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Hip Arthroscopy Rehabilitation Protocol

PHASE 1 0 - 2 Weeks

Aim

  1. Protect Wound, Settle Inflammation and Swelling, Prevent Stiffness

Ice

Up to 7 - 8 times per day, ideally using your BodyICE Kit - Particularly after doing your exercises

Avoid

  1. Deep Hip Flexion past 90 degrees
  2. Rotation that causes pain

Weight Bearing

  1. Partial weight bearing with crutches, with a flat foot on the ground (full weight bearing as tolerated if no labral repair or bony work)

Exercises

  1. Exercise Bike: No resistance, high seat; 2x day for 10 - 20 mins as tolerated.
  2. Stretching (calf pumps, quad stretches)

    Psoas Stretch (lie supine with a pillow under the hip); progress to Prone Lying Below

    • Prone lying "belly time"
    • Progress to propped on elbows, at least 20 minutes twice/day
  3. Quadruped Rocking (can start week 2)
    • On your hands/knees, shift your body weight forward/back then side/side, then diagonal, and eventually into Cat/Camel mode once you feel comfortable.
  4. Range of Motion

    5. Start with gentle supine hip ‘Log Rolling’ (leg flat on the bed being rolled inwards and outwards)

    Passive Circumduction as per below (can start week 2)

    -@30 degrees flexion (3 mins clockwise, 3 mins anticlockwise)

    -@70 degrees flexion (3 mins clockwise, 3 mins anticlockwise)

PHASE 2 2 - 6 Weeks

Aim

  1. Restore Painless Range of Motion
  2. Continue Swelling and Inflammation Control
  3. Ensure proper muscle activation and neuromuscular patterning Core Stability!
  4. Progress to NORMAL Gait with crutches, then without Crutches (as tolerated)

Ice

Continue icing as much as tolerated/required; particularly after exercises/physiotherapy

Avoid

  1. Deep Hip Flexion past 90 degrees
  2. Rotation that causes pain
  3. Loading/jumping/running

Exercises

  1. Wean off crutches as tolerated; only once NORMAL gait and proper gluteus activation
  2. Scar Mobilisation as required
  3. Continue Daily Exercise Bike; add 5mins
  4. Start Hydrotherapy
  5. Continue Phase 1 Exercises
  6. Focus on Core Stability Exercises

Phase 3 Intermediate Phase 6 - 10 Weeks

Aim

  1. Aim for NORMAL range of motion including flexion, rotation
  2. Achieve EXCELLENT core stability, balance, neuromuscular patterning
  3. Improve Muscle Strength

Avoid

  1. Painful extremes of motion, 'pinching'
  2. Explosive movement all repetitions should be controlled, with adequate core stability, and appropriate muscle patterning
  3. Compensation: Particularly Anterior weight shifting, pelvic drop, valgus collapse
  4. Crunches, sit-ups, heavyweights

Exercises

  • Continue Phase 1/2 Exercises
  • Add resistance on the exercise bike as pain allows
  • Other cardio Elliptical, mobile bike, walking
  • Upper Body Strength and Conditioning
  • Increased intensity Hydrotherapy/Swimming
  • Focus on core stability/balance/proprioception Single leg work (flat ground then uneven then unstable surface (Bosu or similar); Progress to Single-leg Squat
  • Phase 3 Exercises as per Below
    • Manual joint mobilisations GENTLE - avoid aggressive traction
    • Strengthening/stability
    • Prone hip extension
      Lie on your stomach. Tight glutes and lift the leg while keeping the knee straight. progress to hip extension off the end of the plinth or over the exercise ball

      • Side laying hip abduction
      Lie on the uninvolved side. Position the upper leg in slight extension and lift up then slowly lower to the starting position. keep toes facing forward and hip extended

      Hip hikes
      Stand sideways on a step with an uninvolved leg on a 4-inch step with the involved lower extremity free of the step. keep both hips facing forward with shoulders and pelvis shoulders level. While keeping your uninvolved leg straight, raise your hip straight up then lower slowly.

