Post Operative Rehabilitation of Hips After Correction of Femoroacetabular Impingement and Labral Tear.

Transcription

1 Post Operative Rehabilitation of Hips After Correction of Femoroacetabular Impingement and Labral Tear. Marcia Milgate November 201 Cayman Islands Cindy Reid

2 ABSTRACT Femoroacetabular Impingement (FAI) is an abnormal structure of the hip joint that can be genetic in origin, or develop over time during growth, as a cause of repetitive activity or following an injury. Often the FAI is a secondary diagnosis in athletes or rather the cause of an injury such as a long distance runner that has presented with a labral tear. The years and miles covered by the runner, without knowledge of genetic FAI, eventually cause strain on the labrum, as well as the surrounding ligaments and muscles, due to its repetitive nature. The individual eventually suffers tears or full detachment of the cartilage. The increasing pain and discomfort becomes acute and initiates the runner to seek treatment. Upon diagnosis the responsibility of an orthopaedic surgeon is to repair the labral tear and the hip joint, as well as preservation of the overall health and longevity of the hip structure. The goal of Pilates is to assist in the rehabilitation of the functionality of the hip joint. Pilates, in partnership with physiotherapy, can help achieve strength, stability, flexibility and balance in the post operative hip joint repair. It is also identifies the need to retrain the muscles of the body to act in harmony, especially the postural support, which have previously compensated for the injury. Ultimately, the runner should be able to return to their training and provide them the tools to manage their joint health with overall improved physicality. 2

3 TABLE OF CONTENTS Title Page 1 Abstract 2 Table of Contents 3 The Hip Joint 4 Case Study 6 Program Development 7 Comprehensive Block System Program - Weeks Comprehensive Block System Program - Weeks 6-13 Comprehensive Block System Program - Weeks Conclusion 15 Bibliography 16 3

4 THE HIP JOINT The hip joint is an incredible part of the mechanical operation of our bodies. A large synovial joint with a ball and socket type formation, it forms the structure from which we perform many of the large, gross motor movements and fundamentally support our body weight whether we are standing or sitting. It affects our ability to move and to maintain our posture. You will find that the two largest bones, the femurs, fit into our pelvis with a unique bone formation and are held by supporting ligaments that make up our pelvis and lower spine. The head and neck of the femur, or cam, projects off the greater trochanter, angling up, sitting into the acetabulum which is the lower outside portion of the Ilium. The head of the femur forms a smooth ball which nestles in the socket wrapped in a layer of articular cartilage and attached by a small ligament called the Liagmentum teres that attaches to the head of the femur in the Fovea capitis. All around the edge of the acetabulum rim is another key ring of cartilage called the labrum which acts almost like a suctioned lip gripping the femoral head, keeping it close, but allowing it a wide range of motion or circumduction. This joint is further supported by small ligaments that attach onto the lower Ilium, Pubic Symphysis and Ischial Tuberosity to the greater trochanter such as the ischiofemorial, posterior, and the pubofemoral, anterior. The Iliofemoral attaches on the posterior of the ilium and wraps from the back to the front anterior of the greater trochanter forming a Y. Femoroacetabular Impingement (FAI) There are three types of FAI: 1. Pincer - the bone structure of the acetabulum extends beyond the normal range or bone spurs have built up along the rim of socket. 2. Cam - the neck of the femur is genetically larger or it develops bone spurs that cause it to rub on the acetabulum during movement. 3. Combined - the joint presents with bone deformities or spurs on both the acetabulum and the femur 4

