S p o r t s & O r t h o p a e d i c S p e c i a l i s t s D R. R Y A N F A D E R H I P A R T H R O S C O P Y W I T H L A B R A L R E P A I R P R O T O C O L This protocol provides appropriate guidelines for the rehabilitation of patients following arthroscopic labral fixation with or without femoroplasty and/or acetabuloplasty. The program may be modified by the referring provider for an individual patient. If questions arise regarding the application of the protocol or the progress of the patient, please contact Sports & Orthopaedic Specialists: Main line: (952) 946-9777 Physical therapy: (952) 914-8631 PROTOCOL OVERVIEW Immediate Rehab (0-2 weeks): Focus on restoration of motion 0-90 degrees & early muscle activation Early Rehab (2-3 weeks): Focus on progression of motion, early/light strengthening Intermediate Rehab (4-5 weeks): Focus on restoration of gait & advanced motion Advanced Rehab (6-12 weeks): Focus on advanced strengthening Sports Specific Rehab (>12 weeks): Focus on dynamic strengthening, return to sport progressions PRECAUTIONS Weeks 0-2: Weeks 3-4: Limit external rotation (ER) to 20 degrees No extension of hip beyond neutral (0 degrees) Toe touch weight bearing (TTWB) No extension of hip beyond neutral (0 degrees) Partial Weight Bearing (PWB) PT FREQUENCY & DURATION -PT evaluation on postop day 1-4 -PT visits twice per week through early rehab program (weeks 0-6). Then once per week. GENERAL GUIDELINES -Manage symptoms to avoid postoperative: Hip flexor tendonitis Trochanteric bursitis Synovitis -The therapeutic exercises listed in this protocol convey the appropriate load for the hip given the time elapsed since surgery in regards to tissue healing. This is not an all-inclusive list of therapeutic exercises. 1
L A B R A L R E P A I R P R O T O C O L WEEKS 0-2: PT EVALUATION ON POSTOP DAY 1-4. CLINIC VISITS 2X/WEEK. HEP 2X/DAY. -PRECAUTIONS Limit external rotation (ER) to 20 degrees No extension of hip beyond neutral (0 degrees) -WEIGHT BEARING & GAIT TRAINING -TTWB with bilateral axillary crutches. -CRYOTHERAPY -Patient will have Game Ready or other cryotherapy device. -Use frequently (every 4-6 hours for the first 72 hours) then continue as needed. -PROM -CPM use for two weeks minimum or until patient has achieved 0-90 hip flexion -Four-six hours per day (split into 1-2 hour segments). -Start at 30-70 degrees flexion and progress to 0-90 degrees by postop week 2. -Stop use of CPM when consistently reaching 0-90 degrees. -May substitute 15 minutes of stationary bike for one hour of CPM (max hip flexion 90 & no resistance) -Hip PROM adhering to precautions. Include manual supine log roll. -THERAPEUTIC EXERCISE -Hip isometrics: Abduction, adduction, extension, ER -Quads sets, hamstring sets -Transverse abdominis sets, pelvic tilts -Prone lying -PATIENT EDUCATION -Encourage frequent position changes to avoid stiffness. Sitting, reclining, supine, prone. -Use pillows to support the hip in neutral for positioning at night. 4/4/2018 2
L A B R A L R E P A I R P R O T O C O L WEEKS 2-3: PT CLINIC VISITS 2X/WEEK. HEP 5-7X/WEEK. -PRECAUTIONS No extension of hip beyond neutral -WEIGHT BEARING & GAIT TRAINING -WBAT progressing from 2 crutches to one crutch. -Step-to pattern to avoid hip extension beyond neutral. -CRYOTHERAPY: Continue to use Game Ready, other cryotherapy device, or ice daily. -SCAR MOBILIZATION: At portal sites. -PROM -CPM use. Continue only if not yet to 0-90 hip flexion. -PROM: Continue. Include ER beyond 20 degrees. -BIKE: Progress from 15-30 minutes with no to light resistance. -THERAPEUTIC EXERCISE -Continue exercises from weeks 0-2 -Hip flexor stretch -Adductor stretch -Glute/piriformis stretch -Bent knee fall outs -Bridge double limb -Clam shell -Side lying hip abduction -PROPRIOCEPTION -Tandem stance -Weight shifting drills 4/4/2018 3
