Pendulum Exercises After Hip Arthroscopy:

A Video Technique
Ryan Sauber, M.D., George Saborio, M.D., Beth M. Nickel, P.A.-C.,
Benjamin R. Kivlan, Ph.D., P.T., and John J. Christoforetti, M.D.

Abstract: Advanced hip jointepreserving arthroscopic techniques have been shown to improve patient-reported func-
tional outcomes with low rates of postoperative complications. Prior work has shown that formation of adhesive scar is a
potential source of persistent pain and cause for revision surgery. As resources for postoperative in-studio physical therapy
become scarce, a home-based strategy to avoid scar formation without adding formal therapy cost may be beneficial. The
purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery
of manual hip pendulum exercises in the postoperative setting. This video technique offers access to our method for
pendulum exercise as part of early recovery after advanced hip arthroscopy.

T he use of arthroscopic hip-preserving procedures in

the management of hip conditions such as labral
tears, chondral lesions, ligamentum teres rupture,
osteonecrosis, hip instability, and femoroacetabular
impingement has increased dramatically over the past
decade.1,2 The rate of hip arthroscopic procedures has
increased by 600% since 2006,3 and this rate is
expected to continue to grow. Despite this high rate of
growth, there remains little consensus on the role of
formal in-studio physical rehabilitation in the post-
operative management of patients undergoing hip
arthroscopy. Many postoperative protocols have been
proposed in the peer-reviewed literature.2,4-8 Most,
however, have been formulated with a lack of
objective evidence using validated patient-oriented
outcome scores.5 Current studies are underway to
From the Center for Athletic Hip Injury, Allegheny Health Network (R.S.,
G.S., B.M.N., J.J.C.); Department of Orthopaedic Surgery, Drexel University
School of Medicine (R.S., G.S., B.M.N., J.J.C.); and John G. Rangos Sr. School
of Health Sciences, Duquesne University (B.R.K.), Pittsburgh, Pennsylvania,
U.S.A.
The authors report the following potential conflict of interest or source of
funding: J.J.C. receives support from International Society for Hip Arthros-
copy, Arthrex, Breg, Allegheny Health Network, and Allegheny Singer
Research Institute.
Received October 3, 2015; accepted April 19, 2016.
Address correspondence to John J. Christoforetti, M.D., Center for Athletic
Hip Injury, Allegheny Health Network, 4815 Liberty Ave, Ste 252, Pitts-
burgh, PA 15224, U.S.A. E-mail: jchristo@wpahs.org
Ó 2016 by the Arthroscopy Association of North America
2212-6287/15953/$36.00
http://dx.doi.org/10.1016/j.eats.2016.04.013
evaluate the efficacy of a formalized rehabilitation
program regarding health-related quality of life and
physical function,4 and stronger evidence is needed to
define the standard of care in postoperative manage-
ment of patients undergoing arthroscopic hip-
preservation surgery.2,4-8
Despite variation in postoperative rehabilitation pro-
grams, most protocols reported in the literature have
asserted that early mobilization is an important
component of postoperative care. Passive motion helps
to nourish joint surfaces, promote tissue remodeling,
and increase tensile strength.9-13 Early passive motion
may also reduce the risk of joint stiffness and
adhesions that may impair normal joint motion.1
Patients who undergo passive circumduction exercises
performed by a physical therapist in the early post-
operative phase of rehabilitation after hip arthroscopy
are 4.1 times less likely to have development of
adhesions compared with those who do not.1 Thus
passive motion in the form of circumduction exercises
may be beneficial to promote healing and lower the risk
of complications.
The current health care climate demands efficiency in
the delivery of care. Insurance carriers are more
restrictive on the number of physical therapy visits
afforded to subscribers, and more financial burden is
placed on patients through co-pays and deductibles. As
a result, physical therapists are often confronted with
the challenge to manage a lengthy postoperative period
with fewer visits. A home-based passive motion
regimen that decreases the number of necessary
outpatient therapy sessions could be a valuable

Arthroscopy Techniques, Vol 5, No 4 (August), 2016: pp e897-e900 e897

e898 R. SAUBER ET AL.

