The hip is the second most common joint replaced in the body after the knee. Many approaches to hip replacement exist, but they all have the same long-term outcome.1 Additionally, surgeons do not routinely refer patients to outpatient rehab following hip replacement as they usually do for knee and shoulder replacement. This is becoming even more the norm in today’s bundled payment structures.2
Conventional Total Hip Replacement Rehab
In conventional total hip replacement rehabilitation, we start out acutely with standard bed exercises, precaution training, gait training, transfer training, and ADL training. This program is usually completed after two to three weeks of home care or rehabilitation. Patients are then often told by their surgeons that the only thing they have to do to further their post-op function is to walk. They are also often told that the leg length discrepancy will take care of itself in time.
Personally, if I was having my hip replaced, I would prefer to accelerate my recovery and address all the impairments that occurred from many years of abnormal gait caused by pain and disuse. In fact, research published in the Journal of Orthopaedic and Sports Physical Therapy in July 2015 demonstrates that there are certain gait characteristics identified years before the hip replacement and that patients who lacked hip mobility—specifically hip extension—were the ones most likely to undergo a total hip replacement.3
Exercises for an Earlier Return to Normal Gait
Can you facilitate an earlier return to normal gait? Are there exercises that address the already established pre-op impairments?
I believe so. My observations and purely investigational studies have concluded that there is a more optimal way to rehabilitate these patients, especially today’s baby boomers who are striving to return to the sports and activities they enjoyed before surgery. This approach involves the following:
1. Early lengthening of hip flexors
Bed exercises are the traditional acute therapy exercises following total hip replacement. Unfortunately, not one of those exercises elongates the hip flexor muscles, which are the most important muscles to lengthen to ensure a more normal gait post-operatively.
All patients who have had a hip replacement desire to walk normally again as soon as possible. By helping them achieve earlier hip extension, this can happen. I strongly recommend having your patients perform the usual bed exercises—and add one more: the heel slide hip flexor lengthening exercise.
Advise your patient to assume a standard heel slide position. When your patient slides their heel out, have them tighten their glute and do a pelvic tilt on the affected side at the very end of full leg extension. This will ensure that the involved side’s hip flexor lengthens via the posterior pelvic tilt on that side.
Another way to perform this is to have your patient simply flex the opposite hip with a basic single knee-to-chest motion and extend their operative leg. Try this exercise out to help your patients get ahead of the curve post-operatively!
2. Early core exercises
The second objective is starting core exercises earlier. I know what you are probably thinking—how can therapists recommend core exercises on day two post-op?
You can! Core sets and chair core exercises are appropriate at all stages of rehabilitation.
3. Facilitate the pelvic girdle and quadriceps
The third objective is functional exercises performed during the first 21 days of rehab and referred to as “gait assistive exercises.” My colleagues in hospitals and home care are often fascinated at how safe and easy these exercises are to perform and how they challenge even the most high-level patients at this stage.
I designed these exercises to functionally facilitate the pelvic girdle and quadriceps muscles. You probably never thought you could make a gluteus medius exercise or a quad set more exciting, but you can—with these exercises that I developed and studied via electromyography a few years ago. You can watch a demonstration of these exercises in the video below, and be sure to follow up with my full MedBridge course, “Hip Arthroplasty: Improving Gait.”
Please implement early hip flexor elongation/stretching and gait assistive exercises to help your hip replacement patients get back on their feet faster. Reach out to me on Twitter, as I truly want your feedback while we all strive to be progressive and achieve higher outcomes, especially in this current competitive climate.
- Jacobs, C. (2014). Paper #17. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; November 7–9, 2014, Dallas.
- Austin, M. S., Urbani, B. T., Fleischman, A. N., Fernando, N. D., Purtill, J. J., Hozack, W. J., Parvizi, J., & Rothman, R. H. (2017). Formal physical therapy after total hip arthroplasty is not required: a randomized controlled trial. Journal of Bone and Joint Surgery, 99(8): 648–655.
- Eitzen, I., Fernandes, L., Kallerud, H., Nordsletten, L., Knarr, B., & Risberg, M. A. (2015). Gait characteristics, symptoms, and function in persons with hip osteoarthritis: a longitudinal study with 6 to 7 years of follow-up. Journal of Orthopaedic & Sports Physical Therapy, 45(7): 539–549.