L A B R A L R E P A I R P R O T O C O L WEEKS 4-5: PT CLINIC VISITS 1-2X/WEEK. HEP 5-7X/WEEK. -WEIGHT BEARING & GAIT TRAINING -Week 4: Progress to FWB with no crutches and focus on restoration of normalized gait pattern. -Do NOT allow patient to limp. Continue with single crutch longer if limping. -Retro walking, side stepping -CRYOTHERAPY: Continue to use ice as needed. -SCAR MOBILIZATION: Continue at portal sites as needed. -PROM: -Continue and include ER beyond 20 degrees. -Assisted stretching of hip flexors, glute/piriformis, ITB. -Hip joint mobilizations with belt ONLY IF NECESSARY. -Lateral and inferior with rotation. -PA glides in prone with rotation. -BIKE: 30 minutes with resistance as tolerated. -ELLIPTICAL: Progress from 10-30 minutes. Spend equal time forward and backward. -THERAPEUTIC EXERCISE -Progressions of previous exercises -Prone hip ER/IR -FABER stretch -Open chain SLR series in standing -Closed chain glutes & quads isotonics (double limb wall squats, leg press, etc) -Hamstring isotonics -Core (Avoid hip flexor tendonitis) -PROPRIOCEPTION -Single leg stance -Balance board double leg stance 4/4/2018 4
L A B R A L R E P A I R P R O T O C O L WEEKS 6-8: PT CLINIC VISITS 1-2X/WEEK. HEP 3-4X/WEEK. -CRYOTHERAPY: Continue to use ice as needed. -SCAR MOBILIZATION: Continue at portal sites as needed. -PROM: -Continue in all planes. -Assisted stretching of hip flexors, glute/piriformis, ITB. -Hip joint mobilizations with belt ONLY IF NECESSARY. -Lateral and inferior with rotation -PA glides in prone with rotation -Teach self-mobilizations as needed. -ELLIPTICAL: Progress from 30 minutes with resistance as tolerated. Spend equal time forward and backward. -TREADMILL: Forward and side stepping (holding on). Progress to slight incline when no Trendelenberg. -THERAPEUTIC EXERCISE -Ongoing self-stretching -Progressions of previous exercises -Open chain SLR series in standing with exercise band -Closed chain glutes & quads isotonics (progress to single limb as able) -Core (Avoid hip flexor tendonitis) -PROPRIOCEPTION -Single leg stance on unstable surfaces 4/4/2018 5
L A B R A L R E P A I R P R O T O C O L WEEKS 9-12: PT CLINIC VISITS 1-2X/WEEK. HEP 3-4X/WEEK. -CRYOTHERAPY: Ice as needed -PROM: -Assisted stretching of hip flexors, glute/piriformis, ITB -Hip joint mobilizations with belt ONLY IF NECESSARY -Lateral and inferior with rotation -PA glides in prone with rotation -Active release therapy and/or soft tissue mobilization -TREADMILL: Forward and side stepping on incline. -THERAPEUTIC EXERCISE -Progressive LE and core strengthening -Endurance activities around the hip -Dynamic balance activities -Double limb plyometrics WEEKS 13-16: PT CLINIC VISITS 1-2X/WEEK. HEP 3-4X/WEEK. -CRYOTHERAPY: Ice as needed -PROM: As needed -THERAPEUTIC EXERCISE -Progressive LE and core strengthening -Single limb plyometrics -Return to run program -Sport specific agility drills 4/4/2018 6
