport.
- •
Unable to progress strength or coordination owing to range of motion limitations
- •
Significant restrictions based on bony morphology observed on radiographs
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Progress training in a progressive fashion to make sure that the muscles and supporting structures have sufficient time to adapt to the loads unique to the sport.
- •
Start with simple controlled sport specific drills in single plane.
- •
Progress to more complex multidirectional drills.
- •
Advance to more unpredictable activities such as partial and then complete scrimmages.
- •
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
Make modifications in training to reduce the amount of internal rotation, adduction, and/or flexion at the hip.
- •
Limit squat depth.
- •
Convert to sumo squat (see Figure 26-10 ).
- •
- •
Focus on controlling dynamic knee valgus during training by avoiding hip adduction and internal rotation during activities.
- •
If unable to make necessary modifications, the athlete may need surgical intervention to reduce the impingement.
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
No pain during gym activities
- •
No pain during sport-specific drills
- •
No pain during practice including scrimmages and game simulation for 2 weeks
Evidence
Multiple-Choice Questions
- QUESTION 1.
Into what direction should range of motion be aggressively pushed?
- A.
Flexion
- B.
Adduction
- C.
Internal Rotation
- D.
None of the above. May be restricted by bony morphology
- A.
- QUESTION 2.
What muscle activation should be minimized during Phase I?
- A.
Gluteus medius
- B.
Quadriceps
- C.
Iliopsoas
- D.
Hamstrings
- A.
- QUESTION 3.
What motion should be controlled during return to sport activities?
- A.
Dynamic knee valgus
- B.
Hip extension
- C.
Trunk extension
- D.
None of the above
- A.
- QUESTION 4.
During which phase can simple plyometrics such as submaximal jumps on a shuttle be initiated?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 5.
Activation of which muscle group should be reinforced during each phase of rehab?
- A.
Hip flexors
- B.
Quadriceps
- C.
Hip abductors
- D.
Hamstrings
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Guiding Principles of Nonoperative Rehabilitation )
- QUESTION 2.
Correct answer: C (see Phase I )
- QUESTION 3.
Correct answer: A (see Phase IV )
- QUESTION 4.
Correct answer: B (see Phase II )
- QUESTION 5.
Correct answer: C (see Box A)
Postoperative Rehabilitation after Femoroacetabular Impingement Treatment, Labral Repair, and Labral Debridement
- Nancy J. Bloom, PT, DPT, MSOT
- John C. Clohisy, MD
- Marcie Harris-Hayes, PT, DPT, MSCI, OCS
- John C. Clohisy, MD
Indications for Surgical Treatment
- •
Nonoperative treatment for at least 3 to 6 months has failed to resolve hip pain. Optimal nonoperative treatment would include corrections for impairments in:
- •
Sitting and standing alignment
- •
Precision of motion during functional activities, exercise and sport
- •
Muscle performance of the proximal hip muscles
The time frame for nonoperative care may be affected by value of the athletic participation for the individual. For example, a professional athlete may choose surgery earlier than a recreational athlete because return to sport is critical to their life.
- •
- •
Persistent pain associated with basic functional activities, such as walking or sitting
- •
There is no pain with basic functional activities, but pain is persistent with athletic activities.
- •
Physical examination and hip imaging consistent with hip impingement disorder
Brief Summary of Surgical Treatment
Major Surgical Steps
- •
Hip exposure via arthroscopy or open technique (mini-open or surgical dislocation)
- •
Correction of acetabular rim disease (rim osteoplasty, labral repair, partial labral resection, articular cartilage procedures)
- •
Correction of femoral disease/deformity (head-neck osteoplasty, relative neck lengthening, trochanteric osteotomy
Factors That May Affect Rehabilitation
See Table 26-1 .
- •
Less invasive (arthroscopy or limited anterior approaches) or open surgical dislocation
- •
Open dislocation is performed with a trochanteric osteotomy, which may extend the partial weight-bearing phase (4 weeks).
- •
Labral repair (as opposed to partial resection) may extend partial weight-bearing phase (2 weeks).
- •
Microfracture will increase time of protected weightbearing.
