FAI Surgery Rehabilitation - Part 3

In parts one and two of this blog we reviewed the pre-operative, early postoperative, and middle-stage rehab phases of FAI surgery. Part three will cover three key milestones in returning to sport: jumping, running, and return to sport clearance. While there are a number of other sport-related milestones, we’d like to highlight these because we receive the most questions about them throughout the rehab process.

Based on the previous blogs, it should be apparent that the variability in post-operative protocols has resulted in a lack of consensus on when to return to higher impact movements like jumping and running in rehab. As is common practice, we often look to the ACL reconstruction literature to guide our decision making because of the relatively higher quantity and quality published, but we need to recognize two foundational limitations:

1. The hip is not the knee. This sounds like an obvious statement, but the roles of the hip and knee differ in the direction and application of forces during athletic movements.
2. Time frames for tissue healing considerations and injury mechanisms are different between ACL reconstructions and labral repairs.

With that said, many post-operative protocols have traditionally used “progression as tolerated” and/or 8-12 weeks to return to impact activities like jumping and running. While symptom tolerance is important in ruling out those who aren’t ready for these progressions, the absence of symptoms alone may not reliably predict who will be successful returning to jumping and running. The risk of progressing to these activities too soon is often a time-based setback in rehab, so our goal is to be as objective as possible with our criteria.

Returning to Jumping

In regards to returning to jumping, it should be recognized that the volume, intensity, frequency, and type of jump matters. Clearly not all jumps are created equal in this regard, as a maximal effort broad jump and low effort pogo jump place distinctly different demands on the hip. Stiff, reactive jumps like the pogo will be more ankle dominant and easier to tolerate earlier in the rehab process. These can be thought of on the progression from extensive to intensive; quick ground contact times with low (extensive) to high (intensive) height focus. Comparatively, explosive vertical and broad jump variations have higher, though different, demands on the hip. The hip is responsible for about one third of the propulsion and landing forces during a vertical jump, while managing nearly half of the propulsion and a quarter of the landing forces during a broad jump.¹ Given an appropriate time after surgery (at least 8 weeks), we use the following criteria to progress to a low starting volume and intensity of jumping:

The peak load on the hip will then be dictated by the intensity (sub-maximal versus maximal) and type (double leg versus single leg) of jump. In general, our plyometric progression criteria follow a few simple rules:

1. Sub-maximal before maximal
2. Double leg before single leg
3. Low hip ROM before high hip ROM
4. Low volume before high volume

Returning to Running

Most post-operative protocols recommend between 3-5 months to return to running, but individuals may not successfully return to running until the 8-9 month mark, and when they do it will still be at a lower volume than before injury to start.^2,3 The physical demands of running on the hip are not negligible; the stabilization demands on the hip abductors during easy running are relatively high at 4-5 times body weights, which is third only to the soleus and quadriceps.^4,5 As we increase our running speed towards sprinting, other hip muscles like the flexors and glute max may see up to a 4 times increase in loading. All of that to say, if the hip hasn’t been prepared for this type of loading, returning to run will not be successful initially. We use a modified criteria for returning to run, both adapted from ACL literature and hip demands during running:⁶

Following two weeks of jumping prep, we begin a run/walk interval program with a goal of gradually extending run time and reducing walk time. The individual’s ability and prior level of activity will strongly dictate the exact progression.

Returning to Sport

Return to sport criteria following FAI surgery is also not well-defined, with a recent systematic review noting 54.5% of studies have not provided guidelines on return to play duration and the remaining 45.5% have recommended 4 months or less.⁷ Given that the average return to sport time is 7.5 months, time-based criteria alone does not appear to accurately predict return to sport success.⁸ Conceptually, return to sport testing is more accurate at identifying individuals that aren’t ready to return to sport than those who are ready. Because our tests represent the simplified “best-case scenario” in a closed environment, they don’t fully represent the chaotic nature of sport. As such, when an individual doesn’t pass the tests in the best-case scenario, there’s a very good chance they’ll do the same or worse as things become more complicated. Different sports, individual athletes, and levels of competition will necessitate a different battery of return to sport tests as well. Below is an example of a return to sport testing battery that we use for ice hockey athletes following FAI surgery:

It should also be noted that the expectations of returning to sport versus returning to pre-injury “normal” need to be managed following FAI surgery. While most individuals will see improvements after surgery through a year, not everyone will return to their pre-injury baseline level of pain or sport performance.⁹ In these cases, the goal will shift to adapting to the new “normal” and focusing on modifiable factors in training through specific and general exercise recommendations.

We hope this blog series on FAI surgery was helpful for you!  As always, if you need guidance with hip pain, please reach out to us!

References:

1. Kotsifaki A, Korakakis V, Graham-Smith P, Sideris V, Whiteley R. Vertical and horizontal hop performance: contributions of the hip, knee, and ankle. Sports Health. 2021;13(2):128-135.
2. Levy DM, Kuhns BD, Frank RM, et al. High rate of return to running for athletes after hip arthroscopy for the treatment of femoroacetabular impingement and capsular plication. Am J Sports Med. 2017;45(1):127-134.
3. Kraeutler MJ, Anderson J, Chahla J, et al. Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol. J Hip Preserv Surg. 2017;4(2):121-130.
4. Vannatta CN, Almonroeder TG, Kernozek TW, Meardon S. Muscle force characteristics of male and female collegiate cross-country runners during overground running. J Sports Sci. 2020;38(5):542-551.
5. Dorn TW, Schache AG, Pandy MG. Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance. J Exp Biol. 2012;215(Pt 11):1944-1956.
6. Rambaud AJM, Ardern CL, Thoreux P, Regnaux JP, Edouard P. Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review. Br J Sports Med. 2018;52(22):1437-1444.
7. O’Connor M, Minkara AA, Westermann RW, Rosneck J, Lynch TS. Return to play after hip arthroscopy: a systematic review and meta-analysis. Am J Sports Med. 2018;46(11):2780-2788.
8. Davey MS, Hurley ET, Davey MG, et al. Criteria for return to play after hip arthroscopy in the treatment of femoroacetabular impingement: a systematic review. Am J Sports Med. 2022;50(12):3417-3424.
9. Thorborg K, Kraemer O, Madsen AD, Hölmich P. Patient-reported outcomes within the first year after hip arthroscopy and rehabilitation for femoroacetabular impingement and/or labral injury: the difference between getting better and getting back to normal. Am J Sports Med. 2018;46(11):2607-2614.