L A B R A L R E P A I R P R O T O C O L WEEKS 17+: Continue to see the patient in clinic every other week until they have met criteria for discharge: -PAIN FREE WITH ADL s & ONLY LOW LEVEL DISCOMFORT WITH SPORTS ACTIVITIES -HIP STRENGTH 5/5 IN ALL PLANES -STEP DOWN TEST x5 from 6-8 inch box with sound biomechanics -SINGLE LEG CROSS-OVER TRIPLE HOP FOR DISTANCE: Limb symmetry index of >85% At discharge visit, instruct patient in ongoing HEP to be completed 3-4x/week until one year after surgery or until the patient has regained prior level of function. 4/4/2018 7
S p o r t s & O r t h o p a e d i c S p e c i a l i s t s D R. R Y A N F A D E R H i p A r t h r o s c o p y w i t h L a b r a l R e p a i r I n i t i a l H o m e E x e r c i s e P r o g r a m -This handout details the most frequently prescribed exercises for the first two weeks following hip arthroscopy with labral repair. Patient should complete these exercises twice per day. -If questions arise, contact Dr. Fader s team at Sports & Orthopaedic Specialists: 952.946.9777 ADDUCTOR ISOMETRIC #1 Lie on back. Legs flat. Ball or towel roll between knees. Squeeze legs together. Feel inner thighs engage. Hold 3 seconds. Complete 20 repetitions. ADDUCTOR ISOMETRIC #2 Lie on back. Knees bent. Feet flat. Ball or towel roll between knees. Press knees together. Feel inner thighs engage. Hold 3 seconds. Complete 20 repetitions. ABDUCTOR/ER ISOMETRIC Lie on back on couch. Knees bent. Feet flat. Press outside of knee against the back of the couch. Feel outside of hip engage. Hold 3 seconds. Complete 20 repetitions.
I N I T I A L H E P : L A B R A L R E P A I R QUADS SET (WITH ISOMETRIC HIP EXTENSION) Place small towel roll under knee. Squeeze quads by pressing your knee down into the towel roll. At the same time, press your heel downward. Hold 3 seconds. Complete 20 repetitions. HAMSTRING SET Lie on back. Knee bent. Foot flat. Press your heel down and back. Feel hamstring engage on back of thigh. Hold 3 seconds. Complete 20 repetitions. TRANSVERSE ABDOMINUS SET Lie on back in neutral spine. Knees bent. Feet flat. Exhale with pursed lips (blowing out candle) and squeeze abdominals. Pull belly button down as if zipping up tight pair of jeans. Inhale and relax. Hold 3 seconds. Complete 20 repetitions.
I N I T I A L H E P : L A B R A L R E P A I R PELVIC TILT Lie on back in neutral spine. Knees bent. Feet flat. Exhale with pursed lips (blowing out candle) and imprint spine (flatten back). Hold 3 seconds. Complete 20 repetitions. PRONE LYING Lie on stomach. Begin at 30 seconds and work up to 3 minutes.
S p o r t s & O r t h o p a e d i c S p e c i a l i s t s D R. R Y A N F A D E R P O S T O P E R A T I V E H I P M A I N T E N A N C E P R O G R A M -This program provides an ongoing rehab program that patients should complete for one year after surgery or until they return to pre-surgery levels of activity. Complete this program three to four times per week (about every other day). You do not have to do all of the exercises at every session. Rotate through the exercises completing approximately 20 minutes of exercise at every session. If any of the exercises increase your hip pain beyond a 3/10, stop completing that exercise and continue with the others. -If questions arise, contact Dr. Fader s team at Sports & Orthopaedic Specialists: 952.946.9777 STRENGTH SINGLE LEG BRIDGE Complete a bridge by pressing through only one leg. CLAM SHELL Lie on side with both knees bent. Lift top knee. (The way a clam would open its shell.) Feet stay together. Keep hips stacked / torso vertical.