5 Labral Tear The labrum is a continuous structure of cartilage that encircles the rim of the acetabulum. A tear is usually caused by the pressure of excess bone build up from FAI. It often happens on the anterior top of the acetabulum. When the support of the cartilage is compromised and there is additional bone mass, the supporting muscles and ligaments are also strained. Musculature The hip joint is designed to perform Flexion, Extension, Adduction, Abduction, External Rotation, Internal Rotation and Circumduction. The deep muscles surrounding the hip joint initiate movement, especially rotation and are key in support. They include the Gluteus minimus, Piriformis, Gemellis superior and inferior, with the Obturator internus and externus and Quadratus femorus in the posterior. The Adductors are made up of the Adductor brevis, longus and magnus, the Gracilis, Pectineus and Sartorius. In the anterior, there is primarily the Iliopsoas or the Illiacus and Psoas major that are both supportive and movers in the hip flexion function. These muscles all perform slightly different functions and work together in different combinations to initiate the range of motion the hip joint was designed for. The superficial muscles or outer layer are also important since they are big movers The Gluteus maximus and medius, and the three muscles that make up the hamstrings, Semimembranosus, Semitendinosus and Biceps femoris at the rear, with the Quadriceps, consisting of the Rectus femoris, Vastas lateralis, intermedialis and medialis in the front and the Tensor fascia lata running down the front side. These are primary movers. 5

6 CASE STUDY A long distance runner, Camille was active in competitive sport her entire life, with competitive skating and skiing from the time she could walk to running in off season from her early teens. As an adult Camille graduated to running year round with increasing mileage for more than twenty years of active running. This was balanced with swimming, tennis and mat work Pilates twice weekly as cross training and core maintenance. In the middle of training for a marathon, Camille fell and suffered a large contusion and deep pain on her left leg and hip area. With physiotherapy and a week off she was able to go back to conditioning for the marathon with a compression wrap on her upper thigh. The injury magnified the niggling pains she had endured previously in her training, but she had the view that they were due to the increased mileage for the marathon. When the marathon was completed, she took a break from running to let herself fully heal and the inflammation time to subside, but the pain only increased and her range of motion decreased in her left hip. Camille was showing symptoms of lower back and deep groin pain with stiffness and restricted movement in flexion of of her left leg, so she sought consultation with physiotherapists and then orthopaedic surgeons. Camille was diagnosed with combined Femoroacetabular Impingement (FAI) with extensive labral tears in her right hip and an anterior labral detachment in her left hip. The FAI was genetic in origin with the acetabulum extending past normal on both sides of the socket. The years of sport had accelerated the development of bone spurs on both the neck of the femur, edge of the acetabulum, as well as nodules on the head of the femur. These had pushed the ball away from the acetabulum stressing the surrounding ligaments and tearing the labrum primarily on the anterior position. The left hip had suffered detachment of the labrum likely due to the impact injury sustained. In the words of her surgeon, he stated that this was as bad as it gets in terms of the diagnosis and if she was older she would be looking at a hip replacement. At 37 years of age, Camille was recommended for immediate surgery to repair the bone structure and reattach the cartilage. She underwent arthroscopic hip surgery to remove the bone spurs to the neck of the femur, reduce the overlap of the pincers on the acetabulum and microfracture was performed on the head of the femur to remove spurs, create a smooth surface and regenerate healthy bone growth. Plastic screws were inserted into the acetabulum and teflon tape used to wrap the labrum and reposition it into place. The joint was cleaned and further cartilage trimmed inside the capsule where needed to alleviate the onset of osteoarthritis in the joint. After weeks recovery Camille could bear weight on her left leg and walk with crutches. At 12 weeks, the same surgery was repeated on her right hip. Camille commenced physiotherapy 2 weeks post surgery in both instances. She was able to ride a stationary bike for mobility, performed supported movement in a swimming pool and did daily stretching and strengthening exercises on the mat. Four months after Camille s second surgery she was recommended by her Physiotherapist to work with a Pilates instructor with training in the use of a reformer to increase her effectiveness at rehabilitation. This was Camille s first introduction to the Pilates equipment. 6

