Adhesions after Hip Arthroscopy | A problem or not?
Have you treated patients with unexplained hip pain and restricted motion after arthroscopic surgery? Have you considered the possibility that adhesions after hip arthroscopy may be contributing to the problem? Adhesions are a natural part of healing after surgical procedures. However, where the development of scar tissue is excessive or where adhesions bind together structures that should naturally slide and glide against one another, pain and dysfunction may arise.
There is growing awareness of this potential issue in the surgical community, and it’s something that rehabilitative health professionals should also be aware of the role adhesions after hip arthroscopy may play in suboptimal outcomes after hip surgery. We may, in fact, have the best opportunity to address this issue and assist our patients and surgical colleagues in achieving optimal outcomes.
I’ve done a deep dive into the literature on this topic and put the information together with my own 30+ years of clinical experience as a physiotherapist, to bring you all the key information you need on adhesions after hip arthroscopy. As it ended up quite a lot of information, I’ve divided the blog into 3 parts to accommodate to everyone’s busy lives.
In this first blog, we’ll be taking a look at what evidence is available around whether adhesions after hip arthroscopy are a problem or not. In Part 2, we’ll cover risk factors and diagnosis of adhesions after hip arthroscopy and in Part 3, we’ll dive into treatment and prevention strategies.
Hip Academy members will have the opportunity to listen, learn and discuss all these topics in advance at our February Masterclass Meeting on this topic (or watch the recording).
In this blog, we'll cover:
- Where do post-operative hip adhesions occur and what impact do they have?
- How common are adhesions after hip arthroscopy?
Problematic hip adhesions are reportedly one of the most common post-operative complications and reasons for ‘failed hip arthroscopy’ and subsequent revision surgery.1,2,3,4,5 Adhesions are also one possible cause of post-operative symptoms in people who need to, or elect to, manage ongoing symptoms non-surgically.
Where do post-operative hip adhesions occur and what impact do they have?
The most common areas for adhesions after hip arthroscopy have been reported to be
- between the capsule and the labrum,
- between the femoral neck and capsule * anteriorly (after osteoplasty), and
- in the periarticular region, particularly involving the hip flexors.
Potential impacts of adhesions generally include pain, restricted range of motion and adverse consequences for joint health. Let’s take a closer look at potential impacts of post-surgical hip adhesions in each location.
Capsulolabral adhesions after hip arthroscopy
Post-operative scarring between the joint capsule and the acetabular labrum can bind the capsule down onto the underlying labrum.1,2 This may be associated with pain from excessive drag of the adhesions on the labrum and capsule, which are both innervated by nociceptors. With adhesions binding the capsule to the labrum, tension generated by capsular muscles like the rectus femoris, iliocapsularis and gluteus minimus may cause further drag on the labrum during active motion. This may be one of the reasons for persistent pain on active flexion after hip arthroscopy.
Range of motion may also be restricted, due to the inability of the capsule to lift away from or slide over the adjacent labrum.
Even if capsulolabral adhesions are painfree, there is concern regarding the impact of such adhesions on joint health. Capsulolabral adhesions can result in labral eversion.1,2 This is when the adhesion to the capsule holds the labrum up away from the femoral head. Labral eversion can break the suction seal, reducing the normal important protective effect of the labrum. The vacuum effect and the trapping of synovial fluid in the central compartment to absorb impact forces, are both key labral protective mechanisms that are disturbed by labral eversion. Could this be one of the reasons that degenerative change of the hip joint accelerates in some people following arthroscopic intervention? Food for thought!
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Capsulofemoral adhesions after hip arthroscopy
Another common site for adhesions after arthroscopic surgery for FAIS is at the site of femoral neck osteoplasty in those undergoing bone remodelling procedures for cam morphology – i.e., where an excessive bony bump at the femoral head-neck junction is surgically removed.1,2 The capsule may scar down onto the raw bleeding bone that needs to heal after osteoplasty. Pain and limited range may again occur from restriction of capsular motion. There is also likely to be ingrowth of nociceptive nerve fibres into the adhesions themselves over time, which for some people may result in pain when the scar tissue is stretched or impinged.