Table 1. Passive Hip Circumduction Exercises at Home Versus

Formal Physical Therapy
Advantages
No cost
No travel required
Performed by trusted caregiver
Performed multiple times daily
Disadvantages
Labor and time intensive
Time required to educate patient and caregiver
Inconsistency of technique

cost-reduction tool. This incentivizes patients to

perform exercises that are critical to their recovery
within their home setting without the direct supervi-
sion of a physical therapist. Fig 1. The patient is relaxed in the supine position, with the
In an effort to decrease formal physical therapy visits orthotic brace removed.
in the early postoperative period, we have used passive
hip circumduction exercises that are administered by a
caregiver by a member of the orthopaedic surgical team
caregiver (spouse, parent, family member, and so on) at
(physician assistant or surgeon) on the first day of the
home as the cornerstone of an independent home
postoperative period.
program within the first 2 to 4 weeks after hip
arthroscopy. The purpose of this technical note is to
introduce a patient-centered educational video tech- Technique
nique for home-caregiver delivery of manual hip Hip pendulum exercises are performed at home by a
pendulum exercises in the postoperative setting trusted member of the patient’s family or a friend. The
(Tables 1 and 2, Video 1). patient assumes a supine position on an elevated
surface, often a couch or a bed, with the orthotic brace
removed (Fig 1). The caretaker stands perpendicular to
Methods the patient’s limb. Open and continual communication
An early postoperative protocol was standardized for is essential to ensure that the exercise is performed in a
patients receiving arthroscopic hip-preservation pro- truly passive manner, without the assistance of the
cedures including labral repair, labral debridement, patient. It is essential that the muscles surrounding the
femoroplasty, acetabuloplasty, synovectomy, liga- hip joint remain relaxed. The caregiver should be
mentum teres debridement, gluteus medius repair, and mindful to offer support to the patient’s lower limb by
capsular plication. The postoperative protocol featured gently cradling the leg across both of the caregiver’s
the following components: (1) passive circumduction
exercises performed by a caregiver, (2) use of a
continuous passive range-of-motion machine (Spectra;
Kinetec) providing passive hip flexion from 0 to 90 for
a total of 6 hours per day, (3) use of axillary crutches
with a foot-flat gait at 20 lb of partial weight bearing,
and (4) use of a hip orthotic brace (T Scope Post-Op hip
brace; Breg) to limit flexion to 90 and extension to 0 .
The pendulum exercises were taught to the patient and

Table 2. Pearls and Pitfalls

Pearls
The patient must be relaxed throughout.
A slow, consistent, fluid motion of the limb is required.
Trust between the caregiver and patient must be established.
The technique should be performed multiple times daily for the
greatest effect.
Communication is needed to avoid painful motion.
Pitfalls
Excessive flexion >90 can be painful. Fig 2. The caregiver is mindful to offer support to the pa-
Performance on a low surface can cause fatigue for the caregiver. tient’s lower limb by gently cradling the patient’s leg across
Patients often try to assist; relaxation should be encouraged. both of the caregiver’s forearms (red arrows).
 PENDULUM EXERCISES AFTER HIP ARTHROSCOPY e899

Fig 3. The caregiver performs the hip circumduction exercise Fig 4. The patient’s patella (red opaque circle) should always
using small clockwise (red arrow) and counterclockwise (blue remain pointed toward the ceiling (red arrow).
arrow) circles of the lower limb by moving the caregiver’s
arms back and forth in a sawing motion (green arrows).
benefits of physical therapy later in the recovery pro-
cess. As the cost of physical therapy continues to rise
forearms (Fig 2). The caregiver performs the hip annually, the home caregiver may reduce the cost of
circumduction exercise by moving the hip in small therapy by instituting home pendulum exercises during
clockwise and counterclockwise circles using a back- the early postoperative period.
and-forth sawing motion of the caregiver’s arms
(Fig 3). The patient’s patella should remain pointed
toward the ceiling throughout the entire exercise
(Fig 4). The circumduction movements are repeated
continuously through an arc of 30 to 70 of hip flexion
for 20 minutes, 3 times per day (Fig 5).

Discussion
Evidence has shown that hip pendulum exercises
may provide protection because they lower the risk of
adhesion formation. Willimon et al.1 presented a Level
IV evidenceebased study using a rehabilitation pro-
gram that included pendulum exercises performed
throughout the day to reduce the rate of adhesions and
arthroscopic revision rates. The results showed a 4.1-
fold increased risk of adhesions in patients who did not
perform circumduction therapy.1 We believe that
physical therapy plays an important role in restoring
normal function after hip jointepreserving arthroscopic
surgery. Initiating a caregiver-based intervention in the Fig 5. Circumduction is repeated continuously through an arc
early stages of recovery allows the patient to maximize of 30 to 70 of hip flexion for 20 minutes, 3 times per day.
e900 R. SAUBER ET AL.
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