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643

The Hip
The hip is often compared with the shoulder in that it is a
triaxial joint, able to function in all three planes, and that it
is also the proximal link to its extremity. In contrast to the
shoulder, which is designed for mobility, the hip is a stable
joint, constructed for weight bearing. However, to carry
out activities of daily living (ADL) in what is considered a
normal manner, at least 120 of hip flexion and at least
20 each of abduction and external rotation are necessary.
97
Forces from the lower extremities are transmitted upward
through the hips to the pelvis and trunk during gait and
other lower extremity activities. The hips also support the
weight of the head, trunk, and upper extremities.
This chapter is divided into three major sections.
The first section briefly reviews highlights of the anatomy
and function of the hip and its relation to the pelvis and
lumbar spine. The second section then describes common
disorders of the hip and guidelines for conservative and
postoperative management, expanding on the information
and principles of management presented in Chapters 10
through 13. The reader should be familiar with that materi-
C H A P T E R
20
STRUCTURE AND FUNCTION OF THE HIP 644
ANATOMICAL CHARACTERISTICS OF THE
HIP REGION 644
Bony Structures 644
Hip Joint Characteristics and
Arthrokinematics 644
Influence of the Hip Joint on Balance and
Posture Control 645
FUNCTIONAL RELATIONSHIPS OF THE HIPS
AND PELVIS 645
Pelvic Motions and Muscle Function 645
Pathomechanics in the Hip Region 647
THE HIP AND GAIT 648
Hip Muscle Function During Gait 648
Effect of Musculoskeletal Impairments
on Gait 648
REFERRED PAIN AND NERVE INJURY 648
Major Nerves Subject to Injury or Entrapment 648
Common Sources of Referred Pain in the Hip and
Buttock Region 648
MANAGEMENT OF HIP DISORDERS AND SURGERIES 649
JOINT HYPOMOBILITY: NONOPERATIVE
MANAGEMENT 649
Related Pathologies and Etiology
of Symptoms 649
Common Impairments 650
Common Functional Limitations/Disabilities 650
Management: Protection Phase 650
Management: Controlled Motion and Return to
Function Phases 650
JOINT SURGERY AND POSTOPERATIVE
MANAGEMENT 652
Total Hip Arthroplasty 652
Hemiarthroplasty of the Hip 663
FRACTURES OF THE HIPSURGICAL AND
POSTOPERATIVE MANAGEMENT 664
Hip FractureIncidence and Risk Factors 664
Sites and Types of Hip Fracture 664
Open Reduction and Internal Fixation of
Hip Fracture 665
PAINFUL HIP SYNDROMES/OVERUSE SYNDROMES:
NONOPERATIVE MANAGEMENT 671
Related Pathologies and Etiology of Symptoms 671
Common Impairments and Functional
Limitations/Disabilities 671
Management: Protection Phase 671
Management: Controlled Motion Phase 671
Management: Return to Function Phase 672
EXERCISE INTERVENTIONS FOR THE HIP REGION 672
EXERCISE TECHNIQUES TO INCREASE FLEXIBILITY
AND RANGE OF MOTION 672
Techniques to Stretch Range-Limiting
Hip Structures 672
Techniques to Stretch Range-Limiting
Two-Joint Muscles 674
EXERCISES TO DEVELOP AND IMPROVE MUSCLE
PERFORMANCE AND FUNCTIONAL CONTROL 676
Non-Weight-Bearing Exercises 676
Closed-Chain Weight-Bearing Exercises 678
Functional Training 681
INDEPENDENT LEARNING ACTIVITIES 682
al as well as the components of a comprehensive examina-
tion of the hip and pelvis before determining a diagnosis
and proceeding to establish a therapeutic exercise program.
The last section describes exercise interventions commonly
used to meet the goals of treatment for the hip region.
STRUCTURE AND FUNCTION OF THE HIP
The pelvic girdle links the lower extremity to the trunk and
plays a significant role in the function of the hip as well as
the spinal joints. The bones of the hip joint consist of the
proximal femur and the pelvis (Fig. 20.1). The unique
characteristics of the pelvis and femur that affect hip func-
tion are reviewed in this section. The function of the pelvis
with respect to spinal mechanics is described in greater
detail in Chapter 14.
