A FOUR-PHASE PHYSICAL THERAPY REGIMEN FOR RETURNING ATHLETES TO SPORT FOLLOWING HIP ARTHROSCOPY FOR FEMOROACETABULAR IMPINGEMENT WITH ROUTINE CAPSULAR CLOSURE

Abstract

Hip preservation surgery has become more common over the past decade and is now a preferred treatment modality for an increasingly diverse array of pathology in the young, active patient with hip pain. In particular, hip arthroscopy has become an increasingly popular treatment choice for active patients diagnosed with femoroacetabular impingement (FAI). Appropriate postoperative rehabilitation is critical for overall patient success and optimal long-term outcome. As surgical techniques continue to evolve, rehabilitation protocols must adapt to accommodate changes in the surgical procedure and ultimately provide the safest and fastest recovery of function for the patient. One such surgical modification has been the incorporation of routine capsular closure as part of the treatment of FAI in the young, active patient. The purpose of this clinical commentary is to present a four-phase rehabilitation protocol for returning to sport following arthroscopic correction of FAI with routine capsular closure.

Level of Evidence

5

INTRODUCTION

Femoroacetabular impingement (FAI) frequently presents in young and athletic patients, a population with a high expectations for return to sport and participation in recreational activities.¹ While initially managed conservatively, many patients eventually require surgery, with many orthopedists choosing arthroscopic correction of the bony deformities underlying FAI and repair of the soft tissues.^2-5 When indicated, hip arthroscopy for FAI is generally successful, with multiple authors reporting improved short and intermediate term outcome scores.^6-9 However, in addition to successful intraoperative management, optimal outcomes are predicated on skillful and thorough postoperative rehabilitation.¹⁰

Arthroscopic techniques have substantially advanced over the last two decades. For example, with regard to acetabular labral treatment options, labral debridement was the only option in the early 2000s; however, current labral treatment options now include labral repair and reconstruction. Over the past fifteen years, rehabilitation protocols have been developed to parallel advances in arthroscopic techniques, with many individual protocols previously reported.^10-20 In general, there are between four and five phases of rehabilitation, beginning immediately postoperatively, and extending to return to sport; however, the exact rehabilitation protocol varies between surgeons and surgical centers.²⁰ Rehabilitation following hip arthroscopy must take into account the higher physical demands that make this patient population unique from the typically older patients undergoing total hip arthroplasty (THA) and subsequent rehabilitation.¹⁹ Additionally, the role of capsular management in hip arthroscopy has received increased scrutiny, with some groups reporting improved clinical outcomes following routine capsular closure..^21,22 Given these findings, postoperative rehabilitation programs should be tailored to the individual to reflect evolving capsular management strategies. The purpose of this clinical commentary is to describe a four-phase physical therapy regimen for returning athletes to sport following hip arthroscopy with routine capsular closure for the treatment of FAI (Figure 1).

Figure 1.

4-Phase return to sport following hip arthroscopy with routine capsular closure for the treatment of femoroacetabular impingement.

SURGICAL PROCEDURE

The senior surgeon author is a high volume hip arthroscopist who has previously described his surgical technique.²³ Briefly, following appropriate in office work-up, diagnostic imaging, and failure of nonoperative treatment interventions including non steroidal anti-inflammatory medication, physical therapy, and corticosteroid injections, young, active patients with a diagnosis of FAI are indicated for arthroscopic treatment. Patients are placed in the supine position on a hip arthroscopy table with a well-padded perineal post (Figure 2A-B). Traction is applied and the central compartment is accessed via the anterolateral and modified anterior portals (Figure 2C). An interportal capsulotomy (approximately 2-4 cm) is performed to expose the acetabular rim. Once in the central compartment a diagnostic arthroscopy is performed and the labrum, chondral surfaces, and acetabular rim are treated. After work in the central compartment is complete, traction is released and the peripheral compartment is accessed. All patients undergo T-capsulotomy through the distal anterolateral accessory (DALA) portal to assist with arthroscopic visualization of the femoral neck. A femoral osteochondroplasty is performed in the peripheral compartment to address cam-type FAI (Figure 2D). Dynamic fluoroscopic examination is used to confirm complete bony resection and absence of residual deformity (Figure 2E). At the conclusion of the case, the entire capsulotomy is repaired with high-strength mattress sutures. The longitudinal portion of the T-capsulotomy is closed using three simple interrupted #2 high tensile strength sutures passed with a suture-shuttling device (Spectrum, Conmed Linvatec, Key Largo, FL). The interportal capsulotomy is subsequently closed with two simple interrupted #2 high tensile strength sutures in simple interrupted fashion using a capsular closure device (Injector, Stryker Sports Medicine, Greenwood Village, CO) (Figure 2F). The case is then completed with closure of the portals and the patient is transferred to the recovery with a brace designed to limit hip abduction and rotation.¹² Following discharge, postoperative rehabilitation begins immediately.

