Total Hip Rehabilitation:

The latest advances

Bridgit Finley, PT, DPT, M.Ed., OCSBoard Certified in Orthopaedics

bfinley@ptcentral.orgwww.ptcentral.org

Facebook

Physical Therapy Central

Choctaw Chickasha Newcastle NormanOKC Pauls Valley Stillwater

ObjectivesCourse Objective:The course participants will be able to: Understand the surgical procedures and

contraindications with specific exercises. Describe normal biomechanics for the hip

joint. Implement the use of outcome measures for

patient’s that have had hip surgery. Utilize the internet to access information in

regards to evidence based practice. Effectively progress patients through the

rehabilitation protocol.

Course Schedule

Evidence Based PracticeAnatomyBiomechanicsHip O-A & SurgeryManual Therapy

Therapeutic ExercisesOutcome Measures

Vision 2020 The first, best choice in musculoskeletal care.

Resources APTA JOSPT Physiopedia Evidence in Motion AAOMPT PEDro NAIOMT

Life Long Learners

Patient Access Autonomous Experts Take our game to the

next level– Specialty Certifications– Manual Therapy

Certifications– DPT

Evidence Based Practice

Integration of the best research evidence with clinical expertise and patient values.

Levels of Evidence– Systematic Reviews– Case Series– Expert Opinion

American Physical Therapy Association Consumers Professional Development Advocacy Reimbursement Learning Center Hooked on Evidence

– Database current research– Earn CEU’s

JOSPT

Journal of Orthopaedic & Sports Physical Therapy

Searched– Hip Arthritis

20 AbstractsFull Text Articles

NAJSPT

Sports Physical Therapy SectionHip ArthritisNorth American Journal of Sports

Physical Therapy

Overview of the Hip

Overview of the Hip

OSTEOARTHRITIS In US, 100 Billion Health Care $ by

2020Progressive loss of articular

cartilage with variable subchondral bone loss.

Prevalence – 10 to 25% in adults age 55 and older.

43 Million people in USStandard of care is THA

Total Hip Arthroplasty

The most common surgical procedure for end-stage hip osteoarthritis.

Primary reason for surgery is pain which interferes with ambulation.

American College of Rheumatology

Classification Hip OA– Cluster 1

Pain in the hip < 115 hip flexion < 15 IR

– Cluster 2 Pain with IR < 60 minutes

morning stiffness > 50 yrs. old

Current guidelines focus on pharmacological and surgical management

X-Ray

Demonstrate loss of joint space, osteophytes and sclerosis.

Dysplasia– tears are more

common in individuals with acetabular dysplasia.

600,000

THA Procedures Performed

Annually

600,000

THA Procedures Performed

Annually

In US, between 1990 and 2002, THA rose from 119,000 to 193,000 annually.62% increase

Total Hip Arthroplasty

The first joint replacement, a total hip arthroplasty, was performed in 1936.

Most widely performed orthopedic procedure performed on adults.

In 2008, the average hospital and physician charge for a THA totaled $ 45,000.

Prosthesis

Materials– Glass– Pyrex– Ivory– Plastics

Dr. Charnley in 1960 developed a low friction

All new designs are adapted from his design.

Artificial Joint

Titanium hip prosthesis

Ceramic head Polyethylene

acetabular cup

Zimmer

Health Care Costs

Physical Therapy 12 visits Manual Therapy

and exercise $1,200

THR $45,000 Surgery,

hospitalization and rehabilitation

Risks and Complications

Medical Risks Heart Attack Stroke Venous

Thromboembolism 1%

Pneumonia UTI Infection 0.2 – 1%

Intra-operative Mal-positioning

– Short/Long 1%– Instability– Loss of ROM

Fracture 2-5% Nerve Damage 1% Dislocation 4-10%

Long Term Risks

Osteolysis– Loosening of the

components– Cement breaks

down– Wear debris– Inflammatory– Pain

Polyethylene wear rate is 0.3mm year

Wear debris Body will absorb

the metal

Osteolysis

Cascade starts from particles

The body creates an inflammatory response.

