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Postoperative Management

of Orthopaedic Surgeries

CONTINUING

PHYSICAL THERAPY
EDUCATION

Independent Study Course 15.2.1

Postoperative Management of the Hip


Keelan R. Enseki, PT, MS, SCS
Centers for Rehab Services
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pennsylvania

Bryan T. Kelly, MD
University of Pittsburgh Medical Center
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pennsylvania

Pete Draovitch, PT, MS, ATC, CSCS


Centers for Rehab Services
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pennsylvania

Marc J. Philippon, MD
University of Pittsburgh Medical Center
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pennsylvania

An Independent Study Course


Designed for Individual
Continuing Education

CONTINUING

Postoperative Management of
Orthopaedic Surgeries

PHYSICAL THERAPY
EDUCATION

Mary Ann Wilmarth, PT, DPT, MS,


OCS, MTC, Cert MDTEditor

April 2005

Dear Colleague,
I am pleased to welcome you to Postoperative Management of
the Hip by Keelan R. Enseki, PT, MS, SCS; Pete Draovitch, PT,
MS, ATC, CSCS; Bryan T. Kelly, MD; and Marc J. Philippon, MD.
This is the first monograph in the Orthopaedic Section Independent Study Course series 15.2 entitled Postoperative Management of Orthopaedic Surgeries.
Keelan Enseki and Pete Draovitch both work at the Centers for Rehab Services at the University of Pittsburgh Center for Sports Medicine. Keelan Enseki is a physical therapist who is a sports certified specialist as well as a certified strength and conditioning specialist. Pete Draovitch is an athletic trainer and physical therapist who specializes in golf fitness and rehabilitation. Dr Kelly and Dr Philippon also work at the University of Pittsburgh Center
for Sports Medicine. Dr Kelly is a specialist in sports medicine and arthroscopic surgery of the shoulder, hip, and
knee. Dr Philippon is a clinical assistant professor of orthopaedic surgery at the University of Pittsburgh School of
Medicine and director of sports-related hip disorders at the University of Pittsburgh Medical Centers (UPMC) Center for Sports Medicine. He is one of the worlds leading orthopaedic hip surgeons. All authors have worked extensively with patients having hip dysfunction and bring a wealth of both clinical and academic experience with them
in writing this monograph.
This monograph starts with a review of anatomical considerations of the hip and surrounding structures. It continues with a discussion of general rehabilitation guidelines. The authors then go into detail regarding both soft tissue and bony injuries to the hip and adjoining structures, including the capsule, labrum, and bony and soft tissues.
This is followed by applicable information concerning specific postoperative interventions.
The second half of the monograph includes 3 cases studies for patients with various hip dysfunctions. The cases
are very clinically applicable and consist of the following: patient history; systems review; tests and measures; evaluation, diagnosis, and prognosis; intervention; reexamination; and termination of physical therapy.
The authors do a great job of covering issues of postoperative management of the hip from start to finish in a very
user-friendly manner. I believe that you will find this monograph to be an informative and useful reference for
working with your patients in any practice setting.
Best regards,

Mary Ann Wilmarth, PT, DPT, MS, OCS, MTC, Cert MDT
Editor

2920 East Avenue South, Suite 200 La Crosse, WI 54601


Office: 608/788-3982 Toll Free: 877/766-3452 FAX: 608/788-3965

TABLE OF CONTENTS
LEARNING OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
REVIEW OF ANATOMICAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Osseous Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Labrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Articular Cartilage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Capsuloligamentous Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Other Significant Structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
GENERAL REHABILITATION GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
SOFT TISSUE INJURIES AND INTERVENTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Labral Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Labral Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Capsular Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Soft Tissue Release Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
BONY INJURIES AND INTERVENTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Microfracture Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Total Hip Arthroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Specific rehabilitation principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
CASE STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Case Study 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Tests and measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Evaluation, diagnosis, and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Termination of physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Case Study 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Tests and measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Evaluation, diagnosis, and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Termination of physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Case Study 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Patient history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Systems review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Tests and measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Evaluation, diagnosis, and prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Reexamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Termination of physical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
REVIEW QUESTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Opinions expressed by the authors are their own and do not necessarily reflect the views of the Orthopaedic Section.
The publishers have made every effort to trace the copyright holders for borrowed material.
If we have inadvertently overlooked any, we would be willing to correct the situation at the first opportunity.
2005, Orthopaedic Section, APTA, Inc.
Course content is not intended for use by participants outside the scope of their license or regulations. Subsequent
use of management is physical therapy only when performed by a PT or a PTA in accordance with Association policies,
positions, guidelines, standards, and ethical principals and standards.

Postoperative Management of the Hip


Keelan R. Enseki, PT, MS, SCS
Centers for Rehab Services
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pa
Pete Draovitch, PT, MS, ATC, CSCS
Centers for Rehab Services
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pa
Bryan T. Kelly, MD
University of Pittsburgh Medical Center
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pa

Figure 1. Flexible instruments allow for greater access


to hip joint structures during arthroscopy.
(A)
Radiofrequency heating probe. (B) Close-up of flexible
tip. Reprinted from Kelly BT, Williams RJ III, Philippon
MJ. Hip arthroscopy: current indications, treatment
options, and management issues. The American Journal of Sports Medicine. 2003;31:10201037. Copyright
2003, by permission of Sage Publications Inc.

Marc J. Philippon, MD
University of Pittsburgh Medical Center
University of Pittsburgh Center for Sports Medicine
Pittsburgh, Pa
LEARNING OBJECTIVES
Upon completion of this monograph, the course participant will be able to:
1. Describe anatomical characteristics of the hip joint
as they relate to potential pathological conditions.
2. Describe indications for surgical procedures of the
hip joint.
3. Understand current surgical techniques used to treat
pathological conditions of the hip joint.
4. Understand and apply concepts of tissue healing
during rehabilitation.
5. Describe intervention techniques utilized during
rehabilitation after surgical procedures of the hip
joint.
6. Apply these techniques to clinical practice.

untreated. Utilization of minimally invasive intervention


techniques provides the potential for a shorter recovery
period and course of rehabilitation for individuals undergoing arthroscopic surgery or total hip arthroplasty.
Numerous indications for surgical intervention of the
hip exist. Currently the most common indicator is
painful, functionally limiting degenerative changes of the
articulating joint surfaces. The most common treatment
for this is a total hip arthroplasty procedure. Appropriate
patient selection is of paramount importance to a successful outcome after hip arthroscopy. Injuries to the hip
in athletes are often categorized as muscle strains or soft
tissue contusions. However, the cause of hip pain may
arise from a number of soft tissue structures in and
around the hip joint. It is important to be able to differentiate extra-articular from intra-articular pathology.
Potential indicators for arthroscopic intervention include,
but are not limited to, symptomatic tears of the labrum,
capsular laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, painful
snapping hip syndrome, and presence of loose bodies.1
Less common indicators also exist, but are beyond the
scope of this monograph.
Due to the inherent anatomical characteristics of the
hip, arthroscopy of the joint is a technically demanding
procedure. The femoral head is deeply recessed in the
acetabulum. The joint is surrounded by a thickened capsule and a large amount of muscle tissue. The proximity
of other structures such as the sciatic or lateral femoral
cutaneous nerves also presents potential complications
when attempting to perform arthroscopy of the hip joint.
The development of improved visualization procedures
and surgical tools such as flexible scopes has helped
improve the effectiveness and safety of such intervention

INTRODUCTION
The surgical options available for management of
pathological conditions of the hip joint have evolved significantly in the last few years. There are a number of
reasons for the advancement of surgical intervention.
Improved diagnostic techniques such as gadoliniumenhanced magnetic resonance arthrography (MRA) have
allowed detection of intra-articular conditions that
would have previously gone unrecognized. Significant
advancement of arthroscopic techniques has contributed
to the improvement of diagnostic capability and an
increased number of surgical options available for select
conditions. The development of flexible scopes and
more versatile instrumentation has been crucial in this
progression (Figure 1). Hip arthroscopy offers a less invasive alternative for hip procedures that would otherwise
require surgical dislocation of the hip. In addition, this
procedure allows surgeons to address intra-articular
derangements that were previously undiagnosed and
1

acetabulum provides over the femoral head will affect


the inherent stability of the hip joint. The center edge
angle is calculated to provide a measurement of acetabular overhang (Figure 2). The center edge angle is
formed between a line extending vertically from the middle of the femoral head and a line from the middle of the
femoral head to the edge of the acetabulum. An angle
significantly less than 30 is considered abnormal and is
associated with decreased joint stability. The femoral
head normally forms two-thirds of a sphere with a flattened area where the acetabulum applies its greatest
load.1 During normal function, rotation is the primary
motion occurring at the joint, with a minor and variable
amount of translation.2 The angles created by the neck of
the femur in both the frontal (angle of inclination) and
transverse (angle of declination) planes can affect stability of the joint.

methods. The purpose of this monograph is to review a


number of currently utilized surgical techniques and
rehabilitation considerations for such procedures.
Given the complex nature of the hip joint (27 muscles
crossing the hip), and the significant weakness that can
occur after these procedures, the authors feel that supervised therapy is essential for full return of function. In
comparing the outcomes of our patients who receive the
full rehabilitation protocol versus those who have shortened or less intense programs, the authors have found
significantly faster and more complete return to full function with the comprehensive program. The duration of
therapy may be lengthened or shortened based upon the
successful achievement of therapeutic goals. High-level
athletes are often able to have a return to full activity
between 3 and 4 months (depending upon the procedure
and the nature of the sport); however, in more sedentary
individuals, full function may not return until 6 to 8
months. Appropriate patient education regarding expectations is critical for complete patient satisfaction.
Due to the overlap of rehabilitation intervention techniques, common principles for various arthroscopic procedures are described using the general rehabilitation
guidelines section as the primary template. Discussion of
rehabilitation following specific procedures is based
upon modifications of this template. The exception is
rehabilitation of patients undergoing total hip arthroplasty procedures. Rehabilitation of patients undergoing
total hip arthroplasty procedures is discussed independently of arthroscopic procedures. It is important to
remember that rehabilitation techniques evolve in conjunction with surgical advancements. Many of the procedures described in this monograph are relatively new
and continue to evolve. The information in this monograph is intended to reflect rehabilitation techniques
based upon the most current surgical techniques being
utilized at the time of publication.
REVIEW OF ANATOMICAL CONSIDERATIONS
In order to understand the rationale behind specific
surgical intervention techniques and subsequent rehabilitation, an appropriate level of anatomical knowledge
regarding the hip joint is necessary. The intention of this
section is to provide the reader with a review of structures and function of the hip joint region. The implications of these concepts will become apparent throughout
the remainder of the monograph.

Figure 2. The center edge angle is represented by the


angle between a line drawn vertically from the center of
the femoral head and a line drawn from the center of
the femoral head to the edge of the acetabulum. A normal angle is approximately 30 in the adult population.

