Hip Joint Mx by Physiotherapy SRS

Physiotherapy for
HIP JOINT Sreeraj.S.R

SreerajSR
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

SreerajSR
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

SreerajSR
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).

SreerajSR
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

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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.

SreerajSR
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)

SreerajSR
Pre-operative Instructions
GOALS:
 Educate patient regarding precautions with transfers and
movements,
 help patient become independent in exercises for postoperative
phases

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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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 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,

SreerajSR
Post-operative Precautions
Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458

SreerajSR
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

SreerajSR
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

SreerajSR
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

SreerajSR
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

SreerajSR
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

SreerajSR
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

SreerajSR
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).

SreerajSR
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

SreerajSR
Stretching Exercises
 Standing Iliotibial Band
Stretch
 Main muscles worked: Tensor
fascia
http://orthoinfo.aaos.org/PDFs/Rehab_Hip_3.pdf

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 Seated Rotation Stretch
 Main muscles worked:
Piriformis

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 Knee to Chest
 Main muscles worked: Gluteus
maximus, gluteus medius

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 Supine Hamstring Stretch
Hamstrings

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Strengthening Exercises
 Hip Abduction
medius, abductors

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 Hip Adduction
Pectineus, Adductor magnus,
Adductor minimus, Adductor
longus, Adductor brevis,
Gracilis

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 Hip Extension (Prone)
maximus

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 Internal Hip Rotation
Minimus, Semitendinosus,
Tensor Fasciae Latae, Gracilis

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 External Hip Rotation
Piriformis,
Gemellus Superior,
Obturator Internus,
Gemellus Inferior,
Obturator Externus
Quadratus Femoris

SreerajSR
Hip Fractures
https://www.nice.org.uk/guidance/cg124/ifp/chapter/your-operation

http://orthoinfo.aaos.org/topic.cfm?topic=A00392

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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.

SreerajSR
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

SreerajSR
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

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PT Rehabilitation – Phase III

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Let Protocols DirectYou, Not Dictate toYou

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Reference
1. http://physioworks.com.au/injuries-conditions-1/hip-arthritis-osteoarthritis
2. Brotzman SB, Wilk KE. Clinical Orthopaedic Rehabilitation. 2nd Edition. Mosby, Inc.; 2003. Chapter 6, The Arthritic Louver Extremity; pp 441-458
3. Maxey L, Magnusson. J. Rehabilitation for the postsurgical orthopedic patient. Mosby, Inc.; 2001. Chapter 10, Total Hip Replacement; pp 172-187
4. Shankman GA. Fundamental Orthopedic Management for the Physical Therapist Assistant. 2nd Edition. Mosby, Inc.; 2004. Chapter 20, Orthopedic Management of the Hip and
Pelvis; pp 335-358
5. http://uconnmsi.uchc.edu/clinical_services/orthopaedic/totaljoint/total_hip.html
6. http://www.massgeneral.org/ortho/patienteducation/pt-ed-hiprehab.pdf
7. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 5th Edition. F. A. Davis Company, 2007. Chapter 20, The Hip, pp 643-685
8. http://www.lockeroomsports.com/blog/hip-bursitis/#.VgF_Dd-qqko
9. http://physioworks.com.au/injuries-conditions-1/trochanteric-bursitis
10. http://orthoinfo.aaos.org/PDFs/Rehab_Hip_3.pdf
11. https://www.nice.org.uk/guidance/cg124/ifp/chapter/your-operation
12. http://orthoinfo.aaos.org/topic.cfm?topic=A00392
13. http://www.physio-pedia.com/Femoral_Fractures
14. http://www.trilliumhealthcentre.org/programs_services/neurosciences_musculoskeletal_services/mississauga/documents/Fractured_hip_patient_information_booklet_April2
008FINAL.pdf
15. 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
16. http://www.msdmanuals.com/home/fundamentals/rehabilitation/rehabilitation-after-a-hip-fracture

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