1. Hydrotherapyexercisesfollowinghiparthroscopysurgery By Louise Grant MCSP Hip Specialist Chartered Physiotherapist Copyright Jan 2011

2. Hydrotherapy exercises following hip arthroscopy INTRODUCTION Essential criteria before commencement of hydrotherapy – Surgical wounds must be fully healed so there is no infection risk. The patient must be sufficiently mobile to be safely be in the pool and surrounding area. They must also have the ability to safely get in and out of the pool.

3. Hydrotherapy exercises following hip arthroscopy EXERCISE TECHNIQUES With this hydrotherapy exercise program, correct posture is essential, and whole body awareness. Although the water supports you, it also can add other challenges; as you move one part of your body you need to be aware of what the rest of your body is doing in the water. Top tips – Ideally, you need the water at chest level, so your body weight is being supported. Starting from your feet, try and be equally weight bearing on each foot, as pain allows. Imagine your foot as a tripod of weight bearing; the big toe, the litte toe and the heel forming three points of equal weight bearing.

4. Hydrotherapy exercises following hip arthroscopy EXERCISE TECHNIQUES Next, find lumbo-pelvic neutral. Place your hands on the top of the iliac crests/pelvic bones. Imagine the rim of the pelvic bones to be like the rim of a bucket. Tuck your tail bone under to tilt your pelvis backwards, then perform the opposite, feeling your lumbar spine hollow. Feel how the ‘rim of the bucket’ tilts backwards and forwards. Finally, position so the ‘rim’ is level, this is called lumbo-pelvic neutral and this position should be maintained when specified in the exercises.

5. Hydrotherapy exercises following hip arthroscopy EXERCISE TECHNIQUES The term ‘trans abds engaged/core engaged’ is used in the exercises. This refers to the the transversusabdominis and associated lumbo/pelvic/core stabilising muscles being active and controlled. To do this, firstly gain lumbo-pelvic neutral. Then, you can either imagine a piece of elastic connecting your two front pelvic bones and the elastic gently drawing them together, or another way is to gently draw in your navel towards your spine. You should feel your lower abdominal muscles activate and ‘connect’, only approximately 20% effort is needed, you should not ‘brace’ your abdominals at 100% effort. You should still be able to breathe, your rib cage should not lift and you should still be able to move the rest of your body. It is advisable to get your Physiotherapist to check you are doing this correctly.

6. Hydrotherapy exercises following hip arthroscopy EXERCISE TECHNIQUES With your pelvis in neutral, transversusabdominis engaged and equal weight bearing in the feet, now you have to think about your body alignment. Your ear, middle of the outer/lateral shoulder, the side of your hip, knee and lateral ankle bone should all be in line. It is important that your upper body is relaxed, your shoulder blades are wide apart and gently drawn down your back. Your neck should feel lengthened, imagine a piece of string attatched to the top of the head, gently pulling upwards, so you feel like you are ‘growing tall’. Postural awareness is important as it helps your body move better and aims to help prevent compensatory or ‘trick’ movements occurring.

8. Moving the limb slowly through the water will be easier than if it is done at speed. Moving at speed will create ‘drag’ and turbulence, thus more challenges. Therefore, early stage exercises are done slowly.

10. Hydrotherapy exercises following hip arthroscopy

12. To introduce early core control/lumbo-pelvic stability and proprioceptive exercises of the hip and pelvis.

14. Level one 2. Pendular hip - abduction. Position as before, moving operated leg out sideways. 3. Pendular hip - rotation. Position leg as before, keeping operated leg straight and relaxed, turn in and out, gently. Copyright PHYSIOCURE

15. Level one 4. Hip circumduction. In pendular position, operated leg straight, relaxed and not in contact with floor (stand on tiptoes on opposite leg). Imagine the foot of the operated leg to be a point of a pencil and draw a small circle clockwise, then anti-clockwise. Make sure this is painfree. Copyright PHYSIOCURE

16. Level one 5. Bilateral calf raises. Stand, holding onto pool side, water should be chest height. Equal weight bearing through feet (as long as painfree). Push through the balls of the feet, raising the heels off the floor trying to keep a good postureand keeping ankles ‘strong’ and straight, not allowing them to rotate. Copyright PHYSIOCURE

