ArticlePDF AvailableLiterature Review

Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol


Abstract and Figures

The number of hip arthroscopy procedures has significantly increased in the last several years, thereby necessitating individualized rehabilitation protocols for patients following hip arthroscopy. The purpose of this article is to review the literature on rehabilitation protocols for patients following hip arthroscopy and to describe a new protocol specifically designed for patients to return to running following hip arthroscopy. A search of PubMed was performed through October 2016 to locate studies of rehabilitation protocols for patients wishing to return to sport/general activity following hip arthroscopy. Patients at our institution who desired to return to running following hip arthroscopy underwent a set of return to running guidelines which are based on goal achievement within a three-phase system that begins with a walking program and finishes with return to distance running. Rehabilitation protocols for patients following hip arthroscopy frequently use a four-phase system in which Phase I focuses on regaining hip range of motion and protection of surgically repaired tissues, and Phase IV involves a pain-free return to sports. Rehabilitation protocols vary in timing in that some include a timeline with each phase taking a certain number of weeks while others are based on goal achievement. There is an overall lack of published outcomes based on patients adhering to various post-hip arthroscopy rehabilitation protocols.
Content may be subject to copyright.
Return to running after arthroscopic hip surgery:
literature review and proposal of a physical
therapy protocol
Matthew J. Kraeutler
, Joy Anderson
, Jorge Chahla
, Justin J. Mitchell
Robyn Thompson-Etzel
, Omer Mei-Dan
and Cecilia Pascual-Garrido
Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO 80045, USA,
University of Colorado Sports Physical Therapy, Denver, CO 80222, USA,
Steadman Philippon Research Institute, Vail, CO 81657, USA and
Department of Sports Medicine, Gundersen Health System, La Crosse, WI 54601, USA
*Correspondence to: C. Pascual-Garrido. E-mail:
Submitted 1 November 2016; Revised 14 February 2017; revised version accepted 18 February 2017
The number of hip arthroscopy procedures has significantly increased in the last several years, thereby necessi-
tating individualized rehabilitation protocols for patients following hip arthroscopy. The purpose of this article is
to review the literature on rehabilitation protocols for patients following hip arthroscopy and to describe a new
protocol specifically designed for patients to return to running following hip arthroscopy. A search of PubMed
was performed through October 2016 to locate studies of rehabilitation protocols for patients wishing to return
to sport/general activity following hip arthroscopy. Patients at our institution who desired to return to running
following hip arthroscopy underwent a set of return to running guidelines which are based on goal achievement
within a three-phase system that begins with a walking program and finishes with return to distance running.
Rehabilitation protocols for patients following hip arthroscopy frequently use a four-phase system in which Phase
I focuses on regaining hip range of motion and protection of surgically repaired tissues, and Phase IV involves a
pain-free return to sports. Rehabilitation protocols vary in timing in that some include a timeline with each phase
taking a certain number of weeks while others are based on goal achievement. There is an overall lack of pub-
lished outcomes based on patients adhering to various post-hip arthroscopy rehabilitation protocols.
The number of hip arthroscopy procedures has signifi-
cantly increased in the last several years [1] and, as such,
has become a focus of several articles in the orthopedic
and sports medicine literature. Coinciding with this
procedural increase is an enhancement in arthroscopic
technology, understanding of intra- and extra-articular
pathologies of the hip, and means by which to return pa-
tients to their previous levels of activity following arthro-
scopic procedures.
Despite these recent advancements, a paucity of literature
exists regarding specific and dedicated rehabilitation
protocols following hip arthroscopy [2,3]. This gap in the
published literature can have a significant impact on pa-
tients, especially those who desire to return to higher de-
mand sporting activity, such as professional or competitive
recreational athletes.
Several rehabilitation protocols exist for patients follow-
ing hip arthroscopy [49], some of which are specifically
geared toward patients following treatment of femoroace-
tabular impingement (FAI) [4,9] or acetabular labral tears
[6]. The reported rehabilitation protocols frequently use a
four-phase system. In the four-phase system, Phase I
focuses on regaining hip range of motion and protection of
CThe Author 2017. Published by Oxford University Press.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (
nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use,
please contact
Journal of Hip Preservation Surgery Vol. 0, No. 0, pp. 1–10
doi: 10.1093/jhps/hnx012
Review Article
surgically repaired tissues. Phase II focuses on progressing
range of motion, improving neuromuscular control, and
achieving independence in activities of daily living with
minimal pain. In Phase III, patients should begin to restore
muscular strength and become recreationally asymptom-
atic. Finally, Phase IV involves a pain-free return to sports.
While most surgeons allow return to sports between 12
and 20 weeks following hip arthroscopy, the exact return
to sport guidelines vary depending on the procedure per-
formed as well as the patient-specific sport. Rehabilitation
protocols further vary in phases based on phase endpoint.
Some promote a timeline in which each phase lasts a cer-
tain number of weeks, while others focus on progression
based on goal achievement by the end of each phase. Each
of these protocols is designed with the goal of returning
patients to activity without symptoms or limitations.
However, these rehabilitation programs are focused on re-
turning patients to sports without any specificity as to
which sport patients are returning. Furthermore, outcomes
have not been published on patients whom were included
in these rehabilitation programs. The currently published
protocols also lack direction for return to specific high-
impact sport activities such as running.
The purpose of this article is to review the literature on
rehabilitation protocols for patients following hip arthros-
copy and to describe a new protocol specifically designed
for patients to return to running following arthroscopic hip
surgery. Institution of a rehabilitation protocol clearly
geared toward patients who are runners allows for more
sport-specific training and patient-centred goals to be
reached throughout the protocol. In addition, a sport-
specific protocol allows physical therapists to pinpoint
milestones and identify possible setbacks if a patient fails
to progress at a certain step of the running progression
The aim of this program is to optimize the return to
running with minimal setbacks by establishing a progres-
sive stepwise program, and includes a dynamic warm-up,
strengthening exercises, a plyometric/drill progression, and
a return to running progression. Drills are meant to im-
prove reactivity, recruitment, and control of the injured
limb, as well as to create symmetrical movement patterns.
This program builds off of previously published protocols
and is the first to discuss specific modalities for a return to
running following arthroscopic hip surgery.
The return to running program was initially developed to
help patients who were attempting to return to running
following hip surgery, though it can be used for any patient
attempting to return to running following a lower
extremity injury or surgery. This program was developed
due to the high rate of recurrent pain or disability seen in
our tertiary centre shortly after attempting to return to
running. Furthermore, it has been our experience that
many patients failed upon return to activity because they
had been cleared to progress based on healing guidelines
rather than functional achievements in terms of strength,
gait, or pain. Most patients were attempting to resume run-
ning at a level they had run previously, and were unable to
sustain or progress secondary to pain in joints, muscles, or
compensating tissues. This program is also used with pre-
habilitation, though most participants are post-surgery after
failing to improve with conservative treatments. Based on
our experience of 3 years using this program, approxi-
mately 400 patients who have undergone hip labral repair,
acetabular rim resection and/or femoral head osteochon-
droplasty for FAI have performed well using the protocol
described below.
