Variability and Comprehensiveness of North American Online Available Physical Therapy Protocols Following Hip Arthroscopy for Femoroacetabular Impingement and Labral Repair Gregory L. Cvetanovich, M.D., Vincent Lizzio, B.S., Fabien Meta, B.S., Derek Chan, D.P.T., Ira Zaltz, M.D., Shane J. Nho, M.D., and Eric C. Makhni, M.D., M.B.A.
Purpose: To assess comprehensiveness and variability of postoperative physical therapy protocols published online following hip arthroscopy for femoroacetabular impingement (FAI) and/or labral repair. Methods: Surgeons were identified by the International Society for Hip Arthroscopy “Find a Surgeon” feature in North America (http://www.isha. net/members/, search August 10, 2016). Exclusion criteria included nonsurgeons and protocols for conditions other than hip arthroscopy for FAI and/or labral tear. Protocols were identified by review of surgeons’ personal and departmental websites and evaluated for postoperative restrictions, rehabilitation components, and the time points for ending restrictions and initiating activities. Results: Of 111 surgeons available online, 31 (27.9%) had postoperative hip arthroscopy physical therapy protocols available online. Bracing was used in 54.8% (17/31) of protocols for median 2week duration (range, 1-6 weeks). Most protocols specified the initial postoperative weight-bearing status (29/31, 93.5%), most frequently partial weight-bearing with 20 pounds foot flat (20/29, 69.0%). The duration of weight-bearing restriction was median 3 weeks (range, 2-6) for FAI and median 6 weeks (range, 3-8) for microfracture. The majority of protocols specified initial range of motion limitations (26/31, 83.9%) for median 3 weeks (range, 1.5-12). There was substantial variation in the rehabilitation activities and time points for initiating activities. Time to return to running was specified by 20/31 (64.5%) protocols at median 12 weeks (range, 6-19), and return to sport timing was specified by 13/31 (41.9%) protocols at median 15.5 weeks (range, 9-23). Conclusions: There is considerable variability in postoperative physical therapy protocols available online following hip arthroscopy for FAI, including postoperative restrictions, rehabilitation activities, and time points for activities. Clinical Relevance: This information offers residents, fellows, and established hip arthroscopists a centralized comparison of publicly available physical therapy protocols following hip arthroscopy. Practicing arthroscopists might find this analysis useful to compare various therapy strategies to their own recommendations. The variability we report can also provide inspiration for future efficacy research toward a more standard rehabilitation.
From the Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center (G.L.C., S.J.N.), Chicago, Illinois; Wayne State University School of Medicine (V.L., F.M.); Department of Orthopaedic Surgery, Henry Ford Hospital Detroit (V.L., F.M., D.C., E.C.M.), Detroit; and Department of Orthopaedic Surgery, William Beaumont Hospital (I.Z.), Royal Oak, Michigan, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received December 16, 2016; accepted June 16, 2017. Address correspondence to Eric C. Makhni, M.D., M.B.A., Division of Sports Medicine, Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 West Grand Boulevard, CFP-627, Detroit, MI 48201, U.S.A. E-mail: [email protected] Ó 2017 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/161266/$36.00 http://dx.doi.org/10.1016/j.arthro.2017.06.045
H
ip arthroscopy has experienced rapid growth over the past decade as an effective treatment for femoroacetabular impingement (FAI).1-4 The procedure involves osteochondroplasty to address bony cam and pincer morphology and labral repair when a tear is present. The procedure provides high rates of pain relief, improved function, and return to sports.5-8 Overall, a recent systematic review estimated that 87% of athletes returned to sport and 82% were able to return at the same level.9 In elite athletes, similar return-to-sport rates have been reported, with 84% return to play from hip arthroscopy for FAI and 77% for cases also involving microfracture.10 Successful recovery from hip arthroscopy for FAI may involve rigorous postoperative physical therapy, particularly in order to return to athletic endeavors.11,12
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Despite this, there is a lack of comparative literature and high-level evidence to guide postoperative rehabilitation from hip arthroscopy for FAI. Various rehabilitation protocols have been proposed in the literature.13-16 Recent systematic reviews on rehabilitation following hip arthroscopy have noted variability in protocols and the lack of comparative studies to guide rehabilitation.11,12 The purpose of this study is to assess comprehensiveness and variability of postoperative physical therapy protocols published online following hip arthroscopy for FAI and/or labral repair. We hypothesized that there would be considerable variability in protocols in terms of postoperative restrictions on weight bearing and range of motion, recommended rehabilitation activities, timeframes of rehabilitation activities, and return to sport.
Methods A search was performed to identify online available hip arthroscopy postoperative protocols for FAI or labral tear for surgeons in North America. The International Society for Hip Arthroscopy (ISHA) “Find a Surgeon” feature was used to identify hip arthroscopy surgeons in North America (http://www.isha.net/members/, search date August 10, 2016). This initial screening process identified 130 individuals. Next, the individuals’ departmental websites were manually searched to identify physical therapy protocols for rehabilitation following hip arthroscopy. A subsequent general Internet search was additionally performed (www. google.com) for any personal surgeon websites with online available hip arthroscopy rehabilitation protocols (search dates August 10-20, 2016). Exclusion criteria included nonsurgeons and protocols for conditions other than hip arthroscopy for FAI and/or labral tear. This search strategy identified 111 surgeons, of whom 27.9% (31/111) had postoperative hip arthroscopy physical therapy protocols for FAI available online (Fig 1). The majority of these protocols were procured from personal websites (23/31, 74%) primarily determined by identification of website copyright at the bottom of the webpage and cross-referenced to personal name in URL and webpage title. The remaining physical therapy protocols were published on institutional/ departmental websites. Furthermore, the information published in these personal or institutional websites also provided information as to which surgeons have completed fellowship training for hip arthroscopy. Protocols were evaluated for postoperative restrictions, which rehabilitation components were included, and the time points for ending restrictions and initiating activities. Time of suggested return to sport was assessed. A list of all rehabilitation parameters that were assessed is shown in Table 1. For each protocol component, we assessed whether the protocols
Members listed on ISHA website "Find a Surgeon" feature n = 130 Excluded: Physical therapists, researchers, or rered surgeons n = 13 Members who are acve surgeons n = 117 Excluded: Members without a personal or departmental website n=6 Acve surgeons with websites available online n = 111 Excluded: Surgeons without publicly available rehab protocols n = 80 Surgeons with published hip arthroscopy rehab protocol online n = 31
Fig 1. Flow chart for study search methodology to identify online available hip arthroscopy physical therapy rehabilitation protocols.
