Rehabilitation of the Hip

33
Erica M. Coplen and Michael L. Voight

Introduction surgical treatment for hip pain has evolved, the hip rehabili-
tation process has followed a similar path.
Over the past decade, hip arthroscopy has gained an increase While the rehabilitation protocols following hip arthros-
in popularity. With the advent of hip arthroscopy, there has copy continue to evolve, the overall fundamental objective
come an increased recognition of intra-articular hip patholo- has remained the same: return the patient back to their prein-
gies and improved techniques for the management of these jury level of activity as quickly and as safely as possible with
various pathologies [1–7]. In 2008, more than 30,000 hip the best possible long-term results. The goal of the rehabili-
arthroscopies were performed, and this number is expected tation plan is to reduce symptoms (modulate pain and
to grow at a rate of 15% over the next 5 years, resulting in inflammation) and improve function (restore mobility,
more than 70,000 hip arthroscopies performed each year by strength, proprioception, and endurance). This is approached
2013 [8]. While mechanical problems can often be corrected through a systematic progression dependent on the patient’s
through surgery, the functional deficits must be corrected status (pathology present) and functional needs. During the
through the rehabilitation process. Therefore, the evolution assessment process, it is important to determine the patient’s
of hip arthroscopy has necessitated a progression in hip reha- level of understanding regarding the pathology, expectations
bilitation to insure optimal postsurgical results. Understanding of goals, and the time frame for achieving them. Patient edu-
the process of rehabilitation from preoperative education cation is the foundation of the rehabilitation plan. The patient
to the patient’s achievement of full function is an integral must comprehend the related precautions and the recom-
part of the patient reaching their full potential postsurgery. mended progression per their individual situation. Through
While it is generally accepted that rehabilitation after hip collaborative consultation with the physician, physical thera-
arthroscopy is vitally important, there is limited evidence- pist, and patient, reasonable goals and expectations can be
based research to support the rehabilitative guidelines [9–12]. formulated for favorable outcomes.
Rehabilitative methodology and techniques commonly
employed after minimally invasive surgical techniques for
other joints, such as the knee, shoulder, elbow, and ankle, Assessment and Overview
have found application in the management of hip disorders.
Understanding and respecting basic principles is always key The physician’s history, examination, and diagnostic studies
to obtaining successful outcomes with any technique. As the determine the patient’s diagnosis and prognosis of surgical
or nonsurgical treatment. The patient’s history and the clini-
cal evaluation assist in determining how the symptoms will
respond to treatment. A course of presurgical treatment (prehab)
may be indicated in some hip cases to regain neuromotor
E.M. Coplen, DPT ( )
Nashville Sports Medicine Physical Therapy, control and decrease stresses to the joint. An appropriate
2011 Church St, Suite 103, Nashville, exercise program can, at times, help restore normal mechan-
TN 37203, USA ics and minimize joint stresses to facilitate healing. In other
e-mail: [email protected]
circumstances, it can “buy time” when a patient desires and
M.L. Voight, DHSc, PT, OCS, SCS, ATC, FAPTA the physician thinks it is beneficial to delay operative inter-
School of Physical Therapy, Belmont University,
vention. Rehabilitation of a patient preoperatively, when the
1900 Belmont Blvd, Nashville,
TN 37212, USA need for surgery has been confirmed, better prepares patients
e-mail: [email protected] psychologically and physically for postsurgical recovery.

J.W.T. Byrd (ed.), Operative Hip Arthroscopy, 411

DOI 10.1007/978-1-4419-7925-4_33, © Springer Science+Business Media New York 2013
412 E.M. Coplen and M.L. Voight

As direct access and autonomous practice for physical

therapists become more prevalent, the rehab provider may
have the opportunity to be the initial caregiver for a patient
with hip pain. Understanding the hip mechanics and how to
properly assess the hip is imperative in deciding whether the
severity of the hip dysfunction requires referral back to their
orthopedic physician or if the problem can be managed con-
servatively. Treating a hip patient conservatively can be just
as important as treating a patient postoperatively.
The foundation of assessment of a hip dysfunction begins
with an understanding of the pathomechanics of the hip and
pelvis. Joint dysfunction can manifest as a primary mechani-
cal complaint or secondarily as a compensatory mechanical
dysfunction. For example, for a patient with degenerative
changes within the joint, the primary disorder is the antalgic
gait due to joint pain. The secondary dysfunction may be due
to weakness of the gluteus medius presenting as an abductor
lurch (Trendelenburg gait) (Fig. 33.1). Disorders of the sac-
roiliac joint (SI joint) and lumbar spine also become consid-
erations with chronic hip dysfunction because of altered gait
and weight-bearing mechanics. Primary problems of symp-
tomatic hip pathology may involve the soft tissue encasing
the joint, the surrounding capsule, or the joint structure. The
irritation and inflammation of the musculotendinous struc-
tures, bursae, or joint capsule can result in concomitant ten-
dinitis, bursitis, or capsulitis. The ligaments of the hip joint
are susceptible to acute tearing and chronic degeneration.
Within the joint, labral or chondral injury can be responsible
for protracted hip symptoms. Femoroacetabular impinge-
ment (FAI) has been suggested as playing a role in the devel-
opment of acetabular labral tears and chondral lesions. FAI is
a newly well-recognized indication for arthroscopic hip sur-
gery [13]. Loose bodies and labral lesions are also well-rec-
ognized indications for arthroscopic surgery, which tends to
produce gratifying results for properly selected patients [3].
Pain-free functional movement necessary to allow partici-
pation in sports is composed of many components: posture,
ROM, muscle performance, and motor control. Impairments
in any of these components can potentially alter required
functional movement. The therapeutic plan of care needs to
be focused on the patient’s functional impairments that are a
result and/or cause of pathology. The clinician can then use
the traditional parts of the clinical examination to refine and
deduce the specific pathoanatomic structures responsible for
the functional limitation.

Fig. 33.1 Trendelenburg gait. Abductor lurch may occur as a compen-

satory mechanism to reduce the forces across the joint. Shifting the
torso over the involved hip moves the center of gravity closer to the axis
of the hip, shortens the lever arm moment, and reduces compressive
joint force. (All rights are retained by Dr. Byrd)
33 Rehabilitation of the Hip 413

hip arthroscopy [17]. They found statistically significant

associations between the preoperative clinical presentation
and arthroscopic operative findings. Acetabular labral tears
detected arthroscopically correlated significantly with symp-
toms of anterior inguinal pain (r = 1), painful clicking epi-
sodes (r = 0.809), transient locking (r = 0.307), and giving
way (r = 0.320). Patients also commonly complain of pain
deep in the hip in which they may grasp/cup their lateral hip
just above the greater trochanter. This is termed the “C” sign
which describes the shape that the hand makes to surround
the hip (Fig. 33.3a, b) [4].

