Hydrotherapy for Hip Rehab

When recovering from hip arthroscopy, hydrotherapy complements land-based rehab. Patients should wait for the incision to heal before entering the water. This lowers the risk of infection. Post-op goals typically involve developing a posteriorly dominant hip, using the glutes for movement. The goals also include strengthening core stability. Hip rehab time frames may vary based on the surgeon’s protocols.

Post-op hips thrive in an aquatic environment. It unloads body weight for early gait training. This allows patients to start low-level functional activities early. Most patients will bear 30-50% of their weight. The amount depends on their height and the water’s depth. Hydrotherapy allows you to safely introduce light jogging, skipping, and easy agilities in water. You can start this 2-3 weeks before transitioning to land. This boosts neuromuscular development, confidence, and recovery.

Note: people recovering from injury or surgery should consult their health professional before undertaking a physical exercise regime.

Hydrotherapy exercises: Post-op hip arthroscopy progression

1. Early stage (0-4 weeks)

In the early stages of hip rehab, patients are often limited to 50% weight bearing. This lasts up to week 4 post-op. The goal is to stop using crutches by the end of 6 weeks. Hip flexion range of motion is often limited to about 100 degrees. External rotation range of motion is often limited to about 20 degrees. During this early stage, be cautious about resistance training for hip flexion strength. The SwimEx pool is perfect for early stage rehab. Most patients will be between 30-50% weight bearing in the water.

Early stage exercises on the treadmill without laminar flow:

Walking exercises: Most hip rehab protocols recommend not overloading the hip flexors early. Patients can begin walking forward and backward on the underwater treadmill, progressing speed as tolerated. Walking backward in the water decreases the use of the hip flexors. Patients may need to start with support rails.

Marching: Many hip rehab protocols limit the person to 90 degrees of hip flexion for the first phase of the protocol. In this marching in the water exercise video, the athlete-patient puts their hands underwater to identify the 90 degree angle.

Lateral Walking: Patients can perform lateral side steps across the treadmill in both directions (left and right). Be careful to maintain external rotation on the lead leg. Keep feet perpendicular to treadmill edges throughout the exercise.

Early stage exercises off the treadmill:

Single leg balance: In this first phase of single leg balance, there’s no current turned on and the athlete-patient is trying to maintain their balance, keeping their hands on their hips.

Single leg squats: Patients can begin with double-leg quarter mini-squats. Add running arms with dumbbells for core stability. For an easier or harder challenge, choose a lighter or heavier dumbbell and vary the speed of arm movements., then progress to single-leg. The buoyancy of the water takes the load off and reduces any concern about falling.

Single leg balance with running arms: Add running arms with dumbbells for core stability. For an easier or harder challenge, choose a lighter or heavier dumbbell and vary the speed of arm movements.

Flutter kick: Start easy with a flutter kick, holding on to the wall. Stronger swimmers can use a kickboard with a light laminar flow.

2. Middle stage (6-12 weeks)

In this phase, there are no limits to range of motion. Goals include normalizing gait, increasing muscular strength and endurance, and developing good neuromuscular control using the glutes and posterior hip.

One suggestion is to create a circuit in the pool that alternates cardiovascular exercises on the treadmill with strength and balance exercises off the treadmill. This will allow alternating focus on integration of core and hip muscles with more functional activities.

Middle stage exercises on the treadmill:

Fast walking: Start with fast walking and progress to light jogging in the last half of the phase.

Backwards walking: Walking backwards into the laminar flow will increase glute activation.

Lateral walking: Perform lateral walking at a controlled pace, then progress to quick, light shuffles in both directions.

Light skipping: Introduce some skipping in the program. This is an easy way to introduce some light jumping and landing on the same foot with just a little skip motion.

Middle stage exercises off the treadmill:

Flutter kicking: Begin to integrate fins and speed up the laminar flow during flutter kick exercises. If you have a SwimEx pool with a deep well option, the athlete-patient can progress to a vertical kick in deep water. They can use their arms to get started, but you can also challenge the athlete-patient with the arms straight across the chest or straight down at their side.

Single leg step-ups or step-downs: Step-ups are a nice way to introduce a little bit of hip extension with less than 90 degrees of knee flexion. You can use a deeper step depending on the height of the athlete-patient.