The Femur
The shape of the femur is designed to bear body weight
and to transmit ground reaction forces through the long
bone, neck, and head to the acetabulum of the pelvis. In
the frontal plane there is an angle of inclination (normally
125) between the axis of the femoral neck and the shaft
of the femur. The angle of torsion formed by the trans-
verse axis of the femoral condyles and the axis of the
neck of the femur ranges from 8 to 25, with an average
angle of 12. There is also slight bowing of the shaft in
the sagittal plane.
69
Hip Joint Characteristics and Arthrokinematics
Characteristics
The hip is a ball-and-socket (spheroidal) triaxial joint
made up of the head of the femur and acetabulum of
the pelvis. It is supported by a strong articular capsule
that is reinforced by the iliofemoral, pubofemoral, and
ischiofemoral ligaments. The two hip joints are linked
to each other through the bony pelvis and to the vertebral
column through the sacroiliac and lumbosacral joints.
69,123
Articular Surfaces
The concave bony partner of the hip joint, the acetabulum,
is located in the lateral aspect of the pelvis and faces
laterally, anteriorly, and inferiorly (see Fig. 20.1). The
acetabulum is deepened by a ring of fibrocartilage, the
acetabular labrum. The articular cartilage is horseshoe-
shaped, being thicker in the lateral region where the
major weight-bearing forces are transmitted. The central
portion of the acetabular surface is nonarticular.
The convex bony partner is the spherical head of the
femur, which is attached to the femoral neck. It projects
anteriorly, medially, and superiorly.
The shapes of the articulating surfaces of the hip joint
and the reinforcing properties of the capsule and ligaments,
as well as the hip musculature, lend mobility coupled with
stability for functional tasks that require wide ranges of
combined movements, such as squatting, tying shoes while
seated, standing up from a chair or walking.
Ligaments
Of the three ligaments that reinforce the joint capsule, the
iliofemoral and pubofemoral ligaments are situated anteri-
orly (Fig. 20.2A), whereas the ischiofemoral ligament is
located posteriorly (Fig. 20.2B).
69,94,98
There is general agreement in the literature that these
three capsular ligaments limit excessive extension of the
hip and that the iliofemoral ligament, also known as the
Y ligament of Bigelow, is the strongest of the hip liga-
ments.
53,69,94,98
However, there is some dispute as to the
functions of each of these ligaments on an individual
basis. The iliofemoral ligament, which reinforces the ante-
rior portion of the capsule, also is thought to limit external
rotation of the hip
94,98
; and the pubofemoral ligament, lend-
ing support to the inferior as well as anterior portion of the
644 ANATOMICAL CHARACTERISTICS OF THE HIP REGION
Sacroiliac
joint
Sacrum
Hip
joint
Pubic
symphysis
Ilium
Pubis
Femur
Ischium
FIGURE 20.1 Bones and joints of the pelvis and hip.
ANATOMICAL CHARACTERISTICS
OF THE HIP REGION
Bony Structures
The structure of the pelvis and femur are designed for
weight bearing and transmitting forces through the hip
joint.
The Pelvis
Each innominate bone of the pelvis is formed by the union
of the ilium, ischium and pubis bones and therefore is a
structural unit. The right and left innominate bones articu-
late anteriorly with each other at the pubic symphysis and
posteriorly with the sacrum at the sacroiliac joints.
69
Slight
motion occurs at these three joints to attenuate forces as
they are transmitted through the pelvic region, but the
pelvis basically functions as a unit in a closed chain.
Influence of the Hip Joint
on Balance and Posture Control
The joint capsule is richly supplied with mechanoreceptors
that respond to variations in position, stress, and movement
for control of posture, balance, and movement. Reflex
muscle contractions of the entire kinematic chain, known
as balance strategies, occur in a predictable sequence when
standing balance is disturbed and regained. Joint patholo-
gies, restricted motion, or muscle weakness can impair
balance and postural control.
33,48
Refer to Chapter 8 for
an in-depth discussion of these concepts.
FUNCTIONAL RELATIONSHIPS
OF THE HIPS AND PELVIS
Pelvic Motions and Muscle Function
The pelvis is the connecting link between the spine and
lower extremities (Fig. 20.3A). Movement of the pelvis
causes motion at the hip joints and lumbar spine articula-
tions. The hip musculature causes pelvic motion through
reverse action. Hip flexors cause an anterior pelvic tilt;
hip extensors, a posterior pelvic tilt; and abductors and
adductors, a lateral pelvic tilt. Rotators cause pelvic rota-
tion. To prevent excessive pelvic motion when moving
the femur at the hip joint, the pelvis must be stabilized
by the abdominals, erector spinae, multifidus, and quad-
ratus lumborum muscles.
capsule, is believed to limit abduction.
