The following is a post operative protocol for physical therapy following hip arthroscopy.

Phase I: Initial Hip Exercises

Ankle Pumps

• Start with first therapy visit
• 20 repetitions (can be done throughout the day)

Isometrics

• Start with first therapy visit
• 20 repetitions, 2 times/day

1. Gluteal sets

Tighten buttock muscles and hold for 5 seconds

2. Quad Sets

Tighten thigh muscles and hold 5 seconds

3. Transverse abdominal Isometrics

Draw belly button in towards spine without moving pelvis or spine hold while taking 5-10 breaths. This exercise is to be completed along with core stabilization exercises.

4. Hip adduction and abduction

No resistance should be added until week 5 or 6.

A. In Flexion

• Lying on your back and with hip flexion not exceeding 70°, move knee in a circular motion (pendulum rotation).
• 3 sets for 5 minutes

B. In Neutral

• Lying on your back with hip und knees straight, move the leg in a circular motion (bring hip into abduction and slight flexion). May be uncomfortable for first few days.
• 30 reps in each direction

C. Passive ROM

• Performed by therapist or caretaker, start with first therapy visit)
• 2 times/ day for 6 weeks

1. Circumduction

• ER is not to exceed 0° for 21 days.
• Internal rotation: no limits.
• Abduction limited to 40° for 4 weeks.

2. Flexion

• Lying on your back have partner bend knee toward chest (90° limit for 10 days). * Increase range as tolerated after 10 days
• 20 repetitions

3. Abduction

• Lying on back with leg straight, have partner bring leg away from your midline
• 20 repetitions

4. Prone Internal Rotation

• Lying on stomach with knee bent to 90°, have partner bring ankle away from your body.
• No external rotation in prone for 3 weeks
• 20 repetitions

5. FABER for ER

• Start Section 5 at week 2
• Lying on back bring involved leg into figure four position with ankle resting on top of opposite knee. Gently lower bent knee towards the table. You may need to start with ankle resting on shin or inside of leg. It is normal to feel lateral hip discomfort.
• Do not push on knee.

D. Stationary biking with no resistance

• 20 minutes, 2 times per day
• Start with first therapy visit
• Increase time by 5 minute intervals every 3 days.
• Do not exceed 30 minutes two times per day. May be performed at home also if stationary bike is available.
• Upright bikes are tolerated better initially.
• Resistance may be initiated at week 6

E. Passive Stretching

• Start at first therapy visit
• 5 repetitions, hold 20 seconds, 2 times/day

1. Piriformis Stretch

• Lying on uninvolved side, bottom leg straight/pelvis stacked) bend involved hip to 50°- 70° flexion, hook your top foot behind uninvolved knee. Stabilizing pelvis, lower the involved knee towards table.
• Stretch should be felt in buttock.
• Avoid pinch in groin.

2. Quadriceps Stretch

• Lying on stomach, have partner bring ankle toward buttock
• Feeling a stretch in front of thigh.

3. General Hip, Knee, Calf Stretching

• Start at 4th week
• Stretching in all directions (including extension) is acceptable from this point forward.

Phase II: Gluteal Progression

• Start at week 2-3
• 3 sets, 10 repetitions, once a day

A. Glute Medius Firing

Attempt to initiate glute medius with assisted side lifts in muscle test position. Work on eccentrics (negatives) until patient can perform lift without pelvic compensation.

B. Side leg raises (Glute Medius focus)

Start only when can properly perform without compensating.
Focus on form. Lying on uninvolved side, raise top leg up and slightly back without moving your trunk (side leg raise)

C. Stomach leg raises (Glute Maximus focus)

Lying on your stomach flex knee 90° degrees or further. Lift your knee off the table keeping the knee flexed. Raise your leg up 6-8 inches.

D. Rose Wall Slides

Lying on uninvolved side with shoulders, hips, and heels flush up against a wall. Slowly slide top involved heel along wall maintaining firm abdominal muscles.

E. Quadruped Racking

• 3 sets, 20 repetitions, once a day
• On your hands and knees, shift your body weight forward on your arms then back onto your legs. You may also shift side to side and in diagonal directions.

F. Standing Hip IR

• 3 sets, 20 repetitions, once a day
• Place knee of involved leg on a stool. Rotate hip without moving trunk so that the stool turns (moving foot outward from your body). Progress to using a resisted band when tolerated.

G. Active Prone IR/ER

• 20 repetitions, once a day
• Lying on your stomach with knee bent to 90°, allow foot to drop out so that the hip is in full IR. Actively rotate hip back to neutral only. Partner gradually adds resistance to this motion in both directions. May go beyond neutral after 4 weeks.

H. Bridging Series

• 3 sets, 20 repetitions, 1 2 times/day

1. Double leg bridge

• Lying on your back place rubber tubing around knees with hip and knees bent. Raise buttocks while keeping core stable slowly lower.
• Progress to single leg bridging

2. Bridge on Swiss Ball

• Lying on your back place feet up on swiss ball. Keep knees straight and core stable as you raise your buttocks, hold 5 seconds then lower.
• Progress to laying with shoulders on ball and feet on floor then lowering and raising your buttocks.
• Add arm rotations in this position or perform with single leg bridge

Water Progression

• If pool available and following weight bearing restrictions, wounds must be completely closed
• Start at week 4
• 20 – 30 minutes, 3 times/week

1. Water Walking

Walk forward, backward and lateral in chest deep water.

2. Water Jogging

In deep water jog in place.