History

Taking a thorough history in any patient case can help deter-

mine an appropriate tailored rehabilitative program.
Understanding the patient’s goals preoperatively and/or post-
operatively can also help guide the rehab. As there are vari-
ous disorders that can result in a painful hip, the history may
be equally varied as far as onset, duration, and severity of
symptoms. For example, acute labral tears associated with an
injury have gone undiagnosed for decades, presenting as a
Fig. 33.2 The hip receives innervation predominantly from the L2–S2 chronic disorder. Conversely, patients with a degenerative
nerve roots of the lumbosacral plexus. (All rights are retained by labral tear may describe the acute onset of symptoms associ-
Dr. Byrd) ated with a relatively innocuous episode and gradual pro-
gression of symptoms [4]. Many patients with FAI who
develop symptoms as adults will often reflect back on the
The clinical presentation of a patient with an acetabular fact that they were never very flexible when they were
labral tear has shown to be anterior hip or groin pain in younger. They commonly complain that they were never able
greater than 90% of patients. Less often, patients can com- to sit cross-legged on the floor (Fig. 33.4a, b). Common
plain of lateral hip pain or pain deep in the posterior buttock. complaints of pain, functional limitations, and impairments
Data suggests that anterior hip or groin pain is more consis- are seen among patients that present with hip pain and/or a
tent with an anterior labral tear, whereas buttock pain is more hip pathology. For example, common functional deficits
consistent with a posterior labral tear. Mechanical symptoms include pain with prolonged sitting; difficulty donning socks
can include clicking, locking or catching, or giving way, with or shoes; inability to squat or sit on low surfaces; and altered
clicking being the most consistently reported mechanical gait with a shortened stance phase, protraction of the hip, and
symptom [14]. The patient can complain of a sharp “catching” decreased hip extension on the involved side. In addition,
pain that is often associated with a popping, and a sensation other common complaints can be loss of ROM, pain with
of locking or giving away of the joint [15, 16]. Patients can increased stride length during the gait cycle, dyspareunia,
have pain in the anterior groin, anterior thigh, buttock, greater and pain with negotiating stairs. Understanding your patient’s
trochanter, and medial knee. The reason for the variety in mechanism of injury, current activity level, and goals for
locations of complaints of pain is that the sensory supply to rehab/surgery will help guide your assessment and treatment
the hip joint is 65% from the obturator nerve; so pain in this for the patient.
area will be referred to the groin and the medial aspect of the
knee. Approximately 30% of the sensory distribution is from
the femoral nerve, which will refer to the anterior portion Physical Examination
of the thigh. The remaining sensory distribution is from
a branch of the sciatic nerve; therefore, the pain will be The clinical assessment includes observation of gait
referred to the buttock [19] (Fig. 33.2). In a retrospective (Fig. 33.5), assessment of hip ROM and strength, perfor-
study by McCarthy and associates, they reviewed 94 con- mance of special tests (as referenced in previous chapters),
secutive patients with intractable hip pain who underwent and observation of basic functional transitional movements
414 E.M. Coplen and M.L. Voight

a a

Fig. 33.3 C sign. Patients commonly complain of pain deep in the hip
and may grasp/cup their lateral hip just above the greater trochanter. Fig. 33.4 (a) Normal cross-legged sitting position. (b) Patients will com-
This is termed the “C” sign which describes the shape that the hand (a) monly demonstrate that they are not able to sit in a cross-legged position
makes to surround the hip (b). (All rights are retained by Dr. Byrd) due to pain or reduced flexibility. (All rights are retained by Dr. Byrd)
33 Rehabilitation of the Hip 415

HEEL STRIKE FOOT FLAT MIDSTANCE PUSH OFF

ACCELERATION MIDSWING DECELERATION

Fig. 33.5 Gait is continuously assessed throughout the rehab process. Schematic illustrates the normal phases of the gait cycle. (All rights are
retained by Dr. Byrd)

such as sit to stand to sit, ascending/descending stairs, and joint is important in guiding your physical examination
balance activities. This also includes understanding the and differential diagnosis. Screening the entire lower extrem-
patient’s specific movement patterns and what elicits their ity chain, including the knees and feet, can be imperative to
painful symptoms. At this time, determining if the patient your evaluation and should be performed during your
has involvement of the lumbar spine, pelvis, or sacroiliac assessment.
416 E.M. Coplen and M.L. Voight

Movement Dysfunction and Assessment an increased chance of poor performance, pain and likeli-
hood of injury, especially with the years of accumulation of
A sport or movement-specific examination is imperative to these accommodations combined with the aging changes of
understanding the contributions of athletic activity to func- the musculoskeletal system.
tional limitations or pain. Motion, related to and produced by The Selective Functional Movement Assessment (SFMA)
all the neuromusculoskeletal contributions of the human is one way of quantifying the qualitative assessment of func-
body, although variable by age remains the prerequisite for tional movement and is not a substitute for the traditional
function. Traditional rehabilitation approaches used with examination process [19]. Rather, the SFMA is the first step
athletes are often based on identification of inflamed tissues in the functional orthopedic examination process, which
(and subsequent symptomatic treatment of those tissues) serves to focus and direct choices made during the remaining
rather than on the correction of the mechanical cause of the portions of the exam, which are pertinent to the functional
tissue irritation. The symptom-based approach makes the needs of the older athlete. The SFMA uses functional
assumption that the painful tissue is the source of the pain movement patterns to identify impairments that potentially
and subsequent dysfunction [18]. Although clinicians are alter specific functional movements. The approach taken
trained to examine both the local area of complaint and the with the SFMA places less emphasis on identifying the
whole patient, typically the sequence of assessment is specific source of the symptoms and more on identifying the cause.
to general, with the examination focused on reproducing the An example of this assessment scheme is illustrated with a
athlete’s pain. By looking at specific tissue first, an opportu- runner that presents with low back pain. Frequently, the
nity is missed to watch the body move as a whole and lost is symptoms associated with the low back pain are not exam-
the overall perspective of what the athlete can functionally ined in light of other secondary causes such as hip mobility.
achieve. All too often clinicians become too focused on the Lack of mobility at the hip is compensated for by increased
special tests that serve to confirm a pathologic diagnosis that mobility or instability of the spine. The global approach
they fail to refine, qualify, and quantify the functional param- taken by the SFMA would identify the cause of the low back
eters of the problem at hand. Reversing the sequence of dysfunction.
assessment by examining gross movements before looking at The functional assessment process emphasizes the analy-
component impairments, the therapist may determine where sis of function to restore proper movement of specific physi-
to focus specific assessment. By taking this approach, gross cal tasks. Use of movement patterns with the application of
movements may provoke or reveal symptoms in the problem specific stresses and overpressure serves to determine if
area as well as in other areas. Observing functional move- dysfunction and/or pain are elicited. The movement patterns
ments that the patient is able or unable to perform and those will also reaffirm or redirect the focus of the musculoskele-
that produce pain may provide a clearer picture of the cause tal problem. Maintaining or restoring proper movement of
of the problem. One exception to initiating the examination specific segments is a key to preventing or correcting
using functional movements is the presence of chemical musculoskeletal pain. The SFMA also identifies where
pain, that is, acute postsurgical or postinjury inflammation. functional exercise may be beneficial and also provides
Pain or inflammation of chemical origin is capable of feedback regarding the effectiveness of such exercise. A
influencing and producing movement dysfunction. Initial functional approach to exercise utilizes key specific move-
treatment emphasis would be directed locally in order to ments that are common to the patient regardless of the
mediate the problem prior to a complete functional specific sport or activities of daily living they participate in.
examination. Exercise that uses repeated movement patterns required for
desired function is not only realistic but also practical and
The Selective Functional Movement Assessment time efficient.
Mobility and stability coexist to create efficient movement in
the human body. Mobility and stability are the fundamental The Scoring System for the SFMA
building blocks of strength, endurance, speed, power, and The SFMA uses seven basic movement patterns to rate and
agility and therefore of all athletic activities. When these rank the two variables of pain and function (Fig. 33.6). The
building blocks are decreased, the patient may compensate hip is affected by five of these (Video 33.1: http://goo.gl/
quality and therefore develop altered biomechanical habits to ZHYvk) (Fig. 33.7). Function comprises mobility and stabil-
allow continued performance of an activity. When required ity. The term functional describes any unlimited or unre-
movements are changed to accommodate less than optimal stricted movement. The term dysfunctional describes
musculoskeletal integrity, negative changes and compensa- movements that are limited or restricted in some way, dem-
tions such as altered joint arthrokinematics can occur. onstrating a lack of mobility, stability, or symmetry within a
Accommodations to altered mobility and stability can pro- given movement pattern. Painful denotes a situation where
duce inefficiency and thus require more energy, resulting in the selective functional movement reproduces symptoms,
33 Rehabilitation of the Hip 417

THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT

SFMA SCORING FN FP DP DN

Active Cervical Flexion

Active Cervical Extension

L
Cervical Rotation-Lateral Bend R

Upper Extremity Pattern 1(MRE) L

R

L
Upper Extremity Pattern 1(LRF) R

Multi-Segmental Flexion

Multi-Segmental Extension

L
Multi-Segmental Roation R

L
Single Leg Stance
R

Overhead Deep Squat

PROVOCATION PATTERNS

Impingement Sign L
R

L
Horizontal Adduction R

Fig. 33.6 SFMA scoring chart

418 E.M. Coplen and M.L. Voight

Multi-Segmental Multi-Segmental Multi-Segmental Single Leg Overhead Deep

Flexion Extension Rotation Stance Squat

Touches toes and ASIS clears the Pelvis rotation > Eyes open > 10 No loss of shoulder
returns to standing toes 50˚ seconds flexion
position with
knees straight

Uniform spinal Maintains normal Trunk/shoulder Eyes closed > 10 Maintain thoracis
curve (> or = to 170˚) rotation > 50˚ seconds extension
shoulder flexion

Posterior weight Spine of the No spine or pelvis No loss of height Hips break parallel
shift scapula clears the deviation
heels

>70˚ sacral angle Uniform spinal No excessive knee Normal dynamic No sagittal plane
curve flexion leg swings deviations of lower
extremities, right
or left

Symmetrical right Symmetrical right

and left and left

Fig. 33.7 SFMA movements that affect the hip are shown

increases symptoms, or brings about secondary symptoms

that need to be noted. Therefore, each pattern of the SFMA Box 33.1 Functional Assessment (Should Be Done
must be scored with one of four possible outcomes. Throughout the Rehab Process, but Official
The seven basic movements or motions that comprise the Assessments by the Orthopedic Physician and the
basic SFMA screen look simple but require good flexibility Therapist Are Done at 4, 8, 12, and 16 Weeks (Which
and control. A patient who is (1) unable to perform a move- Coincide with the Phases of Rehab) Unless Otherwise
ment correctly, (2) shows a major limitation with one or more Indicated by the MD)
of the movement patterns, or (3) demonstrates an obvious – Tailor to each pt
difference between the left and right side of the body has – Functional squat (see SMFA assessment)
exposed a significant finding that may be the key to correct- – Gait
ing the problem.
33 Rehabilitation of the Hip 419

provocation of pain. Consistent limitation and provocation of

– Job/sport requirements symptoms in both the loaded and unloaded conditions may
– Endurance be indicative of a mobility problem [20, 21]. True mobility
– Mobility (ROM) restrictions often require appropriate manual therapy in con-
– Strength junction with corrective exercise.
– Flexibility
How to Interpret the SFMA
Once the SFMA has been completed, the therapist should be
able to do the following: (1) Identify the major sources of
The first five movements examine a combination of upper dysfunction and movements that are affected. (2) Identify pat-
quarter, lower quarter, and trunk movements. The shoulder terns of movement that cause pain where reproduction of pain
and cervical assessments examine upper quarter movement indicates either mechanical deformation or an inflammatory
quality. Each movement is graded with a notation of FN, FP, process affecting the nociceptor in the symptomatic struc-
DP, or DN. All responses other than FN are then assessed in tures. The key follow-up question must be “Which of the
greater detail to help refine the movement information and functional movements caused the tissue to become painful?”
direct the clinical testing. Detailed algorithmic SFMA break- (3) Once the pattern of dysfunction has been identified, the
outs are available for each of the movement patterns, but it is problem is classified as either a mobility or stability dysfunc-
beyond the scope of this chapter to describe. Once dysfunction tion, determine where intervention should commence. With
and/or symptoms have been provoked in a functional manner, the SFMA, the choice of treatment is not about alleviating
it is necessary to work backward to more specific assessments mechanical pain; rather, the SFMA guides the therapist to
of the component parts of the functional movement by using begin by choosing interventions designed to improve the dys-
special tests or range of motion comparisons. As the gross functional nonpainful patterns first. This philosophy of inter-
functional movement is broken down into component parts, vention does not ignore the source of pain; rather, it takes the
the therapist should examine for consistencies and inconsis- approach of removing the mechanical dysfunction that causes
tencies as well as level of dysfunction for each test as com- the tissues to become symptomatic in the first place.
pared to the optimal movement pattern. Provocation of
symptoms as well as limitations in movement or the inability
to maintain stability during movements should be noted. Conservative Treatment

Loaded and Unloaded Implications In some cases, decided by the patient and the surgeon, con-
By performing parts of the test movements in both loaded and servative treatment will be the most desired choice for the
unloaded conditions, the clinician can draw conclusions about patient. The patient may have FAI and/or a labral tear, but
the interplay between the patient’s available mobility and sta- some patients are either not ready for surgery or their symp-
bility. If any of the first five movements are restricted when toms may not be affecting their daily functional activities yet.
performed in the loaded position (e.g., limited, and/or in some Some may have only had symptoms for a short period of time
way painful prior to the end of the ROM), a clue is provided or only with higher level activities. They may decide to treat
regarding functional movement. For example, if a movement their hip conservatively with physical therapy and modification
is performed easily (does not provoke symptoms or have any of their current lifestyle before looking to surgery.
limitation) in an unloaded situation, it would seem logical The goals of conservative treatment, when the diagnosis
that the appropriate joint ROM and muscle flexibility exist is known, focus more on education and comprehensive home
and therefore a stability problem may be the cause of why the exercise programs as compared to the rehabilitative treat-
patient cannot perform the movement in a loaded position. In ment of postoperative patients. Education is imperative in
this case, a patient has the requisite available biomechanical this type of treatment focusing on what activities to avoid
ability to go through the necessary ROM to perform the task, (see Box 33.2) that may accelerate their degenerative
but the neurophysiological response needed for stabilization hip pathology and/or worsen their labral tear. In addition,
that creates dynamic alignment and postural support is not emphasis is put on teaching the patient what they can do to
available when the functional movement is performed.
If the patient is observed to have a limitation, restriction,
Box 33.2 Activities to Avoid Long Term
and pain when unloaded, the patient displays consistent
abnormal biomechanical behavior of one or more joints and – Deep squats/lunges
therefore would require specific clinical assessment of each – High-impact activities – running, jumping, etc.
relevant joint and muscle complex to identify the barriers (articular damage)
that restrict movement and that may be responsible for the
420 E.M. Coplen and M.L. Voight

a b

Fig. 33.8 (a) Normal squatting position. The depth of the squat may the squat no deeper than 45° to decrease the compression on the labrum.
need to be altered postsurgery or if the patient is being treated (All rights are retained by Dr. Byrd)
conservatively for hip pain. (b) The patient is instructed to perform

