Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol For The Hip Arthroscopy International Randomized Controlled Trial

[ clinical commentary ]
JOSH HEEREY, PT1 • MAY ARNA RISBERG, PT, PHD2 • JANICKE MAGNUS, PT, MSc2 • HÅVARD MOKSNES, PT, PhD3
THOMAS ØDEGAARD, PT4 • KAY CROSSLEY, PT, PHD1 • JOANNE L. KEMP, PT, PHD1
Impairment-Based Rehabilitation
Following Hip Arthroscopy:
Downloaded from www.jospt.org at University of Auckland on April 1, 2018. For personal use only. No other uses without permission.
Postoperative Protocol for the HIP

ARThroscopy International
Randomized Controlled Trial
H
ip arthroscopy is commonly used for the manage- quire better reporting. The aim
Copyright © 2018 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ment of femoroacetabular impingement syndrome of this clinical commentary was

(FAIS) and chondrolabral pathology.16,20 Postopera- to (1) provide the reader with a
brief overview of the registered
tive rehabilitation is considered part of the treatment
clinical trial NCT02692807, (2)
algorithm, but high-quality studies on the efficacy of both present a detailed overview of
surgery and postoperative rehabilitation programs are lacking.7,17,37 the postoperative rehabilitation program
Recently, deficits in strength, endurance, and functional capacity to be implemented in the registered clini-
have been demonstrated after hip ar- ventions and poorly defines the criteria cal trial, and (3) provide justification for
throscopy for up to 2 years,6,27,28 high- for exercise progression.7,17 Incomplete exercise and adjunct therapy selections
Journal of Orthopaedic & Sports Physical Therapy®
lighting the need to provide targeted description of physical therapy inter- based on current literature.
rehabilitation. ventions in randomized controlled trials
Postoperative rehabilitation programs makes the translation of study findings METHODS
aim to improve both hip and overall into clinical practice troublesome.49 The
T
physical function. However, the literature unknown and varied physical therapy he HIP ARThroscopy Inter-
outlining these rehabilitation programs interventions for individuals who have national (HIPARTI) Study
provides insufficient detail of the inter- undergone hip arthroscopy for FAIS re- (NCT02692807) is a multicenter,
international randomized controlled trial
UUSYNOPSIS: The number of hip arthroscopies need to improve postoperative care. Postopera- of arthroscopic hip surgery versus sham
for the management of femoroacetabular impinge- tive rehabilitation programs aim to improve hip surgery for FAIS.
ment syndrome and other hip intra-articular function; however, the description of interventions
conditions has grown exponentially in the last as well as criteria for progression are lacking in the The HIPARTI Study
decade. Postoperative rehabilitation is part of the literature. The aim of this clinical commentary was
treatment algorithm, although there is a lack of All patients with hip pain considered
to present a targeted clinical rehabilitation ap-
high-quality studies on the efficacy of both surgery for hip arthroscopy in the routine care
proach for individuals undergoing hip arthroscopy.
and postoperative rehabilitation programs. It is
J Orthop Sports Phys Ther 2018;48(4):336-342. pathways of participating centers will
known that impairments can be present up to be identified in outpatient clinics. Con-
doi:10.2519/jospt.2018.8002
2 years after hip arthroscopy, with individuals
UUKEY WORDS: FAI, femoroacetabular impinge-
sultant orthopaedic surgeons will deter-
exhibiting reduced function and quality of life when
compared to those of similar age, highlighting a ment, hip, strength training, surgery mine a patient’s eligibility in a pragmatic
fashion, based on clinical findings and
1
La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, La Trobe University, Bundoora, Australia. 2Division of Orthopaedic Surgery, Oslo University Hospital;
Department of Sport Medicine, Norwegian School of Sport Sciences, Oslo, Norway. 3Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway.
4
Norwegian Sports Medicine Clinic, Oslo, Norway. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article. Address correspondence to Josh Heerey, La Trobe Sport and Exercise Medicine Research Centre, La Trobe
University, Plenty Road and Kingsbury Drive, Bundoora, VIC 3086 Australia. E-mail: j.heerey@latrobe.edu.au t Copyright ©2018 Journal of Orthopaedic & Sports Physical Therapy®
336 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

radiographic imaging. All eligible pa- (manual therapy, hip muscle exercises, dependent home sessions. The physical
tients will be asked to participate in the trunk exercises, functional exercises, therapists delivering the rehabilitation
study. Inclusion and exclusion criteria are cardiovascular training/load manage- program will attend a training course
provided in TABLE 1. The full study proto- ment, and education) that were selected conducted by one of the study authors.
col has been published.38 A clinical exam- based on current literature outlining To ensure adherence to the rehabilita-
ination, including measurements of hip impairments after hip arthroscopy (FIG- tion program, regular contact will be
range of motion (ROM), muscle strength, URE).6,25,27,28 Strengthening exercises are made between researchers and physical
and function, will be performed by the described based on the recommenda- therapists. A maximum of 12 supervised
research coordinator and the blinded tions by Toigo and Boutellier,46 including sessions will be completed during the 6
independent outcomes assessor at base- load magnitude, number of repetitions, months of rehabilitation. Supervised ses-
line. The patients will also complete sev- number of sets, rest between sets, dura- sions will be performed in hospital out-
eral hip-related questionnaires. The same tion of exercise program, fractional and patient departments, community health
testing procedure will be conducted at 6, temporal distribution of the contrac- centers, or private physical therapy clin-
12, and 24 months postsurgery. tion modes per repetition and duration ics. At the end of each supervised visit,
Prior to surgery, the patients will be of 1 repetition, rest between repetitions, the physical therapist will provide the
randomized to receive an arthroscopic time under tension, volitional muscular patient with a tailored home exercise
surgical procedure or sham surgery (di- failure, ROM, recovery between exercise program, including 4 of the 6 key compo-
agnostic arthroscopy) of the hip. Surgery sessions, and anatomical definition of the nents listed above (hip, trunk, functional
will be scheduled within 4 to 6 weeks af- exercise (APPENDICES A through D, available exercises, and cardiovascular training/
ter inclusion. Contraindications to sham at www.jospt.org). The exercise program load management). The home exercise
surgery are listed among the exclusion is designed to commence within the first program will be performed 2 to 4 times
criteria (TABLE 1). 2 weeks postsurgery, with a total dura- per week. Adequate compliance to the
tion of 6 months. Each patient will be HIPARTI rehabilitation program is con-
Rehabilitation Program followed closely by a physical therapist, sidered to be a mean of 2 individual exer-
Program Outline The HIPARTI pro- who will determine the exact number cise sessions weekly for 6 months.
gram consists of 6 key components and frequency of the supervised and in- Progression Through the Rehabilitation
Program The HIPARTI program was
designed as a progressive, semi-stan-
Inclusion and Exclusion Criteria dardized rehabilitation program to ad-

