Hip Arthroscopy: 10-14 Weeks Post Op Physical Therapy

by Dr. Ginger Garner, PT, DPT, ATC/L

This post is meant as a guide (not therapy or a substitute for therapy) for helping you find the best care possible after your hip arthroscopy. This post covers weeks 10-14, with a few considerations for week 15+ weeks. Celebrating a major win today: At 10 weeks out from hip arthroscopy, I walked to physical therapy without an assistive device. This is a big step forward, no pun intended.

What to Consider in Physical Therapy at 10 Weeks Post Op Hip Arthroscopy

We added new joint mobilizations to the physical therapy regimen today, and they were divinely helpful. I consider these joint mobilizations, specifically in a lateral direction, as part of a normal hip arthroscopy protocol. (see picture below – think of drawing the hip out to the side of the body, not downward or backwards).

Some of the sensations and feelings you may get in the hip that let me know as a therapist, that you need mobilizations, include:

• Angry inner thigh muscles
• Snarky psoas and/or iliacus
• Obturator internus spasming or tightness, which feels like deep back, low sitting bone pain, or even constipation
• Loss of hip flexion, abduction, and external rotation
• Greater trochanter bursitis

If you have recently started walking with no assistive device, you can also just about expect the iliotibial band and tensor fascia lata to be angry (in addition to the stuff above). What do you do about it? Some options include:

• Dry needling
• Soft tissue mobilization
• Manual therapy at the gluteus medius

How do you know if your strength is progressing at this stage? Ask yourself or your therapist these questions:

• Can I do a straight leg raise in staff pose? I use as an indicator of strength and core control progression and coordination
• Do I have full hip range of motion that is painfree?
• Can I contract my hamstrings concentrically (shortening them) without pain? If not, you may have to stick to eccentric (lengthening) hamstring strengthening for a while.
• Is your gluteus medius strength WNL – what we call within normal limits? It should be, if not, make sure you are continuing to work on that.

Clinical Pearls at 10 Weeks

• If your physical therapist is NOT doing joint and scar mobilizations, they aren’t doing a complete, thorough job. Note: mobs must be done only after a specific time frame in therapy, which has to be determined by the surgeon and therapist.
• If your physical therapist is NOT addressing pelvic health, you are going to have gaps in your rehab that impede your full recovery.

What’s Up with Gait Training 10 Weeks After Hip Arthroscopy?

At 10 weeks out I walked with no assistive device into the physical therapy clinic, but I also achieved walking over uneven terrain outside for ¼ of a mile – up and down hills – without a problem. This is a BIG win in the hip arthroscopy rehab world.

What might you have continued difficult with, that is expected at this stage?

• Pelvic coordination – walking may feel “weird” and not natural still. This is okay, your therapist can continue to help with this
• Lack of full hip extension – part of your surgical precautions require limiting hip extension. This means you won’t just magically get your hip extension back without some joint mobilizations and progressive strength and gait training.
• Don’t throw away your crutches and just start walking. You need to step down your assistive device by first transitioning to 1 crutch, then a quad cane, then a straight cane. After you have mastered walking with these pain-free, you can ditch all assistive devices, hopefully for good.

Daydreaming About Your (Active) Future after Hip Arthroscopy

At the 10 week mark, you may also want to start daydreaming about alternate activities you can do to minimize weight bearing while getting your gait back to normal – but that introduce a high intensity aerobic exercise (because goodness knows you’ve had to sit around waiting to heal enough, which can cause other things like back pain and depression).

Many people are worried if they will ever be able to return to the activities they love again. They will show up to my office teary, depressed, and worried.

What do I tell them?

It’s okay to feel this way. I did too. It’s a natural lull in the rehab where you have come SO far from being on a CPM or in a brace all day – but you still have a LONG way to go. Old pain resurfaces (read post 15 for this) and you still have the new, post-surgical pain.

Believe me, I know what it feels like – and trust me, it won’t last forever. You will get better, with the right help. You can return to activities you love – you just have to finish strong in your rehab – which also means finding the best therapist who can bridge the sports medicine and pelvic health gap.

~ Dr. G, speaking from personal and professional experience about the 10-14 week mark in hip scope rehab

Start to take the next step by daydreaming a little. What do you want to return to and how can you do it in a way that minimizes weight bearing, since your walking isn’t normal yet and your strength isn’t either – but that can give you a big dose of natural painkillers and dopamine?

