PostOp Hip Arthroscopy Rehabilitation Allison Mumbleau PT DPT

Post-Op Hip Arthroscopy Rehabilitation Allison Mumbleau, PT, DPT, SCS Jenni Wakeman, PT, DPT, SCS DON’T JUST RECOVER. CONQUER.

Anatomy Hip is a diarthrodial, triaxial joint consisting of the acetabulum and femoral head Femur ◦ Femoral Head 2/3 sphere covered with hyaline cartilage Fovea serves as insertion for ligamentum teres DON’TJUSTRECOVER. CONQUER.

Anatomy Gluteal Complex ◦ Functions: Movement Stability http: //www. dieselsc. com/innovative-glute-activation-get-stronger-and-fix-your-posture/ DON’TJUSTRECOVER. CONQUER.

Anatomy: Ligamentous Structure � Extra-articular ◦ Iliofemoral: taut in extension and ER ◦ Ischiofemoral: taut in IR and hyperextension ◦ Pubofemoral: taut in abduction and ER DON’T JUST RECOVER. CONQUER.

Hip Anatomy � Ligamentous Structure ◦ Intra-articular �Ligamentous teres: secondary restraint against ER ◦ Transverse acetabular ligament DON’T JUST RECOVER. CONQUER.

Labral Anatomy � Structure ◦ Fibrocartilagenous ring that attaches to capsular side of acetabulum and becomes continuous with the articular sided cartilage ◦ Continuous with transverse acetabular ligament ◦ Thinner anteriorly & thicker in the posterior region DON’T JUST RECOVER. CONQUER.

Labral Anatomy DON’T JUST RECOVER. CONQUER.

Labral Anatomy � Vasculature ◦ Primarily avascular, but blood supply to peripheral 1/3 � Nerve Supply ◦ Free nerve endings in labrum �Pain �Pressure �Deep sensation ◦ Anterior and superior aspects of labrum are thought to be the most innervated portions DON’T JUST RECOVER. CONQUER.

Labral Function Suction seal ◦ Helps to maintain synovial fluid ◦ Slows consolidation of articular cartilage Shock absorption Joint lubricator Enhance stability by deepening the joint Increases surface area of acetabulum ◦ Distributes load ◦ Decreases contact stress on articular surfaces DON’TJUSTRECOVER. CONQUER.

Pathologic Labrum ↓ Resistance to flow path of synovial fluid ↓ Suction effect ↑ Pressure applied to articular cartilage ↑ Contact stress by 92% Consolidation of articular cartilage Femoral head micropistoning in acetabulum Destabilization of hip joint Femoral head shifts superiorly, laterally Abnormal arthrokinematics Early joint deterioration DON’TJUSTRECOVER. CONQUER.

Causes of Labral Tears � Traumatic � Atraumatic ◦ ◦ Capsular Laxity FAI Dysplasia Degenerative DON’T JUST RECOVER. CONQUER.

Traumatic Causes of Labral Tears � Rare � Collision or contact sports such as football, hockey, and soccer may result in hip subluxation or dislocation � Associated with chondral lesions of the femoral head or acetabular rim DON’T JUST RECOVER. CONQUER.

Atraumatic Causes of Labral Tears � Femoroacetabular Impingement (FAI): ◦ Bony abnormality causing contact between the femoral head-neck region & the acetabular rim (Groh 2009, Ganz et al. JBJS Br. 2005) ◦ Two types �CAM: pathological contact between abnormally shaped femoral head/neck with normal acetabulum �Pincer: pathologic contact between normal femoral head/neck and abnormal acetabulum DON’T JUST RECOVER. CONQUER.

Causes of Labral Tears � CAM: pathological contact between abnormally shaped femoral head/neck with normal acetabulum ◦ Induces shear and compressive forces between labrum and articular cartilage ◦ Associated pathology: �Chondral at acetabulum with progression to labral detachment DON’T JUST RECOVER. CONQUER.

Causes of Labral Tears � Pincer: pathologic contact between normal femoral head/neck and abnormal acetabulum ◦ Associated pathology: labral and/or cystic changes, and degeneration ◦ Minimal acetabular cartilage affected ◦ Femoral neck bruising/grooving ◦ Repeated microtrauma can cause labral ossification ◦ Contre-coup lesion DON’T JUST RECOVER. CONQUER.

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Atraumatic Causes of Labral Tears � Hip Instability (Capsular laxity) ◦ Global laxity (e. g. Ehlers-Danlos) ◦ Rotational-type athletes � Capsular redundancy on scope � Associated pathology ◦ Labral tears ◦ Elongation of iliofemoral ligament DON’T JUST RECOVER. CONQUER.

