Postoperative pain and inflammation are controlled through medication, use of a continuous passive motion (CPM) machine, early nonresistance biking, and soft tissue modalities. Nonsteroidal anti-inflammatory (NSAIDS), muscle relaxants, and pain medication may be prescribed by the physician. Ice compression devices are recommended 4–5×/day or as needed for pain control and inflammation during the first 2 weeks of recovery. Cryotherapy has been shown to be an efficacious modality with reducing the use of analgesic medication and pain while improving comfort with sleeping and overall satisfaction in postoperative patients [6, 7].

Range of motion is initiated as early as postoperative day (POD) 0. This includes early stationary biking without resistance for 20 min, twice daily to assist with portal drainage. Passive circumduction range of motion performed by a therapist or caregiver is recommended daily. The circular motion performed during this exercise encompasses flexion, extension, abduction, and adduction of the hip and is simple to instruct to caregivers. Additionally, it has been theorized to reduce adhesions about the zona orbicularis of the hip because of the circular motion.

Manual physical therapy techniques , such as lymphatic massage or gentle joint mobilizations (grade 1 and 2), can be used to decrease postsurgical inflammation and control pain. These techniques are performed for 2 weeks after surgery or until inflammation has dissipated. Soft tissue mobilizations to lengthen tissue and decrease reactive muscle tone surrounding the hip joint are then initiated. Anterior musculature, such as the iliopsoas, rectus femoris, tensor fasciae latae, and adductor muscles, tends to respond to surgery with reactive shortening and hypertonicity. This may be due to effusion and positioning the hip in flexion for prolonged periods of time, such as when using the CPM machine. Previous authors have recommended that patients lay in a prone position daily during phase 1 [8].

Passive range of motion is initiated on POD 0 and continued through phases 1 and 2 or until full range of motion is achieved. Initially, flexion, internal rotation (IR), abduction (abd), adduction (add), and circumduction are performed to help restore mobility, prevent fibrosis [8–10], and contribute to joint health [11]. Abduction is restricted to 45° for the first 2 weeks, and external rotation and extension are typically limited to neutral for 2–3 weeks. These limitations prevent capsular stretching at the surgical site. Excessive flexion and IR should be avoided to limit irritation due to compression at the surgical site [9]. The frequency of passive range of motion is varied; however, twice daily is recommended.

Active range of motion is initiated within the first week in order to promote neuromuscular control and normal muscle firing patterns. Exercises, such as cat and camel and quadruped rocking (Figs. 1 and 2), are initiated as early as postoperative day 4. These exercises are recommended to reestablish pelvic control through the stabilizing effect of co-contraction and recruitment of synergistic muscle groups. Quadruped rocking allows gravity-assisted hip flexion to occur while decreasing the pinching sensation a patient may experience in supine flexion. Hip flexor activity is typically limited during the initial 2 weeks of rehabilitation to avoid magnifying anterior hip pain. During week 3, patients may begin light, pain-free hip flexion exercises. Patients and therapists should be aware of compensation patterns, increased irritation of rectus femoris, hip adductors, and tensor fasciae latae (TFL) muscles and tendons; these muscles tend to substitute for iliopsoas weakness or inhibition [1, 12]. Figure 3a, b demonstrates such an exercise. During this exercise, the patient lays supine while rolling a fit ball into hip flexion and extension while maintaining trunk control. This can be performed with (as pictured) or without light resistance.

A key component to prepare the hip joint for weight-bearing and normal gait is reestablishing proper neuromuscular control patterns of the hip. Patients with FAI and labral pathology often develop compensation patterns of the hip, trunk, and lower extremity. These patterns continue after surgery has been performed, which may be harder to correct the longer they have been present. Common patterns that occur prior to surgery include:

In order to restore normal muscle activation, the musculature of the hip, trunk, and lower extremity must be addressed simultaneously. Initially, patients are instructed on isometric exercises that recruit the GM, GMax, quadriceps, hamstrings, and transverse abdominus. Patients are instructed to co-contract trunk musculature with hip and lower extremity musculature in order to promote trunk and pelvic stability.

As swelling and pain decrease, open chain, active assist, and active exercises are initiated with the goal of recruiting inhibited muscles and reducing activity of hypertonic muscles. Three studies have looked at rehabilitation exercises that target gluteal musculature while minimizing hypertonic musculature [13–15]. Selkowitz et al. [13] studied gluteal-specific exercises that reduce TFL activity. Philippon et al. [14] ranked 13 hip exercises in order of GM iliopsoas activity. In a similar study, Giphart et al. [15] ranked the same exercises with regard to gluteal piriformis and pectineus activity. While some exercises in these studies will reduce, for example, TFL activity, they may increase the activity of other muscles, such as the iliopsoas, pectineus, and piriformis. Therapists should use these exercises in the presence of hypertonicity of the specific muscles identified during a patient assessment.

Active assisted exercises include the slide board abduction exercise and can begin during the first postoperative week. Once gluteus medius isolation is mastered with slide board abduction, the patient can progress to standing abduction, and side lying gluteus medius holds. It is important to be aware of TFL substitution during these exercises. Early activation of the deep external rotators can begin week 2 with prone external rotator activation from the position of IR and stopping at neutral. This will activate the rotator muscles with respect to the ER rotation restriction. Furthermore, gluteus maximus activation and transverse abdominis stability can be progressed from an isometric exercise to quadruped hip extensions (Fig. 4).

Criteria to advance to phase 2 include (1) minimal pain with all phase 1 exercises, (2) correct muscle firing patterns with all phase 1 exercises, and (3) minimal complaints of anterior hip pain prior to 100° of passive hip flexion.

Phase 2 begins when weight-bearing restrictions have been discontinued and phase 1 criteria have been met. The main goal of phase 2 is to restore normal gait. Secondary goals include returning the patient to weight-bearing activities of daily living, ascending and descending stairs with alternating gait, and double-limb squatting. Phase 2 may be considered the most critical phase to success after hip arthroscopy because of the neuromuscular challenges the rehabilitation specialist will encounter when returning a patient to unrestricted weight bearing. As patients progress to walking without an assistive device, they are more likely to experience increased anterior hip pain, which is commonly described as hip flexor tendonitis [8, 16]. This pain may be better explained as excessive anterior hip forces on the surgical site created by the femoral head due to insufficient muscle activity during hip extension and flexion motions. This pain may be difficult to control without rest and unloading of the joint until the pain subsides.

The ultimate goal of phase 3 of the rehabilitation program is to restore muscle strength, power, and endurance. Activities of daily living and recreational activities should become relatively asymptomatic during this phase. The physical therapist should continue to monitor compensatory patterns previously described during the progression from open kinetic chain to closed kinetic chain exercises and as the demand for range of motion, joint stability, and neuromuscular control increases. Careful consideration should be taken to determine the best exercise prescription based on the demands and functional goals of the patient while applying basic training principles of load, volume, frequency, and periodization when designing exercise prescriptions [19, 20]. Exercise specificity should be considered with athletes seeking to return to sports participation; however, this should not be overridden by fundamental physiologic, metabolic, and biomechanical voids that must be fulfilled prior to prescribing more complex and specific exercises.

Exercises should emphasize muscles that stabilize the hip joint and reduce anterior joint forces. These muscles include the GM, gluteus maximus, and Iliopsoas [1, 21]. Table 3 presents a series of exercise progressions for each of these muscle groups, which are based on empirical evidence [13–15, 22, 23], clinical rationale, and anecdotal expertise. However, therapists should exercise discrimination when prescribing these exercises based on the individual differences of each patient and clinical findings.