The running progression program should be initiated ap-
proximately 3 months following surgery, although this may
vary to some degree depending on individual patients and
the procedure performed. Patients undergoing cartilage
restoration procedures such as microfracture, microdrilling
or cell therapy, or patients with underlying dysplasia or
borderline dysplasia should start approximately 6 weeks
later, as these patients are typically non-weight bearing for
the first 6 postoperative weeks. While in the early stages of
recovery, the program gives patients a realistic roadmap for
progressive return so that they may work independently
for a time at their own pace before returning to clinic for
Patients should be provided with a few key points to re-
member throughout this program: (i) progress gradually,
giving recovering tissue and joints time to adapt, (ii) avoid
speed and hills in early progressions, (iii) start running on
soft surface or treadmill before progressing to pavement/
road, (iv) cross train especially in initial phases and (v) in-
corporate adequate recovery between runs. Throughout
this progression, patients should continue to monitor their
comfort level, as shown in Table I.
The core principle of the running progression program
is to carefully pass through therapeutic exercises while
building upon a baseline level of fitness. This core program
involves strength maintenance exercises and dynamic
warm-up exercises which are performed coincident with
progression through each phase.
The strength maintenance exercises are designed to
keep certain muscles activated. The gluteal/hip complex,
core and balance exercises all have demonstrated
2M. J. Kraeutler et al.
importance in lower extremity injuries [10,11]. Starting
with quick steps and ladders to keep the feet under
the body, plyometrics improve muscle reaction and body
control and are progressed in intensity and volume.
Plyometrics for increasing maximal explosiveness are not
performed as the protocol is intended for runners rather
than explosive athletes such as football or basketball play-
ers. Video links are provided to the patients, and included
instructions for the dynamic work-up routine as well as all
three phases of the plyometrics program. These videos
allow patients to progress through much of the rehabilita-
tion protocol without constant assistance from a therapist.
Strength maintenance exercises
During this program, it is important to continue strengthen-
ing exercises provided by the physical therapist (Fig. 1;
Table II). The side plank has been shown to activate the
gluteus medius and external oblique abdominis muscles
[12,13], while single-limb squats have been shown to acti-
vate the gluteus medius and maximus [12,14]. The remain-
ing exercises may be more useful for training endurance or
body stabilization during running.
Dynamic warm-up
The purpose of this warm-up is to confirm that the
muscles involved in running are warmed up and activated,
and that the mobility necessary to run is available.
Neuromuscular warm-up activities have been shown to
prevent lower extremity injuries [11], and therefore it is
very important for this warm-up to be performed prior to
each workout or run (Fig. 2;Table III).
Phase 1: Walking program
Patients should be able to walk 30 min pain-free at a fairly
aggressive pace (at least 3.5 miles per hour). Patients
should start on a treadmill before progressing to outdoor
Table I. Patients should continue to monitor their discomfort level throughout their training progress
Acceptable: Continue to progress training Unacceptable: Back off training
General muscle soreness Pain that lasts for 2–3 days after a workout
Slight joint discomfort after workout or next day that resolves
within 24 h
Pain that is evident at the beginning of a run/walk then be-
comes worse as run/walk continues
Slight stiffness at beginning of run or walk that dissipates after
first 10 min
Pain that is keeping the patient awake at night
Pain that changes the patient’s stride
Fig. 1. Strength maintenance exercises. (A) Side plank raises, (B)front
planks, (C)bandwalks,(D)supinebridgeand(E)singlelegsquat
Return to running after arthroscopic hip surgery 3
Phase II: Quick response and plyometric routine
Quick muscle response and plyometrics are initiated in this
phase, progressing to about 500–600 foot contacts between
one and two legs. Thus, if a runner has an average turnover
of 170–180 strides/min, then running for 5–7 min would
be required to reach the necessary 500–600 single-foot
contacts. Plyometric training has been shown to reduce the
energy cost of running when compared with dynamic
weight training [15,16]. Thus, successful completion of
this phase is a good indicator that an athlete is ready to ini-
tiate the running program. Upon completion of the Level I
plyometric program (Table IV), the walk/jog progression
may be initiated if the following criteria have been met:
(i) successful completion of Phase I and II, (ii) no pain
with daily activities and (iii) walk without a limp.
Walk/jog program
The goal of this program is for the patient to initiate and
gradually progress their running volume without an in-
crease in symptoms (Table V). It may be best for patients
to begin the running program on a treadmill as this allows
for more control of speed and distance. Patients should re-
member a few key points during this part of the program:
(i) No hills or incline, (ii) no speed work, (iii) work on
form and (iv) run every other day.
Depending on the patient’s athletic goals and the rec-
ommendations of the physical therapist, a patient may con-
tinue with Level II (Fig. 3;Table VI) and Level III (Fig. 4;
Table VII) plyometric drills, as well as the return to dis-
tance running program (see below).
Phase III: Return to distance running
During this last phase, it is important for patients to find
their baseline. This is the distance the patient can run with-
out pain and again 48 h later. Patients should find their
baseline on a treadmill first as they will have more control
over speed and distance. Patients should run for as long as
Table II. Strength maintenance exercises
Exercise Video links
Side plank raises
Front planks
Band walks
Supine bridge
Single leg squat reach
Fig. 2. Dynamic warm-up.(A) Knee hug to calf raise, (B) in/out heel taps, (C) swing kicks, (D) soldier walks, (E) glute kicks,
(F) walking lunges with reach and rotation, (G) lunge twist, (H) quick steps and (I) Single-leg mini-squat to calf raise.
4M. J. Kraeutler et al.
they are comfortable and stop if running becomes painful.
They should write down their distance, time and pace
each time to track their progress. The goal in this phase
is to find an appropriate distance and speed that does not
increase pain symptoms. When patients feel comfortable
on a treadmill, they may progress to straight-line running
on level outdoor surfaces (e.g. sidewalks and running
Patients should still allow one day between each run,
though at first they may take longer than a day depending
on their comfort level. It is important during this phase for
patients to only change one thing at a time (e.g. distance,
speed, hills). This will allow the patient to identify the
cause of a new source of pain. Finally, patients should pro-
gress gradually. Below are some progression guidelines for
Phase III.
During weeks 1–2, patients should run 2–3 times per
week, with two shorter runs between 50% and 60% of their
baseline distance and one longer run at the baseline dis-
tance. During weeks 3–6, patients should run three times
per week at their baseline level, with a rest day between
each run. Patients should increase their distance by 10%
each week. Starting in week 5, patients should reassess
their baseline and increase running distance accordingly.
Patients must monitor pain during and 24–48 h after
increasing distance. It is important for patients to pro-
gress their weekly volume and long run distance by no
more than 10% each week. Once their goal distance is
reached, patients can then initiate speed or hill work.
