Post-Operative Physiotherapy Rehabilitation Plan

Left Morscher's Procedure with Varus Osteotomy (Two-Level Deformity Correction - Level 4, Grade 5)

Month 1 Protocol (Weeks 1-4)

Understanding the Procedure First

MONTH 1 REHABILITATION PLAN (Weeks 1-4)

Phase 1: Acute Protection Phase (Weeks 1-2)

• Protect osteotomy fixation and hardware integrity
• Control post-operative pain and swelling
• Prevent immobilization-related complications (DVT, chest infections, muscle atrophy)
• Establish safe transfer and mobility with assistive device
• Patient education on precautions

• Touch weight bearing (TWB) to foot-flat weight bearing (FFWB) - operated limb only
• Use two axillary or forearm crutches at all times when upright
• Do not exceed 10-15% body weight through the operated leg without surgeon clearance
• No single-leg stance under any circumstances

• Teach log-rolling technique for turning in bed (maintain neutral hip alignment, no twisting)
• Transfer technique: slide operated leg off bed first, maintaining hip at neutral or slight abduction
• Sit-to-stand: use crutches, push up from bed with both arms, avoid pulling through the operated hip

• Supine with a wedge or abduction pillow between knees when resting
• Avoid hip adduction (crossing legs) at all times
• Avoid extreme hip flexion beyond 70-80 degrees in week 1
• Semi-reclined sitting (30-45 degrees) acceptable for short periods
• No prolonged sitting beyond 20-30 minutes in week 1

• Hip flexion: 0-70 degrees
• Hip IR/ER: 15 degrees each side (gentle passive only)
• Hip abduction: 15 degrees (no forced abduction)
• Hip adduction: Neutral only - NO adduction past midline
• No active hip flexion (avoid iliopsoas recruitment at the osteotomy site)

• Cryotherapy: Ice packs to hip/groin, 15-20 minutes, 4-6x daily for first 5-7 days
• Elevation of limb when supine
• TENS for pain modulation if needed (physiotherapist directed)
• Compression bandaging from foot to knee for edema control

Phase 2: Early Rehabilitation - Protected Mobilization (Weeks 3-4)

• Maintain osteotomy protection
• Gradually expand ROM within safe limits
• Begin gentle muscle activation (short lever arm only)
• Improve circulation and begin neuromuscular re-education
• Safe household ambulation with assistive device

• Continue TWB/FFWB on operated side with bilateral crutches
• Weight bearing progresses only on surgeon's radiological clearance
• Typical clearance for partial weight bearing (PWB 25-30%) may come at 6 weeks

• Hip flexion: 0-80-85 degrees
• Hip ER: 20 degrees
• Hip IR: 15-20 degrees
• Hip abduction: 20-25 degrees
• Hip extension: 0-5 degrees (prone lying progress slowly)

• Soft tissue mobilization to surrounding hip musculature (TFL, gluteals, hip flexors)
• Scar tissue management once wound fully closed (usually after 2-3 weeks post-op)
• Grade I-II joint mobilizations if indicated for pain modulation (surgeon-approved only)

• Waist-deep warm water walking only
• Use of buoyancy jacket
• No breaststroke or kicking drills
• Extreme care entering/exiting pool

GAIT RE-EDUCATION (Throughout Month 1)

1. Week 1-2: Bed-to-chair transfers with bilateral crutches. Focus on safe weight transfer and neutral hip alignment. Avoid Trendelenburg gait pattern.
2. Week 3-4: Supervised corridor walking. Focus on:
   • Even step length
   • Foot flat contact on operated side
   • Avoid hip hiking (lateral trunk shift compensations)
   • Controlled swing through
   • Start with 50-100 meter sessions, 2-3x daily
3. Stair training: Week 3-4, step-to pattern (non-operated leg leads going up, operated leg leads going down). Use handrail + one crutch minimum.

PATIENT EDUCATION

Understanding the Surgery

• The bone has been cut and repositioned. It is held with a plate and screws. This hardware is not fully secure until the bone heals (minimum 6-8 weeks for early callus, 3-4 months for solid union).
• Any fall or excessive force in month 1 can displace the osteotomy and require repeat surgery.