TABLE 1
for the HIPARTI Study dress the 6 key components listed in the
program outline. The program is further
Inclusion Criteria Exclusion Criteria separated into phase 1 (weeks 1 through
• Aged 18 to 50 years • Pain that is not confirmed by physical examination of the hip 4 after surgery) and phase 2 (more than 4
• Hip pain during daily and/or sporting • Evidence of pre-existing osteoarthritis, defined as a Tönnis grade greater
weeks after surgery). The aim of phase 1 is
activities for the last 6 months than 1 or less than a 3-mm superior joint space width on AP pelvic
• Intra-articular hip pain with radiological radiograph
signs of FAIS and/or labral tears eligible • Center-edge angle on radiograph less than 25°
for hip arthroscopy (to be determined • Previous known hip pathology, such as Perthes disease, slipped upper
in a pragmatic fashion by the surgeon, femoral epiphysis, or avascular necrosis Hip muscle
based on clinical examination and • Previous hip injury, such as acetabular fracture, hip dislocation, or exercises
imaging) femoral-neck fracture
• Ability to give written informed consent • Previous hip surgery Education
Manual
and to participate fully in the interven- • Medical conditions complicating surgery, such as inflammatory joint therapy
Hip
tions and follow-up procedures disease (RA, AS, etc)
• Physical inability to undertake testing procedures
Arthroscopy
• Expected lack of compliance related to cognitive impairment, drug Rehabilitation
abuse, or similar
Trunk Functional
• Inability to understand the written and spoken language of the treatment exercises exercises
center
• Intra-articular pathologies present at arthroscopy (large loose body, Cardiovascular
training
chondral flap greater than 1 cm2 detached at 3 sides, complete labral and load
radial flap tear, and labral bucket-handle tear with complete avulsion management
greater than 1.5 cm long) that require surgical management
Abbreviations: AP, anterior-to-posterior; AS, ankylosing spondylitis; FAIS, femoroacetabular FIGURE. Key components of the HIP ARThroscopy
impingement syndrome; HIPARTI, HIP ARThroscopy International; RA, rheumatoid arthritis.
International rehabilitation program.
journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 337

to maximize hip ROM and minimize the are allowed to return to sport. Tests will pain on hip, trunk, and lower-limb muscle
neuromuscular inhibition that is proposed include single-leg hop tests (90% of op- function. The authors used exercise prin-
to occur after hip arthroscopy.7,17,47 Phase 2 posite side), hip muscle strength tests ciples associated with muscular endur-
aims to restore hip, trunk, and functional (abduction, extension, and adduction ance,32 as it is felt that a reduced external
strength, as well as introduce cardiovas- to 90% of the opposite side, or within loading will minimize the risk of postop-
cular exercise. The time frames assigned 90% of previously published agonist- erative complications that may occur with
to each exercise phase and the progres- antagonist ratios),29 quadriceps strength higher resistance exercises. The amount
sion of a patient from phase 1 to phase 2 tests (90% of opposite side),2,44 single-leg of external load (resistance bands or hand
are individualized, with consideration of raise test (at least 16 repetitions),27 and weights) used in each of the exercises is
surgical findings, procedures performed side-bridge trunk endurance (holding for determined by the VAS and RPE, as previ-
during surgery, pain level (measured using at least 40 seconds).27 ously stated. The treating physical thera-
a visual analog scale [VAS]), Borg rating Consistent with best-practice report- pist individualizes phase 1 exercises based
of perceived exertion (RPE), and surgeon ing of interventions, the authors used the on postoperative surgical restrictions.
preference. Patients will be individually Template for Intervention Description
assessed for each component at the initial and Replication19 and the Consensus on HIPARTI Program: Phase 2
physical therapy visit, providing the ba- Exercise Reporting Template.42 This en- Manual Therapy Manual therapy is pro-
sis of the tailored rehabilitation until the ables replicability and improves the ef- vided similar to during phase 1.
next visit. The quality and performance ficacy of intervention-based literature Hip Strengthening Individuals with hip-
of the home exercises will be assessed at (TABLE 2). related pain conditions exhibit deficits in
the beginning of each supervised visit to hip strength.5,22,28 Importantly, it appears

make sure that all patients are adequately HIPARTI Program: Phase 1 that strength deficits persist beyond sur-
progressed with home exercises at an ap- Manual Therapy Manual therapy tech- gical recovery,28 highlighting the inad-
propriate level throughout the rehabilita- niques in conjunction with active exer- equacies of current strategies. The aim of
tion. Patients will be provided with elastic cises are used with the aim of improving the strengthening protocol is to provide
resistance bands and hand weights, and hip ROM and reducing pain.1,48 Neuro- a targeted approach, with systematic and
progressed an exercise level when they physiological mechanisms are thought individualized exercise progressions.
are able to complete the specified exer- to underpin pain reduction after manual The proposed protocol includes the use
cise while maintaining a VAS pain score therapy techniques.48 The evidence for of subjective pain ratings and RPEs to
of less than 2 on a 0-to-10 scale and an manual therapy techniques applied to guide exercise load progressions, with
RPE score of 5 or less. The dosage (sets, intra-articular hip conditions is still de- additional resistance load provided when
repetitions, and duration) is predefined veloping.12,48 It is thought that such tech- the pain rating is less than 2 out of 10 and
in the HIPARTI rehabilitation program niques may improve hip and lumbar ROM the RPE is 5 or less on a 0-to-10 scale.34
(APPENDICES A through D), but being a semi- and reduce the nociceptive input of other As the evidence supporting specific exer-
structured rehabilitation program, the extra-articular structures affected during cises to increase strength, endurance, and
physical therapist can adapt the exercises the postoperative recovery period. Ac- function in hip muscles after hip arthros-
to each individual patient. Alterations tive exercise has shown promise in FAIS, copy is limited, the clinical justification is
made to the rehabilitation program will providing improvements in ROM and often drawn from studies that have used
be documented by the physical therapist. patient function.48 Treatment techniques electromyography (EMG) or morphology
Many patients might not need to perform addressing musculotendinous structures, (eg, from cadaver or modeling studies)
all exercises in each component, but some capsular tightness, and/or pelvic or spi- to identify exercises deemed to be ap-
exercises within each component should nal dysfunction are initiated if hip flexion propriate to create loads sufficient for a
be implemented for all patients. ROM is less than 116° or the contralateral strengthening effect.
To date, no return-to-sport criteria limb (APPENDIX E, available at www.jospt. Hip Extensors The hip extensor group
have been tested and published for pa- org). Optimization of hip flexion ROM is consists of the gluteus maximus, poste-
tients undergoing hip arthroscopic sur- a primary aim of the manual therapy pro- rior head of the adductor magnus, and
gery. As such, the following criteria are gram due to its association with impaired hamstrings.35 Hip extension strength
presented based on current knowledge patient-reported outcomes.25 deficits have been identified in individu-
of impairments and outcomes post hip Exercise Program The exercise program als with hip osteoarthritis,24 FAIS,8 and
arthroscopy.6,25-28 Patients participat- outlined in APPENDIX A provides progres- after hip arthroscopy.28 Alterations in
ing in sports activities should be able sive loading to the hip structures, with the pelvofemoral kinematics are thought to
to successfully complete a number of aim of improving hip ROM and reducing be associated with deficits in hip extensor
selected sport-specific tests before they the effects of postoperative swelling and activity.3,43 Moreover, gluteus maximus