  • Sport cord rotations - begin at 6 weeks
    Start with double leg rotations with the band around the waist, and progress to single leg stance rotations. The patient should focus on good glute and core activation while maintaining a level pelvis and preventing any valgus collapse throughout the lower extremity. Avoid pinching
  • Posterior squats
    Position feet parallel to each other. emphasise proper form with knees remaining above ankles without collapsing in or out. Start with partial knee bends and increase depth per tolerance without complaints of pinching. Progress to squats on unstable surfaces. Can use the wall to facilitate posterior weight shift and proper squat mechanics.
  • Spilt squats/lunges
    Step forward with the involved lower extremity. Lower hips toward floor then push through front foot to return to starting position. Depth is dependent on patient tolerance and no complaints of pinching.
  • Bridging progression
    Lie on the back and position both feet on the ball. Keep knees straight and raise hips off the floor to form a straight line from feet to shoulders, Return to the starting position slowly

    May progress to marching bridges and then single leg bridges after ~6 weeks, once able to perform double leg bridges on the ball without anterior hip pain.

  • Step and holds
    Position in front of the mirror, step forward onto a slightly bent knee and balance for a few seconds. Maintain control of the knee and do not let it move in or out. Knee-shoulder remains positioned directly above the foot.
  • Romanian deadlift
    Start with feet parallel to each other. Lift the uninvolved leg back and off the floor and bend forward at the hips while maintaining a straight lower back position. Only bend forward as far as you can without rounding your lower back
  • Sidesteps
    Start with knees and hips slightly flexed with a resistance band positioned around the ankles. keep feet and knees pointed forward as you step sideways with the leading leg then take a small step in the same direction with the back leg while maintaining tension in the band.
  • Posterior reaches
    Start with knees and hips slightly flexed with the resistance band around the ankle. step back with one leg at a 450 angle then to starting position.
  • Planks
    Lie on your stomach with your elbows and forearms underneath your chest, and prop yourself up to form a plank using your knees/toes and forearms for support. Maintain a flat back. Do not allow your hips to sag towards the ground. Kneeling planks at week 6-trial full planks beginning at week 8.
  • Side planks
    Lie on your side with your elbows on the ground below your shoulder. Lift yourself up to form a plank. hold this position until you can no longer maintain a straight line from your shoulders to your knee/toes.
  • Step-up/step-downs
    Place your foot on a small (2-or 4-inch) step. Step up onto the step then lower uninvolved foot back to the floor. Increase step height per tolerance without pain or symptoms.
  • Stand with an involved leg on a small step. Lower the opposite foot to the ground by slowly bending your knee while keeping the hips/pelvis level. When the foot touches the ground, straighten the knee and return to the starting position. Control knee, do not allow knee collapse, and keep knee bending toes.
  • Criteria for Progression to Phase IV
    • = Ability to complete all phase 3 Exercises without increased pain, swelling or irritation
    • = Demonstrate full pain-free ROM with hip flexion to 115 degrees
    • = Full Weight-bearing without pain and no assistive and able to ambulate 15 minutes without pain or fatigue

Phase 4 Advanced Rehab/Return to Sport (10 - 16 Weeks)

Aim

  1. Improve balance, strength, mobility, endurance, and conditioning until ready to play

Avoid

  1. 'Pushing Through' New pain, swelling, stiffness is a sign to ‘scale back’

Return to Sport Criteria

  1. No pain on all tests; acceptable range of motion
  2. No compensatory movements (pelvic drop, knee valgus, anterior weight shift)
  3. Symmetry
    less than 10% side-to-side difference on single leg stance/hop, quads bulk
  4. Confidence/Trust in your hip
  5. Full Fitness (conditioning, cardiovascular, upper/lower body strength)

Exercises

  1. Continue Phase 3 exercises plus add Plyometrics (below)
  2. Start Running only when comfortable, Progress to Sport Specific Training Strengthening/stability

Three Position squats

Position feet parallel to each other, shoulder-width apart. Now stagger your stance so your surgery foot is in front of the non-surgery foot and feet are shoulder width apart (the farther the stagger distance, the increased difficulty of exercise). Shift more body weight to the posterior leg. Repeat with legs switched.