94,98
Lastly, the
ischiofemoral ligament, although reinforcing the posterior
aspect of the capsule, may also limit internal rotation and,
when the hip is flexed, adduction.
53,94,98
Arthrokinematics of the Hip Joint
During many activities, such as squatting, walking, or
doing leg-press exercises, both the pelvis and femur are
moving. Therefore, joint mechanics can be described by
the movement of the femur in the acetabulum or as the
pelvis moving on the femur.
Motions of the femur. The convex femoral head slides
in the direction opposite the physiological motion of
the femur. Thus, with hip flexion and internal rotation
the articulating surface slides posteriorly; with exten-
sion and external rotation it slides anteriorly; with
abduction it slides inferiorly; and with adduction it
slides superiorly (Box 20.1).
Motions of the pelvis. When the lower extremity is stabi-
lized (fixated) distally, as when standing or during the
stance phase of gait, the concave acetabulum moves on
the convex femoral head, so the acetabulum slides in
the same direction as the pelvis. The pelvis is a link in
a closed chain; therefore, when the pelvis moves, there
is motion at both hip joints as well as the lumbar spine.
C H A P T E R 2 0 The Hip 645
Iliofemoral
ligament
Iliofemoral
ligament
Pubofemoral
ligament
Ischiofemoral
ligament
A B
FIGURE 20.2 Ligaments supporting the hip joint. (A) Anterior view.
(B) Posterior view.
BOX 20.1 Summary of Arthrokinematics
of the Femoral Head in the Hip Joint
Physiological Motions
of the Femur Roll Slide
Flexion Anterior Posterior
Extension Posterior Anterior
Abduction Lateral Inferior
Adduction Medial Superior
Internal rotation Medial Posterior
External rotation Lateral Anterior
Neutral
postition
A Posterior
pelvic tilt
B Anterior
pelvic tilt
C
FIGURE 20.3 (A) Neutral position of the pelvis. (B) Anterior pelvic tilt.
(C) Posterior pelvic tilt. With anterior pelvic tilt the decreased angle
between the pelvis and femur results in hip flexion, and with posterior
pelvic tilt the increased angle results in hip extension.
Anterior Pelvic Tilt
The anterior superior iliac spines of the pelvis move ante-
riorly and inferiorly and thus closer to the anterior aspect
of the femur as the pelvis rotates forward around the trans-
verse axis of the hip joints (Fig. 20.3B). This results in hip
flexion and increased lumbar spine extension.
69
Muscles causing this motion are the hip flexors and back
extensors.
During standing, the line of gravity of the trunk falls
anterior to the axis of the hip joints; the effect is an
anterior pelvic tilt moment. Stability is provided by
the abdominal muscles and hip extensor muscles.
Posterior Pelvic Tilt
The posterior superior iliac spines of the pelvis move
posteriorly and inferiorly, thus closer to the posterior
aspect of the femur as the pelvis rotates backward
around the axis of the hip joints (Fig. 20.3C). This
results in hip extension and lumbar spine flexion.
69
Muscles causing this motion are the hip extensors and
trunk flexors.
During standing when the line of gravity of the trunk
falls posterior to the axis of the hip joints, the effect
is a posterior pelvic tilt moment. Dynamic stability
is provided by the hip flexors and back extensors and
passive stability by the iliofemoral ligament.
Pelvic Shifting
During standing, a forward translatory shifting of the
pelvis results in extension of the hip and extension of
the lower lumbar spinal segments. There is a compen-
satory posterior shifting of the thorax on the upper
lumbar spine with increased flexion of these spinal
segments. This is often seen with slouched or relaxed
postures (see Fig. 14.12B in Chapter 14). Little muscle
action is required; the posture is maintained by the
iliofemoral ligaments at the hip, anterior longitudinal
ligament of the lower lumbar spine, and posterior
ligaments of the upper lumbar and thoracic spine.
Lateral Pelvic Tilt
Frontal plane pelvic motion results in opposite motions
at each hip joint. Pelvic motion is defined by what is
occurring to the iliac crest of the pelvis that is opposite
the weight-bearing extremity (that is, the side of the pelvis
that is moving). When the pelvis elevates, it is called hip
hiking; when it lowers, it is called hip or pelvic drop. On
the side that is elevated, there is hip adduction; on the side
that is lowered, there is hip abduction (Fig. 20.4A). During
standing, the lumbar spine laterally flexes toward the side
of the elevated pelvis (convexity of the lateral curve is
toward the lowered side).