decrease the forces on their hip while maintaining or improv- routine that will not be detrimental to the hip. Recommen-
ing their hip strength and function. dations for cardiovascular exercise are as follows: (in order of
Managing or modifying an athlete’s training program may least-most compressive for the hip) swimming, biking (no
be crucial in preventing further irritable forces or damage to deep hip flexion, may have to adjust seat height), elliptical,
the hip. Deep loaded squatting (loaded flexion) >45°, deep walking, and jogging (limit if the patient does not have to per-
lunges, and deep leg press are activities that are avoided if the form this activity). If the patient already has a comprehensive
athlete is trying to avoid surgery or trying to rehab the injured workout routine, then the goal will be to help assess their cur-
hip (Fig. 33.8a, b). The athlete may benefit from less compres- rent routine and make changes as needed. The comprehensive
sive cardiovascular activities such as swimming and biking to programs may be taught in 1–2 visits or over a period of a few
use in between games, practices, etc. In addition, core (lum- weeks to let the patient acclimate to the new program.
bopelvic) stabilization may be recommended for the athlete Some patients will still respond to manual therapy for
based upon the results of the functional movement assessment temporary symptom relief. Hip mobilizations (described in
(Video 33.2: http://goo.gl/sI4Wm) (Fig. 33.9a–d). Specific post-arthroscopic treatment) as well as long axis traction
findings of your assessment will serve to guide your exercise may be tolerated very well. If the patients do respond well,
progression. This in turn will help accentuate a more neutral these techniques can easily be taught to a spouse, friend, or
pelvis which in turn will open up the acetabulum anteriorly and family member so they can be performed more often.
provide some relief of compression in those with pincer FAI. During the education process, it is very important to
The focus of the exercise program will be on hip/core emphasize the importance of compliance with the strength-
strengthening, maintaining full pain-free hip ROM (reduce ening program as well as avoiding the activities that worsen
risk of developing adhesive capsulitis), maintaining/improv- their symptoms. If after completing the preliminary phases
ing flexibility, and helping the patient develop a cardiovascular of a thorough program that is 4–6 weeks in length or if the
33 Rehabilitation of the Hip 421

a d

Fig. 33.9 Lumbopelvic (core) stabilization may be recommended to the such as running, jumping, or specific sporting activities. (a) Forward core
patient to decrease compression in the hip in someone with a pincer type planks. (b) Side core planks. (c) Side plank with leg lift. (d) Lunge with
lesion or in patients who want to get back to higher level functional activities shoulder PNF pattern. (All rights are retained by Dr. Byrd)

patient continues to have increasing amounts of pain or does geon and the physical therapist and not a strict timeline. The
not respond well to conservative treatment, then it will be rehabilitation program must be individualized with specific
beneficial to refer the patient back to the orthopedic physi- time frames for weight bearing and ROM as determined by
cian. Failure to respond to a poor conservative treatment pro- the pathology and the specific procedures used for correction
gram or lack of compliance to an adequate program does not (Table 33.1). For example, a patient with significant degen-
constitute failure of the rehabilitation program. erative changes that undergoes a microfracture will have a
slower recovery, dictated primarily by their symptoms and
healing precautions. Compliance with the rehabilitation
Treatment/Rehabilitation Progression program is vital to allow for optimal soft tissue and bone
healing. The rehabilitation program will progress through
From the clinician’s subjective and objective assessment and phases that utilize specific criteria to advance or progress to
the information provided by the surgeon, specific areas of the next phase. Early in the rehab process (first 1–2 weeks),
concern and needs will be identified [4]. To achieve the over- the exercise prescription is similar for all pathologies while
all goals for an individual patient, the clinician must assess still being mindful of the labral repair ROM restrictions and
what instruction, monitoring, and equipment are necessary the microfracture weight-bearing precautions. During phase
and must gauge the intensity or aggressiveness of the patient’s 1 of the rehab program, the intensity of rehabilitation is very
functional progression. The rehabilitation program must be conservative and is accomplished not only by supervision
individualized based upon the evaluation findings of the sur- through the first phase but also with the patient performing
422 E.M. Coplen and M.L. Voight

Table 33.1 Weight-bearing guidelines

Procedure WB Crutches ROM
Routine arthroscopic procedure WBAT 5–7 days or when gait is normalized No limits
(loose body removal, labral
debridement, chondroplasty, etc.)
Femoroplasty WBAT 1 month No limits
Acetabuloplasty WBAT 2 weeks or until gait is normalized No limits
Labral repair/refixation 50% BW 1 month 90° of hip flexion; no ER for 4 weeks; week 4–5:
increase to 105° hip flexion, ER to 20°; week 5–6:
115–120° of hip flexion, ER: 40° (pain-free); week
6+: Full AROM/PROM (pain-free)
Microfracture 30# PWB 2 months No limits (emphasize ROM)
Iliopsoas release WBAT 2 weeks or until gait is normalized No limits on PROM, limit AROM flexion to allow
healing to occur, emphasize passive hip extension to
aid in healing process
WB Weight bearing, ROM Range of motion, WBAT Weight bearing as tolerated, BW Body weight, ER External rotation, AROM Active range of
motion, PROM Passive range of motion

their home exercise program independently. Progress through [20, 21]. In other cases, a single comprehensive preoperative
this phase is dependent upon the specific pathology that the visit for instruction, explanation, and demonstration of the
patient had. A patient with debridement of a labral tear, loose expected postoperative rehabilitation protocol will suffice.
body removal, synovectomy, or otherwise healthy joint may The patient should be aware that their rehabilitative respon-
be expected to progress much more aggressively through the sibilities such as an understanding of weight-bearing precau-
protocol phases with the anticipation of regaining full func- tions, wound care, and use of assistive devices begin even
tion and return to sports. Because the patient is moving before leaving the outpatient area. Many of the initial exer-
through the protocol at a faster pace, the use of a well- cises can be performed independently, but the patient should
equipped facility is preferred so that the patient has access to understand the importance of beginning isometric contrac-
rehabilitative tools/equipment that will complement the high tions (Video 33.3: http://goo.gl/dY4V5) at the hip and ankle
level demands of the rehabilitative program. In addition, this plantarflexion and dorsiflexion pumps (Video 33.4: http://
higher level patient may require more clinical attention in goo.gl/OJX4M) to facilitate lower extremity circulation.
order to gauge their response to exercise and assure a safe Reasonable goals are discussed with the patient depending
progression. The four phases of rehabilitation include the fol- on the extent of the injury, prior level of function, extent of
lowing: phase 1, mobility and early exercise; phase 2, inter- the surgery, and extent of the damage in the hip.
mediate exercise and stabilization; phase 3, advanced exercise
and neuromuscular control; and phase 4, return to activity.
While pathology-specific protocols have been developed Initial Visit
for routine arthroscopic procedures, there are general guide-
lines that can be applied across four phases of rehabilitation. The first postoperative visit evaluation (usually day 1 or 2
A sample rehabilitation protocol for routine arthroscopic after surgery) starts when the patient walks through the door.
procedures that require little to no biological healing (loose Initiation of treatment begins with normalization of the
body removal, labral debridement, synovectomy, ligamen- patient’s gait, which involves education about the importance
tum teres debridement, etc.) has been included as supple- and actual demonstration of proper ambulation (Fig. 33.10).
mental material with the included DVD. Sample protocols The patient will then start with week 1 exercises that are listed
for those arthroscopic procedures that require more exten- with the supplemental material. These exercises are meant to
sive biological healing (iliopsoas release, labral repair, improve the initial activation of the muscles surrounding the
femoroplasty, acetabuloplasty, microfracture) have been hip/knee as well as decreasing pain, stiffness, and inflammation.
included in the supplemental material as well. The patient should be aware not to “push through” pain as
Postoperative recovery actually begins with the preopera- they perform the exercises and as they progress through the
tive educational process. This may be a structured prehabili- rehab program. During this visit, the patient should be
tation program that addresses impairments such as pain, educated on their postsurgical restrictions, driving restric-
swelling, postural deviations, compensated mobility, muscle tions, sleeping recommendations, and the importance of
length and muscle strength, decreased proprioception, and compliance with their supervised rehab program. For simpler
muscular and cardiovascular endurance. Hip pain may alter arthroscopic procedures that do not require much biological
lumbopelvic-hip movement, creating patterns which lead to healing, patients may experience prompt decreased pain and
impairments of muscular imbalances and faulty mechanics symptoms when existing at a low activity level. This has been
33 Rehabilitation of the Hip 423