Figure 2.

Arthroscopic procedure for femoroacetabular impingement. Figure 2A: The patient is placed in the supine position with a well-padded perineal post. Figure 2B: The hip is distracted and the patient is prepared for surgery in sterile fashion. Figure 2C illustrates portal placement on a preoperative hip. Figure 2D demonstrates a cam deformity as seen through a T-capsulotomy. Figure 2E demonstrates a completed resection of the cam deformity. The completed capsular closure can be seen in Figure 2F.

REHABILITATION

A four phase rehabilitation protocol is followed to return patients to activity following hip arthroscopy with capsular closure. Criteria for advancement and common pitfalls are also presented.

Phase One: Protect the Joint

Phase one begins postoperatively with the goals of joint healing and achieving symmetrical range of motion by 6-8 weeks assuming no dysfunction of the contralateral nonsurgical lower extremity (Table 1). Initially, the patient is restricted to 20-pound foot-flat weightbearing. The restriction in weightbearing is related to reports of postoperative femoral neck fracture following femoral osteochondroplasty (CAM resection).²⁴ Flat-foot weightbearing is preferred over toe-touch weightbearing due to concerns of Achilles contracture, hip flexor contracture, and lower extremity stiffness related to consistent ankle plantar flexion. Initial range of motion is limited to 90 º of flexion, 30 º of external rotation, 20 º of internal rotation with 90 º of hip flexion, and 30 º of abduction. Importantly, active open chain hip flexor activation should be avoided and extension should be limited to neutral, particularly in the presence of capsular repair.²⁵ Additional precautions include no active straight leg raises and no sitting for longer than 30 minutes at a time. For the first physical therapy visit on postoperative day one, the upright stationary bike is started for 20 minutes with no resistance. The patient is trained on the usage of the brace and the continuous passive motion (CPM) device. Additionally, the patient and caregiver are instructed on passive range of motion maneuvers including hip circumduction in neutral as well as 20 º to 30 º of flexion, and log rolls. Isometric exercises focusing on quadriceps, gluteal, and transversus abdominis (TA) activation are also emphasized. A home exercise program for the first two weeks, if possible, includes 20 minutes of an upright stationary bike, three hours of CPM usage (four hours if a bike is unavailable), passive range of motion exercises for 20 minutes and 20 repetitions of the isometric exercises twice each day. Passive range of motion maneuvers are important for decreasing postoperative stiffness and the development of adhesions while isometric exercises have the advantage of preventing muscular atrophy and hip flexor tendonitis.^19,26 Additionally, Voight et al. found gluteal isometrics valuable for preventing iliopsoas (IP) spasms and decreasing anterior hip pain.¹⁰ The patient is also encouraged to lie prone for two hours per day to prevent hip flexion contractures.^27,28

Table 1.