As for me, at 10 weeks I started to daydream about horseback riding to assist with trunk and pelvic strength and endurance, which would check the box of minimizing weight bearing due to my hip dysplasia and also introduce a non-weightbearing high intensity form of exercise. I also used my Pilates Reformer and prescribed my own regimen of rehab during this time.

What might your aerobic activity be?

Getting Back to Walking Normally Again

Here’s a case study on myself, from my 10 week post-op period where I was trying to normalize my walking, or what we call “gait training” in physical therapy.

Do you feel any of these things at 10-14 weeks?

• The obturator internus (OI) is completely inhibited and the transverse perineal muscle (superficial and second layers of the pelvic floor) is really mad.
• The gluteus medius (GMED) is weak and, prior to surgery, was in a state of chronic tendinopathy for 3 years, as was the psoas and the hamstring.
• The entire spinal mobility is incredibly limited because of the 4-6 weeks of foot flat weight bearing (no more than 20 pounds), and because of pre-existing synovitis and the loss of the hip seal due to the detached labrum. So, as one may suspect, the sacroiliac joint and entire spine is just a wreck.
• The psoas and hip adductors are not inflexible, yet they are tonically contracted. They are “on” all the time, and part of the ramification of that is perpetual groin pain and risk of retearing the labrum (psoas compression induced). 
• The gluts have a gazillion trigger points – which are creating medial knee pain (along with adductor trigger points) and MCL (medial collateral ligament) strain, as well as inhibition of the OI (and weakness of the GMED due to atrophy and “opathy”). 
• Lacking normal hip extension due to the psoas being always “on” – something that has been in existence for 3 years.
• The psoas tendon is thickened and scarred down to the multiple incisions in the region (three of them from the hip surgery)
• Scar tissue adhesions are attached to the GMED and the pelvic floor, fueling some of the problem.
• The transversus abdominis (TA) completely shut down after surgery. It was AMAZING to witness, but sad at the same time. I had to work from the ground up (pelvic floor muscles) to get it to fire again. It was tough work and so disheartening, because I was as strong as possible before the surgery given the pathology in the hip. 
• The deep front line and contralateral arm fascial lines are unbelievable – and after minimal gait/walking/stair climbing – the deep front line of fascia hates me.
• Side notes: I had to sit to do my doctoral work (I was working on my doctorate during my rehab, I know, I was totally insane) and work for my Institute (I was also maintaining my day job, also crazy, given that I had 1 year, 4 and 6 year old boys). All of this limits my recovery because I’m sitting too much. Gah!

Well, that gets us started! Are these deficits congruent with your findings or experience?

To address these issues – I did dry needling (internal and external), joint mobilizations, and myofascial release, for starters.

Clinical Pearls: Go back and re-read every single point that I struggled with, and make sure your therapist addresses them. It’s NOT on the usual protocol, so it’s easily and frequently missed.

Speaking of Yoga after Hip Arthroscopy

Lots of surgeons rightfully tell patients not to do yoga, like ever again, after hip arthroscopy. However, I don’t use regular yoga. I don’t teach ridiculous things like “hip openers” (read my post on Ending Hip Openers: Stop the Madness), and I prescribe only therapeutic yoga that is personalized for the individual’s unique issues after hip arthroscopy.

Given that, I still have a lot to overcome when it comes to educating the public and surgeons alike on what yoga is safe for hip preservation. Not all yoga is therapeutic and not all yoga is safe after hip arthroscopy.

During this 10 week mark, I started to do Medical Therapeutic Yoga-aligned Warrior I and small range of motion in a unilateral/one sided chair (squat). I still could not drop the pelvis down in tree pose – or just standing in mountain, due to a loss of what is called hip accessory motion. Read my post on it.

How did I address the lack of accessory motion in the pelvis that was limiting my progression in therapeutic yoga and walking?

