PT on the Net Research

Hip Replacement


Question:

Do you have any information on hip replacement? The very last article in the research corner was by Steve Rhyan, written in November 2000. I am wondering if an update could be done. My question is, what are some restrictions with a hip replacement client after undergoing Physical Therapy? Are there any exercises or successful programs that trainers have used to strengthen the hip, quads and hamstrings and improve flexibility?

Answer:

There have been some significant advances in the procedures and materials used for the hip replacement, also referred to as a Total Hip Replacement (THR), in the last five years. The incisions are much smaller, the abductor muscles are not cut and the joint capsule is preserved. These advances equate to a more stable joint, quicker return to activity and decreased risk of dislocation of the prosthesis.

Many of the standard and traditional precautions still apply during the first eight weeks post op. But then, depending on the physician who performed the replacement, many of these traditional precautions are no longer concerns. They include:

Part of your decision-making process when developing an exercise program for someone with a THR will be dependent on how long ago they had the procedure as it relates to the advances just mentioned. If they had the procedure 10 years ago and have been out of physical therapy almost as long, that client presents different concerns then a client who had the THR six months ago. The older procedures often carry the restrictions against flexion of the hip beyond 90 degrees coupled with external rotation as well as abducting the hip past the midline when it is flexed to 90 degrees or more. Both of these movements have been associated with dislocation of the hip or decreasing stability of the joint. The client with the more recent procedure but more advanced techniques may actually have less restrictions then the client who had the procedure many years ago. Some hip replacement patients are back playing golf three to six months post op.

Another key question is how soon after physical therapy are you seeing this client? And how many sessions did they have? If you are seeing them directly after being discharged and their insurance limited their number of visits, the best approach would be to continue the directives of the treating physical therapist. If you are seeing them several weeks or months after therapy, many of the advances in functional principles apply to this population as they do with others.

Begin with your musculoskeletal assessment. If the client only has one hip replacement, it is likely there is a history of asymmetrical weight bearing that led to or accelerated the degeneration of that hip. Secondly, an unfortunate side effect for some THAs is an acquired leg length discrepancy because the length of the femoral neck/femoral head prosthesis is not exactly the same as the patient’s original parts. Both of these characteristics should be a key component to your corrective strategy.

The older THR techniques involved cutting through the hip abductor muscles, and often left patients deficient in these key pelvic stabilizers. Observing the client’s gait and watching for a pelvic list during the weight acceptance and stance phase of their gait can let you know if the hip abductors are not stabilizing in the frontal plane. Another option is observing them using a single leg stance assessment. The single leg stance assessment will also help you identify balance and proprioceptive deficits of the involved extremity.

Any procedure that cuts through the muscle and joint capsule will negatively affect proprioception of that joint, as will immobilization during recovery. Part of your progressions should involve proprioceptively challenging stabilization exercises beginning with two legs and progressing to unilateral activities.

Be aware of any substation movement patterns your client may have carried over prior to the surgery as well as newly learned compensations. These won’t be evident only in the involved hip. There are likely to be changes at the knee and ankle on the involved side, the lumbar spine and opposite shoulder girdle.

Your long term goal with your client should be integrative exercises that are transferable to their activities of daily living or recreational activities. These must ultimately involve closed kinetic chain exercises that place a simultaneous demand on the ankle knee and hip, with varying degrees of involvement of all three planes of motion.

Although I have not read this anywhere, common sense tells me not to attempt any myofascial release with the foam roller directly over the prosthesis. I would be concerned that any direct pressure with the roller on the prosthesis could promote instability.

We should all get ready to see more clients with THR and total knee replacements. The American Academy of Orthopedic Surgeons released a projection study earlier this year, predicting that between 2005 and 2030, the number of first-time hip replacements will increase 174 percent (to 572,000 a year) and total knee replacements will increase 673 percent (to 3.5 million a year)!

Finally, it is always prudent of follow up with your client’s surgeon and/or therapist when possible to gather their input. The bodies of the clients I see with THR are as varied as the bodies I see without them.