Hip Arthroscopy: Week 16 Post Op Physical Therapy

What does physical therapy look like, or what should it look like, at the 16 week post op mark after hip arthroscopy? This post is long, and there’s a good reason for that.

What does 16 weeks post-op look like from an orthopedic pelvic PT perspective?

Today I walked to the beach again this morning. It’s 1 mile each way. Yesterday my hip was already sore and painful from trying to wear low (2 inch) heels for an hour and then grocery shop afterward. I ended up having to lie down from fatigue and pain. Boo.

Reflections from Physical Therapy this Week

This week brings more resistance training and continued dry needling and joint mobilizations. In other words – even at the 4-month mark – there is MUCH more work to be done.

Exercises like (blue level) TheraBand assisted double and single squats are on the menu at 4 months post-op. My range of motion (ROM) is limited to 105 degrees (double squat) due to flexion impingement, which painfully stops me from going any further. ROM is limited to 93 degrees hip flexion on the single leg squat. Progression is slow and tedious, I won’t lie.

The 4 Month Hip Arthroscopy Protocol is Not Realistic and Has Major Gaps

I can clearly feel my hip is not ready for heels, or 2-mile walks. And this is at the 4-month mark when *technically* – according to the “protocol” – I should be finished with my hip rehab. Yea, no.

NOTHING could be further than the truth.

The truth is, it is 2025 (and my rehab took place in 2014), and we STILL DO NOT HAVE PROPER protocols that include pelvic health treatment during hip arthroscopy rehabilitation. The International Consensus on Hip Arthroscopy Rehab entirely excluded pelvic physical therapy – there isn’t even a pelvic PT that sat on the committee to create the rehab guidelines. This, in my humble opinion as a 30 year veteran in sports medicine, is a MAJOR FAIL for hip arthroscopy rehab. One simply will not get the outcomes they want – painfree return to activity – without including pelvic PT inside hip arthroscopy rehab protocols, and yet, here we are.

That’s not the only exclusion, however. Manual therapy is largely left out of hip arthroscopy rehab too. I am not sure why, but anecdotally, 100% of patients I see who have “failed hip scope rehab” are still in pain. They did NOT have manual therapy at all or had woefully inadequate rehab that failed to address soft tissue, joint mobilizations, fascial restriction, and scar fibrosis or adhesions.

There’s no excuse for leaving out pelvic physical therapy and manual therapy during hip arthroscopy rehab, and yet, this is what I see as the “norm” by the time patients reach my office, exasperated because they cannot get answers or relief.

Having dedicated a large part of my clinical practice to seeing these cases, and helping them finally fully rehab and manage their pain, is why I started this series. To date, this hip arthroscopy rehab blog series is over 10 years long and counting.

To speak to the influence and importance of manual therapy – note the limitations on my ROM before manual therapy on this day of physical therapy, and then after:

Functional Lateral Glide of Hip (grade IV joint mobilization):

                                                                                                          BEFORE               AFTER

Double squat with blue TheraBand anchored to wall           105, pain*          130, no pain

Single squat with blue TheraBand anchored to wall               93, pain*             100, less pain

Inferior Glide in Supine with FABER and FADDIR Posterior Glide (difficult to do with only 2 people and a gait belt)

Standing hip flexion PROM                                                          128, pain*          135, less pain

*Pain is groin, impingement-type pain – the impingement for me is always sub spinal and lateral pectineus, medial psoas, which is possible that there are adhesions from sub spinal arthroplasty.

I was also able to star side sit better and with less pain after joint mobilizations. The other major improvement is that I maintained my ROM pain-free after therapy ended.  

Functional Joint Mobilizations in ADL and Medical Therapeutic Yoga postures may be the secret weapon to obliterate remaining ROM deficits 

Everyone has bad habits when it comes to posture and gait/walking. You know the story: You get into the same habitual ways of moving, talking, completing mundane tasks like driving or loading the dishwasher or answering emails.

Now, these habits do not always have to be problematic UNLESS they are persistent and repeated. Everything in moderation, right? So even bad posture can be okay, so long as you don’t do it all the time.

However, when you are hypermobile, as I am, my body’s tendency is to take the path of least resistance. What does that look like in the hip?

Hanging on the Y Ligaments

What is that, you ask?

Well specifically, what it looks like for me is laterally shifting away from my right hip while bearing weight only on the left side. At the same time, I posteriorly tilt the pelvis (butt tuck), and overuse my internal obliques, which puts a lower bulge or pooch in my belly and makes it stick out. Guess what this does? It puts unnatural pressure on the pelvic floor and obturator internus. All of that adds up to creation of persistent hip pain – pain that is preventable. It’s preventable if I change my posture.