When initiating hill work, patients should be cautious of
down hills.
The primary setback associated with this program is an
inability to progress due to poor tissue adaptation. This
may be a result of insufficient strength to progress through
the program, or an inability of a patient’s tissue to adapt to
load. It may also be that some patients attempt to skip
steps of the program or do not allow sufficient recovery
time after running.
By following this progression, it is much easier for the
physical therapist to pinpoint where the failure to adapt
occurs and the steps needed to address this failure in order
to continue to progress to the desired activity level.
The purpose of this article is to review the literature on re-
habilitation protocols for patients following hip arthros-
copy and to describe a new protocol specifically designed
for patients to return to running following arthroscopic hip
surgery. Rather than specifying when patients may return
to walking, plyometrics, distance running, et cetera, the
proposed protocol allows for gradual activity progression
based upon the comfort level of the patient and their abil-
ity to accomplish the prior protocol phase without injury
or significant muscle soreness.
A number of prior publications have focused on re-
habilitation protocols following hip arthroscopy, though
most of these emphasize generalized return to sport,
whereas our protocol is designed specifically for patients
wishing to return to running. Voight et al. [8] performed a
review on postoperative rehabilitation protocols for pa-
tients following hip arthroscopy, and although limited
evidence-based data is available to support any one of these
Table III. Dynamic warm-up
Exercise Repetitions Video links
Knee hug to calf raise 2 20 steps
In/out heel taps 2 20 steps
Swing kicks 2 20 steps
Soldier walks 2 20 steps
Glute kicks 2 20 steps
Walking lunges with reach and rotation 2 10 steps
Lunge twist 2 10 steps
Quick steps 2:
20 in place then forward 20 ft
20 in place then backward 20 ft
Single-leg mini-squat to calf raise 12 each leg
Return to running after arthroscopic hip surgery 5
particular protocols, the authors did find that most proto-
cols are divided into four general phases: (i) mobility and
initial exercise, (ii) intermediate exercise and stabilization,
(iii) advanced exercise and neuromotor control and (iv)
return to activity. Similarly, Edelstein [17], Garrison [6]
and Wahoff [9] reported on a four-phase rehabilitation
protocol which was similar to those to which Voight has
referred (Table VIII).
Edelstein’s post-hip arthroscopy rehabilitation protocol
[17] begins with Phase I, which is known as the protective
phase and entails weight-bearing and possibly range of mo-
tion restrictions depending on the procedure (Table VIII).
Phase II focuses on achieving normal activities of daily liv-
ing with little to no discomfort. During Phase III, patients
are to become recreationally asymptomatic through
strength building and core control. This is done through
lunges, squats and box step-ups. Return to running may
begin at 12 weeks postoperatively as long as the require-
ments of each phase are achieved. Finally, the goal of
Phase IV is to return to sports pain-free without de-
veloping muscle breakdown or inflammatory responses.
Similar to our suggestion of only changing one item at a
time during the return to distance running phase, Edelstein
suggests only manipulating one exercise variable per ses-
sion during Phase IV, as this will reduce the chances of a
Garrison et al. [6] reported specifically on rehabilitation
following arthroscopy for acetabular labral tears. Similarly,
this program consists of four phases (Table VIII). The
intermediate exercises in Phase II include kneeling hip
flexor stretches, seated resisted internal and external rota-
tion, wall squats and single-leg bridging. Core strengthen-
ing exercises, typically with the use of an exercise ball, are a
strong focus of Garrison’s Phase III.
Unlike the previous two rehabilitation protocols,
Wahoff et al. [9] utilize a four-phase system that focuses
on progress within each phase prior to advancement to the
next phase (Table VIII). Timelines are not used in this
Table IV. Level I plyometric program
Exercise Repetitions Video links
Ladders (40 ft) Forward—2 feet each box
Lateral—2 feet each box
Forward—1 foot each box
In-in/out (zig–zag shuffle)
Rest 2 min, then repeat 3
2 foot line jumps Front/back with bounce 3 12
2 foot dot hops 3 3 rounds each way
Alternating hop/hold 3 10 total jumps
Alternating 1 leg hops with bounce 3 10 total jumps
Table V. Walk/jog progression
Run interval (min) Walk interval (min) Repetitions Total run time (min) Total time spent (min)
1177 14
2–3 1 5 10–15 15–20
3–5 1 20 24þ
Run until fatigue or form failure, then walk 1–2 min, then repeat for a total run time of 25–30 min
Initiate running outdoors
Jog every other day with a goal of reaching 30 consecutive min
Patients should end each run with a 3–5 min walk and mobility/stretching exercises. Patients should complete each step 2–3 times before progressing to the next step.
6M. J. Kraeutler et al.
protocol, which makes it similar to our return to running
protocol. Wahoff encourages the use of a non-resistant sta-
tionary bicycle until a minimum of 6 weeks postopera-
tively. In addition, the authors discourage the use of a
treadmill even through Phase III due to potential stress
that the moving tread places on the anterior hip. From our
experience, we believe that the advantages of treadmill use
(precise speed and distance, soft surface and incline) out-
weigh the potential increase in hip stress.
Enseki et al. [5] restrict patients to partial weight bear-
ing status for a minimum of 10 days postoperatively and
up to 6 weeks following osteoplasty or hip microfracture
procedures. Full passive range of motion is allowed by 2
weeks postoperatively for the majority of arthroscopic hip
procedures. Before this time, excessive flexion or abduction
may result in increased inflammation of the affected
tissues. Return to jogging is allowed at 8–10 weeks follow-
ing isolated arthroscopic procedures on the labrum.
Competitive athletes may return to play at some point
from 10 to 32 weeks postoperatively depending on the
procedure as well as the sport.
Domb et al.[18] performed a study on return to
sport following hip arthroscopy based on survey responses
from 27 orthopaedic surgeons from high-volume hip arth-
roscopy centers. Seventy percent of the surgeons polled
recommended waiting 12–20 weeks postoperatively before
return to sport. Criteria for returning to sport included
ability to run without pain (70% of hip arthroscopy
Fig. 3. Level II plyometric program. (A) Lateral shuffles,
(B) high knees, (C) forward/backward skips, (D) backpedal,
(E) grapevine, (F) boxer shuffles, (G) Lateral skips and
(H) tap skips.
Fig. 4. Level III plyometric program. (A) Matrix jacks,
(B) 1 foot forward line hops, (C) 1 foot line hops with bounce,
(D) 1 foot dot hops, (E) skater hops and (F) Box hoppers.
