Rehabilitation and return to play following hip arthroscopy in young athletes

Abstract

Hip arthroscopy is a hip preservation surgery used to manage acute pain and injury while attempting to preserve the hip joint and prevent or delay the progression of degenerative changes by restoring stability, reducing pathologic stress and instability, and preventing continued joint incongruity and impingement [1], [2], [3], [4]. Research supports a high likelihood of return to a prior level of athletic participation in athletes of all ages after hip arthroscopy with especially favorable results in athletes under the age of 18 [3-5]. The postoperative rehabilitation process is vital to correct impairments and compensatory strategies. Unfortunately, there is great variability in current rehabilitation protocols.Adolescent athletes returning to activity after hip arthroscopy may be at an increased risk of reinjury and continued pain if return to sport occurs too early [6]. Inconsistencies exist with current protocols and return to sport testing. For instance, assessing readiness for return to sport is often based upon tests and measures utilized for anterior cruciate ligament reconstruction. These tests and measures may not effectively isolate or address hip function and readiness to return to play after hip arthroscopy. This current concept review presents existing literature and a standardized rehabilitation process to restore normal function and maximize a safe return to athletics after hip arthroscopy in the young athlete.

Key concepts: (1)There are few evidence-based postoperative rehabilitation programs for the young athletic population to effectively guide progress toward return to play readiness.(2)Continued hip and core strengthening exercises should be implemented after the return to play to maintain hip and core strength, improve neuromuscular control, and address additional functional impairments that may lead to repeat injury and dysfunction.(3)Patient-reported outcome (PRO) measures are correlated with higher postoperative improvement and should be utilized to assess psychological and physical readiness for return to play.

Keywords: Adolescent; Arthroscopy; Hip; Rehabilitation; Return to sport; Sports.

Figure 1

Positions to avoid both pre and post hip arthroscopy including sitting cross-legged, movements requiring high degrees of hip flexion, and completing functional movements with femoral internal rotation, valgus collapse, and excessive trunk flexion.

Figure 2

A series of self-soft tissue mobilization to address hip tightness using a lacrosse ball targeting the adductor, psoas, and tensor fascia latae.

Figure 3

Soft tissue release to adductor group.

Figure 4

Strategies to improve muscle activation and lower quarter alignment such as squat with band pull at the hips (left) to reduce asymmetrical weight shift and banded squat (middle and right) to improve use of hip abductors.

Figure 5

Prone positioning to gradually stretch anterior core and hip musculature.

Figure 6

Phase 1 core activation including transversus abdominis activation, posterior pelvic tilt, and submaximal pelvic clocks.

Figure 7

Gentle hip mobilizations (long axis traction, left, and lateral distraction, right) with mobilization belt.

Figure 8

Modification of sitting posture to avoid hip flexion beyond 90˚.

Figure 9

Early hip range of motion exercises targeting hip rotation (left, middle) and hip flexion via quadruped rocking (right).

Figure 10

Mobility banded progressions to improve lateral distraction in half kneeling (far left) and pigeon (left middle), posterior positioning of femoral head in half kneeling (right middle), and long axis distraction in sidelying (far right).

Figure 11

Testing position for handheld dynamometry of hip flexion (left), abduction (middle), and extension (right).

Figure 12

Prone strengthening techniques include psoas isometric exercises in neutral hip positioning (left), glute sets with bent knee hip extension (center), and quadruped glute set with bent knee hip extension (right).

Figure 13

Side-lying hip abduction against wall.

Figure 14

Single leg lateral step down (left), banded standing hip external rotation (center), and banded standing clocks (right).

Figure 15

Single leg stance with cues to resist femoral internal rotation.

Figure 16

Dynamic single leg stance with resisted hip extension and abduction.

Figure 17

Single leg bridge progressions.

Figure 18

Modified side plank with hip abduction.

Figure 19

Dynamic hip stability progressions including band resisted lateral bound (left), dynamic forward single leg hop with diagonal medicine ball chop (middle), and skaters with medicine ball slam (right).

Figure 20

Step down test.