Hip Replacement Rehabilitation
Mark Creasey
Spring 2002
The hip is probably the most important joint in the body. Without the hip, we would not be able to do a majority of the movements we can do. The hip allows us to stand, walk, and run on two feet rather than on all fours. The hip can be placed in venerable positions because of it’s wide range of motion. Perhaps one of the most feared injuries that can happen to the hip would be a dislocation of the joint. Not only is the injury very painful, but if an athlete receives this injury, it could be career ending. Even though a majority of hip dislocations happen in the geriatric portion of the population, they can also happen to the younger, more active portion of the population. An extensive evaluation needs to be done following a hip replacement. Many complications can occur such as a severed sciatic nerve, fractures of the femoral head, or severed ligamentum teres. A severed ligamentum teres can result in avascular necrosis of the femoral head. This condition usually happens overtime. To combat this condition a hip replacement is needed. The surgery replaces the normal hip with an artificial one. After the surgery, the person must go through an intense rehabilitation program. Since the hip is so important to us, when faced with a hip injury, we need to take careful consideration in developing a rehabilitation program.
ANATOMY
The hip is the articulation between the concave acetabulum of the pelvis and the head of the femur (Anderson, 2000). The combination of these two structures are known as a ball-and-socket joint. This particular ball-and-socket joint is considerably deep, and it allows for a wide range of motion (ROM). More stability is added due to a fibrocartiloginous acetabular labrum (Anderson, 2000). There is also a joint capsule that surrounds the joint, and attaches to the labrum. The articulating surfaces of the two structures are covered with a hyaline cartilage to reduce friction except for the central femoral head which is cleared for the ligamentum teres (Starkey, 1996).
The ligaments of the hip are large, and provide strong support for the hip. Anteriorly, there is a ligament known as the Y ligament of Bigelow. This ligament runs from the anterior inferior illiac spine then splits to the intertrochanteric line on the femur, and the proximal aspect of the anterior portion of the joint capsule. This provides protection against hyperextension (Starkey, 1996). The Y ligament is accompanied by the pubofemoral ligament. The pubofemoral ligament connects the pubic ramus to the intertrochanteric line, and it provides protection against hyperextension and limits abduction (Anderson, 1996). Posteriorly, the ischiofemoral ligament extends from the posterior acetabular rim to the inner surface of the greater trochanter of the femur. The direction and twisting of the ischiofemoral ligament causes it to limit extension of the hip. Another important ligament to mention is the ligamentum teres. This ligament provides little support for the hip, but serves as a conduit for the medial and lateral circumflex arteries. The femoral triangle is formed by the inguinal ligament superiorly, the sartorius lateraly, and the adductor longus medially (Anderson, 2000). This region houses the femoral nerve, artery, and vein. There are also four primary bursae that are present which reduces friction of the structures as they move across one another.
There are many muscles that originate at the hip. They are split up into anterior, medial, lateral, and posterior musculature. The anterior musculature consists of the rectus femoris, sartorius, and the iliosoas group. The rectus femoris acts as a powerful flexor of the hip. The sartorius contributes to flexion, abduction, and external rotation of the hip. The iliosoas group is the primary flexors when the knee is extended, and work with the rectus femoris when the knee is flexed (Starkey, 1996). Medially, the musculature consists of the adductor group, and the gracilis. There are three adductor muscles, the adductor longus, magnus, and brevis. These muscles work together to adduct the hip (Starkey, 1996). Lateraly, the gluteus medius, tensor fasciae latae (TFL), piriformis, quadratus femoris, obturator internus, obturator externus, gemellus superior, and gemellus inferior. The gluteus medius is a prime abductor of the hip, as well as an important factor in maintaining the torso’s posture during the walking gait. The TFL is an abductor and internal rotator of the hip. The rest are intrinsic muscles, and their primary function is external rotation of the hip (Starkey, 1996). Posteriorly, there is the gluteus maximus. The gluteus maximus is mostly responsible for hip extension while the knee is flexed (Starkey, 1996).
