CASE STUDIES

Journal of Sport Rehabilitation, 2009, 18, 118-134

© 2009 Human Kinetics, Inc.

Rehabilitation After Arthroscopic Repair

of Intra-Articular Disorders of the Hip
in a Professional Football Athlete
Marc J. Philippon, Jesse C. Christensen,
and Michael S. Wahoff

Objective: To report the 4-phase rehabilitation progression of a professional athlete

who underwent arthroscopic intra-articular repair of the hip after injury during the
2006–07 season. Design: Case study; level of evidence, 4. Main Outcome Mea-
sures: Objective values were obtained by standard goniometric measurements, hand-
held dynamometer, dynamic sports testing, and clinical testing for intra-articular
pathology. Results: This case report illustrates improvements in hip mobility, muscle-
force output, elimination of clinical signs of intra-articular involvement, and ability to
perform high-level sport-specific training at 9 wk postsurgery. At 16 wk postsurgery,
the patient was able to return to full preparation for sport for the following season.
Conclusion: After the 4-phase rehabilitation program, the patient demonstrated
improvement in all areas of high-level function after an arthroscopic intra-articular
repair of the hip. The preoperative management to return to sport is outlined, with
clinical outcomes and criteria for return to competition. Keywords: case report, hip
arthroscopy, return to sport

The prevalence of intra-articular disorders of the hip in elite-level athletes is

becoming more apparent with advancements in clinical and diagnostic testing,
especially with respect to acetabular labral tears.1–7 Research has been conducted
on specific clinical signs1,8–12 and diagnostic imaging3,4,13,14 to confirm labral
involvement. Labral lesions have been found to decrease the stability of the joint,
which increases force transmission through the articular cartilage, leading to pre-
mature osteoarthritis.15–17
Labral tears can be associated with femoral-acetabular impingement (FAI),
trauma, capsular laxity, dysplasia, and degeneration.18,19 FAI results in compres-
sion of the anterior superior labrum between the rim of the acetabulum and the
anterior femoral neck.19,20 Two particular types of FAI have been described in the
literature, illustrating morphological formations of osseous prominence on the
femur (cam) and/or acetabulum (pincer).21–24 The presence of FAI with sport

Philippon is with Clinical Research, the Steadman Hawkins Research Foundation, Edwards, CO.
Christensen is with the Howard Head Sports Medicine Center, Vail, CO. Wahoff is with the Howard
Head Sports Medicine Center, Edwards, CO.

118
 Arthroscopic Hip Repair in a Football Athlete   119

activities with repetitive pivoting or flexion has been documented to increase risk
of acetabular labral tears.25,26 Traumatic intra-articular tears have been reported to
occur as a result of subluxations or dislocations, direct hip contact, and sudden
twisting or pivoting motion.10,18
Clinically, a variety of symptoms of labral tears have been documented.12,27
Many patients complain of mechanical symptoms such as catching, painful click-
ing, locking, groin pain, dynamic instability, and restricted range of motion
(ROM).12,28 Vigilant clinical and radiographic testing is necessary to differentiate
these symptoms between intra- and extra-articular pathology. Presence of impinge-
ment with associated labral and/or chondral pathology warrants surgical interven-
tion to repair these lesions.8,18–20,24 Advancements in arthroscopic surgical repair
of these lesions have been shown to maintain the function of the hip joint and
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decrease the development of premature arthrosis.15–17,24

With recent developments in arthroscopic repair, demands to incorporate
appropriate rehabilitation principles into practice have become extremely impor-
tant. Although appropriate evidence supporting rehabilitation for this pathology
has been shown adequate attention,18,19,24,29–32 few articles address the specifics of
a systematic approach to the rehabilitation of a high-level athlete after an
arthroscopic intra-articular repair of the hip.30–32 With a successful rehabilitation
program, a reported 93% of professional athletes returned to an elite level of com-
petition after FAI decompression with associated labral and/or chondral pathol-
ogy.18 The purposes of this case report are to describe the 4-phase rehabilitation
progression, report the clinical outcomes measured, and outline return-to-sport
criteria used to treat a National Football League athlete after arthroscopic intra-
articular repair of the hip.