Osseous Structures
The hip joint is formed by the articulation of the convex femoral head with the concave acetabulum of the
innominate. It is described as a ball and socket joint.
Although it is classified as the same type of joint as the
shoulder, the hip joint has numerous differing characteristics. This is secondary to the fact it is inherently much
more stable and weight bearing in nature. Variations of
femoral head geometry and acetabular depth can affect
stability of the hip joint.1 The amount of coverage the

Labrum
The labrum is a fibrocartilagenous horseshoe-shaped
structure attached to the periphery of the acetabulum
(Figure 3). It is contiguous with the transverse acetabular ligament across the acetabular notch. It attaches
peripherally to the joint capsule at the base. The central
surface is lined with articular cartilage continuous with
that of the acetabulum. The labrum has been found to
2

Capsuloligamentous Structures
The joint capsule of the hip is dense and relatively
inelastic, with reinforcement from 3 ligaments. It attaches proximally to the acetabular rim and distally to the
base of the femoral neck (Figure 4). Two-thirds of the
femoral neck is contained within the capsule. Ligamentous reinforcement consists of the iliofemoral, pubofemoral, and ischiofemoral ligaments (Figure 5). The
iliofemoral ligament, the strongest ligament of the hip,
lends support to the anterior capsule. This ligament primarily serves to limit extension and external rotation. The
pubofemoral ligament reinforces inferior and anterior
portions of the capsule. It resists extension and abduction. The ischiofemoral ligament reinforces the posterior
portion of the capsule. This ligament has the potential to
limit extension and internal rotation. Because of their orientation around the joint, the capsular ligaments become
most taut in a position of full extension.

Figure 3. The labrum surrounds the rim of the acetabulum nearly circumferentially and is contiguous with the
transverse acetabular ligament across the acetabular
notch. The ligamentum teres arises from the margins of
the acetabular notch and the transverse acetabular ligament. Reprinted from Kelly BT, Williams RJ III, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. The American
Journal of Sports Medicine. 2003;31:10201037.
Copyright 2003, by permission of Sage Publications Inc.
have sensory innervation with both proprioceptors and
nociceptors in its superficial layers.3 The intact labrum
contributes to joint stability by deepening the concavity
of the acetabulum and helping to create negative intraarticular pressure. Studies exist suggesting the labrum
plays a role in cartilage consolidation and formation of a
labral seal in hip joint mechanics.4,5 Ferguson et al5
found that absence of the labrum significantly increased
cartilage consolidation and contact pressure of the
femoral head against the acetabulum. They also found
that the labrum had a sealing function in the hip that limited fluid expression from the joint space and had a protective effect on the cartilage layers of the hip. Considering these findings, it can be suggested that labral compromise or deviations from normal structural characteristics could result in a potentially altered load distribution
of the joint surfaces, increasing the potential for damage.6 Much like the meniscus of the knee, the majority of
the labrum in the hip is avascular, with vasculature only
on the outermost layer. This suggests a poor healing
potential for many injuries of this structure.

Figure 4. Expanded view of the hip joint capsule. (A)


Capsular fibers. (B) Proximal insertion of the capsule
into the acetabular rim. (C) Distal attachment of the
capsule along the trochanteric line. Reprinted with
permission from The Physiology of the Joints. Vol. 2:
the lower limb. Kapandji IA, page 33. Copyright 1987,
with permission from Elsevier.
The ligamentum teres originates proximally from the
acetabular fossa and transverse acetabular ligament and
inserts at the fovea of the femoral head (Figure 3).
Although this ligament conducts vessels to the femoral
head in most people,7 it has been thought to play a minor
role in vascularity. It has been traditionally thought that
the ligamentum teres plays no significant role in stability.
Studies exist suggesting that the ligament does become
taut with hip adduction, flexion, and external rotation.8
Additionally, patients suspected of having a traumatic
tear have often been found to suffer from symptoms of
instability and pain.1 Assessing the ligamentum teres
clinically and through diagnostic imaging can prove to

Articular Cartilage
The articular cartilage of the acetabulum and the
femoral head is situated to handle the weight-bearing
characteristics of the joint. The articular cartilage lining
the periphery of the acetabulum is thickest superiorly.
The articular cartilage of the femoral head is thickest
superiorly and posteriorly. Found in the central area of
the femoral head, the fovea capitis is devoid of cartilage
and serves as the proximal attachment for the ligamentum teres. The articular cartilage is avascular and not
innervated.
3

properly, and regaining full passive range of motion


(ROM). Month 2 is the early strengthening phase.
Month 3 focuses on return of full strength, endurance,
and coordination.
The goal of immediate postoperative care for all
arthroscopic procedures is to control inflammation,
maintain ROM, and avoid muscle atrophy of the lower
extremities. A combination of modalities and nonsteroidal anti-inflammatory drugs (NSAIDs) are often
used to control inflammation. Early ROM may be
obtained and preserved through a number of approaches. A continuous motion apparatus is often utilized for
10 days to 6 weeks depending on the procedure. The use
of a stationary bike immediately after surgery can help
obtain ROM without excessive compressive or shear
forces acting at the joint. Excessive ROM may be avoided through use of a brace that limits motion in the sagittal plane (Figure 6). A night immobilization system is
often prescribed to limit excessive external rotation during sleeping hours. Gentle isometric activities (eg,
quadriceps sets, gluteal sets, and abduction and adduction isometrics contraction) are initiated to help prevent
excessive atrophy of lower-extremity musculature.

Figure 5. Anatomical constraints of the hip. Reprinted


from Kelly BT, Williams RJ III, Philippon MJ. Hip
arthroscopy: current indications, treatment options,
and management issues. The American Journal of
Sports Medicine. 2003;31:10201037. Copyright 2003,
by permission of Sage Publications Inc.
be difficult. The suggested role of the ligamentum teres
and subsequent treatment of injury to the structure may
change. Further research to define such changes is necessary at this time.
Other Significant Structures
A number of other structures in proximity to the hip
play significant roles in function of the joint. Muscles of
particular interest include the gluteus medius and the
iliopsoas. The gluteus medius provides the majority of
force required to keep the pelvis stable in the frontal
plane during single limb stance. Weakness of this muscle may result in significant functional impairment. The
iliopsoas is primarily a hip flexor. This muscle crosses
the anterior portion of the joint. Excessive tightness of
this muscle may lead to several problems. In severe cases where less than 10 of extension is allowed, normal
gait may be hindered. Excessive tightness may produce a
snapping sensation as the tendon passes over the femoral
head or other bony structures. The iliotibial band is often
found to be the source or contributing factor to lateral
thigh pain. The iliopsoas, greater trochanteric, and
ischial bursae structures can become inflamed and
symptomatic. The iliopsoas bursae is continuous with
the joint in approximately 20% of the adult population.9
Inflammatory conditions of the joint may result in symptoms manifesting as iliopsoas bursitis.
GENERAL REHABILITATION GUIDELINES
As a general guideline, the authors recommend 3
months of supervised therapy after arthroscopic hip procedures. During month 1, the authors prescribe 1 day of
therapy each week. During month 2, patients receive
therapy 2 days per week. During the final month, where
return of strength, coordination, and endurance are
emphasized, patients have therapy 3 times per week.
Month 1 is the tissue healing phase and focuses on
decreasing inflammation, allowing the tissue to heal

Figure 6. Postoperative brace to prevent movement of


the hip joint in the sagittal plane.
4

labrum. Tears can be defined as midsubstance, frayed,


degenerative, or flapped in nature. Partial labral detachment has also been observed.
Labral injuries may occur through several mechanisms. Common causes of labral tears are listed in Table
2. Traumatic injuries are often observed in athletes and
individuals subject to high-amplitude, short-duration
forces at the hip joint. Common mechanisms of injury
are those that consist of a rotary nature, often in a
weight-bearing position. The most common mechanism
is application of an external force on a hyperextended
and externally rotated hip joint.1 An example of the
rotary mechanism may be noted by the relatively high
incidence of symptomatic labral injuries in golfers. The
hip joint repetitively experiences forceful internal and
external rotation in a weight-bearing position during the
performance of a golf swing. Other athletes at higher risk
for injuries of this nature are dancers, gymnasts, soccer
players, and hockey goaltenders. A portion of athletes

Aquatic activities have proven to be an effective component of the rehabilitation process. Early ambulation in
the pool allows patients to focus on gait symmetry in a
deweighted environment. Active ROM within pain-free
limits can also be initiated in the water. For those individuals concerned with preservation of their cardiovascular fitness, such as distance runners, jogging in an
aquatic vest can be initiated as tolerated. In the authors
experience, aquatic activities have proven to be an
excellent tool to aid in the transition from limited weight
bearing to functional activities on dry land.
Initiation of ROM, strength, and weight-bearing activities varies depending on the specific procedure performed. Though the first 2 weeks of therapy are standard
for most procedures, variations for these activities occur
after this time. Rehabilitation principles for specific procedures are discussed under their respective sections in
the monograph and summarized in Table 1.
SOFT TISSUE INJURIES AND INTERVENTIONS
Labral Resection
Arthroscopic procedures to address labral injuries
have gained popularity only in recent times. In our experience, injuries to the labrum are the most common
source of hip pain identified at the time of arthroscopy.
The labrum deepens the acetabulum and effectively
increases the total contact surface area of the joint. These
characteristics have a potential stabilization effect on the
joint. This effect may be compromised with injury to the
labrum. In the North American population, tears most
commonly occur in the anterior-superior portion of the

Table 2. Common Causes of Labral Tears


Traumatic injury
Joint laxity/hypermobility
Bony impingement
decreased femoral head neck junction offset
overhang of the anterior superior acetabular rim
retroverted acetabulum
Dysplasia
Degenerative changes

Table 1. Rehabilitation Guidelines for Specific Arthroscopic Procedures of the Hip


Activity
Isolated Labral Procedure
Capsular Procedure
(isolated or with labral
procedure)

Microfracture

Stationary bike

Immediately

Immediately

Immediately

Gentle quadriceps,
hamstring, and gluteal
setting

Day 2

Day 2

Day 2

Passive range of motion

Weeks 1 to 2: flexion from


0 to 90

Weeks 1 to 2: flexion
from 0 to 90

Weeks 1 to 2: flexion
from 0 to 90

After 2 weeks: motion as


tolerated

After 2 to 3 weeks: very


gradual pain-free motion

After 2 weeks: variable


progression depending
on procedure

Active range of motion

As tolerated after 2 weeks

As tolerated after 3 weeks

Variable

Stretching

After 3 weeks

After 3 to 4 weeks: hold


hip flexor stretch until
after 4 weeks

After 3 to 4 weeks

Resistance exercise

As tolerated after 2 to 4 weeks

As tolerated after 4 weeks

As tolerated after 4 to 6 weeks

Weight-bearing activities Initiate at 10 days to 4 weeks

Typically 10 days to 4
weeks

Typically 4 to 8 weeks

Functional activities

As tolerated after full


weight bearing

As tolerated after full


weight bearing

As tolerated after full weight


bearing
5

with significant flexibility of the hip joint may demonstrate characteristics that result in decreased femoral
head containment.1 Because the labrum has an effect on
overall joint stability, injuries to this structure are often
found in combination with compromise to other joint
structures. Capsular laxity, articular cartilage lesions, and
subchondral cysts are among those conditions that may
be observed in conjunction with a labral tear.
Injuries to the labrum may also be atraumatic in
nature. Deviations of the hip joints bony architecture
that affect stability may potentially increase the likelihood of labral compromise. Such characteristics include
dysplasia of the hip joint, femoral anteversion, and a
decreased center edge angle. The presence of an osteophyte in the area of the head and neck junction may also
be associated with labral tears. A proportion of individuals have been observed to have a hypoplastic labrum.
This condition results in a loss of the ball-valve effect
around the femoral head compromising joint stability.
Conditions that result in increased generalized ligamentous laxity may also predispose an individual to labral
tears. Such conditions include Ehlers-Danlos syndrome
and Down syndrome. Excessive or constant exposure to
the previously described forces may result in a higher
potential for injury in these individuals.
Diagnosis of labral tears relies heavily on clinical
examination, which then may be confirmed by diagnostic studies. The patients history may reveal a mechanism
consistent with that previously described. Potential clinical findings in patients with labral tears or hip instability are listed in Table 3. A cluster of potential symptoms
should be taken into account. Diagnosis can be complicated by the potential involvement of adjacent regions
such as the lumbar spine and sacroiliac joint. Mechanical symptoms such as an audible and painful pop as
well as an associated decrease in ROM may be
observed. The presence of a snapping sensation should
be interpreted with caution. The underlying mechanism
of such symptoms could involve movement or hypermobility of the iliopsoas tendon or iliotibial band over bony
eminences. Many patients may have been previously
diagnosed with a chronic groin-pull. There may also be
current complaints or a history of low back pain and
symptoms consistent with sacroiliac joint involvement.