Box 33.3 How to Treat a Flare-up

– Ice/use of vasopneumatic compressive device
– Anti-inflammatory
– Assess activity outside of therapy
– Hold on activity or PT for 2–3 days as needed
– Maintain ROM
– Continue isometrics
– Pool therapy
– Contact our clinic if you have any questions

and inflammation, restore pain-free ROM, prevent muscle

inhibition, and normalize gait. The primary constraint during
this phase is soft tissue healing and avoiding the negative
effects of immobilization [22].
The patient’s weight-bearing status can vary depending
on the surgeon’s findings and procedure performed. If the
pathology addressed with the surgical procedure does not
require extensive biological healing, then foot-flat weight
bearing is allowed as tolerated, and crutches are discontin-
ued within the first week (chondroplasty, debridement, loose
body removal, or synovectomy). In those cases where bio-
logical healing is required (i.e., microfracture, femoroplasty,
acetabuloplasty, and labral repair), the patient may remain on
a limited weight-bearing status for up to 8 weeks (see
Table 33.1 for details). Although the discomfort associated
with arthroscopy might be surprisingly little, due to the com-
bination of capsular penetration with the arthroscopic portals
and the traction applied to the capsule during the procedure,
there can still be a significant amount of reflex inhibition.
Fig. 33.10 Crutch/gait training is imperative in normalizing the This reflex inhibition can lead to limited or poor muscle
patient’s gait and provides better stability as they are ambulating. firing, thereby altering normal patterns of movement [11].
(All rights are retained by Dr. Byrd)
Cold compression devices are often used in the initial stages
of rehabilitation to minimize inflammation and reflex inhibi-
termed the “honeymoon period” where most patients feel bet- tion. The gluteus medius muscle is an example of a muscle
ter regardless of their eventual outcome. Early enthusiasm at that commonly exhibits reflex muscle inhibition following
about 1 month following surgery makes it easy for patients to hip injury or surgery. In a typical arthroscopic procedure, the
overdo their activity and results in a flare-up and setback in anterolateral and posterolateral portals pass through this
their recovery. Following more extensive procedures such as muscle. Clinically, it is common to see that the patient will
correction of FAI, stricter precautions are necessary during have a difficult time regaining muscle tone and appropriate
the early recovery, and flare-ups are more frequent at around firing of this muscle postsurgery. This is analogous to the
6–8 weeks as function starts to intensify. A thoughtful reha- effects of an arthroscopic knee surgery on the vastus media-
bilitation strategy can minimize these setbacks, but they are lis muscle. Functionally, the gluteus medius muscle is needed
still frequent enough that, by having warned patients of this to maintain a level pelvis during ambulation. With gluteus
occurrence, they will have more confidence that it can be cor- medius weakness, a Trendelenburg gait will occur as the
rected and is not a sign of an unsuccessful eventual outcome. contralateral pelvis drops when the limb becomes unsup-
See Box 33.3 for how to treat a flare-up if it may occur. ported in the swing phase of gait. Additionally, due to the
short moment arm of the gluteus medius, this muscle causes
a large joint compression force when it contracts during the
Phase 1: Mobility and Initial Exercise single limb stance phase of gait [23–25]. In a patient with hip
articular pathology, it is common to find inhibition of the
During the initial phase of rehabilitation, the goals of the gluteus medius muscle due to pain [11]. Consequently, assis-
program are to protect the repaired tissue, diminish the pain tive devices are helpful to minimize the Trendelenburg pelvis
424 E.M. Coplen and M.L. Voight

drop and reestablish a normal gait pattern with synchronous

muscle activity. The most effective method of neutralizing
compressive forces across the hip is to allow the patient to
apply the equivalent weight of the leg on the ground [26, 27].
This is especially important with microfracture, protecting
the gradually maturing fibrocartilaginous healing response
of the articular surface. Maintaining a true non-weight-bear-
ing status requires significant muscle force to suspend the
extremity off the ground, thus generating considerable
dynamic compression across the joint as a result of muscle
contraction [26, 27]. Resting the weight of the lower extrem-
ity on the ground neutralizes this dynamic compressive effect
of the muscles [26, 27]. The decision on when to discontinue
assistive devices is based upon the patient’s tolerance to
weight bearing and the demonstration of proper firing of the Fig. 33.11 Longitudinal hip distraction. Distraction techniques (longitu-
dinal movement) are most useful when hip movements are painful and also
gluteal muscles without a Trendelenburg gait pattern. following compressive exercises. (All rights are retained by Dr. Byrd)
Early range of motion (ROM) (Video 33.5: http://goo.gl/
yEuQm) is initiated to restore joint motion and decrease the
likelihood of adhesions forming about the joint [22]. Joint
range of motion is normalized by restoring capsular extensi-
bility. Emphasis with passive range of motion is placed upon
internal rotation and flexion to help prevent scarring between
the hip joint capsule and the acetabular labrum. Limitation of
hip flexion and internal rotation also commonly occurs
because of the FAI [12]. Hip extension past neutral is ini-
tially restricted due to increased anterior hip forces and
excessive stress on the anterior labrum and capsule. Active
assisted range of motion exercises are initiated and pro-
gressed to active range of motion, gravity-assisted and then
to gravity-resisted exercises during the postoperative recov-
ery. Exercises are directed in all planes of hip motion, and
the end ranges for motion are determined by the patient’s Fig. 33.12 Inferior/caudal glide mobilization. This technique can be
level of discomfort. Stretching is typically pushed only to performed in varying degrees of flexion. During this mobilization, some
tolerance, and the patient is educated as to these parameters. longitudinal distraction is performed to decrease compression as the
hip is brought into more flexion and the inferior glide is performed.
Manual mobilization techniques can assist in the reduction (All rights are retained by Dr. Byrd)
of compressive forces across the articular surfaces. This may
lessen discomfort and over time enhance cartilage healing
[28]. Regaining full functional pain-free ROM is critical in (Fig. 33.11). Oscillatory longitudinal movements are pro-
preventing concurrent compensatory patterns with the lower duced by pulling gently on the lower extremity down the
back, SI joint, etc. Small accessory oscillation movements long axis of the femur which can be performed in varying
stimulate joint mechanoreceptors assisting in pain modula- degrees of flexion. In addition, capsular stretching can be
tion while at the same time help to maintain capsular mobil- made more specific with three-dimensional mobilization by
ity. Graded mobilization with flexion and adduction rotating the femur into the restrictive barrier and performing
movement or internal rotation is gently implemented with an inferior or caudal glide (Fig. 33.12). During the inferior
the moderately painful joint [12]. Stationary bicycling with glide mobilization (Video 33.7: http://goo.gl/3vgY7), it is
minimal to no resistance is an excellent adjunct to the range key that some longitudinal distraction is provided to prevent
of motion program and should be done daily. increased force on the labrum rather than actually mobilizing
the joint within the capsule. This mobilization can be done in
all quadrants of hip flexion and is imperative to regaining full
Hip Mobilizations functional pain-free mobility. Changing the hand position to
be more medial or lateral is all that has to be done to achieve
Distraction techniques (longitudinal movement) (Video 33.6: this goal. To improve internal and external rotation move-
http://goo.gl/uu0Bf) are most useful when hip movements ment, rotational mobilizations can be performed with sup-
are painful and also following compressive exercises port under the knees of the patient. A bolster may be used to
33 Rehabilitation of the Hip 425

b
c Fig. 33.14 Side-lying hip extension posterior-anterior (PA) mobiliza-
tion. (a) Viewing from the front, during this mobilization, the patient is
instructed to relax the hip but slightly activate the transverse abdominis
to keep the back in neutral while the leg is brought into extension.
(b) Viewing from the back, the therapist’s hand should be placed on the
posterior aspect of the hip. When the patient starts to feel a stretch in the
front of the hip, some motion is backed off and the therapist will pro-
vide a posterior to anterior mobilization. This should all be pain-free.
(All rights are retained by Dr. Byrd)