Case Description
A 25-year-old wide receiver (6′ 3′′, 208 lb) sustained a traumatic collision that
resulted in a right-sided posterior hip subluxation during the second game of the
2006–07 season. Initial imaging ordered by the team physician showed positive
radiographic findings for femoral-head fracture and inconclusive magnetic reso-
nance imaging (MRI) findings for labral pathology. The injury was treated conser-
vatively for 12 months with minimal reduction in symptoms by the team physical
therapist with a diagnosis of hip-flexor strain and fracture, which eventually devel-
oped into avascular necrosis of the femoral head. After failing with conservative
care and being unable to return to his previous level, the patient consulted the
senior author (MJP), and a second MRI confirmed a diagnosis of an acetabular
labral tear. The patient’s chief complaints were debilitating hip pain with associ-
ated locking, catching, popping, restricted active ROM, and inability to perform
at the professional level. In addition, the patient complained of sharp-achy pain
that persisted in various areas of origin (Table 1). Past medical history included a
chronic left hamstring strain and osteitis pubis that had been problematic for 1
prior season with moderate relief with rehabilitation.
The patient consulted the senior author in October 2007, when further diag-
nostic assessment demonstrated a shallow dysplastic right acetabulum with a
center-edge angle of 17° and a cam-impingement lesion with an alpha angle of
 120   Philippon, Christensen, and Wahoff

Table 1  Preoperative Symptom Analog

Anatomical structure Symptoms Location Nature
Lumbar spine pain and stiffness right only intermittent
Buttock/Posterior hip pain right only intermittent
Sacrum/Sacroiliac joint pain right only intermittent
Pubis pain central intermittent
Groin pain right only constant
Lateral hip stiffness right only intermittent
Anterior thigh pain and paresthesia right only intermittent
Posterior thigh pain left only intermittent
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Lateral thigh no symptoms — —

Lower leg/foot no symptoms — —

69°. Literature has supported that a center-edge angle of less than 20° and an
alpha angle greater than 55° are abnormal.33,34 In addition, the osseous cam lesion
at the femoral head–neck junction was found with an anterolateral labral detach-
ment. There was minimal reactive right hip effusion, focal synovitis, and scarring
along the ligamentum teres. Bone edema at the pubic symphysis and parasymphy-
seal region was also present.
This athlete’s presurgical inability to perform at the professional level can be
hypothesized to be a result of an osseous prominence on the femoral head–neck
junction and a shallow dysplastic right acetabulum with a high-energy mechanism
of injury. These physical characteristics, in addition to the traumatic collision,
could predispose any athlete to pathological intra- and extra-articular involve-
ment.
After a discussion with the senior author, the patient was scheduled for sur-
gery the subsequent day. Based on radiographic and MRI findings, a comprehen-
sive physical therapy examination was ordered.

Preoperative Examination
A battery of special clinical tests (Appendix 1) was conducted to elicit symptoms
relative to intra-articular pathology (Table 2). Passive ROM (PROM) was per-
formed using a universal dual-arm goniometer for all cardinal-plane mobility of
the hip, which has shown high reliability for assessing hip PROM (Figure 1).35
A handheld dynamometer (HHD; Microfet 2 Load Cell Dynamometer,
Hoggan Health Industries, Draper, UT, USA) was used in this case with a standard
strain-gauge transducer to objectively document force output. Kendall36 protocols
were used for all test positioning and procedures. Multiple studies have demon-
strated good to excellent reliability with HHD in relation to hip testing.37–41 Scott
et al39 concluded that intraclass correlation coefficients for HHD testing were .81,
.67, and .74 for flexors, abductors, and extensors, respectively.
The HHD tests included 3 isometric trials taken from each muscle group. The
isometric force-output measurements were taken bilaterally from 8 different hip-
muscle actions to establish purposeful measures of overall force output (Figure 2).
 Arthroscopic Hip Repair in a Football Athlete   121

Table 2  Preoperative and Postoperative Clinical Testing for Labral

Pathology
Preoperative Postoperative
Special test Right Left Right Left
Kendall + – + +
Anterior impingement + – – –
Posterior impingement + – – –
Abduction impingement + – – –
Ober + – – –
Dial (log roll) – – – –
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FABER 29 cm 35 cm 19 cm 23 cm

Figure 1 — Preoperative passive hip range of motion. Abbreviations: Flex, flexion; Abd,
abduction; Add, adduction; IR, internal rotation; ER, external rotation.