Table VI. Level II plyometric program
Exercise Video links
Lateral shuffles
High knees
Forward/backward skips
Boxer shuffles
Lateral skips
Tap skips
Return to running after arthroscopic hip surgery 7
Table VII. Level III plyometric program
Exercise Repetitions Video links
Matrix jacks 3 30 s
1 foot forward line hops
a. Pause
b. No pause
a. 3 12
b. 3 12
1 foot line hops with bounce
a. Front/back
b. Side/side
a. 3 10
b. 3 10¼DALpKQE6zfs
1 foot dot hops* 2–3 3 each way
Skater hops 3 45–60 s
Box hoppers 3 12
Jump rope 2–3 sets of:
2 feet 50
R/L alternate 50
R only 15
L only 15
R/L ¼right/left. *Patients should start with a pause, then progress to hot dots
Table VIII. Four-phase rehabilitation programs following hip arthroscopy
Protocol Edelstein et al. [17] Garrison et al. [6] Wahoff et al. [9]
Phase I Phase I (the protective phase) Initial exercise Maximum protection and mobility
Time (weeks) Linear: 0–4
Complex: 0–6
1–4 Varies based on progress
Goals Regain 75% of ROM
Normalize gait
Minimize pain and
Protect the surgically
repaired tissue
Initiate early motion
Protect integrity of repaired tissues
Diminish pain and inflammation
Restore ROM within restrictions
Phase II Phase II Intermediate exercise Controlled stability
Time (weeks) Linear: 4–8
Complex: 6–12
5–7 Varies based on progress
Goals Achieve independence in daily
activities with little or no
Continue progressing ROM
and soft tissue flexibility
Normalize gait
Restore full ROM
Improve neuromuscular control,
balance, proprioception
Phase III Phase III Advanced exercise Strengthening
Time (weeks) Linear: 8–12
Complex: 12–20
8–12 Varies based on progress
8M. J. Kraeutler et al.
centres), ability to jump without pain (59%), ability to re-
produce all motions involved in the sport without pain
(85%) and ability to perform a single-leg squat (19%). The
majority of participating surgeons classified the following
sports as high risk following hip arthroscopy: kickboxing,
football, basketball and wrestling. Golf was the only major
sport classified as low risk by more than half of the
The purpose of this article was to review the literature
on rehabilitation protocols for patients post-hip arthros-
copy and to provide a novel protocol for return to running
following hip arthroscopy. This program builds off of the
background provided by previously described rehabilitation
programs and proposes a functional rehabilitation program
to improve results in a particular subset of patients. The
novel program proposed here has been used with success
in our institution; however, it has not been validated
with long-term outcomes, and therefore should be treated
as a guideline that can be altered according to individual
In summary, this rehabilitation protocol is the first pro-
gram specifically designed for patients who wish to re-
turn to running following hip arthroscopy/injury. Future
studies should focus on obtaining short- and long-term
outcomes based on patients who adhere to these re-
habilitation guidelines as well as other published proto-
cols for athletes returning to sports other than running to
be able to draw comparisons and ultimately assess their
The authors report no funding for this study.
The authors would like to thank the models shown in
Figs. 1–4 for volunteering their time.
None declared.
1. Maradit Kremers H, Schilz R, Van Houten HK et al. Trends in
utilization and outcomes of hip arthroscopy in the United States
between 2005 and 2013. J Arthroplasty 2017; 32(3):750–5.
2. Cheatham SW, Enseki KR, Kolber MJ. Post-operative rehabilita-
tion after hip arthroscopy: A search for the evidence. J Sport
Rehabil 2015; 24:413–8.
3. Grzybowski JS, Malloy P, Stegemann C et al. Rehabilitation fol-
lowing hip arthroscopy—a systematic review. Front Surg 2015;
4. Enseki KR, Martin R, Kelly BT. Rehabilitation after arthroscopic
decompression for femoroacetabular impingement. Clin Sports
Med 2010; 29:247–55.
5. Enseki KR, Martin RL, Draovitch P et al. The hip joint: arthro-
scopic procedures and postoperative rehabilitation. J Orthop
Sports Phys Ther 2006; 36:516–25.
6. Garrison JC, Osler MT, Singleton SB. Rehabilitation after arth-
roscopy of an acetabular labral tear. N Am J Sports Phys Ther
2007; 2:241–50.
7. Stalzer S, Wahoff M, Scanlan M. Rehabilitation following hip
arthroscopy. Clin Sports Med 2006; 25:337–57.
8. Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabili-
tation guidelines for hip arthroscopy in an active population.
Sports Health 2010; 2:222–30.
9. Wahoff M, Ryan M. Rehabilitation after hip femoroacetabular im-
pingement arthroscopy. Clin Sports Med 2011; 30:463–82.
10. Geraci MC, Jr, Brown W. Evidence-based treatment of hip and pelvic
injuries in runners. Phys Med Rehabil Clin N Am 2005; 16:711–47.
11. Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness
of neuromuscular warm-up strategies, that require no additional
Table VIII. (Continued)
Protocol Edelstein et al. [17] Garrison et al. [6] Wahoff et al. [9]
Become recreationally
Have symmetrical
Begin integrated func-
tional strengthening
Restore muscular strength and
Restore cardiovascular endurance
Progress sport progressions
Phase IV Phase IV Sports specific training Return to sport
Time (weeks) Linear: 12–16
Complex: 20–28
12þVaries based on progress
Goals Return to pain-free competitive
Safe and effective return to
competition or previous
activity level
Restore power and maximize plyo-
metric strength
Return to play
ROM ¼range of motion
Return to running after arthroscopic hip surgery 9
equipment, for preventing lower limb injuries during sports par-
ticipation: a systematic review. BMC Med 2012; 10:75.
12. Distefano LJ, Blackburn JT, Marshall SW, Padua DA. Gluteal
muscle activation during common therapeutic exercises. J Orthop
Sports Phys Ther 2009; 39:532–40.
13. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis
of core trunk, hip, and thigh muscles during 9 rehabilitation exer-
cises. J Orthop Sports Phys Ther 2007; 37:754–62.
14. Krause DA, Jacobs RS, Pilger KE et al. Electromyographic analysis
of the gluteus medius in five weight-bearing exercises. J Strength
Cond Res 2009; 23:2689–94.
15. Berryman N, Maurel D, Bosquet L. Effect of plyometric vs. dy-
namic weight training on the energy cost of running. J Strength
Cond Res 2010; 24:1818–25.
16. Bonacci J, Chapman A, Blanch P, Vicenzino B. Neuromuscular
adaptations to training, injury and passive interventions: implica-
tions for running economy. Sports Med 2009; 39:903–21.
17. Edelstein J, Ranawat A, Enseki KR et al. Post-operative guidelines fol-
lowing hip arthroscopy. Curr Rev Musculoskelet Med 2012; 5:15–23.
18. Domb BG, Stake CE, Finch NA, Cramer TL. Return to sport
after hip arthroscopy: aggregate recommendations from high-
volume hip arthroscopy centers. Orthopedics 2014; 37:e902–5.
