Non-­‐Operative Care Package (NOCaP) Pathway Injection: •
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10 ml saline with 40mg Intra-­‐articular steroid Infiltrated under X-­‐ray or ultrasound guidance Permissible every 6 weeks, as required, with a maximum of 3 within the first five months Analgesia: Anti-­‐inflammatories and simple analgesics (paracetamol/codeine) will be taken as required for 5 months Physiotherapy/Activity Modification: •
Phase I: Pain and Activity modification Reduced • Activity modification to prevent terminal range/painful Flexion, activity/ IR and positions of impingement. demands on the • Avoid loaded rotation hip and pain • Avoid anterior directed forces/hyperextension control • Avoid straight leg raise • Assess safe ROM and adapt movement to within this range • Adapt ADL: zig-­‐ zag and wider running course instead of treadmill and narrow straight trails • Avoid cycling otherwise with leg in ER and raise seat to avoid excessive flexion • Avoid prolonged sitting with hip flexed and straight back, intermittently lean back while sitting • Change of player position which require decreased squatting to get ball, changing direction, volume of sports activity, footwear, surface Phase II: Active ROM Pain limits of • Identify pain free ROM limits, AROM within these limits movement, soft • Check for precision of hip movements tissue • Stretch techniques for restricted anterior and posterior restrictions structures Passive and home exercise for Iliopsoas, gluteal muscles, lumbar extensors: e.g. 4 point knee pendulum • Hamstring-­‐ passive knee extension • Hip ER and IR : supported kneeling/prone with knee bent, within limits of pain. Phase III: Muscle strength Address hip • Strengthen Abductors and ER to control of external force muscle moments on weight bearing. imbalance • Abduction weakness: Gluteus medius, minimus, TFL • ER strengthening for dynamic stability: Short ER, Gluteus maximus • Iliopsoas, Gluteus medius and maximus strengthening to counteract anteriorly directed forces on hip (particularly in patients with hyperextension) to reduce forces on labrum •
Gluteus maximus and medius weakness can lead to abnormal hip valgus. Hip valgus increases symptoms with labral pathology Phase III: Segmental stabilisation Address Transverse abdominis and multifidus isolated contraction and lumbopelvic lumbopelvic stabilisation exercises (eg. Bridging, crouching. Prone stability kneeling with ipsilateral extension) Phase IV: Stability and control progression Exercise To be undertaken only once hip stabilisers and global hip muscle control progression to regained include Progression to moderate exercises (lateral bridges, squats, lunges, side functional and shuffling with theraband, shuttle machine) activity, Progress from light advanced sensory motor training: use of swiss ball, proprioception wobble board, dyna disc, jumping bard Phase V: Return to activity and Cardiovascular fitness Functional and Retraining of hip stabilisers in loading positions and activity/sports sports related specific positions to ensure hip and pelvis control activity and Re address any areas of imbalance criteria for Cycling (with precautions in phase I) return to activity Swimming (avoid kicking) Cross trainer Jogging (with precautions in phase I) Return to sports guidelines (Kemp et al 2012: one leg performance and strength tests 90% of unaffected side, strength test indicate balance of muscle strength, protocol from Prof. Kim Bennell: return to specific sports) Duration of PT protocol and number of sessions Duration No of sessions FAIT 5 months, 22 weeks Up to 8 sessions