inhibition has been identified in the pres- ductor strength deficits are present in Hip Adductors The adductor group
ence of joint effusion and labral tears.10,15 many extra-articular and intra-articular consists of the adductor brevis, longus,
Hip Extensor Strengthening Pro- hip conditions.5,8,18,22,33 Suboptimal pelvic and magnus, as well as the pectineus,
gram The hip extensor strengthening control is evident after hip arthroscopy,6 quadratus femoris, and gracilis.35 The
program is outlined in APPENDIX B. Exer- with an increased frontal plane pel- triplanar torque-producing ability of
cises 1 and 2 utilize a position of relative vic obliquity in single-leg weight bear- the hip adductors in weight bearing
hip flexion to maximize the torque-pro- ing, suggesting dysfunction of the hip and non–weight bearing is important
ducing capabilities of the hip extensors.35 abductors.6 for personal and athletic function.35 Hip
Exercise 2 exhibits high levels (59% max- adductor strength deficits are known
Hip Abductor Strengthening Pro-

imal voluntary isometric contraction) of gram The hip abductor strengthening to persist after hip arthroscopy,28 with
muscle activation,36 making it appropri- program is outlined in APPENDIX B. Exer- deficiencies in strength associated with
ate to be used for strength development.36 cise 1 utilizes a single-leg bridge on a sta- impaired patient-reported outcome
Hip Abductors The gluteus maximus ble surface. Work by Ekstrom et al11 and measures.25
(superior portion), gluteus medius, glu- Boren et al4 identified that this exercise, Hip Adductor Strengthening Pro-
teus minimus, and tensor fascia latae are with varying levels of limb stability, may gram The hip adductor strengthening
considered hip abductors.35 The gluteus provide muscular activation (evaluated program is outlined in APPENDIX B. Work
medius has the anatomical characteris- by EMG) that can achieve strength de- by Serner et al41 identified the potential
tics to act as the primary abductor.35,40 velopment. The ability of exercises 2a and of exercises 1 and 2 for strengthening
The hip abductors are important for 2b to improve isometric and eccentric hip the adductor musculature. Importantly,
movement efficiency and maintenance abduction strength has been outlined in the nonexercising leg develops muscu-
of pelvofemoral orientation.35,40 Hip ab- previous literature.30,45 lar activation, as determined by EMG,

TABLE 2 Phase 2 Components of the HIPARTI Rehabilitation Program
Hip, Trunk, and Functional Exercise

Manual Therapy Programs Cardiovascular Loading Patient Education
Why Improvement in hip ROM (flexion of Improvement in hip, trunk, and Improvement in cardiovascular Improvement in patient knowledge
116° or greater) and pain lower-limb muscle function and exercise capacity (APPENDIX F) and expectations of postoperative
(APPENDIX E) functional task performance outcomes (TABLE 3)
(APPENDICES A-D)
Who provided Physical therapists provide manual Physical therapists review and Physical therapists review and Physical therapists provide tailored
therapy techniques progress exercise program progress the program education for the patient
How Manual therapy of the hip conducted Exercises performed and adjusted at Program discussed and adjusted at Review of relevant educational topics
at face-to-face individual sessions the supervised physical therapy supervised physical therapy ses- at face-to-face individual sessions
sessions before independently sions before independently being
being executed in a HEP executed in a HEP
Where Physical therapy clinics Physical therapy clinics and the Physical therapy clinics and the Physical therapy clinics
patients’ home/location of choice patients’ home/location of choice
When and how much Weekly as part of the 30-min super- 2-4 times per week in independent 2-4 times per week in independent Weekly as part of the 30-min super-
vised sessions, until hip flexion home sessions. Can also be home sessions. Can also be vised sessions, until all educational
ROM of 116° or greater is achieved. included in the 30-min supervised included in the 30-min supervised topics are covered. In total, 8-12
In total, 8-12 sessions over a 6-mo sessions sessions sessions over a 6-mo period
period
Tailoring Semi-standardized, with selection of Semi-standardized, with selection of Semi-standardized, with selection of Semi-standardized, with education
manual therapies determined by exercises determined by surgical exercise determined by surgical individualized for each patient
surgical procedure performed procedure performed, surgeon procedure performed, surgeon
and identified impairments recommendations, level of func- recommendations, level of func-
(APPENDIX E) tion, RPE, and pain VAS tion, RPE, and pain VAS
How well Treatment response recorded in Exercise adherence recorded in Exercise adherence recorded in Specific patient concerns will be
participant file mobile phone app/paper diary/ mobile phone app/paper diary/ recorded in participant file
online exercise form online exercise form
Abbreviations: HEP, home exercise program; HIPARTI, HIP ARThroscopy International; ROM, range of motion; RPE, rate of perceived exertion; VAS, visual
analog scale.