Phase One Rehabilitation

Phase 1
Week(s)	1-6
Goals	Protect Joint/Avoid Irritation
	Symmetrical ROM by 6-8 weeks
Visit Frequency	2x/Week
Hip ROM Restrictions	90 ° Flexion (x2 weeks)
	30 ° Abduction (x2 Weeks)
	0 ° Extension (x3 Weeks)
	30 ° ER at 90 ° Flexion (x3 weeks)
	20 ° IR at 90 ° Flexion (x3 weeks)
	20lb FFWB (x3 weeks)
	No Sitting > 30minutes (x3 weeks)
	No Active lifting of surgical lower extremity (x4 weeks)-to avoid
Techniques
	Manual therapy 20-30 minutes/session (xWeeks 1-6) Supine Soft Tissue Mobilization with a focus on TFL, IP, and QL Passive Range of Motion including supine abduction, flexion, prone IR/ER, and supine circumduction in neutral, and 90 ° Hip Flexion
	Isometrics Exercises (quadriceps, adductors, gluteals, supine TA) (xWeeks 1-2)
	Clams/Reverse Clams (xWeeks 1-3)
	TA activation with bent knee fall outs (xWeeks 1-3)
	Prone hip external and internal rotation, hamstring curls
	**Exercises and manual therapy are to be practiced at the clinicians discretion but are not to exceed patient fatigability

ROM: Range of Motion; ER: External Rotation; IR: Internal Rotation; FFWB: Flat Foot Weight Bearing; TFL: Tensor Fascia Lata; IP: Iliopsoas; QL: Quadratus Lumborum; TA: Transversus Abdominis; LBP: Lower Back Pain

At each physical therapy visit in this stage, the patient begins on the upright stationary bike for 20 minutes followed by soft tissue mobilization (STM) for 20-30 minutes. Exercises at this stage include but are not limited to TA activation with bent knee fallouts, clamshell exercises, quadruped rocking, bridging progressions, and prone hip external and internal rotation (Figure 3). STM is designed to mobilize scar tissue and prevent soft tissue contractures with emphasis placed on the adductor musculature, quadratus lumborum (QL), tensor fascia lata (TFL) and iliopsoas (IP) (Figure 4). Additionally, the authors have found that resisted standing shoulder extension and alternating scapation, when combined with gluteal isometric activation is useful for improving core recruitmentand stability in a closed chain position (Figure 5). As Phase one progresses, the patient is weaned from crutches beginning at three weeks postoperatively, unless microfracture was performed in which case crutches are maintained until the six-week time point. Common pitfalls in this Phase include prolonged postoperative inflammation of soft tissue structures including the hip capsule and nearby musculature, hip flexor tendonitis, and lower back and sacroiliac joint pain. Lower back pain can often be managed with increased QL STM and avoidance of pelvic torsion. Hip flexor tendonitis often arises following premature active open chain hip flexor activation, and is commonly seen with toe touch or non-weightbearing gait patterns.²⁶ Compensatory gait patterns are often responsible for postoperative lower back pain (LBP) and hip flexor tendonitis, making patient education on postoperative ambulation critical to a successful recovery.

Figure 3.

Exercises involved in Phase one of rehabilitation. Clams (A), knee fall outs with elastic support (B), bridging progressions (C-F), prone internal rotation (G), and prone external rotation (H).

Figure 4.

Soft tissue mobilization strategies. STM is particularly useful in Phase one for the adductor musculature (A-B), iliopsoas (C), and quadratus lumborum (D).

Figure 5.

Core strengthening exercises in Phase one include standing shoulder extension and alternating scapation with core and gluteal isometric activation.

While the authors do not employ formal criteria for advancement, the patient must demonstrate proper ambulation with a non-compensatory gait, and is encouraged not to push through pain in order to speed rehabilitation time. Further, the patient should demonstrate pain control, decreased edema, adequate strength and preparedness for ambulation without an assistive device. In addition, the patient must have adequate proximal control and the ability to advance to closed chain exercises. Gait related restrictions that preclude progression include pain, a Trendelenberg, or compensated Trendelenberg gait, the presence of a trunk shift, and inadequate proximal control of the abdominal and lower extremity musculature. While specific criteria for advancement varies across institutions, there is general agreement that the patient should be in minimal pain, and ambulate without gait compensation, and display near normal range of motion with the contralateral leg before progressing to Phase two.^17,20

