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Rehabilitation following Hip arthroscopy

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Rehabilitation following Hip arthroscopy Powered By Docstoc
					Rehabilitation following
        Hip arthroscopy
                   Prof. Ernest Schilders
           Leeds Metropolitan University
            Bradford Teaching Hospitals
                      Start
                     Which
                   procedure?
                   Operative
                    Findings




     Pain
 Orginal pain
                    Hip            Return to sport?
                                    Type of sport
  Procedure     arthroscopy            Fitness
   specific                            Type of
Rehab related      Rehab              procedure




                 Progress of the
                      rehab
                     Patient
                   orientated
                 Use assessment
                     criteria
Questions to answer before we start
our rehab program

 What is the exact procedure and operative findings?
  Faster rehab program for simple and longer for complex
  procedures.

 How long was the patient injured before his surgery?
  Conditioning is a very important element of the rehab.
Incidence of pathology in athletes
n=120

 80%
 70%
 60%
 50%
 40%
 30%
 20%
 10%
 0%
       FAI   Instability Ligamentum Teres
                               Tear
Incidence of intraarticular pathology

 80%
 70%
 60%
 50%
 40%
 30%
 20%
 10%
 0%
       Labral tear   cartilage   adhesions   ligamentum
                      lesion                   teres tear
Type of articular cartilage lesion

generalized cartilage
   degeneration


           wave sign


    Partial thickness


       full thickness


                        0%   5%   10%   15%   20%   25%   30%
    Femoroacetabular Impingement

simple            Diagnostic,
                  Removal loose body
                  Labral debridement
                  Ligamentum Teres debridement
Intermediate      CAM decompression
                  Iliotibial band release
                  Iliopsoas release
complex           Acetabular rim trimming + labral
                  repair + CAM decompression
                  Microfracture (prolonged crutches)

Very complex      Acetabular rim trimming+ labral
                  repair+ CAM decompression + capsular
                  plication
Procedures in athletes

                 Microfracture

ligamentum teres debridement

      resection cartilage flaps

            capsular plication

      acetabular rimtrimming

          CAM decompression

                  labral repair

                                  0%   10% 20% 30% 40% 50% 60%
Procedure specific rehab advice
 FAI surgery (1-4 week crutches PWB)

 Microfracture (prolonged use of crutches 6-8 weeks)

 Capsular Plication (use of night splints in internal
  rotation for 4 weeks)
  Clinical and operative findings that
  might have a negative impact on the
  rehab
 Pain and a negative hip arthroscopy

 Presence of extensive grade 4 cartilage lesions.

 Generalised hyperlaxity in patients with instability
  symptoms.

 Centre edge angle below 20 degrees.

 Low preop outcome score.
20y old
professional
football player
• CE angle= 20
• vertical
sloping
weightbearing
surface.
•Perthes
disease
•Generalized
hyperlaxity
Perioperative pain management

 Muscle relaxant at induction (Atracurium 0,6mg/kg)
 Remifentanyl infusion during surgery for blood pressure
  control, muscle relaxation and analgesia.
 Multimodal analgesia at the end of the surgery. NSAID/
  paracetamal and morphine.
 Postoperative pain relief consists of codeine,
  paracetamol and NSAID
 Antibiotics administration at induction.
   Rehabilitation ladders

Process whereby patient/player progresses through
rehabilitation, achieving goals within specific timescales.


Easy to follow.


Based on evidence and agreed with consultant involved.
Other considerations
 Use realistic timescales (Always err on the side of
  caution).