Do's - Month 1

• Always use both crutches when upright
• Sleep on your back or non-operated side with pillow between knees
• Perform all exercises exactly as instructed - slow, controlled, within pain limits
• Keep the operated leg in a neutral or slightly abducted position at rest
• Ice the hip 4-5x daily for the first 1-2 weeks
• Take pain medication as prescribed - do not "tough it out" as pain causes protective spasm and delays healing
• Report any sudden increase in pain, wound drainage, fever, calf swelling, or shortness of breath immediately
• Attend all follow-up appointments - radiological confirmation of healing determines all progression decisions
• Wear compression stockings for DVT prophylaxis as instructed by your surgeon

Don'ts - Month 1

• Do NOT bear full weight on the operated leg
• Do NOT cross legs or adduct the hip
• Do NOT forcefully rotate the hip (especially internal rotation)
• Do NOT sit in deep chairs, sofas, or seats where your hip drops below your knee level
• Do NOT bend forward more than 90 degrees at the hip when sitting (toilet raises recommended)
• Do NOT attempt stairs alone without a physiotherapist having cleared you
• Do NOT drive
• Do NOT sleep on the operated side
• Do NOT perform any unsupervised vigorous exercises
• Do NOT skip physiotherapy appointments

PRECAUTIONS - CLINICAL RED FLAGS

MILESTONES TO ACHIEVE BY END OF MONTH 1

• Independent and safe household ambulation with bilateral crutches (TWB/FFWB)
• Pain controlled to VAS < 3-4/10 at rest
• Hip flexion ROM of 80-85 degrees
• No wound complications
• Independent with all prescribed home exercise program
• Able to perform stairs safely with crutches and supervision
• Transversus abdominis activation achieved
• DVT prophylaxis maintained

CAN THE PATIENT SIT IN A DEEP SQUAT POSITION?

1. Deep squat demands 120-130 degrees of hip flexion - well beyond the safe early post-op limit
2. The varus correction changes the biomechanical axis; deep squat loads this abnormally until full bony union and soft tissue adaptation
3. The iliopsoas and hip flexor complex are under significant strain near the osteotomy site in deep hip flexion
4. Indian/cross-legged sitting (which requires significant external rotation) is also contraindicated for 3-6 months

BEYOND MONTH 1 - BRIEF OVERVIEW (For Context)

• Months 2-3: Partial to full weight bearing progression, active hip strengthening, stationary cycling (elevated seat), swimming (freestyle only), gait normalization
• Months 3-6: Progressive loading, gym-based strengthening, single-leg activities, step-ups, functional squats (limited range), return to sedentary work
• Months 6-12: Return to higher-level function, sports-specific rehabilitation, deep squat gradual re-introduction if cleared

Physiotherapy Exercise Plan

Patient: Master Atharva Dhananjay Shevalkar | Age: 14 years 10 months | Male

Based on Jupiter Hospital Discharge Summary | Discharged: 01/05/2026 | Follow-up: 08/07/2026

Key Clinical Parameters From the Report

PHASE CLASSIFICATION (Based on Discharge Date 01/05/2026)

• Discharged: 01 May 2026
• Current date: 01 July 2026 = ~8-9 weeks post-op
• Next follow-up: 08 July 2026 with X-ray PBH AP + Frog Lateral

EXERCISE PROGRAMME - DETAILED

CATEGORY 1: ANKLE AND TOE EXERCISES

• Position: Lying on back (supine), leg elevated on 2-3 pillows
• How to do it:
  • Point your toes away from you as far as comfortable (plantarflexion)
  • Hold for 3 seconds
  • Pull your toes back toward your shin as far as possible (dorsiflexion)
  • Hold for 3 seconds
  • Return to neutral
• Sets/Reps: 3 sets of 20 repetitions
• Frequency: Every 1-2 hours throughout the day (most important exercise)
• Note: This is the single most important exercise for preventing blood clots in a 14-year-old post hip surgery

• Position: Supine, leg elevated
• How to do it:
  • Slowly rotate your foot in a large circle - clockwise
  • Complete 10 circles clockwise
  • Reverse - 10 circles anti-clockwise
  • Keep knee still; movement is only at the ankle
• Sets/Reps: 3 sets of 10 circles each direction
• Frequency: 4-5x daily

• Position: Supine or seated with limb elevated
• How to do it:
  • Curl all toes downward firmly (as if gripping the floor)
  • Hold 5 seconds
  • Spread all toes wide apart
  • Hold 5 seconds
  • Relax
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 3-4x daily