7 PROGRAM DEVELOPMENT As noted, Camille had been performing exercises in stretching and mobility in increasing amounts in conjunction with what was prescribed by her surgeon and physiotherapist. These involved many Pilates based mathwork movements, stretching, stationary biking and supported movement in the pool. She had been focusing on preventing adhesions from the scar tissue around the joint through gentle stretching daily, fluid motion of the hip joint with the stationary bike and in the pool, but needed to increase her strength, stability and range of motion in the deeper musculature of the hip joint while still having supported assistance. Goals: Strengthen the supporting muscles of the hip to allow for further work in the larger muscle mass Continue to increase flexibility while respecting patient pain tolerance Increase Range of Motion gradually Improve Balance of both muscle use and development equally Retrain Postural Alignment because all the hip muscle groups attach to the pelvis which in turn affect posture and movement. Cautions: Restrict flexion of the hip to 90 degrees and increase incrementally as tolerated by patient No forced compression of the hip joint No Pivot stretching involving the hip (ie. Piriformis stretch with lower leg on thigh and opposing outward pressure on knee) No sudden pivot movement (ie. planting of the foot and turning sharply) The hip is dislocated to perform the surgery and as such, patients wear a brace around their hip and upper thigh to restrict movement and prevent dislocation post surgery for at least the first six weeks up to eight weeks depending on the surgery. Afterwards, movement is increased incrementally with muscle toning regained and flexibility gradually improved. It takes time for the smaller muscles, ligaments and surrounding tissues to recover from the stretching caused by the forced dislocation and stability of the joint is paramount. The joint remains feeling full of fluid and the swelling of tissues can last well past three months surgery depending on the procedures performed. Microfracture increases the healing time as does a labral repair. Patients have describing the sensation saying that Your hip feels very inflated from the fluids they put in there, and it feels very loose. You just feel very cautious because it feels so detached from your body. 1 This sense of detachment makes walking with a natural feeling gait difficult and one can be fearful to push past pain when increasing the difficulty of both strengthening and stretching. Good postural position with neutral spine, equal distribution of weight help the patient to fell secure in pushing past their limits and feeling supported in their movements. Prior to the surgery, Camille s Hip Flexors, larger adductors and hamstrings would have taken over the bulk of supporting her in addition to being a prime mover. With the forced inactivity, these muscles will have tightened 7

8 and but still instinctively want to take over. Teaching Camille to recruit deeper muscles to support the movement in her hip joint will help her rehabilitate. It is key to protect the joint post surgery and buildup stamina as the area heals to move onto larger gross movement. Continuing to work on her flexibility helps to prevent adhesions of the scar tissue forming on the anterior capsule to the extent that it could inhibit movement. With this knowledge, the following program is an example of progression for rehabilitation to get Camille moving on her feet confidently supporting her body weight and participating in full mat work Pilates, with a view to running again when she has clearance from her surgeon. Assumptions Camille continues her physiotherapy exercises on days outside of her Pilates sessions. Camille has regained a sufficient range of motion for her to begin the program which has been approved by her Physiotherapist with a view to trying each and building up strength gradually. The number of repetitions for each movement are a target goal not an absolute and the pain tolerance and ability of Camille will be assessed each session and adjustments made accordingly. Weeks 1-5 Though Camille has experience with Pilates Mat work, she is new to the equipment and will be doing a combination of fundamental exercises utilizing several pieces of equipment. She will be participating in 2 sessions each week and will alternate between programs to keep interest and start to introduce new challenges within a basic framework. Most movement will occur in the sagittal plane except where supported such as the hip work with springs instead of the ropes on the reformer. The focus initially will be proper spinal alignment while in the supine position, abdominal control and support while completing each movement and gradual build up of resistance and difficulty once each exercise is completed correctly and with ease. We will work at control through each movement and have emphasis on the eccentric phase to help with flexibility and strengthening. Warm Up Camille will begin with the fundamental warm up, but not attempt the Spine Twist Supine or Leg Changes until about the third week as the movement is unsupported. The surgery, scar tissue and limited range of motion post procedure cause significant tightness through the Illiacus and Psoas muscles. We want to teach Camille how to recruit her abdominal muscle group instead of relying on the Iliopsoas for support in the pelvic area. We want her to disengage this group of muscles until she had demonstrated good abdominal control before combining the two groups to work together in movements unsupported by equipment.

