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Hip Arthroscopy for Labral Tears and Femoral Acetabular Impingement: The Latest

in Post-Surgical Rehabilitation.

Thank You AZATA!!

Course Faculty

• Scott Cheatham PT, DPT, PhD(c), OCS, ATC, CSCS

– Assistant Professor, Division of Kinesiology

California State University Dominguez Hills, Carson CA.

Objectives

At the conclusion of this presentation the participant will be able to:

• Discuss common arthroscopic techniques for intraarticular hip pathology.

• Discuss post-operative intervention programs after hip arthroscopy.

• Discuss the latest evidence on risk factors and suggested strategies for reducing future pathology.

• Discuss emerging diagnoses classified as external hip impingement.

Types of FAI Progression of Hip Labral Pathology

Excessive loading of the labrum (FAI)

Fraying of the articular margin of the anterior

labrum

Tearing along the articular margin of the

anterior labrum

Delamination of the articular cartilage from

the articular margin adjacent to the labral

lesion

Global labral and articular cartilage

degeneration

McCarthy JC, Noble PC, Schuck MR, et al. The Otto E Aufranc Award the role of labral lesions to development of early degenerative hip disease. Clin Orthop. 2001;393:25–37

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Types of Acetabular Labral Tears

Hip Arthroscopic Surgery

Overview

OSI PROfx Orthopaedic Table. Available at www.osiosi.com/profx.cfm

Orthopedic Table: Patient Positioning

Types of Arthroscopic Surgery

Hip Arthroscopy

OsteoplastyRim Trimming

Chondroplasty MicrofractureAcetabular

Labral Repair

Capsular Plication and

Closure

Osteoplasty Rim Trimming

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Chondroplasty & Osteoplasty

Open Procedure: Measuring the Femoral Head

Arthroscopic: Reshaping of the Femoral Head

Microfracture

Hip Labral Refixation

Arthroscopic Repair Open Repair

Refixation

Autograft or Allograft

Hip Labral Resection Capsular Plication

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Post-Operative Rehabilitation

The Evidence

CEBM Levels of Evidence

Levels of Evidence Grading Criteria

A: Systematic Review of RCT’s

Level 1 B: Individual RCT with narrow CI

C: Series of cases (all or none)

A: Systematic review of cohort studies

Level 2 B: Individual cohort study, RCT with drop outs >20%

C: “Outcomes” Research or ecologic studies

Level 3 A: Systematic Review of case-control studies

B: Individual case-control

Level 4 Case Series

Level 5 Expert’s opinion

OCEBM Levels of Evidence Working Group*. "The Oxford Levels of Evidence ".

Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653

Systematic Reviews

• Cheatham SW, Enseki KR, Kolber MJ. Post-Operative Rehabilitation after Hip Arthroscopy: A Search for the Evidence. J Sports Rehab. 2014; Nov 12. [Epub Ahead of Print]

• Grzybowski JS, Malloy P, Stegemann C, Bush-Joseph C, Harris JD, Nho SJ. Rehabilitation Following Hip Arthroscopy - A Systematic Review. Front Surg. 2015;2:21-25.

Systematic Reviews Level of Evidence

• Cheatham et al. 2014

– Level 4 evidence (N=6)

– Included only research that measured post-operative rehabilitation

– Found 20 clinical commentaries on post-operative rehabilitation

• Grysbowski et al. 2015

– Level 1 evidence (N=1)

– Level 3 evidence (N=2)

– Level 4 evidence (N=15)

– Included research that reported post-operative rehabilitation

Systematic Review

• Summary– A paucity of evidence exists regarding post-operative

rehabilitation after hip arthroscopy. Most of the literature comes from:• Case reports/series (level 4 evidence)

• Clinical commentaries (level 5 evidence)

– A consensus on the best program has yet to be determined.

– The existing evidence suggests that a 4 to 5 stage program with an initial period of weight-bearing and mobility precautions is efficacious in regard to function, patient satisfaction, and return to competitive level athletics.