Individuals with labral compromise may also demonstrate or report specific functional limitations. Gait
asymmetry (eg, ambulation with an externally rotated
lower extremity) may be noted. Patients may report difficulty with prolonged ambulation or sitting. Transitional movements such as getting up from a chair or getting
in and out of a car may be difficult. Balance testing may
demonstrate asymmetry between the affected and unaffected extremity.
If labral compromise is suspected, then further imaging may be performed. To obtain an accurate impression
of the capsulolabral structures or articular surfaces of the
joint, gadolinium-enhanced MRA may be utilized (Figure
7). Magnetic resonance arthrography has been found to
be more sensitive than magnetic resonance imaging
alone.1 Plain radiographs will likely be performed to rule
out fractures, dislocation and subluxation, osteitis pubis,
and degenerative conditions.1

Figure 7. Gadolinium-enhanced magnetic resonance


arthrogram of the hip joint. Arrow indicates a lesion of
the labrum.
The results of both clinical examination and diagnostic tests should be utilized to determine candidates for
arthroscopic labral procedures. Patients who have persistent hip pain for longer than 4 weeks, clinical signs,
and radiographic findings consistent with a labral tear
are candidates for hip arthroscopy.1 Arthroscopy provides a definitive diagnosis of a labral tear (Figure 8). An
unstable portion of the labrum may be debrided in an
attempt to eliminate the observed symptoms. An attempt
is made to spare as much viable tissue as possible in
order to preserve mechanical properties of the joint. In
cases where removal of a portion of the labrum is
thought to pose a significant threat to the mechanics of
the joint, a repair of the structure may be attempted.
The presence of a symptomatic labral tear does not
guarantee a patient is a suitable candidate for hip

Table 3. Potential Findings of Patients With Labral Tears


or Hip Instability

Reports of groin pain


Accompanying low back or sacroiliac joint pain
Difficulty with activities requiring hip rotation
Subjective report of weakness and decreased
stability
Restricted range of motion
Painful clicking sensation
Difficulty and pain transitioning from sit to stand
Difficulty with prolonged sitting
6

aspect of rehabilitation (ROM, strength, and weight bearing) is chosen based on tissue healing properties.
In patients who have had an isolated labral resection
procedure performed, the main factors that affect regaining ROM and strength are soft tissue damage created by
the surgical instrumentation when entering the joint and
the effects of immobility. After the soft tissue healing
process has initiated, a progression from passive ROM to
stretching can proceed. A major concern during this
phase of rehabilitation is to not initiate an inflammatory
response in the joint. Avoidance of excessive flexion or
abduction is a concern. These motions are limited in
order to avoid impingement of capsular and soft tissue
that has not yet healed. Excessive motion in these planes
is indicated by an uncomfortable pinching sensation. The
authors generally recommend beginning stretching as
tolerated around 3 weeks after surgery. In cases where
other procedures have been performed in combination
with a labral resection procedure, specific limitations
may exist. These specific limitations will be discussed in
a later section of the monograph.
The weight-bearing progression during rehabilitation
depends on several issues. The area of the tear and subsequent debridement or repair must be taken into consideration. Most tears in the North American population
of these patients occur in the anterior-superior region of
the labrum. This area represents the weight-bearing portion of the structure. A short period of limited weight
bearing is usually recommended. We generally recommend a range from 10 to 28 days of foot flat (approximately 20 pounds) weight bearing. Complete
nonweight-bearing precautions in patients undergoing
isolated labral procedures are usually not suggested.
Gentle compression aids in providing an environment of
optimal loading to promote healing. Weight-shifting
activities early in rehabilitation help to create this compression without the risks of damage that may occur with
the shear forces that are created with ambulation.
Active ROM and open chain resistive exercises are
utilized after the appropriate ROM and control of baseline symptoms have been established. We recommend
an early emphasis on gluteus medius muscle-strengthening activities. Open chain knee extension and flexion
activities should be progressed as tolerated. Those
patients undergoing additional soft tissue release procedures may have precautions regarding specific motions.
These procedures will be addressed in a later section of
this monograph.
After full weight-bearing status has been achieved,
functional progression is primarily dictated by symptoms. Gait training is often required to ensure symmetrical weight bearing and terminal extension of the affected hip. Careful attention should be given to ensure that
evidence of a Trendelenburg gait does not exist. Weightbearing exercises should be progressed to closed chain
progressive resistance exercises as tolerated. Movement
in all planes of motion should be addressed. Rotary stability is of particular concern. The authors often utilize

Figure 8. Arthroscopic view of a tear in the anteriorsuperior region of the acetabular labrum (indicated by
the arrow).
arthroscopy. Patients with signs of advanced degenerative changes are not generally considered as good candidates. Studies report a direct correlation between
advanced cartilage degeneration and poor outcomes following arthroscopy.10,11 Patients with advanced cases of
osteoarthritis are usually considered more appropriate
candidates for total hip arthroplasty. Patients who are
unable to comply with an extended course of postoperative rehabilitation are not generally considered strong
candidates for arthroscopic hip procedures.
Although isolated debridement of a torn labrum is
often performed, other conditions may be addressed as
well. These conditions are often thought to contribute to
the underlying cause of the observed labral tear. Procedures to address capsular laxity and chondral lesions, as
well as soft tissue release procedures, will be discussed
in separate sections of this monograph. The presence of
osteophytes in the region of the head and neck junction
has been reported in a number of patients with labral
tears. When it is suspected that bony impingement may
be occurring, a cheilectomy (removal of the osteophyte)
may be performed.1
Specific rehabilitation principles
Rehabilitation following arthroscopic surgery to
address labral compromise should take into consideration all those tissues involved during the procedure. The
rehabilitation principles discussed in this section of the
monograph assume an individual undergoing an isolated
debridement or repair of the labrum. The principles discussed in the general rehabilitation guidelines section
apply in these cases. Rehabilitation considerations for
other procedures, including those that may be combined
with labral procedures, are discussed in following sections. When procedures are performed in combination,
utilization of the most conservative approach for each
7

surgery. During the running progression, an individual


may develop those conditions of the hip joint region
common to runners. Such conditions include tendonitis
and bursitis, and if evident, these should be addressed
promptly to optimize the running progression. The concept of relative rest should be emphasized to the patient.
Particular attention should be given to patient symptoms during any phase of transition. Such phases
include the transition from crutches to full ambulation
and from normal activity to higher level activity or return
to training in athletes. The authors have observed that
individuals who have made attempts to push excessively
through discomfort often develop tendonitis (iliopsoas,
rectus femoris, and iliotibial band), bursitis, or synovitis.
In these cases activity must be significantly decreased
until symptoms have subsided to baseline. Avoiding
such situations is a primary concern as a significant
amount of rehabilitation time may be lost in the case of
their occurrence.
Many patients who have had labral tears may report a
history of low back pain or symptoms consistent with
sacroiliac dysfunction. Such problems should be
addressed as indicated by physical examination. Stabilization techniques to enhance lumbopelvic stability can
be utilized as per patient tolerance. Manual techniques
as indicated for the lumbar spine and sacroiliac regions
are frequently useful in addressing symptoms of the
sacroiliac and low back regions. Leg length discrepancies may also exist. Orthotic intervention should be considered as indicated in these cases.

weight-bearing hip rotation activities and will apply


resistance through elastic tubing to increase difficulty
(Figure 9). Open and closed chain proprioception
should be addressed. As mentioned, the superficial layers of the labrum are innervated. Therefore, compromise
of this tissue could be implicated in proprioceptive
deficits. Additional studies are necessary to determine
the potential role the labrum may play in proprioception.
In patients undergoing isolated labral resection, the
authors will initiate single leg stance activities approximately 10 days to 3 weeks after surgery. Perturbation
and functional activities are added and progressed in difficulty as tolerated.

Labral Repair
Procedures to repair a tear of the labrum are relatively new. These may be performed on patients with
detachment of the labrum from the bony acetabular rim
or intrasubstance tears. In these cases it is believed that
debridement of the labrum would potentially have a negative effect on the mechanics of the hip joint.1 The repair
may be performed through use of sutures to reattach the
labrum to the bony surface of the acetabulum. General
results for this procedure were previously described for
12 patients, with early results being favorable (S. Bharam
et al, unpublished data, 2003). Patients subjectively
reported being able to return to their previous level of
function with minimal discomfort.
Figure 9. Resisted external rotation of the hip in a
weight-bearing position using elastic tubing resistance.

Specific rehabilitation principles


The rehabilitation process following repair of the
labrum does not vary significantly from that following a
resection procedure. A limited weight-bearing status
may be prolonged depending on the extent of the repair.
Large tears requiring an extensive repair may have a partial weight-bearing status for 4 to 6 weeks. This may hold
particularly true for individuals who had tears on the
anterior-superior (weight-bearing) portion of the labrum.
After the repair is believed to be stable, functional progression should parallel the process described for labral
resection procedures.