10 M. J. Kraeutler et al.
... Return to running was a primary focus of three included articles, and recommendations were made for this specific activity. 11,13,14 Chen et al. allowed return to run after three months of physical therapy and the patient's demonstrated good stability while performing 30 consecutive single leg squats. 11 Kraeutler et al. recommended similar timing, although a delay of an additional 6 weeks was recommended in the setting of cartilage restoration and/or acetabular dysplasia. ...
... 11 Kraeutler et al. recommended similar timing, although a delay of an additional 6 weeks was recommended in the setting of cartilage restoration and/or acetabular dysplasia. 13 They further recommended a focus on strength-maintaining exercises and a dynamic warm-up, as well as a threephase return-to-run program including 1) walking program, 2) quick response and plyometric routine HIP ARTHROSCOPY REHABILITATION e127 with progression to a walk/jog program, and 3) return to distance running. Kuhns et al. also paid special attention to return to running during phase IV of their rehabilitation. ...
... Kraeutler et al. defined "acceptable" and "unacceptable" symptoms in response to running as a guideline for determining appropriate progression. 13 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 overground program. ...
Full-text available
The purpose of the article is to present an updated literature review, as well as describe our approach to rehabilitation and return to sports following hip arthroscopy for femoroacetabular impingement (FAI) with labral repair. A literature review was performed to identify articles published within the last 10 years that were focused on this topic. Relevant articles were reviewed, and reference lists were searched to identify additional articles. Findings were summarized for rehabilitation phases and return-to-sports assessment. Additionally, advanced rehabilitation topics are reviewed. Several systematic reviews and individual case series were identified. There is relative uniformity concerning the use of a four-phase approach for rehabilitation. However, there is inconsistency in terms of timing and criteria for ultimate return to sport. Advanced rehabilitation topics were reviewed, and description of their relevance at various rehabilitation phases was provided. 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.
... Specifically, 94% at 2 years [8] and 78% of patients at 5 years [6] have reported a successful return to running following hip arthroscopy for intra-articular pathology. While these studies have demonstrated a high incidence of return, substantial heterogeneity exists amongst the specific rehabilitation protocols in the current peerreviewed literature [7,9,10]. ...
... Several different rehabilitation protocols have been described in the literature, both to achieve a successful return to day-today function and athletic performance [7,[11][12][13][14]. While rehabilitation protocols should be focused on returning patients to specific activities, there is currently a limitation in outcome-based evidence to support the published protocols [7,9] Despite the increased expectation of patients returning to activity following hip arthroscopy, there is a limitation in evidence-based rehabilitation protocols. Specifically, there is a limitation in established return to running progression protocols and their demonstrated effects on clinical outcomes [9]. ...
... While rehabilitation protocols should be focused on returning patients to specific activities, there is currently a limitation in outcome-based evidence to support the published protocols [7,9] Despite the increased expectation of patients returning to activity following hip arthroscopy, there is a limitation in evidence-based rehabilitation protocols. Specifically, there is a limitation in established return to running progression protocols and their demonstrated effects on clinical outcomes [9]. The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. ...
Full-text available
The purpose of the current study was to present pre-operative comparisons for recreational athletes attempting a return to running following hip arthroscopy, and the return to running progression protocol used to guide them. A prospective, non-randomized cohort study was conducted to evaluate recreational athletes that returned to running following hip arthroscopy. Return to running was the primary outcome measure and defined as the ability to run at least one mile three times weekly while maintaining patient-reported relief of pre-operative symptoms. Patients included were correlated with the following pre-operative patient-reported outcome measures: hip outcome score (HOS), 12-item international outcome tool (iHOT-12), visual analog scale for pain (VAS) and the Short-Form Health Survey (SF-12). Of the 99 included patients, 94 (95%) returned to running successfully with an average return of 4.8 months. There was no statistical difference in pre-operative comparisons between patients that returned to running and did not return to running (P 0.154). Evaluation of pre-operative clinical outcomes demonstrated no statistical difference between individuals that returned and did not return to running (P 0.177), but a large difference between the two groups was identified for HOS-ADL (64.8 versus 53.7, returned versus did not return), iHOT-12 (33.8 versus 25.4) and VAS (58.6 versus 69.3). Patients who returned to running demonstrated similar intraoperative procedures as those that did not return to running (P 0.214). The current study successfully establishes a management plan and progression protocol for patients identifying a return to recreational running following hip arthroscopy. Level of evidence: 3.
... This interval-based training is an effective way to increase running capacity in untrained novice runners 21 and is recommended following hip and lower limb injuries to safely return to running. [22][23][24] Participants enter the interval training programme at stage 1, 2 or 3 as determined by a 2 min running tolerance test at the initial physical assessment. During this run test, participants will be instructed to run at a slow to moderate pace for as long as they are comfortable, up to a maximum of 2 min. ...
... To reduce the risk of injury due to the rate of progression, participants can only increase one stage per week and must complete at least two sessions per week before progressing to the following stage. 22 The increase in average running time per week (table 1) is greater over the first 6 weeks and reduces throughout the programme. This is due to a conservatively chosen starting point to facilitate confidence with running, facilitate familiarity with sensations associated with muscle fatigue and reduce the interference of possible fatigue-related pain interpreted as injury pain. ...
Full-text available
Poor intervertebral disc (IVD) health is associated with low back pain (LBP). This 12-week parallel randomised controlled trial will evaluate the efficacy of a progressive interval running programme on IVD health and other clinical outcomes in adults with chronic LBP. Participants will be randomised to either a digitally delivered progressive interval running programme or waitlist control. Participants randomised to the running programme will receive three individually tailored 30 min community-based sessions per week over 12 weeks. The waitlist control will undergo no formal intervention. All participants will be assessed at baseline, 6 and 12 weeks. Primary outcomes are IVD health (lumbar IVD T2 via MRI), average LBP intensity over the prior week (100-point visual analogue scale) and disability (Oswestry Disability Index). Secondary outcomes include a range of clinical measures. All outcomes will be analysed using linear mixed models. This study has received ethical approval from the Deakin University Human Research Ethics Committee (ID: 2022-162). All participants will provide informed written consent before participation. Regardless of the results, the findings of this study will be disseminated, and anonymised data will be shared via an online repository. This will be the first study to evaluate whether a progressive interval running programme can improve IVD health in adults with chronic LBP. Identifying conservative options to improve IVD health in this susceptible population group has the potential to markedly reduce the burden of disease. This study was registered via the Australian New Zealand Clinical Trials Registry on 29 September 2022 (ACTRN12622001276741).
... From 2015 to December 2017, only MF was carried out as treatment of chondral defects. Patients were treated a rehabilitated using the Steadman recommended post-operative protocol [18,19]. From January 2018 onwards, BR was adopted as the treatment method for all chondral lesions and this allowed for a facilitated bilateral sequential surgery, enhanced recovery protocol. ...
... The post-operative rehabilitation involved partial weight bearing during Week 1 with crutches and full weight bearing from Week 2 onwards with independence of crutches at the end of this week. For bilateral hip affection, patients who underwent sequential surgery had the same protocol; first side surgery at Week 0, partial weight bearing with crutches for 1 week and full weight bearing for Week 2. Second side surgery took place at the beginning of Week 3 and the same protocol was followed again, allowing for independence of crutches at the end of Week 4 [18,19]. ...
