The document discusses physiotherapy for hip joint arthritis. It describes clinical tests and symptoms for hip arthritis including limited internal rotation and pain. It outlines a 3-phase treatment approach focusing initially on pain relief, then restoring range of motion and strength, and finally maintaining full function. Exercises provided for each phase target the hips, thighs, and low back. Precautions are discussed for both pre-and post-operative periods, including the use of assistive devices and avoidance of certain motions.
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HipArthritis
The classic clinical test for hip arthritis is internal rotation of the hip in
flexion.
With hip arthritis internal rotation will be limited and painful.
Differential diagnoses
Radiographic examination includes an AP and lateral views (modified
frog-leg lateral or Lauenstein) of the hip.
Hip dysfunction and Osteoarthritis Outcome Score (HOOS)
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Problem List
Hip joint pain or tenderness
Hip stiffness, particularly early morning stiffness.
Limited hip joint movement
Weak hip muscles, especially during sit to stand, squatting and stair
climbing.
Hip joint swelling or deformity
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Treatment
PHASE I - Pain Relief & Protection
Anti-inflammatories and analgesics
Regular application of ice packs
A cane in the opposite hand helps to unload the hip significantly
cane should reach the top of the patient's greater trochanter of the
hip while wearing shoes.
http://physioworks.com.au/injuries-conditions-1/hip-arthritis-osteoarthritis
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Treatment
PHASE II - Restoring Normal Hip ROM, Strength
Restoring normal hip joint range of motion,
Muscle length and resting tension
Muscle strength and endurance,
Proprioception
Balance and gait (walking pattern).
http://physioworks.com.au/injuries-conditions-1/hip-arthritis-osteoarthritis
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Treatment
PHASE III – Maintain Full Hip Function & Delaying Hip Surgery
The final stage is aimed at returning the patient to their desired
activities.
HIP STABILIZER Support
Cane support
Assess hip biomechanics and correcting any defects.
Addressing any deficits in core strength and balance
http://physioworks.com.au/injuries-conditions-1/hip-arthritis-osteoarthritis
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Exercises for theArthritic Hip
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
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Surgical Mx
The mainstay of surgical treatment is total hip replacement
http://uconnmsi.uchc.edu/clinical_services/orthopaedic/totaljoint/total_hip.html
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Weight-bearing restrictions
Cemented
as strong as it will ever be 15
minutes after insertion.
allow immediate full weight-
bearing with a cane or walker.
Non-Cemented
Stability is usually adequate by
6 weeks to 6 months
toe-touch weight-bearing for
the first 6 weeks
allow weight-bearing as
tolerated immediately after
surgery.
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PreoperativeSession
Generally includes an assessment of
patient's strength (including upper extremity potential)
ROM
neurologic status
vital Signs
endurance, functional level, and safety awareness
Any existing edema, contractures, and leg length discrepancies
In the evaluation of patient's home
the status of stairways
equipment needs
safety adaptations (such as furniture and electrical cords)
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Pre-operative Instructions
Postoperative exercises can be taught at this time.
These exercises may include the following:
Ankle pumps
Quadriceps sets
Gluteal sets
Active hip and knee flexion (heel slides)
Isometric hip abduction
Active hip abduction
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Pre-operative Instructions
The danger of post operative dislocation is largely a result of
compromised integrity of the hip's joint capsule caused by surgical
disruption.
This information may assist in motivating the patient to adhere to
precautions and the strengthening program.
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Post-operative Precautions for PTs & pts
Straight-Leg raises (SLR) and Side-leg-lifting can produce very large
loads on the hip and should be avoided.
vigorous isometric contractions of the hip abductors should be
practiced with caution
protect the hip from large rotational forces for 6 weeks or more
use a cane in the contralateral hand until the limp stops.This helps
prevent the development of aTrendelenburg gait,
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PostOp. Rehab.: Phase I.
GOALS:
Prevent complications
increase muscle contraction
control of involved leg
help patient sit for 30 minutes
continuously reinforceTHR precautions
DeepVeinThrombosis
Pulmonary embolism
Infection
Anemia
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Week 1 Exercise Program:Sample
Day 1: Isometrics (quadriceps sets, hamstring sets, gluteal sets, Ankle
pumps).