that is considered appropriate for muscle APPENDIX C. The endurance program (ex- cardiovascular conditioning program is
strengthening. Large improvements in ercises 1 to 1.12) utilizes the side-plank a key component of rehabilitation after
eccentric adduction strength have been exercise, which provides high levels of hip arthroscopy. The cardiovascular con-
shown with exercise 1 (30%)23 and ex- EMG activity of the external oblique ditioning program (APPENDIX F, available
ercise 2 (36%)21 over an 8-week exercise musculature.11 In addition, high levels at www.jospt.org) provides a patient-spe-
period. of muscular activation are also observed cific program to increase cardiovascular
Hip External Rotators The gluteus maxi- in the gluteus medius.11 This exercise has loading. All patients are started at level
mus is considered the primary hip joint the capacity to improve both muscular 1 and are able to select their preferred
external rotator.35,36 Additional external endurance and strength, which may be cardiovascular exercise throughout the
rotation torque is produced from the important for maintenance of pelvic po- 3 levels of progression. Structured pro-
shorter external rotators.35 The external sition during repetitive tasks.11 gression criteria (APPENDIX G, available at
rotator group has its most potent torque- Functional Strength Program Patients www.jospt.org) ensure that perceived pa-
producing capacity when the pelvis is post hip arthroscopy have reported func- tient load and symptoms are monitored
rotated upon a fixated femur.35 This functional deficits for up to 2 years after sur- to minimize the risk of symptom aggrava-
tional role enables the performance of a gery.27 Better functional performance is tion. The time frame from surgery is also
dynamic landing and cutting task, deemed associated with better outcomes post hip considered for the progressions, with the
critical for sport-related activities.35 Ex- arthroscopic surgery.27 As such, function- surgeon consulted during the later peri-
ternal rotation torque deficits are present al training is an important component of ods of the program.
12 to 24 months after hip arthroscopy,28 rehabilitation following hip arthroscopy. Patient Education Hip arthroscopy in
with women experiencing greater loss of The functional strengthening program many cases provides reduction in pain
strength when compared to men.28 (APPENDIX D) consists of 3 key weight- and improved functional capacity.31
Hip External Rotator Strengthening Pro- bearing exercises that can be progressed However, a recent review31 highlighted
gram The hip external rotator strength- through using external load in the form that patient dissatisfaction is often re-
ening program is outlined in APPENDIX B. of resistance bands or hand weights. Ad- ported postsurgery because of persistent
Exercises 1 and 2 use non–weight-bear- ditional functional exercises are outlined hip pain and reduced hip function in ac-
ing positions to achieve improvements in that can be provided to the patient, based tivities of daily living and sport activi-
muscular strength. Work by Neumann35 on individual work and return-to-sport ties.31 It appears that there is a need to
highlighted that the gluteus maximus has requirements. The plyometric exercise provide patients with realistic expecta-
the potential to produce external rotation program is a progressive program in tions based on known factors related
torque throughout ranges of hip flexion, which the patient starts at exercise 1 and to poor surgical outcomes. Moreover,
providing justification for our exercise progresses to exercise 1.5 based on the even in the absence of known factors,
protocol. In addition, non–weight- VAS, the RPE, and individualized activ- the outcomes for many patients will still
bearing external rotation exercises have ity requirements. place them below age-matched controls
been shown to be effective in improving Cardiovascular Conditioning Pro- in relation to symptoms, pain, and func-
strength.9,30 gram Patients undergoing hip arthros- tion.26 The authors propose 5 key educa-
Trunk Muscle Strength and Endur- copy have reduced sporting and physical tion components that are supported by
ance Trunk muscle strength and en- activity.14 Therefore, a structured and safe current evidence (TABLE 3).
durance are important for physical
performance and reduction of injury
risk.11 Trunk muscle control and stability Five Key Education Components in the
TABLE 3
are thought important to enable sufficient HIPARTI Study
lower-limb movement control and mobil-
ity.13 Pelvic orientation is known to alter Component
femoroacetabular contact positions,39 1 Weight maintenance with recommended weight loss if BMI ≥25 kg/m2
highlighting the importance of lumbo- 2 The importance of addressing impairments (strength, ROM, and function) after hip arthroscopy, with a particular
focus on the relationship between impairments and patient outcomes
pelvic control in hip-related pathologies.
3 Patients’ expectations of treatments
Deficits in trunk muscle endurance and/
4 Patients’ specific goals of treatment and how to most appropriately achieve these goals
or performance are known to be present
5 Patients’ expectations of returning to sport (identified using current sporting level on the HSAS and desired
bilaterally after hip arthroscopy.27
sporting level on the HSAS) and whether this is possible
Trunk Muscle Strength and Endurance
Abbreviations: BMI, body mass index; HIPARTI, HIP ARThroscopy International; HSAS, Hip Sports
Program The trunk muscle strength Activity Scale; ROM, range of motion.
and endurance program is outlined in

DISCUSSION that many individuals undergoing hip with acetabular labral tears during function?
arthroscopy have features associated Arthroscopy. 2016;32:1045-1052. https://doi.
T
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@ MORE INFORMATION
function at different time points after hip arthros- jelekin.2013.03.007
copy in patients with femoroacetabular impinge- 41. S erner A, Jakobsen MD, Andersen LL, Hölmich
ment: a systematic review with meta-analysis. P, Sundstrup E, Thorborg K. EMG evaluation WWW.JOSPT.ORG

APPENDIX A
HIP, TRUNK, AND FUNCTIONAL EXERCISES

Standard Dosage Information for All Exercises
Load magnitude: 20-repetition maximum
Repetitions: 20
Sets: 3
Rest between sets: 90 seconds
Number of exercise interventions: 2 to 4 per week
Duration of experimental period: 1 to 4 weeks
Rest between repetitions: 1 second
Volitional muscular failure: No
Recovery time: 48 hours
Exercise-Specific
Exercise* Description Dosage Information† Illustration
Hip extension
1. Prone hip exten- The participant is in a prone position, with head resting to side. FTDCM per repetition: concentric,
sion The participant then squeezes the gluteal muscles (of the 2 s; isometric, 1 s; eccentric, 2 s
leg to be exercised) and lifts the thigh and leg away from the TUT: 5 s per repetition, 100 s per set
floor into hip extension. The participant then returns to the ROM: 0° to 10° of hip extension
starting position
1.1. Prone-hold hip The participant is in a prone plank position on knees. The partici- FTDCM per repetition: concentric,
extension (knees) pant then moves the leg to be exercised into hip extension 2 s; isometric, 1 s; eccentric, 2 s
so that the hip is in a neutral hip position. The participant TUT: 5 s per repetition, 100 s per set
then returns to the starting position ROM: 45° to 0° of hip flexion
Hip abduction
1. Bridging with band The participant is lying on the back with hips in 45° of flexion FTDCM per repetition: concentric,
and knees in 90° of flexion. The resistance band is placed 2 s; isometric, 1 s; eccentric, 2 s
around the distal thigh just superior to the patella. The TUT: 5 s per repetition, 100 s per set
participant then abducts the knees against the band so that ROM: 45° to 0° of hip flexion
knees and feet are in line with shoulders. The participant
then lifts the bottom so that a neutral hip position is
achieved, then returns to the starting position
Hip adduction
1. Bent-knee adduc- The participant is lying on the back, with hips bent to 45° of FTDCM per repetition: isometric,
tor squeeze flexion and knees to 90° of flexion. The feet are flat on the 10 s
ground. A ball is placed between the knees so that it is rest- TUT: 10 s per repetition, 200 s
ing between the femoral condyles. The participant squeezes per set
the ball using the adductor muscles ROM: 45° to 45° of hip flexion
Hip external rotation

1. 4-point kneel, The participant is positioned on hands and knees, with hips in FTDCM per repetition: concentric,
external rotation 90° of flexion. The resistance band is fixated and placed 2 s; isometric, 1 s; eccentric, 2 s
around the ankle malleoli of the exercising leg. The partici- TUT: 5 s per repetition, 100 s per set
pant keeps the foot on the ground and trunk stable. The ROM: 10° of hip internal rotation to
participant starts the hip in 10° of internal rotation and then 10° of hip external rotation
turns into 10° of hip external rotation against the resistance
band. The participant then returns to the starting position
Table continues on page E2.
journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | e1