• Position: Supine, leg elevated
• How to do it:
  • Turn the sole of the foot inward (supination/inversion)
  • Hold 3 seconds
  • Turn the sole outward (pronation/eversion)
  • Hold 3 seconds
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 3x daily

CATEGORY 2: ISOMETRIC EXERCISES (No Movement at the Hip Joint)

• Position: Lying flat on back, operated leg straight, small rolled towel under the knee
• How to do it:
  • Tighten the thigh muscle (quadriceps) of the operated leg by pushing the back of the knee downward into the bed/towel
  • You should feel the thigh tighten and the kneecap move slightly upward
  • Hold the contraction firmly for 10 seconds
  • Slowly release
  • Rest 5 seconds between reps
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 4x daily
• Important: No pain at the hip or surgical site during this exercise. If pain occurs, reduce effort to 50% and inform your physiotherapist.

• Position: Lying flat on back, both legs straight
• How to do it:
  • Squeeze both buttock muscles together firmly (as if holding something between them)
  • Hold for 10 seconds
  • Slowly release
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 4x daily
• Note: Can be done simultaneously with quad sets to save time

• Position: Supine, with a large rolled towel or firm pillow under the operated knee (raising it to about 30-40 degrees)
• How to do it:
  • Straighten the knee fully by lifting the foot off the bed
  • Hold the knee fully straight for 5 seconds
  • Slowly lower the foot back down - do NOT drop it
  • The hip should NOT move during this exercise
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily

• Position: Supine, operated leg in neutral (no adduction, no crossing)
• How to do it:
  • Place a pillow or folded towel between your knees
  • Press both knees outward against the pillow, as if trying to open your legs but not actually moving them
  • Hold for 10 seconds
  • Release
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Why: This activates the gluteus medius without creating hip movement - safe for NWB phase

CATEGORY 3: SUPINE RANGE OF MOTION EXERCISES

• Position: Lying flat on back on a smooth surface
• How to do it:
  • Slowly slide the heel of the operated leg up toward the buttock by bending the knee and hip
  • Move only within a comfortable, pain-free range - do NOT force beyond 80-85 degrees
  • Hold at end range for 3 seconds
  • Slowly slide the heel back to the starting position
• Sets/Reps: 3 sets of 10-12 repetitions
• Frequency: 3x daily
• ROM limit: Hip flexion maximum 80-90 degrees - do not push beyond this without physiotherapist guidance
• Do NOT: Force the movement, pull with your hands, or bend your hip beyond a comfortable range

• Position: Lying on back on a smooth surface (wooden floor or smooth bed with a plastic bag under the heel to reduce friction)
• How to do it:
  • Keeping the leg straight and the toes pointing upward
  • Slowly slide the operated leg outward to the side (away from midline)
  • Move to maximum 20-25 degrees - do not force
  • Hold 3 seconds
  • Slowly slide back to neutral
  • NEVER cross the leg past midline (surgeon instruction: DO NOT ADDUCT)
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily

• Position: Lying on back
• How to do it:
  • Bend and straighten the non-operated leg fully at the knee and hip
  • This maintains symmetrical lower limb mobility
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 3x daily

CATEGORY 4: CORE AND TRUNK STABILITY

• Position: Lying on back, knees bent, feet flat
• How to do it:
  • Breathe in gently
  • As you breathe out, draw your lower tummy (navel) inward and upward - as if trying to make your belly button touch your spine
  • Do NOT hold your breath
  • Do NOT flatten the entire back - only the lower tummy moves
  • Hold for 10 seconds while breathing normally
  • Release
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Note for a 14-year-old: Think of it as "sucking in your tummy gently" - not a forceful bracing

• Position: Supine or semi-reclined
• How to do it:
  • Place one hand on chest, one on tummy
  • Breathe in slowly through your nose - the tummy hand should rise, chest hand should stay still
  • Breathe out slowly through pursed lips
  • Each breath cycle = 4 seconds in, 4 seconds out
• Sets/Reps: 10 deep breaths
• Frequency: Every 2 hours, especially in the morning and at night
• Why: A 14-year-old post major hip surgery needs lung expansion to prevent chest infection from immobility

• Position: Supine, knees bent, feet flat on bed
• How to do it:
  • Gently press your lower back down flat into the bed by tightening your tummy and slightly tilting your pelvis
  • Hold 5 seconds
  • Release and allow a small arch back in the lower back
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Important: NO lifting of the hips/buttocks off the bed (no bridging until physiotherapist clears it - depends on surgical X-ray findings)