Here’s how! A colleague helped me do dynamic functional assessment of the hip in multiple positions, and together we discovered that:

• Standing, standing squat, sidelying on the opposite side of the surgical hip all revealed that the scar tissue is more pronounced in sidelying that lying down.
• Address ribcage mobility. Diane Lee is a master of the thoracic spine, and we found that ribs 4,8, and 9 needed mobilization in order to improve my pelvic accessory motion (think rolling the pelvis around in a pelvic clock during tree pose). Adjusting the rings also improved my femoral head position during a squat (malasana pose).
• In sidelying, we uncovered LOTS of scar tissue from an old vertical scar that ran to the ascending colon, iliacus, external and internal oblique, and superficial front line of fascia –the pain felt achy, sharp, and radiated into the surgical groin and front of the surgical hip
• Dry needling helped in the superficial front facial line – into the iliacus and obliques
• MORE soft tissue mobilization PLUS the addition of visceral mobilization. We did these in sidelying and in an all fours position. It worked like a dream! I believe ALL hip scope PT’s should be trained in both pelvic health AND visceral mobs as well as certified in dry needling – I am, and I would not have gotten better with it.  
• After this particular treatment session, my hip flexion normalized, and as I was able to do what I call a “Reverse Hip Hike” while standing on my surgical leg and both legs – with no pain and full range of motion. YES!

One Day Later…10 weeks+

I was able to add Warrior II pose – see how I did it using Medical Therapaeutic Yoga here – but only at the top of my range – NOT a deep pose.

I also added triangle pose – using Medical Therapeutic Yoga approach – see how to do that here – and used it as a gentle hip glide.

Read the full post on how to safely align Triangle Pose here

Finally, I finished with Dancer’s Pose (a small one), Chair Pose, and Tree Pose – but I held the surgical leg in the correct position.

On the Pilates Reformer, I used 1-2 springs with modifications, using a beginner workout protocol for about 20 minutes. It was painfree and successful!

Week 11 Post Op Hip Arthroscopy Rehab

The next week I was teaching a BIG continuing education course on my own, and I won’t lie – it was HARD. My hip desperately needs more therapy than I have time for – and the pain is SO bad it’s distracting me from focusing and keeping me up at night. But I know why – TOO. MUCH. WORK. And not enough time for physical therapy. Ironic huh? But, there’s a silver lining here!

But here’s the positive: I did make some “new” old rehab discoveries today:

Partner Medical Therapeutic Yoga for Superficial and Deep front line/crossed arm line, psoas release, scar tissue did help. Here’s what I taught and did:

Subscribe to my YouTube Channel and follow the Hip Hacks Playlist

1. Fish Pose Modification – Ganesha fold blankets with/without STM as above, cobbler strap release, unilateral hip joint posterior/inferior glide
2. Locust Pose
3. Bow or Half bow Pose
4. Legs up wall with partner release pose (on decline three tier or thoracic spine opener – pelvis has to be right at or over edge (ob/gyn humor – “can you scoot down a little more?” ha.)

All of these I felt the same huge restriction as when I was in physical therapy, but the cool thing is – I got a release when working with a partner on my own.

The next day, I progressed my Medical Therapeutic Yoga Hip Arthroscopy Rehab with adding:

• Reverse chataranga
• Side plank

You STILL may not have full hip flexion. I didn’t, and I AM a hip arthroscopy and pelvic physical therapist. So don’t beat yourself up. You’ll have to work on this repeatedly for it to stick and maintain your hip flexion.

~ Ginger Garner PT, DPT, ATC-Ret

All in all, by the end of the week, I learned I was stronger than I thought, but I also learned about my limits. We had to shift gears in therapy that week (away from strength) because my operative leg was trembling from the exertion of teaching when I tried to launch into my usual therapy progression.

Your progress after hip arthroscopy won’t be linear. Be patient.

Here’s what it feels like to not have full hip flexion at 11 weeks out:

• Your flexion, adduction, and internal rotation movements may hurt.
• Your flexion, abduction, and external rotation movement may ALSO still hurt.
• The psoas will still be snarky, as will the inner thigh muscles.
• These muscles do NOT like me climbing stairs, so I still use a cane to climb them, which helps a TON
• The OI is STILL tender.
• I still cannot do Child’s Pose with full range of motion.
• I still cannot do a headstand or handstand because I cannot kick up and stretch my hamstring yet (it tore due to the labral tear and having to wait 3 years for surgery). I also still do not trust my TA and bandhas (yogic locks). They are not strong enough yet.
• Please make sure your therapist checks your SIJ. It could be exacerbating your loss of hip flexion. That happened to me – it was causing false impingement and preventing my femoral head (ball of hip joint) to seat properly in the hip socket.