69
Muscles causing lateral pelvic tilting include the quad-
ratus lumborum on the side of the elevated pelvis and
reverse muscle pull of the gluteus medius on the side
of the lowered pelvis.
With an asymmetrical slouched posture, the person
shifts the trunk weight onto one lower extremity and
allows the pelvis to drop on the other side. Passive
support comes from the iliofemoral ligament and
iliotibial band on the elevated side (stance leg).
When standing on one leg, there is an adduction
moment at the hip, tending to cause the pelvis to
drop on the unsupported side (hip or pelvic drop).
This is prevented by the gluteus medius stabilizing
the pelvis on the stance side.
Pelvic Rotation
Rotation occurs around one lower extremity that is fixed
on the ground. The unsupported lower extremity swings
forward or backward along with the pelvis. When the
unsupported side of the pelvis moves forward, it is called
forward rotation of the pelvis.
69
The trunk concurrently
rotates in the opposite direction, and the femur on the
stabilized side concurrently rotates internally. When the
unsupported side of the pelvis moves backward, it is called
posterior rotation; the femur on the stabilized side concur-
rently rotates externally, and the trunk rotates opposite
(Fig. 20.4B).
Lumbopelvic Rhythm
A coordinated movement between the lumbar spine and
pelvis occurs during maximum forward bending of the
trunk
25
as when reaching toward the floor or the toes. As
the head and upper trunk initiate flexion, the pelvis shifts
posteriorly to maintain the center of gravity over the base
of support. The trunk continues to forward-bend, being
controlled by the extensor muscles of the spine, until at
approximately 45. At this point for an individual with rela-
tively normal flexibility, the posterior ligaments become
taut, and the facets of the zygapophyseal joints approxi-
mate. Both of these factors provide stability for the inter-
vertebral joints, and the muscles relax.
126
Once all of the
646 FUNCTIONAL RELATIONSHIPS OF THE HIPS AND PELVIS
Lateral pelvic tilt A Pelvic rotation B
FIGURE 20.4 (A) Lateral pelvic tilt. Elevation of the
iliac crest (hip liking) causes relative adduction of
the hip on the elevated side; and lowering of the
iliac crest (hip drop) causes relative abduction of
the hip on the lower side. (B) Pelvic rotation. Forward
motion (forward rotation) of the pelvis causes rela-
tive external rotation of the hip; and backward
motion (posterior rotation) of the pelvis causes
relative internal rotation of the hip.
Anteversion and retroversion. An increase in the torsion
of the femoral neck is called anteversion and causes the
shaft of the femur to be rotated medially; a decrease in
the torsion is called retroversion and causes the shaft of
the femur to be rotated laterally. Anteversion often results
in genu valgum and pes planus. Unilateral anteversion
results in a relatively shorter leg on that side; retroversion
causes the opposite effects.
Hip Muscle Imbalances and Their Effects
Muscles function through habit. Faulty mechanics
from inadequate or excessive length and an imbalance
in strength cause hip, knee, or back pain.
116
Overuse
syndromes, soft tissue stress, and joint pain develop in
response to continued abnormal stresses. The related
muscle imbalances due to postural impairments are
summarized in Box 20.2. Common muscle length-
strength imbalances include the following.
Shortened iliotibial (IT) band with shortened tensor fas-
ciae latae (TFL) or gluteus maximus. Postural impair-
ments often associated with a shortened TFL or gluteus
maximus include an anterior pelvic tilt posture, slouched
posture, or flat back posture (see Chapter 14).
Dominance of the two-joint hip flexor muscles (TFL, rec-
tus femoris, sartorius) over the iliopsoas. This imbalance
may cause faulty hip mechanics or knee pain from over-
use of these muscles as they cross the knee.
vertebral segments are at the end of the range and stabilized
by the posterior ligaments and facets, the pelvis begins to
rotate forward (anterior pelvic tilt), being controlled by the
gluteus maximus and hamstring muscles. The pelvis contin-
ues to rotate forward until the full length of the muscles is
reached. Final range of motion (ROM) in forward bending
is dictated by the flexibility of the various back extensor
muscles and fasciae as well as hip extensor muscles.