17. Level one 6. Calf stretch. Stand with one foot in front of the other, lumbar spine neutral, trans abds engaged. Slowly bend the front knee, keeping the back knee straight, stop when you feel a stretch in the back calf, and hold. Copyright PHYSIOCURE

18. Level one 7. Quads stretch. Stand in a good posture. Lumbar spine neutral, trans abds engaged. Bend one knee, bringing your heel of your foot towards your bottom, if you can, hold onto the foot with your hand to assist. You should feel a stretch in the front of your thigh. Do not hollow your back. Squeeze your bottom gently to increase the stretch. Copyright PHYSIOCURE

19. Level one 8. Hamstring stretch. Standing in a good posture, lumbar spine neutral, trans abds engaged. The leg to be stretched should be straight and extended out in front of you. The opposite knee slightly bent. Keeping your back controlled, lower your bottom down towards the floor, increasing the bend in your knee but so you feel a stretch in the back of your straight leg, hold. Do not stretch into pain. Copyright PHYSIOCURE

20. Level one 9. Adductor stretch. Standing in a good posture, lumbar spine neutral, trans abds engaged. Left foot pointing forward, right foot pointing outwards. Bend the right knee, keep left knee straight. Keep your pelvis facing forward. You should feel a stretch in the inner thigh. Do not stretch into pain. Repeat on the opposite side. Copyright PHYSIOCURE

21. Level one 10. Anterior/posterior pelvic tilts. Woggle between upper thighs, hips and knees at right angles, feet off floor, in a sitting position, holding onto pool side. Siting up straight, engage trans abs, tuck tail bone under, tilting pelvis posteriorly, then do the opposite to create a lumbar lordosis. Copyright PHYSIOCURE

22. Level one 11. Lateral pelvic tilts. With the woggle in the same position, now try lateral pelvic tilts, as you lengthen one side of your pelvis/loin, the other side should shorten. Copyright PHYSIOCURE

23. Level one 12. Woggle in same position, hold onto pool side, marching on the spot. 13. Woggle in same position, hold onto pool side, both feet off the floor, perform a gentle cycling movement with both legs. Copyright PHYSIOCURE

24. Level one 14. Small knee bends. Weight equal between feet, feet pointing slightly out, lumbar spine neutral, posture correct, engage trans abds, bend at hips/knees/ankles so knees point over the middle of the toes. Knees should be only be bent about 30 degrees. Engage gluts/trans abs/quads/hams throughout the whole movement. Copyright PHYSIOCURE

25. Level one 15. Chest openings. Stand with knees slightly bent with your back against the pool side. Elbows tucked into sides and flexed to 90 degrees, shoulders pulled gently down, neck lengthened and engage trans abds. With palms facing up, rotate arms outwards, keeping elbows tucked into sides. Do not let breastbone lift or back arch. Copyright PHYSIOCURE

26. Level one 16. Upper body rotations. Standing, knees slightly bent, back against the pool side. Arms out in front of you with a float under the palms.Engage trans abds. Move the float across the water so you are rotating the upper body but keeping the hips facing forwards. Do each way. Copyright PHYSIOCURE

27. Level one 17. Upper abdominals. Standing, knees slightly bent, back against the pool side. Arms out in front of you with a float under the palms. Engage trans abds, set shoulder blades and neck posture. Push the float down through the water towards the thighs, keeping the arms straight; and slowly then return to the surface. Copyright PHYSIOCURE

28. Level one 18. Row. Standing, knees slightly bent, back against pool side. Ensure correct posture and set trans abds. Hold float vertically in hands, close to chest. Push float away from body, straightening both arms and then return, pulling float back to start position. The ease of the exercise depends on how much the float is immersed in the water. Copyright PHYSIOCURE

30. To increase range of movement and add in rotation challenges.

31. To re-educate gait, posture, balance, proprioception.

32. To progress strengthening without provoking pain.

34. Level two 2. Supine floating. Bilateral hip abduction. Ensure neck, spine and pelvis are supported and trans abds engaged. Start with legs straight out and together, then seperate the legs into a ‘V’ shape, then return to start position. Copyright PHYSIOCURE