Our objective was to obtain maximum force output within limits in which pain
was not reported.
The patient also underwent a functional return-to-sport test to provide a base-
line of muscle-endurance performance. This test is a sport-cord agility test (Figure
3) designed to gauge an athlete’s ability to participate in training. The test consists
of 3 minutes of cord-resisted single-knee bends to 70° of knee flexion and cord-
resisted lateral agility, diagonal agility, and forward box lunge. The ability to land
in a soft, controlled manner and flex to 70° of knee flexion without pain or com-
pensation is assessed during the agility tests, and there should be no pain or pinch
in the hip with the lunges. One point is given for every 30 seconds of single-knee
bend performed for a maximum of 6 points, 1 point is given for every 20 seconds
during agility tests for a maximum of 5 points, and 1 point is given for every 30
seconds of lunges for a maximum of 4 points. If the patient is unable to score at
least 1 point during the single-knee bends the test is discontinued because all 4
 122   Philippon, Christensen, and Wahoff
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Figure 2 — Preoperative isometric hip force. Abbreviations: Flex, flexion; Abd, abduc-
tion; Add, adduction; IR, internal rotation; ER, external rotation; Ham, hamstring.

tests rely on the ability to perform single-knee-bend movements. During preop-

erative testing, the patient was unable to tolerate more than 20 seconds on the first
task (single-knee bends) of the sports test because of pain in the hip and compen-
sation. The patient failed the sports test and was issued a score of 0 out of 20 (17
out of 20 to pass) because of continued pain and an inability to show proper bio-
mechanics. Currently, nothing in the literature supports the validity or reliability
of this test, but clinically we have found it useful to support return to sport.
On initial physical therapy examination, the patient demonstrated an unusual
case of increased PROM and nearly symmetrical muscle-force output of the
affected hip (Figures 1 and 2). The typical clinical presentation of loss of internal
rotation and pain with flexion, adduction, and internal rotation has been reported
as indicating labral pathology.22,42–44
This patient’s findings were consistent with literature that has shown that
individuals with persistent hip pain for more than 4 weeks, clinical provocative
labral-involvement signs, and MRI findings of a labral tear are appropriate candi-
dates for hip arthroscopy.19 After evaluation, it was determined that the patient
was a good candidate for surgical intervention for intra-articular hip pathology.

Operative Intervention
A right hip arthroscopy with debridement and repair of the torn labrum was per-
formed. The patient was placed in the supine position, and 2 standard arthroscopic
portals (anterior and anterolateral) were used to evaluate all pertinent structures.24
Surgical intervention included preparing bony bed on the acetabular rim to sup-
port labral repair, osteoplasty of the femoral neck for treatment of the cam lesion,
chondroplasty of the acetabular rim, debridement of the torn ligamentous teres,
synovectomy, capsular plication for redundant capsule, and removal of loose
chondral fragments.20,24,45,46 Overall, the patient tolerated the operation extremely
well without complication and was able to initiate postoperative rehabilitation less
than 12 hours after surgery.
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Figure 3 — Functional return-to-sport test to provide a baseline of muscle-endurance

performance. (a) Single-knee bends with sport cord. (b) Lateral agility with sport cord. (c)
Diagonal lateral agility with sport cord. (d) Forward box lunge with sport cord.

123
 124   Philippon, Christensen, and Wahoff

Postoperative Rehabilitation
Phase I: Mobility and Protection.  The preliminary treatment for an arthroscopic
acetabular labral repair is to protect the repaired tissue while initiating early but
restricted PROM. The patient was seen twice a day for 10 days under the supervi-
sion of the senior physical therapist and author before returning to the team for
continued rehabilitation. After the athlete’s return to the team, weekly communi-
cation was maintained via phone conversation to monitor rehabilitation progres-
sion. Precautions in phase I consist of adherence to foot-flat (20 lb) weight bearing
precaution to protect the femoral neck after the osteoplasty, ROM limits of exter-
nal rotation and extension to protect the capsule plication, and hip-flexion ROM
restrictions to help mitigate pain.
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The initial phase of rehabilitation emphasized hip circumduction, flexion,

