A literature review was performed to identify articles published within the past 10 years that were focused on the topic of postoperative rehabilitation and return-to-sport assessments following hip arthroscopy for the treatment of FAI. Articles that focused on nonoperative treatment of FAI were not included in this review. Abstracts of selected articles were screened, and a full-text review of selected articles was performed. Additional articles were included on the basis of review of reference lists of selected articles, and our experience with rehabilitation of these patients.
Using the identified studies, rehabilitation and return to sport recommendations were analyzed and categorized. Return to sport recommendations were considered in the context of guidelines for other common surgical procedures, including anterior cruciate ligament (ACL) reconstruction.
Special considerations for advanced rehabilitation were also reviewed in the context of the included articles, as well as our clinical practice. Advanced topics, including the use of patient-reported outcomes, video gait analysis, wearable motion sensor technology, and anti-gravity treadmill utilization are described along with the relevant literature and our clinical experience.
The most important findings of this review are the relative uniformity in the general rehabilitation guidelines with a four-phase approach, although there is substantial variability in criteria for return to sport. Therefore, a structured yet individualized plan with incorporated functional testing is recommended.
It is important for the surgeon to encourage an open line of communication with the physical therapy team. If surgery is elected, 1-2 preoperative sessions with the physical therapist will allow review of the surgeon’s office visit notes, as well as a patient assessment for identification of preoperative functional deficits, such that a plan to address these deficits can be incorporated into the postoperative plan. The surgeon can support this communication by providing the therapist with a detailed operative report that includes a section focusing on the postoperative rehabilitation plan.
Specific factors that may influence rehabilitation timing and progression through an established postoperative rehabilitation guideline must be considered. Surgeon identified characteristics may include patient anatomy (e.g., borderline acetabular dysplasia) and tissue characteristics (e.g., complex labral tear, compromised labral integrity, large tear size, and capsular laxity). Certain combinations of these factors may support a delayed progression through a rehabilitation guideline, including delayed weight bearing and ROM progression.
Within the four-phase approach for rehabilitation, progression to the next phase is based on timing and requires mastery of activities in the previous phase. Phase 1 includes protection of the labral and capsular repair with limited weight-bearing and restricted range of motion. Phase 2 includes progression of weight-bearing, return to walking, and early strengthening. Phase 3 includes advanced strengthening exercises and early agility drills with a consideration of return to running. Phase 4 builds upon the previous phases and individualizes agility drills, running goals, and functional testing for return to sport.
While there is general agreement of the overall structure of the phased rehabilitation approach, there is substantial variability with return to sport preparation and assessment following hip arthroscopy. Determination for return to sport following hip arthroscopy requires a multifactorial approach. Patient readiness, patient-reported outcomes (PRO), objective scoring, and specific sport testing are all important components to consider.
The ACL reconstruction literature serves as a reasonable guide when considering RTS, as readiness in this setting is felt to strongly influence reinjury rate. With regard to ACL reconstruction, there are numerous variations of RTS testing in the literature with some agreement on common key assessments (e.g., variations of single leg hop/jump). Rather than a defined testing protocol, recommendation for RTS following hip arthroscopy appears to rely on the absence of pain during a series of activities (including running, jumping, lateral agility drills, and single-leg squats) based on a survey of the hip.
- Domb B.G.
- Stake C.E.
- Finch N.A.
- Cramer T.L.
Return to sport after hip arthroscopy: Aggregate recommendations from high-volume hip arthroscopy centers.
The reliance on general recommendations and absence of a universally accepted functional test issued for hip arthroscopy highlights the importance of fully understanding the patient’s sport and occupational demands and tailoring the assessment to the individual patient. Recent literature recommends hip abduction/adduction strength >90% to uninvolved side for return to sport.
- Thorborg K.
- Couppe C.
- Petersen J.
- Magnusson S.P.
- Holmich P.
Eccentric hip adduction and abduction strength in elite soccer players and matched controls: A cross-sectional study.
There are multiple RTS tests available, including the Hop Test, Y-balance, and Vail Hip Sports Test, although there is not yet consensus on an optimal test. One consideration from the ACL reconstruction literature that could be modified for hip arthroscopy is a comprehensive RTS test from University of Pittsburgh Medical Center (UPMC) Sports Medicine, which focuses on high-intensity impact and agility tests for return to sport (Table 2
- Joreitz R.
- Lynch A.
- Rabuck S.
- Lynch B.
- Davin S.
- Irrgang J.
Patient-specific and surgery-specific factors that affect return to sport after ACL reconstruction.
Table 2Sample Return to Sports Testing Protocol
Protocol from Joreitz et al.,
- Joreitz R.
- Lynch A.
- Rabuck S.
- Lynch B.
- Davin S.
- Irrgang J.
Patient-specific and surgery-specific factors that affect return to sport after ACL reconstruction.
adapted from a protocol designed for anterior cruciate ligament reconstruction.