9 Footwork Camille will concentrate on her maintaining her neutral spine, lateral breathing and abdominal control as she learns the footwork series on the reformer. She will complete all five weeks on the reformer to allow her to develop strong pelvic control in the supine position. Working from a lesser spring tension initially to perfect the movement in her foot positions which will allow her to focus as well on the smaller muscles supporting her hip joint as she changes from parallel to v-position and moves her legs further apart in the open position. The single leg work will challenge her to maintain equal weight and balance in her pelvis, as well as identify individual weaknesses. As she progresses, I will add weight when beneficial without compromising her body position. Footwork on the Cadillac will be avoided due to the downward compression of the springs and Push Through Bar position. Abdominal Work Much of Camille s abdominal gains will be empasized in her core position through the Block of exercises. She will only do the Hundred Prep in order to work at holding both legs in table top position with correct alignment of her spine while lifting her head and chest. Placing a small rolled towel or half deflated pilates ball to squeeze between her thighs helps to focus her adductors and engage more than the hip flexors to hold the extended isometric contraction. Hip Work Camille will do all her work on the Cadillac so that the springs can help support the weight of her legs while she concentrates on her position and alignment. The circles will be the most difficult initially and we will work with small movement to encourage her to increase her range of motion by circumduction. I will hold her heel and help support her through the movement. Once she builds up strength, she will be able to see gains in her external and internal rotators, as well as her adductors and abductors. It will be key to get her to recognize and fire up all the small muscles so that she does not wholly rely on the large hip flexors and hamstrings. Spinal Articulation As Camille is still limited in how far she can bring her leg to her body in flexion, she has been advised to concentrate on bridging. Therefore, I have her warming up with the pelvic curl and building on it in this block by doing the bottom lift where her feet are elevated on the foot bar and changing the level in which she must raise her hips and articulate through her spine. I can start with football in a lower position and move it higher to increase the challenge. As well, I will start with all the springs on to focus on the movement and gradually reduce the number of springs depending on her progress and the strength of her hamstrings and abdominals. Stretches Camille will benefit from the supported stretching exercise of the standing lunge. She is required to stretch through her hip flexors daily and the reformer will help her push a bit further each time. We will also use the Barrel to give her a static stretch in some of the 9

10 sessions allowing her to focus individually on either the hip flexor or hamstring in a supported position without adding the additional flexion. Full Body Integration (FBI) The dynamic movement of the Scooter exercise will challenge Camille to focus on hip disassociation, balance securely on the supporting leg and control while on a lighter spring tension. As she demonstrates proper movement, the tension can be increased to work on strength too. Any additional FBI will be the introduction of Up Stretch 1 in week 3 if Camille is comfortable taking the flexion in her hip beyond the 90 degrees and experiences no pain. Arm Work Camille will find balance in working her upper body without compromising her lower half. Maintaining a neutral spine and holding her legs in table top position will be challenging. Using the ball between her thighs as in the abdominal work will be helpful. Leg Work The Chair will allow Camille concentrated effort on her hamstrings as well as balance while standing on one leg. If Camille finds it difficult to get down onto the floor, then I will eliminate the Hamstring Curl. We will continue with the Footwork to build up strength in her legs. She will likely need assistance to perform Leg Press Standing and should only attempt in the third week. Performing an exercise in a standing position while balancing her weight on one leg will train the supporting muscles of her hip joint and teach her to trust her gains in strength. If she is too unstable, then the exercise should be avoided until she has completed further single leg work on the reformer. Lateral Flexion and Rotation The restriction not to compress the hip joint at this stage and not being able to go much past 90 degrees in flexion limits the exercises that Camille can do on the equipment. At this point we are complementing the physiotherapy exercises she is already doing such as Side lift on the mat. Using the Barrel to get Camille to use her trunk to initiate a lateral movement incorporate a whole body approach to her overall flexibility and strength. We want to strengthen her whole core to improver her posture and functional movement. She has not been able to reach down and touch the floor, whether sitting or standing, for more than six months. The Side Over Prep will condition her body to perform simple tasks outside Pilates without her straining. She may only be able to achieve the Side Over Prep in the first 5 weeks. I will use a compression pad to provide additional cushioning between her hip and the barrel if needed. The movement should initiate from the abdominal obliques. Back Extension Again, sticking to fundamental back extension and using the equipment to build upon mat exercises. The Breaststroke Prep on the Reformer will support her legs as she engages her core and maximizes the extension she can achieve while holding onto the