35. Level two 3. Supine floating, trunk side bends. Assuming the position as in exercise 2. Keep both legs together and core stable, glide them laterally to one side, then the other. One side of the waist should shorten and the other lengthen. Copyright PHYSIOCURE

36. Level two 4. Hip circumduction. In supine floating position. Both legs out straight. With operated leg, point the foot, imagining it is the point of a pencil and draw a circle clockwise and then anti-clockwise. It is better to have good control and technique rather than making it too hard and this affect your quality of movement. Experiment with ‘circle size’ and how immersed the leg is in the water. Copyright PHYSIOCURE

37. Level two 5. One leg balance. Aim to bring knee up to hip height but in painfree range. Keep core controlled and spine in a neutral position. Try and do slowly with minimum support from pool side. Copyright PHYSIOCURE

38. Level two 6. Hip internal rotation in standing. Holding onto pool side. Spine neutral and trans abds engaged. Bend the knee of the operated leg to 90 degrees, then rotate the lower leg outwards so a gentle stretch in the hip is felt. Copyright PHYSIOCURE

39. Level two 7. Standing ‘FABER’ stretch. Keep pelvis level and controlled. Place one ankle above the opposite knee, so the leg is turning out. Next, squat down gently so a stretch is felt.

40. Level two 8. Thoracic extension. Stand, facing the pool side, arms straight, holding onto side. Spine neutral, shoulder blades wide and gently drawn down the back, trans abds engaged. Bend your elbows bringing your breastbone forwards towards the pool side, lifting the ribcage and extending the thoracic spine. Then return, maintaining postural control. Copyright PHYSIOCURE

41. Level two 9. Hip side glides in standing. Stand sideways on to the pool side. Forearm resting on the pool side for support. Keeping the legs together and hips pointing forwards. Glide the pelvis towards the pool wall, ensuring there is no rotation of the pelvis or body. Copyright PHYSIOCURE

42. Level two 10. Thoracic rotations. Start by standing facing the pool side, holding on at arms length distance away. Engage trans abds for core control, keep hips facing forward. Remove one hand from the pool side and reach with it under the opposite arm so you are rotating the thoracic spine and stretching around the back of the shoulder. Copyright PHYSIOCURE

43. Level two 11. One leg knee dips. Start with both feet facing forwards, feet hip distance apart. Balance on one leg, ensuring the pelvis is level, trans abds engaged and bottom squeezed of the stance leg. You can lightly hold onto the pool side if needed. If you are able to balance comfortably, then bend the knee of the stance leg approximately 30 degrees, keeping the kneecap pointing forwards. Slowly repeat. Copyright PHYSIOCURE

44. Level two 12. One leg calf raises. Either hold onto pool side, use floats or balance independently. Stand on one leg, keeping your pelvis level, trans abds engaged. Lift the heel of the weight bearing leg so you are standing on the ball of your foot. Try to keep the ankle and knee facing forwards and the weight evenly distributed through the ball of the foot. The slowly lower the heel and repeat. Use as a balance and control exercise. Copyright PHYSIOCURE

45. Level two 13. Supported walking. Place a woggle under both arms and hold onto it at the front of your body. Walk forwards, then backwards in the water. Try and concentrate on equal stride length, relaxing your upper body and performing a ‘heel to toe’ walking action. Copyright PHYSIOCURE

46. Level two 14. Water cycling with floats. Place a woggle between your thighs and a float under each hand. Cycle stationary in the water or make it harder and travel around the pool. Copyright PHYSIOCURE

48. To perform advanced flexibility, core stability, strength and proprioceptive exercises.

49. To introduce sports specific skills.

51. Level three 2. Hip flexor stretch. Stand at the pool side, holding on. Bend one hip and knee so ball of foot is in contact with pool wall (in a comfortable position). Let the other leg hang straight to feel a gentle stretch in the front of the hip/thigh.You can bend the knee of the hanging leg, taking the heel towards the bottom if the first stage of the exercise does not produce a stretch. Copyright PHYSIOCURE

52. Level three 3. Side steps. Practise walking sideways in the water. Small steps to start and increasing in length as able. Progress with speed increases and balance challenges. Copyright PHYSIOCURE