 Use common sense, as injured patients/players will
  progress at different rates.
Frank Gilroy
Post surgical
                                                                  Increased shearing activities,
general rehabilitation
ladder                                                             agility, sports specific rehab


                                                        Advanced strengthening and
                                                             proprioception



                                                   Regain full ROM
                                       Increased strengthening and proprioception


                           Regain ROM
                        Early strengthening


               Surgery

   Pre-op preparation
                                                                                    Timescales depend on
                                                                                     consultant involved
                                                                                            Playing again!
8-12 week ladder
                                                                                     Phase 4
                                                                  Short sprints and shuttle runs, increasing core
                                                                    stability work. Gradual return to sports
                                                                                 specific training



                                                                   Phase 3
                                           Straight line running, strengthening exercises, increased
                                                          pool work and full stretches


                                          Phase 2
                                Jogging 20-30 minutes, light
                                stretching and pool exercises


                            Phase 1
               Gentle walking and light stretching



           Surgery
                                                                              Timescales depend on consultant
   Pre-op preparation                                                                    involved
Week 1


 Ankle pumps
Week 1


 Ankle pumps,

 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction
Isometrics
   These are static exercises. When you do
    the exercise you should feel the muscles
    tighten without movement of the joints.
    Try to do twenty repetitions of each
    exercise, 2 times a day.


     Gluteal sets: tighten your buttock
       muscles – hold for 5 seconds.

     Quads sets: tighten the front thigh
       muscles – hold for 5 seconds.

     Transversus Abdominus:
       Draw belly button in towards spine without
       moving pelvis/spine – hold while taking 5
       breaths.

     Hip abduction: Lying on your
       back with hip and knees bent, place a belt
       around your thighs near your knees and push
       out against the belt – hold 5 seconds
Week 1


 Ankle pumps,

 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction

 Stationary bike – start 20 mins x 2 daily
 Stationary Biking with high
  seat and minimal
  resistance.

 As soon as you are
  comfortable enough to get
  onto a bike, cycle for 20
  minutes 2 times a day.
   Increase the time by 5
    minutes after 3-4 days until
    you have reached a
    maximum of 45 minutes
    twice a day.
   No resistance should be
    added until week 5-6.
Week 1


 Ankle pumps,

 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction

 Stationary bike – start 20 mins x 2 daily

 Passive stretching, Piriformis stretch (side lying),
  Quads stretch (prone), Adductor stretch (sitting)
Passive stretching exercises
                      Lying on your good side
                       (bottom leg straight and
                       pelvis stacked) bend your
                       involved hip to between
                       50° to 70° flexion and hook
                       top foot behind uninvolved
                       knee. Steadying the pelvis,
                       lower the involved knee
                       towards bed. Stretch
                       should be felt in buttock,
                       avoiding a pinch in groin.




Piriformis stretch
Quadriceps stretch
                  Do 5 repetitions, hold for
                   20 seconds, and twice a
                   day.

                  Lie on your stomach with
                   your hips flat on the bed.
                   Ask a partner bring ankle
                   toward buttock, feeling
                   stretch in the front of the
                   thigh.

                  If it is too painful to lie on
                   your front, you can do this
                   stretch lying on your good
                   side.
Adductor stretch
                    Do 5 repetitions, hold for
                     20 seconds, and twice a
                     day.

                    Sit in a chair with the feet
                     on the floor. Carefully
                     move the knee of the
                     affected leg out to the side
                     so the hip is opening out
                     (abducting). Do the stretch
                     as comfort allows and feel
                     the stretch on the inside of
                     the thigh.
Week 1


 Ankle pumps,

 Isometrics – Gluteal, Quads, Trans Abs, Hip abduction

 Stationary bike – start 20 mins x 2 daily

 Passive stretching, Piriformis stretch (side lying), Quads
  stretch (prone), Adductor stretch (sitting)

 Price
Week 2


 Week 1 exercises (including)

 Quadruped rocking
Quadruped rocking
                 3 sets, 20 repetitions, once
                  a day.

                 On your hands and knees
                  shift your body weight
                  forward on your arms, and
                  then back onto your legs.
                  Also shift your weight side
                  to side and in diagonal
                  directions.
Week 2


 Week 1 exercises (including)

 Quadruped rocking

 Standing Hip IR
Standing hip internal rotation
                   3 sets, 20 repetitions, once
                    a day.

