Hip Replacement and Physiotherapy

Total hip replacement has matured into a routine operation for the relief of hip pain and disability due to hip arthritis, giving some of the greatest quality of life increases of all medical procedures. Typically performed in older people, many get a good result from their hip replacement surgery but many do not reach their greatest potential due to lack of follow up rehabilitation in the post-operative period.

An osteoarthritic hip joint is likely to cause a degree of pain and disability for a year or more before the person comes to operation. This period of difficulty can cause influential changes in the tissues around the hip which can be relevant in the postoperative period. Pain and weakness can make us use our joints less, avoiding pushing them to the ends of their movement, a process which gradually reduces the joint’s range of motion. Adaptive shortening occurs in the hip’s ligaments, as the structures shorten in response to the fact that the joint is not being put through its full range any more in the normal daily pattern.

A second consequence of the pain and the stiffness is the development of weakness in the large muscles which serve the hip joint. The hip is a weight bearing joint involved in moving the bodyweight around and it generates very high forces in activity. To manage this the hip has the largest muscles in the body either attached to it or nearby to it. The hip extensors, including the glutei, are large powerful muscles which facilitate walking, running, stairs and getting up from a seated position. Loss of power in these muscles can be disabling and threaten independence.

The hip abductors, a smaller muscle group of the gluteal muscles, are important in controlling the side to side stability of the pelvic girdle in gait, with weakness of these muscles interfering with walking. Standing on one leg in walking we hold the opposite side of the pelvis up to avoid it dropping and make bringing through the moving leg more difficult. The hip abductor muscles do this and if weak we feel unstable in walking and tend to lurch towards the weak side, making us lean our trunk towards the other side to restore balance. This is described as a positive Trendelenberg sign.

The abnormal Trendelberg gait imposes unnatural forces on the hip and requires side flexion of the spine to hold balance on each step. The abnormal gait which results fails to strengthen the hip abductors and remedy the problem. With hip problems we tend not to extend our hips fully so the gait cycle is shortened as the hip extensor muscles fail to attain full movement and power. A restriction in hip joint movement and the presence of muscular weakness makes mobility more difficult and can make the outcome of the operation less satisfactory in the absence of rehabilitation.

Coordination and balance can also be compromised and is often not particularly good before the joint replacement. Insertion of a normal joint into the hip does normalise the joint and immediately improves the mechanical actions of the muscles acting upon it. However, the feedback from the hip area, the joint position sense, may be poor and leave the patient with poor balance and a tendency towards the risk of falling.

Physiotherapy assessment of a hip problem covers many aspects of joint function which relate to the ability to perform routine daily functional activities. The pattern of gait will be noted and corrective work prescribed to improve the cycle of walking as an abnormal gait can be habitual and easily improved. Knee, hip and spinal ranges of motion will be assessed to ascertain whether stiffness or any limitation is interfering with normal movement.

Large ranges of movement are discouraged in the hip due to the possibility of dislocation and so the physiotherapist checks the hip muscle power in all the muscles around the joint and the joint position sense and balance. The physiotherapy rehabilitation will consist of hip joint mobilising exercises, strengthening work, gait correction and balance practice. Hip arthroplasty generally gives a very good outcome but this could be improved at times by rehabilitation.

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