3. Swimming

We prefer frog kick as in the breast stroke.

Gait Progression: “Crutch weaning”

• USE TWO CRUTCHES as you increase weight bearing.
• Start when patient becomes weight bearing as tolerated

1. Weight shifting exercises

• Focus on avoiding Trendelenburg
• Compensated Trendelenburg

2. Increase weight-bearing tolerance

3. wGradually add 25% weight on surgical leg every 1-3 days until 100%, continuing to use both crutches during this period, Return to crutches avoiding early fatigue. Avoid limping and focus on correct walking, weight shift, and mechanics. Make sure patient is getting full hip extension.

A. Balance Progression

• Initiate once patient is weight bearing as tolerated
• 3 sets, hold 30 seconds, once a day
  • Single Leg Stance
  • Dyna disc: Start with poles for support
  • Progress by touching the opposite foot to the ground @ 9, 10.5, 12, 1.5 and 3 o’clock positions.
  • Add Dynamic Balance activities as tolerated

Phase III: Intermediate Exercises

• “Closed Chain, Single Plane”
• Start at week 6
• For specific questions about running, dance, skating and golf, please
  review Phase III progressions for potential start times.

A. Double 1/3 knee bends

• 3 sets, 20 repetitions, once a day
• Start standing with feet shoulder width apart, bend at the knees to 60°. Do not allow knees to go past toes.
• Progress by using a sport cord for resistance.

B. Advanced Core Progression

• 3 sets, 20 repetitions, once a day

1. Planks

• Lie on either side with your knees bent resting on your
  elbow. Lift your hips up to a straight line, and then slowly lower. Progress by performing with legs straight.
• Progress to performing on back and stomach positions

2. Pilates

• Train with an instructor
• Footwork series, Skater series, Hip extensions

C. Side Stepping

• 3 sets, 20 repetitions, once a day
• Place rubber tubing around ankles. Bend at the knee and sidestep in each direction while maintaining the bent knee position and chest upright.

D. Elliptical Trainer

• 15 – 20 minutes, 3 times/week
• Begin with minimal resistance and increase intensity over time as tolerated.

E. Single 1/3 Knee Bends

• 3 sets, 20 repetitions, once a day
• Same starting position as double knee bends but with only surgical leg. Bend knee to 60° flexion while maintaining a level pelvis and not letting the knee “fall in” (corkscrew)
• Progress by adding cord for resistance (sport test exercise)
• Other single leg closed kinetic chain exercises:
  • Lateral Step Downs
  • Balance Squats: With one leg behind you on a chair, squat with your opposite leg to 70 degrees. Perform with opposite leg on chair.
  • Lunges
  • Reverse Lunges

Phase IV: Advanced exercises “multi directional & plyometric”

8 Start at week 8

A. Plyometrics

• Water to dry land progression
• 10 sets, 1 – 2 minutes, 3 – 5 times/ week
• Begin with water: in chest deep water, perform forward bounding. Focus on absorption when landing
• Progress to dry land plyos.

B. Side to side lateral agility with cord

• 3 sets, 50 reps, 3 times/ week
• Attach the sport cord from the side with the surgical leg facing the cord. Step sideways to create tension on the cord. From a single knee bend position on the surgical side, explode off laterally, touching momentarily with the opposite leg before the tension pulls you back. Emphasize the absorption back onto the surgical leg.

C. Forward/ Backward running with cord

• 3 sets, 1 2 minute intervals, 1 time/ day
• Shift from one leg to the other while running in place without exaggerating the absorption and push off motion. Face the cord for backwards running.

Running

• Expect to have mild limping/ discomfort/ awkwardness
• This should go away gradually. Common sense dictates that if limp worsens or there is pain, running should stop. Progress to the next phase each week.

Walk Run Ratio	Sets/Total Time	Frequency
R 1	4 minutes/ 1 minute 4 sets 20 min	4-5 times/week
R 2	3 minutes/ 2 minutes 4 sets 20 min	4-5 times/week
R 3	2 minutes/3 minutes 4 sets 20 min	4-5 times/week
R 4	1 minute/ 4 minutes 4 sets 20 min	4-5 times/week
R 5	10 minute Jog 2 sets 10 min	4-5 times/week

From 10 min. jogging, increase as tolerated.

Golf

Begin after 3 week of walking. Don’t carry bag and do not pull cart.

Regimen	Volume	Frequency
G1	Putt, chip, ½ swing only	1 bucket For 1-2 weeks
G2	8-9 Irons, ¾ swing only	1 bucket For 2 weeks
G3	All irons, use cart, full swing, 9 holes	For 2 weeks
G4	Full play, walking 18 holes	Time frame?

Phase V: High Level Activities

• Return to sport at 12 weeks

A. Initial agility drills

• Straight Plane Agility
• Chop Downs/Back Pedaling jog forward, stutter step to a stop, absorb and push off smoothly into a back pedal.
• Side Shuffles Start with feet shoulder width apart, maintain an athletic stance and shuffle to the right, then back to the left.

B. Multi Plane Agility

• Z Cuts
• W Cuts
• Cariocas

4. Ghiardelli’s

Start by crossing the right leg over iliac crest, swing the left leg out from behind the right absorbing and touching the ground with your left hand in one fluid motion. Repeat to the right side.

Functional Sport Test

Passing the Sport Test = you are cleared with discretion!!! Once the patient passes the Functional Sports Test, Dr. Carreira leaves the responsibility up to the patient and coach to continue to progress training for sport. This includes proper conditioning and sport specific agility.