While this has not been mentioned in the literature, I also do wonder about the implications for joint health with adhesions of the capsule to the femoral neck. Synovial flow between the central and peripheral (outside the femoroacetabular articulation but within the capsule) compartments is essential for joint health. The capsule and the zona-orbicularis usually act as ‘bellows’ to help pump the fluid around the joint. Significant adhesions may disturb this flow with potential to disturb nutrient delivery and optimal distribution of fluid.6
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Periarticular adhesions after hip arthroscopy
Excessive adhesions may also develop on the outer surface of the capsule, between the capsule and the periarticular muscle.7,8 This has been reported to occur most commonly along the anterior portal pathway – the pathway of the arthroscopy port at the front of the hip which usually passes through the sartorius and rectus femoris before entering the anterior capsule of the hip joint. Excessive adhesions from scar tissue around this portal can tether the deep aspect of the rectus femoris and/or iliopsoas to the capsule.7,8 Posterolateral tethering of the gluteus minimus or medius muscles after hip arthroscopy has also been reported.8 Such adhesions have been visualised on both ultrasound and Magnetic Resonance Imaging.7,8
For some people with excessive peri-articular adhesions after hip arthroscopy, pain and limitation of range may be experienced with active motion or passive stretching of the tethered area. Such tethering of the pericapsular muscles may also alter their natural lines of forces and action, possibly impacting on their normal joint protection function and predisposing to extra-articular soft tissue impingement – for example impingement of the proximal rectus femoris between the Anterior Inferior Iliac Spine and the femoral neck (subspine impingement or AIIS impingement).
How common are adhesions after hip arthroscopy?
The incidence of problematic adhesions – adhesions that are causing persistent pain and/or restricted motion following hip arthroscopy - is unclear, due to a lack of high-quality data, and regular co-existence of adhesions with other pathologies that are also addressed at revision surgery. This makes is difficult to determine the level of contribution of the adhesions to persistent symptoms.
There have been 2 systematic reviews published in the last couple of years, aiming to bring together the available information. Den Hartog et al (2023) reported that of 6747 patients who underwent primary hip arthroscopy (6874 hips; 44% female), the percentage with adhesions confirmed on revision arthroscopy varied across studies between 0 and 26%.4 Considering only patients who underwent revision arthroscopy, 30% had adhesions +/- other pathology. Most revision surgeries occurred within three years.
In 2024, another systematic review reported that adhesions were identified at revision surgery in around 5.5% of 4145 patients (4,211 hips; 33% female) who underwent primary hip arthroscopy.5 Adhesions were commonly identified in concurrence with other pathologies such as residual FAI, labral pathology, chondral pathology, hip dysplasia and microinstability, extra-articular hip disorders (e.g., abductor, adductor and hamstring pathology), and synovial disorders.
These figures may however underestimate the incidence of post-operative adhesions, as this only accounts for patients who elected to undergo revision surgery. These statistics do not include those who were unwilling or unable to undergo revision or whose persistent symptoms were not severe enough to risk further surgery.
Intra-articular adhesions can be identified on MRI and identification of peri-articular hip adhesions have been visualised on ultrasound.7,8,9 Unfortunately, participant numbers are low in these studies.
One prospective MRI study performed MR arthrogram on 34 patients (17 asymptomatic and 17 symptomatic) at 1 year following arthroscopic treatment for FAIS, to assess the frequency of post operative findings.9 The most common pathological finding was capsular adhesion. Capsular adhesions at the anterior femoral neck were present in 12 of the 34 patients (35%) and capsulolabral adhesions that obliterated the paralabral sulcus were present in at least one location in almost all patients (94-100% depending on radiologist), regardless of group.9
Periarticular adhesions of the deep surface of the iliopsoas or rectus femoris were reported on all 24 consecutive patients referred for ultrasound guided injection with persistent anterior hip pain and/or limited hip flexion following hip arthroscopy for FAIS.7
We certainly need much more research in this space to clarify just how big a problem adhesions after hip arthroscopy are, in the medium and longer term. It seems that post-operative adhesions are highly prevalent but may only be a problem in a relatively small number of patients – that is, if we consider ‘a problem’ to be persistent symptoms of high enough severity to warrant revision hip arthroscopy. We need to remember of course that the contribution of adhesions to those persistent symptoms is currently unclear, as most surgeries also address other pathologies such as recurrent labral tears, chondral pathology or under-resected cam morphology. We also need to be mindful of other systemic and psychosocial contributors to persistent pain.
However, it would be premature to brush off the issue of adhesions after hip arthroscopy, particularly when we consider the potential for longer term adverse effects on joint health. Adhesions may be one of the many factors that may contribute to good but not great surgical outcomes, and progression to an osteoarthritic hip. So, let’s learn all we can about this potential issue and see if we can do something about it, before it becomes a problem for our patients.
Bookmark my blog and keep an eye out for the next instalment on this topic. The next blog will cover risk factors and diagnosis of adhesions after hip arthroscopy.