CATEGORY 5: UPPER LIMB AND NON-OPERATED LOWER LIMB EXERCISES

• Position: Seated on a firm chair or edge of bed
• How to do it:
  • Place hands on chair armrests or beside your hips
  • Press down firmly through your arms, lifting your body slightly off the seat
  • Hold 5 seconds
  • Lower slowly
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Why: This builds the triceps and shoulder depressor strength needed to safely take weight through the walker during NWB walking

• Position: Lying on back, non-operated leg straight
• How to do it:
  • Tighten the thigh muscle first
  • Lift the straight leg to approximately 45 degrees
  • Hold 5 seconds
  • Slowly lower - do NOT drop
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily

CATEGORY 6: NWB MOBILIZATION WITH WALKER

• Walker Setup: Adjust walker height so your elbows are slightly bent (about 15-20 degrees) when hands rest on the walker
• Technique:
  1. Stand upright - do not lean forward excessively
  2. Move walker forward one step length
  3. Step through with non-operated leg (right leg)
  4. Bring operated leg (left) forward - toe touch only or swing through, NO weight through it
  5. Move walker forward again
  6. Maintain upright posture - do not lean to one side
• Distance: Start with short distances (50-100 meters per session)
• Frequency: 3-4 short walking sessions per day as tolerated ("walking as frequently as possible" - surgeon instruction)
• At school: Use walker at ALL times. Sit during classes with operated leg elevated on a second chair or footrest if possible.
• Rest: Sit and elevate limb after every 15-20 minutes of activity

CATEGORY 7: LIMB ELEVATION PROTOCOL

• When lying down: Place 2-3 firm pillows under the operated leg from heel to calf - heel and calf supported, knee slightly bent, hip neutral
• The foot should be above the level of the heart (approximately 30-45 degrees elevation)
• When sitting: Place a stool or chair in front of you to rest the leg at hip height or slightly higher
• Duration: Elevate whenever resting - aim for minimum 2-3 hours of elevation during the day
• At school: Request a chair to rest the leg on when sitting at a desk

DAILY SCHEDULE (Sample for Atharva - School Day)

WHAT NOT TO DO - EXERCISE PRECAUTIONS (From Report)

IMPORTANT NOTES FOR ATHARVA'S PHYSIOTHERAPIST

1. Current status at 8-9 weeks post-op: If follow-up X-ray on 08/07/2026 shows early callus formation, weight bearing progression (partial WB 25-30%) will be cleared by Dr. Taral Nagda. Prepare the patient for this transition with exercises 12, 13, 14 already established.
2. Bridging: Can be introduced after follow-up clearance if X-ray is satisfactory.
3. The child is 14 years old - bone healing is faster than adults; however, the correction is severe (Level 4, Grade 5), so do not accelerate beyond surgeon clearance.
4. School attendance: Permitted but ensure the school has facilities to rest the leg elevated. Walker must be used at all times on school premises.
5. Progress to watch before 08/07 follow-up:
   • Hip flexion ROM achieving 80-90 degrees
   • No wound complications
   • No calf swelling or fever (DVT signs)
   • Consistent pain < 3/10 at rest

CONTACT SURGEON IMMEDIATELY IF:

• Sudden sharp pain at surgical site
• Wound oozing, redness, or smell
• Leg swelling especially in the calf
• Fever above 38.5°C
• Operated leg appears rotated differently or shorter than before

REVISED PHYSIOTHERAPY EXERCISE PLAN

Patient: Master Atharva Dhananjay Shevalkar | 14y 10m | Male

Status: Full Weight Bearing with Walker | ~8-9 Weeks Post Left Morscher's Varus Osteotomy

Current Phase: Phase 2-3 Transition | Pre-Follow-up (Next: 08/07/2026)

⚠️ CRITICAL CLINICAL NOTE BEFORE STARTING

• Maintain the walker - do NOT wean to single crutch or unsupported walking until X-ray on 08/07/2026 confirms callus
• No adduction remains a hard rule throughout
• No impact loading (running, jumping) until full radiological union
• The exercises below reflect FWB status but still protect the osteotomy from rotational stress and impact