Full-text available
In an attempt to bridge the osteoarthritis (OA) gap, this study compared biological reconstruction with traditional microfracture (MF) techniques in patients with femoroacetabular impingement and focal cartilage defects. Cohorts of two groups were investigated; age, gender and Tonnis grade matched comparison for outcomes between MF and newer biological reconstruction techniques hip arthroscopy surgery using autologous matrix-induced chondrogenesis and bone marrow aspirate combination. Outcomes investigated were pre-op and post-op mean iHOT-12 scores up to 18 months after surgery with a Kaplan-Meier survivorship analysis. Of 111 patients, 46 patients underwent MF and 65 biological reconstruction hip arthroscopy including cam/pincer osteoplasty and labral repair surgery. Age range was 20-69, mean age 45 years for both groups, Tonnis grading was as follows: Grade 0: 26% versus 30%, Grade 1: 52% versus 47% and Grade 2: 22% versus 23% in MF and biological reconstruction groups, respectively. The mean post-operative iHOT-12 score differences between MF and biological reconstruction were significant at 1-year minimum follow-up (P ¼ 0.01, SD 2.8). Biological reconstruction allowed for an enhanced recovery protocol. The MF group had a 67.4% survivorship for conversion to hip replacement at 18 months (32.6% failure rate for any reason) and biological reconstruction had 100% survivorship at 18 months post-operatively with no failures for any reason. This study provides further support to the evidence base for biological reconstructive techniques as superior to MF in combination with joint preservation arthroscop-ic surgery, even in the face of focal cartilage defects and offers both surgeons and patients a potential bridging of the OA gap.
... Due to the amount of variability between rehabilitation protocols, timelines to initiate running progressions range from 1-to 6-months postprocedure. 5,[14][15][16][17][18] Even though that range is fairly large, a survey conducted by Rath et al. 16 of 26 arthroscopy surgeons at the International Society for Hip Arthroscopy in 2015 identified that most protocols allow for running at the 3-to 4-month time point. ...
Full-text available
Antigravity treadmills are being used in rehabilitation programs but have not been used consistently with posthip labral repair arthroscopy surgeries. The purpose of this study was to review the posthip labral protocol used by eight National Collegiate Athletic Association Division I collegiate athletes (all ages 18–21) from multiple sports that used the antigravity treadmill as a bridge between “no running” and “on-ground running.” The authors found that athletes who did this returned to play between 4.5 and 7 months, had a better overall functional status, and had no re-injuries. This is the first known study of its kind available in the literature.
... The physical examination tests we used included passive hip range of motion (supine, lateral, and prone), the flexionadduction-internal rotation test, the flexion-abductionexternal rotation test, the ligamentum teres test, the posterior impingement test, use of the Beighton hypermobility score, and subjective reports of hip instability. 15 ...
Full-text available
Background Despite the rapid growth in the use of hip arthroscopy, standardized data on postoperative pain scores and activity level are lacking. Purpose To quantify narcotic consumption and use of the stationary bicycle in the early postoperative period after hip arthroscopy. Study Design Case series; Level of evidence, 4. Methods In this prospective case series, patients undergoing a primary hip arthroscopy procedure by a single surgeon were asked to fill out a daily survey for 9 days postoperatively. Patients were asked to report their pain level each day on a visual analog scale from 1 to 10, along with the amount of narcotic pain pills they used during those postoperative days (PODs). Narcotic usage was converted to a morphine-equivalent dosage (MED) for each patient. Patients were also instructed to cycle daily starting on the night of surgery for a minimum of 3 minutes twice per day and were asked to rate their pain as a percentage of their preoperative pain level and the number of minutes spent cycling on a stationary bicycle per day. Results A total of 212 patients were enrolled in this study. Pain levels (POD1, 5.5; POD4, 3.8; POD9, 2.9; P < .0001) and the percentage of preoperative pain (POD1, 51.6%; POD4, 31.8%; POD9, 29.5%; P < .01) significantly decreased over the study period. The amount of narcotics used per day (reported in MED) also significantly decreased (POD1, 27.3; POD4, 22.3; POD9, 8.5; P < .0001). By POD4, 41% of patients had discontinued all narcotics, and by POD9, 65% of patients were completely off narcotic medication. Patients were able to significantly increase the number of minutes spent cycling each day (POD1, 7.6 minutes; POD4, 13.8 minutes; POD9, 19.0 minutes; P < .0001). Patients who received a preoperative narcotic prescription for the affected hip were significantly more likely to require an additional postoperative narcotic prescription ( P < .001). Conclusion Patients can expect a rapid decrease in narcotic consumption along with a high degree of activity tolerance in the early postoperative period after hip arthroscopy.
... While a number of these return to running progressions are available online, there have been some published in the literature. 20,21 Essentially, all of these programs involve walk: jog intervals that progressively reduce time walking and increase time jogging, most of them up to about thirty minutes of jogging. The authors are not aware of any research comparing these programs to determine the ideal time frame with associated walk:jog ratios. ...
In the terminal phases of athletic rehabilitation, transitioning back to sport is a critical aspect to prepare an athlete for return to full participation. Numerous interval sport programs have been published in the literature and return to sports guidelines and criteria-based progressions for returning to sport have been published, but no such protocol exists for returning to the task of sprinting. Any field or court athlete must be able to sprint as part of his/her sport demands. Because of the absence of a specific progression, sports rehabilitation professionals lack knowledge about objective criteria to progress to sprinting as well as a progressive program to do so. Given that sports rehabilitation professionals have limited visits to complete rehabilitation or their athletes have limited financial resources to do so, it is imperative that a structured, criteria-based progression be available. The purpose of this clinical suggestion is to provide a criteria-based return to sprinting progression. Level of evidence: 5.
... Hip pain in runners can be a disabling and frustrating limitation to activity. 17,19,24 For those with symptomatic hip pain secondary to FAIS, hip arthroscopy has been a successful treatment with a high rate of return to sport. 21 Runners with the pain will have a typical insidious onset of pain. ...
Running and cycling have become among the top athletic activities in the United States. While endurance sports can lead to decreased cardiovascular disease and chronic comorbidities, it can lead to musculoskeletal injury. Hip injuries in endurance athletes can be associated with both intra-articular and extra-articular disorders, resulting in prolonged decrease physical function and inability to return to sport. This review provides physicians with a summary of hip injury commonly presented in long distance runners and cyclist, as well as clinical exam recommendations for the source of hip pain in these endurance athletes.