Phase Two: Return to Full Weight Bearing

The goal of Phase two is to ensure the transition to full weight bearing progresses in a steady manner without the onset of deleterious compensatory strategies. (Table 2) The authors have found that the most difficult aspect of this phase is successfully weaning the patient off crutches. Aquatic therapy can assist in getting patients off crutches and can be started in week three, provided that the surgical incisions are completely healed. While not a requirement for the rehabilitation protocol, aquatic therapy can be utilized as a supplement in the early stages of Phase two to improve mobilization and neuromuscular control as well as correct gait.²⁹ Other exercises in the early stages of this Phase include quadruped rocking and alternating shoulder flexion with hip extension, standing weight shifts in all directions, standing double leg knee bends (mini-squats), prone hip extension, and tall kneeling with an emphasis on core activation for all exercises (Figure 6). Additionally graded joint mobilization can begin with posterior and inferior glides beginning in week five (Figure 7). Importantly, STM for at least 20 minutes per session is continued through this phase in order to treat specific ROM limitations, prevent soft tissue irritation and tendonitis, and mobilize scar tissue around the portal sites.

Table 2.

Phase Two Rehabilitation

Phase 2
Weeks	3-10
Goals	Non Compensatory Gait progression
Visit Frequency	2x/Week
Techniques
	Begin aquatic therapy (xWeek 3 if available and incisions are healed) Exercises include heel raises, side steps, UE exercises for core activation and mini squats.
	Continue manual therapy techniques
	Standing weight shifts a/p and side to side (xWeeks 3-4)
	Backward and lateral walking (xWeeks 3-4)
	Standing double leg knee bends (xWeeks 3-4)
	Prone hip extension (xWeeks 3-5)
	Tall kneeling exercises (xWeeks 3-6)
	Begin elliptical forward and reverse with no resistance (xWeek 6)
	Joint mobilization (xWeeks 6-10)
	Advance double leg squat (xWeeks 6-10)
	Forward step ups-beginning at 0.2 meters and advancing vertically as tolerated to 0.5 meters (xWeeks 6-10)
	Modified planks and side planks with oppositional movement (xWeeks 6-10)

Figure 6.

Exercises for the early stages of Phase two include rocking and alternate lower extremity extension and shoulder flexion in the quad position (A-B), core activation with half kneeling (C), and weightbearing isometric gluteus medius activation (D).

Figure 7.

Posterior and inferior joint mobilization can begin in Phase two of rehabilitation with inferior belt femoral glide (A), lateral to medial/inferior femoral glide (B), and medial to lateral femoral glide (C).

The second half of Phase two is designed to transition the patient to Phase three. It begins at week 6 with the introduction of both forward and backward elliptical training starting at low resistance for short durations. Additional exercises in the latter stage of this phase include single leg balancing with isometric abduction of the nonsurgical limb, eccentric psoas exercises, pole walks, internal oblique pulls, weightbearing hip internal and external rotation, functional walks with co-contraction of the core, gluteals, and gastrocnemius, as well as single leg stance with contralateral hip flexion and extension (Figure 8). One major pitfall of this phase is over-activation of the hip musculature as the patient gradually increases activity and hip range of motion. One specific example is with the development of hip flexor tendonitis, where weakness in the iliopsoas following arthroscopy results in hyperactivation and irritation of secondary hip flexors such as the rectus femoris, tensor fascia lata, and sartorius.¹⁵ These pitfalls can be minimized with STM at each therapy session as well as tactile and verbal cueing during exercises to promote proper muscle activation and technique. The patient can progress to Phase three when they are able to successfully demonstrate good proximal and distal control, avoid compensatory movements secondary to fatigue, and have minimal pain (pain 1-2 points higher than baseline on a 1-10 scale) throughout the entirety of the therapy session.

Figure 8.

Later in Phase two, rehabilitation exercises begin to incorporate more functional movement about the hip. These include single leg balance of the surgical side with isometric abduction of non-surgical side (A), single leg stance with contralateral hip flexion and extension (B-C), functional walks with co-contraction of the core, gluteals, and gastrocnemius (D), and pole walks (E-F).

Phase Three: Return to Pre-Injury Function

Phase three is designed to return the patient to their pre-injury functional level with emphasis placed on dynamic exercises in all hip motion planes (Table 3). Lasting generally from weeks 8-16, it is more individualized than Phases one and two, and can last longer for patients with higher demands on their hip. In this phase, lunges, split squats, side steps, and retro-walks are instituted to complement the single leg balance, squat, and trunk rotation carried over from the end of Phase two. Joint mobilization and STM are continued on an as needed basis to manage isolated cases of pelvic malalignment, muscle over-activation and used to prevent tendonitis. Additional exercises at this stage include side planks with opposite lower extremity tri-planar motion, resisted squats with Theracord rows, and core roll ups without flexor activation (Figure 9). Later in this phase, hip rotational exercises are introduced, while agility drills are deferred until Phase four.

