Rehabilitation. Friday, October 14, :00 11:45am General Session Rehabilitation following FAI Surgery Mark Ryan, MS, ATC, CSCS USA

Transcription

1 Rehabilitation Friday, October 14, :00 11:45am General Session Rehabilitation following FAI Surgery Mark Ryan, MS, ATC, CSCS USA Best Tip Srino Bharam, MD USA Best Tip Robroy Martin, PhD, PT USA Best Tip Per Hölmich, MD DENMARK Best Tip Rodrigo Mardones, MD CHILE

2 Slide 1 Hip Rehabilitation Following FAI Surgery Mark Ryan, MS ATC CSCS Rehabilitation Coordinator for Dr. Mark Philippon Howard Head Sports Medicine Steadman Philippon Research Institute Vail, Colorado Slide 2 OBJECTIVES Outline Initial ROM and Weightbearing restrictions General Philosophies Define Phases 1-4 and Goals of Each Slide 3 REHABILITATION PHASES

3 Slide 4 PHASE 1: PROTECTION & MOBILTIY Goals 1. Protect the integrity of the repaired tissues 2. Diminish pain and inflammation 3. Restore ROM within the restrictions 4. Preserve muscle function (glutes and stabilizers) Slide 5 PHASE 1: RESTRICTIONS/PROTECTION ROM Restrictions Capsular Protection: No ER x days, No extension x days Limit Flexion to 120 degrees x 14 days Limit Abduction to 45 degrees x 14 days Crutches 20# Flat Foot Weightbearing Non-McFx: 21 days, 50% BW x 7 days, then wean McFx: 6-8 Weeks, 50% BW x 7 days, then wean Hip Brace: 21 days Slide 6 PHASE 1: REDUCE INFLAMMATION Lymphatic Massage: Week 1 Cryotherapy: Game Ready Soft Tissue: Weeks 2-8 Scar Mobs IT Band Glute Med TFL

4 Slide 7 PHASE 1: EARLY MOBILITY: PROM Circumduction, Logs Rolls, CPM, Bike Slide 8 CPM Machine Used to reduce risk of adhesions and to promote post-op fluid movement Week 1: 4-6 hours/day 0-45 degrees Week 2: 4-6 hours/day 0-70 degrees Week 3: 4-6 hrs 0-80 degrees Week 4: 1-2 hrs 0-80 degrees Set machine at 10 degrees of Abduction Slide 9 PHASE 1: EARLY MOBILITY/ AROM AROM: Cat/Camel, Ab/ Adduction

5 Slide 10 PHASE 1: EARLY MOBOLITY AQUATICS BIKING Slide 11 PHASE 1: EARLY MUSCLE ACTIVATION ISOMETRICS: Glute Max, Quads, Transverse Abdominus, IR/ER Standing Abduction Slide 12 PHASE 2: EARLY STABILIZATION GOALS Wean off crutches GOLDEN RULE: No limping, use crutches as long as necessary until you can walk normally without them. Normalize Gait Continue Mobility Early Closed Chain Strengthening Stabilization

6 Slide 13 PHASE 2: NORMALIZE GAIT Aquatics Gait Training Slide 14 PHASE 2: CONTINUED MOBILITY Active Butterflies, FABER Slides Slide 15 8 WEEK MD FOLLOW UP Strength and ROM testing compared bilaterally, glute firing pattern evaluation Surgeon evaluates hip with physical exam, gait analysis Decision made to continue with Phase 2 rehab, or progress to Phase 3 and functional activities

7 Slide 16 PHASE 2: STABILIZATION Single leg stance, Resisted Stool Rotations, RDLs Slide 17 PHASE 2: EARLY CC STRENGTHENING Double knee bends Lunges Balance squats Pilates Slide 18 PHASE 3: GOALS Return to Functional Activity (Sport drills and skills) Strength and Stability: Bilaterally equal Pass Sport Test (SL Squats, Lateral Agility, Diagonal Agility, Lunges)

8 Slide 19 PHASE 3: Return to Sport Progressions 3 P s Pain-free Progressive Predictable to Performance Slide 20 Hip Sports Test Test Components Maximum score 1. Single leg squat (single knee bend) 3 min max 6 points 2. Lateral agility test 100s max 5 points 3. Diagonal agility test 100s max 5 points 4. Forward single leg lunges 2 min max 4 points Total 20 points Slide 21 Sports Test Single leg squat (single knee bend = 6pts): Time: 3 min Inadequate form: Trendelenburg Locked knee in extension Collapse of the leg in internal rotation and adduction Using the chair as support Lack of endurance: Inability to maintain rhythm Trembling

9 Slide 22 Lateral Agility (5 pts): Time: 100 seconds Inadequate form: Sports Test LACK OF ABSORPTION Trendelenburg Collapse of the leg in internal rotation and adduction Lack of endurance: Inability to maintain rhythm Trembling Slide 23 Sports Test Forward Bench Lunge (4 pts): Time: 2 min Inadequate form: Trendelenburg Avoidance of maximum flexion Lack of endurance: Inability to maintain rhythm Trembling