                   Place knee of the operated
                    leg on a chair. Rotate the
                    hip by       moving your
                    foot outward from the
                    body. Progress the exercise
                    by using a resisted band
                    when tolerated.
Internal rotation strengthening with
             thera bands




Start position       Finishing position
Week 2


 Week 1 exercises (including)

 Quadruped rocking

 Standing Hip IR

 Heel slides with/without strap

 Cons r/v
Weeks 3-4

 Pain relief – Price, electrotherapy or mobilisation

 Gait re-education

 ROM exercises (Cont week 1 & 2 exercises)

 Stretching (piriformis and quads) include Faber, calf, hamstring
  and ITB

 Gym work (if appropriate) Bike – no resistance but increase time
  (aim to build for 45 mins x 2 daily), Leg press – low weights and
  repetitions, Cross trainer – min resistance monitor time, Swiss
  ball

 Core stability

 Hydrotherapy
Faber
        lying on your back bring
        involved leg into a figure
        four position with the ankle
        resting above the opposite
        knee. Gently lower the
        bent knee towards the
        floor. You may need to
        start with ankle resting on
        the shin or inside of the
        leg. It is normal to feel
        some hip discomfort
        underneath the thigh. DO
        NOT PUSH ON THE KNEE.
Weeks 3-4

 Pain relief – Price, electrotherapy or mobilisation

 Gait re-education

 ROM exercises (Cont week 1 & 2 exercises)

 Stretching (piriformis and quads) include Faber, calf, hamstring
  and ITB

 Gym work (if appropriate) Bike – no resistance but increase time
  (aim to build for 45 mins x 2 daily), Leg press – low weights and
  repetitions, Cross trainer – min resistance monitor time, Swiss
  ball

 Core stability

 Hydrotherapy
Weeks 5-6

 Cont weeks 1-2 and 3-4
  (include the follwing)

 Gym work within capabilities
  ( inc resistance on bike alter
  time)

 Balance work – wobble
  board, trampette

 Core stability – progress as
  able

 HEP – lunges, lateral side
  steps, knee bends, fartlek
  (jog/walk)
Weeks 7+


 Week 1-2 exercises can be stopped

 Cont with weeks 3-4 and 5-6

 Increase hydrotherapy exercises (squats, step
  ups/downs, ¼ - ½ lunges.

 Running – progress from straight line to multi-directional

 Sports specific
Advanced hydrotherapy
Advanced hydrotherapie
Which questions do we have to ask
ourselves?

 How do we know that our rehab is progressing steadily,
  what is normal and what is abnormal?

 What are the standards we can realistically aim for?
  (measurements of outcomes)

 Can we separate the built up of fitness from a hip
  arthroscopy specific rehab program?
Which assessment criteria can we use
during rehab?
 Pain

 Functional scores
  Modified Harris Hip Score
  Hip outcome osteoarthritis score (HOOS)
  SF 36

 Subjective assessment?

 Objective Static information
  Range of motion
  Strength test
  Log roll test

 Objective dynamic evaluation
  SPORTS TEST
Pain following the procedure
 Procedure related
  Adhesions, microfracture, labral repair, decompression CAM or
  pincer. INFECTION

 Traction related
  adductor pain
  Pectineus
  Sciatic pain
  Ankle pain

 Rehab related
  Iliotibial band and trochanteric bursitis
  Psoas
  Hip flexors
  Synovitis

 Sacro iliac joint pain.
Pain and Stiffness
 Pain:
  Reintroduce analgesia, NSAID rarely steroid injection.
  Limited rest
  Concentrate on Deep Rotators of the hip.


 Stiffness:
  ROM stuck (very rarely) ; check X rays or CT scan to
  investigate for residual impingement
Risk factors for adhesions
 More complex arthroscopic procedures.

 Pre-operative sensations of stiffness that limits
  function.

  Possible risk factors
  Longer time on crutches
  Grade 4 articular cartilage lesions treated with
  microfracture.
Iliotibial band
 Compression of the trochanteric bursa due to iliotibial
  band tightness.
  *Weakness of the hip abductors causing increased hip
  adduction.
  *Swelling bursa due to fluid extravasation.
  *swelling and insufficiency muscles due to portal
  trauma.

 Osteopathic technique to reduce the tightness,
  myofascial release. “ counterstrain a positional release
  technique”.
Research in progress, Iliotibial band
tightness

 Weakness of the hip abductors and imbalance between
  adductor/abductor strength.