included or did not include the item. For initial postoperative restrictions and adjunct therapies, the times at which these commenced and were discontinued were both assessed. For rehabilitation activities, the time at which the patients could first begin that activity was evaluated (since generally no stop dates for these activities were specified). Statistical Analysis Fisher exact tests were used to compare categorical variables between individuals with and without online available physical therapy protocols for hip arthroscopy. For rehabilitation activities, the data were analyzed using descriptive statistics using median and range.
Results In general, timelines often accompanied postoperative instructions and rehabilitation exercises, creating a comprehensive protocol. Protocols containing general therapy guidelines (e.g., guidance on bracing,
VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS Table 1. Hip Arthroscopy Rehabilitation Protocol Elements Category Accessory postop therapy
Motion and weight bearing
Stretching
Strengthening
Proprioception
Functional testing Activity/sport
Protocol Elements Ice/CryoCuff/Game Ready, crutches, brace use, neuromuscular electrical stimulation, continuous passive motion Flexion/extension, abduction/adduction, external rotation/internal rotation, and weight-bearing considerations Prone lying, manual therapy, active release therapy, anterior capsule stretching, soft tissue mobilization, anterior/posterior/inferior glides Isometrics (quadriceps, glutes, etc.), hamstring curls, prone hip extension, tall kneeling, ½ kneeling, standing double leg 1/3 knee bends, step-ups, single/ double leg squats, lunges, single/double leg bridges, modified planks, planks Standing weight shift, backward/lateral walking, side stepping, single leg balance, slide board, retro walks with resistance Gait assessment Stationary bike, elliptical, hip rotational activities, agility drills, jogging/running, Alter G, cutting, plyometrics, sport specific drills
continuous passive motion [CPM] use, etc.) without explicitly stated time points were still included in our analysis. These comprised 7/31 (23%) of the protocols reviewed in this study. Characteristics of Individuals With Online Available Protocols Comparison of surgeons with online hip arthroscopy protocols available (n ¼ 31) to those without protocols available (n ¼ 80) revealed no differences in percentage with sports medicine fellowship training (27/31 [87.1%] vs 58/80 [72.5%], P ¼ .136) and percentage with adult reconstruction fellowship training (7/31 [22.6%] vs 14/80 [17.5%], P ¼ .592), but they did reveal a lower rate of pediatric fellowship training (0/31 [0%] vs 11/80 [13.8%], P ¼ .0324). There was no significant difference in the rate of people obtaining additional dedicated hip preservation fellowship training beyond their initial fellowship (11/31 [35.5%] vs 17/80 [21.3%], P ¼ .146). Postoperative Adjunctive Treatments and WeightBearing Restrictions Bracing was used in 54.8% (17/31) of protocols for median 2-week duration (range, 1-6 weeks; Fig 2).
3
Rationales for bracing included normalization of gait pattern while walking, hip protection, prevention of abduction and flexion/extension, and nighttime protection. Nighttime protection with the use of a hip brace or derotational boots was specified by 6/31 (19.4%) of protocols, for duration median 2 weeks (range, 1-2). Ice was specified by 18/31 (58.1%) of protocols for median 2.5 weeks (range, 1-8). Icing methods varied from dedicated ice machines and cold packs to bags of ice cubes. CPM was used in 16/31 (51.6%) of protocols for 3 to 6 hours per day for median 4 weeks (range, 2-4). E-STIM was included in 9/31 (29.0%) protocols for median 2 weeks (range, 1-4). Most protocols specified the initial postoperative weight-bearing status (29/31, 93.5%), most commonly partial weight-bearing with 20 pounds foot flat (20/29, 69.0%; Fig 3). Less common weight-bearing restrictions included touchdown weight bearing (4/29, 13.8%), weight bearing as tolerated (4/29, 13.8%), and nonweight bearing (1/29, 3.4%). The duration of weightbearing restriction was median 3 weeks (range, 2-6). In cases combined with microfracture, 10/29 (34.5%) protocols specified a prolonged weight-bearing restriction for median 6 weeks (range, 3-8). Postoperative Range of Motion Limitations All protocols (31/31, 100%) recommended immediate postoperative motion. The majority of protocols specified initial postoperative range of motion limitations (26/31, 83.9%), for median 3 weeks (Fig 4). Maximum flexion was specified in 17/31 (54.8%) of protocols, with median 90 (range, 60 -90 ) for duration median 3 weeks (range, 1.5-12). Maximum extension was specified in 15/31 (48.4%) of protocols, with median 0 (range, 0 -30 ) for duration median 3 weeks (range, 2-4). Maximum internal rotation was specified in 8/31 (25.8%) of protocols, with median 20 (range, 0 -20 ) for duration median 3 weeks (range, 3-5). Maximum external rotation was specified in 18/31 (58.1%) of protocols, with median 20 (range, 0 -30 ) for duration median 3 weeks (range, 2-6). Finally, maximum abduction was specified in 12/31 (38.7%) of protocols, with median 30 (range, 25 -45 ) for duration median 3 weeks (range, 2-4). A precaution of no active hip abduction was applied by 3/31 (9.7%) protocols for 4 weeks (range, 4-5). Stretching, Strengthening, and Proprioception There was substantial variation in the recommended rehabilitation activities and time points for initiating activities (Fig 5). Differences were even apparent with the wording used to indicate rehabilitation initiation, with 8/31 (26%) protocols recommending a specific postoperative day to start therapy, in comparison with other protocols outlining therapy initiation with more broad, weekly, time points (e.g., postop week 0 or
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% Protocols Reporng Inial Post-Operave Recommendaon
A
100 90 80 70 60 50 40 30 20 10 0 Bracing
B
Nighme protecon
Bracing
2
Nighme protecon
2
Ice
CPM
E-STIM
Fig 2. Immediate postoperative adjunctive treatments. (A) Percentage of protocols specifying each modality and (B) range of recommended duration with median and range are shown.