Re-absorbs the bone.

12 months

A Squeaking hip ?

Stryker Highly durable

ceramic hips in 2003.

7% of patients from 2003-2005 developed squeaking

Squeaky Walk

Trendelenburg

(+) for weakness in Abductor muscles

Tendinous avulsion

Sonography used to diagnosis

Test Gait

Glut Medius controls Adductor MomentHip Abductor

function in closed chain is to maintain a level pelvis.

Trendelenburg Gait

Have patient stand on one leg and assess if the pelvis drops.

(+) Trendelenburg Sign

Subjective History

DJD (> 50)Usually no specific mechanism of

injuryGroin pain; behind greater

trochanter, anterior thigh to kneeStiffness in the morningLoss of ROM (Flexion, IR) Increased pain with WB (bony)

Functional Limitations

WalkingStair climbingPutting on shoesShaving legsRising from a chair

Causes of Hip OA

Congenital Dysplasia– Genetics

Disease Process Trauma Compensation

– Leg length, lumbar pathology

X-Ray

Gold Standard

– Joint Space Narrowing

– Osteophytes

– Subchondral Bony Change

Femoroacetabular Impingement (FAI)Contact between the femoral

head-neck junction and the acetabular rim.

Impingement occurs with the combined movement of hip flexion, adduction, and internal rotation.

Precursor to early hip O-A

Acetabular labral pathology secondary to femoroacetabular impingement (FAI)

Acetabular labral pathology is frequently present in highly active individuals 20-40 yo.

Gradual on-set with repetitive microtrauma.

Diagnosis of FAI

Scour Test– FADIR – anterior-superior labrum– EABDER – posterior-inferior labrum

Log Roll Test

Scour Test The examiner moves the

patient’s hip through a range of motion from hip flexion and adduction to hip extension and abduction, while adding a compressive force through the hip joint as well as movement into hip internal and external rotation. The test is considered positive if there is a reproduction in hip pain and/or intraarticular joint clicking.

Log Roll Test The examiner passively

moves the patient’s lower extremity through the maximal available range of hip external (A) and internal rotation (B).

Eliciting a clicking or popping sensation may indicate an acetabular labral tear, while increased total range of motion when compared to the opposite side may indicate ligament or capsular laxity

Impingement Test The examiner passively

moves the patient’s lower extremity into a position of hip flexion, adduction, and internal rotation.

A positive test is reflected by increased hip or groin pain.

FABER Test The examiner passively

positions the testing limb in a position of hip flexion, abduction, and external rotation.

The examiner assesses the perpendicular distance from the knee on the tested lower extremity to the table.

A decrease in this distance or pain, when compared to the uninvolved side, is

suggestive of intra-articular hip pathology.

Hip Impingement

Hip Special TestsMartin et alJOSPT July 2006 Intra-articular Tests

FABER Test Scour Test Resisted SLR Log Roll Test Distraction FAI

Hip Arthroscopy

Recent Developments

Recent Developments

Clinical Prediction RuleChilds September 2008

Loss of IR– < 15 degrees

Loss of Flexion– < 115 degrees

(+) Scour Test (+) FABER Test (+) Hip Flexion

Test

Twenty-one (29%) of the 72 subjects had radiographic evidence of hip OA.

A clinical prediction rule consisting of 5 examination variables was identified.

If at least 4 of 5 variables were present, the positive LR was equal to 24.3

95% confidence interval: 4.4-142.1, increasing the probability of hip OA to 91%.

Diagnosis Hip O-A

Made with certainty on the basis of history and physical exam.

