Athletic Training and Sports Health Care

Sports Medicine Digest 

Evidence-Based Rehabilitation for Hip Arthroscopy

Dillon E. Hyland, MS, LAT, ATC; Zachary K. Winkelmann, MS, LAT, ATC; Kenneth E. Games, PhD, LAT, ATC

Abstract

Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health. 2010;2:222–230.

Clinical Question: How successful are general and specific rehabilitative protocols in improving strength, endurance, range of motion, and flexibility following hip arthroscopy?

Study Selection: A literature review was conducted of articles in PubMed, EMBASE, and PEDro published between 1992 to 2009 focusing on the hip, rehabilitation, and physical therapy.

Main Results: This review identified four distinct phases of post-surgical hip rehabilitation: (1) mobility and initial exercise, (2) intermediate exercise and stabilization, (3) advanced exercise and neuromuscular control, and (4) return to activity. Each phase of rehabilitation and progressive training corresponds to a phase of healing.

Conclusions: Clinicians should be proactive in the use of hip progressive phasic rehabilitative guidelines (PPRG) in conjunction with their own clinical judgment and patient values to ensure positive therapeutic outcomes.

Summary: Hip arthroscopy has become an increasingly common procedure, with prevalence increasing by 25 times its original rate between 2006 and 2013.1,2 Sports health care professionals are recommending arthroscopic procedures most often due to the less invasive nature of arthroscopy and the decreased time in return to activity for sporting populations.3 Despite these positive findings for arthroscopy, 47% of patients report pain resulting from athletic activity following hip athroscopy.2 Patients report varying locations of this pain, primarily in the groin, anterior hip, and lateral hip. Pain was also reported but less frequent in the posterior hip and with a C-sign distribution.2

Voight et al.1 support the hip PPRG rather than specific exercise prescription. PPRG allow clinicians to use their own clinical judgment in prescribing specific exercises to reach a specific treatment goal in conjunction with physician restrictions. PPRG offer a larger rehabilitative view, providing context through generalized exercise types and insight focused on assessing imbalances and substitutions.1 Hip PPRG provide a contextual frame-work with which a clinician can operate, whereas specific surgical rehabilitation protocols suffer from a lack of uniformity and validation.1

Phase 1: Mobility and Initial Exercise. Phase 1 is based on the initial healing, return to a pain-free range of motion, and joint extensibility. This can be accomplished through multiplanar motion, joint mobilizations, gait training through muscle reeducation, and correction of altered muscle contraction and movement patterns caused by a reflex inhibition, with an emphasis on appropriate post-surgical precautions including weight bearing and level of pain.1,2 Immediately after surgery, isometric exercises prove useful to increase tone and basic strength while healing occurs.1,2 Appropriate examples of dynamic stability exercises include double leg bridging, reverse clam shell, mini-squats, and short arc leg press.1 Aquatic therapy can also be a viable treatment option.

Phase 2: Intermediate Exercise and Stabilization. This phase typically begins 4 to 6 weeks after arthroscopy depending on the local trauma sustained during the surgical procedure.1 The goals of phase 2 are characterized by full pain-free range of motion, progressive strength and stabilization, the addition of weight bearing and progressive resistance training, and the elimination of muscular imbalance and substitution patterns.1,4 The recognition of muscular imbalance and substitutions can be identified through tests such as the pelvic rotation, pelvic tilt, torso rotation, and bridge with leg extension tests.1 These tests can detect imbalances and facilitate the subsequent correction of lower abdominal, erector spinae, hip flexors, and gluteal musculature.1

Phase 3: Advanced Exercise and Neuromuscular Control. The role of neuromuscular control is essential in the therapeutic rehabilitation process because fatigue can negatively influence kinesthetic and proprioceptive awareness. As such, activities focused on functional movement patterns and dynamic stabilization may be effective transitional exercises.1,2

Although these goals are similar to those of phase 2,…

Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health. 2010;2:222–230.

Clinical Question: How successful are general and specific rehabilitative protocols in improving strength, endurance, range of motion, and flexibility following hip arthroscopy?

Study Selection: A literature review was conducted of articles in PubMed, EMBASE, and PEDro published between 1992 to 2009 focusing on the hip, rehabilitation, and physical therapy.

Main Results: This review identified four distinct phases of post-surgical hip rehabilitation: (1) mobility and initial exercise, (2) intermediate exercise and stabilization, (3) advanced exercise and neuromuscular control, and (4) return to activity. Each phase of rehabilitation and progressive training corresponds to a phase of healing.

Conclusions: Clinicians should be proactive in the use of hip progressive phasic rehabilitative guidelines (PPRG) in conjunction with their own clinical judgment and patient values to ensure positive therapeutic outcomes.