11 footbar. With the Swan Prep on the Barrel, she can start with the extension and gradually add the arms. Finish The Roll Down and the Rest Position are contraindicated for Camille as this point as they are too much compression in the joint and are too the 90 degrees flexion. After the back extension exercises it beneficial to stretch and articulate through the spinal column. Having Camille go into an all fours position and complete a few Cat Stretch exercises will give her a release. Additionally, she can lay supine and hold her knees at 90 degrees to her abdomen and rock from side to side. Weeks 6- Camille will continue to build up strength by increasing tension in some of the Foot Work and adding the Wunda Chair to challenge her balance and postural alignment in the upright position. She will start with her extended leg bent in the Single Leg exercises on the Wunda Chair. We will stay on the Cadillac for the hip work, but add single leg focus alternating with double legs and aim to increase range of motion. Increasing her abdominal work and adding postural challenges to the arm work will keep her interested and build upon the whole body conditioning. Adding the Side Split will increase balance and weight distributing while the Hip Opener will work her external rotators and improve flexibility. I will add variety to the Back Extension to balance out the abdominal work. Weeks The Warm Up and Foot Work will continue in the same manner, with Camille aiming to straighten her stationary leg in the Wunda Chair single leg work. I will also have her bring her knees higher to increase the range of motion and hip flexion while maintaining her balance. Abdominals will follow the increased difficulty and work towards control and endurance. The biggest change will be to introduce the straps on the reformer and challenge Camille to perform the hip work without the support of the springs on the Cadillac. This will increase the work on her hip rotators, adductors and abductors. I will also have her try the Long Spine to add variety to her spinal articulation without deep flexion of Short Spine as long as she demonstrates strength and control in the straps. I will add in another block of Full Body Integration at the intermediate level to diversify the session and keep Camille s interest. The Skating Single Leg will give her another challenge for balance and posture, while working her Gluteal muscle group. I add back in the Hamstring Curl to work on increased strengthening and not just range of motion. The Side Kneeling Stretch will change the lateral movement to a shorter contraction and also increase her balance while kneeling that will mimic daily functions outside class. We will switch up the back extension and I will encourage her to push her improve her strength and the range of thoracic movement, while balancing weight in her pelvis. 11

12 Weeks Sessions Per Week BLOCK Session 1 Reps Session 2 Reps Warm Up Mat or Cadillac Platform Mat or Cadillac Platform Pelvic Curl 6 Pelvic Curl 6 Introduce in Week 3 Spine Twist 3-4 Spine Twist 3-4 Chest Lift 6- Chest Lift 6- Chest Lift with Rotation 4-6 per side Chest Lift with Rotation 4-6 per side Single Leg Lifts 6 per side Single Leg Lifts 6 per side Introduce in Week 3 Leg Changes 6 per side Leg Changes 6 per side Foot Work Reformer Reformer Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Heel Single Leg Toes 20 Count Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Heel Single Leg Toes 20 Count Abdominal Work Reformer Reformer Hundred Prep 6- Hundred Prep 6- Hip Work Cadillac Cadillac Supine Leg Series Frog Walking Bicycle (Reverse) Supine Leg Series Frog Walking Bicycle (Reverse) Spinal Articulation Reformer Reformer Starting with all springs Bottom Lift 4-6 Bottom Lift 4-6 Stretches Reformer Barrel Standing Lunge 2 ea side Hip Flexor 3-5 breaths Hamstring 3-5 breaths Full Body Integration Reformer Reformer Scooter - per side Scooter - per side Introduce in Week 3 (ROM permitting) Up Stretch Up Stretch Arm Work Reformer Reformer ` Arms Supine Series Extension Adducton Triceps Arms Supine Series Extension Adducton Triceps Leg Work Wunda Chair Wunda Chair Hamstring Curl - Hamstring Curl - Introduce in Week 3 Leg Press Standing - Leg Press Standing - Lateral Flexion/Rotation Barrel Barrel Side Over Prep 4-6 per side Side Over Prep 4-6 per side Back Extension Reformer Barrel Breaststroke Prep 6- Swan Prep 4-6 Finish Mat or Cadillac Platform Mat or Cadillac Platform Cat Stretch 4-6 Cat Stretch