10 Srino Bharam, MD New York, NY, USA Introduction Rehabilitation Friday, October 14 th, rd Annual ISHA Meeting, Paris, France Is formal rehab necessary? Evolution of the postoperative rehab protocols Hip rehab in 2011 Surgeon s prospective Multidisciplinary approach Patient expectations Predictors of outcome Patient evaluation Symptoms Strength deficits ROM limitation FAI consideration Extra-articular soft tissue considerations Address before surgery? Surgical management Patient goals Initial postoperative rehab (week 0-4)- Phase 1 Weight bearing progression Passive motion concepts Rotational precautions Weeks (4-8)- Phase II Normalize gait

11 Hip joint mobs Progress hip strengthening Progress core strengthening Propioception activities S. Bharam Weeks (8-12)- Phase III Progressive ROM and strengthening Hip endurance exercises Dynamic balance exercises Week (12-16)- Phase IV Plyometrics Sport specific drills Avoiding postoperative complications Tendonitis Bursitis Scar tissue around portal sites Loss of motion Abnormal gait patterns My Best Tips

12 Rehabilitation After Arthroscopic Surgery to Correct Femoroacetabular Impingement Phase 1: 0-3 weeks Maximum Protection Phase 2: 3-6 weeks Moderate Protection Phase 3: 6-12 weeks Minimal Protection RobRoy L. Martin PhD, PT, CSCS Duquesne University Pittsburgh, PA UPMC Center for Sports Medicine 1 Phase 4: weeks Functional Progression Phase 5: weeks Sports Specific-Work Related Retraining 2 Phase 1 Phase 1 Pearls and Perils 0-3 weeks- Maximum Protection Goals: Maintain ROM- Quadruped Rocking Prevent muscular weakness and inhibition Protect repaired tissue Decrease pain Decrease inflammation Do enough BUT not to much Use pain to guide!! Do not forget exercises to target trunk/core 3 4 Phase weeks- Moderate Protection Goals: Increase ROM to near normal Use gentle distraction techniques General pain free status Increase strength Normalize gait with D/C of assistive device Phase 2 Pearls and Perils Make sure to include hip flexion combined with adduction and internal rotation Distraction allows to achieve more ROM Do not progress off assistive device to quickly Use cane if necessary Exercises and gait training can be done in water can include swimming with leg buoy No kicking aqua-suspended jogging Limit motion 5 6

13 Phase weeks- Minimal Protection Goals: ROM 100% normal Increase strength of trunk and entire LE to near normal Normal gait pattern Phase 3 Weight Bearing Status/Assistive Device: FWB no assistive device Any subtle deviations should be corrected with appropriate interventions: Stretching Mobilization Strengthening Stabilization Proprioceptive 7 8 Phase 3 Exercises: ROM should emphasize stretching. Joint mobilizations should be added to address any limitations particularly with flexion, internal rotation, and adduction. i.e. lateral distraction, long axis distraction, and posterior capsule mobilization General flexibility should be addressed as needed particularly the piriformis, gluteus medius, rectus, ITB, and hamstrings 9 Phase 3 Pearls and Perils Make sure the trunk-core muscle are encaged during exercises and gait Do not forget plantar flexors 85% of the forward propulsion Normalize motion Combine Hip adduction-flexion-internal rotation Correct subtle deviations Particularly hip internal rotation 10 Phase 3 tape Phase 3 Pearls and Perils S.E.R.F Hip Strap: DonJoy 11 12

14 Phase weeks- Functional Progression Goals: Strength of trunk and LE 100% normal Tolerate sport-job specific positions with proper lower extremity alignment Phase 4 Pearls and Perils Work on strengthening in functional positions Movements meaningful for the patients goals Do not progress to FAST 13 Monitor LE position Do not allow poor technique 14 Phase weeks- Sports Specific-Work Related Retraining Goals: Return to 100% normal sport and work activity level Phase 5 Pearls and Perils Be creative in program design Thank You 17

15 Lecture: Best Tip Per Hölmich, MD

16 Rehabilitation: Best Tip Rodrigo Mardones M.D. Rehabilitation is a process that starts right after hip arthroscopy or we should said during the surgery. Arthroscopic FAI treatment is a continuous process that begins with surgery and ends with full return to daily and sports activities. Achievement of this goal requires the completion of different steps, initiating with surgery, early and late rehabilitation period leading to re-activation up to normal muscle strength and pain-free full range of motion. Our rehabilitation protocol had dramatically changed over more than 850 procedures, leading to early sports return and less postoperative tendonitis. Step 1: Surgery Two factors that greatly affected our results were: 1. Reducing traction time 2. Use of a PRP clot over bony resection at the end of the surgery Step 2: Early rehabilitation period We think that best tips at this period are: 1. Start right after surgery with a the use of a CPM machine in order to avoid scar formation. 2. Ergonometric bicycle at 12 hours without any resistance 3. Full weight bearing with two crutches to avoid limping and pain. 4. Adding circumferential exercises from the beginning to your routine. Step 3: Late rehabilitation period During this period periarticular tendonitis appears mostly because suspension of rehabilitation and daily sports activity. Tips for this period are:

17 1. Strict follow-up with periodical controls 2. Follow specific activities (worksheet) 3. Specialized rehabilitation team 4. Constant evaluation to assess flexibility