X-ray is definitive CPR – Child’s et al.Hip Guidelines – CibuklaPhysiopedia

1975 Management THA

Phase I – immobilization. If unstable will use hip spica cast x 3 weeks. (2-5 days)

Phase II – mobilization. Isometric, isotonic (AAROM, AROM). Trochanter detached and transplanted distally. 2-3 week and D/C to home. Crutches x 8 weeks. Walk day 7 - WBAT

ROM goals– Flexion 90, ER 15, Abd 15, IR 0, Add 0

2010 THA Management

Hospital 1-3 days/Out-patientAmbulate day 1 – FWB

– AROM day 1– Isotonic week 1– C-V by day 10

ROM goals– Flexion 125, Add. 30, ER 50, IR 30 by

week 12

MusclesMuscles

Gluteus Medius

Gluteus Medius – main hip abductor

Primary stabilizer of hip and pelvis

Trendelenburg sign

Gluteus Maximus

TFL envelops the muscles of the thigh

Counteracts the backward pull of the gluteus maximums of the ITB.

Hip extensors are 3 times as strong as the flexors

Psoas

Iliopsoas bursa – present in 98% of adults.

Lies under the psoas tendon

Overuse and impingement syndromes

SLR Exercises

Must have excellent core strength

This is a core exercise,

If neutral pelvis is not maintained

Hip External Rotators

Hip capsule is cut and the ER are retracted so that the joint can be exposed.

THA – now most repair the capsule

Surgical Incisions

Journal of Orthopedic Surgery Chung, et al. Smaller incision Operating time Blood loss Narcotic use Length of Stay Assistive device Harris Hip Score

2004 9.2 20 49 55 136 200 2.2 2.64 4.4 5.4 21 25 95 93

Metal-on-Metal Hip Resurfacing

Arthroplasty

Metal-on-Metal Hip Resurfacing

Arthroplasty

Resurfacing

Main advantage is bone conservation for younger patients

Early resurfacing failed because of polyethylene

5 year follow-up excellent resultsComplication

– Femoral neck fracture– Osteonecrosis

High Failure Rate

1970, materials available at the time had insufficient wear resistance

Incorrect patient selection1999, re-introduced Same revision rate as THA at 4

years– Women 2 x than men– 1-3%

Design

Metal on Metal– Cause release of inflammatory

cytokines– Metal allergy

Large ball – decrease wear rateCementedTHA - Cementless acetabular

fixation – bony in growth

Patient Selection

Young and active Isolated hip diseaseExcellent bone qualityNormal kidney function

Contra-indicatedSevere acetabular dysplasiaObesity

Surgery

High learning curve– Posterior approach – Capsulotomy – preserve lateral

muscles but sacrifice medial circumflex artery

– Implant positioning– Limited candidates

Outcomes

94-99% survival rates at 5 years446 hips, patients < 55 yrs oldPrimary diagnosis of OANo difference in ROMGait analysis – no difference THAHip impingement

Birmingham Hip Resurfacing

Traditional THA

Floyd Landis

Won the Tour de France in 2006

Stripped of his title

Road with Lance 2002-2004

Osteonecrosis – crash in 2002

Sept 2006 Surgery

Tour de France

Birmingham Hip Resurfacing Part 1 Part 2 Part 3 Part 4 Part 5

Rehabilitation Considerations

Surgical ApproachSelection of appropriate hip

precautionsCemented vs. non-cementedWeight bearing precautionsEarly mobilization (prevent DVT)Early rehab can improve short

term outcomes.

BioengineeringBioengineering

Viscosupplementation

Injection of artificial lubricants into the joint.

Centeno et al. reported on the partial regeneration of an arthritic human hip joint using mesenchymaltem cells.

