Rehabilitation following hip arthroscopy can vary significantly. Existing programs have been developed as a collaborative effort between physicians and rehabilitation specialists. The evolution of protocol advancement has relied upon feedback from patients, therapists and observable outcomes. Although reports of the first femoroacetabular impingement (FAI) surgeries were reported in the 1930's, it was not until recently that more structured, physiologically based guidelines have been developed and executed. Four phases have been developed in this guideline based on functional and healing milestones achieved which allow the patient to progress to the next level of activity. The goal of Phase I, the protective phase, is to progressively regain 75% of full range of motion (ROM) and normalize gait while respecting the healing process. The primary goal of Phase II is for the patient to gain function and independence in daily activities without discomfort. Rehabilitation goals include uncompensated step up/down on an 8 inch box, as well as, adequate pelvic control during low demand exercises. Phase III goals strive to accomplish pain free, non-compensated recreational activities and higher demand work functions. Manual muscle testing (MMT) grading of 5/5 should be achieved for all hip girdle musculature and an ability to dynamically control body weight in space. Phase IV requires the patient be independent with home and gym programs and be asymptomatic and pain free following workouts. Return to running may be commenced at the 12 week mark, but the proceeding requirements must be achieved. Athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patient's pre-operative health status and post-operative physical demands will direct both the program design and the program timetable.

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging. Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.

Recent technological improvements have resulted in a greater number of surgical options available for individuals with hip joint pathology. These options are particularly pertinent to the relatively younger and more active population. The diagnosis and treatment of acetabular labral tears have become topics of particular interest. Improvements in diagnostic capability and surgical technology have resulted in an increased number of arthroscopic procedures being performed to address acetabular labral tears and associated pathology. Associated conditions include capsular laxity, femoral-acetabular impingement, and chondral lesions. Arthroscopic techniques include labral tear resection, labral repair, capsular modification, osteoplasty, and microfracture procedures. Postoperative rehabilitation following arthroscopic procedures of the hip joint carries particular concerns regarding range of motion, weight-bearing precautions, and initiation of strength activities. Postoperative rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint. Postoperative rehabilitation should be based upon the principles of tissue healing as well as individual patient characteristics. As arthroscopic procedures to address acetabular labral tears and associated pathology evolve, physical therapists have the opportunity to play a significant role through the development of corresponding rehabilitation protocols.

The level of understanding of pain in the nonarthritic hip has made significant strides in the last couple of decades beginning with the discoveries of Reinhold Ganz, MD. However, even with the detection of subtle bony abnormalities, including femoroacetabular impingement, a clinician's ability to differentiate pain generators in the hip has been ambiguous. Deciphering the etiology of the pathology versus the pain generator is essential in prescribing the proper treatment. The Layer Concept developed by Dr. Bryan Kelly, is a systematic means of determining which structures about the hip are the source of the pathology, which are the pain generators and how to then best implement treatment. Four layers will be discussed in this article. Layer I, the osseous layer, Layer II, the inert tissue layer, Layer III, the contractile layer and Layer IV, the neuromechanical layer.

Rehabilitation guidelines following hip arthroscopy have been presented in the literature with common themes consisting of initial protection, restoration of lumbo-pelvic stability, neuromuscular re-education, and return to sport training. The purpose of this review is to present hip arthroscopy guidelines in 4 phases and to address common pitfalls that may delay the rehabilitative process. The goal of phase 1 should be to protect healing tissues through activity modifications. Phase 2 intends to return the patient to pain-free community ambulation without compensation or irritation. A review of hip muscular actions during gait is presented to guide exercise progressions during this phase. Phase 3 should reestablish neuromuscular control through strength and endurance training to provide the foundation for return to functional activities or sports training progressions. The last phase of rehabilitation is dedicated to reestablishing power, speed, agility, and skill for advanced sports and advanced functions.