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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.
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Leve
l one 7. Quads stretch. Stand in a
good posture. Lumbar spine
neutral, trans abds engaged.
Bend one knee, bringing your
heel of your foot towards your
bottom, if you can, hold onto
the foot with your hand to
assist. You should feel a stretch
in the front of your thigh. Do not
hollow your back. Squeeze your
bottom gently to increase the
stretch.
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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
neutral, trans abds engaged.
Left foot pointing forward, right
foot pointing outwards. Bend
the right knee, keep left knee
straight. Keep your pelvis facing
forward. You should feel a
stretch in the inner thigh. Do
not stretch into pain. Repeat on
the opposite side.
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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
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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.
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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.
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