Hip Conditions and Interventions
PTA 104 Orthopedic Dysfunctions

Instructional Use Statement

The following information is used for instructional purposes for students enrolled in the Physical Therapist Assistant Program at Lane Community College. It is not intended for commercial use or distribution or commercial purposes. It is not intended to serve as medical advice or treatment.

Contact howardc@lanecc.edu for permissions

Introduction Screen-cast (Approximately 10 min)

Objectives

1. Describe non-surgical management principles for hyper mobility disorders in the hip.
2. Describe the varied surgical approaches for THA and hemiarthroplasties and report their precautions.
3. Describe post-operative management of THA and hemiarthroplasties and relate how the surgical approach will affect exercise selection for the client.
4. Integrate principles of exercise to create a post-operative program for management of a patient with hip fracture.
5. Describe non-surgical management of overuse injuries of the hip.

Guided Learning

You should be glad to know that you can apply your knowledge and skills as it relates to arthritis management, fracture repair, hypomobile and hypermobile syndromes, and symptoms and soft tissue healing will continue to help guide clinical decision-making. As we cover the hip, the new focus is:

• recognizing specific SAFETY parameters specific to certain hip conditions (fracture, surgical approaches, and joint replacements)
• applying knowledge of open and closed chain activities as it relates to hip function
• expanding knowledge of therapeutic exercises; connecting exercises to improving function

PTA Scope of Practice

Our text is very detailed in providing an overview of surgical interventions for the hip. Here are some scope of practice guidelines which can help you focus on the most important components:

In general, a PTA is not expected to make clinical decision about patient progressions as it relates to indications for surgery, prosthetic type and design, benefit of cement versus cementless prosthesis placement procedures, or implantation of components.

A PTA is expected to recall and recognize signs and symptoms of a post-operative medical emergency, these include:

• Signs and symptoms of a Deep Vein Thrombosis (DVT); a clot in the vasculature can block circulation to the operative limb, create pain and swelling, and increase risk for the clot breaking and traveling to vessel in the lungs, heart and brain.
• Signs and symptoms of infection, particularly on or around the incision site

A PTA is expected to effectively instruct the patient, family, caregivers, and staff in weight-bearing and post-surgical precautions (and assess the effectiveness of this instruction). The goal is continuous patient, family, and staff adherence to post-surgical status to optimize recovery and minimize risk for reinjury, including post-operative dislocation.

A PTA is expected to interpret the rehabilitation phase based on the initial evaluation, plan of care, patient subjective and tests and measures during treatment. Never forget the powers of observation and rapport.

Protocols provide a framework; however, a PTA must apply clinical reasoning and assess the patient response to interventions and make informed decision to progress to higher level activities. Close coordination with the patient, physician, and PT is essential in ensuring safe and timely progression toward goals.

Video Resources

Videos are included to support your understanding of testing and movement interventions

There are approximately 42 minutes of videos included as part of this lecture.

Expectations for Applied Kinesiology and Gait

You are expected to be able to:

recall normal ROM and directions of motion for the hip

recall origins, actions, insertions, and innervations of muscles that cross the hip joint

identify postural impairments that result from shortened muscles that cross the hip joint

identify abnormal gait patterns that result from weak muscles that cross the hip joint

recall impact of WB status on gait pattern, type of assistive device, safety, and ability to progress gait

Students are encouraged to review course material from PTA 132/132L to reinforce kinesiology knowledge of the hip joint. For example:

• What postural compensation in standing and gait will you expect on the affected side if the evaluation includes "+Trendelenberg"?
• What accessory hip abductor may become overused as a result of primary hip abductor weakness?
• Hamstrings may progressively dominate as primary hip extensors as a result of hip pathology, pain, or post-surgical weakness.
• What postural compensations can you expect at the spine when hamstrings dominate hip flexion?
• How might a new onset of knee pain with sit to stand connect with this pattern of muscle imbalance?
• Why would hamstrings "cramp" during a bridging activity?
• How would you try and correct this imbalance through exercise and functional training?

If you do not know the answers to the questions above, start researching and refreshing, check with peers, and use forums to confirm your understanding.

Review of Hip Joint Function

The hip is the most proximal joint connecting the leg to the spine. It is mobile, stable joint, and is subject to degenerative, overuse and traumatic forces which can disrupt normal joint and muscle function. Painful weight bearing, painful gait, or instability with gait/falls are the most common impairments that prompt a patient to seek medical attention.

Recall from our fracture lecture that hip and femur fractures are common, and surgical interventions can vary from joint replacements, to open-reduction-internal fixation (ORIF), to external fixation.

The goals of any surgical intervention to the hip joint are to reduce/eliminate pain, create a joint stable enough for functional activities, and restore enough ROM and strength for functional activities. Post-operative weight-bearing restrictions vary greatly and is defined by the surgeon.

Functional ROM in the hip joint for ADLs is

120 degrees flexion

20 degrees ER

20 degrees abduction.

Gait requires at least 30 degrees of flexion and 10 degrees of extension.