Causes of Labral Tears Psoas Impingement ◦ Portion of the tendinous area of the psoas becomes symptomatic ◦ Psoas compresses the labrum resulting in crushing and sometimes tearing of the labral tissue DON’TJUSTRECOVER. CONQUER.

History and Subjective Exam Groin pain starting slow and insidiously or after a minor traumatic incident ◦ Can also occur over the greater trochanter ◦ Deep in buttocks ◦ Low back ◦ Sacroiliac joint region Pain reported with prolonged sitting, walking, and athletic participation Clicking or snapping during ambulation Complaints of instability or giving way Increased stiffness, weakness, and decreased performance Duration of symptoms (onset of symptoms to surgery) on average 2 years DON’TJUSTRECOVER. CONQUER.

Clinical Presentation: Objective Range of Motion SUPINE ASSESSMENT -Likely cause pain in the individual with FAI as combined flexion and internal rotation results in abutment of the femoral neck with the anterior superior acetabular rim. PRONE ASSESSMENT - Avoid hip flexion and prevent impingement related symptoms - Contribution of capsuloligamentous structures to rotational ROM Special Tests ANTERIOR IMPINGEMENT SIGN (FADIR) +: reproduction of anterior hip pain + in 99% of pts w/ FAI POSTERIOR IMPINGEMENT SIGN +: reproduction of pain FABER +: reproduction of anterior and/or lateral hip pain with limited ROM + in 97% of pts w/ FAI HIP DIAL TEST +: >45 deg with absence of rebound LOG ROLL TEST +: reproduction of pain with IR DON’T JUST RECOVER. CONQUER.

Conservative Rehabilitation: Key Points Correcting the following can decrease pain and increase function ◦ Functional movement patterns ◦ Gait faults, neuromuscular control deficits ◦ Muscle imbalances particularly dynamic muscular stability ◦ Joint proprioception ◦ Soft tissue extensibility ◦ Joint mobility deficits ◦ Dysfunctions in low back and SIJ Be aware of Patient Education ◦ Motion-induced trauma to the hip joint ◦ Activities to avoid ◦ Positions to avoid DON’TJUSTRECOVER. CONQUER.

Arthroscopic Surgery � http: //bryankellymd. com/fai-movie. html DON’T JUST RECOVER. CONQUER.

Surgery � Addressing Labral Pathology ◦ Reconstruction �IT band or rectus femoris tendon sheath autograft (Dr. Philippon & Dr. Kelly) �Anterior tibialis or posterior tibialis allograft (Dr. Folk) DON’T JUST RECOVER. CONQUER.

Surgery � Addressing Capsular Laxity ◦ Capsular shift or plication ◦ Capsulorrhaphy DON’T JUST RECOVER. CONQUER.

Surgery � Addressing chondral damage ◦ Chondroplasty �Removing loose fragments of cartilage �The cartilage is taken out of the joint by a motorized shaver or a grasper DON’T JUST RECOVER. CONQUER.

Surgery � Addressing chondral damage ◦ Microfracture Indications Contraindications - Focal or contained lesions - Typically <2 -4 cm in size - Full thickness defects (Grade IV) - Unstable lesion with intact sub-chondral bone - Partial thickness defects - Non-compliant patient - Bony defects associated with chondral lesion Considerations - Age of patient - Activity level - Acetabular chondral defects respond well - Femoral chondral defects respond okay DON’T JUST RECOVER. CONQUER.

Surgery � Synovectomy ◦ Rid the capsule of inflamed tissue by using a radio frequency probe DON’T JUST RECOVER. CONQUER.

Surgery � Gluteus Medius Repair ◦ Indications: �Late middle-aged women (25%), men (10%) �Unremitting pain over greater trochanter, worst with: �Weight bearing �Resisted abduction �Pressure on lateral hip (lying on side) �Degenerative tears > acute tears �Undersurface, partial-thickness tears most common DON’T JUST RECOVER. CONQUER.

Surgery � Gluteus Medius Repair ◦ Debridement and repair DON’T JUST RECOVER. CONQUER.

Dr. Folk’s Preferences � Determine weight-bearing status at 1 st follow -up (~10 days post-op) � Information to include for 1 st post-op visit ◦ ◦ Managing ADL’s Pain level ROM Gluteal activation � Communication with Allison & Jenni if ◦ Uncontrolled pain ◦ Not meeting phase appropriate goals DON’T JUST RECOVER. CONQUER.

Post-Operative Restrictions � Weight bearing • Flat foot weight-bearing (PWB 20%) • Must NOT be NWB • Neutralizes muscular forces • Avoid hip flexion contracture, hypertonicity, tendonitis � Debridement ◦ 1 -2 weeks FFWB � Labral Repair and/or Rim Trim and/or Osteoplasty ◦ 3 -4 weeks FFWB � Microfracture ◦ 6 weeks FFWB DON’T JUST RECOVER. CONQUER.