REVISED EXERCISE PROGRAMME - FULL WEIGHT BEARING PHASE

CATEGORY 1: GAIT RETRAINING (Top Priority Now)

• Position: Standing upright with walker in front
• How to perform correctly:
  1. Stand tall - ears, shoulders, hips in one vertical line. Do NOT lean forward over the walker
  2. Advance walker one step ahead
  3. Step forward with the non-operated right leg first - full heel-to-toe contact
  4. Step through with operated left leg - full heel-to-toe contact, equal step length
  5. Avoid hip hiking (lifting the pelvis on the left side during swing)
  6. Avoid lateral trunk lean to the right during left leg stance
  7. Keep toes pointing forward - not excessively turned out
• Distance/Duration: 3-4 sessions daily; 100-200 meters per session
• Surface: Start on flat even ground; progress to slight inclines after 1 week
• Key cue for Atharva: "Walk tall, even steps, equal time on each leg"
• At school: Walker at all times in corridors; avoid crowded areas where falls are possible

• Position: Standing at walker, feet shoulder-width apart
• How to perform:
  • Slowly shift your body weight sideways onto the operated left leg
  • Hold for 5 seconds feeling the weight through the left foot
  • Shift back to center
  • Then shift onto the right leg
  • Shift back to center
  • This is a slow, controlled rocking motion - not a sway
• Sets/Reps: 3 sets of 10 shifts each side
• Frequency: 3x daily
• Why: Begins loading the operated leg in a controlled way; trains the hip abductors to accept load

• Position: Walking with walker on a tiled or marked floor
• How to perform:
  • Mark two lines on the floor with tape approximately 40-45 cm apart (normal step length for a 14-year-old)
  • Practice stepping so each foot crosses to the opposite tile line
  • Focus on equal step length on both sides
  • Count steps aloud: "left, right, left, right" at an even rhythm
• Duration: 5-minute sessions
• Frequency: 2x daily
• Why: After major hip surgery children habitually develop an antalgic short-step on the operated side; correcting this early prevents long-term gait abnormalities

CATEGORY 2: STANDING HIP STRENGTHENING (Now Possible with FWB)

• Position: Standing at walker, operated leg performing the movement
• How to perform:
  • Stand on the right (non-operated) leg
  • Hold walker firmly with both hands
  • Slowly lift the left (operated) leg out to the side, keeping the knee straight and toes pointing forward
  • Lift to approximately 20-30 degrees only - do NOT force
  • Hold for 3 seconds at the top
  • Slowly lower - do NOT drop the leg
  • Maintain upright trunk - do NOT lean to the right
• Sets/Reps: 3 sets of 10-12 repetitions
• Frequency: 3x daily
• Progression: When 3x12 is easy with no pain, hold 5 seconds at the top
• Do NOT: Swing the leg, use momentum, let the trunk lean excessively

• Position: Standing at walker
• How to perform:
  • Stand on right leg, hold walker firmly
  • Slowly move the left leg backward (hip extension) - keep knee straight
  • Move only 15-20 degrees behind neutral - do NOT hyperextend
  • Hold 3 seconds
  • Slowly return to neutral
  • Keep your back straight throughout - do NOT arch the lower back
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Key cue: "Squeeze your buttock as you take the leg back"
• Why: Gluteus maximus strength is essential for stair climbing, sitting to standing, and normal gait push-off

• Position: Standing at walker, feet shoulder-width apart, both feet flat
• How to perform:
  • Hold walker for support
  • Slowly bend both knees to approximately 20-30 degrees only (very small squat)
  • Keep heels flat on the floor
  • Keep knees tracking over toes (do not let knees fall inward)
  • Hold 3 seconds at the bottom
  • Slowly straighten back up
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Critical limit: 20-30 degrees only - this is not a full squat. Do NOT go deeper than this at this stage
• Why: This is the first closed-chain strengthening exercise - loads quadriceps, gluteals, and hip extensors together in a functional pattern

• Position: Firm chair (not too low) with walker in front
• How to perform - Standing Up:
  1. Slide to edge of chair
  2. Place operated foot slightly back (not far back, just level with or slightly behind the other foot)
  3. Lean forward slightly at the trunk - "nose over toes"
  4. Push up through BOTH legs equally - push the floor away
  5. Grip walker and straighten up fully
• How to perform - Sitting Down:
  1. Back up to chair until you feel it behind both legs
  2. Reach back with one hand while gripping walker with the other
  3. Lower slowly using both legs - do not drop
  4. Land on middle of chair - do not let the hip slam down
• Sets/Reps: 3 sets of 10 repetitions (stand up and sit down = 1 rep)
• Frequency: 3x daily - also practice during natural daily activities (every time you sit or stand from a chair, do it with this technique)
• Chair height: Keep chair height so hip is at or slightly above 90 degrees - NOT a low sofa or floor-level seat