Table 3.

Phase Three Rehabilitation

Phase 3
Weeks	8-16
Goals	Return to pre-injury level
Visit Frequency	2x/Week
Restrictions
	Avoid agility drills until week 16
	Avoid weight bearing hip rotational activities until week 10
	Avoid treadmill walking until week 12
Techniques
	Manual Therapy as needed
	Side steps and retro walks with resistance (xWeeks 8-16)
	Single leg balance-squat, trunk rotation (xWeeks 8-16)
	Planks and side planks (xWeeks 8-16)
	Single leg bridges (xWeeks 8-16)
	Weightbearing hip rotational activities (xWeeks 10-16)

Figure 9.

Exercises for Phase three include introducing rotational elements into hip motion (A-B), as well as Theracord assisted squats (C-D).

A treadmill walking program can begin at week 12, which can also be supplemented by light running using the Alter-G M320 anti-gravity treadmill (AlterG, Fremont CA). The Alter-G is a valuable addition to the rehabilitation regimen as both velocity and bodyweight percentage can be independently controlled (Figure 10; . This allows the patient to start running at reduced bodyweight earlier on in the rehabilitation timeline. This can function as an augment to the patient's cardiovascular fitness, accelerate the patient's neuromuscular reeducation following surgery, as well as improve the patient's confidence while running.^30,31 By only altering one variable at a time, either bodyweight or velocity, the therapist can slowly and safely advance the patient to return to run while being careful to watch for compensatory running patterns. In a pilot study evaluating return to run following Achilles tendon repair, Saxena et al. reported that the Alter-G allowed patients to progress to full weight bearing and running two weeks sooner than with the treadmill alone.³¹

Figure 10.

Triple Extension during running in Phase four.

The most common pitfalls during this phase result from rushing to return to activity. These pitfalls can manifest as decreased soft tissue mobility, recurrence of gait or running abnormalities, increased reports of pain, hip girdle tendonitis, or recurrence of pelvic malalignment. To prevent these setbacks, the therapist should watch for the presentation of increased femoral internal rotation, excessive pronation, hip drop/genu valgus, as well as an unequal arm swing as running is increased. If these deleterious motions are observed, running progression can be slowed to prevent the onset of compensatory and counterproductive running mechanics. The patient can progress to Phase four when they are able to complete all of the Phase three exercises without pain and can maintain good proximal and distal control with both running and other functional activities.

Phase Four: Return to Running and Sport

The goal of Phase four is to return the patient to full participation in their sport or recreational activity, focusing in particular on power, endurance, and agility (Table 4). While this phase is often tailored to be sport specific for each athlete, common exercises include box jumps, lateral cutting, scissor jumps, and single leg squats. Most institutions recommend that the patient be able to pass a series of functional return to sport tests where the patient is able to consistently display pain free running, jumping, lateral agility drills, and single leg squats.³² While the authors do not require a formal return to sport test to pass Phase four, a thorough return to running evaluation beginning at 16 weeks in an anti-gravity treadmill (AlterG; Fremont, CA) or 20 weeks on a standard treadmill. To progress to running, the patient must be able to demonstrate completely asymptomatic gait as well as the ability to complete all Phase three exercises without excessive fatigue. Advantages of the AlterG include the ability to identify and correct incorrect or compensatory running movements in a limited weight-bearing setting. For running evaluations, it is important for the therapist to witness triple extension with full body weight bearing running. Triple extension includes concurrent hip extension, knee extension, and ankle plantar flexion and is necessary for a powerful push off with running. Hip extension is particularly important to ensure adequate stride length and maintain the hip in a relatively neutral position. Verbal and tactile cues should be employed by the therapist to ensure the patient's running form is mechanically sound.³³ Common deficits include Trendelenburg and compensated Trendelenburg with single leg squatting, and a valgus knee angle with lateral agility testing.

