hydrotherapy exercises following hip arthroscopy surgery

Hydrotherapy exercises

following hip arthroscopy

surgery

By Louise Grant MCSP

Hip Specialist Chartered Physiotherapist

Copyright Jan 2011

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INTRODUCTIONEssential criteria before

commencement of hydrotherapy –1. Surgical wounds must be fully

healed so there is no infection

risk.

2. 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.

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EXERCISE TECHNIQUESWith 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.

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EXERCISE TECHNIQUESNext, 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.

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EXERCISE TECHNIQUES

The term ‘trans abds engaged/core

engaged’ is used in the exercises. This

refers to the the transversus abdominis

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.

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EXERCISE TECHNIQUES

With your pelvis in neutral,

transversus abdominis 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.

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HYDROTHERAPY PRINCIPLES• Being deeper in the water will be

more supportive to the body

when doing level one exercises.

• 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.• Floatation aids can be used to

increase buoyancy on the surface

of the water. However, if they are

used under the surface, they can

be used for resistance work.

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CONSIDERATIONS

* When you are exercising in water,

some of the exercises may feel easy.

Be cautious, and start with a 10-20

minute session and observe the after-

effects. It may be more tiring than

expected.*Build up the sessions gradually so

pain is not provoked.*Every patient is different, and so it is

important to liase with your

physiotherapist how often you should

do the hydrotherapy exercises and for

how long and at which level.

*The number of repetitions and the

length of time you hold the stretches

in this guide, should be dictated by

your physiotherapist.*As with every exercise program,

some exercises may need to be

modified to suit the individual.

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one

•Wounds healed.•Patient may still be on elbow crutches, partial weight bearing.

•Early range of movement stage.

Level two

•Full weight bearing, no elbow crutches.•Increase range of movement.•Balance, posture, proprioceptive, strength and core stability work.

Levelthree

•Increase flexibility.•Increase strength and endurance with cardio vascular challenges.

•Advanced proprioceptive and core stability work.

•Sports specific skille.

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LEVEL ONE Aims – • To encourage early stage

gentle mobilisation of the hip,

pelvis and lumbar spine

without provoking pain.

• To introduce early core

control/lumbo-pelvic stability

and proprioceptive exercises

of the hip and pelvis.

• To mobilise the thoracic and

shoulder area which can

become stiff from the use of

elbow crutches.

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l one

1. Pendular hip movement,

flexion/extension. On tip toes

on unoperated side, so

operated leg is hanging

relaxed, gently move

operated leg backwards and

forwards in a painfree range.

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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.


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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.


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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 posture and

keeping ankles ‘strong’ and

straight, not allowing them

to rotate.


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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.


Leve

l one 7. Quads stretch. Stand in a

good posture. Lumbar spine


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.


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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.


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9. Adductor stretch. Standing in

a good posture, lumbar spine


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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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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.


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LEVEL TWOAims –• To encourage symmetry of

movement in function.

• To increase range of movement

and add in rotation challenges.

• To re-educate gait, posture,

balance, proprioception.

• To progress strengthening

without provoking pain.

• To have a ‘whole body

approach’ in addressing other

areas of the body affected.

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1. Supine floating. Lie in the water

on your back, supported by

floatation aids. Perform a cycling

movement with your legs.

Remember to engage your trans

abds, keep good pelvic and spine

control. Only do the range of

movement and speed that is

painfree.


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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.


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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.


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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.


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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.


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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.


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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.

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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.


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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.


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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.


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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.


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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.


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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.


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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.


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LEVEL THREEAims –• To increase cardio vascular

work.• To perform advanced

flexibility, core stability,

strength and proprioceptive exercises.

• To introduce sports specific

skills.• To introduce swimming.

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1. Lunges. Standing. One leg in

front, one behind, feet, knees, hips

facing forward. Spine neutral, core

engaged, gluteals gently squeezed.

Bend front knee over toes, and

bend the back knee keeping good

alignment and control. Easy version

is to do holding onto pool side,

progress by adding in balance

challenges and advancing with

‘walking lunges’ and increasing

speed and changing directions of

movement.


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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.


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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.


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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.


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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 control and alignment of leg

throughout. Try different speeds of

movement, balance challenges by

reducing hand contact on pool side

and woggle length.


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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.


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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.


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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.


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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.


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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..

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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

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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.


Ack

now

ledgem

ent s

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.


http://www.physiocure.org.uk/

hydrotherapy exercises following hip arthroscopy surgery

Health & Medicine

hydrotherapy exercises

body weight

body awareness

upper body

body alignment

lumbopelvic neutral

early stage exercises

hydrotherapy exercise