The return to the upright position begins with the hip
extensor muscles rotating the pelvis posteriorly through
reverse muscle action (posterior pelvic tilt) then the back
extensor muscles extending the spine from the lumbar
region upward. Variations in the normal synchronization
of this activity occur because of training (as with dancers
and gymnasts), faulty habits, restricted muscle or fascia
length, or injury and faulty proprioception.
Pathomechanics in the Hip Region
Abnormal structure or impaired function of the hipsuch
as a leg-length discrepancy, decreased flexibility, or muscle
imbalancescan contribute to stress in the spine or other
joints of the lower extremities.
Decreased Flexibility
Decreased flexibility in the structures around the hip joint
cause weight-bearing forces and movement to be transmit-
ted to the spine rather than absorbed in the pelvis. Tight
hip extensors cause increased lumbar flexion when the
thigh flexes. Tight hip flexors cause increased lumbar
extension as the thigh extends. Hip flexion contractures
with incomplete hip extension during weight bearing also
place added stresses on the knee because the knee cannot
lock while the hip is in flexion unless the trunk is bent
forward. During weight bearing tight adductors cause
lateral pelvic tilt opposite the side of tightness and side
bending of the trunk toward the side of tightness. The
opposite occurs with tight abductors.
Asymmetrical Leg Length
Functional as well as structural asymmetries of the lower
extremities affect the posture of the pelvis.
Unilateral short leg. A unilateral short leg causes lateral
pelvic tilting (drop on the short side) and side-bending
of the trunk away from the short side (convexity of lateral
lumbar curve toward side of short leg). This may lead to
a functional or eventually a structural scoliosis. Causes
of a short leg could be unilateral lower extremity asymme-
tries such as flat foot, genu valgum, coxa vara, tight hip
muscles, anteriorly rotated innominate bone, poor stand-
ing posture, or asymmetry in bone growth.
Coxa valga and coxa vara. A pathologically large angle
of inclination between the femoral neck and shaft of the
femur is called coxa valga, and a pathologically smaller
angle is called coxa vara. Unilateral coxa valga results
in a relatively longer leg on that side and associated genu
varum. Unilateral coxa vara leads to a relatively shorter
leg with associated genu valgum.
C H A P T E R 2 0 The Hip 647
BOX 20.2 Hip Muscle Imbalances Related
to Postural Impairments
Anterior Pelvic Tilt Posture
Short TFL and IT band
General limitation of hip external rotation
Weak, stretched posterior portion of the gluteus medius
and piriformis
Excessive medial rotation of the femur during the first
half of stance phase of gait with increased stresses on the
medial structures of the knee
Associated lower extremity compensations including
medial rotation of the femur, genu valgum, lateral tibial
torsion, pes planus, and hallux valgus
Slouched Posture
Shortened rectus femoris and hamstrings
General limitation of hip rotators
Weak, stretched iliopsoas
Weak and shortened posterior portion of the gluteus
medius
Weak, poorly developed gluteus maximus
Associated lower extremity compensations including hip
extension, sometimes medial rotation of the femur, genu
recurvatum, genu varum, and pes valgus
Flat Back Posture
A shortened rectus femoris, IT band, and gluteus
maximus
Variations of the above two postures
Dominance of the TFL over the gluteus medius. This
imbalance leads to lateral knee pain from IT band ten-
sion or medial rotation of the femur with medial knee
stresses from an increased bowstring effect.
Dominance of hamstring muscles over the gluteus max-
imus. The gluteus maximus becomes short and the range
of hip flexion decreases; compensation occurs with
excessive lumbar spine flexion whenever the thigh is
flexed. Limited mobility in the gluteus maximus also
causes increased tension on the IT band with associated
trochanteric or lateral knee pain. Overuse of the ham-
string muscles causes decreased flexibility as well as
muscle imbalances with the quadriceps femoris muscle
at the knee. The hamstrings dominate the stabilizing
function by pulling posteriorly on the tibia to extend the
knee in closed-chain activities. This alters the mechanics
at the knee and may lead to overuse syndromes in the
hamstring tendons or anterior knee pain from imbalances
in quadriceps pull.
Use of lateral trunk muscles for hip abductors. This
results in excessive trunk motion and increased stress
in the lumbar spine.
THE HIP AND GAIT
During the normal gait cycle, the hip goes through a ROM
of 40 of flexion and extension (10 extension at terminal
stance to 30 flexion at midswing and initial contact).