APPENDIX A
Exercise-Specific
2. Prone external The participant is positioned in prone, with head resting to side. Same as exercise 1
rotation The hip is in a neutral position and the knee is bent to 90°
of flexion. The resistance band is fixated and placed around
the ankle malleoli of the exercising leg. The participant
keeps the pelvis on the ground and trunk stable. The partici-
pant starts the hip in 10° of internal rotation and then turns
into 10° of hip external rotation against the resistance band.
The participant then returns to the starting position
Trunk
1. 4-point trunk The participant is balancing on the ipsilateral knee and contra- FTDCM per repetition: concentric,
exercise lateral hand. The participant then extends the contralateral 2 s; isometric, 1 s; eccentric,
hip/knee and ipsilateral hand into neutral shoulder and hip 2s
positions. From this position, the participant then touches TUT: 5 s per repetition, 100 s
the knee to the elbow, then returns to the starting position per set
ROM: 90° to 0° of hip flexion
and 90° to 180° of shoulder

flexion
Functional
1. Wall slides with The participant stands 1 foot length in front of the wall, with feet FTDCM per repetition: concentric,
band shoulder-width apart. The resistance band is placed around 2 s; isometric, 1 s; eccentric,
the distal thigh just superior to the patella. The participant 2s
then abducts the knees so they are wider than the hips. The TUT: 5 s per repetition, 100 s
participant then slides down the wall until he or she is in 90° per set
of hip and knee flexion, then returns to the starting position ROM: 0° to 90° of hip flexion
2a. Bench squats The participant stands 1 foot length in front of the bench, with Same as exercise 1
feet shoulder-width apart. The participant then bends at the
hips and squats to 90° of hip and knee flexion, touching the
buttocks lightly on the bench. The participant then returns
to the starting position
e2 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

APPENDIX A
Exercise-Specific
2b. Squats on BOSU The participant stands on a BOSU ball, with feet shoulder-width Same as exercise 1
apart, then bends at the hips and squats to 90° of hip and
knee flexion. The participant then returns to the starting
position
3. Assisted step-ups The participant places the foot of the exercising leg on top of the FTDCM per repetition: concentric,
step. The participant holds an exercise stick in the contra- 2 s; isometric, 1 s; eccentric,
lateral hand, then pushes up through the foot, moving into 2s
full knee extension and a neutral hip position. The foot of the TUT: 5 s per repetition, 100 s
leg not being exercised is placed onto the step for balance if per set
needed. The participant then returns to the starting position ROM: 45° to 0° of hip flexion
Abbreviations: FTDCM, fractional and temporal distribution of contraction modes; ROM, range of motion; RPE, rate of perceived exertion; TUT, time under
tension; VAS, visual analog scale.
*Exercises that should be implemented for each participant are represented numerically (eg, 1, 2, 3). When an exercise includes a number and letter (eg, 2a, 2b),
either exercise can be chosen by the physical therapist, based on the VAS, RPE, and participant preference. Exercises with a decimal point (eg, 1.1, 1.2) should be
progressed sequentially based on the VAS and RPE.
†
Exercise dosage can be modified based on surgical findings, procedures performed, postoperative pain, and surgeon recommendations.

APPENDIX B
HIP-STRENGTHENING EXERCISES
Standard Dosage Information for All Exercises
Repetitions: 10
Sets: 3
Duration of experimental period: 24 weeks
Exercise-Specific
Hip extension
1. Standing hip The participant is standing with the hip to be exercised in 45° of FTDCM per repetition: concentric,
extension hip flexion. The participant holds onto a stationary object to 2 s; isometric, 1 s; eccentric,
stabilize the upper body. The resistance band is fixated and 2s
placed behind the knee of the participant. The participant TUT: 5 s per repetition, 50 s
then extends the hip so that it moves into a neutral hip posi- per set
tion, then returns to the starting position ROM: 45° to 0° of hip flexion
2. Single-leg deadlift The participant stands on the leg to be exercised. From a single- FTDCM per repetition: concentric,
leg standing position (maintaining a neutral spinal position), 2 s; isometric, 1 s; eccentric,
the participant flexes at the hip, moving into 90° of hip 2s
flexion and moving the contralateral hand/arm toward the TUT: 5 s per repetition, 50 s
floor. The participant then returns to the starting position. per set
The resistance band is placed underneath the foot of the ROM: 0° to 90° of hip flexion
leg being exercised and held in the contralateral hand if
required. If the participant requires additional support to
perform the exercise correctly, then he or she is permitted to
use the hand to hold onto a stationary object
Hip abduction
1. Bridge with leg The participant is lying on the back with hips in 45° of flexion FTDCM per repetition: concentric,
extension and knees in 90° of flexion. The resistance band is placed 2 s; isometric, 1 s; eccentric,
around the distal thigh just superior to the patella. The 2s
participant then abducts the knees against the band so that TUT: 5 s per repetition, 50 s
knees and feet are in line with shoulders. The participant per set
then lifts the bottom so that a neutral hip position is ROM: 45° to 0° of hip flexion
achieved. The participant then extends the affected leg,
repeating this movement on the unaffected leg, and then
returns to the starting position

APPENDIX B
Exercise-Specific
2a. Standing hip The participant stands on the leg not being exercised. The FTDCM per repetition: concentric,
abduction resistance band is fixated and placed around the ankle 2 s; isometric, 1 s; eccentric,
malleoli of the exercising leg. The participant then places 2s
the contralateral hand on a stationary object to maintain TUT: 5 s per repetition, 50 s
stability. The leg to be exercised is moved outward into 45° per set
of hip abduction. The participant then returns to the starting ROM: 0° to 45° of hip abduction
position
2b. Sidelying hip The participant is positioned in sidelying, with the leg to be exer- FTDCM per repetition: concentric,
abduction cised placed upmost. The resistance band is placed around 2 s; isometric, 1 s; eccentric,
both the ankle malleoli. The participant uses the ipsilateral 2s
hand to maintain stability. The upmost leg starts in contact TUT: 5 s per repetition, 50 s
with the downmost leg and is then moved into 45° of abduc- per set
tion. The participant then returns to the starting position ROM: 0° to 45° of hip abduction
Hip adduction
1. Standing hip The participant stands on the leg not being exercised. The FTDCM per repetition: concentric,
adduction resistance band is fixated and placed around the ankle mal- 2 s; isometric, 1 s; eccentric,
leoli of the exercising leg. The participant maintains a level 2s
pelvis, with the hands placed on a stationary object. The TUT: 5 s per repetition, 50 s
participant starts the exercising leg in 45° of abduction, then per set
the leg is moved into adduction toward the nonexercising ROM: 45° to 0° of hip abduction
leg, so that the feet are gently touching. The participant then
2. Copenhagen The participant places the exercising leg on an exercise sling or Load magnitude: NA
adductor exercise bench as shown. The participant then pushes up into a side Repetitions: 6
plank position by using the shoulder and exercising leg. The Sets: 2
downmost leg is lowered to the ground with the foot lightly FTDCM per repetition: concentric,
touching the floor. The leg is then adducted so that the foot 3 s; eccentric, 3 s
is touching the exercise sling or bench. The participant then TUT: 6 s per repetition, 36 s
returns to the starting position per set
ROM: 45° to 0° of hip abduction
2.1. Copenhagen Same as exercise 2 Load magnitude: NA
adductor exercise Repetitions: 8
Sets: 2
FTDCM per repetition: concentric,
3 s; eccentric, 3 s
TUT: 6 s per repetition, 48 s
per set