Day 2: Continue previous exercises, Supine hip range of motion within
allowed ranges (passive to active as tolerated), Hip abduction active
assisted to active range of motion, Heel slides (heel toward buttocks),
Bridging
Days 3–4: Continue previous exercises, Dynamic Exs.
Days 5–7: Continue previous exercises, Mini-squats, Standing hip
flexion upto 90 degrees (surgical leg), Standing hip extension (surgical
leg), Standing hip abduction (surgical leg), Forward step-up
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Transfers Independence
Getting out of Bed
Slide your legs toward the edge of
the bed; keep your operated leg
straight
Push yourself up to your forearms
and onto your hands
Slide your legs so that your heels are
over the edge of the bed
Scoot your hips forward until both
feet are on the ground
Getting into Bed
Sit on the edge of the bed with both
feet on ground
Scoot your hips backwards as you
keep your weight on your hands
Lower yourself onto your forearms
Slide your legs onto the bed; keep
your operated leg straight
Once in bed, keep your toes pointed
up
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GaitTrainingUsing walker
Place the walker one step ahead of you
Lean into it and pick up the operated leg, bend the knee and step
forward, planting the heel down first
Bring your good leg up to the operated leg
Repeat the process
Progression
Bring your good leg up to the front of the operated leg
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GaitTrainingUsingCrutches
Place the crutches one step ahead
Place weight on the good leg
bring the operated leg up between the crutches
Bring good leg up beyond the crutches
advance to a two-point gait pattern.
This means move the crutches and operated leg at the same time,
and then move good leg beyond the crutches
while standing, the crutches should always be kept in front of and
slightly out to the side to prevent from falling.
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StairClimbing
Going Upstairs
Put one hand on the banister and
carry the crutch under the other arm
Put your weight through your arms
and step up with good leg
Then step up with operated leg
Then the crutch
Coming Downstairs
Place the crutch under one arm and
the opposite hand on the banister
Start down the stairs with the
crutches first
Then operated leg
Then good leg
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Stair climbing and descending using a crutch
https://orthoinfo.aaos.org/en/recovery/total-hip-replacement-exercise-guide/
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GaitTrainingUsingCane
Transition from crutches to a single-point cane usually occurs 3 to 4
weeks after surgery.
Hold the cane in the hand opposite the hip replacement.
Put weight on good leg.
Move the cane and operated leg forward.
Support weight on both the cane and operated leg.
Then step through with good leg.
Then start the next step.
Walk up and down stairs using the same technique as using crutches
in one.
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Postoperative I -6 weeks
GOALS:
Improve patient independence
Prevent falls
Prevent complications
Promote safety and independence with community ambulation
Improve lower extremity strength
Return to former employment or previous hobbies as indicated
Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 10, Total Hip Replacement; pp 172-187
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Postoperative I -6 weeks
Continuation and progression from previous phase interventions.
Home evaluation for safety.
Patient education by review of precautions
Performance of bed mobility transfers.
Gait training on level surfaces, uneven surfaces, and stairs..
Closed chain exercises (mini-squats, step-up, heel raises)
Treadmill, SLR, Hip Abduction
Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 10, Total Hip Replacement; pp 172-187
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General criteria for home discharge
Gait Dependence
ADL Dependence
Adherence/awareness to hip precautions
Independence Home exercise program
Psychological status for depression, anxiety etc.
Cognitive status (MMSE)
Social background
Co-morbidity
A Post-total Hip Replacement Discharge Scoring System (PTHRDSS).
Wong J, Wong S. Criteria for Determining Optimal Time of Discharge after Total Hip Replacement. Clinical Performance and Quality Health Care. 1999; 7 (4): 161-166
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Signs of complications
Thigh pain with walking that clears quickly with sitting down, possibly indicating intermittent
claudication.