The RTS test should be administered near the end of the 4th phase of rehabilitation, prior to clearing an athlete for unrestricted return to sports, especially if they are returning to a collision or contact sport. Although phase 4 typically begins 12 weeks postsurgery, it is important that the patient is meeting the proper criteria to be transitioned to phase 4 based on musculoskeletal objective measures rather than timing alone. The UPMC RTS test, like many other RTS tests, considers a passing score to be 90% of the uninvolved extremity, although it is our opinion that this number should instead target >95%. Upon completing the RTS test for any athlete, it is the responsibility of the physical therapist to provide the data to the orthopedic surgeon to make the final decision for clearance to return to unrestricted athletics.
Special Considerations for Advanced Rehabilitation
A reasonable target for all patients is return to activities of daily living, as well as a reasonable exercise routine to support a healthy lifestyle, and this can be assessed with patient-reported outcomes (PROs). Depending on the occupational and recreational goals, many patients may benefit from advanced rehabilitation techniques for return to high-level activities.
Collection of PROs may be performed preoperatively and at regular intervals in follow-up.
- Menge T.J.
- Briggs K.K.
- Rahl M.D.
- Philippon M.J.
Hip arthroscopy for femoroacetabular impingement in adolescents: 10-year patient-reported outcomes.
Some commonly used PROs include the modified Harris hip score (mHHS), hip outcomes score (HOS; activities of daily living and sports-specific subscales), nonarthritic hip score (NAHS), and lower extremity functional scale (LEFS); several other PROs are used and could also be considered. Tracking the scores and graphically displaying the results for the patient at selected intervals could be beneficial both in terms of patient education, as well as readiness for return to sport. However, a PRO more specific to the patient’s sport or activity level may be more useful, and the Patient-Specific Functional Scale (PSFS) allows the physical therapist and patient to determine which activities or movements are most pertinent for return to their sport. The PSFS could also be issued at each session or weekly to better monitor a patient’s progress.
Video Gait Analysis
Video gait analysis is a valuable assessment tool following hip arthroscopy and may reduce short- and long-term complications as patients return to running. Although 2-D video gait analysis has limitations compared to 3-D video gait analysis, it can provide excellent information for the running athlete, as it relates to key phases of gait and potential areas for improvement. Souza et al. describes 17 different variables that can be assessed for evidence-based videotaped running biomechanics analysis.
An evidence-based videotaped running biomechanics analysis.
Two key areas of emphasis to evaluate are landing pattern at initial contract and hip drop/pelvic obliquity. This can be accomplished with a more expensive multiview synchronized system or a tablet-based application. The authors of this study have used both types of systems and currently use an Apple iPad (Cupertino, CA) with the Technique by OnForm (OnForm, Shelton, CT).
Landing pattern, evaluated from a lateral view, describes foot position at initial contact, and broadly includes heel strike, midfoot strike, or forefoot strike. Tibial angle at initial contact can be simultaneously assessed. Magnitude of vertical ground reaction force (vGRF) may correlate with symptom development and perhaps reinjury; vGRF is greater when landing in front of the runner’s center of mass (COM) compared to a landing closer to the COM. This influences the ability to generate proper muscle stiffness at impact throughout the entire lower extremity and may reduce injury at the ankles, knees, and hips.
Cadence (steps per unit time) manipulation is a method position of foot strike relative to COM. For example, a patient with a heel strike landing pattern with foot strike in front of their COM, increasing cadence may improve the runner’s efficiency in transitioning to midstance and terminal stance, but also reduce their risk for injury. In a study in 2011 by Heiderscheit et al., a 5% increase in cadence resulted in decreased vertical excursion of COM and braking impulse.
- Heiderscheit B.C.
- Chumanov E.S.
- Michalski M.P.
- Wille C.M.
- Ryan M.B.
Effects of step rate manipulation on joint mechanics during running.
Furthermore, a 10% increase in step frequency resulted in decreased vGRF at the hip and knee, peak hip adduction angle, and peak hip adduction and internal rotation moments.
Hip drop and pelvic obliquity need to be assessed with single-leg standing and walking in routine rehabilitation. Although these may appear normal, higher-level activities, including running, may emphasize asymmetry due to muscle weakness and technique. With this insight, the clinician will appropriate dynamic activities to support hip functional stability during impact or single limb loading, which may decrease the risk of reinjury. Although normative data for acceptable pelvic drop in running is limited, Schache et al. reported an average pelvic drop of 5.4° ± 2.6° just prior to take-off.
- Schache A.G.
- Blanch P.
- Rath D.
- Wrigley T.
- Bennell K.
Three-dimensional angular kinematics of the lumbar spine and pelvis during running.