• Position: Standing at walker, both feet flat
• How to perform:
  • Rise up on both tiptoes as high as comfortable
  • Hold 3 seconds
  • Slowly lower both heels - do NOT let heels drop suddenly
• Sets/Reps: 3 sets of 15 repetitions
• Frequency: 3x daily
• Why: Maintains calf strength and venous pump function; also improves ankle proprioception for safe walking

CATEGORY 3: PROGRESSIVE HIP ROM EXERCISES (Upgraded for FWB Phase)

• Position: Standing at walker
• How to perform:
  • Hold walker firmly
  • Slowly lift the left knee upward as if marching - to approximately 60-70 degrees hip flexion
  • Hold 3 seconds
  • Slowly lower - do NOT drop
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• ROM limit: 70 degrees maximum in this phase (not a high knee lift)
• Do NOT: Swing the knee up with momentum; avoid any pain at the groin or surgical site

• Position: Lying flat on back
• How to perform:
  • Slide the left heel toward the buttock by bending knee and hip
  • Move to comfortable end range (targeting 90-100 degrees by this phase)
  • Hold 5 seconds
  • Slide back slowly
• Sets/Reps: 3 sets of 12-15 repetitions
• Frequency: 3x daily
• ROM target at 8-9 weeks: 90-100 degrees hip flexion
• Progress: When 90 degrees is achieved pain-free, you can add a gentle overpressure with hands clasped around the thigh (NOT the shin) to reach 100 degrees

• Position: Lying face down on bed or firm surface; small pillow under lower tummy for comfort
• How to perform:
  • Tighten the buttock muscle of the left leg
  • Lift the entire left leg straight up off the bed - about 10-15 cm
  • Hold 3 seconds
  • Slowly lower
  • Keep the pelvis flat on the bed - do NOT rotate or hike the hip
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 2x daily
• Why: Prone lying itself is therapeutic at this stage - it stretches the anterior hip capsule and hip flexors which tend to tighten after varus osteotomy. Aim for 20-30 minutes of prone lying daily even without exercise.

• Position: Lying on back on smooth surface
• How to perform:
  • Slide operated leg outward to 30-35 degrees (increased from NWB phase)
  • Hold 3 seconds
  • Return slowly to neutral
  • Still: DO NOT adduct past neutral (surgeon instruction remains)
• Sets/Reps: 3 sets of 12 repetitions
• Frequency: 3x daily

CATEGORY 4: CORE AND LUMBOPELVIC STABILITY (Essential at This Stage)

• Position: Lying on back, knees bent to 90 degrees, feet flat on bed hip-width apart
• How to perform:
  • Tighten tummy (transversus abdominis) first
  • Tighten buttock muscles
  • Slowly peel the lower back, then mid back off the bed, lifting hips up
  • Lift until body forms a straight line from knees to shoulders
  • Hold 5 seconds at the top
  • Slowly lower - vertebra by vertebra, from upper back down to lower back
  • Do NOT bounce at the bottom
• Sets/Reps: 3 sets of 10 repetitions
• Frequency: 3x daily
• Progression in 1-2 weeks: Hold bridge position for 10 seconds; then progress to single-leg bridge (non-operated leg only) when comfortable

• Position: Lying on back, arms pointing straight up to ceiling, knees bent at 90 degrees (tabletop position)
• How to perform:
  • Brace the core (tummy tight, back pressed to floor)
  • Slowly lower the right arm overhead toward the floor AND simultaneously lower the left leg (operated) toward the floor - both moving at the same time
  • Lower to just above the floor (do not touch)
  • Hold 3 seconds
  • Return both to starting position
  • Repeat with the opposite arm and leg
• Sets/Reps: 3 sets of 8 repetitions each side
• Frequency: 2x daily
• Key: Lower back must stay flat against the floor throughout - if it arches, stop and do not go as far