Post-Operative Rehabilitation

Criterion Based Protocol

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Hip Arthroscopic Rehabilitation ProtocolSpecial Considerations

Procedure PROM WB CPM Brace

Osteoplasty Rim Trimming

No limits FWB X 21 days then 50% (1 wk)

4-6 hrs (3 days) then 1-2 hrs (wks)

21 days

Chondroplasty No Limits WBAT 4-6 hrs (3 days) then 1-2 hrs (wks)

None

Microfracture No Limits FFWB (6-8 wks) 4-6 hrs (6-8 wks) None

Labral Repair Flexion up to 120ABD up to 45No ER (17-21 days) No Ext > 0 (17-21 days)

NA 4-6 hrs (3 days) then 1-2 hrs (wks)

17-21 days

Capsule Plication and Capsule Closure

Flexion up to 120ABD up to 45No ER (17-21 days) No Ext > 0 (17-21 days)

NA 4-6 hrs (3 days) then 1-2 hrs (wks)

17-21 days

* CPM- May still be prescribed. Primarily used to move the LE for nutrition and maintain ROM

Case Report 2012

• Cheatham SW, Kolber MJ. Rehabilitation after Hip Arthroscopy and Labral Repair in a High School Football Athlete. Int J Sports Phys Ther. 2012 April; 7(2): 173–184.

Case History

• Patient: – 18- year-old senior male high school athlete – 210 lbs. with muscular build and excess body fat

• Mechanism: – Insidious onset of deep “anterior groin pain” for one year prior to diagnosis. – Intermittent “groin” pain during and after physical activity which eventually

became more severe.

• Diagnosis: – Left mixed cam-pincer femoroacetabular impingement with an anterosuperior

labral tear.– Confirmed by MRA

• Surgical Intervention: – Acetabular and femoral head osteoplasty & chondroplasty, capsular

synovectomy, plication, and an anterior superior labral repair.

• Post-Surgical Orders: Evaluate and treat with crutch ambulation (WBAT)

*Please see publication for more details

Mixed Impingement

• Combined. Combined impingement just means that both the pincer and cam types are present.

Assessment

• Pain: – (4-5/10) with left hip flexion/adduction

• Posture & Gait: – Compensatory right trunk shift in an effort to unload the affected

left limb in standing and gait ambulation with crutches.

• ROM:– Decreased left hip ROM in all planes due to pain and

“apprehension” by the patient.

• Strength & Muscle Length: – General weakness (3/5) and decreased length of the left hip

musculature (rectus femoris, hamstrings, abductors/ITB)

• Palpation:

– Tenderness in the anterior hip musculature.

• Pelvic and LE Neurovascular Screen: (-) for medical “red flags”

Post-Operative Program

Four (4) Criterion Based Phases

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Phase I

Phase I: Guidelines

• Focus: Protect the repaired tissue, restore ROM, control pain & inflammation, and restore neuromuscular control.

• Criteria to advance to Phase II: Full weight bearing, minimal pain with phase I activity, ROM ≥ 75% of the uninvolved side, and proper muscle firing patterns.

• Precautions: Avoid hip flexor pain and following ROM & weight bearing restrictions. An external brace may be worn.

Phase I: Parameters

• Range of Motion: AAROM/AROM/PROM

– Upright bike riding, ankle pumps, towel slides, prone lying, quadruped rocking, and standing IR/ER with chair

• Strengthening:

– Isometrics for the hip and leg muscles, resisted prone IR/ER, three way leg raises, sidelying clams, double leg bridges, leg press.

• Stretching:

– Gluteals and hamstrings

– Hip flexor & adductor stretching began at 4 weeks.

• Manual Therapy:

– PROM and joint mobilization (began at 5 weeks due to plication)

• Home Program:

– Daily prone lying and passive range of motion.

Phase I: Manual Therapy

Circumduction• Beck (2008) found adhesion

formation between the joint capsule and the resected femoral neck which may lead to soft tissue impingement by squeezing the acetabular labrum during hip flexion and internal rotation.

