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Rehabilitation following Hip arthroscopy. Prof. Ernest Schilders Leeds Metropolitan University Bradford Teaching Hospitals. Questions to answer before we start our rehab program.

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rehabilitation following hip arthroscopy

Rehabilitation following Hip arthroscopy

Prof. Ernest Schilders

Leeds Metropolitan University

Bradford Teaching Hospitals

questions to answer before we start our rehab program
Questions to answer before we start our rehab program
  • What is the exact procedure and operative findings?Faster rehab program for simple and longer for complex procedures.
  • How long was the patient injured before his surgery?Conditioning is a very important element of the rehab.
procedure specific rehab advice
Procedure specific rehab advice
  • FAI surgery (1-4 week crutches PWB)
  • Microfracture (prolonged use of crutches 6-8 weeks)
  • Capsular Plication (use of night splints in internal rotation for 4 weeks)
clinical and operative findings that might have a negative impact on the rehab
Clinical and operative findings that might have a negative impact on the rehab
  • Pain and a negative hip arthroscopy
  • Presence of extensive grade 4 cartilage lesions.
  • Generalisedhyperlaxity in patients with instability symptoms.
  • Centre edge angle below 20 degrees.
  • Low preop outcome score.
slide11

20y old professional football player

  • CE angle= 20
  • vertical sloping weightbearing surface.
  • Perthes disease
  • Generalized hyperlaxity
perioperative pain management
Perioperative pain management
  • Muscle relaxant at induction (Atracurium 0,6mg/kg)
  • Remifentanyl infusion during surgery for blood pressure control, muscle relaxation and analgesia.
  • Multimodal analgesia at the end of the surgery. NSAID/ paracetamal and morphine.
  • Postoperative pain relief consists of codeine, paracetamol and NSAID
  • Antibiotics administration at induction.
rehabilitation ladders

Rehabilitation ladders

Process whereby patient/player progresses through rehabilitation, achieving goals within specific timescales.

Easy to follow.

Based on evidence and agreed with consultant involved.

other considerations
Other considerations
  • Use realistic timescales (Always err on the side of caution).
  • Use common sense, as injured patients/players will progress at different rates.
frank gilroy post surgical general rehabilitation ladder

Increased shearing activities,

agility, sports specific rehab

HIGH STRESS

Advanced strengthening and proprioception

MEDIUM STRESS

Regain full ROM

Increased strengthening and proprioception

LOW STRESS

Regain ROM

Early strengthening

Surgery

Frank GilroyPost surgicalgeneral rehabilitation ladder

Pre-op preparation

Timescales depend on consultant involved

slide16

MEDIUM STRESS

8-12 week ladder

Playing again!

HIGH STRESS

Phase 4

Short sprints and shuttle runs, increasing core stability work. Gradual return to sports specific training

Phase 3

Straight line running, strengthening exercises, increased pool work and full stretches

Phase 2

Jogging 20-30 minutes, light stretching and pool exercises

LOW STRESS

Phase 1

Gentle walking and light stretching

Surgery

Timescales depend on consultant involved

Pre-op preparation

week 1
Week 1
  • Ankle pumps
week 11
Week 1
  • Ankle pumps,
  • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
isometrics
Isometrics
  • These are static exercises. When you do the exercise you should feel the muscles tighten without movement of the joints. Try to do twenty repetitions of each exercise, 2 times a day.
    • Gluteal sets: tighten your buttock muscles – hold for 5 seconds.
    • Quads sets: tighten the front thigh muscles – hold for 5 seconds.
    • TransversusAbdominus: Draw belly button in towards spine without moving pelvis/spine – hold while taking 5 breaths.
    • Hip abduction: Lying on your back with hip and knees bent, place a belt around your thighs near your knees and push out against the belt – hold 5 seconds
week 12
Week 1
  • Ankle pumps,
  • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
  • Stationary bike – start 20 minsx 2 daily
slide21

Stationary Biking with high seat and minimal resistance.

  • As soon as you are comfortable enough to get onto a bike, cycle for 20 minutes 2 times a day.
    • Increase the time by 5 minutes after 3-4 days until you have reached a maximum of 45 minutes twice a day.
    • No resistance should be added until week 5-6.
week 13
Week 1
  • Ankle pumps,
  • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
  • Stationary bike – start 20 minsx 2 daily
  • Passive stretching, Piriformis stretch (side lying), Quads stretch (prone), Adductor stretch (sitting)
passive stretching exercises
Passive stretching exercises
  • Lying on your good side (bottom legstraight and pelvis stacked) bend your involved hip to between 50° to 70° flexion and hook top foot behind uninvolved knee. Steadying the pelvis, lower the involved knee towards bed. Stretch should be felt in buttock, avoiding a pinch in groin.