There is also some lateral pelvic tilt and hip abduction/
adduction of 15 (10 adduction at initial contact, 5 abduc-
tion at initial swing); and hip internal/external rotation
along with pelvic rotation totaling 15 transverse plane
motion (peak internal rotation at the end of loading, peak
external rotation at the end of pre-swing). Loss of any of
these motions affects the smoothness of the gait pattern.
105
Hip Muscle Function During Gait
Hip Flexors
The hip flexors control hip extension at the end of stance,
then contract concentrically to initiate swing.
105
With loss
of flexor function, a posterior lurch of the trunk to initiate
swing is seen. Contractures in the hip flexors prevent com-
plete extension during the second half of stance; the stride
is shortened. To compensate, a person increases the lumbar
lordosis or walks with the trunk bent forward.
Hip Extensors
The hip extensors control the flexor moment at initial foot
contact, and the gluteus maximus initiates hip extension.
105
With loss of extensor function, a posterior lurch of the
trunk occurs at foot contact to shift the center of gravity
of the trunk posterior to the hip. With contractures in the
gluteus maximus, some decreased range occurs in the ter-
minal swing as the femur comes forward, or the person
may compensate by rotating the pelvis more forward. The
lower extremity may rotate outward because of the external
rotation component of the muscle, or the gluteus maximus
may place greater tension on the iliotibial band through its
attachment, leading to irritation along the lateral aspect of
the knee with excessive activity.
Hip Abductors
The hip abductors control the lateral pelvic tilt during
swinging of the opposite leg.
105
With loss of function of
the gluteus medius, lateral shifting of the trunk occurs over
the weak side during stance when the opposite leg swings.
This lateral shifting also occurs with a painful hip because
it minimizes the torque at the hip joint during weight bear-
ing. The tensor fasciae latae also functions as an abductor
and may become tight and affect gait with faulty use.
Effect of Musculoskeletal Impairments on Gait
Bony and joint deformities change alignment of the lower
extremity and therefore the mechanics of gait. Painful con-
ditions cause antalgic gait patterns, which are characterized
by minimum stance on the painful side to avoid the stress
of weight bearing.
REFERRED PAIN AND NERVE INJURY
The hip is innervated primarily from the L3 spinal level;
hip joint irritation is usually felt along the L3 dermatome
reference from the groin, down the front of the thigh to
the knee.
35,72
For a detailed description of referred pain
patterns and peripheral nerve injuries in the hip and but-
tock region, see Chapter 13.
Major Nerves Subject to Injury or Entrapment
Sciatic nerve. Entrapment may occur when the sciatic
nerve passes deep to the piriformis muscle (occasionally
it passes over or through the piriformis).
Obturator nerve. Isolated injury is rare, although uterine
pressure and damage during labor may occur.
Femoral nerve. Injury may result from fractures of the
upper femur or pelvis, during reduction of congenital
dislocation of the hip, or from pressure during a forceps
labor and delivery.
Common Sources of Referred Pain
in the Hip and Buttock Region
If painful symptoms are referred to the hip and buttock
region from other sources, primary treatment must be
directed to the source of the irritation. Common sources
of referred pain into the hip and buttock region include:
648 REFERRED PAIN AND NERVE INJURY
JOINT HYPOMOBILITY:
NONOPERATIVE MANAGEMENT
Related Pathologies and Etiology of Symptoms
Osteoarthritis (Degenerative Joint Disease)
Osteoarthritis is the most common arthritic disease of the
hip joint. The etiology may be the aging process, joint
trauma, repetitive abnormal stresses, obesity, or disease.
The degenerative changes include articular cartilage break-
down and loss, capsular fibrosis, and osteophyte formation
at the joint margins.
40
These effects usually occur in
regions undergoing the greatest loading forces, such as
along the superior weight-bearing surface of the acetabu-
lum (see Fig. 11.6).
Other Joint Pathologies
Rheumatoid arthritis, aseptic necrosis, slipped epiphyses,
dislocations, and congenital deformities can also lead to
degenerative changes in the hip joint (see Fig. 11.2).
Nerve roots or tissues derived from spinal segments L1,
L2, L3, S1, and S2
Lumbar intervertebral and sacroiliac joints
MANAGEMENT OF HIP DISORDERS
AND SURGERIES
To make sound clinical decisions when treating patients
with hip disorders, it is necessary to understand the various
pathologies, surgical procedures, and associated precautions
and identify presenting impairments, functional limitations,
and possible disabilities. In this section common patholo-
gies and surgeries are presented and related to correspon-
ding preferred practice patterns (groupings of impairments)
described in the Guide to Physical Therapist Practice
1
(Table 20.1). Conservative and postoperative management
of these conditions is also described in this section.