Summary: Hip arthroscopy has become an increasingly common procedure, with prevalence increasing by 25 times its original rate between 2006 and 2013.1,2 Sports health care professionals are recommending arthroscopic procedures most often due to the less invasive nature of arthroscopy and the decreased time in return to activity for sporting populations.3 Despite these positive findings for arthroscopy, 47% of patients report pain resulting from athletic activity following hip athroscopy.2 Patients report varying locations of this pain, primarily in the groin, anterior hip, and lateral hip. Pain was also reported but less frequent in the posterior hip and with a C-sign distribution.2

Voight et al.1 support the hip PPRG rather than specific exercise prescription. PPRG allow clinicians to use their own clinical judgment in prescribing specific exercises to reach a specific treatment goal in conjunction with physician restrictions. PPRG offer a larger rehabilitative view, providing context through generalized exercise types and insight focused on assessing imbalances and substitutions.1 Hip PPRG provide a contextual frame-work with which a clinician can operate, whereas specific surgical rehabilitation protocols suffer from a lack of uniformity and validation.1

Phase 1: Mobility and Initial Exercise. Phase 1 is based on the initial healing, return to a pain-free range of motion, and joint extensibility. This can be accomplished through multiplanar motion, joint mobilizations, gait training through muscle reeducation, and correction of altered muscle contraction and movement patterns caused by a reflex inhibition, with an emphasis on appropriate post-surgical precautions including weight bearing and level of pain.1,2 Immediately after surgery, isometric exercises prove useful to increase tone and basic strength while healing occurs.1,2 Appropriate examples of dynamic stability exercises include double leg bridging, reverse clam shell, mini-squats, and short arc leg press.1 Aquatic therapy can also be a viable treatment option.

Phase 2: Intermediate Exercise and Stabilization. This phase typically begins 4 to 6 weeks after arthroscopy depending on the local trauma sustained during the surgical procedure.1 The goals of phase 2 are characterized by full pain-free range of motion, progressive strength and stabilization, the addition of weight bearing and progressive resistance training, and the elimination of muscular imbalance and substitution patterns.1,4 The recognition of muscular imbalance and substitutions can be identified through tests such as the pelvic rotation, pelvic tilt, torso rotation, and bridge with leg extension tests.1 These tests can detect imbalances and facilitate the subsequent correction of lower abdominal, erector spinae, hip flexors, and gluteal musculature.1

Phase 3: Advanced Exercise and Neuromuscular Control. The role of neuromuscular control is essential in the therapeutic rehabilitation process because fatigue can negatively influence kinesthetic and proprioceptive awareness. As such, activities focused on functional movement patterns and dynamic stabilization may be effective transitional exercises.1,2

Although these goals are similar to those of phase 2, the emphasis within phase 3 is to build on basic stabilization and progress to more functional exercise. This begins with closed kinetic chain dynamic stabilization exercises that allow for progressive weight transference and synergistic muscular patterns.1 The integration of aquatic therapy to accomplish dynamic movement early in this phase may be advantageous to integrate the patient to modified range of motion exercises.1,2 Dynamic movement patterns with strength integration can become an integral step of progression and includes partial squats, lunges, and dynamic weight shifts.1,2 Clinicians may consider the use of progressive neuromuscular control exercises such as static, double limb exercises, continuing to dynamic and single limb exercises with and without visual inputs. Additional mental processing tasks, such as catching a ball or picking up an item, that incorporate the upper extremity should be incorporated to increase the difficulty throughout the phase.1,2

Phase 4: Return to Activity. The return to activity timelines are reflective of the pathophysiology and surgical procedure paired with impairment (decreased strength), functional limitations (inability to run, jump, etc.), and disability (inability to fulfill sport participation role). As a result, this process should remain fluid and be modified as necessary to match the level of disablement to the rehabilitation goals for the patient.1 Return to activity is a primary motivator to engage in therapeutic rehabilitation for athletes and active individuals,5 but only 82% of athletes are able to return to their sport participation level following injury.5 Prolonged hip pain and resulting arthritic changes can result in societal limitations such as removal from athletic participation.5

Interestingly, athletic competition level has shown a link for return to sport rates in which athletes competing in higher-level competition are more likely to return to sport.5 The data suggest a positive correlation regarding return to sport and increased level of competition.5 Professional athletes return more quickly, likely due to the socioeconomic pressures regarding sport as an occupation compared to sport as a recreational activity, such as collegiate and high school athletics.5

The findings in this study identify specific rehabilitation protocols for return to activity that lack validation.1 Additionally, the evidence is inconclusive regarding the phased integration of progressive exercise and stabilization. We suggest that clinicians use generalized guidelines for rehabilitation following hip arthroscopy and incorporate other aspects of evidence-based medicine including the patient's values in relation to treatment outcomes and clinical experience working with similar patients.

References

  1. Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health. 2010;2:222–230. doi:10.1177/1941738110366383 [CrossRef]
  2. Kivlan B, Nho S, Christoforetti J, et al. Multicenter outcomes after hip arthroscopy: Epidemiology (MASH Study Group). What are we seeing in the office, and who are we choosing to treat?Am J Orthop. 2017;46:35.
  3. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy. 2008;24:1135–1145. doi:10.1016/j.arthro.2008.06.001 [CrossRef]
  4. Groh MM, Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105–117. doi:10.1007/s12178-009-9052-9 [CrossRef]
  5. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. Br J Sports Med. 2015:bjsports-2014-094414.
Authors

From the Neuromechanics, Interventions, and Continuing Education Research (NICER) Laboratory, Department of Applied Medicine and Rehabilitation, Indiana State University, Terre Haute, Indiana.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Dillon E. Hyland, MS, LAT, ATC, 567 North 5th Street, Indiana State University, Terre Haute, IN 47809. E-mail: dhyland@sycamores.indstate.edu,

10.3928/19425864-20181002-03

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