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Member Masterclass: Adhesions after Hip Arthroscopy
Adhesions after hip arthroscopy have been cited as one of the most common reasons for ‘failed hip arthroscopy’ - persistent pain and returning for revision arthroscopy. If you see patients after hip arthroscopy, this is an important topic!
The literature suggests that what happens in the early rehab period has a major impact on the risk of developing adhesions and requiring revision surgery. So, it’s very important to be aware of:
- what causes adhesions,
- where they form & the the implications
- assessment methods and clinical clues,
- possible treatment strategies, but perhaps most importantly,
- how to prevent adhesions - this is where we are likely to have most impact on patient outcomes.
We’ll be covering all these topics in the meeting, and I’m going to show you some cool ultrasound pictures collected by my team and I as we explored strategies for gentle active capsular mobilisation after surgery.
The live masterclass is followed by member questions and discussion on this topic.
You can benefit from this lecture too - the recording will become part of our growing library of member resources.
This blog was written by Dr Alison Grimaldi
Dr Alison Grimaldi is a physiotherapist, researcher and educator with over 30 years of clinical experience. She has completed a Bachelor of Physiotherapy, a Masters of Sports Physiotherapy and a PhD, with her doctorate topic in the hip region. Dr Grimaldi is Practice Principal of PhysioTec Physiotherapy in Brisbane and an Adjunct Senior Research Fellow at the University of Queensland. She runs a global Hip Academy and has presented over 100 workshops around the world.
Check Out Some More Relevant Blogs
- Ruzbarsky JJ, Soares RW, Comfort SM, Arner JW, Philippon MJ. Adhesions in the setting of hip arthroscopy. EFORT Open Rev. 2023 Nov 1;8(11):792-797.
- Philippon MJ, Ryan M, Martin MB, Huard J. Capsulolabral adhesions after hip arthroscopy for the treatment of Femoroacetabular Impingement: Strategies during rehabilitation and return to sport to reduce the risk of revision. Arthrosc Sports Med Rehabil. 2022 Jan 28;4(1):e255-e262. doi: 10.1016/j.asmr.2021.10.031. PMID: 35141559; PMCID: PMC8811550.
- Willimon SC, Briggs KK, Philippon MJ. Intra-articular adhesions following hip arthroscopy: a risk factor analysis. Knee Surg Sports Traumatol Arthrosc. 2014 Apr;22(4):822-5.
- Den Hartog TJ, Leary SM, Schaver AL, Parker EA, Westermann RW. The incidence and outcomes following treatment of capsulolabral adhesions in hip arthroscopy: A systematic review. Iowa Orthop J. 2023 Dec;43(2):146-155. PMID: 38213862; PMCID: PMC10777703.
- Keogh JAJ, Keng I, Ifabiyi M, Patel M, Duong A, Malviya A, Wuerz TH, Ayeni OR. Adhesions after hip arthroscopy are associated with revision but show poorly defined criteria for diagnosis and operative management: a systematic review. Arthroscopy. 2024 Apr 30:S0749-8063(24)00303-7. doi: 10.1016/j.arthro.2024.04.008. Epub ahead of print. PMID: 38697325.
- Field RE, Rajakulendran K. The labro-acetabular complex. J Bone Joint Surg Am. 2011 May;93 Suppl 2:22-7. doi: 10.2106/JBJS.J.01710. PMID: 21543684.
- M V Reddy S, Ayeni O, Vatturi SS, Yu H, Choudur HN. Ultrasound-guided release of post-arthroscopy extra-articular hip adhesions in femoroacetabular impingement: a novel technique. Skeletal Radiol. 2021 Dec;50(12):2541-2548. doi: 10.1007/s00256-021-03766-z. Epub 2021 Apr 12. PMID: 33844029; PMCID: PMC8038923.
- Woodward RM, Philippon MJ. Persistent or recurrent symptoms after arthroscopic surgery for Femoroacetabular Impingement: A review of imaging findings. J Med Imaging Radiat Oncol. 2019 Feb;63(1):15-24. doi: 10.1111/1754-9485.12822. Epub 2018 Oct 27. PMID: 30369089.
- Kim CO, Dietrich TJ, Zingg PO, Dora C, Pfirrmann CWA, Sutter R. Arthroscopic hip surgery: Frequency of postoperative MR arthrographic findings in asymptomatic and symptomatic patients. Radiology. 2017 Jun;283(3):779-788. doi: 10.1148/radiol.2016161078. Epub 2016 Dec 7. PMID: 27930091.