well tolerated by postoperative patients and may be started

during week 4 and on. If patients continue to have ROM
limitations long term, then it is important that mobilizations
be taught to someone who is available to perform them on
Fig. 33.13 (a) Internal rotation mobilizations. (a) bolster is used to the patient on a more consistent basis. Another option for
prop the hip up into approximately 30° to allow the capsule to be on
slack. This will help relax the patient as the mobilization is performed.
those who have limitations in IR/ER is to have the patient in
(b) External rotation mobilizations. (c) Prone internal/external stretch. prone and perform IR/ER stretching at 90° of knee flexion.
The patient’s pelvis should be stabilized while the hip is stretched into The patient is to initiate the motion after an outside force
internal or external rotation. A contract-relax method can also be uti- (therapist) stabilizes the pelvis with one hand, then the other
lized in this position. (All rights are retained by Dr. Byrd)
hand either pushes or pulls the hip into more internal or
external rotation as tolerated by the patient (perform 3–5
reps of 10 s). The prone position can be useful to perform a
put the hip into about 30° of hip flexion which allows the contract-relax method for increased IR/ER (Fig. 33.13c).
capsule to be on slack (Fig. 33.13a, b). Rotational mobiliza- Limitations in anterior hip mobility can be seen in the termi-
tions (Video 33.8: http://goo.gl/KZNNK) into each end range nal stance phase of gait and can be addressed with the side-
direction can be started during week 3–4 of the initial phase lying hip extension posterior-anterior mobilization
of rehab unless the patient has ROM restrictions. Working (Fig. 33.14a). The patient begins side-lying on the nonopera-
into small amplitude end range rotational mobilizations are tive side, and the leg is passively brought into extension,
426 E.M. Coplen and M.L. Voight

Table 33.2 Single leg squat criterion Criterion To be rated “good”

Overall impression across five trials
Ability to maintain balance Patient does not lose balance
Perturbations of the person Movement is performed smoothly
Depth of the squat The squat is performed to at least 60° knee flexion
Speed of the squat Squat is performed at a rate of 1 per s
Trunk posture
Trunk/thoracic lateral deviation No trunk/thoracic lateral deviation
Trunk/thoracic rotation No trunk/thoracic rotation
Trunk/thoracic lateral flexion No trunk/thoracic lateral flexion
Trunk/thoracic forward flexion No trunk/thoracic forward flexion
The pelvis “in space”
Pelvic lateral deviation No pelvic lateral deviation
Pelvic rotation No pelvic rotation
Pelvic tilt No pelvic tilt
Hip joint
Hip adduction No hip adduction
Hip “femoral” internal rotation No hip “femoral” internal rotation
Knee joint
Apparent knee valgus No apparent knee valgus
Knee position relative to foot position Center of knee remains over the center of the foot

keeping the lumbar spine in neutral. The hip is brought back recruited while at the same time maintain all surgical precau-
far enough to feel a stretch in the anterior hip, but no pain tions with regard to forces on the healing tissues. Isometric
should be felt. Some extension motion is then released, and a exercises are the simplest and least likely to aggravate under-
posterior-anterior mobilization is performed with the heel of lying joint symptoms [29]. These include isometric sets for
the hand placed in the posterior hip area (Fig. 33.14b). Small the gluteals, quadriceps, hamstrings, adductor and abductor
oscillatory motions (10–15) are made by the therapist utiliz- muscle groups, and lower abdominals [29]. Additionally,
ing their own core, and then the leg is brought back to neu- isometric contraction of the antagonistic muscle group may
tral. This can be repeated as tolerated. Oscillatory movements inhibit spasms and promote pain relief.
in a compression mode, stopping short of the pain position, Specific emphasis in the strengthening program is placed
can be helpful especially for patients with pain in weight upon isolating and strengthening the gluteal muscles (Video
bearing. The posterior-anterior mobilization can also be used 33.10: http://goo.gl/nwldn). The gluteus medius muscle is
as an accessory movement at the limit of physiological range one of the key stabilizers of the hip during gait [25]. Initial
when a goal of treatment is to increase the range of motion of assessment of isolated gluteal muscle weakness can best be
the joint. The presence of a capsular pattern of the hip as accomplished with standardized manual muscle testing pro-
described by Cyriax is often found secondary to the postop- cedures in the side-lying and prone positions. The dynamic
erative effusion [28]. Characteristic of that pattern is a gross quality of single leg support as a part of the kinetic chain can
limitation of flexion, abduction, and internal rotation with be assessed functionally with a single leg squat. The single
minimal loss of extension and external rotation [17, 28]. limb squat test requires frontal plane stability of the pelvis
Regardless of the pattern of restriction, every attempt must and control of the lower limb in both the frontal and trans-
be made to restore full capsular mobility and all physiologi- verse plane, both of which require high gluteus medius mus-
cal range of motions. In cases with painful restricted motion, cle activation (Table 33.2 with scoring criterion). The single
the clinician must carefully assess the end feel to motion and leg squat test also significantly activates the gluteus maximus
physical status of the joint in order to determine whether muscle. The relationship between hip muscle strength and
mobilization techniques are a viable treatment option. control of the hip and knee motions during a single leg task
A key postoperative goal is the restoration of dynamic hip has been established [30]. The motion of the single limb
stability. The prevention of muscle inhibition can be achieved squat requires stability of the lumbopelvic region while at
through early muscle-toning exercises (Video 33.9: http:// the same time providing eccentric control of hip flexion and
goo.gl/jRBPZ) which are performed within the first week concentric hip extension.
after surgery. Progression is dependent on the patient’s toler- Weak or fatigued gluteal muscles can result in excessive
ance but should not be overly aggressive. Exercise selection pelvic rotation and femoral internal rotation. Gluteal
should be based upon evidence related to the specific muscles isometrics in a neutral pelvic position may decrease
33 Rehabilitation of the Hip 427