and internal-rotation PROM secondary to potential adhesion formation within the
joint capsule. Other important goals during phase I of treatment are to reduce the
amount of acute inflammation and pain. In addition, isometric exercises were
implemented to mitigate muscle inhibition and atrophy. Early activation of the
gluteal, hamstring, quadriceps, deep rotators, and transverse abdominal muscles is
emphasized to facilitate synergistic muscle activation and core musculature.
PROM exercises began 4 hours after surgery to prevent immobilization while
promoting tissue healing and neuromuscular reeducation. A continuous-passive-
motion machine was set at 0° to 90° of hip flexion for 2 weeks postsurgery (4
hours each day), along with use of a stationary bike at zero resistance for 20 min-
utes. Cryotherapy was strongly encouraged and was applied for 20 minutes 5 or 6
times per day. A continued PROM regimen was implemented 24 hours postsur-
gery as described in Appendix 2.
The patient was allowed 20 lb of flat-foot weight bearing, which was calcu-
lated with a calibrated medical scale and recommended for 2 weeks’ duration. For
the first 10 days postsurgery, the athlete wore specialized foot pumps to alleviate
the risk of deep-vein thrombosis and foot boots to limit hip external rotation when
supine. A functional hip brace was used for 10 days postsurgery to protect the hip
from excessive hip flexion and limit abduction and extension movement. Patient
was advised to spend 2 or more hours per day in a prone position to prevent hip-
flexor contracture secondary to the flexion PROM required postoperatively.20
The criteria to advance to phase II consist of minimal pain with all phase I
exercises and more than 75% ROM relative to the uninvolved lower extremity.31
Phase II: Stabilization.  The intermediate phase of rehabilitation began at weeks
2 to 3 postsurgery, with core-stabilization exercises and progressive resistive exer-
cise in addition to continued PROM and gait training. Precautions in phase II were
no ballistic stretching, no conditioning on a treadmill, and avoidance of adductor
and flexor tendinitis. Balance training and neuromuscular reeducation were initi-
ated to promote proper gait mechanics.
At this point, hip-flexion motion was progressed at the patient’s tolerance
with no restrictions. External rotation was still restricted to 0° for an additional
week to prevent stress to the plication closure of the capsular repair. Continued
advancement to full PROM, restoring a functional gait pattern, and core stabiliza-
tion were key elements in phase II.
 Arthroscopic Hip Repair in a Football Athlete   125

The criteria to progress to phase III were full PROM, normal gait mechanics
without limitations, normal muscle-activation patterns, more than 60% hip-flexor
strength relative to the contralateral lower extremity, and more than 70% adduc-
tion, abduction, extension, internal-rotation, and external-rotation strength of the
hip in comparison with the uninvolved limb.31
Phase III: Strengthening.  The advanced phase of rehabilitation was initiated
during week 6 postsurgery, with emphasis on muscle-endurance strength and car-
diovascular conditioning. Advanced cord-resisted agility and single-leg-bend
activities were started to prepare the patient for the functional return-to-sport test.
Gradual progression with no specific precautions was emphasized in phase III,
while contact activities were restricted until weeks 16 to 20. The criteria to begin
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phase IV consisted of passing the return-to-sport test.

Phase IV: Return to Sport.  The sport-specific phase was implemented at week
12, with the athlete’s integration into team practice in preparation for competitive
return to high-level sport. The purpose of this phase is full return to competition
without limitations in elite sport function, other than restrictions on full-contact
training.
The athlete’s return to prior professional-level training depended on approval
from the senior author and passing the functional return-to-sport test. At week 16,
the senior author cleared the patient to return to full-contact training without
restrictions in preparation for the 2007–08 season.