The progression to running varies significantly among


individuals. Factors such as preoperative condition,
extent of injury, and body composition affect return to
running activities. Using devices such as the elliptical
trainer or step trainer may be useful in providing a transitional period to running. The authors typically initiate
these activities 4 to 6 weeks after surgery as tolerated. In
our experience running may be initiated as early as 6
weeks, but more often is initiated closer to 10 weeks after
8

Capsular Procedures
Although the hip joint is inherently stable, cases of
instability exist and can be a significant source of pain
and functional limitation. In comparison to the shoulder,
the hip joint relies much less on adjacent soft tissue for
stability. In a normal hip this is secondary to the inherent osseous stability of the joint.1 The labrum and capsule act together to provide joint stability. In the case
where one structure is compromised, a disproportionate
load may be placed on the other structure. Injuries or soft
tissue abnormalities such as labral tears or iliofemoral
ligament insufficiency can disturb the complex buffer
mechanism in the hip and result in increased tension in
the joint capsule and its ligament and decreased ability
to absorb stress or overstress. During arthroscopic examination, labral tears and capsular laxity are often concurrent findings. In many cases, deficiency of the
iliofemoral ligament is also observed. There may be a
proportionately higher load on the soft tissue structures
in joints with deviations of bony architecture (eg, the
presence of dysplasia). Several authors have described
the presence of capsular redundancy following recurrent
dislocation.12,13 Dall et al12 have suggested that when the
suction effect of the labrum is lost due to a tear, the capsular labral relationship is compromised and subtle instability may develop causing capsular elongation and
attenuation. Furthermore, this subtle instability can be
an important factor in the development of hip pain.1,6,12
Currently, biomechanical studies are being performed to
determine the effects of capsular and labral compromise
on movement characteristics of the femoral head.1
Hip instability can be a difficult condition to diagnose. Injury can occur through traumatic or atraumatic
mechanisms. A thorough history combined with clinical
examination is required to make an accurate diagnosis of
instability. Dynamic fluoroscopy may be used to further
strengthen the hypothesis of joint laxity.6 A sense of
instability may be reported as opposed to the joint physically giving away. Athletes commonly report a traumatic onset or specific symptom provoking maneuvers.
Common examples include throwing a football to the
sideline or swinging a golf club.6 A subset of this population may be able to voluntarily sublux the hip. These
are often individuals with an atraumatic onset of symptoms. These patients often show signs of generalized ligamentous laxity. Patients that fall into this category may
include those with disorders that affect connective tissue
such as Ehlers-Danlos syndrome, Down syndrome, and
Marfan syndrome. Careful attention should be paid during the physical examination to ensure that patients who
seemingly can sublux the hip through rotational movements are not actually snapping the iliopsoas or iliotibial
band over a bony landmark. The latter is a much more
common clinical finding and not a direct indicator of
joint instability.
Even less common than hypermobility of the hip is
global capsular tightness. These patients present with a

capsular pattern of decreased motion and closely resemble the clinical findings associated with adhesive capsulitis of the shoulder. They typically have significant
synovitis associated with their decreased motion. Nonoperative management should be the mainstay of treatment for these patients, focusing on physical therapy to
regain motion and anti-inflammatory medications to
decrease the inflammation. Fluoroscopically guided
corticosteroid injections directly into the hip joint may
help decrease the local inflammation. If patients are
unresponsive to nonoperative treatment, they may be
considered for arthroscopic capsular release. Mixed
results have been observed in these cases.
Options to treat capsular laxity include thermal capsulorrhaphy, plication, or a combination of these procedures. One author (MJP)9 has had extensive experience
treating hip instability with capsular thermal modification. This is achieved using a monopolar radiofrequency
heating probe. A probe with a flexible tip allows greater
access to areas of the joint that are more constrained.1
The goal of the procedure is to achieve a volumetric contraction of the capsule to reduce capsular redundancy,
thereby enhancing joint stability.6 Capsular plication is a
relatively newer procedure.
Capsular tension is
achieved through the use of sutures. Short-term results
for these procedures appear to be promising; however,
additional research is required to determine the longterm effectiveness of this approach.1
Labral resection or repair procedures are often combined with capsular modification procedures. As previously mentioned, labral tears and capsuloligamentous
compromise are often found concurrently. Assuming an
interactive nature regarding the role these structures play
in providing stability of the hip joint, addressing compromise of only one structure could potentially compromise the long-term results of surgery. Once injury to the
labrum is addressed, restoration of normal capsular tension should be considered to achieve the balance of contribution to joint stability that these structures normally
provide.
Specific rehabilitation principles
The most significant issue of rehabilitation for those
patients undergoing capsular modification procedures is
early limitation of ROM to allow appropriate healing and
reestablishment of capsular tension characteristics.
Global and focal cases of synovitis have been noted during arthroscopy. In such cases, avoiding additional
inflammation is of significant concern. Weight bearing
and strength progression are typically similar to the protocol described for labral procedures. Often capsular
modification is performed in conjunction with a labral
procedure. Depending on the extent of the procedure, a
partial weight-bearing status may be assigned for 10 days
to 4 weeks after surgery. Protected early ROM is imperative. There are particular concerns with excessive external rotation, flexion, and abduction. Excessive external
rotation can potentially place an inappropriate amount
9

Intra-articular cases may be candidates for surgical


removal of loose bodies or debridement of displaced tissue.
A detailed history and physical examination are
required in determining the source of snapping hip syndrome.1 A patient will often be able to voluntarily elicit
the snapping or clicking sensation during physical examination. Patients who are experiencing intra-articular
snapping hip syndrome may describe a painful clicking
sensation as opposed to the snapping sensation more
often associated with those of a musculotendinous
mechanism. Description of location is the most obvious
factor in determining the source of symptoms. Internal
snapping is generally localized over the anterior portion
of the groin, whereas external snapping is localized over
the greater trochanter.1 Intra-articular clicking may be
observed when initiating rotational motion.1
Most cases of internal and external snapping hip
respond well to conservative treatment. Such treatment
includes utilization of NSAIDs, injection, and physical
therapy intervention. However, there are refractory cases that are suitable to be addressed surgically.16 Until
recently, tissue release or lengthening procedures had to
be performed in an open fashion.1619 Recent advances in
arthroscopic technology have expanded the options
available for such procedures.1 Early results are promising; however, further study is necessary.

of tension through the anterior portion of the capsule.


Excessive flexion or abduction may cause impingement
of unhealed tissue into the joint, creating discomfort and
potentially encouraging the inflammatory response.
The authors typically limit movement from neutral to
90 of flexion in the sagittal plane, with minimal movement in other planes for the first 7 to14 days of treatment.
Approximately 7 to 14 days after surgery, rotation is gently initiated through active rotation with the affected
knee resting on the exam stool or floor in a quadruped
position. The patient is instructed to rotate the hip using
the knee as an axis only within an ROM that is comfortable. A gradual increase of motion in the sagittal plane
is typically initiated at approximately 7 to 14 days after
surgery. The authors have observed most patients can
tolerate greater flexion without discomfort using a rocking to heel method in quadruped compared to supine
flexion-based activities. Stretching may be initiated as
tolerated around 21 to 28 days after the surgery. Gentle
joint distraction techniques for the purpose of relieving
pain can be initiated around 21 days postoperatively.
Direction-specific mobilization techniques may be utilized as indicated after approximately 28 days. Caution
should be exercised when utilizing these procedures.
Full ROM as tolerated is typically recommended at
approximately 4 to 5 weeks after surgery.
After a patient has reached full weight-bearing status,
the rehabilitation process for an isolated capsular procedure or combined labral-capsular procedure typically
follows the same course as an isolated labral procedure.
Functional progression is based primarily on symptomatic reaction to activity. For example, when a patient
can ambulate a mile without residual pain or limping,
the authors will begin a gentle jogging progression.

Specific rehabilitation principles


The primary concerns following tissue release and
lengthening procedures are controlling the postoperative
inflammatory response and allowing appropriate healing
time for those tissues being released. When performed
with other procedures such as labral resection or repair
and capsular modification, the previously mentioned
postoperative concerns regarding ROM and weight bearing that occur with such procedures apply. Nonweightbearing limitations, partial weight-bearing limitations,
and ROM limitations may apply in these cases. Early
pain-free ROM is indicated. In order to allow appropriate healing and to avoid initiating an exaggerated inflammatory response, early stretching is usually avoided.
Stretching is typically initiated as tolerated approximately 4 weeks after surgery. An attempt is made to initiate
stretching in a manner and time frame that promotes
maintenance of the appropriate muscle tissue length
while avoiding an inflammatory response. The primary
muscles of interest are the iliopsoas, rectus femoris, iliotibial tract, and hamstrings. Isometric exercise for those
muscle groups not directly affected by the surgical procedure can be initiated immediately. This usually
includes exercises for the quadriceps, hamstrings, and
gluteal muscle groups. Submaximal isometric exercises
for the involved structures are typically initiated 3 weeks
after surgery. This includes isometric flexion for an iliopsoas lengthening procedure and abduction for an iliotibial band lengthening procedure. Straight leg raise activities in the plane of action for the involved musculo-

Soft Tissue Release Procedures


In rare cases, surgical release of soft tissue structures
may be indicated. The most common indications for
such procedures are painful and functionally limiting
cases of snapping hip syndrome (coxa saltans) that have
not responded favorably to conservative treatment.1 Soft
tissue release procedures may be performed in isolation
or may be combined with other procedures (eg, labral
debridement).
Allen and Cope14 described 3 types of snapping hip.
External snapping hip is caused by snapping of the posterior iliotibial band or anterior portion of the gluteus
maximus over the greater trochanter.14,15 The snapping
sensation usually occurs when the hip moves from an
extended to flexed position.14,15 Internal snapping hip
occurs when the iliopsoas tendon is displaced over the
bony landmarks of the iliopectineal eminence or femoral
head.1,15,16 The intra-articular case of snapping hip syndrome is often caused by a loose body in the joint.15,16
This could include a fragmented piece of bone, a portion
of torn labrum, a chondral flap, or synovial chondromatosis.1 Individuals with external and internal snapping
hip may be candidates for a soft tissue release procedure.
10

McCarthy et al10 found a high association of chondral


injuries and labral tears. They found 73% of patients
with fraying or tearing of the labrum had chondral damage.10 Such patients may be candidates for procedures
where the labrum is resected or repaired along with a
microfracture procedure or unstable flap resection.
Future studies are necessary to determine the long-term
success of microfracture procedures of the hip joint.

tendinous structures are usually avoided for a minimum


of 4 weeks. The authors experience has been that early
initiation of such activities is associated with an inflammatory-type response resembling tendonitis. Once tolerance of gentle isometrics and active ROM has been
established, a progression of weight-bearing strengthening exercises and functional activities should be initiated.
BONY INJURIES AND INTERVENTIONS
Microfracture Procedures
Patients with focal osteochondral pathology may be
candidates for a microfracture procedure. Diagnosis of
such pathology can be difficult.20,21 Results from clinical
examination will most likely have to be supported by
imaging studies to confirm a chondral lesion diagnosis.
When symptoms do not respond to treatment and tests
that suggest intra-articular pathology are positive, a more
extensive diagnostic work-up should be considered.1
Although gadolinium-enhanced MRA and cartilage-sensitive magnetic resonance imaging are the suggested
imaging techniques in suspected cases of chondral
lesions, there are limitations in reliability.1,22
The mechanism of osteochondral injury can be difficult to diagnose. The patient will often recall a traumatic
event with an immediate onset of symptoms.1 However,
the injury may be preceded by a seemingly trivial event
or no discernable cause, which is often the case in degenerative conditions. An increased incidence of this injury
type has been noted in young, physically active men who
experience impact loading over the greater trochanter
during athletic or other strenuous activities.1 The typical
description of the lateral impact injury is a direct blow to
the greater trochanters, such as during a fall. The high
bone density of this area allows transfer of energy from
the external force to the joint surface. The final result is a
chondral lesion of the femoral head or acetabulum without osseous injury.1 Arthroscopic findings have helped to
support the logic behind the lateral impact mechanism.21
The progression of chondral lesions can lead to
extremely disabling consequences, the most significant
being global degeneration of the articulating surfaces.
The difficulty in diagnosing these lesions and the limited
success of nonoperative treatment provide a reasonable
rationale for the use of hip arthroscopy in the treatment
of chondral injuries.1
The stage and size of a chondral lesion play an important role in determining if an individual is a potential
candidate for a microfracture procedure. Microfracture
of medium-sized defects has been performed in many
patients with full-thickness lesions.1 The presence of a
larger lesion may limit the available treatment options.
Individuals with such lesions may be candidates for a
resurfacing procedure. A limited number of resurfacing
procedures have been performed. In the authors experience, early results appear favorable; however, further
outcome studies are necessary. A limited number of
autologous chondral transplantations from the lateral
femoral condyle have been performed.1