| Procedure | Weight Bearing | Movement | |||
|---|---|---|---|---|---|
| Hip Flexion | Hip Extension | Hip Rotation | Hip Abduction | ||
| Labral resection | 50% WB * × 2 weeks then progress to full WB | Active and Passive w/in comfort level but no >90° × 4 weeks | No >0° × 4 weeks | As tolerated | As tolerated |
| Labral repair | FF × 2 weeks then progress to full WB | Active and Passive w/in comfort level but no >90° × 4 weeks | No >0° × 4 weeks | 10° MR and LR × 4 weeks | As tolerated |
| Osteoplasty chondroplasty osteochondroplasty | 50% WB × 2 weeks then progress to full WB | Active and Passive w/in comfort level but no >90° × 4 weeks | No >0° × 4 weeks | As tolerated | As tolerated |
| Microfracture | FF ** × 8 weeks then progress to full WB | Active and Passive w/in comfort level but no >90° × 4 weeks | No >0° × 4 weeks | As tolerated | As tolerated |
| Surgical dislocation w/trochanteric osteotomy | FF × 4 weeks then progress to full WB | Active and Passive w/in comfort level but no >90° × 4 weeks | No >0° × 4 weeks | As tolerated | 4 weeks: No active abduction 8 weeks: add resistance |
| Arthroscopy + limited open osteochondroplasty | The addition of a limited anterior open procedure to correct CAM impingement does not add any additional precautions. Follow precautions for procedures performed in the scope. | ||||
| Combinations | Review procedures and follow most conservative precautions. Exp 1: Labral repair and osteoplasty: TTWB × 2 weeks, no MR or LR or hip flexion >90° Exp 2: Labral repair, osteoplasty, and microfracture: TTWB × 8 weeks, no MR or LR or hip flexion >90° | ||||
Before Surgery: Overview of Goals, Milestones, and Guidelines 1
1 Prehabilitation, if appropriate, is described in the Nonoperative Rehabilitation section of this chapter.
Assuming nonoperative treatment has not satisfactorily resolved the hip symptoms, the patient needs to be readied for surgery. Treatment should include:- •
Education regarding positioning, mobility and equipment required postsurgically.
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Lying down
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Sitting
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Crutch training: gait, stairs, sit to and from standing
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Bed mobility
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Transfers: car, commode, tub/shower
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Basic strengthening for upper extremities and nonsurgical lower extremity (LE)
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Strengthening for primary hip muscles of the surgical LE without increasing pain
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Encourage cardiovascular fitness to build endurance. Select activities or equipment that minimize forces due to weightbearing and avoid extreme ranges of hip motion. The activity should not increase symptoms.
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Education of potential precautions and postoperative activity level
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Recognize that surgical techniques can be combined; therefore follow the most conservative protocol. For example, labral tear and osteochondroplasty will need to follow labral tear precautions.
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Understand the surgical procedure or combination of procedures and associated precautions (see Table 26-1 ).
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Understand the specific tissues affected in the surgery (e.g., labrum, acetabulum, femoral head, femoral head-neck junction, cartilage, muscles) and the healing rate of tissues and the moderators affecting healing, such as age, anthropomorphics, and health of patient. Understand the alignment, positions, and movements that may increase stress to the involved structures.
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Most hip pain problems exist several months before surgery, which results in significant tissue adaptations. The longer the duration of symptoms, the more likely it is to find significant impairments in ROM; strength and flexibility and recovery may be slower. Exercise selection should be carefully graded to match the condition of the tissues.
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Avoid pushing end ROM. Normal ROM is highly variable and individual differences need to be respected.
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Emphasis should be placed on precision of movement and proper muscle activation during all therapeutic exercise, functional activities, and sporting skills.
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Understand structural variations and their impact on goals for treatment.
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Musculoskeletal impairments in the nonoperative lower extremity and lumbar spine are common and need to be addressed.
Phase I (days 0–2, 4, or weeks 8 postoperatively depending on procedure): Immediate Postoperative Period, Minimal Weightbearing (Foot Flat)
See Table 26-1 .
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Movement impairments may be observed during attempted exercise performance. For example, hip medial rotation (MR) may be observed during hip flexion exercises. Observed impairments should be corrected.
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In general, do not push hip ROM too soon or too aggressively.
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Very often a continuous passive movement system is prescribed for passive range of hip flexion and extension. Do not rely on the machine setting alone for ROM. To avoid hip flexion beyond 90°, educate the patient to consider the influence of the trunk/pelvic position on hip flexion when setting up to use the CPM device. When out of the device, precise hip flexion is most easily achieved when combining hip and knee flexion.
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An active straight leg should not be used for hip flexor or quadriceps strengthening or hamstring stretching in this population.
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Pain in the adductor region is often felt during hip abduction exercises. In those cases, cue to activate the gluteus medius and downgrade the movement until it can be performed without a sensation in the adductors.
| PHASE I (weeks 0 to 2, 4, or 8) | PHASE II (weeks 2 to 12) | PHASE III (weeks 2 to 16) | PHASE IV (weeks 12 to 24) |
|---|---|---|---|
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Goals
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Minimize stress to the affected structures during basic mobility and exercise.
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Decrease pain and inflammation.
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Minimize the effects of immobilization (joint, muscle, and circulation).
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Begin cardiovascular activities within precautions.
Protection
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Instruction in precautions for exercise and daily activities (see Table 26-1 )
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Two crutches for ambulation
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Bracing if prescribed by surgeon
Equipment
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Raised toilet seat
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Tub bench and hand held shower
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Long-handled devices: reacher, shoehorn, sponge
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Continuous passive motion (CPM) device
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Assistive device: crutches
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Compressive stocking or mechanical compressive device
Basic Functional Mobility and Positions
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Lying down:
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Supine (most frequently used): pillow under knees for first few days only. May also place bolsters/towel roll/pillow on the outside of thigh to control lateral rotation (LR).
