Rehabilitation following Hip arthroscopy

1. Rehabilitation following Hip arthroscopy Prof. Ernest Schilders Leeds Metropolitan University Bradford Teaching Hospitals

3. 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.

4. Incidence of pathology in athletes n=120

5. Incidence of intraarticular pathology

6. Type of articular cartilage lesion

7. Femoroacetabular Impingement

8. Procedures in athletes

9. 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)

10. 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.

11. 20y old professional football player • CE angle= 20 • vertical sloping weightbearing surface. • Perthes disease • Generalized hyperlaxity

12. 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.

13. 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.

14. Other considerations • Use realistic timescales (Always err on the side of caution). • Use common sense, as injured patients/players will progress at different rates.

15. 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

16. 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

17. Week 1 • Ankle pumps

18. Week 1 • Ankle pumps, • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction

19. 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

20. Week 1 • Ankle pumps, • Isometrics – Gluteal, Quads, Trans Abs, Hip abduction • Stationary bike – start 20 minsx 2 daily

21. 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.

23. 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)

24. 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

25. 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.

26. 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.

27. 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

28. Week 2 • Week 1 exercises (including) • Quadruped rocking

29. 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.

30. Week 2 • Week 1 exercises (including) • Quadruped rocking • Standing Hip IR

31. 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.

32. Internal rotation strengthening with thera bands Start position Finishing position

33. Week 2 • Week 1 exercises (including) • Quadruped rocking • Standing Hip IR • Heel slides with/without strap • Cons r/v

34. 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

35. 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.

37. 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

41. 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)

42. 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

43. Advanced hydrotherapy

44. Advanced hydrotherapie

45. 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?

46. 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

47. 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.

48. 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

49. 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.

50. 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”.