• Position: Lying on the right (non-operated) side, body in a straight line
• How to perform:
  • Tighten the core
  • Lift the left (operated) leg upward - keeping it in line with the body (not angled forward)
  • Toes should point slightly downward (this targets gluteus medius specifically)
  • Lift to 30-35 degrees maximum
  • Hold 5 seconds
  • Slowly lower - do not drop
• Sets/Reps: 3 sets of 12 repetitions
• Frequency: 3x daily
• Progression in 1-2 weeks: Add a light resistance band around the thighs
• Why: Gluteus medius is the primary hip abductor. After varus osteotomy it is mechanically altered - rebuilding its strength prevents Trendelenburg gait

• Position: Lying on the right side, hips bent to 45 degrees, knees bent to 90 degrees
• How to perform:
  • Keep feet together stacked
  • Keeping feet together, rotate the top left knee upward - opening like a clamshell
  • Open to 30-45 degrees
  • Hold 5 seconds
  • Slowly close - do not let gravity drop the knee
• Sets/Reps: 3 sets of 12 repetitions
• Frequency: 3x daily
• Why: Targets deep external rotators (piriformis, gemelli, obturators) without loading the hip - important for hip joint stability after osteotomy

CATEGORY 5: STAIR TRAINING (Permitted at FWB with Walker/Rail)

• Equipment: A single step or low platform (15 cm high maximum) + handrail
• Going UP:
  1. Stand facing step, operated leg stepping UP first
  2. Place left (operated) foot fully on the step
  3. Push through the left leg to bring the body and right leg up
  4. Stand on the step
• Coming DOWN:
  1. Non-operated right leg steps DOWN first
  2. Lower slowly with left leg controlling the descent
  3. Both feet on lower level
• Sets/Reps: 3 sets of 10 step-ups each leg
• Frequency: 2x daily
• Safety: Always use handrail + walker or wall for support; never attempt stairs alone without support
• Note for school: Use elevator where possible; if stairs unavoidable at school, use handrail and go slowly

CATEGORY 6: STRETCHING AND FLEXIBILITY

• Position: Standing at walker in a small lunge position
• How to perform:
  • Place the right foot forward and left foot back (a small lunge, not a deep one)
  • Keep the left knee slightly bent - do NOT fully kneel
  • Gently shift body weight forward until you feel a stretch at the front of the left hip and thigh
  • Hold 20-30 seconds
  • Release slowly
• Sets/Reps: 3 repetitions each side
• Frequency: 2x daily (especially after sitting for long periods at school)
• Why: Hip flexors (iliopsoas) tighten significantly after hip surgery; this restricts hip extension and causes a flexed-hip walking pattern

• Position: Lying on back
• How to perform:
  • Bend the left hip to 90 degrees (knee bent initially)
  • Slowly straighten the knee until a stretch is felt at the back of the thigh
  • Hold 20-30 seconds
  • Keep the lower back flat - do NOT let it arch
• Sets/Reps: 3 repetitions
• Frequency: 2x daily
• Do NOT: Pull on the leg forcefully or create hip flexion beyond 90 degrees at this stage

• Position: Standing at walker, facing a wall
• How to perform:
  • Step the right foot forward, left foot back
  • Both feet flat, back knee straight
  • Lean gently into the wall - feel stretch in the left calf
  • Hold 20-30 seconds
• Sets/Reps: 3 repetitions each side
• Frequency: 2x daily

DAILY SCHEDULE - REVISED FOR FWB STATUS (School + Home)

PROGRESSION TARGETS - TO BE ASSESSED AT 08/07/2026 FOLLOW-UP

IF X-RAY ON 08/07/2026 CONFIRMS BONE CALLUS - NEXT STEPS

1. Stationary cycling (elevated seat, no resistance initially)
2. Single-leg balance progression (operated leg, near support)
3. Resistance band exercises for all hip directions
4. Begin walker-weaning - progress to single crutch or forearm crutch
5. Hydrotherapy/pool walking if wound fully healed
6. School PE participation (non-impact only - swimming, walking)

ABSOLUTE RESTRICTIONS - STILL IN PLACE

WHEN TO STOP AND CONTACT SURGEON

• Sharp pain at the surgical site during or after any exercise
• Sudden change in how the leg feels (rotation, length)
• New or worsening swelling
• Pain that does not settle within 30 minutes of stopping exercise
• Any fever or wound changes before 08/07/2026 appointment