Introduction

After attending the APA breakfast on femoroacetabular impingement (FAI) with Joanne Kemp, where Joanne made a point that perhaps physiotherapists aren't doing enough to rehabilitate patients following hip arthroscopy for FAI, I became curious to know how post-op hip rehabilitation has evolved over the past 10 years.

One common statement throughout the research I read on this topic was, that despite the massive and rapid changes which have occurred in hip arthroscopy, there still remains to be no consensus about several aspects of rehabilitation (Aprato, Gastaldo, Pasquero & Masse., 2015; Enseki, et al., 2006). One of the most obvious reasons for the lack of evidence is due to "heterogenity in study, subject, and surgical demographics"(Grzybowski, et al., 2015, p. 1). Despite this, many protocols currently do exist and are most are based on the clinical experience of the author. Upon reading many of these protocols it is clear that there is not a big discussion about assessment, clinical reasoning and the specifics of exercise prescription, which I feel might discourage Physiotherapists from engaging in a rehabilitation program that appears to be prescriptive.

As hip surgery, particularly arthroscopic surgery, is a quickly developing area of treatment and as the range of procedures continues to expand, it is imperative that we review our knowledge of rehabilitation protocols to ensure we are providing the best treatment. What I hope to achieve with this blog is to discuss current rehabilitation protocols and how they are designed. To actually get detail with this topic I aim to address each phase individually and discuss the questions that have come to my mind while reading around this topic.

The first of which is...

Who is the ideal surgical candidate?

Currently, FAI and labral repair are the most common indications for surgery (Aprato et al., 2015) but other reasons for referral include: cartilage lesions, labral injuries, loose body retrieval, synovitis, instability and torn ligament trees, to list a few. What we will discuss further in this blog is how rehabilitation needs to evolve to account for the increasing number of surgical techniques.

Two questions that I often ask myself are:

When is surgery indicated?
What are the key physical impairments and diagnostic features that patients need to satisfy a referral to an orthopaedic surgeon?

Interestingly, neither of these questions were addressed in the papers I read on this topic and yet I think this is the most important question to ask ourselves, why are patients being referred for surgery? Before we consider what rehabilitation is needed, we first need to think about why surgery is the best option and what we expect from the surgery. It certainly is not used as a cure.

Possible goals are to:

Change anatomical alignment and joint congruency.
Improve joint space.
Repair labral tears and other pathological structures.
Promote healing.

HOW ARE PROTOCOLS DESIGNED?

Generally speaking, protocols are broken into phases

Phase 1: 0-4 weeks
Phase 2: 4-8 weeks
Phase 3: 8-12 weeks
Phase 4: 12-16 weeks

The timeline provided for each phase should serve as a guideline and not an absolute, and progression through each phase needs to be criterion-based (Spencer-Gardner, et al., 2014). There is one distinct problem with current protocols in that "the rehabilitation programme following hip arthroscopy for FAI will differ based on the operative findings and management of the soft tissue structures about the hip including the labrum and hip capsule” (Spencer-Garner et al., 2014, p. 849). Therefore, older protocols don’t allow for enough flexibility when they are structured according to time. The key differences in rehabilitation will often be in the length of phase I and the speed of progression towards phase II. For surgeries/injuries that require a longer period of modified weight bearing and restrictions on range of movement, they may be in phase I for up to 6 weeks. There has been a shift therefore for protocols to become criterion-based, meaning they still involve similar steps and exercises within each phase, but the duration and progression is based on more variables. Spencer-Garner et al (2014) and Edelstein et al (2012) both present criterion based protocols and discuss the precautions, common pitfalls and clinical indications for progression rather than specific exercises.

When looking through protocols that list exercises in each phase, they indication to move between phases is often based on mastery of current exercises. If you're not familiar with a post-op protocol then Fowler Kennedy clinic, Proaxistherapy and Stalzer et al., 2005 explain exercises specific to each stage. When I see the word "mastery" it triggers me to consider what criterion I would use to justify my exercise progression? Are patients actually good enough for something new or harder? ... or ... Do we automatically progress them for the sake of progression each visit? Rapidly progressing patients was the biggest pitfall discussed in current papers about protocols and the failure to recover. The authors explain that often we progress exercises too rapidly and without respect of pain with without first developing the neuromuscular control and progression truely needed to reach the next phase.

So they are criterion based phases of rehab through which patients can progress based on their ability to master exercises within each phase. Often what I find difficult to understand about exercise protocols is which patient will benefit most from these exercises? The confusion lies not in the protocols themselves, which seem to be consistently generic, but the lack of connection to the patient and diagnosis. There is a huge degree of variability in conditions that result in hip pain or progress to arthroscopic procedures and I struggle with the idea that all can wake from the anaesthetic and embark on the same clinical pathway. "As surgeries to correct disorders of the acetabular labrum and associated pathology are performed more often, post operative protocols must reflect the evolution of these procedures and the demands of the patient population" (Enseki, et al., 2006, p. 516-517).