What are common reasons women “hang on their Y ligaments” in their hip?

First, the Y ligament is known as the iliofemoral ligament.

• Childrearing and baby carrying (when you carry your baby on your hip by sticking your hip out. I call it getting “kicked out of gear.”)
• Hypermobility
• Hip dysplasia
• Weak posterior chain (read: gluts)
• Tight hip flexors
• Ligamentous laxity
• Hormonal changes

How to Improve Your Hip Posture

There are several ways to improve your standing and dynamic hip posture. Here are a few clinical pearls from how I chose to tackle the problem. Because, keep in mind, when I had surgery I had a 3-year-old, 7-year-old, and 9-year-old boys. I could not take time off from my company (I was a solopreneur with a small staff with no redundancy built in and no one to take my place), and I was also working on my doctorate and writing my first textbook. All at the same time. No wonder my hip posture was falling to the wayside.

Functional Mobilization –

Mountain to Chair to Garland Pose for Screw Home of the Hip

The way I did this pose is to do a chair pose to a squat (garland or malasana variation – see photo at right where I am doing a kneeling warrior I version). The yoga belt exacts a lateral force. See the photo above for a posterior-inferior glide functional mobilization, which is also very helpeful.

How do you know if you need this mobilization? This mob may be for you if you:

• Posteriorly tilt your pelvis out of habit
• Lose spinal neutral easily
• Laterally shift your trunk away from your operative hip
• Find your operative femoral head is anteriorly translated
• Find your operative innominate (entire hip bone, called the ilium) rotated anteriorly or forward
• Your core muscles (transversus abdominis chiefly) and synergists (obturator internus, chiefly) are shut down because of these actions
• During dry needling, all hip flexors and even the skin above them are highly hypersensitive and reactive, even having a histamine response locally (skin flushes red, local hives can arise)
  • Those muscles can also include, in addition to the hip flexors:
  • Piriformis (medial and lateral sides)
  • Quadratus femoris (lateral)
  • Hamstring (medial distal and lateral proximal)
  • Gluteus maximus (lateral to inferior hip rotator area)

When You are Doing Physical Therapy at Home

At week 16 I attempted my first Sun Salutation. I felt a serious strain or load on my hamstrings (right) that they did NOT like. I also felt a lot of groin impingement in the “usual” area with trying to do a forward bend. I only got through 2 repetitions, sadly, and thankfully knew I needed to stop. I am not ready for sun salutes quite yet. However, the following Medical Therapeutic Yoga-aligned yoga poses I did were successful:

• Warrior I with trunk diagonal patterns
• Warrior III
• Warrior II
• Tree
• Squat
• Lunge
• Side Plank
• Three-Legged Downward Facing Dog (an achievement!)
• Extended Side Angle
• Staff Pose (long sitting)
• Wide Angle Forward Seated Bend
• Half Upward Facing Bow

Overall, the yoga practice WAS successful because even though I was not ready for Sun Salutations, I could do all of the other poses with the proper motor patterning and pain-free.

Clinical Pearls from the 16 Week (Four Month) Mark

• Physical therapy will very likely be FAR from finished unless you are a pro athlete with unlimited access to high quality ortho and pelvic PT, dry needling, joint mobilizations, and manual therapy, including myofascial release AND you also started at a high level of fitness.
• Sexual activity is challenging at this stage. You will need consistent internal pelvic floor and/or obturator internus releases with joint mobilizations to get enough flexion and required abduction and external rotation or internal rotation. If you are struggling with intimacy you likely will need pelvic rehab to resolve it, please book a free consult at www.garnerpelvichealth.com or consult your local pelvic PT who has experience with sexual health and hip arthroscopy rehab.
• You may notice your psoas is not quite as snarky, however the tensor fascia lata (TFL) and rectus femoris can still be VERY angry. I believe this can be worsened and risk increased for this if you had an anterior inferior iliac spine chondroplasty (check your surgical notes).

How to Best Get Pain Free Hip Range of Motion Back at 16 Weeks Post Hip Arthroscopy

Range of motion should be 100% regained after hip arthroscopy. If you don’t have it, then you aren’t done with rehab yet. Range of motion may improve slowly. I have found the best combination of treatment for it is to combine functional joint mobilization with myofascial release. In my own rehab at week 16, I spent an entire hour working on functional mobs in various seated or squatting positions. It felt like putting a puzzle together.