(a) (b)

(c)

Fig 2. Hip Circumduction (Clockwise)

a) Starting position b) Hip external rotation + abduction

c) Hip adduction + internal rotation

Phase I: AROM Activity

Chair External Rotation Chair Internal Rotation

Phase II

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Phase II: Guidelines

• Focus: Protect the repaired tissue, restore ROM, restore a normal gait pattern, and progressively increase muscle strength.

• Criteria to advance to Phase III: Pain-free gait, full painfreeROM, hip flexion strength >60% of the uninvolved side, all other hip motions (abd, add, ext, IR, ER) strength >70%

• Precautions: Avoid forceful or ballistic stretching, no treadmill, and preventing hip flexor and joint irritation.

Phase II: Parameters

• Range of Motion: AAROM/AROM/PROM

– Continue with Phase I activity

• Strengthening:

– Phase I activity with the addition of: bilateral squats, side stepping, and ¼ lunges (sagittal & frontal plane).

• Stretching:

– Phase I stretching continued with the addition of foam rolling

• Cardiovascular:

– Elliptical & upright stationary bicycle

• Manual Therapy:

– Soft-tissue mobilization (Iliopsoas), PROM, and joint mobilization

• Home Program:

– Phases I & II activity and the addition of the elliptical and upright bike

Illiopsoas Level I (Opposite Side) Illiopsoas Level II (knee supported)

Illiopsoas Level III (Hip Flexed) Illiopsoas Level IV (Hip Movement)

Phase II: Manual Therapy

Phase III

Phase III: Guidelines

• Focus: Further restore muscular endurance & strength, improve cardiovascular endurance, and optimize neuromuscular control, balance, and proprioception

• Criteria to advance to Phase IV: Hip flexion strength >70% of the uninvolved side, all other hip motions (abd, add, ext, IR, ER) strength >80% of the uninvolved side, cardiovascular fitness equal to pre-injury level, and ability to participate in controlled initial agility drills

• Precautions: Avoid forceful or ballistic stretching, no treadmill, preventing hip flexor and joint irritation, and avoiding contact sports.

Phase III: Parameters

• Range of Motion: AAROM/AROM/PROM

– Continue with Phase I and II activity

• Strengthening:

– Continue with Phase II activity with the addition of multidirectional closed kinetic chain (CKC) exercises and basic movement on the TRX© suspension training system were introduced including (e.g. single leg squats, side lunges).

• Abdominal Core:

– Progressive core exercises using the TRX© suspension training system (e.g. suspended planks, gluteal bridges).

• Stretching:

– Basic stretching and self-myofascial release techniques were continued with emphasis on the rectus femoris, hip flexors, tensor fascia lata, and adductors .

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Phase III: Parameters

• Cardiovascular:

– Elliptical & upright stationary bicycle

• Manual Therapy:

– Soft-tissue mobilization(Iliopsoas), PROM, and joint mobilization

• Home Program:

– Phases I to III activity and the continuation of cardiovascular conditioning with the elliptical and stationary bike.

Phase III: CKC Activity

Phase III: Core Exercises

Phase IV

Phase IV: Guidelines

• Focus: Work towards returning to competition

• Criteria to advance to Phase IV: Hip flexion strength >85% of the uninvolved side, full pain-free ROM, ability to perform sports specific drills at full speed, and successful completion of any sports related testing.

• Precautions: Pain free activity

Phase IV: Parameters

• Range of Motion: AAROM/AROM/PROM

– Continue with Phase I to III activity as needed

• Strengthening:

– Continue with phases I to III activity as needed. Sports specific activity introduced such as: low level plyometrics, multi-directional agility drills, and circuit training. Progressive jogging activity began at 12 weeks.

• Abdominal Core:

– Advanced core strengthening exercises on the TRX© (e.g. mountain climbers).

• Stretching:

– Phases I to III activity as needed with the addition of a dynamic warm-up.