Fig. 33.15 Gluteal isometrics done in a neutral pelvis position may

decrease overactivity of the iliopsoas and provide a decrease in anterior Fig. 33.16 Side-lying hip abduction may be done to aid in strengthen-
hip pain. (All rights are retained by Dr. Byrd) ing the gluteus medius, but if the patient has concurrent hip flexor
irritation, this may need to be done in slight internal rotation. (All rights
are retained by Dr. Byrd)
overactivity of the iliopsoas and provide a decrease in ante-
rior hip pain [31–33] (Fig. 33.15). Proper strength and con-
ditioning of these muscles is important due to the influence maximus. Table 33.3 provides a list of gluteal exercises
on the hip, pelvis, and back [34]. A commonly seen substi- listed in hierarchy of activation based upon EMG data that
tution pattern for gluteus medius weakness is overactiva- was normalized to a maximum volitional isometric contrac-
tion of the tensor fascia lata and the iliopsoas with abduction tion (MVIC). Previous research has indicated that muscle
strength testing. Typically, the patient will flex and exter- activation greater than 50–60% MVIC is considered ade-
nally rotate their hip in order to achieve abduction. In order quate for muscle strengthening [36].
to alleviate this problem, the patient is asked to keep their An aquatic program is often beneficial for allowing early
hip in neutral or in slight extension while lifting their hip return to exercise and can begin as soon as the portal sites
into abduction. have healed and the sutures have been removed [11]. A
It has been established that iliopsoas pain and tenderness pool program will allow for muscle relaxation which allows
can be common during postoperative rehabilitation [12, for earlier joint mobilization and gentle strengthening in a
35]. The same exercises that are used to strengthen the glu- reduced-weight environment. The water buoyancy can pro-
teal muscles may also aggravate an inflamed iliopsoas mus- vide assistance to movement in all planes and safer resis-
cle. Therefore, exercise selection for strengthening the tance with active exercises. Gait activities can be progressed
gluteal muscles must also reduce the activation of the iliop- in waist deep water with minimized compression of the sur-
soas muscle 34. Supine hip flexion, side-lying hip abduc- gical site. Once the goals of phase 1 have been met and
tion with external hip rotation, and the hip clamshell there is minimal to no pain with the phase 1 exercise pro-
progression have been identified to also activate the iliop- gram, patients are progressed to the intermediate phase of
soas muscle considerably and should be avoided with con- the rehabilitation program. The patients should have
current hip flexor irritation [35] (Figs. 33.16 and 33.17a–f). achieved close to full range of motion and accomplished a
The clamshell progression (Video 33.11: http://goo.gl/ normalized gait pattern without crutches in order to
UJIl0) is used to emphasize both internal and external rota- progress.
tions while strengthening the gluteus medius in the neutral
position significantly activate the iliopsoas and is safe to
use [35]. Other strengthening exercises with low concur-
rent iliopsoas activation include double to single leg bridg- Box 33.4 Common Complaints Postsurgery
ing (Video 33.12: http://goo.gl/yIj8q), stool hip rotations,
resisted hip extension, side-lying hip abduction with the – Nonpainful popping
heel against the wall, prone heel squeezes, and side-lying – Feeling of stiffness
hip abduction (Video 33.13: http://goo.gl/33OAW) with – Mild swelling (should return to normal within
internal hip rotation [35] (Fig. 33.18a–i). In addition, 2 weeks)
patients can also start performing a limited arc leg – Sharp pains with quick or rotating movement of the
press (Video 33.14: http://goo.gl/ew19Q) and mini-squats hip up to 12 weeks post-op
(Video 33.15: http://goo.gl/HVnCf) to also work on gluteus
428 E.M. Coplen and M.L. Voight

a b

c d

e f

Fig. 33.17 Clamshell progression. (a) Classic clamshell. (b, c) Level 2 clamshell with hip in an isometric abduction position. (d) Reverse clam-
shell. (e) Level 2 reverse clamshell. (f) Resisted clamshell. (All rights are retained by Dr. Byrd)

Phase 2: Intermediate Exercise muscular compromise can manifest by three different

and Stabilization mechanisms: (1) Arthrokinetic Inhibition: The neuromus-
cular phenomenon that occurs when a muscle is inhibited
The intermediate phase of rehabilitation typically begins by joint dysfunction or the capsule that crosses the joint.
around week 4 and is a progression of the range of motion/ Overuse leads to shortening/tightening (not spasm) of pos-
stretching (Video 33.16: http://goo.gl/LF0Vi and Video tural muscles; disuse leads to a weakening/inhibition of
33.17: http://goo.gl/AJx93) and strengthening exercises phasic muscles. (2) Synergistic Dominance: The neuromus-
(Video 33.18: http://goo.gl/zzSTs) started in phase 1. The cular phenomenon that occurs when synergists, stabilizers,
range of motion exercises should be continued until full and neutralizers take over for a weak or inhibited prime
pain-free range of motion is present. Strengthening and sta- mover. (3) Reciprocal Inhibition: The neuromuscular phe-
bilization exercises should advance throughout this phase to nomenon that occurs when a tight muscle decreases the
challenge the patient and correct any muscle weakness or neural drive to its functional antagonist. This leads to com-
imbalance that was present. Weight-bearing (progressive pensation patterns and predictable injury patterns. The most
resistive exercises) resistance exercise (Video 33.19: http:// common muscle imbalance seen is tightness of the hip
goo.gl/hz5Jh) and resistance to the bicycling program can flexors and erector spinae muscles with weakness of the
be added during this phase. Emphasis must be placed upon gluteals and abdominal musculature resulting in an anterior
the elimination of muscle imbalances and motor substitu- pelvic tilt with an increased lumbar lordotic curve. Therefore,
tion patterns that occur with tasks of ADL. The most com- core stabilization exercises (Video 33.20: http://goo.gl/
mon cause for muscle imbalance is chronic overuse or FSwdO) are progressed in conjunction with the hip progres-
injury which leads to neuromuscular compromise and an sive resistive exercise program (Video 33.21: http://goo.gl/
eventual change in the elasticity of the muscle. The neuro- SrYh0).
33 Rehabilitation of the Hip 429

Core stability is an exceedingly important, yet often over- stabilization program with injury in the upper quarter. Often
looked, aspect of hip rehabilitation after both injury and sur- patients develop the strength, power, and endurance of
gery, and may be especially critical in optimizing performance specific extremity musculature to perform required activities
and minimizing the risk of reinjury. Core stabilization/ but are deficient in muscular strength of the lumbopelvic-hip
strengthening emphasizes training of the trunk musculature complex. The core stabilization system must be checked as
to develop better pelvic stability and abdominal control. part of the assessment and specifically challenged as part
A simple analogy could be made comparing the core of the rehabilitation program [4]. The basic screen
stabilization component after surgery to that of a scapular involves several basic screening tests. The Pelvic Tilt Test

a b

c d

Fig. 33.18 (a) Double leg bridge. (b) Single leg bridge. (c, d) Stool (h) Hip abduction with hip in internally rotated position. (i) Mini-squat.
hip internal/external rotation. (e) Resisted hip extension. (f) Side-lying (All rights are retained by Dr. Byrd)
hip abduction with heel against the wall. (g) Prone heel squeezes.
430 E.M. Coplen and M.L. Voight

e f

Fig. 33.18 (continued)

33 Rehabilitation of the Hip 431

Table 33.3 Results: gluteus medius – especially the gluteal muscles. This test will highlight any
Exercise %MVIC gluteus medius inhibition or weakness in the gluteus maximus due to over-
Side plank abduction, DL down 103.11 recruitment of the synergistic muscles, like the hamstrings
Side plank abduction, DL up 88.82 and lower back. If the pelvis on the unsupported side drops or
Single limb squat 82.26 the support leg shakes, this indicates instability in the gluteal
Clamshell (hip clam) 4 76.88 muscles on the support side. If the support leg hamstrings or
Front plank 75.13 lower back start to cramp, this also indicates inhibition of the
Clamshell (hip clam) 3 67.63 gluteals and recruitment of synergistic muscles – LOOK
Side-lying abduction 62.91 FOR CRAMPING. The most common reason for a failed test
Clamshell (hip clam) 2 62.45 is a deactivation of the gluteals. The patient is used to recruit-
Lateral step-up 59.87
ing the hamstrings and lower back for hip extension, so when
Skater squat 59.84
asked to go into a bridge position those muscles go into
Pelvic drop 58.43
hyperactivity. Next, when the leg is extended, this position
Hip circumduction, stable 57.39
Dynamic leg swing 57.30
should normally be easy for the gluteals to support, but if the
Single limb dead lift 56.08 gluteals are inhibited, cramping of the synergistic muscles
Single limb bridge, stable 54.99 will usually occur. Weakness in the abdominals, legs, and
Forward step-up 54.62 gluteals can also show a positive test. The patient will not
Single limb bridge, unstable 47.29 show signs of cramping, but instead they will say the test is
Clamshell (hip clam) 1 47.23 not easy or that one leg is easier than the other. An integrated
Quadruped hip ext, DOM 46.67 functional unit of an effective core stabilization system plus
Gluteal squeeze 43.72 a strong lumbopelvic-hip musculature complex is important
Hip circumduction, unstable 37.88 for efficient weight distribution, absorption, and transfer of
Quadruped hip ext, non-DOM 22.03 compressive forces [36].