Now that we've seen how the current criterion-based protocols are designed, let's look deeper into the structure of each phase. Before I begin, I need to add that I have one issue with all these papers - there is no discussion about the role of objective examination and assessment for monitoring change in patient populations. This I feel can lead to one big error, every one get the same set of exercises and no one has time to monitor change or progress because therapists are too busy dishing out loads of rehab. Furthermore, nothing gets done specifically and we don't collect data that in the end would advocates for our involvement with these patients.

Phase 1

In many protocols phase I lasts between 2-4 weeks. This is often referred to as the protection phase and universally involves elements of gait training, beginning painfree passive range of movement exercises, isometric strengthening exercises, pain management and hands-on therapy.

The primary goals of early rehabilitation are to “minimise pain and inflammation, protect the repaired tissue, and initiate early motion exercises” (Garrison, Osler & Singleton., 2007, p. 243). “Reducing joint inflammation and protecting soft-tissue repair is the cornerstone of the initial rehabilitation process for surgery” (Spencer-Garner et al., 2014, p. 850). So when you’re in phase I perhaps you can ask yourself the questions:

What can I do to assist with this tissue repair?
How do we know if this is being achieved?
How do we know when phase I is either complete or needs to be extended?

Weight bearing (Enseki et al., 2006, p. 522):

Some surgeries may allow for immediate weight bearing and these include "labral debridement, synovial chondromatosis loose body removal, osteoarthritis debridement, septic arthritis debridement and trochanteric bursectomy" (Grzybowski, et al., 2015, p.4).
Others require a short period of PWB e.g. a labral resection and capsular modification are PWB for 10-14 days.
Some require a long period of PWB e.g.
- Labral repair PWB 10-28 days,
- Osteoplasty and rim trimming PWB 4-6 weeks to avoid excessive compressive and tensile forces to the femoral neck and head-neck junction,
- Microfracture PWB 4-6 weeks to avoid reinitiating of the inflammatory response and protect early fibrocartilage formation

PWB (partial weight bearing) is usually going to involve a heel-toe pattern which is most closely associated with normal gait (unless otherwise stated by the surgeon). Many protocols emphasise the need to avoid excessive hip flexion loads during phase I and to remember that psoas overactivity is likely to occur if the patient lifts there leg with a straight leg raise or holds it off the floor continuously during gait. This is one of the reasons why PWB is encouraged over NWB.

Range of motion exercises (Enseki et al., 2006, p. 522; Spencer-Garner et al., 2014, p. 850):

Labral repair and resection should regain painfree PROM within 2 weeks.
If a capsular modification is performed then hip extension and external rotation are additional range of movement restrictions to consider and many authors suggest limiting these movements to <10 degrees for the first 3 to 4 weeks with the aim of protecting the anterior portion of the capsule.
Stationary bike and hydrotherapy are great treatment options for ROM and gain retraining and can be progressed to further challenge strength and endurance in later stages of rehabilitation. In regards to the stationary bike, for the first 4 weeks no resistance is recommended and it is better to use an upright bike with the seat high enough to keep the hip below 90 degrees of flexion.
Examples of passive ROM exercises performed by the therapist are log rolls in supine moving the leg through IR/ER and then progressing to prone with knee bent to 90 degrees.

Strengthening exercises:

“Emphasis is placed on eliminating substitution patterns and progressing activities into specific functional movement patterns” (Enseki, et al., 2006, p. 523).
Many protocols recommend beginning with isometric strengthening of hip extensors, abductors and adductors.
Isometric hip flexion should be delayed compared to other hip strengthening exercises and usually isn’t commenced until phase II (Spencer-Garner et al., 2014).

Patient education & communication with the surgeon:

“Early establishment of realistic patient goals in relation to known joint integrity will help to minimise disappointment and frustration for both the patient and therapist alike” (Enseki, et al., 2006, p. 523).
“With this in mind, communication between the surgeon and the rehabilitation team becomes of utmost importance in ensuring that the appropriate restrictions are applied in each case” (Spencer-Garner et al., 2014, p. 849).
“Because new surgical procedures are constantly evolving, it is the responsibility of the physical therapist to stay up to date with the most current techniques as well as to establish and maintain good communication with the orthopaedic surgeon” (Garrison, Osler & Singleton., 2007, p. 242).

Common pitfalls during phase I include excessive weight bearing, pushing through pain with exercises and rapid progression of exercise volume and intensity. Many authors emphasis that we also need to take time prior to surgery to educate patients about the phases of rehab, the goals and likely exercises, and how to transfer and use crutches. This will help them prepare for phase I and allow rehab to begin immediately after the surgery.