Outcomes
On follow-up examination at 9 weeks, clinical signs of impingement were nega-
tive (Table 2) and the patient reported no mechanical symptoms with rehabilita-
tion training. The patient did present with mild asymptomatic bilateral hip-flexor
tightness (positive Kendall test), which was clinically hypothesized to be caused
by hip-flexor overuse during rehabilitation.
In addition, preoperative and postoperative comparison values of force output
via HHD also showed improvement. Postoperatively, the patient demonstrated an
increase in force output of 89% hip external-rotation, 83% hip-abduction, 80%
hip-adduction, 65% hip-flexion, 57% hip internal-rotation, and 23% hip-extension
strength compared with preoperative measurements. Hamstring force output also
showed a tremendous gain (356%), which was likely a result of both diminished
pain and muscle hypertrophy. A decrease in force output of 0.6% on hip abduction
with external rotation was noted (Figures 4 and 5).
Measurements of PROM showed a slight increase, with a 13° improvement
in both hip flexion and adduction at follow-up. A 4° improvement was observed in
hip abduction, whereas no change was found with hip internal and external rota-
tion (Figure 6). At follow-up, PROM comparison between hips (Figure 7) indi-
cated symmetry in hip abduction and adduction, whereas there was a minimal
difference in internal rotation (10°), hip flexion (5°), and external rotation (5°).
There was also a 10-cm improvement in the FABER distance test relative to
preoperative and postoperative testing (Table 2). The FABER distance test is
defined as a measure of the distance from the lateral femoral epicondyle to the
 126   Philippon, Christensen, and Wahoff
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Figure 4 — Preoperative and postoperative (follow-up) hip-force dynamometer measure-

ments. Abbreviations: Flex, flexion; Abd, abduction; Add, adduction; IR, internal rotation;
ER, external rotation; Ham, hamstring.

Figure 5 — Postoperative hip-force-output (follow-up) measurements. Abbreviations:

Flex, flexion; Abd, abduction; Add, adduction; IR, internal rotation; ER, external rotation;
Ham, hamstring.

examination table. A positive test is confirmed if asymmetry is found between

hips. In addition, one noticeable deficit in our patient was bilateral hip-flexor
tightness (positive Kendall test).
Improved muscle endurance and functional technique were also verified with
the functional return-to-sport test. This test is used to evaluate an athlete’s perfor-
mance when the athlete is fatigued, assess an athlete’s ability to accept load
through the hip with agility-specific exercises, and provide an objective clearance
protocol for athletes. Unpublished data have been collected to support correla-
tions between passing this test and high subjective reports of overall function.47
 Arthroscopic Hip Repair in a Football Athlete   127
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Figure 6 — Preoperative and postoperative (follow-up) hip passive range of motion. Ab-
breviations: Flex, flexion; Abd, abduction; Add, adduction; IR, internal rotation; ER, exter-
nal rotation.

Figure 7 — Postoperative hip passive range of motion (follow-up). Abbreviations: Flex,

flexion; Abd, abduction; Add, adduction; IR, internal rotation; ER, external rotation.

Preoperatively, the patient was issued a score of 0 out of 20 on the sport test
because of his inability to perform the test secondary to hip pain and poor biome-
chanical performance. At follow-up testing, he scored 20 out of 20 without any
sign of pain while using excellent technique and minimal verbal cuing.
A subjective report of restrictions in function was evaluated, with the patient
reporting hip-flexor tightness and gluteal weakness in the involved hip leading to
an inability to accelerate with sprinting at his preinjury level. At follow-up, the
patient reported no pain or discomfort with the left hamstring or pubic cleft with
rehabilitation or training. The patient’s follow-up measurements were reevaluated
during postoperative week 9, whereas most patients are reassessed at week 12.
The senior author’s decision to evaluate and release the athlete to higher level
sport-specific training earlier than expected was based on the athlete’s ability to
successfully complete the return-to-sport test and demonstrate no clinical signs of
 128   Philippon, Christensen, and Wahoff

intra-articular pathology. The athlete was not fully released to return to training
until postoperative week 12 and was not cleared for full competition without
restrictions until postoperative week 16.

Discussion
The purpose of this case report was, first, to report the clinical outcomes achieved
for this high-level athlete. Before surgical intervention, the patient demonstrated
5 out of 7 clinical signs of hip pathology (Table 2).10,11 The patient also displayed
a dramatic decrease in force output before surgical and rehabilitation interven-
tions (Figure 4). In addition, he was unable to successfully complete a closed-
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kinetic-chain sport test because of significant pain and discomfort.