But what are the results of it?

Improved hip flexion, abduction, and external rotation (FABER) – think easy seated pose in yoga, and child’s pose.

When to Start Plyometrics (Jumping, Bounding, and other High Impact Activity)

This week I started trying various plyometric activities – bounding, skipping, karaoke, short jogging over flat terrain. I am still not ready for them, but it was a good test that let me push my boundaries.

I ended up with some hamstring pain at the origin (ischial tuberosity) and the morning after, good old snarky psoas pain. Why? Because my posterior chain (think: gluteals) WASN’T ready for that high level of activity.

I knew this already, but you have to test the edges of your limits to know what is possible.

What Yoga Practice Looks Like a Few Days Later

So given that I know my boundaries now, here’s what I’m working on next. Note this was a 20 minute workout:

• Medical Therapeutic Yoga – this series and Ebook

I noticed my psoas is painful with hook lying marches and the hamstring on the operative side HATES ME. It feels like tendinosis.

The flip side to this is – I can stabilize my pelvis and low back, no problem.

• Sun Salutes – I can do them today, but my right fingers do not touch the ground in a forward fold.
• Chair Pose – I still feel myself posteriorly tilting (butt tucking and flat backing) and shifting away from the right hip (out of hip flexion).
• Downward facing dog – Hip flexion is finally fine BUT not with the right hamstring. That one is going to take more work.
• Standing Postures – All standing postures are modified to avoid hip flexion past 70 degrees, especially if there is any trunk flexion (forward folding).
• Prayer Twist – I used Prayer Twist Pose for stabilization combined with Proprioceptive Neuromuscular Facilitation (PNF) at the thoracolumbar (TL) junction. I can tell immediately that it’s limited as the pain is right at the TL junction.
• Reclined Hero – this pose is tough on the tensor fascia lata and rectus femoris mostly, but it’s wonderful for length and mobility.
• Half Moon – I cannot stand unilaterally in half moon or warrior III poses on the right due to HS tendinitis (but do it modified).
• Child’s Pose – can do with knees together only if push right leg isometrically into ground to take compression off groin impingement. 

What Hands On Treatment Should Be Included in PT at Week 16 & Why Psych-Informed PT is Necessary during Hip Arthrosocpy Rehab

Be aware that you are going to continue to have very angry muscles even at month 4. The operative hip and spine all the way to the upper trapezius and rhomboids can be VERY angry.

As a result, you can feel super emotional – angry, grieved, sad, crying. All the feelings. We do hold emotional trauma in our bodies physically, so now is the time to learn to LET IT GO.

I cried more than once in a PT session, and you shouldn’t be ashamed of it or avoid it. PT’s can help you process that emotional trauma through manual therapy, breathing exercises, and release techniques. Most pelvic PT’s also have some level of trauma informed training, so it’s important to find a PT who does.

Do we hold fear in our rhomboids, psoas, jaw, or back? Yes, I believe so, even though randomized controlled trials cannot measure it. We know that emotional pain can result in physical pain.

During this rehab time, I also had to work full time, advocate for one of my children’s special needs diagnosis on my own – without a partner – and write my textbook, Medical Therapeutic Yoga, while working on my doctorate at UNC Chapel Hill. On top of that, I was still sleep deprived from raising 3 elementary and preschool-aged children. It was exhausting.

That led me to taking a break at month 4, for 2 weeks, before only increasing my intensity by ONE NEW EXERCISE per week.

So if you need permission to set boundaries in your own self-care and rehab process, I am giving you that permission now. Give yourself that permission now.

These protocols are mere suggestions based on limited research and experience in working with women specifically. So give yourself permission to advance through rehab at your own pace. No pressure, no guilt.

You will reach the finish line. You can fully get back to yourself again.

Can you Push Too Hard Too Soon? Yes.

As much as I gave myself permission to step back and not keep pushing to be “normal again” as the 4 month protocols said I should – it was too late.

I have groin pain exactly like before surgery, back pain, psoas pain. All of it back, full force.

I feel defeated. 4 months was supposed to be when I was FINISHED with therapy, not feeling the SAME PAIN all over again.

Groin pain back, HS pain back, Psoas pain back.

The hip hurts all day now and in any position. I’m very frustrated but mostly scared – hoping I didn’t reinjure the labrum.

I made the decision with my care team to lay off all loading of the leg – no walk to the beach, which was only on flat ground. No standing yoga postures. ONLY unloaded lumbopelvic stabilization and gluteal work.