2.5
Ice
4
CPM
2
E-STIM 0
2
4
6
8
10
12
14
16
Range of Recommended Duraon (Weeks)
week 1). Initial rehabilitation starting immediately postoperatively focused on isometric quadriceps strengthening and anterior capsular stretching along with soft-tissue mobilization and manual therapy. Anterior capsular stretching was recommended in 3/31 protocols, with 2 of these protocols having a counterintuitive restriction in hip extension. Further investigation of these protocols revealed that anterior capsule stretching was initiated after the hip extension restriction. Hip rotational activities, standing weight shifts, and prone hip extension are added in the first 2 weeks. Fourteen additional activities for strengthening and proprioception were specified over the first 6 weeks postoperatively, with variation among protocols as to
which activities were recommended and at what postoperative time point they were prescribed. Return to Activities and Return to Sport Return to activities began with stationary bicycling at median 0 weeks. There was considerable variability in inclusion of these activities among protocols, as well as time at which patients were allowed to begin them (Fig 6). Progression occurred through walking, elliptical, agility, running, cutting/pivoting, return to sport specifics, and return to sport. Time to return to running was specified by 20/31 (64.5%) protocols at median 12 weeks (range, 6-19), and return to sport timing was specified by 13/31 (41.9%) protocols at median
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VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS
% Protocols Reporng Weight-Bearing Restricon
A
100 90 80 70 60 50 40 30 20 10 0 WBAT
NWB
TDWB
PWB
B 3
No microfracture or not specified
6
Microfracture
0
2
4
6
8
10
Range of Recommended Duraon (Weeks)
Fig 3. Postoperative weight-bearing restrictions. (A) Percentage of studies suggesting each weight-bearing restriction are shown, with the postoperative weight bearing 20 pounds foot flat as the most common restriction. (B) Duration of weight-bearing restriction is shown with median and range.
15.5 weeks (range, 9-23). Advancement criteria for return to sport and return to sport specific training also varied. Protocols explicitly stating these criteria comprised only 32% (10/31) of the total reviewed, with only one protocol highlighting different criteria for different sports.
case series, generally involving 4- or 5-phase rehabilitation with initial weight-bearing and mobility limitations that varied among studies.12 Grzybowski et al. also performed a recent systematic review of 18 studies analyzing rehabilitation following hip arthroscopy, finding that rehabilitation programs were poorly reported and had considerable variability between surgeons.11 The results of the present study suggest that the variability in rehabilitation following hip arthroscopy found in these 2 recent systematic reviews of the published literature also applies to the online protocols published by a group of hip arthroscopy surgeons. These inconsistencies compel us to believe there is a need for future studies to compare various aspects of hip arthroscopy rehabilitation in order to generate evidence to guide treatment. Another potential cause of the variability and poor reporting identified in our analysis of online hip arthroscopy physical therapy protocols could be secondary to poor availability of online materials regarding rehabilitation. Some surgeons may prefer not to make these materials available publicly, or they may only publish limited rehabilitation guidelines online rather than their full protocols. In fact, the majority of surgeons identified on our search (72%, 80 of 111) did not have an online publicly available rehabilitation protocol following hip arthroscopy and were excluded
A 90
Flexion
0
Extension IR
20
ER
20
Discussion This study found that a minority of surgeons has a publicly available online physical therapy protocol for rehabilitation following hip arthroscopy for FAI. Furthermore, the protocols available online are highly variable regarding postoperative restrictions, postoperative adjunctive therapies such as bracing and CPM, and inclusion and timing of initiation of various rehabilitation activities, thus confirming our study hypotheses. Despite the importance of physical therapy to postoperative recovery and return to activities after hip arthroscopy, the literature contains limited data to guide rehabilitation after hip arthroscopy.11-16 These data consist primarily of Level IV and V evidence, and no comparative studies are available to our knowledge. Cheatham et al. recently systematically reviewed the literature on postoperative rehabilitation following hip arthroscopy, finding 6 studies that were case reports or
30
Abducon 0
20
40
60
80
Maximum Recommended ROM (Degrees)
B Flexion
3
Extension
3
IR
3
ER
3
Abducon
3 0
5
10
15
Range of Recommended Duraon (Weeks)
Fig 4. Postoperative range of motion restrictions including (A) maximum degrees for each motion and (B) duration of postoperative restriction.