P O S T O P H I P M A I N T E N A N C E SIDELYING HIP ADDUCTION Lie on side with top leg bent over the bottom leg and foot flat on the floor. Squeeze inner thigh and lift bottom leg 2-3 inches off the floor. PRONE HIP EXTENSION Lie on stomach. Engage core. Squeeze buttock and lift leg up as high as you can without arching your back. SIDELYING HIP ABDUCTION Lie on side with bottom leg bent. Engage core. Lift top leg up and slightly back.
P O S T O P H I P M A I N T E N A N C E HIP ABDUCTION WITH CABLE COLUMN OR BAND Loop band on ankle and secure tightly at other end. Thread the band behind stance leg. Hold on for balance if needed. Stand tall and pull leg out against band. HIP EXTENSION WITH CABLE COLUMN OR BAND Loop band on ankle and secure tightly at other end. Hold on for balance if needed. Stand tall and pull back against the band. HIP ADDUCTION WITH CABLE COLUMN OR BAND Loop band on ankle and secure tightly at other end. Hold on for balance if needed. Stand tall and pull in against band.
P O S T O P H I P M A I N T E N A N C E WALL SQUAT Lean against wall with feet 12-18 inches from wall. Squat down to perform MINI squat. Hold 3 repetitions for 60 seconds. WALKING SQUAT Secure exercise band just above the knees. Perform a mini squat. Step sideways from a standard squat to a wide squat. Then step back to a standard squat again. Complete 2x15
P O S T O P H I P M A I N T E N A N C E HIP HIKE Stand on step on one leg. Keep both knees straight. Drop pelvis down until foot is below the height of the step. Then imaging pulling foot out of quicksand and hike hip upward. STEP DOWN Stand on 4-6 inch step. Squat on a single leg as if stepping down until heel brushes the floor. SQUAT ON BOSU OR BALANCE BOARD Perform squats on Bosu or balance board. Complete 2x15.
P O S T O P H I P M A I N T E N A N C E KNEELING ROTATION WITH CABLE COLUMN / BAND / MEDICINE BALL Start kneeling on your heels. Pull up and across your body until you are in a tall knee. SINGLE LEG ROMANIAN DEAD LIFT Stand on one foot. Keep your body straight from head to heels. Tip forward until hands reach knee height. FORWARD LUNGES Take a large step forward and bend both knees to complete a lunge. Continue walking forward while completing lunges. Keep knees aligned.
P O S T O P H I P M A I N T E N A N C E CORE FRONT PLANK Perform a front plank on forearms and feet. Hollow shoulder blades. Squeeze glutes. Hold 3x30 seconds. SIDE PLANK Perform a side plank on forearm and feet. Hold 3x30 seconds. Right & left. BIRD DOG Position yourself on hands and knees. Neutral spine. Extend leg behind you and at the same time, lift opposite arm. Hold 3x30 seconds. Right & left.
P O S T O P H I P M A I N T E N A N C E STRETCH ADDUCTOR STRETCH Take a wide stance. Lunge/lean to the side to stretch opposite inner thigh. Use hands for support if needed. Hold 3 repetitions for 30 seconds. HIP FLEXOR STRETCH Take a long stride. Squeeze your glutes. Then press hips forward to feel a stretch across front of the hip/thigh. Hold 3 repetitions for 30 seconds. STANDING IT BAND STRETCH In standing, cross affected leg behind. Bend forward and turn your trunk in the direction of your front leg. You may hold on for balance. Hold 3 repetitions for 30 seconds.
P O S T O P H I P M A I N T E N A N C E PIRIFORMIS STRETCH Sit with tall posture. Cross ankle over knee. Pull knee across body toward your armpit. Feel a stretch in your glute. Hold 3 repetitions for 30 seconds. HIP FLEXOR / IT BAND STRETCH Lie on back with two pillows under hips. Reach involved leg down and across midline. Bend other knee over the top to stabilize the straight leg. Feel stretch across the front of the hip. 10-15 minutes while applying ice to the hip.