AFTER HIP ARTHROSCOPY
Rehabilitation after hip arthroscopy is a stepwise process beginning the day after surgery. This rehabilitation program is not fixed in stone and may be adapted depending on intra-operative findings and results.
But in general: Most of my patients will receive a continuous passive motion with a machine in the ward post operative. This machine will begin early range of motion exercises of the hip. It is essential to begin these movements in order to avoid adhesions or scar tissue formation in the hip joint.
On the first day or the morning after surgery the physiotherapist will direct you in mobilizing out of bed with a pair of crutches. You will be instructed to place weight on the affected leg in a manner known as flatfoot partial weight-bearing. This is normally necessary for a period of two weeks, but may be extended in patient’s with hip dysplasia or where there has been a lot of bone resection or cartilage graft procedures.
You will be given a set of exercises to perform in the first two weeks. Generally they should be done with 3 sets of 10 repetitions 3 times a day.
They are as follows:
- Lying on your stomach with the pelvis flat on the bed and the knee bent.
In this position and the foot is allowed to rotate outwards and inwards.
This should be done 10 times.
- Stand upright with a good foot on a small step so the operated side is raised off the ground. Now keep the operated leg straight with the foot facing forward and in a circular fashion swing the leg around in ever widening circles. Each circle should count as one and be repeated 10 times. Try and keep the pelvis as still as possible so the movement is concentrated at the hip joint.
- Standing upright, pushing the pelvis forward and the leg with a bent knee backwards followed by rotating the foot outwards and inwards as you were doing when lying on the stomach. The emphasis should be on pushing the knee backwards so the thigh is vertical and the hip extended to neutral. Again outwards and inwards rotation to count as one cycle and this should be repeated 10 times.
- A forth movement is to lift the leg with a bent knee and flex the hip to 90 degrees. Then move the knee outward while rotating the foot up to a figure of four position, then in a smooth motion move the leg back down into the straight vertical standing position. This is again repeated 10 times.
These 4 simple exercises should be done at home for the first two weeks. You will then be seen in the rooms to remove your dressings which are waterproof enough to shower with. Generally they will last the distance from time of discharge.
With the review at the two week mark a letter of referral for the physiotherapist will be given, and until 3 months after the date of surgery the emphasis for the rehabilitation is on regaining full range of movement at the ball and socket joint of the hip. For the initial 6 weeks, the stretching should take place to the point of pain, and the following 6 weeks stretching should take place into pain in order to regain full range of motion. Remember that true movement at the hip joint is very dependent on keeping the pelvis as stable as possible and not allowing it to move. When the pelvis moves this will be false movement at the hip joint and no true stretching will be obtained. The stretching program must be combined with joint position sense (proprioception), or balance work with the physiotherapist. Inevitably some muscle strengthening will occur during this rehabilitation but the emphasis is not on strengthening the muscles until after 3 months.
From 3 to 6 months after surgery a functional rehabilitation program should be instituted with an emphasis on muscle strength rebuilding. This will include controlled closed chain as well as eccentric rapid change in direction type activities. This rehabilitation will include early jogging on a treadmill and subsequent gradual progression with exercise intensity. Generally once the physiotherapist is happy that you have achieved a full range of movement at the hip and that you have a good sense of balance, you may be transferred to the care of a biokinetisist who will assist with the exercising of your muscles.
I always expect there to be some discomfort with the stretching program and once more when the active muscle strengthening exercises are instituted. The hip may often be more painful for a while but usually will settle down. With the high end sports men and women, they are usually able to return to their sport of preference at between 4 to 6 months after the surgery.
Most importantly, I only make a final outcomes assessment as to the success of surgery at 6 months after the operation and again at 1 year.
Details for the physiotherapist:
- Combat inflammation:
- Anti inflammatories for 10 days
- Ice Packs 3 x per day for first 3 days
- Early adhesion prevention:
- Limited ROM :
- Flex to 90 deg only
- Log rolling with hip in extension, active and passive IR to 20deg and ER 10deg
- Avoid leg falling into ER (support lateral aspect of foot in bed when supine, knees clamped together when turning, lie on unaffected side only)
- No extension beyond -10 deg.
- Do not sleep with pillows under knees.
- CPM with ROM 0 to 80 deg if availible
- Standing (hip in extension knee bent to 90deg) Int. Rot. movements to 20 deg and Ext. Rot. to 20 deg only
- Standing on step flexion/extension pendulum motion swings at hip with knee extended conbine with circumduction movement with pelvis stabilised.
- Limited ROM :
- Mobilization partial weight bearing with crutches (+/- 9kg flat foot gait).
FIRST 14 DAYS
- Partial weight bearing with crutches as above.
- ROM exercises as above 3sets of 10, 3 X per day
- CPM for 2 hours per day; flex and extend 0 to 80 deg with leg neutral, if available for first 2 weeks.
- Can do stationary cycling in upright position without resistance and leg in neutral rotation. Seat height set with leg straight heel on pedal at lowest point.
- Gentle repetitive Int. Rot. movement with leg in 0 deg extension.
- Aquatic walking after 10 days.
AFTER 14 DAYS
- Progress to full weight bearing. No running, jumping or impact weight bearing till 60 days post surgery especially if any bony resection was done.
- Progressive Resistance Exercises(PRE’s), in all directions. Regain full passive ROM. Stretch within pain limit for 1st 6 weeks then into pain. full active and passive ROM by 12 weeks post op.
- Aquatic walking and treading water in cycling motion.
- Lumbopelvic (Core) muscle stabilization activities to run in parallel with PRE’s . Important to incorporate single leg standing activity and progress to single leg squats by 3 months post op.
- Balance and functional activities initiated as allowed by weight bearing restrictions. Emphasize re-establishing dynamic rotation stability and motor control especially gluteal muscle firing sequence. Proprioceptive rehabilitation very important.
- Aim for return to full activity between 3 to 6 months with functional rehab after 3 months.