 Reduced hip mobility compared to controlateral side

  an issue to address early in the rehab, before athletes
  have increased their activities to significantly
Which assessment criteria can we use
during rehab?
 Pain

 Functional scores
  Modified Harris Hip Score
  Hip outcome osteoarthritis score (HOOS)
  SF 36

 Subjective assessment?

 Objective Static information
  Range of motion
  Strength test
  Log roll test

 Objective dynamic evaluation
  SPORTS TEST
Modified Harris Hip score
 Preoperatively                 39-96

 2 months postop                58-100

 6 months postop                74-100

 Minimum of 12 months postop.   70-100
 Overall the average pre-op MHHS was
  62.1 (95% CI 57.8-66.4)
  and the average post-op MHHS, after
  minimum 1 year, had statistically
  significantly increased to 94.8 (95% CI
  92.8-96.9) (p<0.001).
 Average return to sport was 2.4
 months.
Which assessment criteria can we use
during rehab?
 Pain

 Functional scores
  Modified Harris Hip Score
  Hip outcome osteoarthritis score (HOOS)
  SF 36

 Subjective assessment?

 Objective Static information
  Range of motion
  Strength test
  Log roll test

 Objective dynamic evaluation
  SPORTS TEST
Sports Test M Phillipon
Test Components                    Maximum score
1.Single knee squat (single knee   6 points
bend)
2 Lateral agility test             5 points
3. Diagonal agility test           5 points
4. Forward single leg lunges       4 points
                                   Total 20 points
Sports test M Philippon
                                 Passed
Scoring criteria subsets          > or = 17 points
Time            20-30 seconds
Endurance
Form
                                 Failed
Pain                              < 17 points
Total           1 point
Timing to sport
 Difficult to predict.

 Should be athlete orientated rather the rehab
  orientated.

 Need for objective measurements before allowing
  athletes to go back to sports.
Risk factors for reinjury
 History of injuries and low level of off-season sport
  specific training.

 Consider the time an athlete has been out with an
  injury, before having surgery.
Risks of early return
 Persistent Pain

 Prolonged rehabilitation time.

 Low performance

 Re-Injury( new labral tear, articular cartilage lesion)

 New Injuries.

  Emery et al. Med SciSports Exerc, 2001.
When would I stop an athlete from
returning?
 Lack of endurance in sports
  specific tasks.

 Pain in sports specific
  positions.
  Progressive adaptations can
  be feasible. Dressage: start
  with small horses before
  wide horse, stirrups higher,
  to sit in a flexed more
  abducted position.
 Endurance muscles fibers are the first to be lost after hip
  surgery and take longer to recover.


  Suaetta et al. J ApplPhysiol, 2008.
  Deschenes et al. Am J Physiol, 2002.
  Ferrettiet al. J ApplPhysiol, 2001
Principles
 If possible see patient/player pre-operatively
  to prepare joint involved, and explain process
  and timescales involved.


 Always work closely with the surgeon involved.


 Whenever possible follow evidence based
  guidelines.
rockclimbing
     netbal
martial arts
     rowing
      dance
     cycling
     hockey
      tennis
  basketball
    running
horse riding
        golf
      rugby
      soccer

               0   2   4   6   8   10   12   14
Return to sports following
impingement surgery
 Soccer                   2-4 month

 Rugby                    2-3 month

 Basket ball              5 month

 Hockey                   3-4 month

 Dance                    3 month

 Martial arts             3 month

 Tennis                   2 month

   sports involving twisting and turning
  Return to sports following
  impingement surgery
 Golf                             2-3month

 Cycling                          6week-2 month

 Running                          2 month

 Rowing                           2 month

 Rockclimbing                     3 month




            Sports not involving twisting and turning
                      Start
                     Which
                   procedure?
                   Operative
                    Findings




     Pain
 Orginal pain
                    Hip            Return to sport?
                                    Type of sport
  Procedure     arthroscopy            Fitness
   specific                            Type of
Rehab related      Rehab              procedure




                 Progress of the
                      rehab
                     Patient
                   orientated
                 Use assessment
                     criteria
Thank you for your
    attention

				
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