Beruflich Dokumente
Kultur Dokumente
of Orthopaedic Surgeries
CONTINUING
PHYSICAL THERAPY
EDUCATION
Bryan T. Kelly, MD
University of Pittsburgh Medical Center
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
CONTINUING
Postoperative Management of
Orthopaedic Surgeries
PHYSICAL THERAPY
EDUCATION
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
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.
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.
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
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.
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
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
Microfracture
Stationary bike
Immediately
Immediately
Immediately
Gentle quadriceps,
hamstring, and gluteal
setting
Day 2
Day 2
Day 2
Weeks 1 to 2: flexion
from 0 to 90
Weeks 1 to 2: flexion
from 0 to 90
Variable
Stretching
After 3 weeks
After 3 to 4 weeks
Resistance exercise
Typically 10 days to 4
weeks
Typically 4 to 8 weeks
Functional activities
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
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
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.
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
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
Failed Reconstruction
Osteotomy
Cup arthroplasty
Femoral head prosthesis
Girdlestone
Total hip replacement
Resurfacing arthroplasty
Tuberculosis
*Adapted and reprinted with permission from Campbells Operative Orthopaedics.23 Copyright 1998, with permission
from Elsevier.
12
squatting motion. The amount of movement during longaxis distraction of the hip joints was deemed symmetrical with no change of symptoms noted.
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.
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
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
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
21
REFERENCES
17. Gruen GS, Sciosa TN, Lowenstein JE. The surgical
treatment of internal snapping hip. Am J Sports Med.
2002;30:607613.
18. Faraj AA, Moultan A, Sirivastava VM. Snapping iliotibial band. Report of ten cases and review of the
literature. Acta Orthop Belg. 2001;67:1923.
19. Kim DH, Baechler MF, Berkowitz MJ, Rooney RC,
Judd DB. Cox saltans externa treated with Z-plasty of
the iliotibial tract in a military population. Mil Med.
2002;167:172173.
20. Byrd JW. Lateral impact injury: a source of occult hip
pathology. Clin Sports Med. 2001;20:801815.
21. Byrd JW. Hip arthroscopy. The supine position. Clin
Sports Med. 2001;20:703731.
22. Potter HG, Linklater JM, Allen AA, Hannafin JA,
Haas SB. Magnetic resonance imaging of articular
cartilage in the knee. An evaluation of fast-spin-echo
imaging. J Bone Joint Surg Am.1998;80:12761284.
23. Canale ST, ed. Campbells Operative Orthopaedics.
9th ed. New York, NY: Mosby; 1998:296461.
24. Ranawat CS, Atkinson RE, Salvati EA, Wilson PD Jr.
Conventional total hip arthroplasty for degenerative
joint disease in patients between the ages of forty and
sixty years. J Bone Joint Surg Am. 1984;66:745752.
25. McDonald I. Bilateral replacement of the hip and
knee in rheumatoid arthritis. J Bone Joint Surg Br.
1982;64:465468.
26. Wegener ST, Belza BL, Gall EP, eds. Clinical Care in
Rheumatic Diseases. Atlanta, Ga: American College
of Rheumatology; 1996.
27. Drinker H, Murray WR. The universal proximal
femoral endoprosthesis: a short-term comparison
with conventional hemiarthroplasty. J Bone Joint
Surg Am. 1979;61:11671174.
28. Bochner RM, Pellicci PM, Lyden JP. Bipolar hemiarthroplasty for fracture of the femoral neck. Clinical
review with special emphasis on prosthetic motion.
J Bone Joint Surg Am. 1988;70:10011010.
29. Phillips TW. The Bateman bipolar femoral head
replacement. A fluoroscopic study of movement over
a four-year period. J Bone Joint Surg Br. 1987;69:
761764.
30. Neumann DA, Cook TM. Effect of load and carrying
position on the electromyographic activity of the gluteus medius muscle during walking. Phys Ther.
1985;65:305311.
31. Stern SH, Fuchs MD, Ganz SB, Classi P, Sculco TP,
Salvati FA. Sexual function following total hip arthroplasty. Clin Orthop. 1991;269:228235.
32. Kendall FP, Kendall McCreary E, Provance PG. Muscle Testing and Function. 4th ed. Baltimore, Md:
Williams & Wilkins; 1993.
22