Hip function is impacted by integrity of spinal nerves (L1, L2, L3, S1, and S2)

Hip Examination

This is for your information only to demonstrate the examination process: I especially appreciate how the provider has summarized the examination process using this phrase: Look-Feel-Move.

PT Examination process is systematic and consistent with as assessment of musculoskeletal and neuromuscular contributors. It includes

• Subjective and medical history review
• Observation and posture assessment (sitting, standing, lying, gait, functional transitions)
• ROM and strength (open chain testing and functional testing)
• Palpation: muscles, tendons, ligaments, fascia, relevant bony landmarks on pelvis, femur, and knee
• Neurological testing: reflexes, sensation and peripheral nerve function, coordination
• Joint (combined and accessory) motion
• Special tests
• Internal rotation-flexion-axial compression maneuver - test for impingement in the socket
• Thomas Test - Tests for passive insufficiency of hip flexors and hip flexion contraction; labral tear
• Flexion-Adduction Test - test for hip disease
• Positive Trendelenberg - Test for lateral hip weakness
• Patrick's Test - Also called FABER - Discriminates between hip and SI joint
• Hip Scour Test - Screening test for degenerative joint disease
• Ober's Test - Assesses IT Band - TFL flexibility and lateral hip muscle flexibility

Hip Conditions

Hip Joint Repair

Total Hip Replacement

Post-operative management of THA and hip fractures will be among the most commonplace services rendered by PTAs to members of the older adult and geriatric populations.

Approximate video length: 4 minutes

Link to this video for a demonstration of post-operative precautions common to a total hip replacement

Approximate video length: 8 minutes

Comparison of hip precautions

Understand precautions due to both surgical approach and in cases of THA use of cement or uncemented. You will likely encounter patients questioning their personal limitations when someone else in the gym with the same original pathology has different restrictions. It is necessary to be able to logically explain the reason for the difference, to assist them in adhering to their post-surgical instructions.

Clinical Pearl: Patients often do not fully appreciate precautions in both open and closed chain motions. Take time to quiz your patient on the "do's" and "dont's" during functional movements that require open chain motions (e.g., bed mobility) and closed chain motions (e.g., sit to stand). Could you effectively and efficiently educate a patient in how to demonstrate joint protection strategies during these sample activities? If not, now is the time to practice!

Dislocation occurs in less than 5% of cases, and less than 2% during first several months of rehabilitation. Posterior dislocation is most common, regardless of approach. Posterior approach has highest incidence of dislocation. A dislocation presents as a shortening of the involved leg that was not previously present, paired usually with positioning of ER and severe complaint of pain. Patient will be in extreme, unrelenting pain. Failed hip ORIF has a similar presentation. Report these changes immediately to the supervising PT and discontinue all treatment until further evaluation by the surgeon

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Anterior and lateral approaches have a lower dislocation risk. However, the abductors typically partially or completely disrupted during surgery. Patients are usually restricted to no SLR or no active abduction exercises for six (6) weeks.

Patients commonly present with Trendelenberg weakness patterns that require additional support during early gait training.

Excessive stress to healing abductors may result in tendon avulsion and permanent, irreparable injury.

Approximate video length: 2 minutes

.

 ORIF

Close monitoring of patient-specific weight bearing restrictions is important. The surgeon decides and progresses weight bearing status and this is communicated in the chart as a "patient order".

Unlike THA, the integrity of the bone, its ability to heal, and the secondary soft tissue trauma typically results in slower gait progressions. Surgeons will generally not allow any hip muscles resistance training for 4-6 weeks.

Clinical Preparedness: If a patient asked you to explain why they can not start "using those bands" to help strengthen their leg, could you apply your knowledge of tissue healing and muscle function to respond appropriately? Try it! How do you know how well you were able to explain why resistance bands are not appropriate at this time?

Hip Rehabilitation Progression

As a reminder, movement progression should consider the rehabilitation stage, goals (increase ROM, increase strength, increase stability, or some combination) and exercise and movement progressions should consider the health condition, contextual factors, and clinical practice guidelines

1. Acute-phase/Joint protection: Goal is to reduce pain, allow damaged structures time to go through the acute healing process, submaximal effort in affected muscles, conditioning to areas unrelated to surgery/injured area to maintain endurance, modalities and manual therapies to promote soft tissue healing and break pain cycle, stretching of affected areas is typically passive.
2. Subacute-phase/Controlled motion: Goal is to gradually restore normal movement in positions where patient can be most successful and use the least amount of compensation. Continued use of an assistive device for gait is common. Activities transition toward active stretching and progression through AAROM and AROM with respect to any surgical precautions; functional activities are introduced with modifications as needed to allow for progressive return to prior level of function through increased control of muscle timing, stability, and coordination; open and basic closed chain exercise with some body weight and/or gravity as resistance is common. Cross-friction massage to well-healed scars or to the musculotendinous junction may be indicate to restore muscle extensibility and function. Manual therapy to increase joint mobility may be introduced
3. Return to function: Goal is to increase the ability for the affected limb to accept increasing weight for increasing periods of time (increase strength and endurance); patient-specific return to function may include work-retraining, and return to recreation/sport.