APPENDIX B
Exercise-Specific
2.2. Copenhagen ad- Same as exercise 2 Load magnitude: NA
ductor exercise Repetitions: 10
Sets: 2
3 s; eccentric, 3 s
per set
2.3. Copenhagen ad- Same as exercise 2 Load magnitude: NA
ductor exercise Repetitions: 10
Sets: 3
3 s; eccentric, 3 s
per set
Hip external rotation

1. 4-point kneel, The participant is positioned on hands and knees, with hips in FTDCM per repetition: concentric,
external rotation 90° of flexion. The resistance band is fixated and placed 2 s; isometric, 1 s; eccentric,
around the ankle malleoli of the exercising leg. The partici- 2s
pant keeps the foot on the ground and the trunk stable. The TUT: 5 s per repetition, 50 s
participant starts the hip in 10° of internal rotation and then per set
turns into 10° of hip external rotation against the resistance ROM: 10° of hip internal rotation
band. The participant then returns to the starting position to 10° of hip external rotation
2. Prone external The participant is positioned in a prone position with head Same as exercise 1
rotation resting on hands. The hip is in a neutral position and the

knee is bent to 90° of flexion. The resistance band is fixated
and placed around the ankle malleoli of the exercising leg.
The participant keeps the pelvis on the ground and the
trunk stable. The participant starts the hip in 10° of internal
rotation and then turns into 10° of hip external rotation
against the resistance band. The participant then returns to
the starting position
Abbreviations: FTDCM, fractional and temporal distribution of contraction modes; NA, not applicable; ROM, range of motion; RPE, rate of perceived exer-
tion; TUT, time under tension; VAS, visual analog scale.
†

APPENDIX C
TRUNK-STRENGTHENING AND ENDURANCE EXERCISES

Standard Dosage Information for All Trunk-Strengthening Exercises
Repetitions: 10
Sets: 3
FTDCM per repetition: concentric, 2 seconds; isometric, 1 second; eccentric, 2 seconds
TUT: 5 seconds per repetition, 50 seconds per set
Standard Dosage Information for All Trunk Endurance Exercises
Load magnitude: Not applicable

Exercise-Specific
Trunk muscle strength
1. 4-point trunk The participant is balancing on the ipsilateral knee and contra- ROM: 90° to 0° of hip flexion
exercise lateral hand. The participant then extends the contralateral and 90° to 180° of shoulder
hip/knee and ipsilateral hand into neutral shoulder and hip flexion
positions. From this position, the participant touches the
knee to the elbow, then returns to the starting position
2. Pallof press The participant is standing with feet shoulder-width apart and ROM: 0° to 90° of shoulder
knees in slight flexion, holding the band in the hands and flexion
against the umbilicus. The participant pushes the band out
so that both shoulders are in 90° of flexion and the elbows
are extended, then returns to the starting position

APPENDIX C
Exercise-Specific
3. Gym-ball sit-up The participant is sitting on the gym ball. The participant then ROM: 0° to 90° of hip flexion
walks the feet forward until lying flat and the lumbar spine is
in contact with the ball. Hands are placed behind the head.
The participant curls the spine up toward the pelvis using
the abdominal muscles. The participant then returns to the

starting position
Trunk muscle endurance

1. Side bridge (knees) The participant is positioned with the side to be exercised facing Repetitions: 5
down toward the floor. The participant then pushes up onto Sets: 1
the elbow and knee so that the hips are in a neutral position, Rest between sets: NA
then returns to the starting position FTDCM per repetition: isometric,

30 s
Rest between repetitions: 30 s
per set
1.1. Side bridge (knees) Same as exercise 1 Repetitions: 5
Sets: 1
Rest between sets: NA
FTDCM per repetition: isometric,
50 s

per set
1.2. Side bridge (knees) Same as exercise 1 Repetitions: 5
Sets: 1
80 s
per set
1.3. Side bridge (feet) The participant is positioned with the side to be exercised facing Repetitions: 5
down toward the floor. The participant then pushes up onto Sets: 1
the elbow and feet so that the hips are in a neutral position, Rest between sets: NA
then returns to the starting position FTDCM per repetition: isometric,
30 s
per set

APPENDIX C
Exercise-Specific
1.4. Side bridge (feet) Same as exercise 1.3 Repetitions: 5
Sets: 1
50 s
per set
Sets: 1
80 s
per set
1.6. Side bridge (feet) The participant is positioned with the side to be exercised facing Repetitions: 20
with rotational down toward the floor. The participant then pushes up onto Sets: 3
arm-reach lift the elbow and feet so that the hips are in a neutral position. Rest between sets: 30 s
The participant then moves the hand and rotates the trunk FTDCM per repetition: concentric,
so that the hand is placed on the lower back. The participant 2 s; isometric, 1 s; eccentric,
then rotates the trunk and hand so that the arm finishes in 2s
90° of shoulder abduction. The participant then returns to Rest between repetitions: 1 s
the starting position TUT: 5 s per repetition, 100 s
per set
with rotational Sets: 3
arm-reach lift Rest between sets: 30 s
2 s; isometric, 1 s; eccentric,
2s
per set
1.8. Side plank with The participant is positioned with the side to be exercised facing Repetitions: 5
gym ball down toward the floor. The participant then places one foot Sets: 1
in front and one behind on the gym ball. The participant Rest between sets: NA
then pushes up onto the elbow and feet so that the hips are FTDCM per repetition: isometric,
in a neutral position, then returns to the starting position 30 s
per set

APPENDIX C
Exercise-Specific
1.9. Side plank with Same as exercise 1.8 Repetitions: 5
gym ball Sets: 1
50 s
per set
gym ball Sets: 1
80 s
per set
1.11. Side plank with The participant is positioned with the side to be exercised facing Repetitions: 20
rotational arm lift down toward the floor. The participant then places one foot Sets: 3
and gym ball in front and one behind on the gym ball. The participant Rest between sets: 30 s
then pushes up onto the elbow and feet so that the hips are FTDCM per repetition: concentric,
in a neutral position. The participant then moves the hand 2 s; isometric, 1 s; eccentric,
and rotates the trunk so that the hand is placed on the lower 2s
back. The participant then rotates the trunk and hand so Rest between repetitions: 1 s
that the arm finishes in 90° of shoulder abduction, then TUT: 5 s per repetition, 100 s
returns to the starting position per set

rotational arm lift Sets: 3
and gym ball Rest between sets: 30 s
2 s; isometric, 1 s; eccentric,
2s
per set
Abbreviations: FTDCM, fractional and temporal distribution of contraction modes; NA, not applicable; ROM, range of motion; RPE, rate of perceived exer-
tion; TUT, time under tension; VAS, visual analog scale.
†