A positiveTrendelenburg sign that does not resolve with treatment, possibly caused by damage
to gluteal innervation
Severe rubor and swelling at the surgical site with accompanying fever, possibly indicating a
wound infection
Unexplained swelling of the limb that does not dissipate with elevation, possibly indicating
thrombo embolic disease
General systemic effects, possibly indicating an allergy to the implant materials (rare),
postoperative anemia, pulmonary embolus, or other medical complications
Persistent, severe pain, unexplained limb shortening or extreme rotation, or pain with rotation of
the limb possibly resulting from dislocation of the prosthesis, heterotopic ossification, or a
fracture of the adjacent bone or reflex sympathetic dystrophy
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Bursitis
There are 4 different types
of hip bursitis:
1. Trochanteric bursitis
2. Iliopsoas bursitis
3. Gluteal bursitis and
4. Ischial bursitis
http://www.lockeroomsports.com/blog/hip-bursitis/#.VgF_Dd-qqko
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Treatment
PHASE I - Acute Phase - Pain Relief & Protection
Ice therapy
Electrotherapy
Deloading taping techniques
Soft tissue massage
Temporary use of a mobility aid (e.g. Cane or crutch)
to off-load the affected side.
http://physioworks.com.au/injuries-conditions-1/trochanteric-bursitis
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Treatment
PHASE II - Restoring Normal ROM, Strength
Normal hip joint range of motion
Muscle length and resting tension
Muscle strength and endurance
Proprioception, balance and gait (walking pattern).
http://physioworks.com.au/injuries-conditions-1/trochanteric-bursitis
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Treatment
PHASE III - Restoring Full Function & Prevention
Aim at returning to desired activities
HIP STABILIZER Support
Assess hip biomechanics and correcting any defects
Addressing any deficits in core strength and balance
http://physioworks.com.au/injuries-conditions-1/trochanteric-bursitis
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PreOp. Rehab
Where possible patients should be evaluated prior to surgery:
To establish pre-morbid mobility, functional status and social history.
Respiratory assessment and treatment if indicated.
Explanation of post-operative physiotherapy and precautions.
Objective assessment of joint range and muscle power of the
unaffected limbs.
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Complications
Complications from the fracture:
The sharp ends of the broken bone may lacerate blood vessels or nerves.
Acute Compartment Syndrome
Risk of infection, especially with open fractures
Complications from surgery:
Infection
DeepVeinThrombosis or Pulmonary Embolism
Damage to nerves or blood vessels
Fat Embolism
Delayed union, Mal-union or non-union
Hardware Irritation to the overlying muscles and tendons)
http://www.physio-pedia.com/Femoral_Fractures
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Changes in Behaviour
Delirium can happen suddenly for someone and is common for older
persons
Behaviour changes include:
Hyperactivity (restless state, constant motion)
Hypo activity (inactive, withdrawn, sluggish state)
Attempts to escape one’s environment (often resulting in falls)
Removal of medical equipment (e.g., intravenous lines, catheters)
Disturbances in vocalizations (e.g., screaming, calling out,
complaining, cursing, muttering, moaning).
http://www.trilliumhealthcentre.org/programs_services/neurosciences_musculoskeletal_services/mississauga/documents/Fractured_hip_patient
_information_booklet_April2008FINAL.pdf
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PhysicalTherapy DischargeGoals
Get in and out of bed without physical assistance
Transfer from bed to chair safely with use of walker/crutches without
physical assistance
Walk 150 feet with walker/crutches safely without physical assistance
Climb and descend curb/stairs with/without rail with supervision or no
physical assistance needed
Patient Guide Hip Fracture Treatment. Baylor Health Care System; 2009. Available at:
https://www.baylorhealth.com/PhysiciansLocations/Dallas/SpecialtiesServices/Orthopaedics/Documents/Hip%20Fractures%20Guide_Web.pdf
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CaneWalking
A cane that is too long or too
short can cause low back pain,
poor posture, and instability.
The cane should be held on the
side opposite the injured leg.
http://www.msdmanuals.com/home/fundamentals/rehabilitation/rehabilitation-after-a-hip-fracture
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PT Rehabilitation – Phase I
Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 11. Open Reduction and Internal Fixation of the Hip: pp188-204
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PT Rehabilitation – Phase II
Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 11. Open Reduction and Internal Fixation of the Hip: pp188-204
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PT Rehabilitation – Phase III
Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 11. Open Reduction and Internal Fixation of the Hip: pp188-204