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Phase IV: Parameters

• Cardiovascular:

– Elliptical & upright stationary bike, jogging

• Manual Therapy:

– Soft-tissue mobilization and joint mobilization as needed.

• Home Program:

– Phases I to III activity and the introduction of jogging for cardiovascular conditioning. Eventual return to sports specific activity.

Phase IV: Advanced Activity

Discharge & Follow-Up

• Discharge, 1-month, and 4-month post-discharge

– Discharge: 16 weeks of rehabilitation

– Pain: 0/10 with all activity

– Left Hip: Full pain-free ROM, MMT 5/5, no signs of impingement

– Neuromuscular control: Good control with single leg and multidirectional activity.

– Muscle length: Mild muscle length deficits in the hamstrings and hip flexors.

– Return to sport: Training for season and returned to full pain-free unrestricted activity

– Home Program: Continued maintenance exercises by patient

Post-Surgical Rehabilitation Pearls

• Phase I: – Try and avoid intra-articular adhesions and Iliopsoas

irritation. Gain early hip strength and neuromuscular control.

• Phase II-III: – Monitor deep hip flexion and motions of impingement.

Restore myofascial restrictions of hip musculature. Add additional abdominal core exercises.

• Phase IV: – SL multi-direction hip control should one criteria for return

to activity. Restore total body conditioning.

• * Special Testing: – Should be included in each phase as a repeated measure

(FADIR, FABER)

Case Report: 3.6 year Follow-Up

• Cheatham SW, Kolber MJ. Rehabilitation after Hip Arthroscopy and Labral Repair in a High School Football Athlete: A 3.6 Year Follow-Up with Insight into Potential Risk Factors. Int J Sports Phys Ther. 2015; 10 (4):530-539

Case History

• Patient:– 21- year-old male with a mesomorphic build. – He finished collegiate football in 2013 and was still a student finishing his

degree coursework.

• Primary Complaint: – Insidious onset (3 months ago) of right “deep anterior groin pain” after

activity. – 3/10 pain after 30 min. of weight training, jogging, and sports (e.g.

basketball).

• Mechanism:

– Right hip pain described as “similar to his left hip” (no known mechanism)

• Diagnostics: Not available for right hip.

• Self-Referral:– Patient seen via direct access for examination of primary complaint

*Please see publication for more details

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Assessment

• Posture: – Moderate sway back with an anterior tilted

pelvis

• Gait: – Right lower extremity demonstrated a

shortened stride which decreased the cadence.

• Function:– Bilateral squats: limited to 80-90⁰

– Single leg squat: Knee valgus collapse (40-60⁰)

– Multidirectional: Knee valgus collapse

• Palpation:

– Tenderness in the anterior hip musculature

Assessment

• ROM:– AROM/PROM: Decreased right hip flexion (100⁰) and

internal rotation (30⁰)

• Muscle Length: – Decreased hamstring, rectus femoris, and hip flexor

length.

• Muscle Strength: – 4/5 in all hip muscles, 5/5 knee & ankle

• Special Testing: – (+) FADIR Test

• Sensitivity: 75-100%, specificity: 10-100%

– (+) FABER Test • Sensitivity:44-100% , specificity: 57%-100%

* Limitations: Exam repeated from 2012 for direct comparison. No PRO’s, digital goniometry, or HHD used.

Clinical Decision Making

• Diagnosis:– Possible right hip FAI and labral pathology.

• Plan:– Referral to Orthopedic Surgeon for examination and possible magnetic

resonance arthrography.