53. Level three 4. Bilateral hip flexion. Using the side of the pool. Hold firmly onto the edge and place both feet on the pool wall with both knees and hips bent (this must be comfortable). Use your feet to push you away a little, but keep holding on, then use your arms to pull you back. Do not push into or provoke pain. Copyright PHYSIOCURE

54. Level three 5. Resisted knee extension Carefully place woggle under foot, like a ‘stirrup’. Hold onto the pool side. Start with hip and knee flexed. Keep back straight and abdominals connected. Push down through the heel of the foot to straighten the leg. Return to flexed position. Ensure good controland alignment of leg throughout. Try different speeds of movement, balance challenges by reducing hand contact on pool side and woggle length. Copyright PHYSIOCURE

55. Level three 6. Hip lateral rotation with woggle. Standing at the pool side, place woggle under lower thigh. Hold onto pool side, ensure good posture and abdominal connection. Float the bent hip/knee outwards, keeping the pelvic bones pointing forwards (do not twist pelvis). Then return to start position. Copyright PHYSIOCURE

56. Level three 7. Resisted hip abduction and adduction with woggle. Place woggle under foot. Push down firmly so it is touching the bottom of the pool. Hold onto pool side, good posture, abdominals connected, stand on tip toes of weight bearing leg. Slide the leg out to the side, keeping the woggle in contact with the pool floor so you don’t lose control. Then slide back to start position. Progress with reduced contact to pool floor only when advised by your physiotherapist. Copyright PHYSIOCURE

57. Level three 8. Resisted hip flexion and extension with woggle. Place woggle under foot. Push down firmly so it is touching the bottom of the pool. Hold onto pool side, good posture, abdominals connected, stand on tip toes of weight bearing leg. Slide the leg forward, leg straight, moving from the hip. Then slide backwards, keeping woggle in contact with floor. Progress with reduced contact to pool floor only when advised by your physiotherapist. Copyright PHYSIOCURE

58. Level three 9. Hip circumduction with woggle. Place woggle under foot. Push down firmly so it is touching the bottom of the pool. Hold onto pool side, good posture, abdominals connected, stand on tip toes of weight bearing leg. Keeping the leg straight, imagine it is a pencil and draw a small circle clockwise for a few repetitions, then anticlockwise. Circles can be made bigger as you progress. Progress with reduced contact to pool floor only when advised by your physio. Copyright PHYSIOCURE

59. Level three 10. Aqua jogging. You can choose to use a special aqua jogger device, floats or use nothing. Firstly check you can walk comfortably in the water,then try and build up your walking speed. Next, try a program of walking one minute, jogging one minute, gradually building up the time. Progress, so jogging is more predominant. Add resistance by using elastic resistance bands designed for use in water, secured around your trunk and to a distal appropriate secure fastening. To additionally increase postural and proprioceptive challenges, experiment with raising your arms above your head, so you are not using your upper body to compensate in lumbo-pelvic stability..

60. Level three 11. Multi joint movement. With the water level at shoulder height, practice one arm abduction and opposite hip abduction. The same can be done doing one arm flexion/extension and the opposite hip flexion and extension. Using floatation devices under the water and experimenting with different speeds will bring about proprioceptive and stability challenges. Please do this under the guidance of your physiotherapist to ensure good technique and quality of movement. Copyright PHYSIOCURE

61. Level three 12. Swimming on front or back. Crawl/kick legs holding float. Ensure core and spinal control is good to avoid compensatory rotation or extension of the spine. Activate trans abds during the actiivty and also make sure your gluteals are controlling hip extension and spinal muscles are compensating. Copyright PHYSIOCURE

62. Acknowledgements The author, Louise Grant MCSP accepts no responsibility for persons using this guide. The guide should be used under the instruction and guidance of your physiotherapist. For further information on hip arthroscopy physiotherapy, pilates and hydrotherapy, log onto www.physiocure.org.uk. Thank you to all my hip arthroscopy patients who have assisted and inspired me to publish this guide. Published by PHYSIOCURE Jan 2011. Copyright Jan 2011. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form, or by any means, electronic, mechanical, or otherwise, without the prior permission of the author/copyright owner. Copyright PHYSIOCURE