Piriformis stretch

quadriceps stretch
Quadriceps stretch
  • Do 5 repetitions, hold for 20 seconds, and twice a day.
  • Lie on your stomach with your hips flat on the bed. Ask a partner bringankle toward buttock, feeling stretch in the front of the thigh.
  • If it is too painful to lie on your front, you can do this stretch lying on your good side.
adductor stretch
Adductor stretch
  • Do 5 repetitions, hold for 20 seconds, and twice a day.
  • Sit in a chair with the feet on the floor. Carefully move the knee of the affected leg out to the side so the hip is opening out (abducting). Do the stretch as comfort allows and feel the stretch on the inside of the thigh.
week 14
Week 1
  • Ankle pumps,
  • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
  • Stationary bike – start 20 minsx 2 daily
  • Passive stretching, Piriformis stretch (side lying), Quads stretch (prone), Adductor stretch (sitting)
  • Price
week 2
Week 2
  • Week 1 exercises (including)
  • Quadruped rocking
quadruped rocking
Quadruped rocking
  • 3 sets, 20 repetitions, once a day.
  • On your hands and knees shift your body weight forward on your arms, and then back onto your legs. Also shift your weight side to side and in diagonal directions.
week 21
Week 2
  • Week 1 exercises (including)
  • Quadruped rocking
  • Standing Hip IR
standing hip internal rotation
Standing hip internal rotation
  • 3 sets, 20 repetitions, once a day.
  • Place knee ofthe operated leg on a chair. Rotate the hip by moving your foot outward from the body. Progress the exercise by using a resisted band when tolerated.
internal rotation strengthening with thera bands
Internal rotation strengthening with thera bands

Start position

Finishing position

week 22
Week 2
  • Week 1 exercises (including)
  • Quadruped rocking
  • Standing Hip IR
  • Heel slides with/without strap
  • Cons r/v
weeks 3 4
Weeks 3-4
  • Pain relief – Price, electrotherapy or mobilisation
  • Gait re-education
  • ROM exercises (Cont week 1 & 2 exercises)
  • Stretching (piriformis and quads) include Faber, calf, hamstring and ITB
  • Gym work (if appropriate) Bike – no resistance but increase time (aim to build for 45 minsx 2 daily), Leg press – low weights and repetitions, Cross trainer – min resistance monitor time, Swiss ball
  • Core stability
  • Hydrotherapy
faber
Faber

lying on your back bring involved leg into a figure four position with the ankle resting above the opposite knee. Gently lower the bent knee towards the floor. You may need to start with ankle resting on the shin or inside of the leg. It is normal to feel some hip discomfort underneath the thigh. DO NOT PUSH ON THE KNEE.