Wearable Motion Sensor Technology
In recent years, sports rehabilitation centers have been employing motion sensor technology to monitor ROM, strength, force, power, and other valuable metrics to assist with clinical decision making. DorsaVi (London, UK) produces a wearable sensor applied to the patient’s mid-leg to produce instant quantifying data based on the instructed movement and has been shown to be reliable and valid. This device can also measure a patient’s degree of genu valgum/varus, tibial inclination, and speed during a single-leg squat test . The portable sensors also allow sport testing on the playing field for running analysis to measure ground reaction force, cadence, speed, initial peak acceleration, and ground contact time. The data are easily archived, enabling comparison to baseline and time-specific measurements.
Anti-Gravity Treadmill Considerations
Incorporation of an antigravity treadmill (our practice currently uses a model from AlterG [AlterG, Fremont, CA]) into rehabilitation following hip arthroscopy and other lower extremity procedures has proven to be useful in our practice and can be considered throughout the rehabilitation process after initiation of weight-bearing. We consider the following three segments: early mobility and gait retraining, preparation for return to running, and supplemental running). Individualized assessment of the patient’s function by the physical therapist influences timing of progression.
Early Mobility and Gait Retraining
During the period of partial weight-bearing (PWB), an antigravity treadmill allows unloading to 20% of bodyweight and may be used to assist the patient in normalizing their gait pattern. Advanced communication with the surgeon is important to confirm their agreement with this approach during the PWB period. Early attention may aid in normalizing gait while avoiding an upper body trunk shift or a Trendelenburg gait pattern. It is believed that there is an elevated risk of symptoms related to the hip flexors during the first several postoperative weeks, and this must be evaluated. Garrison et al. discussed the importance of early motion exercises and reestablishing a symmetrical gait pattern to prevent concomitant stress throughout the lower extremity and spine, as well as a decreased risk for muscle imbalance and risk of lower crossed syndrome (characterized by gluteus inhibition due to a tight iliopsoas muscle-tendon unit).
- Garrison J.C.
- Osler M.T.
- Singleton S.B.
Rehabilitation after arthroscopy of an acetabular labral tear.
Compared to aquatherapy, an antigravity treadmill will simulate this unloaded environment with more specificity in gait, with the goal of allowing appropriate loading of the hip joint, while minimizing unnecessary stresses to healing tissue.
Preparation for Return to Running
Following gait normalization with walking, appropriate strengthening, and adequate soft tissue healing time, preparation for running may begin. According to our findings, 12 weeks is the most commonly referenced time for initiating return to running, providing that adequate rehabilitation progress and key functional milestones have been achieved. The authors of this study believe that it is important the patient demonstrates near normal strength prior to starting unloaded running in an antigravity treadmill and normal strength with proper gluteus recruitment prior to over-ground running. When starting this segment in an antigravity treadmill, a walk/run progression or a time-based running progression are frequently used. Progressively decreasing the percentage of body weight is a variable that can be used over a constant period of time as well. Patient-reported discomfort during and after running is an important consideration. Kraeutler et al. defined “acceptable” and “unacceptable” symptoms in response to running as a guideline for determining appropriate progression.
- Kraeutler M.J.
- Anderson J.
- Chahla J.
- et al.
Return to running after arthroscopic hip surgery: Literature review and proposal of a physical therapy protocol.
Utilization of a gradual return to run progression may avoid setbacks secondary to poor technique and soft tissue inflammatory concerns. The goal of this segment is to have the patient nearly unweighted, before progressing to an over-ground program.
The goal of this phase is to assist the patient in getting back to their prior level of function as it relates to running. On the basis of our findings, a relatively high rate of return to running has been reported in some case series following hip arthroscopy, although intensity and distance are inconsistently reported. For example, Levy et al. reported a mean weekly distance of 9.5 ± 6.5 miles prior to injury that decreased to 6.4 ± 5.8 miles postoperatively (P
< .01); despite decreased mileage, all 2-year outcomes scores improved significantly (P
- Levy D.M.
- Kuhns B.D.
- Frank R.M.
- et al.
High rate of return to running for athletes after hip arthroscopy for the treatment of femoroacetabular impingement and capsular plication.
The use of an antigravity treadmill may allow patients to supplement their over-ground training program with some unloaded running with the goal to increase weekly mileage similar to a preoperative status, while minimizing the cumulative loading effect through the hip joint. Additionally, use of an antigravity treadmill provides an environment allowing patients to work on increasing speed in a potentially safer setting.
The strength of recommendations of this review article is limited by the quality and type of evidence in the literature, and this field is primarily supported by level IV and V studies. A summary of recommendations for rehabilitation and progression of activity, including return to sport and running, is provided. Individualized detailed protocols for specific patient anatomy, surgical procedure details, and athletic activities are not yet able to be provided. Advanced rehabilitation techniques are reasonable in select patients in consultation with the surgeon, although detailed studies are not available to guide clinicians.
A four-phase approach to rehabilitation following hip arthroscopy for FAI is widely used with general uniformity, although the timing and level of detail concerning assessment and readiness for return to sport are variable. Advanced rehabilitation techniques may be used in select patients returning to high-level activities.