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A
Isometric quadriceps exercises Prone lying and anterior capsular … SoŌ Ɵssue mobilizaƟon Manual therapy Hip rotaƟonal acƟviƟes Standing weight shiŌs Prone hip extension Tall kneeling and 1/2 kneeling with core Hamstring curls Single leg balance Single leg bridges Side steps Standing double leg 1/3 knee bends Double leg squat Posterior/inferior glides Forward step ups Modified planks Slide board exercises Planks Anterior glide Lunges
0 0 0 0 1
0
2 2 2.5 2.5 3 3.5 4
4 4 5 5 5 5.5 6 6 6 5
10
15
Start Date Range (Weeks)
% Protocols ReporƟng AcƟvity RecommendaƟon
B 100 90 80 70 60 50 40 30 20 10 0
accordingly. The increasing role of online information for hip arthroscopy and FAI generally have been evaluated in several recent studies that have found considerable variability in the content of online information about hip arthroscopy and FAI.17,18 From this study, we suggest that hip arthroscopy surgeons endeavor to make more information available online about hip arthroscopy rehabilitation, since this could help communication with therapists, patients, and other medical providers and potentially improve patient care.
20
Fig 5. Stretching, strengthening, and proprioception activities including (A) recommended start date for each activity with median and range and (B) percentage of protocols including each specific activity.
Limitations This study has several limitations. The search strategy of identifying members of the major hip arthroscopy association (ISHA) was chosen to avoid selection bias inherent in using an online search engine alone to identify surgeons. Although this method allowed us to avoid selection bias, it is probable that not all practicing hip arthroscopists are members of ISHA. Furthermore, the search was limited to North America in order to maintain consistency of protocols within similar health care systems. Therefore, the results may
7
VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS
A
Staonary Bike
Backward and lateral walking
0 2.5 3
Alter G
5 6.5
Ellipcal Retro walking with resistance
12 12 12 12 12
Agility Running Cung/Pivong Plyometrics Sport specific acvites
15.5
Return to Sport 0
5
10
15
20
25
Start Date Range (Weeks)
B % Protocols Reporng Acvity Recommendaon
Fig 6. Return to activities and return to sport, including (A) recommended start date for each activity with median and range and (B) percentage of protocols including each specific activity.
100 90 80 70 60 50 40 30 20 10 0
not apply to other regions of the world that were not analyzed. Also, as individuals from multiple backgrounds including sports medicine, pediatrics, and adult reconstruction perform hip arthroscopy, a search of a specialty society in any one of these areas would introduce bias as rehabilitation strategy might vary based on fellowship training background. Of note, fellowship training background was determined using the information that is published on a given surgeon’s personal or institutional website. Such information may be inaccurate, incomplete, and difficult to confirm without a centralized fellowship database. Our search strategy could introduce a different bias, since searching ISHA members with online available rehabilitation protocols might be biased toward surgeons with academic
practices or younger surgeons, for instance. In addition, no attempt was made to contact surgeons without online available protocols, since the goal of the study was to assess the rehabilitation recommendations that are publicly available online. The fact that a minority of surgeons in our sample have publicly available protocols is another limitation. It is difficult to elucidate what bearing these additional therapy protocols would have in regards to our results. This might indicate an area of further study that could involve a survey of ISHA members to further address practice patterns as they relate to physical therapy following hip arthroscopy. Furthermore, protocols generally did not differentiate between different procedures performed that could impact rehabilitation including capsular closure, labral
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repair versus debridement, and labral or capsular reconstruction. The exception was microfracture for which many protocols recommended prolonged weight-bearing restriction. Protocols were not analyzed to determine how many had videos accompanying therapy recommendations since this was a level of detail that was rarely included in the website that contained the physical therapy protocols. We feel that a study investigating the quality of rehabilitation protocols would be better suited to include analysis of video and picture demonstrations of exercises, as this addition could enhance the rehabilitation experience, from a quality standpoint, for patients and rehab professionals alike. Finally, the literature contains limited comparative studies on hip arthroscopy rehabilitation,11,12 as well as limited studies identifying optimal rehabilitation protocols following surgery, and therefore our analysis is unable to comment on whether the online protocols are in keeping with the best available evidence-based medicine.
Conclusions There is considerable variability in postoperative physical therapy protocols available online for hip arthroscopy for FAI, including postoperative restrictions, rehabilitation activities, and time points for activities.
References 1. Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661-665. 2. Cvetanovich GL, Chalmers PN, Levy DM, et al. Hip arthroscopy surgical volume trends and 30-day postoperative complications. Arthroscopy 2016;32:1286-1292. 3. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am 2012;94:e23. 4. Bozic KJ, Chan V, Valone FH 3rd, Feeley BT, Vail TP. Trends in hip arthroscopy utilization in the United States. J Arthroplasty 2013;28:140-143. 5. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 10-year followup. Clin Orthop Relat Res 2010;468:741-746.
6. Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint space predicts THA after hip arthroscopy in patients 50 years and older. Clin Orthop Relat Res 2013;471:2492-2496. 7. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br 2009;91:16-23. 8. McCarthy JC, Jarrett BT, Ojeifo O, Lee JA, Bragdon CR. What factors influence long-term survivorship after hip arthroscopy? Clin Orthop Relat Res 2011;469:362-371. 9. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. Br J Sports Med 2015;49: 819-824. 10. McDonald JE, Herzog MM, Philippon MJ. Return to play after hip arthroscopy with microfracture in elite athletes. Arthroscopy 2013;29:330-335. 11. Grzybowski JS, Malloy P, Stegemann C, Bush-Joseph C, Harris JD, Nho SJ. Rehabilitation following hip arthroscopy: a systematic review. Front Surg 2015;2:21. 12. Cheatham SW, Enseki KR, Kolber MJ. Postoperative rehabilitation after hip arthroscopy: a search for the evidence. J Sport Rehabil 2015;24:413-418. 13. Voight ML, Robinson K, Gill L, Griffin K. Postoperative rehabilitation guidelines for hip arthroscopy in an active population. Sports Health 2010;2:222-230. 14. Malloy P, Malloy M, Draovitch P. Guidelines and pitfalls for the rehabilitation following hip arthroscopy. Curr Rev Musculoskelet Med 2013;6:235-241. 15. Spencer-Gardner L, Eischen JJ, Levy BA, Sierra RJ, Engasser WM, Krych AJ. A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement. Knee Surg Sports Traumatol Arthrosc 2014;22:848-859. 16. Domb BG, Sgroi TA, VanDevender JC. Physical therapy protocol after hip arthroscopy: clinical guidelines supported by 2-year outcomes. Sports Health 2016;8:347-354. 17. Ellsworth B, Patel H, Kamath AF. Assessment of quality and content of online information about hip arthroscopy. Arthroscopy 2016;32:2082-2089. 18. MacLeod MG, Hoppe DJ, Simunovic N, Bhandari M, Philippon MJ, Ayeni OR. YouTube as an information source for femoroacetabular impingement: a systematic review of video content. Arthroscopy 2015;31:136-142.
Purpose: To assess comprehensiveness and variability of postoperative physical therapy protocols published online following hip arthroscopy for femoroacetabular impingement (FAI) and/or labral repair. Methods: Surgeons were identified by the International Society for Hip Arthroscopy “Find a Surgeon” feature in North America (http://www.isha. net/members/, search August 10, 2016). Exclusion criteria included nonsurgeons and protocols for conditions other than hip arthroscopy for FAI and/or labral tear. Protocols were identified by review of surgeons’ personal and departmental websites and evaluated for postoperative restrictions, rehabilitation components, and the time points for ending restrictions and initiating activities. Results: Of 111 surgeons available online, 31 (27.9%) had postoperative hip arthroscopy physical therapy protocols available online. Bracing was used in 54.8% (17/31) of protocols for median 2week duration (range, 1-6 weeks). Most protocols specified the initial postoperative weight-bearing status (29/31, 93.5%), most frequently partial weight-bearing with 20 pounds foot flat (20/29, 69.0%). The duration of weight-bearing restriction was median 3 weeks (range, 2-6) for FAI and median 6 weeks (range, 3-8) for microfracture. The majority of protocols specified initial range of motion limitations (26/31, 83.9%) for median 3 weeks (range, 1.5-12). There was substantial variation in the rehabilitation activities and time points for initiating activities. Time to return to running was specified by 20/31 (64.5%) protocols at median 12 weeks (range, 6-19), and return to sport timing was specified by 13/31 (41.9%) protocols at median 15.5 weeks (range, 9-23). Conclusions: There is considerable variability in postoperative physical therapy protocols available online following hip arthroscopy for FAI, including postoperative restrictions, rehabilitation activities, and time points for activities. Clinical Relevance: This information offers residents, fellows, and established hip arthroscopists a centralized comparison of publicly available physical therapy protocols following hip arthroscopy. Practicing arthroscopists might find this analysis useful to compare various therapy strategies to their own recommendations. The variability we report can also provide inspiration for future efficacy research toward a more standard rehabilitation.
From the Division of Sports Medicine, Department of Orthopaedic Surgery, Rush University Medical Center (G.L.C., S.J.N.), Chicago, Illinois; Wayne State University School of Medicine (V.L., F.M.); Department of Orthopaedic Surgery, Henry Ford Hospital Detroit (V.L., F.M., D.C., E.C.M.), Detroit; and Department of Orthopaedic Surgery, William Beaumont Hospital (I.Z.), Royal Oak, Michigan, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Received December 16, 2016; accepted June 16, 2017. Address correspondence to Eric C. Makhni, M.D., M.B.A., Division of Sports Medicine, Department of Orthopaedic Surgery, Henry Ford Hospital, 2799 West Grand Boulevard, CFP-627, Detroit, MI 48201, U.S.A. E-mail: [email protected] Ó 2017 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/161266/$36.00 http://dx.doi.org/10.1016/j.arthro.2017.06.045
H
ip arthroscopy has experienced rapid growth over the past decade as an effective treatment for femoroacetabular impingement (FAI).1-4 The procedure involves osteochondroplasty to address bony cam and pincer morphology and labral repair when a tear is present. The procedure provides high rates of pain relief, improved function, and return to sports.5-8 Overall, a recent systematic review estimated that 87% of athletes returned to sport and 82% were able to return at the same level.9 In elite athletes, similar return-to-sport rates have been reported, with 84% return to play from hip arthroscopy for FAI and 77% for cases also involving microfracture.10 Successful recovery from hip arthroscopy for FAI may involve rigorous postoperative physical therapy, particularly in order to return to athletic endeavors.11,12
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Despite this, there is a lack of comparative literature and high-level evidence to guide postoperative rehabilitation from hip arthroscopy for FAI. Various rehabilitation protocols have been proposed in the literature.13-16 Recent systematic reviews on rehabilitation following hip arthroscopy have noted variability in protocols and the lack of comparative studies to guide rehabilitation.11,12 The purpose of this study is to assess comprehensiveness and variability of postoperative physical therapy protocols published online following hip arthroscopy for FAI and/or labral repair. We hypothesized that there would be considerable variability in protocols in terms of postoperative restrictions on weight bearing and range of motion, recommended rehabilitation activities, timeframes of rehabilitation activities, and return to sport.