Specific rehabilitation principles


Rehabilitation of patients undergoing microfracture
procedures carries particular concerns. The primary
concern is to allow healing of the affected articular surfaces. An attempt should be made to create an environment that minimizes compressive and particularly shear
forces. Articular damage is often on the weight-bearing
surface of the femur or acetabulum. A nonweight-bearing or partial weight-bearing status for 4 to 8 weeks is
usually assigned to the patient. This may vary depending
on the extent and location of the chondral lesion.
Weight-shifting activities may be initiated earlier, but
caution should be exercised with early ambulatory activities. The combination of weight bearing and rotational
motion can create potentially damaging shear forces at
the joint surfaces. When transitioning from a limited
weight-bearing status to ambulating independently, the
patient should be monitored for any symptoms indicative
of joint inflammation. If allowed to persist without a
period of relative rest, this condition can become
extremely difficult to control. In the case such symptoms
do occur, it is recommended that the patient temporarily
resumes a partial weight-bearing status, utilizes prescribed anti-inflammatories, and uses modalities such as
ice, compression, and electrical stimulation applications
as indicated. A therapeutic pool can be utilized to begin
early gait training and weight-bearing activities. Rangeof-motion progression for microfracture procedures is
usually similar to those guidelines followed for a labral
resection or repair. If performed in conjunction with a
capsular modification procedure, additional ROM
restrictions may be recommended.
Total Hip Arthroplasty
Total hip arthroplasty is the most common reconstructive hip procedure performed in the adult population.23 Hip arthroplasty techniques have dynamically
evolved since their initiation. Innovations in biomechanical knowledge, materials, prosthetic component
design, surgical approach, and rehabilitation concepts
have allowed continued improvement of surgical outcomes. The intention of this section of the monograph is
to review indications, surgical techniques, and rehabilitation principles as they apply to total hip arthroplasty
procedures.
Indications for total hip arthroplasty are based upon
medical diagnosis and degree of symptomatic functional
limitation. As with many surgical procedures, there are
indications that are not completely agreed upon. Specif11

include activity modification, strengthening, flexibility


techniques, weight modification, and utilizing assistive
devices.
The method of approach utilized during an arthroplasty procedure may have implications on subsequent
rehabilitation. Therefore, the therapist must establish an
adequate understanding of these approaches in order to
safely optimize therapeutic activities. The direction of
approach influences precautions during rehabilitation
and ADLs.
The most commonly utilized approach is the posterior or posterior lateral approach.26 In these cases, the
head of the femur is dislocated in a posterior direction
from the acetabulum. In cases where the posterior or
posterior lateral approach is utilized, caution should be
exercised to avoid positions of extreme internal rotation,
flexion, and adduction. These precautions are to help
ensure that a posterior dislocation of the hip joint does
not occur. The most common activities in which dislocations occur after a posterior lateral approach are: rising
off a low surface, twisting the trunk toward the affected
side with feet planted, bending to tie shoes from a seated position, and rolling over in bed.26
Less commonly, an anterior or anterior lateral
approach may be utilized. In these cases, the head of the
femur is dislocated in an anterior direction from the

ic factors may also affect the choice of prosthetic materials as well as the surgical approach.
A number of medical conditions may be considered
indicators for a total hip arthroplasty procedure. A list of
these conditions is contained in Table 4. A wide scope
of arthritic conditions can be included as potential indicators for the procedure. This includes but is not limited
to rheumatoid and osteoarthritis.24,25 Other indications
include avascular necrosis (of various origins); select cases of congenital subluxation or dislocation; nonunion of
femoral neck, trochanter, and acetabular fractures; failed
reconstructive procedures; select metabolic disorders;
infectious disorders; and the presence of certain classifications of tumors.23
The degree of functional limitation that must be present in order to consider an individual as a candidate for
total hip arthroplasty may vary and has evolved over
time. Historically, patients 60 to 75 years of age who suffer from intractable and incapacitating pain have been
considered potential candidates for total hip arthroplasty.23 This age span has recently been expanded.23 The
overall goal consistently is to decrease pain symptoms in
order to improve the activities of daily living (ADLs) of
the individual undergoing the procedure. More conservative methods should be considered before making a
definitive choice for surgery. Conservative options may

Table 4. Disorders of the Hip Joint for Which Total Hip Arthroplasty May Be Indicated*
Avascular Necrosis
Arthritis
Postfracture or dislocation
Rheumatoid
Idiopathic
Juvenile rheumatoid
Slipped capital femoral epiphysis
Ankylosing spondylitis
Hemoglobinopathies (sickle cell disease)
Degenerative joint disease
Renal disease
Primary
Cortisone induced
Secondary
Alcoholism
- Slipped capital femoral epiphysis
Caisson disease
- Congenital dislocation/dysplasia
Lupus
- Coxa plana (Legg-Perthes disease)
Gaucher disease
- Paget disease
Nonunion, femoral neck and trochanteric fractures with
- Traumatic dislocation
head involvement
- Fracture, acetabulum
- Hemophilia

Hip Fusion and Pseudoarthrosis

Failed Reconstruction
Osteotomy
Cup arthroplasty
Femoral head prosthesis
Girdlestone
Total hip replacement
Resurfacing arthroplasty

Bone Tumor Involving Proximal Femur or Acetabulum

Hereditary Disorders (eg, achondropasia)

Pyogenic Arthritis or Osteomyelitis


Hematogenous
Postoperative
Congenital Subluxation or Dislocation

Tuberculosis
*Adapted and reprinted with permission from Campbells Operative Orthopaedics.23 Copyright 1998, with permission
from Elsevier.
12

the adjacent bone.23 A bioactive compound may be


applied to the stem in order to improve osseous integration. Further research is necessary to determine the
effectiveness of nonporous, cementless femoral prosthetic components.
As with femoral components, the original method of
fixation for the acetabular component was cementbased. Loosening is a particular problem with the
acetabular component. Despite improvements in design
and technique, long-term survival of cemented acetabular components has not significantly improved.23 Currently, this option tends to be exercised in elderly and
less active individuals.
In more active and younger individuals, a cementless
acetabular component is often the device of choice.
Most cementless components are porous over the entire
surface that makes bony contact.23 These components
utilize various methods of initial fixation, but all rely on
ingrowth of bone to establish long-term stability.
In select cases, a bipolar endoprosthesis may be utilized. These systems are compromised of a metallic
acetabular cup and a polyethylene liner that contains a
socket for a femoral prosthesis. The proposed advantage
of such a system is the presence of 2 locations of movement. Inner movement occurs at the interface between
the femoral prosthesis and the polyethylene liner. Outer
movement occurs between the metallic cup and the
acetabulum. The amount and proportion of movement
that occurs at each interface is not completely agreed
upon.23,2729 The amount of motion appears to depend on
multiple factors including prosthetic design, inner head
size, and articular cartilage status.23
As with other surgical procedures, technological
advances have allowed the initiation of total hip arthroplasty through a minimally invasive method. The overall
goal of this method is utilization of smaller incisions to
permit joint replacement with minimal damage to adjacent tissue. This can be accomplished through various 1incision or 2-incision techniques utilizing an anterior or
posterior approach. Computer-aided models are also
being developed in an attempt to improve the effectiveness and decrease complications associated with total
hip arthroplasty. It can be suggested that minimally invasive joint replacement should allow for an accelerated
course of rehabilitation in comparison to conventional
techniques. Research comparing conventional and minimally invasive procedures in terms of technical demand
of the surgery, complication rate, functional outcomes,
cost effectiveness, and subsequent course of rehabilitation is ongoing at this time. Further data regarding these
factors will determine the usefulness of this technique in
future practice.
Patients undergoing total hip arthroplasty are at risk
for numerous complications. A number of complications
are inherent to the specific procedure, while others are
reflective of the population on which the surgery is performed.23 The most severe complications usually occur

acetabulum. In order to avoid anterior dislocation of the


hip joint, caution should be exercised to avoid positions
of extreme external rotation, extension, and abduction.
There is no universal agreement on how long hip ROM
precautions should be followed. Recommendations
range from 4 weeks to life.26 Recommendations may
vary depending on the patients age, condition of surrounding bone, the type of prosthetic utilized, presence
of other medical conditions, and other factors deemed
important by the surgeon performing the procedure.
In select situations, a trochanteric osteotomy and lateral reattachment may be performed in conjunction with
an arthroplasty procedure. This was originally advocated to increase the lever arm of the abductor mechanism
at the hip joint. In order to obtain the beneficial tradeoffs of bone preservation, and avoid problems related to
reattachment of the greater trochanter, trochanteric
osteotomy and lateral reattachment procedures are not
routinely emphasized at this time.23 For these procedures, a prolonged limit of weight-bearing status and
avoidance of active hip abduction for 8 to 12 weeks is
often recommended.
The method of prosthetic fixation influences how
aggressively activity can be initiated. This holds particularly true in the early phase of rehabilitation. Components can be classified as cemented or noncemented.
This classification can be applied to femoral and acetabular components. A combination of 1 cemented and 1
cementless component may also be utilized. All femoral
components consist of a metal stem that is inserted into
the medullary canal.23 A primary concern regarding the
femoral component is improving fixation within the
femoral canal in order to improve longevity.23 No single
system appears superior to others. Rather, selection is
based upon a multitude of individual factors. Factors
that influence component selection include the patients
individual needs, expected level of activity, bone quality
and dimensions, availability of implants, and experience
of the surgeon.23
The early standard for femoral component fixation
was implantation with acrylic-based cement. Utilization
of cemented femoral components remains a popular
choice in many cases today. A primary concern regarding the cemented technique is the potential for mechanical loosening of the prosthetic component within the
femoral canal.
In response to the concern for mechanical loosening
of the femoral component and other complications associated with cement fragmenting, numerous cementless
systems that rely on biological fixation have been developed. Most of these systems attempt to initiate bony
ingrowth upon a porous prosthetic surface. This
approach is often advocated for relatively younger, more
active individuals.
A newer development is the nonporous, cementless
femoral component. These devices may utilize an array
of surface modifications to create a macrointerlock with
13

ponents were utilized, weight bearing may be limited for


4 to 8 weeks, depending on the presence of other limiting factors. A walker is most often utilized for early gait
training. Younger or generally healthier patients may
progress to crutches as appropriate. Stair and curb negotiation, as well as car transfers should be covered as
appropriate for the patients living situation. Before discharge, ROM precautions should be reviewed and the
patient should be able to apply these to ADLs. Unless
limited by the surgeon, exercises emphasizing extension
should be addressed. This can be addressed early by
lying in a supine position without pillows underneath the
legs and progressing to time spent in the prone position.
A short-term goal of at least 10 of extension will be
required for most individuals to achieve a normal gait
pattern.
Long-term rehabilitation in the outpatient setting is
usually initiated 4 to 6 weeks after surgery. Goals of
rehabilitation at this time should include: continued
strength improvement, improvement in flexibility, ambulatory progression, return to ADLs, and return to recreational activity as appropriate. As determined by the
assigned weight-bearing status, a progression from walker or crutches to a cane can be initiated. The cane
should be utilized until the patient can ambulate without
a limp. Particular emphasis should be placed on improving the strength of hip abductor musculature. The patient
should be monitored for signs of functional weakness of
the gluteus medius muscle (Trendelenburg sign or gait).
The patient should be instructed to carry loads on the
side of the surgical procedure. Neumann and Cook30
found that loads carried on the contralateral side significantly increase the loads placed on the surgical side,
while loads up to 20% of an individuals body weight
carried on the same side as the arthroplasty produced no
more abductor electromyographic activity than ambulation alone. Stretching activities emphasizing the hamstrings and hip flexor muscle groups should be emphasized. Tightness of these muscle groups can significantly affect an individuals ability to ambulate and perform
other ADLs such as stair negotiation.
Recommendations for return to normal activities vary
by surgeon preference and are affected by individual factors. Independent ambulation may range from approximately 6 weeks to 3 months in cases of revision or structural bone grafting.23 When arthroplasty is performed on
the left hip, patients may be allowed to resume driving as
early as 6 weeks. When the right hip is involved, the
individual must be functionally tested to determine the
ability to operate a vehicle safely. Time for return to
occupational duties is affected by individual factors and
occupational demand. Some patients can return to
occupations requiring limited lifting and bending around
3 months postoperatively.23 Sexual activity may be
resumed as tolerated, given the patient adheres to ROM
precautions. Stern et al31 found that patients usually
resume sexual activity 4 to 6 weeks postoperatively.