Table 4.

Phase Four Rehabilitation

Phase	4
Weeks	16-32
Goals	Return to sport
Visit Frequency	2x/Week
Restrictions	Assess functional strength and proximal control prior to advancing to Phase four
Techniques
	Running-can start in alter G at 16 weeks, non-alter G at 20 weeks
	Agility (xWeeks 20-32)
	Cutting (xWeeks 24-32)
	Plyometrics (xWeeks 24-32)
	Return to sport specific exercises (xWeeks 24-32)

Table 5.

Criteria to advance

	Criteria to Advance
1	Strength and preparedness for ambulation without an assistive device
	Good pain control
2	Good proximal and distal control during exercises
	No compensatory movements secondary to fatigue
	Minimal pain during therapy sessions (pain 1-2 points higher than baseline on a 1-10 scale)
3	Complete all Phase 3 exercises without pain
	Maintain good proximal and distal control with running and functional activities
4	Pass running assessment in Alter-G or treadmill
	Pass return to sport functional test(s) as applicable

Table 6.

Pearls/Pitfalls of rehabilitation following hip arthroscopy for FAI.

Phase	Pearls	Pitfalls
1	Do not stress anterior capsule for 6 weeks	Capsule Stiffness Hip Flexor Tendonitis LBP from compensatory movements Exceeding patient fatigability
2	Provide tactile and verbal cueing to enable non-compensatory gait Advance exercises only as patient exhibits good proximal control with previous exercises Hold all weight bearing exercises until week 6 if microfracture was performed Do not force hip flexion, extension, and external rotation Can incorporate belt mobilization into manual therapy	Compensatory movements in gait due to pain, fatigue, or joint restrictions Premature wean from crutches Gait abnormalities Hip adductor and tensor fascia lata over-activation Decreased hip extension during exercises and ambulation
3	Continue to treat specific range of motion limitations as needed Focus on functional exercises Advance exercises only if patient shows good neuromuscular control	Gait abnormalities or pelvic mal-alignment
4	Muscular over activation during activity	Performance of running analysis prior to cutting/agility Phase 4 exercises

DISCUSSION

Rationale for Capsular Closure

Historically, the treatment of many conditions of the hip required an open surgical procedure; however, over the last two decades open procedures have largely be replaced with arthroscopic procedures. These arthroscopic techniques, in general, have not placed emphasis on the treatment of the hip capsule. In the case of arthroscopic FAI treatment, most of the early descriptions detailed extended capsulotomies and even capsulectomies for adequate visualization of femoral-sided cam deformities.³⁴ Only recently has more attention been paid to the capsule during arthroscopic treatment of hip conditions.^21,35 The current protocol was developed using multiple expert opinions and clinical commentaries on hip arthroscopy rehabilitation as guides.^{14,15,19,26,27,36} Additionally, clinical practice guidelines have been published for non-arthritic hip pain by the Orthopedic Section of the American Physical Therapy Association.³⁷ The present commentary outlines a rehabilitation protocol for a high volume hip arthroscopy center similar to what has been presented in the literature in terms of general rehabilitation time frame and Phased postoperative progression. Modifications to previously existing rehabilitation protocols include techniques designed to address the closed hip capsule following arthroscopic correction of FAI.

In arthroscopic treatment of hip conditions without capsular closure, iatrogenic instability caused by non-repaired capsulotomy or capsulectomy has become an increasing concern.^38-41 Recently, there have been case reports of hip dislocation and subluxation following arthroscopic surgery for FAI without capsular repair.^42-45 Capsular defects following hip arthroscopy have now been reported as one of the causes necessitating revision surgery for continued pain and/or instability.⁴⁶ The clinical importance of capsular repair has been illustrated by Frank et al. as they demonstrated increased sports specific activity following hip arthroscopy for FAI with complete capsular repair compared to partial capsular repair.²¹ Additionally, Wylie and colleagues have recently reported on 33 cases of symptomatic instability after hip arthroscopy without capsular repair and improvement in patient reported outcomes two years after revision hip arthroscopy in which the capsule was completely closed.²² These previous authors concluded that the contemporary treatment of FAI should include central compartment chondrolabral repair, surgical correction of osseous FAI, as well as complete capsular closure to optimize hip functional outcome and return to athletic activity. The clinical evidence stressing the importance of hip capsule integrity has also been corroborated with numerous biomechanical studies.^47-50