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BIOMECHANICS
There are a wide range of movements that can be done in the hip. The hip can move up to 160 degrees of flexion, 15 degrees of extension, 90 degrees of internal and external rotation, and 90 degrees of abduction (Hay, 1982). The hip can also move into a wide range of circumduction, which is reliant upon flexion, extension, abduction, and adduction. In the standing position, the hip becomes a major weight-bearing joint because of the amount of force of the structures above the hip, as well as the amount of tension from the strong hip muscles. During the normal walking gait, the forces can increase to at least six times the person’s body weight (Anderson, 2000).
MECHANISM OF INJURY
A typical hip dislocation is the result of a direct force applied to when the knee is in the flexed position. This is not easily done because the hip is a deep ball-and-socket joint surrounded by many muscles, ligaments, and a joint capsule which strongly holds the femoral head in place. However, when a dislocation does occur, it is usually a posterior dislocation. This immediately places the leg in a internally rotated and adducted position. The athlete complains of immediate, intense pain that does not allow for any type of movement in the extremity (Starkey, 1996). The dislocation can result in a severed sciatic nerve, or a fracture to the femoral head. Another condition to be aware of would be avascular necrosis of the femoral head. Avascular necrosis of the hip is a condition in which the ligamentum teres becomes disrupted or severed, resulting in a loss of blood supply to the femoral head. Without a constant blood supply, the femoral head begins to undergo degenerative changes. This condition may will not happen immediately, so follow-up by the physician needs to be taken serious. An athlete with degeneration of the hip will complain of pain that is present during weight bearing (Starkey, 1996). Treatment of avascular necrosis is a total replacement of the hip.
SURGERY
A typical total hip arthroplasty consists of removal of the femoral head and neck, as well as the cartilage covering the accetabulum (Siopack, 1995). The portion of the femur that gets removed is replaced a high molecualar steel that is similar in shape and size that was previously there. A high-molecular-weight polyethylene replaces the articulating surface of the acetabulum (Siopack, 1995). These components can either be put into place with cement, or they can be done without using cement. Typically, the elderly portion of the population receive the traditional method of total hip arthroplasty using cement. However, the younger, more active portion of the population receives a newer method of fixing the replacement components into place (Havard Health 2002) The cementless components have pitted surfaces so that bone can grow into them, making them stronger, and more durable.
REHABILITATION PROTOCOL
PHASE I: PROTECTION PHASE (POST-OP - WEEK 1)
The patient is usually kept in the hospital for 3 to 10 days, depending on how well the patient heals after surgery (Hip Injuries and Disorders). In which case the patient is then given instructions to the use of crutches or a walker. Rehabilitation exercises should be started almost immediately, so that there is no further atrophy to the muscles of the lower extremity. The goals for the patient is to reduce swelling, reduce pain, learn proper ambulation techniques, and restore a slight amount of range of motion (ROM) .
A. Reduce swelling and control pain.
- Ice/Muscle Stimulation: interferential stimulation and ice complimented with rest, compression, and elevation.
B. Learn proper ambulation technique
C. Restore a slight amount of ROM
1. Ankle pumps: 3 sets of 10 reps
2. Ankle rotations: clockwise and counter clockwise 20 times each direction
3. Knee flexion with towel: 2-3 minutes 5 times/day
For the patient to move to the Phase II, he must have decreased swelling, decreased pain, be able to use crutches or walker with out any complications, and have restored slight ROM. To measure these goals, a pain scale needs to be established and reported each day to be sure the pain is going down, girth measurements need to be measured and compared to previous treatments to be sure that swelling is being decreased, and ROM needs to be measured with a goniometer compared to pre-operative ROM. By the end of this phase, the patient should not need the use of crutches/walker at all times of the day. Another aspect to look into during this phase is the motivation and confidence level the athlete is portraying. Be sure to evaluate these conditions daily, so that the athlete does not become depressed because of the injury. After passing each of the goals, the patient should be able to move on to Phase II of the rehabilitation program.
PHASE II: MOTION PHASE (WEEK 2 - WEEK 5)
This is the longest phase in the rehabilitation protocol, and it is probably the most important. It is also probably the most important because it includes strengthening and conditioning of the entire lower kinetic chain. In this phase, the patient must have slight, if any, edema, light to mild pain, regain all ROM/flexibility for each joint in the lower extremity, regain 75 to 80 percent of muscular strength/endurance, and regain nearly all proprioceptive ability compared to the contralateral side. While completing the above goals, the patient should develop an acceptable level of overall physical fitness.
