Hip Resurfacing and Arthroscopy Rehabilitation

Role of the Physiotherapist Pre-operative guidance and information Guide rehabilitation Motivation Support Facilitate Discharge

Stages of Rehabilitation Stage 1 Day 1 – Day 5/7 Post op Initial contact and explanation of rehabilitation Safe transfers from bed-chair-walking Increasing mobility and exercise tolerance Stairs Gait re-education (walking aids) Teaching of home exercise programme

Home Exercises Circulation exercises Range of motion exercises in supine and standing Extension – Gluteus Maximus Flexion – Iliopsoas Hip Abduction – Gluteus Medius Teach basic core stability HEP – TA and Psoas

Stages of Rehabilitation Stage 2 2 weeks– 4 weeks Re-evaluation of ROM exercises Improve ROM Muscle strength testing Improve muscle strength and control and personalise the exercise programme to the patient Gait Education/Walking Aids Exercise tolerance

Stages of Rehabilitation Stage 3 4 weeks – 6 weeks Fine tune dynamic stability – specific muscle improvement. Proprioception Core Stability Exercise Tolerance

Aims of the Rehabilitation Programme 1. Restore normal range of active and passive movement 2. Restore dynamic stability of the muscles in the lumbar/pelvic/hip region 3. Restore balance and proprioception 4. To regain normal functional ability for the individual patient

1. Restore Normal ROM Mobilising exercises Manual Mobilisations Muscle lengthening techniques (sustained stretch) Muscle energy techniques

2. Restore Dynamic Stability Facilitate muscles that act as local stabilisers and those that act as global stabilisers of the pelvis on the weight bearing leg Failure causes gait abnormalities -Antalgic -Trendellenburg (glut medius) -Glut maximus gait

3. Balance and Proprioception Impulses originating from joints, muscles, tendons and deep tissue Processed by the CNS to provide information about joint position, motion, vibration and pressure This is the process by which the body can vary muscle contraction in immediate response to incoming information regarding external forces.

3.Balance and Proprioception Wobble-boards PNF stretches and exercises Swiss Balls – Core stability

Strength and ROM Exercises Hip Abduction Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius. Proximal stability and control Pelvis control

Strength and ROM Exercises Hip Abduction Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius. Proximal stability and control Pelvis control

Strength and ROM Exercises Hip Abduction Aim to increase strength and dynamic stability of the hip through increased strength of Gluteus Medius. Proximal stability and control Pelvis control

Strength and ROM Exercises Hip Flexion Improve functional range of motion and strengthen Ilio Psoas Control of Trunk on Pelvis movement

Strength and ROM Exercises Hip Flexion Improve functional range of motion and strengthen Ilio Psoas Control of Trunk on Pelvis movement

Strength and ROM Exercises Hip Extension Strengthen the gluteus maximus muscles and improve gait Dynamic stability

Strength and ROM Exercises Hip Extension Strengthen the gluteus maximus muscles and improve gait Dynamic stability

Strength and ROM Exercises Hip Extension Strengthen the gluteus maximus muscles and improve gait Dynamic stability

Strength and ROM Exercises Hip Extension Strengthen the gluteus maximus muscles and improve gait Dynamic stability

Discharge Criteria Full weight-bearing gait without walking aids Good hip stability/control – absence of Gait disturbances. Good proximal stability and muscle strength Full/Functional Pain free ROM Advise patient to continue with exercise programme for up to 6 months. 6 weeks of physiotherapy prior to discharge, may require more if returning to a specific sport

Resurfacing vs THR Ease of movement - ROM Confidence in the prosthesis Less pain Mobility progress No precautions Dynamic Stability Return to activity quicker Limited ROM – slower progress Initially apprehensive More painful Mobility takes longer Combined movement limitations Less Stability Slow return

Hip Arthroscopy Rehabilitation

Aims of Physiotherapy Address pattern of recruitment of muscles involved in hip movement Restore normal range of movement and gait pattern Increase core stability and proprioception (balance reactions) Return patient to previous lifestyle/sport

Stage 1 (immediate Rehabilitation) This should be followed whilst the patient is using walking aids, and may last 2 days -> 6 weeks dependent on the level of surgical intervention.

Exercises during Stage 1 aim to: Restore range of movement Maintain muscle function Allow tissue healing and pain to settle

Exercises (Stage 1) Range of movement (flex, ext abd) Begin core stability HEP: 1. TA setting 2. Pelvis tilting with TA control Gentle stretches ( quads, hams, piriformis) Bent knee fallout with theraband Static Quads, Hams, Gluts etc.

Precautions Do not push through hip flexor pain May need to keep to specific range of movement restrictions May need to keep to specific weight bearing restrictions

Criteria for progression to stage 2 Minimal pain with stage 1 exercises ROM (85% of uninvolved side) Correct muscle recruitment patterns for initial exercises Do not progress until patient is fully weight bearing

Stage 2 (Intermediate Rehabilitation) Exercises taught at this stage are aimed at: restoring and maintaining movement promoting normal walking patterns strengthening muscles improving balance reactions There is a strong focus on core stability work at this stage.

Exercises (stage 2) Cycling (stationary bike) low resistance Swimming (no breast stroke) -front crawl -kicking with float Progression of core stability HEP -Bridging -Heel slides Proprioception Work

Exercises (Stage 2) Strengthening with theraband -Flex, ext, abd, add, int/ext rot, PNF patterns Side stepping Stretches (Piriformis, ITB, Quads, Hams etc) Passive Stretches/ Joint mobilisations Gait Reeducation

Precautions No forced stretching No treadmill use Avoid inflammation of anterior structures of hip

Criteria for progression to stage 3 Full ROM Pain free / normal gait pattern Hip strength 70% of uninvolved side

Stage 3 (Advanced Exercises) The goals at this stage are the restoration of muscular and cardiovascular endurance, and the improvement of balance reactions. Return to social sport should be possible at this stage.

Exercises (stage 3) Gradually build up gym routine to pre-injury level -Cross trainer -Stepper -Cycling Introduce gentle jog and gradually build up time and intensity

Exercises (Stage 3) Introduce Ball work, Starting with a light ball and gradually introduce full size ball with drills Lunges

Criteria for progression to stage 4 Cardiovascular fitness equal to pre-injury level Demonstrates no faulty muscle recruitment patterns during stage 3 exercises Hip strength 80% of uninvolved side

Stage 4 (sport specific training) Not all patients require rehabilitation to this level. Those who take part in competetive sport will certainly benefit from further strengthening and more sport specific exercises. Training regimens should be developed in conjunction with sports club physio /personal trainer.

Stage 4 (Sports specific Training) Speed Endurance Plyometrics Advanced proprioception exercises Multidirectional Full sport specific training can begin

Criteria for return to full competition Full, painfree range of movement Hip strength >90% of the uninvolved side Ability to perform sport specific drills at full speed without pain

Conclusion Physiotherapy is an integral part of the process of recovery for patients undergoing any hip surgery in order to restore: -Movement -Strength -Core stability -Proprioception -Function