• FAI: sensitivity: 91%, specificity: 80%

• Labral Tear: sensitivity: 87%, specificity: 64%

• Risk Factors: Identified 3 risk factors

– Extreme pelvic position

– Muscle weakness

– Age and gender

Risk Factors

Re-Injury or Future Occurrence

Extreme Pelvic Position

Anterior Tilted Pelvis Posterior Tilted Pelvis

Ross et al. 2014; Lewis et al. 2007, 2015)

Muscle Weakness

• Hip flexors (Casartelli et al. 2011,2012)

• Hip extensors (Lewis et al 2007, 2015)

• Hip abductors (Cheatham and Kolber 2012, 2015)

• Hip adductors (Hunt et al. 2013)

• Hip external rotators (Hunt et al. 2013)

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Gender and Age

• Risk for Bilateral FAI

– Younger males with radiographic findings of a higher hip alpha angle (> 50-55⁰) and acetabular anteversion (Klingenstein et al. 2013)

Extra-Articular Hip Impingement

A New Diagnostic Category

Emerging Findings

• A subset of individuals who undergo arthroscopic hip surgery have poor outcomes.

• This growing subpopulation suggests an underlying pathology may be missed during the initial examination of a suspected intra-articular pathology.

• There is an emerging group of external hip impingement conditions that may be linked to this subpopulation.

• Four (4) specific conditions have been identified

Subspine Impingement

• Pathology: A prominent AIIS abnormally contacts the distal femoral neck during hip flexion.

– Due to an avulsion injury to the AIIS from excessive muscle activity of the rectus femorisduring repetitive knee flexion and hip extension.

• Patient: Average age: 14–30 years

• Gender: Males more than females

• Clinical Presentation:

– Complaint: "anterior hip pain”

– (+) Pain with hip flexion

– (+) Radiograph for prominent AIIS

A) Subspine Impingement

Central Iliopsoas Impingement

• Pathology: 1. A repetitive traction injury of the

iliopsoas tendon that is scarred and adherent to the capsule-labrum complex of the hip.

2. A tight or inflamed iliopsoas tendon that causes impingement during hip extension.

• Patient: Average age: 19-35 years

• Gender: Females more than males

• Clinical Presentation: – Complaint: “anterior hip pain”

– (+) Pain with hip flexion

– (+) Positive hip impingement test

– (+) MRA B) Iliopsoas Impingement

Ischiofemoral Impingement

• Pathology:

– A narrowed space between the ischial tuberosity and the lesser trochanter resulting in repetitive impingement of the quadratus femoris muscle.

• Patient: Average age: 14-30 years

• Gender: Females more than males

• Clinical Presentation:

– Complaint: non-specific pain in the hip, groin, and buttocks with active adduction and external rotation

– (+) Pain with hip extension, external rotation, and adduction

– (+) Radiographs and MRI

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Greater Trochanteric-Pelvic Impingement

• Pathology: – A painful and pathological contact

between the greater trochanter and ilium when the hip is actively or passively moved into abduction and extension.

• Patient: Average age: 5-41 years

• Gender: No predilection

• Clinical Presentation:– Complaint: “lateral hip and groin pain”

• reproduced with active hip ABD and Ext.

– (+) Pain with hip ABD and Ext – (+) Trendelenburg gait – (+) Radiographs – *Linked to Legg–Calvé– Perthes Disease

Final Thoughts

• There is a growing body of knowledge regarding the post-surgical management of patient who underwent hip arthroscopy.

• The 4 to 5 phase post-surgical criterion based program seems to be the standard.

• Hot topics currently being studied include:

– The optimal post-surgical program

– Identifying and reducing risk factors for recurrence or new pathology during post-surgical rehabilitation.

– Identifying other forms of hip impingement

Questions?

Thank You!Scheatham@csudh.edu

References

1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013;29(4):661-665.

2. Harris JD, McCormick FM, Abrams GD, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthroscopy. 2013;29(3):589-595.

3. Byrd JW, Jones KS. Hip arthroscopy in athletes: 10-year follow-up. Am J Sports Med. 2009;37(11):2140-2143.

4. Cheatham SW, Enseki KR, Kolber MJ. Post-Operative Rehabilitation after Hip Arthroscopy: A Search for the Evidence. J Sport Rehabil. 2014. [Epub ahead of print]

5. Bizzini M, Notzli HP, Maffiuletti NA. Femoroacetabular impingement in professional ice hockey players: a case series of 5 athletes after open surgical decompression of the hip. Am J Sports Med. 2007;35(11):1955-1959.

6. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res. 2010;468(3):741-746.

7. Kemp JL, Collins NJ, Makdissi M, et al. Hip arthroscopy for intra-articular pathology: a systematic review of outcomes with and without femoral osteoplasty. Br J Sports Med. 2012;46(9):632-643.

8. Cheatham SW, Kolber MJ. Rehabilitation after hip arthroscopy and labral repair in a high school football athlete. Int J Sports Phys Ther. 2012;7(2):173-184.

9. Reiman MP, Goode AP, Cook CE, et al. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabularimpingement/labral tear: a systematic review with meta-analysis. Br J Sports Med. 2014.[Epub ahead of print]

10. Klingenstein GG, Zbeda RM, Bedi A, et al. Prevalence and preoperative demographic and radiographic predictors of bilateral femoroacetabular impingement. Am J Sports Med. 2013;41(4):762-768.

11. Ross JR, Nepple JJ, Philippon MJ, et al. Effect of changes in pelvic tilt on range of motion to impingement and radiographic parameters of acetabular morphologic characteristics. Am J Sports Med. 2014;42(10):2402-2409.

12. Lewis CL, Sahrmann SA. Effect of posture on hip angles and moments during gait. Man Ther. 2015;20(1):176-182.

13. Lewis CL, Khuu A, Marinko LN. Postural correction reduces hip pain in adult with acetabular dysplasia: A case report. Man Ther. 2015.[Epub ahead of print]

14. Lewis CL, Sahrmann SA, Moran DW. Effect of hip angle on anterior hip joint force during gait. Gait Posture. 2010;32(4):603-607.

References

1. Kennedy MJ, Lamontagne M, Beaule PE. Femoroacetabular impingement alters hip and pelvic biomechanics during gait Walking biomechanics of FAI. Gait Posture. 2009;30(1):41-44.

2. Casartelli NC, Maffiuletti NA, Item-Glatthorn JF, et al. Hip muscle weakness in patients with symptomatic femoroacetabular impingement. Osteoarthritis Cartilage. 2011;19(7):816-821.

3. Casartelli NC, Leunig M, Item-Glatthorn JF, et al. Hip flexor muscle fatigue in patients with symptomatic femoroacetabular impingement. Int Orthop. 2012;36(5):967-973.

4. Beck M. Groin pain after open FAI surgery: the role of intraarticular adhesions. Clin Orthop Relat Res. 2009;467(3):769-774.

5. Lewis CL, Sahrmann SA, Moran DW. Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. J Biomech. 2007;40(16):3725-3731.

6. Hunt MA, Guenther JR, Gilbart MK. Kinematic and kinetic differences during walking in patients with and without symptomatic femoroacetabular impingement. Clin Biomech (Bristol, Avon). 2013;28(5):519-523.

7. Rylander JH, Shu B, Andriacchi TP, et al. Preoperative and postoperative sagittal plane hip kinematics in patients with femoroacetabular impingement during level walking. Am J Sports Med. 2011;39 Suppl:36S-42S.

8. Diamond LE, Dobson FL, Bennell KL, et al. Physical impairments and activity limitations in people with femoroacetabular impingement: a systematic review. Br J Sports Med. 2015;49(4):230-242.

9. Lamontagne M, Kennedy MJ, Beaule PE. The effect of cam FAI on hip and pelvic motion during maximum squat. Clin Orthop Relat Res. 2009;467(3):645-650.

10. Casartelli NC, Maffiuletti NA, Item-Glatthorn JF, et al. Hip muscle strength recovery after hip arthroscopy in a series of patients with symptomatic femoroacetabular impingement. Hip Int. 2014;24(4):387-393.

11. Papavasiliou AV, Bardakos NV. Complications of arthroscopic surgery of the hip. Bone Joint Res. 2012;1(7):131-144.