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Hip Case Study 1 : OA

Arthur Black is an otherwise fit and healthy 67 year old who has had longstanding
problems with his left hip. He was diagnosed with OA hip by his GP and has recently
had a total hip replacement. He returned home 6 days post operation and has been
referred to the domiciliary physiotherapist for assessment and treatment. Arthur is a
retired engineer who usually cycles and runs alternate days; he is keen to return to his
usual activities. He is managing his pain with NSAIDs. He has a medical history of
insulin dependent diabetes and previous episodes of low back pain

Anatomy & Pathology


OA most common arthritis is caused by low grade inflammation and results in pain at
joints – there is abnormal wearing of the cartlidge that covers and acts as a cushion
inside the joints – also destruction or decrease in synovial fluid – pain on weight
bearing ligaments – aetiology can be trauma or weight bearing.

OA hip replacement – problems include thromboembolic , neurovascular injury,


dislocation, leg length discrepancy and stiffness

Subjective Examination
Where\What : hip post op pain different from chronic sharp pain around hip

When: aks patient

How: post operative pain

0-10 rating: lower range than before op

24 hour cycle: ask patient

Better for: better for light movement

Worse for: too much rest = stiffness

Type of pain: stiffness mild vs sharp chronic around hip

Past Medical History/ General History:


Ask about family history of OA
Red Flags and general concerns: check for diabetes – low back pain indicates
chronic OA – side effects of operation – DVTS, dislocation, leg length discrepancy.
And neurovascular injury

SH: typically active

DH: ask about insulin , taking NSAID’s

Patients main outcome: return to regular exercise

Objective Examination

Working Hypothesis: patient is recouperating with a background of OA

Advice & Consent: give and obtain

General Observations: walking - gauge severity of problem

Acute Observations:
skin colour
swelling
posture
muscle bulk
deformity - are there any signs of infection or vascular injury

Active, Passive, and Resisted Tests:


Throughout be aware of possibility of prosthetic dislocation , neurovascular injury –
expect to find some stiffness – adductors and internal rotators are cut during operation
– most painful – may pain active and resisted but noticeably less in passive. Expect
muscles on affected leg to be weaker – especially the forceably cut and rested
adductors and internal rotators.
Flexion
Extension
Abduction
Adduction
Int rotation
Ext rotation

Special Tests:
Homan’s test – passive dorsiflexion in supine – positive sign = pain in calf. A
standard test for DVT’s – may be relevant

Functional Tests: observe walking

Palpation: examine seeking to confirm stiffness in hip as main presenting


problem – solitary sign indicates a successful operation

Measurements:
True leg length ( asis to medial maleolus )
Apparent leg length ( umblicius to medial maleolus )
Record any movements in passive that are particularly stiff

Advice & Possible Treatment:


Tell possibility of OA in back – non weight bearing exercises will target stiffness .
Wear related complications are rare – prosthetic lossening may still occur