Week 12 and beyond: Post Hip Arthroscopy Physical Therapy

The short list is:

• GMED, TFL, and piriformis trigger points are HUGE
• Psoas is tender where it attaches (not origin at low back)
• The posterior GMED has left the building. It’s not firing at all. So, I drug out the electrical stimulation. We’re gonna make this thing work 😉 We used Russian stim with functional patterns to get it going. (see photos below)
• Have your PT check your posterior fibers of your GMED. If they are not firing, you may get false impingement.
• If your hamstring and psoas are continuously angry, try walking backwards up the stairs for therapy. In addition to decreasing irritation, it improved my gait and pelvic mobilitly.
• Continue joint mobs – super important!

Medical Therapeutic Yoga Flow

For those of you who LOVE yoga and want to get back to it, here are some of the poses I included (aligned using Medical Therapeutic Yoga methodology) in my VERY FIRST standing yoga flow sequence (eeeeee, I was so excited):

Standing Posture Sequence

Note: I prescribe this myself and practice on my own, this is not in a class setting

• Partial warrior I
• Partial Warrior III
• Partial Warrior II
• Half Moon
• Triangle
• Tree
• All required manual assistance to help fire the right muscles, especially the deep gluteal sling.

If you have dysplasia, which makes a good outcome more tricky – there are extra barriers to success. Consider the following:

• In Warrior III it may be hard to unilaterally stand on the surgical leg and lift the normal leg higher than a few inches from ground secondary to hamstring pain.
• In Tree pose, you may be unable to lift the surgical leg more than a few inches from ground due to psoas, GMIN, and deep gluteal sling weakness.
• In all standing postures the tricky femoral head may want to sit too far forward in the joint, which can cause ITB (iliotibial band) pain and hip snapping, as well as pelvic floor and impingement pain.
• This is why the deep gluteal sling is SO important to be able to voluntarily control. It can help ease the pain of false impingement.

Seated Postures Included

• Moon Salutation (subscribe to my YouTube Channel and follow the MTY Playlist)
• 1 Sun Salutation – still really hard to do because downdog creates false impingement due to lack of hip flexion
• Simple seated postures

Improving Your Sleep

If you had to wait a long time to get a diagnosis in order to get surgery, which means your treatment was delayed, you may have a harder time getting good sleep. I did. I could not sleep on my right side for 3 years.

So don’t beat yourself up if you can’t find a comfortable position. It’s normal when you have a labral tear. There are many theories on why, but the “why” is less important than the fix.

Here’s a few pointers to consider:

• Work on the deep gluteal sling (see below for image of “hip lock” – the deep gluteal sling) in physical therapy so the femoral head is optimally positioned. When it isn’t, it can give you groin pain that feels like an ache, muscle spasm in the inner thigh muscles, or a pinching feeling.
• Don’t put the surgical side ASIS (hip point that sticks out in the front of your pelvis) ahead of the other leg. What does this look like? See the wrong way below.

• Keep your pelvis and hips in neutral. What does this look like? See below. IMPORTANT: This picture is STILL NOT FULLY correct, because the hip is not in neutral. In order for it to be correct, you would need a pillow between the knees that is FIRM, in order to keep the hips in neutral.

Physical Therapy – 13 Weeks Post Hip Arthroscopy

I needed a lot of dry needling, so we included:

• Iliocostalis
• QL 
• Hamstring 
• Gmed
• Piriformis
• All right side except piriformis was both sides

This instantly improved the femoral head position, and ilia (pelvic) mobility!

Got an Infection?

About 13-14 weeks out, I noticed pus coming out of the scar closest to the pubic bone. Luckily, wound care is part of our professional scope in physical therapy, so I handled the problem myself. I know it’s due to a stitch working it’s way to the surface. The stitch eventually worked it’s way out, the infection cleared, and all was well.

If this happens to you – and there is an oozing wound coupled with redness, swelling, streaking of redness away from the wound, and/or a fever, you should seek immediate medical attention. Never ignore signs of infection.

By the 14 week mark….

I am still missing the last 20 degrees of hip flexion, and my trigger points are still the same as last time, but I self treated them with soft tissue work, a foam roller, and lateral joint mobilizations.