weeks 3 41
Weeks 3-4
  • Pain relief – Price, electrotherapy or mobilisation
  • Gait re-education
  • ROM exercises (Cont week 1 & 2 exercises)
  • Stretching (piriformis and quads) include Faber, calf, hamstring and ITB
  • Gym work (if appropriate) Bike – no resistance but increase time (aim to build for 45 minsx 2 daily), Leg press – low weights and repetitions, Cross trainer – min resistance monitor time, Swiss ball
  • Core stability
  • Hydrotherapy
weeks 5 6
Weeks 5-6
  • Cont weeks 1-2 and 3-4 (include the follwing)
  • Gym work within capabilities ( inc resistance on bike alter time)
  • Balance work – wobble board, trampette
  • Core stability – progress as able
  • HEP – lunges, lateral side steps, knee bends, fartlek (jog/walk)
weeks 7
Weeks 7+
  • Week 1-2 exercises can be stopped
  • Cont with weeks 3-4 and 5-6
  • Increase hydrotherapy exercises (squats, step ups/downs, ¼ - ½ lunges.
  • Running – progress from straight line to multi-directional
  • Sports specific
which questions do we have to ask ourselves
Which questions do we have to ask ourselves?
  • How do we know that our rehab is progressing steadily, what is normal and what is abnormal?
  • What are the standards we can realistically aim for? (measurements of outcomes)
  • Can we separate the built up of fitness from a hip arthroscopy specific rehab program?
which assessment criteria can we use during rehab
Which assessment criteria can we use during rehab?
  • Pain
  • Functional scoresModified Harris Hip ScoreHip outcome osteoarthritis score (HOOS)SF 36
  • Subjective assessment?
  • Objective Static informationRange of motionStrength testLog roll test
  • Objective dynamic evaluationSPORTS TEST
pain following the procedure
Pain following the procedure
  • Procedure relatedAdhesions, microfracture, labral repair, decompression CAM or pincer. INFECTION
  • Traction relatedadductor painPectineusSciatic painAnkle pain
  • Rehab relatedIliotibial band and trochanteric bursitisPsoasHip flexorsSynovitis
  • Sacro iliac joint pain.
pain and stiffness
Pain and Stiffness
  • Pain: Reintroduce analgesia, NSAID rarely steroid injection.Limited restConcentrate on Deep Rotators of the hip.
  • Stiffness:ROM stuck (very rarely) ; check X rays or CT scan to investigate for residual impingement
risk factors for adhesions
Risk factors for adhesions
  • More complex arthroscopic procedures.
  • Pre-operative sensations of stiffness that limits function.Possible risk factorsLonger time on crutchesGrade 4 articular cartilage lesions treated with microfracture.
iliotibial band
Iliotibial band
  • Compression of the trochanteric bursa due to iliotibial band tightness. *Weakness of the hip abductors causing increased hip adduction.*Swelling bursa due to fluid extravasation.*swelling and insufficiency muscles due to portal trauma.
  • Osteopathic technique to reduce the tightness, myofascial release. “ counterstrain a positional release technique”.
research in progress iliotibial band tightness
Research in progress, Iliotibial band tightness
  • Weakness of the hip abductors and imbalance between adductor/abductor strength.
  • Reduced hip mobility compared to controlateral sidean issue to address early in the rehab, before athletes have increased their activities to significantly
which assessment criteria can we use during rehab1
Which assessment criteria can we use during rehab?
  • Pain
  • Functional scoresModified Harris Hip ScoreHip outcome osteoarthritis score (HOOS)SF 36
  • Subjective assessment?
  • Objective Static informationRange of motionStrength testLog roll test
  • Objective dynamic evaluationSPORTS TEST
modified harris hip score
Modified Harris Hip score
  • Preoperatively 39-96
  • 2 months postop58-100
  • 6 months postop74-100
  • Minimum of 12 months postop. 70-100
slide54

Overall the average pre-op MHHS was 62.1 (95% CI 57.8-66.4) and the average post-op MHHS, after minimum 1 year, had statistically significantly increased to 94.8 (95% CI 92.8-96.9) (p<0.001).

  • Average return to sport was 2.4 months.
which assessment criteria can we use during rehab2
Which assessment criteria can we use during rehab?
  • Pain
  • Functional scoresModified Harris Hip ScoreHip outcome osteoarthritis score (HOOS)SF 36
  • Subjective assessment?
  • Objective Static informationRange of motionStrength testLog roll test
  • Objective dynamic evaluationSPORTS TEST
sports test m philippon
Sports test M Philippon
  • Passed> or = 17 points
  • Failed< 17 points
timing to sport
Timing to sport
  • Difficult to predict.
  • Should be athlete orientated rather the rehab orientated.
  • Need for objective measurements before allowing athletes to go back to sports.
risk factors for reinjury
Risk factors for reinjury
  • History of injuries and low level of off-season sport specific training.
  • Consider the time an athlete has been out with an injury, before having surgery.
risks of early return
Risks of early return
  • Persistent Pain
  • Prolonged rehabilitation time.
  • Low performance
  • Re-Injury( new labral tear, articular cartilage lesion)
  • New Injuries.Emery et al. Med SciSportsExerc, 2001.
when would i stop an athlete from returning
When would I stop an athlete from returning?
  • Lack of endurance in sports specific tasks.
  • Pain in sports specific positions.Progressive adaptations can be feasible. Dressage: start with small horses before wide horse, stirrups higher, to sit in a flexed more abducted position.
slide62

Endurance muscles fibers are the first to be lost after hip surgery and take longer to recover.Suaetta et al. J ApplPhysiol, 2008. Deschenes et al. Am J Physiol, 2002. Ferrettiet al. J ApplPhysiol, 2001

principles
Principles
  • If possible see patient/player pre-operatively to prepare joint involved, and explain process and timescales involved.
  • Always work closely with the surgeon involved.
  • Whenever possible follow evidence based guidelines.
return to sports following impingement surgery
Return to sports following impingement surgery
  • Soccer 2-4 month
  • Rugby 2-3 month
  • Basket ball 5 month
  • Hockey 3-4 month
  • Dance 3 month
  • Martial arts 3 month
  • Tennis 2 month

sports involving twisting and turning

return to sports following impingement surgery1
Return to sports following impingement surgery
  • Golf 2-3month
  • Cycling 6week-2 month
  • Running 2 month
  • Rowing 2 month
  • Rockclimbing 3 month

Sports not involving twisting and turning