Cameron W. MacDonald PT DPT GCS OCS FAAOMPT Program Director/ Chief Fellow - Regis University Manual Physical Therapy Fellowship Program

Manual Therapy Fellowship

Owner Beinn Sonas Physical Therapy Services

BACKGROUND & PURPOSE: There is growing interest in hip intraarticular impairments and pathologies. Hip surgery for hip labrum and intra-articular pathology is growing rapidly. Research though addressing rehabilitation post arthroscopic hip surgery is minimal, with no known research addressing prolonged mechanical impairments in this patient cohort. This case report demonstrates a successful impairment based approach to chronic right anterior hip/groin pain in a college level athlete, who had failed to return to participation in competitive events including long-jump and hurdling after hip labral and femoral head interventions. DESCRIPTION: A 20 year-old female presented 19 months post surgery for labral dysfunction plus femoral head delamination, with persistent anterior hip/groin pain and an inability to return to hurdling and long jump. Original trauma was due to a fall during cheerleading in her sophomore year of high-school, with delayed identification of right hip intra-articular pathology over three years. A hip labral tear was identified pre-operatively, and arthroscopic examination at the time noted that the right femoral head was delaminated 75%. Chrondroplasty and osteoplasty were completed to address this lesion in conjunction with the labral repair. Subsequent rehabilitation was completed at the University she attends, with an attempted return to sports participation at approximately 12 months. Due to persistent groin pain and irritation to the right iliotibial band outside referral was made to Physical Therapy. The initial examination noted impairments in anterior capsule mobility, restricted right hip flexor muscle length, hip external rotation (ER) restriction of 10 degrees and weakness in the posterior hip rotary muscles under eccentric and concentric loads. Weakness in the right hip posteriorly in the gluteus medius, gluteus minimus, adductors in extension and the medial hamstrings was graded at 4-/5. pain was rated at 9/10 with attempted participation in cross-country and athletic training. The patient also presented with local pain in response to unilateral lumbar PA¶s from the thoraco-lumbar junction down to the L5 level. There was an altered firing pattern in the right sided lumbar multifidi with the multifidi firing prior to the gluteal musculature in hip extension. A compensation was noted with right sided lumbar extension excessive with diminished right hip extension. No neurological signs were present through the lumbo-sacral plexus and through either lower extremity. INTERVENTIONS: Specific interventions included traction manipulation of the right hip, belted mobilization with combined inferior and rotational glides of the right hip, prone hip internal rotation (IR) and ER mobilization and anterior glides of the hip joint with combined rectus femoris and iliospoas muscle stretching. Following the primary manual interventions, posterior neuro-motor retraining of the hip was completed. Eccentric retraining was emphasized, though concentric and proprioceptive neuro-muscular interventions were also utilized. A progression was made from neutral and at rest positions to more dynamic and unstable positions. OUTCOMES: Following nine sessions of physical therapy, the patient was able to return to full competition without limitation, including all events in the heptathlon. Hip ER restriction was resolved and pain decreased in running from 9/10 to 1/10 with no limitations in a functional squat. Lumbar and the altered muscle recruitment resolved, with no ITB tenderness on firm palpation. The patient also returned to long jump, participation in the 400 meters and achieved personal best times and distances. DISCUSSION-CONCLUSION: Rehabilitation post hip arthroscopy is currently focused on a four-step progression, with minimal consideration of delayed recovery. The current emphasis of hip labral rehabilitation is on assuring a smooth and stable intra-articular hip joint complex with optimal regional strength and range of motion. Manual interventions and posterior hip eccentric control is minimally addressed. This case report identifies an impairment-based approach aimed at mobility restrictions and posterior hip rotary control deficits enabling a full return to athletic participation. Future research to further review the importance of these approaches in this patient cohort is warranted.

One Patient¶s Hip Journey«

Manual Interventions ± a selection.

Exercise Interventions ± a selection

A healthy hip, then a cheerleading fall. Three years of progressive dysfunction.

Anterior right hip capsular mobilization with rectus femoris and iliospoas stretching. Shoulder block allows for contract-relax interventions.

Eccentric IR, concentric ER with a moving Pilates reformer box set-up/. The Ball maintains hip spacing.

Surgical repair with interventions to address femoral head delamination.

Anterior femoral head glide with 10-20 degrees abduction to avoid inferior acetabular loading. Addition of rectus manual stretch. Pillow to prevent excess lumbar extension in techniques.

Eccentric ER, concentric IR with a moving Pilates Reformer box set-up.

Hip IR mobilization through contralateral pelvic rocking once the end range barrier was established in IR of the right hip first. The Hip was taken into IIR firsts, medial knee stabilized then the pelvis rocked away from the right hip.

Prone eccentric Hip ER, concentric IR on moving reformer box base.

Despite per protocol rehabilitation, unable to return to competitive sports at College level. Technique particular for this patient. posterior tissue stabilization of the femur with manual ER of the hip to lengthen the IR¶s of the hip early in joint ROM. Prone eccentric hip IR, concentric ER on moving reformer box base.

Residual Impairments: noted 19 months post-operative. Right hip groin pain with attempted hurdling Right sided lumbar spine pain with training, especially running on uneven terrain Pain rates on numeric pain rating scale to 9/10 Restriction identified in manual examination of hip capsule anterior mobility Right hip posterior soft tissue mobility impairments with ER restriction of 10 degrees  Only 4-/5 right hip muscle strength through the gluteal complex and deeper posterior hip musculature  Restricted right hip flexor mobility      Treatment Plan: impairment based interventions with functional re-assessments  Prognosis ± unclear, unique case presentation  Timeline considerations ± 19 months post surgical interventions, healing that could occur in the joint considered complete.  Irritability ± low, but pain high post activity, and occasionally very sharp (first attempt at return to hurdles)  Motivation ± high, but very frustrated  External factors ± scholarship implications if unable to compete Long axis traction manipulation of the hip. In this patient extra care was taken to not let the femur µtap¶ back on the acetabulum due to the delamination history. Combined inferior and posterior glides of the hip joint with belted mobilization with movement. The axilla catch of the knee allows for inferior glide whilst the belt allows for inferior translation as the femur is moved into progressive flexion.
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Bilateral strap hip circles.

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