My hip rotation is almost normal, as is my gait, and I’m ready to hit Manhattan to teach a continuing education course for Herman and Wallace Pelvic Rehab Institute on prenatal therapeutic yoga.

An interesting point – I am spending time daily in modified hero’s pose – with a block or bolster in order to improve my flexion, internal rotation, and adduction range of motion. It works!

Gait less impaired now – looking more normal (increased hip extension on toe off, more pelvic translation in all planes) 

My Post Op Hip Arthroscopy Physical Therapy while Working in Manhattan

I made it through NYC – walking about 1 mile or less at a time, negotiating stairs in subway, stabilizing while standing on subway, wearing up to 2 inch heels (max!) and walking short distances and teaching. Whew. I was worried, but I did it. I’m so used to walking 5 or more miles a day while in the city, so I knew I was going to have to be intentional and limit my walking. And of course, be extra careful not to fall.

For first time since surgery I feel like I may be better off than before surgery, because I wouldn’t have been able to do NYC pre-surgically. Yes, I had deep posterior, medial knee, and obturator internus pain, however I know why, and that makes it not scary.

I know why some pain remains -it is directly related to my remaining deficits, which are normal for this time frame. Heck, I’m not even done with formal therapy yet! They include:

• SIJ torsion/hypo mobility,
• weakness of hip stabilizers and
• lack of seating of femoral head,
• tight posterior capsule, among other things.
• Missing 20 degrees of hip flexion, 3 degrees of extension
• Manual muscle testing is not yet normal
  • Hip rotators and abductors are 3+/5
  • Hip flexion is 4-5 and painful
• All ROM gives my inner thigh muscles – specifically the pectineus and medial psoas pain and anterior impingement with range of motion and muscle testing.

See the YouTube short at the just over 3 month mark

At 14 weeks post op hip arthroscopy, here’s a sampling of some of the therapy I employed:

• Seated flexion, abduction, and external rotation – what does it look like? Is it painfree?
• Is all knee pain resolved? Oftentimes you can have knee pain resulting from hip traction during surgery or during normalization of the gait due to being on crutches for so long.
• Hip impingement test was still positive, so dry needling and manual therapy continued, including points like:
  • OI, pectineus,
  • adductor longus and magnus,
  • piriformis laterally and medially,
  • cocyggeus
• I started to do joint mobilizations in multiple planes along with active contract/relax (active release) techniques and shoulder and trunk stabilizer work. This improved femoral head positioning greatly!
• I still need mindfulness – conscious, active thought – in order to recruit the proper motor patterns (make muscles fire together when they are supposed to). Work on the Bosu and just uneven surfaces in general, using theraband, and Medical Therapeutic Yoga all helped increase my hip flexion and rotation by 10 degrees each in a single session. See the YouTube short below:

Work on TB-assisted or use PNF in FABER for seating femoral head on own (via hip ER, abductors, TATD with PFM to seat head via pulling it posteriorly; imagine isotonically pulling long axis of femur into acetabulum posteriorly) – this works! increases FABER ROM immediately, as well as hip flexion ROM

Clinical Pearls at 14 Weeks

• Dry needling must continue until neuromuscular re-education is is complete. 
• Pilates Reformer – therapeutically prescribed for your issues only – can work wonders. I continued to use 1.5 springs and do my own therapy using workout 1, with no problem.
• Try Muscle Energy – as in the video above if you are at a stuck point with strength and motion
• Try hydrotherapy – using warm water hydrotherapy worked wonders for gaining the rest of my hip flexion. I was able to flex nearly 140 degrees without the leg moving out to the side, with no pain, after using it for several sessions. I used a muscle energy pattern in FABER as in the video above. I also use hydrotherapy for massage – getting in front of the jets works out the TFL, deep hip rotators, even the OI and iliacus! In my hot tub, lol, I have to hold on to the side of the tub because the jet is so strong. 

Hip Arthroscopy: Looking Ahead at 15+ Weeks Post Op Physical Therapy

What muscles still may feel angry? Common complaints can include:

• Feeling rigid through entire surgical side and hip
• Snarky psoas
• Happy Helper quadratus lumborum (see photo at right)
• Fascia of the trunk and respiratory diaphragm are all guarded

Make sure your therapist looks for:

• Rotation at the thoracolumbar junction in seated rotation
• Fascial mobility in the trunk and diaphragm
• Visceral mobility and motility
• Pelvic diaphragm issues
• Possibility of using dry needling in spinal region(s)
• Trophic and histamine response on the surgical side to manual therapy
• Sensory changes in the painful region(s)

Do you have a high pain tolerance? That could be a BAD THING.