Advancement in hip arthroscopic technique, expanding indications, and a growing body of literature support its use for addressing intra- and extra- articular hip pathology. As a result of expanding treatment options, hip rehabilitation protocols have evolved to meet the demands of a diverse, active patient population. Rehabilitation following hip arthroscopy focuses on activity modifications to allow for soft tissue healing, gait training, reestablishment of neuromuscular control, strength and endurance training, and sports-specific training. Hip arthroscopy has also shown reliable improvement in patient-reported outcome measures over short- and intermediate- term follow-up. The literature involving return-to-play rates after hip arthroscopy in athletes demonstrates favorable outcomes. The incidence of complications following hip arthroscopy, including but not limited to venous thromboembolism and heterotopic ossification, is low. Current rehabilitation regimens are based primarily on physical therapist and clinician experience. Future studies are needed to define objective outcome measures to determine appropriate postoperative protocol.
Background: Interportal and T-capsulotomies are popular techniques for exposing femoroacetabular impingement deformities. The difference between techniques with regard to the force required to distract the hip is currently unknown. Purpose: To quantify how increasing interportal capsulotomy size, conversion to T-capsulotomy, and subsequent repair affect the force required to distract the hip. Study design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric hip specimens were dissected and fixed in a materials testing system, such that pure axial distraction of the iliofemoral ligament could be achieved. The primary outcome measure was the load required to distract the hip to a distance of 6 mm at a rate of 0.5 mm/s. Each hip was tested in the intact state and then sequentially under varying capsulotomy conditions: 2-cm interportal, 4-cm interportal, half-T (4-cm interportal and 2-cm T-capsulotomy), and full-T (4-cm interportal and 4-cm T-capsulotomy). After serial testing, isolated T-limb repair and then subsequent complete repair were performed. Repaired specimens underwent distraction testing as previously stated to assess the ability to restore hip stability to the native profile. Distraction force as well as the relative distraction force (percentage normalized to the intact capsule) were compared between all capsulotomy and repair conditions. Results: Increasing interportal capsulotomy size from 2 to 4 cm resulted in significantly less force required to distract the hip ( P < .001). The largest relative decrease in force was seen between the intact state (274.6 ± 71.2 N; 100%) and 2-cm interportal (209.7 ± 73.2 N; 76.4% ± 15.6%; P = .0008). There was no significant mean difference in distraction force when 4-cm interportal (160.4 ± 79.8 N) was converted to half-T (140.7 ± 73.5 N; P = .270) and then full-T (112.0 ± 70.2 N; P = .204). When compared with the intact state, isolated T-limb repair partially restored stability (177.3 ± 86.3 N; 63.5% ± 19.8%; P < .0001), while complete repair exceeded native values (331.7 ± 103.7 N; 122.7% ± 15.1%; P = .0008). Conclusion: The conversion of interportal capsulotomy to T-capsulotomy did not significantly affect the force required to distract the hip in a cadaveric model. However, larger interportal capsulotomies resulted in significant stepwise decreases in distraction force. When performing interportal or T-capsulotomy, the iliofemoral ligament strength is significantly decreased, but complete capsular repair demonstrated the ability to restore joint stability to the native, intact hip. Clinical relevance: Increasing interportal capsulotomy size decreases the force required to distract the hip. In an effort to maximize visualization and minimize the magnitude of iliofemoral ligament fibers cut, many surgeons have moved from extended interportal capsulotomy to T-capsulotomy. Interportal and T-capsulotomies result in equivalent hip distraction, partial capsular repair marginally improves hip stability, and only complete repair has the ability to restore the hip to its native biomechanical profile.
Full-text available
Context: Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy. Objectives: (1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, (2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols, and (3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy. Data sources: Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched. Study selection: Level I-IV evidence clinical studies with minimum 2-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included. Data extraction: All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the modified Coleman methodology score. Results: Eighteen studies were included (2,092 subjects; 52% male, mean age 35.1 ± 10.6 years, mean follow-up 3.2 ± 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return to sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported. Conclusion: The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. Strengths and limitations in the literature were identified. Future studies should recognize and report the essentials of rehabilitation following hip arthroscopy.
Full-text available
Context: Hip arthroscopy has become an increasingly popular option for active individuals with recalcitrant hip pain. Conditions that may be addressed through hip arthroscopy include labral pathology, femoral acetabular impingement (FAI), capsular hyperlaxity, ligamentum teres tears, and the presence of intra-articular bodies. Though the body of literature examining operative procedures has grown, there is a paucity of evidence that specifically examines the efficacy of postoperative rehabilitation programs. To date, there are no systematic reviews that have evaluated the available evidence on post-operative rehabilitation. Objectives: The objective of this study was to evaluate the available evidence on post-operative rehabilitation programs following arthroscopy of the hip joint. Evidence acquisition: A search of the PubMed, CINAHL, SportsDiscus, Proquest, and Google Scholar® databases was conducted on January, 2014 according the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting systematic reviews. Evidence synthesis: Six studies met the inclusion criteria and consisted of either case series or case reports (level 4 evidence) that described a four or five phase post-operative rehabilitation program. The available evidence supports a post-operative period of restricted weight-bearing and mobility restrictions, however, the specific interventions within the post-operative phases are variable with no comparison trials. Conclusion: The results of this review have identified a paucity of evidence surrounding post-operative rehabilitation after hip arthroscopy. Existing reports are descriptive in nature, thus the superiority of a particular approach cannot be determined. One can surmise from existing studies that a 4 to 5 stage program with an initial period of weight-bearing and mobility precautions is efficacious in regard to function, patient satisfaction, and return to competitive level athletics. The clinician may consider such a program as a general guideline but should individualize the treatment according to the surgical procedure and surgeon guidelines. Future research should focus on comparative trials to determine the effect of specific post-operative rehabilitation designs.
Full-text available
With the evolution of hip arthroscopy has come an increased recognition of intra-articular hip pathologies and improved techniques for their management. Whereas mechanical problems can often be corrected through surgery, functional deficits must be corrected through the rehabilitation process. Therefore, the evolution of hip arthroscopy has necessitated a progression in hip rehabilitation to ensure optimal postsurgical results. Literature review was conducted with PubMed, EMBASE, and PEDro (1992 to 2009) with the terms hip, rehabilitation, and physical therapy. Although it is generally accepted that rehabilitation after hip arthroscopy is important, there is limited evidence-based research to support the rehabilitative guidelines. The common goal of hip rehabilitation should remain focused on the return to pain-free function of the hip joint. Outcome data indicate that this goal is being met; however, further data are required to completely validate the long-term success of hip rehabilitation after arthroscopy.