13 Weeks 6-2 Sessions Per Week BLOCK Session 1 Reps Session 2 Reps Warm Up Cadillac Cadillac Roll Up with Roll Up Bar 6 Roll Up with Roll Up Bar 6 Mini Roll-Ups Mini Roll-Ups Mini Roll-Ups Oblique 6 per side Mini Roll-Ups Oblique 6 per side Roll Up Top Loaded 6 Roll Up Top Loaded 6 Foot Work Wunda Chair Reformer Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Single Leg Toes Single Leg Heel Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Toes Single Leg Heel 20 Count Abdominal Work Cadillac Reformer Roll Up Bottom Loaded 6 Hundred Prep 4-6 Breathing w/ Push Through Bar 6 Hundred (Vary Position of Legs) Work to Full Set Hip Work Cadillac Cadillac Supine Single Leg Series Frog Hip Extension Bicycle (Reverse) 6 ea Supine Leg Series Frog Walking Bicycle (Reverse) Spinal Articulation Reformer Reformer Bottom Lift 4 Bottom Lift 4 Introduce in Week 7 Bottom Lift with Extension 2 Bottom Lift with Extension 2 Stretches Barrel Reformer Hip Flexor 3-5 breaths Standing Lunge 2 ea side Hamstring Adductors 3-5 breaths 3-5 breaths Full Body Integration Reformer Reformer Up Stretch 1 4 Elephant 4 Scooter - per side Arm Work Reformer Cadillac *Sit on Box to start to release gripping in the hip flexors and focus on balance Arms Sitting Series * Chest Expansion Biceps Rhomboids Hug-A-Tree Salute Arms Standing Series Chest Expansion Hug-A-Tree Punching Biceps Leg Work Reformer Wunda Chair *Start with legs close together Side Split* per side Hip Opener - Lateral Flexion/Rotation Barrel Barrel Side Overs 4-6 per side Side Overs 4-6 per side Back Extension Reformer Barrel Pulling Straps 1 Swan Prep (with Arms) 6 Pulling Straps 2 Finish Mat or Cadillac Platform Mat or Cadillac Platform Cat Stretch 4-6 Cat Stretch

14 Weeks Sessions Per Week BLOCK Session 1 Reps Session 2 Reps Warm Up Cadillac Cadillac Roll Up with Roll Up Bar 6 Roll Up with Roll Up Bar 6 Mini Roll-Ups Mini Roll-Ups Mini Roll-Ups Oblique 6 per side Mini Roll-Ups Oblique 6 per side Roll Up Top Loaded 6 Roll Up Top Loaded 6 Foot Work Wunda Chair Reformer Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Single Leg Heel Single Leg Toes Parallel Heels Parallel Toes V-Position Toes Open V-Position Heels Open V-Position Toes Calf Raises Prances Single Leg Heel Single LegToes 20 Count Abdominal Work Cadillac Reformer Breathing with Push Through Bar 6 Coordination 6 Bottom Lift with Roll Up Bar 6 Hundred (Work to straight legs) Full Hip Work Reformer Reformer Supine Leg Series Frog Openings Supine Leg Series Frog Openings Spinal Articulation Reformer Reformer Bottom Lift with Extension 6 Long Spine 4 Stretches Barrel Reformer Hip Flexor 3-5 breaths Standing Lunge 2 ea side Hamstring 3-5 breaths *ROM Permitting Adductors* 3-5 breaths Full Body Integration Reformer Reformer Up Stretch 1 6 Reverse Knee Stretch Up Stretch 2 4 Arm Work Reformer Cadillac *Use Box if still needed Arms Sitting Series * Chest Expansion Biceps Rhomboids Hug-A-Tree Salute Arms Standing Series Chest Expansion Hug-A-Tree Punching Biceps Full Body Integration Reformer Cadillac Introduce in Week 7 Down Stretch 6 Thigh Stretch w/ Roll Up Bar 6 Leg Work Reformer Wunda Chair Skating Single Leg per side Hamstring - Hip Opener - Lateral Flexion/Rotation Barrel Wunda Chair Side Overs 4-6 per side Side Kneeling Stretch 6 per side Back Extension Reformer Wunda Chair Pulling Straps 1 Swan Basic 4 Pulling Straps 2 Back Extension Single Arm 4 ea Finish Mat or Cadillac Platform Mat or Cadillac Platform Cat Stretch 4-6 Cat Stretch