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Side lying on uninvolved side (once patient is able to log roll while maintaining precautions, see bed mobility): pillows between knees. Avoid side lying on involved side.
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Prone (less commonly used for resting position): pillow under hips.
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Sitting: Assess use and type of chair at home. Make recommendations to achieve the following:
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Hips should be higher than knees (may need wedge or pillow on chair or use of recliner).
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Weightbearing should be symmetrical
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Avoid low surfaces.
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Feet and spine should be supported.
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Avoid prolonged periods (>20 to 30 minutes) of sitting upright.
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Do not cross legs.
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Standing with crutches: Allow the foot on the involved side to rest flat on the ground, but avoid putting too much weight through the involved limb. Foot flat is preferred over toe-touch weightbearing to avoid prolonged positioning of hip flexion. Avoid leaning on axillae. Avoid prolonged periods of standing.
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Bed mobility:
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Rolling: Assume hook lying, place pillow between knees, and log roll toward the nonsurgical side.
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Supine to sitting: Perform log rolling as above. Once on side, use upper extremities or uninvolved LE to assist in moving the surgical LE to the edge or push up to sitting.
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Sit to and from stand: Scoot forward in the chair. Place involved LE in front of body with knee straight and the opposite foot underneath the seat. Place hands on armrests and use upper extremities to assist standing or sitting. Control the descent when sitting down ( Figure 26-12 ).
FIGURE 26-12
Sit to and from stand. The goal is to avoid hip flexion greater than 90° and place minimal weight on the involved lower extremity. Scoot to edge of chair, place involved lower extremity in front of body with knee straight, and use upper extremities to assist.
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Gait: Use two crutches and minimal weightbearing. Encourage heel to toe pattern to foster normal hip, knee, and ankle motion without placing more than the weight of limb on the foot.
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Stairs: Instruct in a step to cadence, lead with the involved LE when descending stairs, and lead with the uninvolved LE when ascending stairs. The use of two crutches or one crutch and a railing is dependent on the safety and comfort of the patient.
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Car transfers: Seat should be moved back and reclined. Back up toward the seat, using car or crutch to assist in sitting down. Lean back into car and use hands or opposite foot to assist moving the LE on the surgical side into the car.
Management of Pain and Swelling
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Ice
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Oral pain medications as prescribed by physician
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Elevation of LE in supine position
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Compressive stocking or mechanical compression devise
Techniques for Progressive Increase in Range of Motion, Muscle Activation, and Other Therapeutic Exercises
Exercises may have multiple purposes such as increasing joint ROM, muscle activation, strengthening, endurance, or flexibility.
Exercises Primarily for the Hip
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Hip flexion: (Precaution: no hip flexion >90°, no active straight leg raises )
Cue to stabilize pelvis by using the lower abdominals
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Supine or sitting semi reclined: use of CPM to 60°
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Supine: heel slide
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Slide foot along surface to the hook-lying position and return. Keep hip in neutral rotation. If painful, a cue to dig the heel in slightly to increase the use of the hamstrings may help. Cue to relax between repetitions.
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Initially may need to place a pillow under the knees for comfort, but eventually the pillow should be removed to achieve hip extension to 0°.
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Supine hook-lying: active-assistive hip flexion toward 90°
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Use towel or upper extremities (UEs) to assist with lifting thigh ( Figure 26-13 )
FIGURE 26-13
Supine/hook lying: active-assistive hip flexion toward 90°. Use towel to assist with lifting thigh. Gradually progress the exercise by reducing the amount of assistance.
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Progress to active hip flexion without assistance.
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Quadruped: partial rocking backward
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Start with the hips in 60° of flexion. Cue to push with the hands while rocking backward toward 90°. Avoid flexing the lumbar spine as the hip flexes.
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Standing on uninvolved LE: active hip flexion through partial range motion
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Hip extension: (Precaution: no hip extension >0 ° )
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Any position: gluteal isometric contractions.
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Standing on uninvolved LE:
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Active hip extension (knee extended): lift lower extremity from starting position to 0° (hamstrings)
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Active hip extension (knee flexed to 90°): lift lower extremity from starting position to 0° (gluteus maximus)
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Prone with a pillow placed under the hips to avoid increased hip joint force during active hip extension (may need to avoid until after removal of ankle pumps or in general rolling over is safe given rotation precaution). Cue to contract abdominals before performing hip extension.
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Active hip extension (knee flexed to 90°): lift lower extremity from starting position to 0° (gluteus maximus). Cue to contract the gluteals and avoid pushing down with the nonmoving LE ( Figure 26-14 )
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