within a short time period after the procedure. As with


any surgical procedure, the patient should be monitored
for signs consistent with the development of a deep vein
thrombosis. Nerve injury has been estimated to occur in
up to 3% of those individuals undergoing primary arthroplasty. The sciatic nerve, particularly the peroneal division, is most often affected. The femoral and obturator
nerves are compromised less often. Dislocation may
occur at any time, but the risk is greatest for the first 3
months after surgery.23 The majority of dislocations are in
a posterior direction, secondary to the dominance of the
posterior and posterior lateral approach. The rate of dislocation increases following revision procedures. Sudden pain and apparent shortening of the limb are potential indicators of dislocation. Other postsurgical complications include infection, vascular compromise, limb
length discrepancy, bladder and urinary tract complications, heterotopic ossification, femoral or acetabular
fractures, component loosening, and osteolysis.23
Specific rehabilitation principles
Though no universal postoperative protocol for total
hip arthroplasty exists, common principles exist. A complete approach to rehabilitation can be divided into preoperative, early postoperative, and long-term rehabilitation stages. The time spent at each stage varies among
individuals.
Preoperative therapy should focus on patient education and optimizing the strength and flexibility. The
patient should have realistic expectations regarding the
goals of the procedure and the progression of rehabilitation. The importance of adhering to postoperative precautions should be emphasized. Time should be allotted
to review transfer techniques, ambulation with assistive
devices, and modified performance of ADLs. Exercise
activities to preserve ROM and optimize strength while
not exacerbating symptoms should be established.
Postoperative rehabilitation usually begins the day
after the surgery. Avoiding excessive adduction can be
achieved through use of an abduction pillow. Sitting at
bedside is typically allowed 1 or 2 days postoperatively,
as long as ROM precautions are consistently followed.
Unless stability issues exist, gentle bed exercises are usually initiated at this time. Activities include active plantarflexion and dorsiflexion ROM for the ankle, isometrics
for the quadriceps and gluteal muscles, and limited heel
slide exercises for hip flexion. Rotation can be addressed
within tolerable limits, with internal rotation being limited to the neutral position. Transfers to and from the bed,
chair, and toilet should be reviewed.
Gait training may begin as soon as the second day
after surgery. The surgeon will determine the weightbearing status of the patient. The weight-bearing status
will vary depending on means of component fixation,
presence of structural bone grafts, stress risers in the
femur, and presence of a trochanteric osteotomy.23
Cemented components typically allow for a more
aggressive approach to ambulation. If cementless com14

Tests and measures


Selective tension tissue testing produced asymmetry
of results when comparing the involved to the uninvolved side. Active ROM, passive ROM, and resisted
testing did not yield deficits on the uninvolved side.
Active ROM and passive ROM were equal on the affected side. Side-to-side comparison yielded a 20 flexion
deficit and a 10 abduction deficit. End-feels for flexion
and abduction were empty and painful for the involved
hip joint. Although all other motions were symmetrical
to the uninvolved side, internal and external rotation
motions were painful at the end ROM. With the exception of internal rotation, manual muscle testing (MMT)
yielded global weakness of muscle groups crossing the
hip joint. Strength was assessed via MMT at 4/5 for flexion, extension, external rotation, and abduction. All
resistive testing elicited soreness with maximal exertion.
This was particularly evident when testing hip flexion
with an emphasis on the iliopsoas MMT position.32 The
discomfort was not as severe as the pain described as the
primary complaint. Hand-held dynamometer testing of
the gluteus medius muscle yielded 18 kilograms of force
on the right (involved) extremity, compared to 24 kilograms of force on the left (uninvolved) extremity.
Special testing for the sacroiliac joint resulted in findings listed below indicative of potential dysfunction. Palpatory assessment of pelvic landmarks in standing
demonstrated a relatively higher posterior superior iliac
spine, with lower anterior superior iliac spine and iliac
crest on the right (involved) side in comparison to the left
(uninvolved) side. Assessment in the seated position
gave the same results for posterior superior iliac spine
and iliac crest position characteristics. Increased cranial
movement of the right posterior superior iliac spine was
observed during standing and seated flexion tests. Lumbar ROM was within normal limits with an increase of
central local soreness at end-range flexion.
Special tests for the hip joint produced asymmetrical
findings between the involved and uninvolved sides that
suggested potential articular pathology. During the
Thomas test, the patient was able to fully extend the posterior aspect of the involved thigh to the table, with the
knee flexed to approximately 75 and no appreciable
deviation in the frontal or transverse planes. However,
pain was noted with overpressure at the end of the
Thomas test maneuver. The FABER test showed symmetrical motion with right groin pain and stiffness in the
region of the right sacral sulcus. The Scour test produced
groin pain accompanied by a pinching sensation. A
painful clicking sensation was also elicited when the
patients hip was brought from extension and neutral
rotation to a position of combined flexion, internal rotation, and horizontal adduction. In the authors experience this position often produces groin pain in individuals with symptomatic tears of the acetabular labrum.1 In
addition, the patient acknowledged groin pain occurring
at the end range of descent when performing a deep

There is considerable debate regarding the level of


athletic activity that is advisable for individuals undergoing total hip arthroplasty. In general, any activity that
subjects the prosthetic components to an extreme
amount, or a prolonged period, of impact loading
increases the chances of prosthetic failure. Of particular
concern is the increased stress that occurs at the bonecement interface with high-impact loading activities.
Recommended activities include: swimming, golfing,
walking, bowling, and limited dancing.26 In our clinical
practice, the authors have noted particular success with
golfers returning to regular frequency of play without
major complication. Patients should be advised regarding the amount of potential stress during particular activities as well as the potential consequences of excessive
loads across the prosthetic components.
CASE STUDIES
Case Study 1
Patient history
A 28-year-old woman physical therapist and graduate
student was referred to physical therapy with a primary
complaint of right hip pain. The patient reported a 2month history of groin pain that gradually progressed to
the point that it was limiting the majority of her ADLs.
The pain was often accompanied by a popping or clicking sensation that had not been present until the onset of
the primary complaint. Symptoms had been particularly
aggravated by walking on inclined surfaces, running,
prolonged sitting, prolonged standing, and crossing her
legs (particularly right over left). Prior to the onset of
symptoms, she was completely independent with ADLs
and participated in various general fitness activities on a
regular basis. In the last 3 weeks she reported development of discomfort in the lumbar spine and right sacroiliac region. These symptoms typically occurred in conjunction with the onset of the primary complaint of right
hip pain. Pain levels ranged from 2/10 at rest to 8/10
with symptom-provoking activities. The patient had primarily addressed the discomfort with periods of relative
rest and over-the-counter NSAIDs. This method of treatment had produced minimal change in her symptoms.
She had an appointment with an orthopaedic physician
specializing in hip disorders in 14 days.
The patient could not state a specific mechanism of
onset. She did fall off a horse onto the lateral portion of
the affected limb 2 years prior to the current episode.
The patient recalled experiencing a brief period of lateral thigh soreness and low back stiffness. These symptoms
resolved without treatment and did not cause further
complications.
Systems review
Observation yielded a 110-pound woman experiencing minimal distress at the time of evaluation. The
patients gait pattern appeared antalgic, with accompanying reports of pain. Gross assessment of lower-extremity alignment and the lumbar spine appeared within normal limits.
15

squatting motion. The amount of movement during longaxis distraction of the hip joints was deemed symmetrical with no change of symptoms noted.

lating with crutches for moderate distances at the time of


her physician office visit.
During the consultation, the physician performed a
clinical evaluation and ordered diagnostic tests for the
patient. Magnetic resonance arthrogram results confirmed the clinical suspicion of a labral tear. A decision
was made to perform arthroscopic examination and
surgery as indicated.
Intra-articular pathology was discovered during
arthroscopic evaluation of the hip joint. A tear of the
anterior superior portion of the labrum was confirmed. A
small lesion of the articular cartilage on the weight-bearing portion of the femoral head was noted. The joint capsule was deemed lax and a large degree of synovial
inflammation was noted. Biopsy of the synovial tissue
was negative for rheumatic variants. There was concern
regarding bone composition, as it was noted how easily
the arthroscopic probe could puncture the osseous surface. A future bone density study was scheduled. The
surgeon also expressed concern over the patients low
body fat composition.
As a result of the findings noted during arthroscopic
evaluation, a combination of procedures was performed.
The patient underwent debridement of the unstable
labral tear, thermal capsular modification, a microfracture procedure, and partial release of the iliopsoas tendon. The patient tolerated the procedure well without
major complications. A partial weight-bearing status of
approximately 20 pounds was assigned for 6 weeks. The
patient was to utilize a continuous passive motion
machine 4 hours per day for a total of 6 weeks. The
device was to be set between neutral and 85. She was
instructed to use a postoperative brace set between neutral and 90 flexion during the day, along with an immobilization system at night for 4 weeks. Medications consisted of Bextra (prescription anti-inflammatory medication), Vicodin (pain reliever), and 10 days of subcutaneous Fragmin injections (anticoagulant therapy).
The patient reported to physical therapy 1 day after
surgery. She was generally sore but did not report significant pain. Stationary cycling with minimal resistance
and the seat set high enough to prevent hip flexion
beyond 90 was initiated immediately. The following
exercises were started immediately and made part of the
initial home exercise program: active ankle plantar flexion and dorsiflexion, quadriceps and gluteal isometrics,
and posterior pelvic tilts. The initial treatment session
was tolerated without difficulty.
The patients second visit occurred a week from
surgery. She continued to report minimal pain at rest
(0/10 to 2/10). Local hip discomfort was slightly
increased with general mobility. The patient tolerated
passive ROM between neutral and 90 without significant discomfort. Additional exercise recommended at
this visit included hamstring isometrics, gentle rotation of
the hip as tolerated with the knee resting gently on an
exam stool, short arc knee extension, and submaximal
manually resisted hip abduction and adduction.