Progression from phase I to II when (Grzybowski, et al., 2015):

Normalised gait without assistance and tolerance of full weight bearing,
Minimal pain,
No trendelenburg,
Ability to do a side lying SLR,
ROM more than 75-80% of uninvolved side with no pinching pain during flexion.

Phase 2

Phase I lasts up to 8 weeks and this is the strengthening phase. The goals for the duration of Phase II are to gain full mobility and stability, begin stretching around the 6 week mark, advance strengthening exercises as weight bearing restrictions are lifted.

In phase II you are going to progress weight bearing and walking until no gait aids are required, continue to mobilise into painfree range of movement, progress to isotonic and resisted strengthening exercises, add balance and proprioceptive exercise, and develop a modified cardio program.

Strengthening exercises (Spencer-Garner et al., 2014):

Exercises are first performed isotonically and then become resisted. By the end of phase II you might expect your patient to complete a clam with theraband, 4PK hip lift (fire hydrant), sustained glut bridge with leg extension and child’s pose.
During this phase of strengthening it is important to consider the role of the trunk and it’s influence on lumbopelvic and hip control. As the progression of exercises occurs many protocols begin to incorporate modified side bridging exercises into the program. Later in phase 3 & 4 there are many functional strengthening exercises that involve trunk control and rotational control with cables and weights.
It is important not to progress too quickly. Ensure that your patient is performing ROM and strength exercises with good form, high repetition, low load and painfree.
For external ROM you can begin with bent knee fall out movements in supine and progress to rotation kneeling on a stool.
For other trunk strength you can think about progressing to prone plank, side plank, bridging, tall kneeling cable chops.
Balance is added as it is closely linked with the normalisation of gait.

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Begin psoas training:

Edelstein et al (2012) was the only paper I read that specifically address the function of psoas and it’s place in the rehab protocol. In fact, many articles address the increased compressive loads seen in a supine SLR and its potential not only to load a healing joint but also to lead to hip flexor tendinopathy. Furthermore, not one article I read promoted the SLR exercise. Edelstein et al (2012) however was the first to provide a detailed description of psoas eccentric loading exercises using the trunk as the moving level in the strengthening of hip flexion. The explain that “following hip arthroscopy, patients often present with the psoas muscle inhibited. This is demonstrated by difficulty in performing hip flexion and an inability to control hip extension through stance phase of gait. As a result, these patients may begin to develop a hip flexor tendonitis. not necessarily of the pass, however more often of the secondary hip flexors including the tensor fascia lats, rectus femoris and sartorial” (Edelstein, et al., 2012, p. 18). In this paper the authors use a seated trunk lowering hinge to eccentrically load the pass with the affected knee in an extended position and supported by the therapist.

Gait:

“It is important to maintain a symmetrical gait pattern to prevent concomitant stress throughout the lower extremity and spine” (Garrison, Osler & Singleton., 2007, p. 246). So ask yourself if they can walk painfree with a normal gait and without crutches? To achieve this they also need to perform a side lying SLR without pain and with proper form. This will ensure no trendelenburg sign occurs during gait.

Progression from phase II to III when (Grzybowski, et al., 2015):

Normal function of ADLs without pain,
Painfree normal gait,
Full ROM,
No pain,
Manual muscle tests 5/5, good core stability, good control of a single leg squat, good control of balance, good performance of a bridge etc.

If you're thinking the same as me then you might be wondering what is good? Again this points out that progression is effected by the goals set by the therapist and their proficiency in performing assessments of both structural and function tests. Hopefully in the upcoming blogs we will take a closer look at dynamic balance, single leg squat control and other assessments of hip functional strength in the hope of knowing more how good is defined.

What are some exercise considerations?

In 2013, Selkowitz, Beneck & Powers published a paper looking at the muscle activation patterns of the gluteal muscles and tensor fascia latae (TFL) during exercises commonly prescribed for rehabilitation. The outcome of the study would be to provide information as to which exercises maximise the activation of GMed and Sup-Gmax while minimizing the activation of TFL. You can read more about these exercises here. In addition to this, Grimaldi et al (2009) published a series of articles exploring changes in gluteal muscle firing and bulk associated with hip OA. Currently, FAI is being viewed as early stages of hip OA, so at what point are we going to take the findings of these studies into consideration? These findings have been explored in previous blog on motor control impairments with hip OA.

A second consideration with exercise is the muscles which patients recruit to perform movement. Edelstein and colleagues (2012) also present a criterion-based protocol and during the early phases of rehabilitation that emphasis that clinicians should be aware of the role of the adductor muscle group in acting as both secondary hip flexors and extensors and the implications this might have. It seems that there is an increasing emphasis on quality over quantity.