Quarter squats with a push/pull into flow: A single leg squat with dumbbells pushing against the laminar flow requires more stability from the athlete-patient. It also requires a little bit of core stabilization. You can advance this exercise by using a treadmill or running pad for this exercise or a higher laminar flow.

Quick feet on step: Build balance, strength, and mobility with quick feet on steps exercises.

Single leg balance with arms running: Advance the standard single leg balance exercise by adding running arms with dumbbells. Make this exercise easier or harder by adjusting the dumbbell size and varying the speed of the arm movements.

Core rotation progression: Start with a simple core rotation using hands only, with a progression to using dumbbells.

Core basketball drill: For a core challenge, have the athlete-patient hold a ball underwater and perform figure eights. You can make the figure eights as big as possible, as wide as possible, and as fast as possible.

Core dumbbell press: In this anti-rotation, core stabilization exercise, the laminar flow is moving from the athlete-patient’s right to left, and the athlete-patient must move the dumbbell against the flow of water. Adjust the speed of the laminar flow to make this exercise easier or harder.

Jumps to squat and stabilization: The water is an ideal environment for working on jump mechanics. Jumping out of the water creates an excellent concentric force.

Banded hip extensions: The athlete-patient can perform a banded hip extension in the pool, with or without the laminar flow. With the laminar flow on, the hip extensions work a little harder, while the hip flexors work a lot less.

Double to single leg line hop progression: Start with two legs and progress to one in a single leg line hop progression. Increase difficulty by increasing the speed. In the water, patients can use their hands to counter balance themselves.

3. Late Stage (12-16 weeks)

This phase introduces low-impact plyometrics. It also includes agility drills and faster running to build strength and endurance. The SwimEx pool and current allows you to be very aggressive and to begin working on explosive power. In the water, the athlete-patient can do more difficult activities without getting sore. This is because impact forces are minimized. Start agility drills in the water before introducing them on land.

Late stage exercises on the treadmill

Running: The athlete-patient can now transition to running on the treadmill, increasing the treadmill speed and laminar flow and duration as tolerated.

Skipping: To further challenge agility and power development, progressively increase skip height, movement speed, and laminar flow resistance.

Lateral shuffle: Enhance agility and power with lateral shuffles. Change directions, incorporate Carioca variations, and progressively elevate speed and laminar flow resistance.

Late stage exercises off the treadmill – core exercises for strength and stability:

Deep water vertical flutter kick: More challenging deep water vertical flutter kicks while playing catch boosts core strength and stability.

Horizontal flutter kick holding a ball under water: In this exercise, the athlete-patient holds a ball underwater while kicking against the laminar flow. This will challenge the core without making the hip flexors work too hard.

Core rotations: The SwimEx laminar flow allows for more challenging core rotations with larger moving objects, flow speed manipulations and sport-specific drills (basketball, batting) with or without added resistance (dumbbells).

Late stage exercises off the treadmill – agility exercises for hips and legs:

Tuck jumps: Quick tuck jumps off the bottom of the pool is an easy plyometric activity that will help improve agility.

Running on the angled pads: Running on the angled pad in a SwimEx pool helps to keep the body leaning forward with good running form.

Lateral hops on the angled pads: Another plyometric challenge is performing lateral hops on the angled pads.

Single leg bounding on the slant pads: Single leg bounding on a slanted pad is a more challenging exercise. The laminar flow helps to encourage good body lean and form.

Jump with pivot: Adding a counter-movement pivot increases exercise difficulty. In this exercise, the athlete-patient jumps to grab the ball and pivots before handing the ball back.

The SwimEx pool offers an ideal aquatic environment for optimal hip rehab. This is primarily due to its versatility and its wide, consistent laminar flow. From early gait training to explosive plyometrics, hydrotherapy can benefit every stage of hip rehab. As strength and confidence grow, patients can progress seamlessly for a complete recovery journey. Discover how hydrotherapy can make hip rehab smoother and faster. For more rehab videos, visit our Hydrotherapy Videos page.

~ Authored by Connie Peterson, PhD, LAT, ATC, athletic trainer at James Madison University.

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