Methods A search was performed to identify online available hip arthroscopy postoperative protocols for FAI or labral tear for surgeons in North America. The International Society for Hip Arthroscopy (ISHA) “Find a Surgeon” feature was used to identify hip arthroscopy surgeons in North America (http://www.isha.net/members/, search date August 10, 2016). This initial screening process identified 130 individuals. Next, the individuals’ departmental websites were manually searched to identify physical therapy protocols for rehabilitation following hip arthroscopy. A subsequent general Internet search was additionally performed (www. google.com) for any personal surgeon websites with online available hip arthroscopy rehabilitation protocols (search dates August 10-20, 2016). Exclusion criteria included nonsurgeons and protocols for conditions other than hip arthroscopy for FAI and/or labral tear. This search strategy identified 111 surgeons, of whom 27.9% (31/111) had postoperative hip arthroscopy physical therapy protocols for FAI available online (Fig 1). The majority of these protocols were procured from personal websites (23/31, 74%) primarily determined by identification of website copyright at the bottom of the webpage and cross-referenced to personal name in URL and webpage title. The remaining physical therapy protocols were published on institutional/ departmental websites. Furthermore, the information published in these personal or institutional websites also provided information as to which surgeons have completed fellowship training for hip arthroscopy. Protocols were evaluated for postoperative restrictions, which rehabilitation components were included, and the time points for ending restrictions and initiating activities. Time of suggested return to sport was assessed. A list of all rehabilitation parameters that were assessed is shown in Table 1. For each protocol component, we assessed whether the protocols
Members listed on ISHA website "Find a Surgeon" feature n = 130 Excluded: Physical therapists, researchers, or rered surgeons n = 13 Members who are acve surgeons n = 117 Excluded: Members without a personal or departmental website n=6 Acve surgeons with websites available online n = 111 Excluded: Surgeons without publicly available rehab protocols n = 80 Surgeons with published hip arthroscopy rehab protocol online n = 31
Fig 1. Flow chart for study search methodology to identify online available hip arthroscopy physical therapy rehabilitation protocols.
included or did not include the item. For initial postoperative restrictions and adjunct therapies, the times at which these commenced and were discontinued were both assessed. For rehabilitation activities, the time at which the patients could first begin that activity was evaluated (since generally no stop dates for these activities were specified). Statistical Analysis Fisher exact tests were used to compare categorical variables between individuals with and without online available physical therapy protocols for hip arthroscopy. For rehabilitation activities, the data were analyzed using descriptive statistics using median and range.
Results In general, timelines often accompanied postoperative instructions and rehabilitation exercises, creating a comprehensive protocol. Protocols containing general therapy guidelines (e.g., guidance on bracing,
VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS Table 1. Hip Arthroscopy Rehabilitation Protocol Elements Category Accessory postop therapy
Motion and weight bearing
Stretching
Strengthening
Proprioception
Functional testing Activity/sport
Protocol Elements Ice/CryoCuff/Game Ready, crutches, brace use, neuromuscular electrical stimulation, continuous passive motion Flexion/extension, abduction/adduction, external rotation/internal rotation, and weight-bearing considerations Prone lying, manual therapy, active release therapy, anterior capsule stretching, soft tissue mobilization, anterior/posterior/inferior glides Isometrics (quadriceps, glutes, etc.), hamstring curls, prone hip extension, tall kneeling, ½ kneeling, standing double leg 1/3 knee bends, step-ups, single/ double leg squats, lunges, single/double leg bridges, modified planks, planks Standing weight shift, backward/lateral walking, side stepping, single leg balance, slide board, retro walks with resistance Gait assessment Stationary bike, elliptical, hip rotational activities, agility drills, jogging/running, Alter G, cutting, plyometrics, sport specific drills
continuous passive motion [CPM] use, etc.) without explicitly stated time points were still included in our analysis. These comprised 7/31 (23%) of the protocols reviewed in this study. Characteristics of Individuals With Online Available Protocols Comparison of surgeons with online hip arthroscopy protocols available (n ¼ 31) to those without protocols available (n ¼ 80) revealed no differences in percentage with sports medicine fellowship training (27/31 [87.1%] vs 58/80 [72.5%], P ¼ .136) and percentage with adult reconstruction fellowship training (7/31 [22.6%] vs 14/80 [17.5%], P ¼ .592), but they did reveal a lower rate of pediatric fellowship training (0/31 [0%] vs 11/80 [13.8%], P ¼ .0324). There was no significant difference in the rate of people obtaining additional dedicated hip preservation fellowship training beyond their initial fellowship (11/31 [35.5%] vs 17/80 [21.3%], P ¼ .146). Postoperative Adjunctive Treatments and WeightBearing Restrictions Bracing was used in 54.8% (17/31) of protocols for median 2-week duration (range, 1-6 weeks; Fig 2).