BiomechanicsBiomechanics

Hip Dysplasia

Displacement of femoral head in acetabulum

Left hip is more often involved

80 % Females Breech birth First born

Hip Dysplasia

Less degress of femoral head coverage

Decreased joint surface areaNormal 30-40%Angle of inclination >125 degrees

Increased femoral anterversionAcetabular retroversionMcCarthy & Lee found 72% of

patients with dysplasia had labral tears

Ball and Socket Joint

Flexion to 110-120Extension 10-15

Abduction 30-50Adduction 25-30ER 30-45

IR 20-35

Rolls anterior glides posteriorRolls posterior glides anteriorRolls laterallyRolls mediallySpins anteriorly and laterallySpins posteriorly and medially

Mobilization

Flexion

ExtensionAdduction Internal Rotation

Posterior / Inferior GlideAnterior GlideLateral GlideLateral Glide

Distraction

General joint mobility

Can be diagnostic

Gentle let off Place in open

packed position Don’t grab ankle

Posterior

Gain – Flexion– Adduction

Be careful not to create impingement

Exercise

Posterior Mobilization

Psoas & TFL Release

Follow with psoas stretch

Psoas Stretch

Avoid lumbar extension

Have patient posterior pelvic tile

Can flex or extend the knee

Lateral Mobilization

Gain– Adduction– Internal Rotation

Lateral Mobilization

To gain adduction

Can also work on ER

Lateral Mobilization

Patient self mob Must stretch

lateral structures ITB

– Don’t let hip IR

Inferior Mobilization

Excellent technique to use with hip impingement

Test – re-test

Caudal/Inferior Mobilization

Mulligan technique – mobilization with movement.

Measure flexion or IR and mobilize and re-measure

Anterior Mobilization

Assess gait– Pelvic wink

To gain extension and external rotation

Stress the anterior labrum– If had labral

repair

Anterior Mobilization

Mobilize anterior capsule

Self stretch and exercises – army crawl

Anterior Self Stretch

Kneeling Mobilization

Psoas and TFL stretching

Cyriax

Capsular pattern – specific and proportional loss of movement

Most common cause of capsular pattern is arthritis

Capsular Pattern

Cyriax IR Flexion Abduction

If capsular pattern of restriction; joint is arthritic.

If non capsular pattern; not joint.

Cyriax listed in ascending order

– Loss of internal rotation– More than flexion– More than abduction

Noncapsular Restrictions

FracturesOsteomiylitisLabral tearsCancer

BursitisCapsular Irritation

– Synovitis– Impingement

Resting Closed Packed

Flexion 30 degreesAbduction 30 degreesExternal Rotation 10-15 degrees

ExtensionAdduction Internal Rotation

Stable position of the jointTighten capsule

Muscle Imbalances

TightnessPsoasAdductorsQuadratus LumborumTFLPiriformis

WeaknessGlut MaximusGlut MediusQuadsHip ERCore Muslces

– Abs– Errector spinae

FACILITATED MUSCLES

Iliopsoas Rectus Femoris TFL QL Hip Adductors Piriformis Hamstring Lumbar Erector

Spinae

Medial Hip Mobilization

Makofsky, et al. Journal of Manual

and Manipulative Therapy 2007

Increase in abductor muscle force

Prior to exercise

Abductor Strength

Outcome

Measures

Outcome

Measures

Lower Extremity Function ScaleOrdinal Scale 0 “extreme

difficulty” to 4 “no difficulty”Patient rate ability to perform 20

different activities0 to 80 scale, 80 no limitations.Minimum detectable change 9

scale points

Harris Hip Score

Scores on 10 different variables– Pain– ROM– Gait– ADLs

Score range from 0 “worst” to 100 “best”.

Harris Hip Score

Hip Outcomes Measures

Validity Reliability Includes

– Pain– ROM– Function

Surgeon & Patient disagree on outcomes

Harris Hip Score Charnley Score Oxford Hip Score The Hip

Disability and Osteoarthritis Outcome Score

Patient Based Scales

Site Specific– Oxford Hip Scale

Health Status– Designed for RA– 20 Tasks– SF-12

Disease-Specific– Hip & Knee OA– WOMAC

Oxford– 12 item

questionnaire– THR– Validated against

SF-36– Short, practical

and valid

Activity Limitation

6 Minute Walk Test How far a person can

walk in 6 minutes. Can use walking aids. Treadmill is good.