A. ROM/Flexibility
1. ABC’s: 3 reps/ 3 x day
2. Ankle pumps: 2 x 25
3. Ankle rotations: clockwise/counter clockwise 2 x 25
4. BAPS board
a. sitting: clockwise/counter clockwise 50x each direction
b. standing: clockwise/counter clockwise 50x each direction
5. Lying towel slides: 5 minutes/ repeated throughout the day
6. Active knee/hip flexion: 5 minutes/ repeated throughout the day
7. Lying abduction: 5 minutes/ repeated throughout the day
8. Standing abduction/adduction/flexion/extension: 5-10 minutes/ repeated throughout the day
9. Prone hangs: without weight 5-10 minutes daily; progress to using weighted prone hang if necessary
10. Exercycling (ROM using bike): backward motion 10-15 minutes progress to forward/backward motion 20-30 minutes
B. Proprioception
1. Weight shifts: 5 minutes/ repeat throughout the day
2. Balance on injured leg
a. eyes open: 3x30 sec
b. eyes closed: 3x30 sec
c. proprioception tossing ball: 3x30 sec
d. trampoline eyes open: 3x30 sec
e. trampoline eyes closed: 3x30 sec
f. trampoline tossing ball: as long as tolerated
g. changing directions: going from straight ahead jumping to right/left side: repeated several times
C. Strengthening/Endurance
1. Isometric exercises for the ankle using a wall or clinician: 3x10/daily
2. Theraband exercises for the ankle (plantar flexion, dorsiflexion, inversion, eversion): 3x10 in all directions.
3. Heel raises (standing/sitting): 2-3 sets of 25; progress to using free weight or weight machine
4. Quad sets: 2 sets of 50 reps
5. Gluteal sets: 2 sets of 25 reps
6. Straight leg raises (flexion, extension, adduction, abduction): 2 sets of 25 reps in each direction
7. Terminal knee extension: start in lying position, progress to standing using theraband: 2-3 sets of 25 reps
8. Squats: start with half squats then progress to full squats: 3 sets of 10 reps
9. Leg press: start with half then progress to full: PRE program
10. Hamstring curls using a machine: start off with using theraband or ankle weights(3x10) then progress to machine using a PRE program
11. Standing hip ranges of motion (flexion, extension, abduction, adduction): start off without weight then progress to ankle weight: 3 x 10 then, using a PRE program, progress to using a machine that will allow these motions
12. Hip bridges: 3x10: start off with athlete being on the floor, then progress to using a Swiss Ball
13. Attach the athlete to a weight machine, add weight accordingly, have athlete walk as far as the machine allows. The athlete should be able to control the weight both going out and coming back. 5 min/day
14. Have the athlete either ride a stationary bike, or walk on a treadmill for about 20 - 30 minutes/day
15. After completing the exercises for this phase, the athlete must also be involved in stretching program. At the end of every session, the athlete must work on stretching: the gastroc/soleus group, quads, hamstrings, hip flexors, and hip internal/external rotators.
16. Gait pattern should also be observed and corrected, as seen fit, on a daily basis
For the athlete to be able to move on to Phase III, he must have reduced local symptoms, and displayed adequate wound healing to be able to participate in at least part of the athlete’s regular practice or conditioning. A sufficient amount of ROM, flexibility, muscular strength/endurance, and proprioception should have returned, so that the athlete can participate in at least part of regular practice or conditioning sessions. Another aspect to look into during this phase is the motivation and confidence level the athlete is portraying. Be sure to evaluate these conditions daily, so that the athlete does not become depressed because of the injury. To be sure the athlete is progressing, a measurement of each criteria should be done a couple of times a week. Measure ROM/flexibility using a goniometer then compare to contralateral side, measure proprioception by comparing to contralateral side or by timing the athlete, and measure strength by performing manual muscle tests and compare to contralateral side. Endurance can be observed daily while the athlete is performing the exercises, and also while he is on the stationary bike or treadmill.