Modifications to Rehabilitation Following Capsular Closure

Following capsular closure, an emphasis is placed on protecting the anterior capsule and labrum, as strain on these structures with excessive hip flexion or hip extension past neutral the can impair healing.²⁵ Graded joint mobilizations are an important addition to the rehabilitation protocol as it promotes safe hip range of motion while minimizing the risk for postoperative stiffness and contracture. If the capsule is left open, mobilization is contraindicated due to the risk of increased pain and the potential for iatrogenic instability manifesting as hip subluxation or dislocation.⁴⁵ With capsular closure however, hip joint mobilizations are recommended to prevent excessive capsular stiffness, muscular guarding, and postoperative pain.²⁸ Mobilizations begin with Grade I and progress through Grade III as tolerated. Mobilizations include inferior manual or belt assisted femoral glides, anterior to posterior femoral glides, lateral to medial femoral glides, medial to lateral femoral glides, and posterior to anterior femoral glides (Figure 7). Grade IV-V mobilizations are contraindicated to avoid excessive capsular laxity following arthroscopic closure (Table 7). As patients have varying degrees of preoperative capsular laxity, before undergoing a mobilization protocol, the therapist should discuss with the surgeon the quality of the capsular intra-operatively, as well as the state of repair. Repercussions following inadequate joint mobilization following capsular closure include gait deficit, decreased range of motion and a delayed return to sport. Graded joint mobilization is commonly used in the conservative management of FAI with an intact capsule, and we have found that following capsular closure, mobilization techniques reduce postoperative joint hypomobility and improve rehabilitation progression.⁵¹

Table 7.

Graded Joint Mobilization

Grade	Description
I	Small amplitude movement at the beginning of the available ROM
II	Large amplitude movement within the available ROM
III	Large amplitude movement that reaches the end ROM
IV	Small amplitude movement at the very end range of motion
V	High velocity thrust of small amplitude at the end of the available range and within its anatomical range (manipulation)

Return to Activity and Sport

Return to sport is an important outcome measure for the young adult population undergoing hip arthroscopy for FAI and can be complicated by rehabilitation setbacks. To return to high intensity athletics, the patient must be able to demonstrate adequate high velocity and low velocity strength capable of explosive power generation.²⁶ Currently, there is limited data regarding validated return to sport assessments specific to hip arthroscopy, however the Vail Hip Sports Test ™, a modification of the Vail Sport Test ™, has been used as a functional assessment for returning to sport following hip arthroscopy.^18,52 Scored out of a maximum of 20 points, exercises include single leg squats for 3 minutes (6 points; 1 point every 30 seconds), lateral and diagonal bounding for 100 seconds each (5 points; 1 point every 20 seconds), and a forward box lunge for 2 minutes (4 points; 1 point every 30 seconds). The Tuck-Jump test is another functional assessment designed for ACL rehabilitation that has also been modified for the hip arthroscopy population.¹⁸ While useful to assess overall athletic competence, hip specific tests that take into account the unique rotational profile of the joint may be more advantageous to assess return to sport in the future. It has been the authors’ experience that patients are ready to begin return to sport activities once they successfully demonstrate treadmill running with correct form and minimal fatigability.

CONCLUSION

Appropriate postoperative rehabilitation is critical for overall patient success and optimal long-term outcome. As surgical techniques continue to evolve, rehabilitation protocols must adapt to accommodate changes in the surgical procedure and ultimately provide the safest and fastest recovery of function for the patient. One such surgical modification has been the incorporation of routine capsular closure as part of the treatment of FAI in the young, active patient. This clinical commentary details the authors current four-phase physical therapy program and the modifications made to incorporate the addition of capsular closure to the treatment of FAI. Following a step-wise approach including joint protection, progression to full weightbearing, addressing strength and function, and performing sport-specific rehabilitation will prepare an athlete for the safe and expedient return to sport following hip arthroscopy for the treatment of FAI.