I noted loss of hip flexion ROM as well plus:

• Myofascial restriction in lateral raphe, diaphragm, iliacus, all back with a vengeance.
• If I had to blame it on something  – I think it is from the tiny bit of sports testing I tried to do at the park. However the protocols don’t even go that far to recommend even that testing. They are sending people back to activity and sport without even considering the testing I did on myself, which is more proof that the protocol is inadequate.  

What Does Manual Therapy Look Like During a Flare? (because you WILL have a flare)

You can end up needing to step it back and do a lot of manual therapy. Some can include:

• Suboccipital release
• Back & Neck Work
• Shoulder, including Subscapularis, Release
• Myofascial Release (MFR) to all the areas listed above on the operative side:
  • Iliacus, diaphragm, quadratus lumborum (bilateral) strain/counterstrain, lateral raphe, iliocostalis, hamstring
  • I layered secondary MFR to the lower right quadrant, so we were doubling up on treatment. I also found a fantastic tender point at the iliopsoas junction while in suboccipital release. I was able to release it, with much relief.

What Does Physical Therapy Movement Look Like During a Flare?

Lots of manual therapy FIRST then:

• No plyometrics for a week
• Start hip eccentrics and deep gluteal stabilizer work – gluteus maximus, gluteus medius in plank, prone hip extension, side plank
• Sidelying Series – Pilates based with limited hip flexion
• In plank, I could not lift my left leg against gravity which means my gluteus maximus is, at best, likely a 3+/5 on a manual muscle testing scale. Poor.

And to think that I can pass the “tests” to return to sport and “graduate” from physical therapy. This is madness. Again, another reason that the protocol is NOT adequate.

Wins Hip Arthroscopy: Week 16 Post Op Physical Therapy

• The hip scope protocol is NOT enough, nor is it adequate. It’s based on consensus that only considered orthopedics, not pelvic health.
• There is a mountain of pelvic health work that must be done in order to graduate from physical therapy post hip scope.
• There is also a mountain of manual therapy that must be done.
• Do not beat yourself up if you did not get these things during your hip scope rehab. You can still get them done and you can still fully recover.
• After this week of lessons, and backing off of the pace – my hip range of motion returned and I had less impingement. However, I still feel left sacroiliac joint pain at the inferior lateral angle (the right side of the bottom of the sacrum pictured at left), which means my right hip is still not moving normally functionally.
• You will have a flare or setback because that’s part of being human and testing your limits. Do not panic, you’ll have many tender points and compensatory patterns, especially from this protective but painful trifecta – quadratus lumborum (QL), psoas, and the hamstring. It should inform your therapy program, instead of derailing it. It could mean that local stabilizers may not yet be reliable enough.
• Able to do a slew of yoga poses IF they are aligned using Medical Therapeutic Yoga principles.
• Able to return to walking up to 2 miles (still not painfree but working on it).
• Psoas is getting LESS snarky.
• More aware of habitual “childcare” postures that are hurting long-term stability of the hip.
• Able to let go of expectations for full return to activity at the “end of the protocol”.
• 4 months is really just getting started with rehab. It will take many more months of physical therapy to be fully ready to return to activity.

Hip Arthroscopy: Week 17 Post Op Physical Therapy

Moving forward, as I do my own physical therapy during rest week, I have noticed the following in my own movement analysis:

• Thoracolumbar (TL – the part of the spine where the thoracic spine meets the lumbar spine, or t:12-L1) junction where the psoas connects is NOT moving when I do Windshield Wipers, and the TFL is rigidly on. I am working hard on getting the multifidus to fire and the vertebral segment to move there.
• The QL at the 12^th rib attachment is quite rigid. It’s probably contributing to the TL rigidity.
• The TFL (tensor fascia lata) is remarkably snarky and rigid – again likely to to TL rigidity.
• I need to do obturator internus release internally or externally before starting therapy (movement or manual therapy). I chose to do them over a Ganesha Fold blanket.
• My left transversus abdominis and obliques are weaker than my right but I can still stabilize my pelvis lying down in hook lying without a problem and without pain.
• I can do a unilateral (one legged) bridge pose except the right hamstring howls at me.  
• I cannot resume 2 mile walks yet due to the right hamstring.
• I can do full boat pose for short spurts.
• The internal snapping hip is still present with after surgery and the AIIS decompression.
• My right vastus medialis oblique is nearly equal size to the right now. Finally.
• I still have deep gluteal sling and gluteal firing delay in walking, but I am working on 90/90 series without an issue. So, it’s patterning and endurance that’s a problem, more than actual strength alone.
• I suspect the gluteal minimus/medius may be weak.*
• I’m unable to do full child’s pose – impingement occurs.
• Limited to less than 20 degrees hip flexion in wide angle seated forward bend due to HS pain.
• Using gua sha for fascial brushing after showers with vitamin E – it is helping with the terrible fascial related scar tissue and fibrosis that adheres the superficial layers of the dermis to the psoas, TFL, and gluteals.