Full-text available
Lower limb injuries in sport are increasingly prevalent and responsible for large economic as well as personal burdens. In this review we seek to determine which easily implemented functional neuromuscular warm-up strategies are effective in preventing lower limb injuries during sports participation and in which sporting groups they are effective. Seven electronic databases were searched from inception to January 2012 for studies investigating neuromuscular warm-up strategies and injury prevention. The quality of each included study was evaluated using a modified version of the van Tulder scale. Data were extracted from each study and used to calculate the risk of injury following application of each evaluated strategy. Nine studies were identified including six randomized controlled trials (RCT) and three controlled clinical trials (CCT). Heterogeneity in study design and warm-up strategies prevented pooling of results. Two studies investigated male and female participants, while the remaining seven investigated women only. Risk Ratio (RR) statistics indicated 'The 11+' prevention strategy significantly reduces overall (RR 0.67, confidence interval (CI) 0.54 to 0.84) and overuse (RR 0.45, CI 0.28 to 0.71) lower limb injuries as well as knee (RR 0.48, CI 0.32 to 0.72) injuries among young amateur female footballers. The 'Knee Injury Prevention Program' (KIPP) significantly reduced the risk of noncontact lower limb (RR 0.5, CI 0.33 to 0.76) and overuse (RR 0.44, CI 0.22 to 0.86) injuries in young amateur female football and basketball players. The 'Prevent Injury and Enhance Performance' (PEP) strategy reduces the incidence of anterior cruciate ligament (ACL) injuries (RR 0.18, CI 0.08 to 0.42). The 'HarmoKnee' programme reduces the risk of knee injuries (RR 0.22, CI 0.06 to 0.76) in teenage female footballers. The 'Anterior Knee Pain Prevention Training Programme' (AKP PTP) significantly reduces the incidence of anterior knee pain (RR 0.27, CI 0.14 to 0.54) in military recruits. Effective implementation of practical neuromuscular warm-up strategies can reduce lower extremity injury incidence in young, amateur, female athletes and male and female military recruits. This is typically a warm-up strategy that includes stretching, strengthening, balance exercises, sports-specific agility drills and landing techniques applied consistently for longer than three consecutive months. In order to optimize these strategies, the mechanisms for their effectiveness require further evaluation.
Full-text available
Rehabilitation following hip arthroscopy can vary significantly. Existing programs have been developed as a collaborative effort between physicians and rehabilitation specialists. The evolution of protocol advancement has relied upon feedback from patients, therapists and observable outcomes. Although reports of the first femoroacetabular impingement (FAI) surgeries were reported in the 1930's, it was not until recently that more structured, physiologically based guidelines have been developed and executed. Four phases have been developed in this guideline based on functional and healing milestones achieved which allow the patient to progress to the next level of activity. The goal of Phase I, the protective phase, is to progressively regain 75% of full range of motion (ROM) and normalize gait while respecting the healing process. The primary goal of Phase II is for the patient to gain function and independence in daily activities without discomfort. Rehabilitation goals include uncompensated step up/down on an 8 inch box, as well as, adequate pelvic control during low demand exercises. Phase III goals strive to accomplish pain free, non-compensated recreational activities and higher demand work functions. Manual muscle testing (MMT) grading of 5/5 should be achieved for all hip girdle musculature and an ability to dynamically control body weight in space. Phase IV requires the patient be independent with home and gym programs and be asymptomatic and pain free following workouts. Return to running may be commenced at the 12 week mark, but the proceeding requirements must be achieved. Athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patient's pre-operative health status and post-operative physical demands will direct both the program design and the program timetable.
Full-text available
Over the past few years, arthroscopy of the hip joint is becoming more common as a technique in both the diagnosis and treatment of hip pain. A frequent cause of hip and groin pain is a tear of the acetabular labrum. Patients with labral tears complain of pain in the groin region and pain with clicking in the hip without a history of pain prior to the original onset. Once a patient presents with signs and symptoms of hip pain that are greater than four weeks in conjunction with indicative findings of a labral tear by way of MRI, he or she may be considered a good candidate for arthroscopy of the hip joint. Little evidence exists in the current literature on rehabilitative procedures performed after arthroscopy of the acetabular labrum. The purpose of this clinical commentary is to suggest a rehabilitation protocol after acetebular labral debridement or repair.
Background: The utilization of hip arthroscopy continues to increase in the United States. The purpose of this study was to examine trends in hip arthroscopy procedures and outcomes. Methods: We performed a retrospective cohort study using Optum Labs Data Warehouse administrative claims data. The cohort comprised 10,042 privately insured enrollees aged 18-64 years who underwent a hip arthroscopy procedure between 2005 and 2013. Utilization trends were examined using age-specific, sex-specific, and calendar-year-specific hip arthroscopy rates. Outcomes were examined using the survival analysis methods and included subsequent hip arthroscopy and total hip arthroplasty (THA). Results: Hip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. The overall 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In the subset of patients in whom laterality of the subsequent procedure could be determined, about half of the subsequent hip arthroscopy procedures (46%) and almost all of the THA procedures (94%) were on the same side. Decreasing age was significantly associated with the risk of subsequent arthroscopy (P < .01), whereas increasing age was significantly associated with the subsequent risk of THA (P < .01). The 5-year cumulative incidence of THA reached as high as 35% among individuals aged 55-64 years. Conclusion: The utilization of hip arthroscopy procedures increased dramatically over the last decade in the 18-64-year-old privately insured population, with the largest increase in younger age-groups. Future studies are warranted to understand the determinants of the large increase in utilization of hip arthroscopy and outcomes.
Hip arthroscopy is a minimally invasive surgical technique often performed in athletes who want an expeditious return to sport. To the authors' knowledge, no studies in the literature provide a time frame or criteria for return to sport after hip arthroscopy. The purpose of this study was to develop an aggregate recommendation for return to sport after hip arthroscopy based on data assimilated from high-volume hip arthroscopy centers. Twenty-seven orthopedic surgeons from high-volume hip arthroscopy centers completed a survey regarding return to sport after hip arthroscopy. The questionnaire asked surgeons to give a time frame for return to sport and to choose meaningful criteria that an athlete must meet prior to return to sport. Surgeons were asked to categorize various common sports as high, medium, or low risk with regard to the hip. The aggregate results were used to create standardized recommendations for time, criteria, and risk for return to competitive sports. Regarding time frame for return to sport, 70% of surgeons recommended 12 to 20 weeks. In addressing criteria for return to sport, 85% of surgeons recommended that patients need to be able to reproduce all motions involved in their sport without pain. A majority of surgeons recommended criteria of pain-free running, jumping, lateral agility drills, and single-leg squats. Finally, surgeons categorized sports requiring the most movement and impact of the hip joint (football, basketball, wrestling, and martial arts) as high-risk sports. Sports with less impact on the hip, such as golf, were ranked as low risk.
Hip arthroscopic techniques to repair labral tears and address femoroacetabular impingement (FAI) are evolving. This article discusses the different phases of rehabilitation and the rehabilitation protocol. Although there is evidence to support arthroscopic procedures to address labral tears and FAI, there are few published evidence-based rehabilitation studies dedicated to postoperative rehabilitative care. It is thought that by following the restrictions set by the physician while performing early circumduction, using the minimal criteria to advance through each subsequent phase, and allowing patients to perform functional sport progressions throughout the rehabilitation athletes will be able to return to sport smoothly and effectively.