People can be SO good at minimizing pain perception in their brain that they can override protective pain responses in the higher centers of the brain. But, the body doesn’t lie – it can shut down certain areas, and cause trophic or histamine changes in the skin and surrounding fascia, even if you feel it is “painfree.” So in spite of you shutting down your own pain response – you can still have pathology in an area, as evidenced by the signs above.

So if you are REALLY good at handling pain – be careful and be ready to accept help. Let your PT look at ALL areas in the region to make sure there aren’t tissue issues that are hindering your progress.

This happened with me. As a result of my expertise in birth as a 3 time mom, as a PT, and of course as a hip scope patient, I was able to override the typical pain response. Not good.

When is yoga a detriment to healing and recovery because you’ve shut down your perception of pain?

It doesn’t mean I shut down consciousness of pathology – I know it’s there, but as a mom of three and CEO – just like a soldier in combat – I can’t stop for just a little pain. I have to keep going. And so pain doesn’t take over – but the micro pathology persists and becomes traumatic failure. 

Here are some of the clinical pearls I discovered as I navigated tuning into my pain a bit more, instead of pushing through it:

• I used proprioceptive neuromuscular facilitation with soft tissue mobilization in sideyling over a bolster. I could feel the historical lack of movement in the pelvis, due to the long-term loss of hip internal rotation. Sound like Greek? Don’t worry – what I’m saying is – experiment with movement over bolsters. See what you find – and have your therapist evaluate your movement. A good one will find all kinds of things to treat.
• Don’t forget to adjust the rib cage to allow for improved thoracolumbar rotation.
• Don’t forget to Scar Dry Needling. A “feathering technique” is SUPER helpful in the areas of the scars. There, I could feel the offending muscles (that were in remote areas) immediately spasm and begin to release the anterior/front scar.
• Don’t neglect doing visceral manipulation and mobilization. I had an old scar that ran right through the psoas. So, it had to be released at each level.
• Mobilize the respiratory diaphragm.
• Check your seated rotation and gait – When I worked inside an MTYoga Warrior I – I actively palpated the TL junction to make sure the ribcage was moving adequately on each side.

Wins! 14 Week Post Op Hip Arthroscopy Self Check-In

• At 14 weeks, today is the first day I could get up and get the boys off to school – and that was still with some help.
• Getting the femoral head to “seat” or “screw home” with coordinated thoracic and SIJ synchronization is hard.
• I have no gross strength deficits; however, that means I could cheat my way through the final PT checkout test(s).
• This is why I don’t use regular strength testing and sports testing alone. You can pass with flying colors and still not be ready to return to activity.
• I make sure the muscles are firing in a coordinated pattern – which is called neuromuscular patterning.
• You still may not be able to sleep through the night on the surgical side yet. No worries, it will come!
• Practice returning to normal gait with the help of your therapist. Use step-down gait devices, straight or quad cane, to make sure you don’t move to quickly. On my first long walk, I felt pain in my hamstring the entire time, but I also knew my deep hip stabilizers were not firing when they should. As a result, my GMED had trigger points afterwards, and I couldn’t stretch my hamstring without pain. Working to improve the guarding in my spine and pelvic floor (which happens due to necessary surgical precautions) helped improve my gait and make it more natural again.

Stay tuned for the next post in this series. Don’t miss a post – sign up for our newsletter. We never spam and we try not to waste your time.

Want to Learn More?

For Pelvic and Ortho PT’s – Are you a PT who wants training in pelvic health informed sports medicine? Take my Hip Differential Diganosis and Integrative Management CEU (12 CEU approved for PT)

For Everyone – Here are the workshops I offer related to hip labral tears and injury

Hip Preservation: Make Yoga Fit Your Hips

The Snarky Psoas: To Stretch or Not to Stretch

Is it Back Pain or My Hip: Demystifying the SIJ Connection

Do I Have a Labral Tear? Tips for Self-Care & Pain Management