Band Hip Flexor Progression

Start in a supine position with feet supported by a ball and band around the foot. pull back on the band, bringing the knee toward the hip. Stop once the knee is above the hip. Avoid excessive flexion or any pinching in the hip. Progress to feet unsupported then to bridge position on ball.

Walking Lunges

Step forward with one leg in front, feet shoulder-width apart, and bend both knees to lower pelvis towards the floor. Straighten your knees and step forward to advance the other leg in front. you should be making forward progress. Repeat across the length of the room. Be sure not to lower past any "pinch" pain. Progress to walking lunges with rotation - can or pinch symptoms.

Reverse lunge with X chop
Posterior leg elevated on surface ~1-2 feet high (low plinth, couch seat). Hold a 1-2-pound weight (medicine ball) in hands. With both knees slightly bent and arms starting at one shoulder, chop down moving weight to opposite hip. Increase knee bending as you chop down. Repeat 10 times.

Then keeping legs in same position, switch starting position of arms to begin at opposite shoulder and repeat 10 times. You've made an 'X' with arm chops. Switch legs and make an 'X' with the arm chop again.

Plyometrics (10-12 Weeks)
All landings should be performed quietly and controlled, with knees behind toes and no knee valgus.

Discontinue and return to strengthening exercise if pain increases with any plyometric activity.

Shuttle

Double leg (DL) hops Begin with minimal resistance, as this is one of your first plyometric exercises, Push off the footplate and land with equal weight on both legs. Land with feet shoulder-width apart, knee behind toes and no valgus knee positioning. Repeat (slowly and with control) for 15 seconds before stopping.

Only progress to jogging and hops with rotation if no pain with DL hops.

Single leg (Sl) hops jogging

SL hops begin with minimal resistance. repeat (slowly and with control) for 5 seconds before stopping.

Only trial jogging and hops with rotation if there is no pain.

Jogging with the same minimal resistance, alternate SL landings on footplate. Repeat (slowly and with control) for 15 seconds before stopping

Dynamic strengthening and stability

Hop-ups

DL hop up to 2-inch box-soft, quiet landing with good knee position. progress to a 4-inch box. trail SL if not painful and with proper mechanics

Hop downs

DL hop down from 2-inch box to floor. Remember important landing mechanics progress to 4-inch box. Trial SL if not Painful and proper mechanical.

DL line jumps

Jump forward across the room for distance - but note that control and proper landing mechanics are more important than distance itself. Be sure each landing is quiet and controlled before beginning next jump.

SL line jumps

Jump forward across the room for distance – but note that control and proper landing mechanics are more important than distance itself. Be sure each landing is quiet and controlled before beginning the next jump.

First alternative legs - jump from R to L.

Then continue on the same leg - jump from R to R to R

3-way hop drill (DL first and trail SL)

  • Perform small DL hops forward and backward over line for 15 seconds Remember soft and quiet landings!
  • Perform small DL hops sideways back and forth over line for 15 seconds
  • If no pain with the above, perform small Dl rotational hops (no line needed) for 15 seconds
  • keep feet shoulder-width apart and maintain proper landing mechanics before the trial of SL hops

3-ways jog matrix

  • Slowly jog forward and then backpedal to return
  • Repeat down and back with side shuffling
  • Repeat with carioca

Agility ladder drills

Begin walk/jog program after 12 weeks if able to complete above exercises without pain/pinch

criteria to progress to walk/jog program

  • 20 heel touches
  • Ambulation with symmetrical gait
  • No weight shifts with squatting
  • No pain with Sl hopping