C H A P T E R 2 0 The Hip 649
TABLE 20.1 Hip Pathologies and Related Preferred Practice Patterns
PATHOLOGY/SURGICAL PROCEDURE PREFERRED PRACTICE PATTERNS AND ASSOCIATED IMPAIRMENTS
1
Abnormal posture (anterior pelvic tilt posture,
posterior pelvic tilt posture, rotated or shifted pelvis
related to spinal and lower extremity flexibility and
strength imbalances or structural malalignment)
Arthritis (osteoarthritis, rheumatoid arthritis,
traumatic arthritis)
Aseptic necrosis
Slipped epiphyses
Dislocation
Postimmobilization arthritis (stiffness)
Acute arthritis
Acute tendonitis, bursitis, muscle pull
Fracture (femoral or pelvic)
Total hip arthroplasty
Surface replacement arthroplasty
Hemiarthroplasty
Labral tear
Osteotomy
Open reduction and internal fixation of femoral
fracture or fracture-dislocation
Sciatic, obturator, or femoral nerve injury or
entrapment in the pelvis and hip region
Pattern 4BImpaired posture
Pattern 4DImpaired joint mobility, motor function, muscle
performance, and ROM associated with connective tissue
dysfunction
Pattern 4EImpaired joint mobility, motor function, muscle
performance, and ROM associated with localized
inflammation
Pattern 4GImpaired joint mobility, muscle performance, and
ROM associated with fracture
Pattern 4HImpaired joint mobility, motor function, muscle
performance, and ROM associated with joint arthroplasty
Pattern 4IImpaired joint mobility, motor function, muscle
performance, and ROM associated with bony or soft tissue
surgery
Pattern 5FImpaired peripheral nerve integrity and muscle
performance associated with peripheral nerve injury
Postimmobilization Hypomobility
A restriction in the capsular tissues leading to joint hypo-
mobilities as well as tightness in the surrounding periartic-
ular tissues may occur anytime the joint is immobilized
after a fracture or surgery.
Common Impairments
Pain experienced in the groin and referred along the
anterior thigh and knee in the L3 dermatome.
Stiffness after rest.
Limited motion with a firm capsular end-feel. Initial-
ly, limitation is only in internal rotation; in advanced
stages the hip is fixed in adduction, has no internal
rotation or extension past neutral, and is limited to
90 flexion.
35
Antalgic gait usually with a compensated gluteus medius
(abductor) limp.
Limited hip extension leading to increased extension
forces on the lumbar spine and possible back pain.
Limited hip extension preventing full knee extension
when standing or during gait leading to increased knee
stresses.
Impaired balance and postural control.
48
Common Functional Limitations/Disabilities
Hip joint impairments interfere with many weight-bearing
activities and ADL.
30,49
Early stages. There is progressive pain with continued
weight bearing and gait or at the end of the day after
repetitive lower extremity activities. The pain may
interfere with work (job-specific) or routine household
activities that involve weight bearing, such as meal
preparation, cleaning, and shopping.
Progressive degeneration. The individual experiences
increased difficulty arising from a chair, climbing stairs,
squatting, and other weight-bearing activities, as well as
restricted routine ADL such as bathing, toileting, and
dressing (putting on pants, hose, socks).
Management: Protection Phase
Chapter 11 describes the general principles and plan of
care in the treatment of osteoarthritis and rheumatoid
arthritis, and Chapter 10 describes general management
of joints during acute, subacute, and chronic stages of tis-
sue injury and repair. In conjunction with medical manage-
ment of the disease for inflammation and pain, correction
of faulty mechanics is an integral part of decreasing pain in
the hip. Faulty hip mechanics may be caused by conditions
such as obesity, leg-length differences, muscle length and
strength imbalances, sacroiliac dysfunction,
30
poor posture,
or injury to other joints in the chain.
23
The following goals
and interventions are emphasized during the acute stage of
tissue healing and the protection phase of nonoperative
management.
Decrease Pain at Rest
Apply grade I or II oscillation techniques with the joint
in the resting position.
Have the patient rock in a rocking chair to provide gentle
oscillations to the lower extremity joints as well as a
stimulus to the mechanoreceptors in the joints.