15 CONCLUSION In our case study, Camille was facing a uncertain future with respect to her ability to run due to her age and the extent of her injury. Before the fall, she had unknowingly learned to cope with the discomfort of FAI and this had lead to pain management and an imbalance in posture and muscle synergy. She needed the tools to retrain her body to function more efficiently and successfully rehabilitate her hips post surgery. The program developed for Camille not only allowed her a safe and effective rehabilitation, it inspired her to continue private training with the Pilates equipment and recruit friends to join her in group classes. She gained sufficient strength, flexibility and balance to begin suspension training workouts and graduate to swimming laps. A year and a half after her second surgery, Camille began running short distances again much to the delight of her hip surgeon. While she has not returned to long distance, she has a better balance of cross training and continues to include a comprehensive Pilates program. She has confessed a great respect for the equipment and has purchased a reformer of her own to give herself the flexibility to continue her own self practice. By varying sessions and keeping Camille challenged and supported, she was able to achieve incremental gains and did not become frustrated by repetitive exercises. This successful outcome reinforces the understanding for myself that a Comprehensive Pilates Block System Program can be successful at enabling post operative rehabilitation of not only hip joints, but after many types of surgical procedures, injuries and pathologies. 15

16 BIBLIOGRAPHY Cash, Mel. Pocket Atlas of the Moving Body. London, United Kingdom: Random House, Hip Impingement. Washington University Orthopedics, Washington University Physicians St. Louis, MO, USA< 3206/Services/Sports-Medicine/Overview/Hip/Hip-Impingement.aspx> Hip Labral Tear. Washington University Orthopedics, Washington University Physicians, St. Louis, MO, USAhttps:// 3495/Services/Hip-Knee/Adolescent-and-Young-Adult-Hip-Disorders-Center/Hip- Labral-Tear-FAQs.aspx Isacowitz, Rael. Study Guide: Comprehensive Course. Costa Mesa, CA USA: Body Arts and Science International, Isacowitz, Rael and Clippinger, Karen. Pilates Anatomy. Champaign, IL, USA: Human Kinetics, MacPhee, Nancy. Heather Moyse On The Road to Recovery After Hip Surgery. Halifax, NS, Canada. The Guardian, 24 December Heather Moyse on the road to recovery after hip surgery Nancy MacPhee Dec. 24, 2014 Published Article for The Guardian, Charlottetown, Prince Edward Island, Canada. Wong, Dr. Ivan. Hip Surgery Patient Information Guide. Dr. Ivan Wong Orthopaedic Surgery & Sports Medicine. Halifax, NS, Canada. Copyright < Wong, Dr. Ivan. Femoroacetabular Impingement (FAI) and Labral Tear. Dr. Ivan Wong Orthopaedic Surgery & Sports Medicine. Halifax, NS, Canada. Copyright < Femoroacetabular-Impingement1.pdf> Morphopedics, Psoas American Physical Therapy Association, Hip Labral Tear cid=fabdfb4e-5fb b341-df5d04a93605 OrthoInfo, American Academy of Orthopaedic Surgeons, Types of FAI 16

17 theanatomybody.com. Anatomy & Physiology, , Rice University Pelvic-Girdle-and-Lower-Limbs Healthjade Copyright201 Towson Orthopaedic Associates Copyright