PHASE III: STRENGTHENING PHASE (WEEK 6 - WEEK 8)
This phase of the rehabilitation program will test what has been done up until now. During this phase the athlete will continue with completing exercises in the clinic, as well as participating in a portion of practice or condition sessions. In this phase, the athlete must regain 100 percent, or more, ROM/flexibility, proprioception, muscular strength/endurance, and overall confidence/motivation compared to where he/she was before the injury. The athlete should also restore optimal overall physical fitness. This phase should give the athlete an opportunity to do more sport specific activities. Also, normal gait pattern, during both walking and running, should be re-established during this phase.
A. ROM/Flexibility
1. If the athlete is still lacking ROM, he/she needs to complete this with the assistance of the BAPS board in the standing and seated position. 25-50 reps in each direction
2. After completing the exercises for this phase, the athlete must also be involved in stretching program. At the end of every session, the athlete must work on stretching: the gastroc/soleus group, quads, hamstrings, hip flexors, and hip internal/external rotators.
3. Gait pattern should also be observed and corrected, as seen fit, on a daily basis
B. Proprioception
1. If the athlete is still lacking proprioception, he/she should completely regain using the exercises from the previous phase
2. New proprioception exercises should be incorporated in this phase. The exercises should portray sport specific activities the athlete may need while playing the sport.
C. Strength
1. Leg press: PRE program
2. Squats: PRE program; start off with light weight then adjust accordingly
3. Heel raises: PRE program (standing/seated position)
4. Hip extension, flexion, adduction, abduction with a weight machine: PRE program
5. Walking with weight attached to waist: PRE program
6. Lunges: work up to doing 100 yards
D. Endurance
1. Stationary bike: 20-30 minutes/day
2. Treadmill: 20-30 minutes/day
3. Stairmaster: 15-20 minutes/day
- Rotate these exercises it may not be necessary to do all these each day
4. Slide board
a. side-to-side: 2 sets 15-20 sec
b. X-Country: 2 sets 15-20 sec
c. Bridge position: X-country or W pattern: 2-3 sets 15-20 sec each
5. Jogging: start off slow then progress as the athlete’s endurance gets better
6. Dot drills: 2 sets 30 sec change pattern
7. A plyometric program can be designed during this phase. Be sure not to include it more that 2-3 days a week, and do not incorporate after a leg workout routine. Progress accordingly, do not start off with something the athlete can not do.
For the athlete to be able to move on to phase IV, the athlete must have regained all ROM and proprioception the athlete had prior to the injury. Muscular strength and endurance should be close (90-100 percent) to where the athlete was at prior to injury. The athlete’s overall physical fitness should allow him/her to participate in a majority of the practice or conditioning activities. Measure ROM/flexibility using a goniometer then compare to contralateral side, measure proprioception by comparing to contralateral side or by timing the athlete, and measure strength by performing manual muscle tests and compare to contralateral side. Endurance can be observed daily while the athlete is performing the exercises, and also while he/she is performing any of the endurance exercises listed above. Another important factor is that the athlete MUST have a release from his/her physician stating that the athlete has fulfilled the goals, and is physically able to participate. Be sure that the athlete is mentally able to return to play.
PHASE IV: RETURN TO PLAY
During this phase the athlete should have completed a vast majority of the rehab protocol. Exercises may still need to be done to maintain overall physical fitness. The athlete should be at 100 percent, or better, compared to previous level of fitness. The hip should be protected in any way seen fit, so that there is no chance for re-injury. This phase may last until the athlete has resigned from playing sports.
SUMMARY
There is a lot of activity that goes on at the hip. The hip is probably the most important joint in the human body. Any injury that occurs to this area should be corrected immediately. A total hip arthroplasty is not a common condition seen in sports, but if the occasion arises, it does not need to be taken lightly. The athlete must go through, and complete, an intense rehabilitation program. The rehabilitation program should include exercises for the entire lower extremity, the ankle, knee, and all the muscles surrounding the hip. It is important to incorporate the entire lower chain, so that every joint is in proper working order. Each joint should be as strong, if not stronger, than it was before the injury. The athlete should be comfortable with the rehabilitation program. Research has shown that the faster the rehablitation protocol is enforced, the faster the person returns to normal daily activities (Munin, et al, 1998). When designing a rehabilitation program, the person should take into consideration as to the patient’s age, gender, and activity level. After conclusion of a successful program the patient should be able to perform normal activities of daily living in the manner he/she could before the injury.
Works Cited
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