Stair Measure Patients are

instructed to ascend and descend 9 stairs (step height 20cm)

Timed measure in seconds

Rehabilitation Protocol

AgeHealth Status

– Control pain and swellingBody WeightBody Build -

Week 2-3

Goals– Patient Education– Decrease Edema– Incision Healing– Independent HEP– ROM: flexion 90, abduction 35, ER

35, IR 20, adduction 20

Treatment

ModalitiesMFR/ MassagePROMTransfer and gait trainingRhythmic StabilizationMET / Manual Stretching

Modalities

US– At incision and piriformis/ITB

NMS– Glut Medius with isometric ABD.

IFC & CP– Control swelling and pain– At the end of treatment

Manual Therapy

MFR– ITB– Piriformis– Psoas

Hip PROM

Watch for compensation at the pelvis.

Capsular pattern?

End-feel? Pain?

PROM

Hip Rotation

PROM of left hip Loss of IR > loss

of hip ER End-feel usually

empty and painful.

MET – manual stretching

Soft tissue and capsular tightness

Have not moved hip though this motion in years

Gait

Hip extension– 15-20 degrees

Pelvic– Rotation– Side bending

Most patients will have LBP

Rhythmic Stabilization

Neutral Position– Manual

resistance in ER and IR

Muscle Energy Technique

Hamstrings Psoas Lumbar Spine

Hamstring Stretch

Lumabr spine is protected

Increase stretch with APT

Contract quads will inhibit hamstrings

Exercises

Exercise Pro Handout Week 2-3

Week 5-6

Hip Flexion 100-110, add. 40, ER 40, IR 30

Quad/Ham strength 70%(-) Trendelenburg Initiate Hip PRENeutral alignment lumbar spine

Treatment

Myofascial Release– Psoas– Posterior Hip Capsule

PROM/Jt. MobilizationCore Stabilization

Thomas Test

Psoas Stretch– Thigh off the

table– Tight iliopsoas

and rectus femoris muscle (knee flexion)

Mobilization

Leg traction – inferior glideDistraction – inferior or caudal

glide.Mobilization with movement

– Belt– MET to restore IR/ER or hip flexion

Joint Mobilization

Whitman & ClelandSeptember 2007

Hip OA when treated with manual therapy (mobilization)– 5 PT sessions– Total PROM increases 82 degrees– Harris Hip Score 25 points

Case Report JOSPT Dec. 2007Vol. 37, Num. 12

73 yo female with THA revision2 yrs s/p revision admitted to

hospital 10/10 hip pain after lifting her foot to put on her shoe

X-ray normal d/cPT – manual therapy – 4 PT visits4 year follow up

Proprioception

Arthritic hips lose input secondary to loss of articular cartilage.

THR – no input from the hip joint. Must retrain neuromuscular system.

Balance activities.

Airplane

Balance Hip Strength Functional

Therapeutic Exercise

THA Protocol Exercise Pro Handout

Week 5-6

Week 6-12

Walk 1 mileC-V Endurance 20-40 minutesPain FreeEqual strength between legsFlexion 130, ER 45, IR 35

S.E.R.F. Strap

Pulls the hip into ER

JOSPT September 2008 Vol 38, N 9

50% self report decrease pain

Decreases hip impingement

Treatment

D/C all modalitiesManual techniques if necessary

Exercise Pro Week 6-12

10 days S/P 12 Weeks

Contraindications

Home exercises. Exercises were commenced following manual physical therapy in the clinic

Upright bicycle: 10 – 20 min Gluteus medius clamshell exercises: 3

sets of 12 Hip abduction in sidelying: 3 sets of

12 Core transverse abdominus: 2 sets of

20 in supine with hips flexed to 45° Bridge with straight leg raise: 3 sets

of 10 Hip flexor stretch kneeling or

sidelying: 30 sec × 3 Single leg balance: up to 60 sec Tandem stance eyes open or closed:

up to 60 sec

• Recumbent Bike• SLR• Aggressive Glut Medius Strengthening

QuestionsQuestions