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REVIEW ARTICLE
Return to running after arthroscopic hip surgery:
literature review and proposal of a physical
therapy protocol
Matthew J. Kraeutler
1
, Joy Anderson
2
, Jorge Chahla
3
, Justin J. Mitchell
4
,
Robyn Thompson-Etzel
2
, Omer Mei-Dan
1
and Cecilia Pascual-Garrido
1
*
1
Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO 80045, USA,
2
University of Colorado Sports Physical Therapy, Denver, CO 80222, USA,
3
Steadman Philippon Research Institute, Vail, CO 81657, USA and
4
Department of Sports Medicine, Gundersen Health System, La Crosse, WI 54601, USA
*Correspondence to: C. Pascual-Garrido. E-mail: pascualgarridoc@wudosis.wustl.edu
Submitted 1 November 2016; Revised 14 February 2017; revised version accepted 18 February 2017
ABSTRACT
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.
INTRODUCTION
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 [4–9], 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
V
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This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
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1
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
program.
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.
BACKGROUND
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.
RUNNING PROGRESSION PROGRAM
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
follow-up.
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).
PHASES OF THE PROGRAM
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
surfaces.
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
reach.
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 https://youtu.be/x_F_xfiCZtA
Front planks https://youtu.be/3_YvcCUitzQ
Band walks https://youtu.be/baeAQXHvwhY
Supine bridge https://youtu.be/WQrmXZDyLrU
Single leg squat reach https://youtu.be/_R5ZbG-eYRM
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
tracks).
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.
DISCUSSION
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 https://youtu.be/RiYVoDjdbys
In/out heel taps 2 20 steps https://youtu.be/6lZT2tPZsmw
Swing kicks 2 20 steps https://youtu.be/0G6czNCrTXg
Soldier walks 2 20 steps https://youtu.be/hB3OsqYJuW8
Glute kicks 2 20 steps https://youtu.be/H2OQ9v4k8g8
Walking lunges with reach and rotation 2 10 steps https://youtu.be/0GO1ZsckaDk
Lunge twist 2 10 steps https://youtu.be/DVFwBCQQnHo
Quick steps 2:
20 in place then forward 20 ft
20 in place then backward 20 ft
https://youtu.be/BMLrzElmuNM
Single-leg mini-squat to calf raise 12 each leg https://youtu.be/BqDe0lrGoas
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
setback.
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-out
In-in/out (zig–zag shuffle)
Rest 2 min, then repeat 3
https://youtu.be/fK-4giDn9Wc
2 foot line jumps Front/back with bounce 3 12 https://youtu.be/7cqjvO8yhUk
2 foot dot hops 3 3 rounds each way https://youtu.be/zB6s32K_654
Alternating hop/hold 3 10 total jumps https://youtu.be/f33-b-spZeo
Alternating 1 leg hops with bounce 3 10 total jumps https://youtu.be/hjxtS7t0_SU
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 http://youtu.be/IcTPmEF1apU
High knees https://youtu.be/sUVnMWfl210
Forward/backward skips https://youtu.be/nPkXN_AhO6k
Backpedal https://youtu.be/xkiPM47agQo
Grapevine https://youtu.be/rQL7PJYu6nY
Boxer shuffles https://youtu.be/ug1A8gfDzjo
Lateral skips https://youtu.be/As1THjXMufs
Tap skips https://youtu.be/JUOpDv4uPUM
Return to running after arthroscopic hip surgery 7
Table VII. Level III plyometric program
Exercise Repetitions Video links
Matrix jacks 3 30 s https://youtu.be/2LT9CbeAVfQ
1 foot forward line hops
a. Pause
b. No pause
a. 3 12
b. 3 12
https://youtu.be/niv_fS0usGc
1 foot line hops with bounce
a. Front/back
b. Side/side
a. 3 10
b. 3 10
https://www.youtube.com/watch?v¼DALpKQE6zfs
1 foot dot hops* 2–3 3 each way https://youtu.be/kQfms_RmTpo
Skater hops 3 45–60 s https://youtu.be/0I4ziA73p7w
Box hoppers 3 12 https://youtu.be/JdSVfzDfT0A
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
inflammation
Protect the surgically
repaired tissue
Initiate early motion
exercises
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
discomfort
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
Goals
(Continued)
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
surgeons.
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
needs.
CONCLUSIONS
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
effectiveness.
FUNDING
The authors report no funding for this study.
ACKNOWLEDGEMENTS
The authors would like to thank the models shown in
Figs. 1–4 for volunteering their time.
CONFLICT OF INTEREST STATEMENT
None declared.
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Table VIII. (Continued)
Protocol Edelstein et al. [17] Garrison et al. [6] Wahoff et al. [9]
Become recreationally
asymptomatic
Have symmetrical
ROM
Begin integrated func-
tional strengthening
Restore muscular strength and
endurance
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
state
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
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