3
Rationales for bracing included normalization of gait pattern while walking, hip protection, prevention of abduction and flexion/extension, and nighttime protection. Nighttime protection with the use of a hip brace or derotational boots was specified by 6/31 (19.4%) of protocols, for duration median 2 weeks (range, 1-2). Ice was specified by 18/31 (58.1%) of protocols for median 2.5 weeks (range, 1-8). Icing methods varied from dedicated ice machines and cold packs to bags of ice cubes. CPM was used in 16/31 (51.6%) of protocols for 3 to 6 hours per day for median 4 weeks (range, 2-4). E-STIM was included in 9/31 (29.0%) protocols for median 2 weeks (range, 1-4). Most protocols specified the initial postoperative weight-bearing status (29/31, 93.5%), most commonly partial weight-bearing with 20 pounds foot flat (20/29, 69.0%; Fig 3). Less common weight-bearing restrictions included touchdown weight bearing (4/29, 13.8%), weight bearing as tolerated (4/29, 13.8%), and nonweight bearing (1/29, 3.4%). The duration of weightbearing restriction was median 3 weeks (range, 2-6). In cases combined with microfracture, 10/29 (34.5%) protocols specified a prolonged weight-bearing restriction for median 6 weeks (range, 3-8). Postoperative Range of Motion Limitations All protocols (31/31, 100%) recommended immediate postoperative motion. The majority of protocols specified initial postoperative range of motion limitations (26/31, 83.9%), for median 3 weeks (Fig 4). Maximum flexion was specified in 17/31 (54.8%) of protocols, with median 90 (range, 60 -90 ) for duration median 3 weeks (range, 1.5-12). Maximum extension was specified in 15/31 (48.4%) of protocols, with median 0 (range, 0 -30 ) for duration median 3 weeks (range, 2-4). Maximum internal rotation was specified in 8/31 (25.8%) of protocols, with median 20 (range, 0 -20 ) for duration median 3 weeks (range, 3-5). Maximum external rotation was specified in 18/31 (58.1%) of protocols, with median 20 (range, 0 -30 ) for duration median 3 weeks (range, 2-6). Finally, maximum abduction was specified in 12/31 (38.7%) of protocols, with median 30 (range, 25 -45 ) for duration median 3 weeks (range, 2-4). A precaution of no active hip abduction was applied by 3/31 (9.7%) protocols for 4 weeks (range, 4-5). Stretching, Strengthening, and Proprioception There was substantial variation in the recommended rehabilitation activities and time points for initiating activities (Fig 5). Differences were even apparent with the wording used to indicate rehabilitation initiation, with 8/31 (26%) protocols recommending a specific postoperative day to start therapy, in comparison with other protocols outlining therapy initiation with more broad, weekly, time points (e.g., postop week 0 or
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G. L. CVETANOVICH ET AL.
% Protocols Reporng Inial Post-Operave Recommendaon
A
100 90 80 70 60 50 40 30 20 10 0 Bracing
B
Nighme protecon
Bracing
2
Nighme protecon
2
Ice
CPM
E-STIM
Fig 2. Immediate postoperative adjunctive treatments. (A) Percentage of protocols specifying each modality and (B) range of recommended duration with median and range are shown.
2.5
Ice
4
CPM
2
E-STIM 0
2
4
6
8
10
12
14
16
Range of Recommended Duraon (Weeks)
week 1). Initial rehabilitation starting immediately postoperatively focused on isometric quadriceps strengthening and anterior capsular stretching along with soft-tissue mobilization and manual therapy. Anterior capsular stretching was recommended in 3/31 protocols, with 2 of these protocols having a counterintuitive restriction in hip extension. Further investigation of these protocols revealed that anterior capsule stretching was initiated after the hip extension restriction. Hip rotational activities, standing weight shifts, and prone hip extension are added in the first 2 weeks. Fourteen additional activities for strengthening and proprioception were specified over the first 6 weeks postoperatively, with variation among protocols as to
which activities were recommended and at what postoperative time point they were prescribed. Return to Activities and Return to Sport Return to activities began with stationary bicycling at median 0 weeks. There was considerable variability in inclusion of these activities among protocols, as well as time at which patients were allowed to begin them (Fig 6). Progression occurred through walking, elliptical, agility, running, cutting/pivoting, return to sport specifics, and return to sport. Time to return to running was specified by 20/31 (64.5%) protocols at median 12 weeks (range, 6-19), and return to sport timing was specified by 13/31 (41.9%) protocols at median
5
VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS
% Protocols Reporng Weight-Bearing Restricon
A
100 90 80 70 60 50 40 30 20 10 0 WBAT
NWB
TDWB
PWB
B 3
No microfracture or not specified
6
Microfracture
0
2
4
6
8
10
Range of Recommended Duraon (Weeks)
Fig 3. Postoperative weight-bearing restrictions. (A) Percentage of studies suggesting each weight-bearing restriction are shown, with the postoperative weight bearing 20 pounds foot flat as the most common restriction. (B) Duration of weight-bearing restriction is shown with median and range.
15.5 weeks (range, 9-23). Advancement criteria for return to sport and return to sport specific training also varied. Protocols explicitly stating these criteria comprised only 32% (10/31) of the total reviewed, with only one protocol highlighting different criteria for different sports.