Note from 2025: Ultrasound Imaging Should Be a Critical Part of Hip Arthroscopy Rehab

*11 years ago when I went through this rehab, I had no access to ultrasound imaging. Now, I can measure the exact output of the gluteus medius vs minimus, which would have helped me tremendously and saved me an extra month or two of therapy. My ability to do imaging absolutely saves time, money, and pain for my patients now.

FB Post – Spoiler Alert: Specialized “hippie” PT is still as important at 4 months post-op as it is in the immediate/acute post-op phase.

I’m coming up on four months post-surgical this week and let me say, I will still be continuing with intensive PT into 2015.

I can say with confidence as a PT and “hippie,” that the 4-month mark as an estimated “return to sports” is not only not realistic, but detrimental to a person’s self-confidence, self-efficacy, and possibly even the surgical repair/correction.

Retraining neuromuscular patterning and ditching “learned” (but impaired) post-surgical coping strategies for movement requires some seriously focused effort from both PT and patient.

To that end, I hope to begin writing about my hip labral adventures, in full living color (and video!), come 2015. The past 3+ years of traveling this path have taught me a thing or two about “best fit” care for hips. 

FB responses

KN: I do certainly hope that you can make appearances at orthopedic and PT conferences to help spread the message. Every single PT protocol from the surgeons said I would be running again at 16 weeks post-op. What a hideous joke that was for a triathlete. I’m still on crutches and in terrible pain nearly seven months out.




JA: I just want to be able to sit at a movie with my kids or walk at the park with them  I figured “sports related stuff” is a long way away … 4 months post-op are you better than you started? How severe was your pain prior to surgery?




My response to KN:  I am so sorry to hear of your struggle, but let me say this – I feel your pain and I understand the depth and width of it. I went through 3 years of conservative therapy before deciding to go surgical. I was also newly postpartum 3 years ago – which means I was completely starting a ground zero after a traumatic labral tear during delivery of my third son. The positive point here though is this – PT for hip labral injuries is relatively new – and an INCREDIBLY powerful modality for turning these surgical and nonsurgical patients into success stories. A skilled surgeon is, as always, a fraction of the hard work that needs to be done to guarantee success. I hope to be speaking about this in my CE course on Hip Labral Injury (see below for link).

My response to JA: Pain drove me to the surgical table. By the end, even grocery shopping had become difficult. Remarkable synovitis (bloody joint), discovered at time of surgery, validated how much havoc the joint was wreaking on my physical body. But as mom of three boys all birthed naturally – I know pain and can take it with the best of them. So for many, many years, I used yoga to “outsmart” my pain gauge – thus dampening or overcoming the feeling (but not the perception) of pain. Yoga is an excellent chronic pain management tool, but for me, I had cultivated the skill of pain management a little too well. Other PT’s have found this to be true of mothers in pain and combat soldiers – hence the similar rates of PTSD, chronic pain, fibromyalgia, etc. It is possible to train yourself to ignore pain TOO well.



My final response:  To answer your post-op pre-op comparison, to date, I’m better in some ways (with respect to compressive and distractive stability) but in many others ways I am still worse. Let me clarify: in a post-surgical situation, you bring your pre-surgical deficits to the table (whether it be an overactive psoas or loss of ROM or functional stability) but you also acquire NEW post-surgical pathophysiologies (like scar tissue, atrophy, loss of propprioception, neuromuscular patterning, myofascial mobility, I could go on and on…). Add to that the period of precaution and contraindication (immobility) and you have even more pathophysiology. That is part of the reason why 4 months is not NEARLY enough time for return to sports. Nor is 4 months nearly enough time to be completely better than you were pre surgically. I hope this clarifies my point.






JA: Ok, that makes a lot of sense … thank you for that explanation!





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Want to Learn More?

For Pelvic and Ortho PT’s – Are you a PT who wants training in pelvic health informed sports medicine?

• Hip Differential Diganosis and Integrative Management CEU

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