Evaluation, diagnosis, and prognosis


Based on the patients history, observation, and physical examination, it was determined there was a high
likelihood of hip joint involvement accompanied by
sacroiliac dysfunction. Treatment of the hip region
would focus on addressing the strength impairments
observed during physical examination. A collective
decision was made with the patient to attempt manual
treatment of the sacroiliac region and conservative treatment of the hip region. Because special tests for hip joint
involvement (Scour, FABER, and combined flexion, internal rotation, with horizontal adduction) were positive, it
was agreed that the patient should consult with an
orthopaedic physician specializing in hip disorders.
Therapy would be adjusted as advised by the
orthopaedic physician after the patients office appointment in 14 days.
Intervention
A mobilization technique for the presence of an anterior rotation of the right innominate was performed. The
patient was placed in a supine position with the therapist
standing opposite to the side being mobilized. The
patient was then placed in a position of side-bending
toward the restricted side by moving her legs and trunk.
The patient was asked to clasp her hands behind her
neck. The therapist then rotated the patients trunk
toward him without losing the side-bending position.
The therapist then placed his free hand on the anterior
superior iliac spine of the restricted side and delivered a
thrust in a downward direction. Quadruped rocking
activities and gentle lumbopelvic stabilization exercises
were recommended as part of the initial home exercise
program. The patient tolerated the technique well, but
did not report an immediate change of symptoms.
Gentle isometrics and ROM activities for the hip were
recommended. Activities included gluteal, quadriceps,
abductor, and adductor isometrics within a tolerable
range. Unresisted stationary bike riding and heel slides
were recommended as tolerated for ROM in the sagittal
plane. Closed chain activities were deferred taking into
account patient apprehension and the tendency for
symptoms to increase with weight bearing.
The patient followed up in therapy 2 times prior to the
physician office appointment. She reported the symptoms occurring in the right sacroiliac region had
decreased slightly, then remained steady at a lower level
than previously reported (5/10 with symptom-provoking
activities, compared to 8/10 before intervention). The
symptoms occurring in the right groin region gradually
increased up to the time that the patient had her consultation with the orthopaedic physician. During this time,
activities were diminished in an attempt to minimize any
further inflammatory response. The patient was ambu16

Aquatic activities were initiated 14 days postoperatively after suture removal. The initial session lasted 20
minutes and consisted of ambulation with an emphasis
placed on gait symmetry. The pool was utilized each visit for 6 weeks until the patient had permission to progress
to weight-bearing activities on land. The progression of
activities in the pool included multiple-direction ambulation, active ROM, treading, and eventually deweighted
jogging. The patient tolerated all aquatic activities with
minimal discomfort.
After 3 weeks, strength activities were gradually progressed, and the visit frequency was increased to 2 times
per week. Open chain activities for the knee and hip
were progressed as tolerated beginning 2 weeks after
surgery. The exception was supine straight leg raise exercises. This activity was held until 4 weeks secondary to
the iliopsoas release procedure that was performed.
Minimal discomfort was reported with progression of
open chain activities for the knee. Occasional groin and
lateral thigh soreness occurred after performing straight
leg raises in sidelying. This discomfort would subside
within a day of resting.
A progression of all closed chain activities was initiated at 6 weeks. At this point, frequency of therapy visits
was increased to 3 times per week. Gait progression was
comprised of ambulating with 1 crutch for increasing
distances, then following a similar progression ambulating with no assistive device. Low-level groin soreness
would occur after ambulating moderate to long distances
in the community; however, this would decrease with
relative rest of approximately 24 hours. No discomfort
was noted ambulating within the patients residential
building or university building in which she spent a considerable amount of time. A balance progression from
double to single leg activities with varying perturbation
was initiated as well. Surfaces of varying stability were
utilized as deemed appropriate for the patients skill level. Gentle spring-loaded leg press activities, hip-sled
abduction, and resisted rotation utilizing elastic tubing in
a weight-bearing position were added between 6 and 8
weeks (Figure 10). Exercise on the elliptical trainer was
initiated at 8 weeks. Minimal pain was reported during
progression of weight-bearing resistive exercise and
elliptical training. Intermittent periods of groin and lateral thigh discomfort would be reported the day after
activities. Utilization of ice and relative rest was effective in controlling this discomfort.

Figure 10. Abduction performed on a spring-loaded


reformer device. Emphasis is placed on the eccentric
component of the activity.
al muscle testing for abduction and external rotation of
the affected hip yielded a grade of 4+/5 with no discomfort. Resistive testing for adduction and extension was
graded at 5/5. Specific MMT of the iliopsoas was graded 4/5 with minor residual soreness. Symptoms indicative of sacroiliac joint involvement were not present.
Gait observation revealed no deviations with the patient
ambulating at normal walking speed.
Termination of physical therapy
Formal physical therapy at our facility was discontinued after 10 weeks due to the fact that the patient was
traveling abroad. A brief subjective follow-up was conducted over electronic mail at 12 weeks after surgery. At
that point the patient had no difficulty with ambulating
or ADLs. She was able to complete the entire prescribed
rehabilitation protocol without difficulty. She was
preparing to initiate jogging as permitted with her working and travel schedule.

Reexamination
A complete reevaluation was performed at 10 weeks
after surgery. The patient reported 0/10 pain at rest,
increasing to 2/10 with days of maximum activity. The
patient was not allowed to initiate jogging until 12 weeks
after surgery. Passive and active ROM of the surgical hip
were equal and yielded a 10 deficit in flexion and 5
deficit of internal rotation in comparison to the uninvolved limb. Tightness and pinching in the area of the
groin were noted at end range of these motions. Manu-

Case Study 2
Patient history
A 44-year-old man tae kwon do master instructor was
referred to physical therapy 1 day after undergoing
arthroscopic examination and surgery of the left hip.
17

Arthroscopic evaluation revealed an unstable tear of the


superior portion of the labrum that was subsequently
debrided. Thermal modification of the capsule was performed to address laxity that was observed under examination. A small, focal cartilage lesion was found in the
nonweight-bearing portion of the femoral head. A decision was made to defer performing a procedure for the
cartilage lesion. A single loose body was observed in the
anterior portion of the joint and subsequently removed.
The patient described an 18-month history of progressive left hip pain. The pain primarily would occur
during various forms of kicking. Initially, the discomfort
was noted to occur when rotating about the affected hip
as it served as his stance leg. Shortly after, pain would
occur in the open chain delivery position. Symptoms
would persist after practice and time to recovery progressively increased until persistent pain rated as 4/10
became the baseline condition. The pain became equally as intense during the patients regular golf outings. Prior to surgery the patient had limited his tae kwon do
instruction to include minimal physical participation and
was not participating in golf. Transitioning from a sitting
to standing position after being seated for a prolonged
period of time also exacerbated the groin pain. An occasional sensation of painful clicking and transient locking
was also reported to occur sporadically. The patient
reported accompanying low back stiffness, but he did not
feel this to be a significant factor in limiting his activity.
He had no significant prior medical history except an
elbow fracture 3 years earlier that healed without complication. After 18 months of unsuccessful conservative
treatment, the patient was referred to an orthopaedic surgeon specializing in hip disorders. Clinical examination
and MRA revealed a labral tear. A decision was made to
perform arthroscopy on the affected hip.

neutral to 80 of flexion. Isometric contraction for hip


abduction, adduction, and extension as well as knee
extension and flexion could be initiated in all directions
against gentle resistance. There was no evidence of postoperative complications.
Evaluation, diagnosis, and prognosis
After the physical examination, it was deemed that
the patient should receive physical therapy on a regular
basis with the long-term goal of returning to his duties of
instructing tae kwon do students. The patient would
attend physical therapy 1 time per week for the first
month, 2 times per week for the second month, and 3
times per week for an additional month. An attempt
would be made to test and simulate the activities that the
individual would have to return to before discharge from
therapy.
Intervention
The patient was issued the standard postoperative
exercises that included ankle ROM as well as quadriceps, hamstring, abdominal, and gluteal isometric activities. Twenty minutes of unresisted pedaling on the stationary bike was also performed. He reported no difficulty with the initial session.
The 3 weeks following surgery consisted of a gradual
therapeutic exercise progression. Active and light resistive activities for the knee and ankle were prescribed.
Active abduction and extension exercises for the hip
were gradually introduced as tolerated. The patient was
instructed on how to perform gentle active assisted ROM
for rotational movement. Emphasis was placed on performing all activities in a range that created minimal discomfort. An aquatic ambulation and exercise progression was initiated after 10 days. During this time, the
patient reported minor groin discomfort and occasional
low back stiffness for up to 24 hours after therapy. Ice
compression and relative rest for approximately 24 hours
were recommended to help moderate this response. At
the end of 3 weeks the patient was able to ambulate
without discomfort and felt ready to begin a weight-bearing and functional progression.
At 3 weeks after surgery, a weight-bearing progression
was initiated. To avoid initiation of an inflammatory
reaction, weight-bearing activities were initially performed in supine utilizing a spring-loaded leg press. This
allowed both double and single leg activities to be performed at a selected proportion of the individuals body
weight. Once tolerance in the supine position was
established, a progression of weight-bearing squatting
activities was followed. Range of motion was adjusted to
avoid the anterior pinching sensation that the patient
would occasionally report at end-range flexion. It was
thought that this sensation may be due to approximation
of inflamed soft tissue at end-range flexion. This sensation diminished by 6 weeks after surgery. The elliptical
trainer was utilized starting 6 weeks after surgery.

Systems review
The patient reported to the clinic ambulating on
crutches and in a postoperative brace. He reported 1/10
pain at rest and 6/10 pain with movement during basic
mobility. The discomfort occurred in the groin and lateral thigh area. The patient denied any low back discomfort or sensation alteration in the surgical limb. The
patient was assigned a partial weight-bearing status of
approximately 20 pounds for 3 weeks by the orthopaedic
surgeon. He was to wear the postoperative brace and
utilize a night immobilization system for 4 weeks. A
continuous passive motion machine was to be utilized 4
hours per day, for a total of 4 weeks. The patient was prescribed the standard postoperative antibiotic medication,
anti-inflammatory drug, anticoagulant, and pain control
medication.
Tests and measures
All patients undergoing hip arthroscopy in the
authors facility receive a basic postoperative physical
examination. The patient experienced minor groin discomfort during passive ROM in the allowed range of
18