Time to Stretch Your Brain

What should you observe during functional mobility that indicates a patient is independent with post-operative precautions? For example, what is the best:

1. Sit to stand pattern?
2. Dynamic gait adaptation?
3. Supine to sit pattern?

In order to be sure the iliopsoas group is the primary hip flexor, how many degrees of SLR should the patient attain during active or active-assisted exercise?

Use the Can You Help Me? forum to confirm your understanding or help clear muddy points.

Summary of Rehab Principles

Active Learning Exercise

 Create a tables as illustrated below for each of the following conditions:

• hip flexion contracture
• hip osteoarthritis
• hip muscle strain (adductor, iliopsoas, quadriceps, hamstrings)
• iliotibial band syndrome
• greater trochanteric pain syndrome (GTPS)
• hip fracture repair (ORIF)
• total hip replacement ( posterior and anterior lateral approaches)

Then use a 0-5 scale to rate your understanding and confidence in selecting the intervention and delivering clear and evidence-based treatment

Test your understanding by using forums to discuss with your classmates. Apply your ratings of confidence and understanding to help guide further or reinforced study

Exercises in Dutton provide some context for possible interventions depending on tissue healing stage. Don't forget to access your APTA PTNow resources for exercise examples. Just be sure you can defend a clinical decision before selecting an exercise

Acute / Joint Protection Intervention Planning

Condition:

Subacute / Controlled Motion Intervention Planning

Condition:

Now compare your intervention plans for joint protection and controlled motion stages related to the selected hip conditions. How do they differ? Can you see indications for a progression? Would you be able to identify when it is appropriate to progress a patient? Can you provide patient-centered education in the above areas? Use the CAN YOU HELP ME? forum to discuss your findings.

Sample Hip Exercises

Level (Basic) for non-THA conditions: Goal is to increase strength of major hip stabilizers in non-weight bearing and weight bearing positions.

Clam shells, hip abduction, bridging, straight leg lifts (supine and prone), side planks, wall squats with Theraband loop and general flexibility exercises as indicated

Level (intermediate): dynamic (surface or body-on-leg) single leg stance activities, lunges (forward), lateral step-in-out, step-down (multidirection); side plank progression (on dynamic surface; leg elevated or offset). Note: small hand weights or arms extended forward will add the additional demand to multidirectional stabilizers

In the video below, watch the model and see if you notice the compensatory movement at the femur? What weakness pattern does the compensation suggest? What modifications would you make to this exercise to improve form and prevent injury?

Level (Advanced): Resisted dynamic stability, high stepping, lateral hop, box jumps

General Arthoplasty Concern

Arthroplasties are planned surgical interventions that address a specific and often long-standing degenerative condition.

However, a planned surgery does not obviate a smooth and easy recovery. An arthroplasty results in substantial trauma surrounding body tissues and body systems may be slow to recover from the operation.

Muscles spasm and guard, there is bruising from the use of surgical spreaders and vascular trauma. Edema is very significant, and patients will move with an effort to protect the affected side. 

Bones are remodeling in much the same as they do following a fracture. The joint capsule and many ligaments are recovering from a significant stretch during the surgical dislocation and prosthesis placement. 

Expect to apply similar approaches and attention to pain management as you would with an unplanned, traumatic bone and joint injury that requires surgical repair.

I want to highlight again don't get too bogged down in all the surgical details. Apply your kinesiology knowledge of involved structures to learn (not memorize) the "why" behind the precautions.

Be sure you can reflect on how you know what you know (applied knowledge, evidence, patient feedback).

You will never be asked to weigh in or recommend prosthetic components or surgical approaches (and if you are, be sure you recall your scope of practice before responding).

Focus on:

1. any immediate SAFETY ELEMENTS, especially in the early rehab stages,
2. APPLYING knowledge of tissue healing in progressing activity,
3. EDUCATING the patient in how to move and exercise safely,
4. OBSERVING and INTERPRETING patient performance and providing appropriate feedback
5. PROMOTING patient adherence through effective and patient-centered MOTIVATION
6. COMMUNICATING and COLLABORATING with the supervising PT any unexpected responses or outcomes

The single greatest predictor of recovered functional level/activity level following arthroplasty is pre-surgical functional/activity level. 

This finding has been consistent across short-term and long-term follow-up studies.  This highlights the importance of advocating for more therapy services pre-surgery to maximize functional recovery post-surgery. It also brings up a challenge to encourage patients to seek more than pain relief as an outcome of the surgery. Promoting positive health behaviors prior to and following surgery is an essential component to improving quality of life.

Practical Prevention Tips

Patients with acute, post-operative hip conditions should be instruction and receive reinforced instruction and practice in DVT and pulmonary embolus prevention

1. use of incentive spirometer frequently during day
2. use of sequential pumps while in hospital (types will vary)
3. active ROM in ankles (pumps, circles), and isometric LE exercises
4. positioning and repositioning for skin and contracture management and post-operative motion precautions
5. absolute adherence to post-operative motion and WB precautions

End of Lesson