Post-Operative Restrictions � Range of motion ◦ All procedures �Flexion < 90° & ER < 30° for two weeks ◦ Capsular Repair �ER and extension limited to neutral for 3 weeks DON’T JUST RECOVER. CONQUER.

POD #1: Interventions � Dressing change � Gait and transfer training � Upright Bike � Ankle Pumps � PROM ◦ Circumduction (2 x/day every day) � Isometrics ◦ TA ◦ Glutes ◦ Quads � Ice/compression DON’T JUST RECOVER. CONQUER.

POD #1: Patient Education � Do not elevate leg (maintain flat supine position) ◦ Band or pillow to prevent ER if capsular repair � Avoid flexion straight leg raise � Weight bearing restrictions � Motion restrictions � Lay on stomach for >2 hours/day DON’T JUST RECOVER. CONQUER.

Phase I: Keys � Managing pain and swelling � Neuromuscular control/re-education ◦ Appropriate gluteal muscle activation and firing patterns ◦ Lumbopelvic coordination � Motion Restoration � Circumduction ◦ Decrease adhesion formation � Progressive weight-bearing DON’T JUST RECOVER. CONQUER.

POW #3 -4 � Weaning ◦ ◦ off crutches Normalize gait pattern on crutches AVOID hip flexor tendonitis and joint inflammation Pay attention to movement patterns early Continued groin discomfort is normal �Muscle weakness and increased joint forces with WB DON’T JUST RECOVER. CONQUER.

Return to Sport Testing DON’T JUST RECOVER. CONQUER.

References � � � � � Enseki KR, Martin RL, Draovitch P, Kelly BT, et al. The hip joint: arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006; 36(7): 516 -25. Enskei KR, Martin R, and Kelly BT. Rehabilitation after arthroscopic decompression for femoroacetabular impingement. Clin Sports Med. 2010; 29(2): 247 -55. Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther. 2006; 36: 516 -25. Ferguson SJ, Bryant JT, Ganz R, Ito K. The acetabular labrum seal: a proelastic finite element model. Clin Biomech. 2000; 15: 463 -8. Ferguson SJ, Bryant JT, Ganz R, Ito K. The material properties of the bovine acetabular labrum. J Orthop Res. 2001; 19: 887 -96. Fitzgerald RH Jr. Acetabular labrum tears: diagnosis and treatment. Clin Orthop. 1995; 311: 60 -68. Ganz R, Leunig M, Leunig-Ganz K, Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res 2008; 466: 264 -72. Garrison C, Osler M, Singleton S. Rehabilitation after arthroscopy for an acetabular labral tear. N Am J Sports Phys Ther. 2007; 2(4): 241 -8. Groh MM and Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009; 2: 105 -117. DON’T JUST RECOVER. CONQUER.

References � Lewis CI, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006; 86(1): 110 -121. � Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med. 2003; 31: 1020 -1037. � Mc. Carthy MD, J. N. P. , Philip; Aluisio MD, Frank; Schuck MD, Michael; Wright MD, John; Lee RN, Joann (2003). "Anatomy, Pathologic Features, and Treatment of Acetabular Labral Tears. " Clinical Orthopaedics and Related Research 406: 38 -47. � Kim, Y. A. , H (1995). "The nerve endings of the acetabular labrum. " Clin Orthop Surg. 320: 176181. DON’T JUST RECOVER. CONQUER.

References � � � Philippon MJ, Christensen JC, and Wahoff MS. Rehabilitation after arthroscopic repair of intra-articular disorders of the hip in a professional football player. Journal of Sports Rehabilitation. 2009; 18: 118 -134. Philippon MJ, Maxwell RB, Johnston TL, Schenker M, Briggs KK. Clinical presentation of femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc. 2007; 15(8): 1041 -1047. Philippon MJ and Schenker ML. Athletic Hip Injuries and capsular laxity. Oper Tech Orthop. 2005; 15: 261 -6. Philippon MJ, Schenker, M. L. , Briggs, K. K. , Kuppersmith D. Femoroacetabular impingement in 45 professional athletes: associated pathologies and return to sport following arthroscopic decompression. Knee Surg Sports Traumatol Arthrosc. 2007; 15: 908 -14. Philippon MJ, Souza BGS, and Briggs KK. Labrum: Resection, repair, and reconstruction sports medicine and arthroscopy review. Sports Med Arthroscop Rev. 2010; 18: 76 -82. Philippon MJ, Weiss DR, Kuppersmith DA, Briggs KK, Hay CJ. Arthroscopic labral repair and treatment of femoroacetabular impingement in professional hockey players. Am J Sports Med. 2010; 38: 99 -104. DON’T JUST RECOVER. CONQUER.