APPENDIX D
FUNCTIONAL STRENGTHENING AND PLYOMETRIC PROGRAM

Standard Dosage Information for All Functional Strengthening Exercises
Repetitions: 10
Sets: 3
FTDCM per repetition: concentric, 2 seconds; isometric, 1 second; eccentric, 2 seconds
Standard Dosage Information for All Plyometric Exercises
Load magnitude: Not applicable
Repetitions: 10
Sets: 3
FTDCM per repetition: concentric, 1 second; eccentric, 2 seconds
Rest between repetitions: 5 seconds
Exercise-Specific
Functional
1a. Bench squats The participant stands 1 foot length in front of the bench, with ROM: 0° to 90° of hip flexion
feet shoulder-width apart. The participant then bends at the

APPENDIX D
Exercise-Specific
1b. Squats on BOSU The participant stands on a BOSU ball, with feet shoulder-width ROM: 0° to 90° of hip flexion
apart, then bends at the hips and squats to 90° of hip and
knee flexion. The participant then returns to the starting
position
2. Standing lunges The participant steps forward with the exercising leg, keeping the ROM: 0° to 90° of hip flexion
trunk upright. The participant then moves into a position of
90° of hip and knee flexion, ensuring the knee of the exercis-
ing leg moves over the foot during the lunge. The other leg is
positioned in a neutral hip position and 90° of knee flexion.
The participant then returns to the starting position
3. Step-ups The participant places the foot of the exercising leg on top of the ROM: 45° to 90° to 0° of hip
step. The participant then pushes up through the foot, mov- flexion
ing into full knee extension and a neutral hip position. The
foot of the leg that is not being exercised can be placed onto
the step for balance if needed. The participant then returns

APPENDIX D
Exercise-Specific
Functional (additional
exercises)
4. Single-leg squats The participant stands on the exercising leg, then bends at the ROM: 0° to 90° of hip flexion
5. Sideways sliding The participant stands with feet shoulder-width apart, then ROM: 0° to 45° of hip flexion
places 1 foot on a slide board. The foot is moved into
abduction while performing a squatting movement on the
exercising leg, ensuring the knee moves over the foot. The
participant then returns to the starting position
6. Bulgarian lunges The participant steps forward with the exercising leg, keeping the ROM: 0° to 90° of hip flexion
trunk upright. The participant then moves into a position of
on a bench (as shown) and in neutral hip position and 90°
of knee flexion. The participant then returns to the starting
position

APPENDIX D
Exercise-Specific
7. Standing lunges on The participant steps forward with the exercising leg, keeping the ROM: 0° to 90° of hip flexion
BOSU trunk upright. The participant then moves into a position of
positioned in a neutral hip position and 90° of knee flexion

on a BOSU ball. The participant then returns to the starting
position
8. Leg press (single The participant places the exercising leg onto the leg-press plate. ROM: 45° to 90° of hip flexion
leg) The participant then presses down onto the leg-press plate,
moving the knee into full extension. The leg-press plate is
then lowered toward the participant, ensuring that the par-

ticipant does not exceed 90° of hip flexion. The participant
then returns to the starting position
9. Calf raise with The participant stands with feet shoulder-width apart, then ROM: 0° to 0° of hip flexion
extended knee pushes down through the ball of the big toe and into ankle
plantar flexion. The participant achieves full ankle plantar
flexion with the knees in full extension. The participant then

APPENDIX D
Exercise-Specific
Plyometric
1. Jump onto box/ The participant stands 1 foot length behind the box/step/BOSU ROM: 0° to 90° of hip flexion
step/BOSU ball, with feet shoulder-width apart. The participant then
(double-leg land- jumps as quickly as possible onto the box. The participant
ing) performs a soft landing by moving into hip, knee, and ankle
flexion
1.1. Jump onto box/ The participant stands 1 foot length behind the box/step/BOSU ROM: 0° to 90° of hip flexion
step/BOSU (single- ball on the exercising leg, then jumps as quickly as possible
leg landing) onto the box. The participant performs a soft landing by
moving into hip, knee, and ankle flexion
1.2. Jump off box/step/ The participant stands on a box/step/BOSU ball, with feet ROM: 0° to 90° of hip flexion
BOSU (double-leg shoulder-width apart, then jumps as quickly as possible
landing) onto the floor. The participant performs a soft landing by
moving into hip, knee, and ankle flexion

APPENDIX D
Exercise-Specific
1.3. Jump off box/step/ The participant stands on a box/step/BOSU ball on the exercis- ROM: 0° to 90° of hip flexion
BOSU (single-leg ing leg, then jumps as quickly as possible onto the floor. The
landing) participant performs a soft landing by moving into hip, knee,
and ankle flexion
1.4. Multidirectional The participant stands with feet shoulder-width apart, then ROM: 0° to 90° of hip flexion
jump, double leg jumps as quickly and as far as possible forward/backward,
side to side, or diagonally. The participant performs a soft
landing by moving into hip, knee, and ankle flexion. One set
of 10 repetitions is performed in each direction
1.5. Multidirectional The participant stands on the exercising leg, then jumps as ROM: 0° to 90° of hip flexion
jump, single leg quickly and as far as possible forward/backward, side to
side, or diagonally. The participant performs a soft landing
by moving into hip, knee, and ankle flexion. One set of 10
repetitions is performed in each direction
Abbreviations: FTDCM, fractional and temporal distribution of contraction modes; ROM, range of motion; RPE, rate of perceived exertion; TUT, time under
tension; VAS, visual analog scale.
†