Thirdly, when do you address biomechanical issues and muscle patterns retraining? FAI is an overload in impingement positions with a predisposing structural abnormality. While surgery is targeting at promoting healing, it doesn't change the movement patterns patients have developed over time. So at what point do we discuss sitting posture, sleeping positions, work ergonomics and running posture? This was not specifically addressed in the papers I read and again I feel we should be considering when is the best time specifically retrain movements like sit to stance, single leg stance, single leg squat to ensure patients have optimal biomechanics and muscle activation patterns? There is so much going on in these phases that my fear is the deep gritty detail is being lost.

WHERE DOES MANUAL THERAPY FIT IN?

Manual therapy is most commonly described as a part of physiotherapy treatment during phase I and II. There was only one paper I read that offered a clear overview of what “manual therapy” meant in their clinical experience. Tijssen et al (2016) offer a clear outline of the exercise and hands-on therapy which could be included in rehabilitation for this population, from which, the therapist must select the most appropriate treatment based on clinical reasoning. Upon reviewing the possible treatment options for hands-on therapy, this paper included:

Inferiorly-directed manual mobilisation of the hip.
Grade 3 or 4 left unilateral PA mobilisation of the lumbar spine in side lying.
AP or PA mobilisation of the ilium.
Trigger point release and soft tissue massage of the iliopsoas, rectus femoris, sartorius, adductors, gluteus minimus and medius, TFL and quadratus lumborum muscles (Table 1 p. 5).

ISN'T THIS ALL A LITTLE TOO MUCH?

Who can effectively complete all that treatment in the time allocated to a physio session? Plus be expected to review and progress exercises? It is unrealistic to expect a therapist to effectively treat that many areas and personally I see that as a non-specific over treating of a patient. What I'd like to see is a rational or framework which links clinical assessment to treatment choices, but, that is not available. So it brings me to think that younger therapists aren't prepared with the tools needed to navigate these protocols and perhaps this is why we aren't doing a good enough job?

If we don't distill it down, our treatment goals it will be unachievable, our sessions rushed and poorly executed and exhausting for the therapist. What I didn't find when reading about this topic, were papers examining the assessment itself and the objective measures of improvement throughout each phase. Perhaps another topic to consider separately?

Do we strengthen and mobilise everything?
Do we look for specific patterns in motor control and activation?
What are the best clinical tests to use to monitor progress?

Many of the papers I read offered a lot of advice for phase I and II but got a lot more vague in the later phases. I respect that this is a reflection of the difficultly in detailing a sport-specific return to activity program, however it doesn’t allow clinicians to truely grasp the entirety of the program. I've done my best therefore to continue to look at phases 3 & 4 in further detail.

Sian :) tbc...

REFERENCES:

Alessandro, A., Marco, G., Francesco, P., & Alessandro, M. (2015). Rehabilitation after Hip Arthroscopy. J Orthop Res Physiother, 1(001).

Edelstein, J., Ranawat, A., Enseki, K. R., Yun, R. J., & Draovitch, P. (2012). Post-operative guidelines following hip arthroscopy. Current reviews in musculoskeletal medicine, 5(1), 15-23.

Enseki, K. R., Martin, R. L., Draovitch, P., Kelly, B. T., Philippon, M. J., & Schenker, M. L. (2006). The hip joint: arthroscopic procedures and postoperative rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 36(7), 516-525.

Garrison, J. C., Osler, M. T., & Singleton, S. B. (2007). Rehabilitation after arthroscopy of an acetabular labral tear. N Am J Sports Phys Ther, 2(4), 241-50.

Grzybowski, J. S., Malloy, P., Stegemann, C., Bush-Joseph, C., Harris, J. D., & Nho, S. J. (2015). Rehabilitation following hip arthroscopy–a systematic review. Frontiers in surgery, 2, 21.

Spencer-Gardner, L., Eischen, J. J., Levy, B. A., Sierra, R. J., Engasser, W. M., & Krych, A. J. (2014). A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy, 22(4), 848-859.

Stalzer, S., Wahoff, M., Scanlan, M., & Draovitch, P. (2005). Rehabilitation after hip arthroscopy. Operative Techniques in Orthopaedics, 15(3), 280-289.

Tijssen, M., van Cingel, R. E. H., Staal, J. B., Teerenstra, S., de Visser, E., & Nijhuis-van der Sanden, M. W. G. (2016). Physical therapy aimed at self-management versus usual care physical therapy after hip arthroscopy for femoroacetabular impingement: study protocol for a randomized controlled trial. Trials, 17(1), 1.

Waho M, Dischiavi S, Hodge J, Pharez JD. (2014) Rehabilitation after labral repair and femoroacetabular decompression: criteria-based progression through the return to sport phase. Int J Sports Phys Ther 9: 813-826.