Activities to improve proprioception were initiated in


conjunction with the weight-bearing progression. Initially, the patient was unable to maintain a single leg
stance for 25 seconds. After 3 sessions the patient was
able to hold a single leg stance position in excess of 30
seconds with his eyes closed. A progression of single leg
activities on variable surfaces and with various perturbation techniques was initiated.
The demands of the patients occupation required a
significant amount of flexibility in all planes of motion at
the hip joint. Stretching was initiated for the hamstring
muscle group and the iliotibial band at 3 weeks after
surgery. Flexibility activities for the adductor muscle
group, rectus femoris muscle, and iliopsoas muscle were
deferred until 4 weeks after surgery. We have observed
that caution must be exerted when actively or passively
creating tension across the hip flexor muscle group. If
not monitored carefully, symptoms resembling tendonitis
may develop with excess activity. The patient did experience an increase of resting groin pain when stretching
the iliopsoas muscle approximately 6 weeks after
surgery. Stretching of this muscle group was deferred for
5 days, and NSAIDs were resumed. The symptoms
reduced to baseline in 5 days, and stretching was
resumed with caution. At 8 weeks after surgery, the
patient was allowed to carefully begin stretching activities specifically utilized during conditioning for tae kwon
do. The patient had minimal discomfort while progressing to stretching daily.
Lumbopelvic and rotational stability of the hip were
of particular concern in this patients case. The level of
tae kwon do that he participated in required rapid movement of the peripheral limbs while maintaining central
stability of the trunk and pelvis. A specific progression
towards kicking was initiated. The patient began by kicking in the pool at a reduced speed, utilizing the affected
limb for both kicking and stability. Exercises involving
rapid external and internal rotation against a resistive
tubing system in a weight-bearing position were prescribed. Activities for lumbopelvic stabilization were initiated on the physioball and later progressed using external influences such as medicine balls. As components of
the routine were deemed tolerable, various motions were
combined with a progression of performance speed. By
10 weeks after surgery the patient was able to kick unopposed with minimal groin pain after repetitive kicking
drills. Occasional discomfort and stiffness of the lateral
and posterior thigh would develop a few hours to a day
after repetitive kicking activities. This was deemed an
appropriate reaction to activity of this nature, due to the
patients relatively low level of activity over a significant
period of time since the surgery. When this was
observed, additional recovery time allowed the symptoms to diminish.
The final stage of rehabilitation for this patient
emphasized the development of power and attenuating
loads with landing. Plyometric activities were initiated

approximately 11 weeks after surgery. These activities


were utilized to develop the power and speed required
to return to the patients previous level of training. Activities initially consisted of stepping and dropping off boxes of varying heights, emphasizing landing technique.
Shortly after, single plane jumping tasks were added to
the program. The patient did report occasional groin
pain upon landing. This complaint was carefully monitored and became less frequent with time. The patient
reported minimal difficulty progressing to multiple level
box jumps by 14 weeks after surgery.
Reexamination
The patient was reexamined in detail approximately
14 weeks after surgery. Passive and active ROM of the
involved hip were symmetrical except for an 8 deficit of
flexion and a 3 deficit of internal rotation with the hip
in both neutral and 90 of flexion. Groin pain could only
be elicited with overpressure at the end range of internal
rotation and horizontal adduction. Strength was symmetrical with the exception of the iliopsoas and gluteus
medius muscles. The iliopsoas muscle was graded 4/5
with slight groin discomfort, while the gluteus medius
muscle was graded at 4+/5 with no discomfort.
Termination of physical therapy
Formal physical therapy ended 14 weeks after surgery.
At this time the patient had no difficulty with ADLs. He
did report increased hip joint and low back stiffness on
long car trips he had to frequently take to teach and lecture. The patient was able to golf 18 holes without pain
during or after the activity. He was back to demonstrating techniques in class but had not initiated full-contact
activities. The patient reported that he was not planning
on participating in a significant amount of full-contact
activities in the future. Because the patient was able to
complete all desired activities at this time, it was agreed
he would be discharged and continue to follow the protocol designed during his course of rehabilitation. In a
1-year follow-up over the telephone, the patient reported
resumption of instructing tae kwon do at all levels as prior to the surgery and with minimal complaints of pain.
Case Study 3
Patient history
A 57-year-old woman was referred to physical therapy 3 weeks after undergoing a total hip arthroplasty procedure for the right lower extremity. The patient received
a porous cementless femoral component paired with a
cementless acetabular component. A cementless
femoral component may have been chosen to decrease
the chance of component loosening (compared to a
cemented prosthetic component) in this relatively young
and active individual. A posterior lateral approach was
used to perform the surgical procedure. The patient had
stayed in the hospital for 4 days after surgery, without
unexpected complications occurring.
19

She lived in a 1-story home with her husband, which


had 4 steps and bilateral rails to enter. At the time of
evaluation, the patient stated she had no difficulty with
ambulation using the walker, negotiating the stairs outside of her house with minimal assistance from her husband, or transfers. The patient was told by her
orthopaedic surgeon to use the walker for 4 weeks, after
which she could progress her weight-bearing status as
deemed appropriate by her physical therapist.
The patient had a history of progressive hip pain and
general loss of mobility over a 6-year time period. The
symptoms were gradual in nature with no specific mechanism of onset. She decided to seek a physicians advice
when her ability to ambulate and negotiate stairs became
significantly limited. Diagnostic imaging revealed
degenerative joint changes deemed secondary to
osteoarthritis. The patients past medical history was significant for hypertension and high cholesterol, which
were medically controlled at the time of evaluation. A
collective decision was made to undergo elective total
hip arthroplasty.
Before the onset of progressive pain, the patient led a
physically active lifestyle that included walking approximately 1 to 3 miles on a regular basis, as well as golfing
regularly during the summer months. She held a fulltime job as a secretary at an accounting firm but currently was not working secondary to her postoperative
status. The patients goals included returning to independent ambulation and ADLs without pain, as well as
returning to golf and a regular walking schedule. She
currently experienced minimal pain at rest. The patient
did report stiffness upon rising in the morning and the
development of anterior and lateral thigh discomfort after
ambulating with the walker in public or transferring frequently throughout the day. She rated the pain 4/10 at
worst. Her assigned home exercise program from the
hospital included: ankle active ROM, quad sets, gluteal
sets, heel slides, submaximal isometric abduction and
adduction, standing hip flexion, and standing hamstring
curls.

the hamstrings and rectus femoris was performed. The


patient was able to ambulate with the walker in the clinic on a level surface for approximately 350 feet before
stopping secondary to general fatigue and increasing
groin soreness.
The patient was able to demonstrate full comprehension and application of postoperative precautions. Given the posterior lateral approach that was utilized, she
was to avoid excessive adduction (no crossing legs), flexion (no bending forward while sitting), and internal rotation to decrease the chance of posterior joint dislocation.
She was still sleeping with an abduction pillow, which
was to be utilized for a minimum of 4 weeks after the
procedure.
Evaluation, diagnosis, and prognosis
After the physical examination was complete, it was
decided that the patient should participate in physical
therapy on a regular basis with the long-term goals of
returning to full community ambulation, stair negotiation, ADLs, and golfing. The patient would attend therapy 1 time per week for 2 weeks; then, after reaching full
weight-bearing status, she would attend therapy 2 times
per week for approximately 2 to 3 months as appropriate.
Intervention
The first visit focused on reviewing and modifying the
patients existing home exercise program. Standing
abduction within the walker was added to the protocol.
The patient was able to demonstrate and tolerate the
modified home exercise program without difficulty.
The patient reported to the second therapy session
with little change of status. The second session focused
on initiation of weight-bearing activities and ambulation
with a standard cane. Stretching of the hamstring and
hip flexor muscle groups was also emphasized. The
importance of obtaining extension (at least 10 for normal gait) was communicated to the patient. Before
attempting ambulation, multidirectional weight shifting
and half squats were performed within the walker. After
an explanation of the proper technique, the patient
attempted ambulating with the cane. She demonstrated
difficulty stepping through on the affected leg. The primary reason for this was apprehension; pain was minimally increased with the activity. At the conclusion of
the session, the patient was assigned weight-shifting
activities using the cane to increase tolerance of movement into extension during weight bearing.
The patient reported to the third session reporting significant improvement regarding tolerance of weight
bearing. She demonstrated the ability to ambulate using
symmetrical step lengths with the cane. This session
focused on stair negotiation using the cane and 1 rail.
Range-of-motion measurements were taken at the conclusion of the session. The patient demonstrated
improvement of extension (12) and external rotation
(34) of the affected hip.

Systems review
Observation yielded a 57-year-old, medium-build
woman in minimal distress. With the walker, there were
no obvious postural asymmetries. The patient appeared to
be distributing weight symmetrically in her static stance.
Tests and measures
A standard postoperative physical examination was
performed on the patient. Significant passive ROM
deficits included a measurement of 8 extension on the
right compared to 17 on the left, and 23 of external
rotation on the right compared to 41 on the left. Maximal effort MMT was deferred at the time of evaluation.
However, it was noted the patient demonstrated a 12
difference between passive and active abduction in sidelying and groin pain with active flexion of the involved
hip. Tightness was observed when flexibility testing of
20

The next 2 weeks focused on increasing flexibility,


functional strength, and balance. The patient initially
demonstrated a significant Trendelenburg sign. Weight
was added to sidelying straight leg raises, and single leg
balance activities with an emphasis on keeping the
pelvis level were initiated. The patient did report an
increase of posterior lateral thigh soreness with the
strengthening progression. This was treated successfully
with cold modalities and 1 to 2 days of rest during times
of significant soreness.
After sufficient ability to ambulate and negotiate stairs
with the cane and maintain static balance was established, the focus of treatment was placed on independent
ambulation and mobility. The patient initially had difficulty loading on the affected extremity during the stance
phase of gait. The patient did not feel this was secondary
to pain. Passive and active extension of the affected hip
was 15 at this time. Gluteus medius and maximus MMT
was judged as 4+/5. Due to these findings and selfreport, it was deemed that apprehension was the primary limiting factor. A decision was made to initiate an
aquatic-based ambulation program. The patient practiced ambulation in waist-high water. An emphasis was
placed on symmetry of step length and stance time of the
surgical leg. The patient tolerated this activity well with
no adverse reaction. Over the course of the next 2
weeks, the patients gait improved dramatically.
After 6 weeks of physical therapy, the patient reported no major difficulty with ambulation, stair negotiation,
driving, or occupational duties. The remainder of treatment sessions focused on increasing tolerance to extended ambulation and returning to golf activities. Ambulation distance was increased approximately 10% per
week, walking every other day. As she accommodated to
this, variable inclines and walking surfaces were added
to the walking regimen. The patient had minimal difficulty with this progression.
The patient decided to attempt 9 holes of golf on her
own 8 weeks into physical therapy. She reported difficulty generating club speed and soreness of the anterior
thigh the day after activity. This pain was rated 3/10 and
lasted 2 days. The patient was instructed to hold off on
playing golf until an appropriate progression could be
established.

A progression of activities was developed to ensure a


safe transition to golf activities. Additional stretching,
with a focus on external rotation, was prescribed. Rotational strength was addressed. Initially, internal and
external resistance exercises were performed in an open
chain fashion utilizing cuff weights and resistive bands.
As treatment progressed, internal and external rotation
activities were performed in weight bearing utilizing an
elastic tubing system that wrapped around the patients
pelvis. The patient also practiced swinging a golf club
against resistance. Finally, a progression back to full golf
activity was initiated. This consisted of driving range
activities, 9 holes of golfing, and then a full course of
golfing. She was initially allowed to participate 1 time
per week. By the conclusion of physical therapy, the
patient was golfing 3 times per week. The patient did
note occasional soreness the day after full course play.
She noted this rarely lasted more than 24 hours and was
relieved with cold modalities and stretching.
Reexamination
After 12 weeks of physical therapy, the patient reported no pain with ambulation, stairs, ADLs, or occupational duties. She was able to golf, with occasional discomfort the day after playing. This discomfort was rated
at 2/10 at worst and lasted very briefly. The patient
demonstrated 15 of extension and 39 of external rotation for the surgical hip. Gluteus medius and maximus
strength of the surgical hip was 5/5, and hip flexion was
4+/5. She was walking approximately 1 mile, 3 times per
week, with minimal discomfort
Termination of physical therapy
After 12 weeks of treatment, a decision was made to
end physical therapy services. This decision was made
based upon the objective findings for ROM, strength,
and functional capacity, as well as the patients satisfaction with results. The patient planned to continue golfing and gradually increasing her walking distance. During a 6-month follow-up session with the physician, the
patient reported minimal difficulty with all activities.
She did have occasional anterior thigh discomfort after
multiple golfing sessions, which she stated was very brief
and rated at 1/10.

21

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