APPENDIX E
MANUAL THERAPY
Target of Treatment Assessment Method Technique Aim Description Dosage
Perceived muscle guard- Palpation, pain, reduced STM and TPT of iliopsoas, To reduce pain and TPT with the muscle posi- 30 to 60 seconds of digital
ing/increased tone ROM adductors, gluteals, increase hip ROM tioned on stretch pressure per trigger
piriformis, TFL, Massage longitudinally point

and ES along the muscle 2 to 5 minutes per muscle
belly
Lumbar dysfunction Pain, palpation, ROM Mobilization of lumbar To improve lumbar spine Unilateral PAIVMs, grade 3 to 5 sets of 30 to 60
spine mobility and restore III or IV seconds
normal lumbopelvic
movement
Pelvic and SIJ asym- Pain, palpation, ROM Correction of SIJ asym- To optimize the position Massage to iliopsoas 2 to 5 minutes
metries metries of the ilium and there- Mobilization of SIJ 3 to 5 sets of 30 to 60
fore the orientation of seconds
the acetabulum
Hip capsule tightness Palpation of femoral head, Manual traction if Increase hip flexion and/or Seatbelt around patient’s 3 sets of 10 seconds. If
glide in squat ligamentum teres is IR/ER ROM proximal femur and tolerated, increase
intact or ligated and therapist’s hips. by 1 set per treat-
patient is more than Gentle inferior and/or ment session to a
3 months post labral lateral traction force maximum of 6 sets
repair applied. May include in total
patient actively mov-
ing hip into flexion as
traction is applied
Bony limitations Hard end feel in ROM tests None Treat according to None NA
limitations
Abbreviations: ER, external rotation; ES, erector spinae; IR, internal rotation; NA, not applicable; PAIVMs, passive accessory intervertebral movements;
ROM, range of motion; SIJ, sacroiliac joint; STM, soft tissue massage; TFL, tensor fascia latae; TPT, trigger point therapy.

APPENDIX F
CARDIOVASCULAR PROGRAM
Level Exercise Type Dosage
1 Cycling (stationary or road bike; no MTB), swimming (no breaststroke), other 10 min every second day
aquatic activity (water aerobics, water jogging; no egg-beater kick), walking
(on flat terrain; no beach walking or hiking), kayaking, rowing (if flexion
ROM greater than 100°), elliptical cross-trainer
1.1 Same as level 1 20 min every second day
1.2 Same as level 1 30 min every second day
1.3 Same as level 1 30 min total, including 5 × 60 seconds at high intensity every second day
1.4 Same as level 1 30 min, including up to 10 × 60 seconds or 5 × 2 min at high intensity every second day
1.5 Same as level 1 45 min, including up to 15 min total at high intensity every second day
2 May include but not limited to dance, running,* MTB, athletics, netball, 2 min every second day (can be combined with 30 min of level 1 activity)
racquet sports
2.1 Same as level 2 5 min every second day (can be combined with 30 min of level 1 activity)
2.6 Same as level 2 45 min every second day, including 10 min at higher intensity (can be combined with 15 min
of level 1 activity)
2.7 Same as level 2 50 min every second day, including 20 min at high intensity (can be combined with 10 min
of level 1 activity)
2.8 Same as level 2 Up to 1 h, 3 times per week, with full load
3 Football codes (soccer, rugby, American football, Australian rules football) and 30 min every second day (can be combined with 20 min of level 1 or 2 activity)
all other high-impact pivoting and/or kicking sports

3.1 Same as level 3 50 min every second day (can be combined with 20 min of level 1 or 2 activity)
3.2 Same as level 3 Up to 1 h, 3 times per week, with full load
Abbreviations: MTB, mountain biking; ROM, range of motion.
*Patients with known large cartilage lesions who wish to progress to running will be educated about the possible risks associated with this activity.

APPENDIX G
CARDIOVASCULAR PROGRAM PROGRESSION GUIDELINES

Exercise Progression HIPARTI Progression Guideline
Level 1 to level 1.5 cardiovascular exercise All exercise must occur within ROM restrictions for the first 6 wk after surgery
Progression occurs when previous level is completed successfully, with pain VAS* less than 20 mm and Borg RPE† of 5 or less
Level 1.5 to level 2 cardiovascular exercise Cannot progress from level 1 to level 2 until level 1.5 is completed with pain VAS* less than 20 mm and Borg RPE† of 5 or less
Patient able to complete single-leg hop on each leg greater than 65 cm
Patient able to complete more than 16 single-leg raises on each leg
Patient is 3 mo postsurgery
Level 2 to level 2.8 cardiovascular exercise Progression occurs when previous level is completed successfully, with pain VAS* less than 20 mm and Borg RPE† of 5 or less
Level 2.8 to level 3 cardiovascular exercise Cannot progress from level 2 to level 3 until level 2.8 is completed
Patient able to complete single-leg hop on each leg greater than 65 cm
Patient able to complete more than 16 single-leg raises on each leg
6 mo postsurgery (unless approved by the surgeon)
Level 3 to level 3.2 cardiovascular exercise Progression occurs when previous level is completed successfully, with pain VAS* less than 20 mm and Borg RPE† of 5 or less
Abbreviations: HIPARTI, HIP ARThroscopy International; ROM, range of motion; RPE, rate of perceived exertion; VAS, visual analog scale.
*VAS pain scale: 0 to 100 mm, with 0 being no pain and 100 the worst possible pain.
†
Borg RPE scale: 0 to 10, with 0 being nothing at all, 5 hard, and 10 extremely strong (“maximal”).

Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol For The Hip Arthroscopy International Randomized Controlled Trial

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[ clinical commentary ]

Postoperative Protocol for the HIP

ment of femoroacetabular impingement syndrome of this clinical commentary was

336 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

Inclusion and Exclusion Criteria dardized rehabilitation program to ad-

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 337

the beginning of each supervised visit to hip strength.5,22,28 Importantly, it appears

338 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

Hip Abductor Strengthening Pro-

Hip, Trunk, and Functional Exercise

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 339

340 | april 2018 | volume 48 | number 4 | journal of orthopaedic & sports physical therapy

Ther. 2014;44:A1-A32. https://doi.org/10.2519/

doi.org/10.1093/ptj/76.3.248 neuromusculature inhibition: a foundational

Ther. 2011;6:206-223. following hip arthroscopy – a systematic review.

journal of orthopaedic & sports physical therapy | volume 48 | number 4 | april 2018 | 341

25. Kemp JL, Makdissi M, Schache AG, Finch CF, https://doi.org/10.1002/acr.21806

bjsports-2013-093312 view of studies evaluating gluteus maximus and

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HIP, TRUNK, AND FUNCTIONAL EXERCISES

Hip external rotation

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and 90° to 180° of shoulder

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Hip external rotation

rotation resting on hands. The hip is in a neutral position and the

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TRUNK-STRENGTHENING AND ENDURANCE EXERCISES

Number of exercise interventions: 2 to 4 per week

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the abdominal muscles. The participant then returns to the

Trunk muscle endurance

then returns to the starting position FTDCM per repetition: isometric,

Rest between repetitions: 30 s

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returns to the starting position per set

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FUNCTIONAL STRENGTHENING AND PLYOMETRIC PROGRAM

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positioned in a neutral hip position and 90° of knee flexion

then lowered toward the participant, ensuring that the par-

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repetitions is performed in each direction

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piriformis, TFL, Massage longitudinally point

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all other high-impact pivoting and/or kicking sports

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25. Kemp JL, Makdissi M, Schache AG, Finch CF, https://doi.org/10.1002/acr.21806