15.2.1 - Postoperative Management of the Hip Monograph

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 University of Pittsburgh Center for Sports Medicine Pittsburgh, Pennsylvania Pennsylvania

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

Pete Draovitch, PT, MS, ATC, CSCS Centers for Rehab Services University University of Pittsburgh Center for Sports Medicine Pittsburgh, Pennsylvania Pennsylvania

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

An Independent Study Course Designed for Individual Continuing Education

CONTINUING

Postoperative Management of Orthopaedic Surgeries

PHYSICAL THERAPY

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

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. 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 Manage- ment 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 physical therapist who is a sports certified specialist as well as a certified strength and conditioning specialist. Pete Draovitch 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, 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 Center’s (UPMC) Center for Sports Medicine. He is one of the world’s world’s 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. 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 East Avenue Avenue South, South, Suite 200 200 La Crosse, Crosse, WI 54601 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 Jour- nal of Sports Medicine. 2003;31:1020–1037. 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

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.

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.

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;31:1020–1037. 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;31:1020–1037. 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

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.

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

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°



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


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 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



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 joint’s 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 patient’s 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 non–weight-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

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.

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. 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 al 12 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

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.

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. 16–19 Recent advances in arthroscopic technology have expanded the options available for such procedures. 1 Early results are promising; however, further study is necessary. 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. Non–weightbearing 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

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.

McCarthy et al 10 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.

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 non–weight-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

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

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

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

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)

Congenital Subluxation or Dislocation

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

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 patient’s 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 patient’s 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

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.23,27–29 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 13

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

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 patient’s 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 Cook 30 found that loads carried on the contralateral side significantly increase the loads placed on the surgical side, while loads up to 20% of an individual’s 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 individual’s 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 al 31 found that patients usually resume sexual activity 4 to 6 weeks postoperatively.

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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 non–weight-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 patient’s 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 individual’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 physician’s advice when her ability to ambulate and negotiate stairs became significantly limited. Diagnostic imaging revealed degenerative joint changes deemed secondary to osteoarthritis. The patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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.

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REFERENCES 1. Kelly BT, Williams RJ, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med . 2003;31: 1020–1040. 2. Harding L, Barbe M, Shepard K, et al. Posterior-anterior glide of the femoral head in the acetabulum: a cadaver study. J Orthop Sports Phys Ther . 2003;33: 118–125. 3. Kim YT, Azuma H. The nerve endings of the acetabular labrum. Clin Orthop . 1995;320:176–181. 4. Ferguson SJ, Bryant JT, Ganz R, Ito K. An in vitro investigation of the acetabular labral seal in hip joint mechanics. J Biomech . 2003;36:171–178. 5. Ferguson SJ, Bryant JT, Ganz R, Ito K. The influence of the acetabular labrum on hip joint cartilage consolidation: A poroelastic finite model. J Biomech . 2000;33:953–960. 6. Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med . 2001;20: 817–829. 7. Wertheimer LG, Lopes Sde L. Arterial supply of the femoral head. A combined angiographic and histological study. J Bone Joint Surg Am. 1971;53: 545–556. 8. Rao J, Zhou YX, Villar RN. Injury to the ligamentum teres. Mechanism, findings, and results of treatment. Clin Sports Med . 2001;20:791–799. 9. Philippon MJ. Arthroscopy of the hip in management of the athlete. In: McGinty JB, ed. Operative Arthroscopy . 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2003:879–883. 10. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The role of labral lesions to the development of early degenerative hip disease. Clin Orthop . 2001; 393:25–37. 11. Glick JM. Hip arthroscopy. The lateral approach. Clin Sports Med . 2001;20:733–747. 12. Dall D, Macnab I, Gross A. Recurrent anterior dislocation of the hip. J Bone Joint Surg Am. 1970;52: 574–576. 13. Liebenberg F, Dommisse GF. Recurrent post-traumatic dislocation of the hip. J Bone Joint Surg Br . 1969;51:632–637. 14. Allen WC, Cope R. Coxa saltans: the snapping hip revisited. J Am Acad Orthop Surg .1995;3:303–308. 15. Schaberg JE, Harper MC, Allen WC. The snapping hip syndrome. Am J Sports Med . 1984;12:361–365. 16. Dobbs MB, Gordon JE, Luhmann SJ, Szymanski DA, Schoenecker PL. Surgical correction of the snapping iliopsoas tendon in adolescents. J Bone Joint Surg Am. 2002;84:420–424.

17. Gruen GS, Sciosa TN, Lowenstein JE. The surgical treatment of internal snapping hip. Am J Sports Med . 2002;30:607–613. 18. Faraj AA, Moultan A, Sirivastava VM. Snapping iliotibial band. Report of ten cases and review of the literature. Acta Orthop Belg . 2001;67:19–23. 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;167:172–173. 20. Byrd JW. Lateral impact injury: a source of occult hip pathology. Clin Sports Med. 2001;20:801–815. 21. Byrd JW. Hip arthroscopy. The supine position. Clin Sports Med . 2001;20:703–731. 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;80:1276–1284. 23. Canale ST, ed. Campbell’s Operative Orthopaedics . 9th ed. New York, NY: Mosby; 1998:296–461. 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;66:745–752. 25. McDonald I. Bilateral replacement of the hip and knee in rheumatoid arthritis. J Bone Joint Surg Br . 1982;64:465–468. 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;61:1167–1174. 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;70:1001–1010. 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: 761–764. 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;65:305–311. 31. Stern SH, Fuchs MD, Ganz SB, Classi P, Sculco TP, Salvati FA. Sexual function following total hip arthroplasty. Clin Orthop . 1991;269:228–235. 32. Kendall FP, Kendall McCreary E, Provance PG. Mus- cle Testing and Function. 4th ed. Baltimore, Md: Williams & Wilkins; 1993.

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15.2.1 - Postoperative Management of the Hip Monograph

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