After successful surgical intervention and a 4-phase rehabilitation program,
the patient reported no complaints of instability or impingement. On examination,
no symptoms of labral pathology could be elicited with clinical testing. No pain
or discomfort was reported with high-level rehabilitation training, and the patient
demonstrated considerable improvements in overall function as demonstrated by
his ability to successfully pass the return-to-sport test.
The 4-phase rehabilitation program was outlined secondary to the lack of
literature to support the progression from postoperative status to return to com-
petition in the athletic population. Initially, acute postoperative principles should
be followed with importance placed on controlling swelling and pain, restoring
PROM, and preventing muscle atrophy. Stabilization with neuromuscular
retraining should then be emphasized, followed by strengthening and finally
sport-specific training.
The return-to-sport criteria for this athlete after arthroscopic intra-articular
repairs of the hip were based on a 3-tier program. Clinically, the patient’s ability
to return to competition was dictated by successfully completing the sport test,
demonstrating improvement in all clinical outcome measures, and final approval
by the senior author.
Although the athlete met all criteria to return to competition and was com-
pletely capable of competing at the professional level, because of unrelated hip
problems he was placed on the reserve list for the duration of the 2006–07 season.
He confirmed and reported improvements in overall hip mobility, muscle strength,
pain reduction, and high-level function with sport-specific activities. Although
one cannot conclude that there is a cause-and-effect relation with a case report, the
clinical outcomes reported are relevant in nature and supported in the existing
literature in respect to postoperative management of arthroscopic intra-articular
hip repairs.26,28,29

Conclusion
This case report highlighted the multifactorial progression of rehabilitation with a
professional athlete undergoing arthroscopic intra-articular repair of the hip. A
sequenced illustration of preoperative management to return to sport was out-
lined, with clinical outcomes and criteria for return to competition. A 4-phase
rehabilitation progression was employed to provide the most optimal environment
 Arthroscopic Hip Repair in a Football Athlete   129

for healing and prevent any possible irritation or disruption to the repaired labrum.
Continued research is needed to establish more concrete evidence in postoperative
management to provide clinicians with guidelines to improve patient outcomes.

Acknowledgments
The authors recognize the patient who participated in the case report and the Steadman-
Hawkins Research Foundation; without their cooperation this project would not have been
possible.

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Appendix 1: Examination Procedures

for Intra-Articular Hip Pathology
• Kendall Test: The subject is supine with both knees bent over the edge of the
exam table. The subject is instructed to hold the nontesting knee against the
chest. A positive test is confirmed when the test knee demonstrates less than
90° of knee flexion while the contralateral knee is flexed to the chest.8
• Anterior Impingement Test: The subject is supine with the examiner passively
positioning the hip into 80° to 90° of flexion and maximum internal rotation
and adduction. A positive test is confirmed with pain at end-range motions.9
• Posterior Impingement Test: The subject is in the Kendall testing position
with the examiner passively internally and externally rotating the hip. A posi-
tive test is confirmed with a report of pain with passive mobility testing.
 132   Philippon, Christensen, and Wahoff

• Abduction Impingement Test: The subject is supine with the examiner pas-
sively moving the hip into maximum abduction. A positive test is confirmed
with a report of pain on the lateral aspect of the hip.
• Ober Test: The subject is side lying with the examiner passively abducting
and extending the test hip. The examiner slowly lowers the upper limb to the
examination table. A positive test is confirmed if the subject’s upper limb is
unable to fall to the table.8
• Dial (Log Roll): The subject is supine with the hip in neutral flexion/exten-
sion and abduction/adduction. The examiner passively rolls the hip into full
internal and external rotation. A positive test is confirmed with asymmetrical
range of motion, pain, or clicking.9
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• FABER Test: The subject is supine with the examiner passively positioning
the hip into flexion, abduction, and external rotation. A positive test is con-
firmed with asymmetrical hip range of motion. The distance from the lateral
femoral epicondyle to the exam table is measured.8
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Appendix 2: Revised Protocol for Arthroscopic Hip Rehabilitation

133
(continued)
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134