case series, generally involving 4- or 5-phase rehabilitation with initial weight-bearing and mobility limitations that varied among studies.12 Grzybowski et al. also performed a recent systematic review of 18 studies analyzing rehabilitation following hip arthroscopy, finding that rehabilitation programs were poorly reported and had considerable variability between surgeons.11 The results of the present study suggest that the variability in rehabilitation following hip arthroscopy found in these 2 recent systematic reviews of the published literature also applies to the online protocols published by a group of hip arthroscopy surgeons. These inconsistencies compel us to believe there is a need for future studies to compare various aspects of hip arthroscopy rehabilitation in order to generate evidence to guide treatment. Another potential cause of the variability and poor reporting identified in our analysis of online hip arthroscopy physical therapy protocols could be secondary to poor availability of online materials regarding rehabilitation. Some surgeons may prefer not to make these materials available publicly, or they may only publish limited rehabilitation guidelines online rather than their full protocols. In fact, the majority of surgeons identified on our search (72%, 80 of 111) did not have an online publicly available rehabilitation protocol following hip arthroscopy and were excluded
A 90
Flexion
0
Extension IR
20
ER
20
Discussion This study found that a minority of surgeons has a publicly available online physical therapy protocol for rehabilitation following hip arthroscopy for FAI. Furthermore, the protocols available online are highly variable regarding postoperative restrictions, postoperative adjunctive therapies such as bracing and CPM, and inclusion and timing of initiation of various rehabilitation activities, thus confirming our study hypotheses. Despite the importance of physical therapy to postoperative recovery and return to activities after hip arthroscopy, the literature contains limited data to guide rehabilitation after hip arthroscopy.11-16 These data consist primarily of Level IV and V evidence, and no comparative studies are available to our knowledge. Cheatham et al. recently systematically reviewed the literature on postoperative rehabilitation following hip arthroscopy, finding 6 studies that were case reports or
30
Abducon 0
20
40
60
80
Maximum Recommended ROM (Degrees)
B Flexion
3
Extension
3
IR
3
ER
3
Abducon
3 0
5
10
15
Range of Recommended Duraon (Weeks)
Fig 4. Postoperative range of motion restrictions including (A) maximum degrees for each motion and (B) duration of postoperative restriction.
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G. L. CVETANOVICH ET AL.
A
Isometric quadriceps exercises Prone lying and anterior capsular … SoŌ Ɵssue mobilizaƟon Manual therapy Hip rotaƟonal acƟviƟes Standing weight shiŌs Prone hip extension Tall kneeling and 1/2 kneeling with core Hamstring curls Single leg balance Single leg bridges Side steps Standing double leg 1/3 knee bends Double leg squat Posterior/inferior glides Forward step ups Modified planks Slide board exercises Planks Anterior glide Lunges
0 0 0 0 1
0
2 2 2.5 2.5 3 3.5 4
4 4 5 5 5 5.5 6 6 6 5
10
15
Start Date Range (Weeks)
% Protocols ReporƟng AcƟvity RecommendaƟon
B 100 90 80 70 60 50 40 30 20 10 0
accordingly. The increasing role of online information for hip arthroscopy and FAI generally have been evaluated in several recent studies that have found considerable variability in the content of online information about hip arthroscopy and FAI.17,18 From this study, we suggest that hip arthroscopy surgeons endeavor to make more information available online about hip arthroscopy rehabilitation, since this could help communication with therapists, patients, and other medical providers and potentially improve patient care.
20
Fig 5. Stretching, strengthening, and proprioception activities including (A) recommended start date for each activity with median and range and (B) percentage of protocols including each specific activity.
Limitations This study has several limitations. The search strategy of identifying members of the major hip arthroscopy association (ISHA) was chosen to avoid selection bias inherent in using an online search engine alone to identify surgeons. Although this method allowed us to avoid selection bias, it is probable that not all practicing hip arthroscopists are members of ISHA. Furthermore, the search was limited to North America in order to maintain consistency of protocols within similar health care systems. Therefore, the results may
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VARIABILITY OF HIP ARTHROSCOPY PHYSICAL THERAPY PROTOCOLS
A
Staonary Bike
Backward and lateral walking
0 2.5 3
Alter G
5 6.5
Ellipcal Retro walking with resistance
12 12 12 12 12
Agility Running Cung/Pivong Plyometrics Sport specific acvites
15.5
Return to Sport 0
5
10
15
20
25
Start Date Range (Weeks)
B % Protocols Reporng Acvity Recommendaon
Fig 6. Return to activities and return to sport, including (A) recommended start date for each activity with median and range and (B) percentage of protocols including each specific activity.
100 90 80 70 60 50 40 30 20 10 0
not apply to other regions of the world that were not analyzed. Also, as individuals from multiple backgrounds including sports medicine, pediatrics, and adult reconstruction perform hip arthroscopy, a search of a specialty society in any one of these areas would introduce bias as rehabilitation strategy might vary based on fellowship training background. Of note, fellowship training background was determined using the information that is published on a given surgeon’s personal or institutional website. Such information may be inaccurate, incomplete, and difficult to confirm without a centralized fellowship database. Our search strategy could introduce a different bias, since searching ISHA members with online available rehabilitation protocols might be biased toward surgeons with academic
practices or younger surgeons, for instance. In addition, no attempt was made to contact surgeons without online available protocols, since the goal of the study was to assess the rehabilitation recommendations that are publicly available online. The fact that a minority of surgeons in our sample have publicly available protocols is another limitation. It is difficult to elucidate what bearing these additional therapy protocols would have in regards to our results. This might indicate an area of further study that could involve a survey of ISHA members to further address practice patterns as they relate to physical therapy following hip arthroscopy. Furthermore, protocols generally did not differentiate between different procedures performed that could impact rehabilitation including capsular closure, labral
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repair versus debridement, and labral or capsular reconstruction. The exception was microfracture for which many protocols recommended prolonged weight-bearing restriction. Protocols were not analyzed to determine how many had videos accompanying therapy recommendations since this was a level of detail that was rarely included in the website that contained the physical therapy protocols. We feel that a study investigating the quality of rehabilitation protocols would be better suited to include analysis of video and picture demonstrations of exercises, as this addition could enhance the rehabilitation experience, from a quality standpoint, for patients and rehab professionals alike. Finally, the literature contains limited comparative studies on hip arthroscopy rehabilitation,11,12 as well as limited studies identifying optimal rehabilitation protocols following surgery, and therefore our analysis is unable to comment on whether the online protocols are in keeping with the best available evidence-based medicine.
Conclusions There is considerable variability in postoperative physical therapy protocols available online for hip arthroscopy for FAI, including postoperative restrictions, rehabilitation activities, and time points for activities.
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