(Video 33.22: http://goo.gl/JKuUU) is a great test for overall

mobility of the hips and the lumbar spine and the patient’s Phase 3: Advanced Exercise
ability to control the position of their pelvic posture. This test and Neuromotor Control
examines the ability to mobilize and control the movement of
the pelvis linking the lower body with the upper body. The Proprioceptive deficits routinely occur in conjunction with
test begins with having the patient tilt their pelvis forward articular injuries [18]. The acetabular labrum contains free
and backwards. Begin by having the patient create an arch in nerve endings and sensory organs [11, 25]. It is believed that
their back (rolling pelvis forward) and then flattening their these free nerve endings contribute in nociceptive and prop-
lower back (rolling their pelvis backward). Observe for both rioceptive mechanisms [18]. The acetabular labrum also
the motion available and the smoothness or nature of the improves the stability of the hip joint by maintaining a nega-
movement. The quality of the movement indicates the fre- tive intra-articular pressure [37]. With injury to the labrum,
quency of use on a day-to-day basis. The Pelvic Rotation Test this negative pressure is lost and stability of the hip is
(Video 33.23: http://goo.gl/x7TDY) checks the patient’s abil- adversely affected. This inhibits normal motor response and
ity to rotate their lower body independently from their upper decreases neuromuscular stabilization of the joint. The aim
body. This movement requires good mobility of the spine, of proprioceptive retraining is to restore these deficits and
hips and pelvis, and simultaneous stability of the trunk. Look assist in reestablishing neuromotor control. The elements
for smooth turns to the right and left with no choppiness or necessary for reestablishing neuromuscular control are prop-
lateral movement (no lateral movement of the pelvis). This rioception, dynamic joint stability, reactive neuromuscular
test requires the use of hip rotators and oblique abdominals to control, and functional motor pathways [18]. Joint position-
rotate the pelvis. The Torso Rotation Test (Video 33.24: http:// ing tasks performed early in the rehabilitative process can
goo.gl/z8gvu) checks the patient’s ability to rotate their upper enhance proprioceptive and kinesthetic awareness. More
body independently from their lower body. This movement advanced proprioceptive neuromuscular techniques incorpo-
requires good mobility of the trunk and simultaneous stabil- rated in functional patterns of movement or modified ranges
ity of the hips and pelvis. Look for any movement of the hips may be acceptable transition exercises, depending on the
or extension/side bending of the thoracic spine vs. rotation. symptoms and status of the hip (Fig. 33.19a–c).
(There should be no motion below the waistline.) The Bridge Dynamic stabilization exercises encourage muscular co-
with Leg Extension Test (Video 33.25: http://goo.gl/tIwqq) is contractions to balance joint forces. Closed chain methods
a great test for stability in the pelvis, lumbar spine, and core allow progressive weight-bearing transference to the lower
432 E.M. Coplen and M.L. Voight

a b

Fig. 33.19 Advanced proprioceptive neuromuscular hip exercises. (a) Single leg balance on balance pad. (b) Single leg balance on BOSU ball.
(c) Mini-squats on BOSU ball. (All rights are retained by Dr. Byrd)
33 Rehabilitation of the Hip 433

extremity in a manner that lessens the shear and translational

forces across the joint surface [18]. This begins with simple Box 33.5 Timeline of Cardio
static balance maneuvers, starting with full stance, and – Bike (day 3–1 week post-op depending on
evolving to single limb stance, with and without visual input. procedure)
Progression is then made to a combination of balance and – Elliptical (4–5 weeks post-op or 8–9 weeks for
strength activities. Bilateral heel raises (Video 33.26: http:// microfracture)
goo.gl/svEd1) and mini-squats (Video 33.27: http://goo.gl/ – Walking program (week 8)
KEFsI) are progressed to unilateral heel raises and mini- – Jogging (start assessment at week 10–12 depending
squats (Video 33.28: http://goo.gl/9zpNw). More advanced on type of surgery and extent of bone work)
closed kinetic exercises such as partial squats, lunges (Video – Sprinting (week 14+)
33.29: http://goo.gl/WHcdw), and dynamic weight shifts are
encouraged initially in the pool. Low force, slow speed, and
controlled activities may be transitioned to high progressive
force, fast speed, and uncontrolled activities if the joint
Box 33.6 Checklist for Return to Play a Specific Sport
allows without becoming overstressed. For example, balance
devices (Video 33.30: http://goo.gl/Y4DPu), mini-trampo- – Can perform all required activities to participate in
lines, and unlimited creative upper extremity activities while a game without compensation or pain
balancing can further challenge the neuromuscular system – Full functional ROM/strength
(Fig. 33.20a–m). Emphasis in the balance and functional – May need to communicate with athlete’s trainer/
training program (Video 33.31: http://goo.gl/X77M2) should coach to discuss return to play
be focused upon core stabilization and proper recruitment of – Educate athlete on the importance of maintaining
the gluteus medius muscle group. full strength/ROM, flexibility, and activities to avoid
Static stabilization, transitional stabilization, and dynamic long term
stabilization are phases of progression from closed chain
loading and unloading, to conscious controlled motion with
high joint tolerance, and ultimately to unconscious control
and loading of the joint. Thus, depending on the patient’s These may include a functional squat test, a functional single
tolerance, the exercise program may progress from slow to leg step-down test, running/sprinting assessments, cutting/
fast, simple to complex, stable to unstable, low force to high lateral movements, and sport-specific tests. These must be
force, and general to specific [18]. kept within the constraints dictated by the type of hip pathol-
ogy that has been addressed. Improving quality of life is cer-
tainly a goal of arthroscopic procedures but must be kept
Phase 4: Return to Activity within the framework of a realistic outlook.
For some cases, depending on the extent of pathology and
The ultimate time frame for return to function depends upon the extent of surgical debridement, the explosive character of
the type of hip pathology present and the specific demands of compressive forces generated by certain specific physical
the patient’s anticipated activities. and sports activities may need to be curtailed or modified
Functional exercises simulating the patient’s daily activi- with substitutions that the joint can tolerate during healing.
ties or sport-specific programs must be individualized to In fact, some patients or athletes may need to change the
meet the patient’s goals. Each patient or athlete’s reassess- sport position or the sport altogether. Lastly, the clinician
ment and phase 4 rehab program will need to be tailored to must ensure that the patient’s expectations and the goals of
their specific demands of their sport or activity. It is beyond rehabilitation coincide by emphasizing education for current
the scope of this chapter to include individualized programs and future hip management. The patient’s compliance with a
for each sport for phase 4 rehab and specific functional tests. continued management program should include maintaining
Functional tests are used at this time to assess the readiness muscle balance (strength, flexibility, and proprioception) and
of the patient to return to unrestricted activity (Fig. 33.21). improving overall function.
434 E.M. Coplen and M.L. Voight

a b

Fig. 33.20 Dynamic stabilization exercises. (a) Single leg ball toss on plyobox. (i) Lateral quick steps on plyobox. (j) Double leg hops on
BOSU ball. (b) Single leg balance with PNF pattern. (c–e) Airplane plyobox. (k) Double leg hop hurdle drill. (l) Single leg hop hurdle drill.
balance activity. (f) Plyobox jumps. (g) Jumping mechanics are assessed (m) Double leg lateral hop hurdle drill. (All rights are retained by
and corrected during these exercises. (h) Forward quick steps on Dr. Byrd)
33 Rehabilitation of the Hip 435

c d

Fig. 33.20 (continued)

436 E.M. Coplen and M.L. Voight

f g

h i

Fig. 33.20 (continued)

33 Rehabilitation of the Hip 437

Fig. 33.20 (continued)

438 E.M. Coplen and M.L. Voight

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