138
Decrease Pain During Weight-Bearing Activities
Provide assistive devices for ambulation to help reduce
stress on the hip joint. If the pain is unilateral, teach the
patient to walk with a single cane or crutch on the side
opposite the painful joint.
If leg-length asymmetry is causing hip joint stress, grad-
ually elevate the short leg with lifts in the shoe.
Modify chairs to provide an elevated and firm surface,
and adapt commodes with an elevated seat to make sit-
ting down and standing up easier.
Decrease Effects of Stiffness
and Maintain Available Motion
Teach the patient the importance of frequently moving
the hips through their ROM throughout the day. When
the acute symptoms are medically controlled, have the
patient perform active ROM if he or she can control the
motion or with assistance if necessary.
If a pool is available, have the patient perform ROM in
the buoyant environment.
Initiate nonimpact activities such as swimming, gentle
water aerobics, or stationary cycling.
Management: Controlled Motion
and Return to Function Phases
As healing progresses and symptoms subside, the
emphasis of management includes the following
goals and interventions.
Progressively Increase Joint
Play and Soft Tissue Mobility
Joint mobilization techniques. Progress joint mobilization
to stretch grades (grade III sustained or grade III and IV
oscillation) using the glides that stretch restricting capsular
tissue at the end of the available ROM (see Box 20.1 and
Figs. 5.45 through 5.47 in Chapter 5). Vigorous stretching
should not be undertaken until the chronic stage of healing.
Passive stretching, neuromuscular inhibition, and self-
stretching techniques. Stretch any range-limiting tissues.
Suggested techniques are described in Chapter 4 and in
the exercise section later in this chapter.
Improve Joint Tracking and Pain-Free Motion
Mobilization with movement (MWM) techniques
87
may be
applied through the use of a mobilization belt to produce a
pain-free inferolateral glide and then superimposing motion
to the end of the available range. As with all MWM tech-
niques, no pain should be experienced during application of
the technique. Principles of MWM are described in Chapter
5; specific hip MWM techniques are described here.
650 JOINT HYPOMOBILITY: NONOPERATIVE MANAGEMENT
Increase Extension
Patient position: Supine with the pelvis near the end of the
treatment table in the Thomas test position (opposite thigh
held against the chest) and a mobilization belt secured
around the proximal thigh and your pelvis.
Procedure: Stabilize the patients pelvis with the palm of
the hand closest to the patients head. Use the mobilization
belt to produce a pain-free inferolateral glide while the
caudal hand presses against the extended thigh to create
pain-free end-range extension (Fig. 20.5C).
Increase Extension During Weight Bearing
Patient position: Standing with the unaffected foot up on a
stool and a mobilization belt secured around the proximal
thigh and your pelvis.
Procedure: Stabilize the pelvis with both hands and apply
a pain-free lateral glide with the mobilization belt while
the patient lunges forward to produce painless extension
of the affected hip (Fig. 20.5D).
Increase Internal Rotation
Patient position: Supine with the involved hip flexed and
a mobilization belt secured around the proximal thigh and
your pelvis.
Procedure: Stabilize the patients pelvis with the palm of
the hand closest to the patients head. Use the mobilization
belt to produce a pain-free inferolateral glide while the
caudal hand grips around the flexed thigh and shin to cre-
ate pain-free end-range internal rotation (Fig. 20.5A).
Increase Flexion
Patient position: Supine with the involved hip flexed and
a mobilization belt secured around the proximal thigh and
the pelvis.
Procedure: Stabilize the patients pelvis with the palm
of the hand closest to the patients head. Use the mobiliza-
tion belt to produce a pain-free inferolateral glide while
the caudal hand grips around the flexed thigh and shin to
create pain-free end-range flexion (Fig. 20.5B).
C H A P T E R 2 0 The Hip 651
A B C D
FIGURE 20.5 Mobilization with movement using an inferolateral glide increasing (A) pain-free internal rotation,
(B) pain-free flexion, (C) pain-free extension, and (D) extension during weight bearing.
Improve Muscle Performance in Supporting Muscles
Initiate exercises that develop strength and control of
the hip musculature (especially the gluteus maximus,
gluteus medius, and rotators) and that improve stability
and balance when performing weight-bearing activities.
Begin with submaximal isometric resistance; progress
to dynamic resistance as the patient tolerates movement.
If any exercises exacerbate the joint symptoms, reduce
the intensity. Also reassess the patients functional activ-
ities and adapt them to reduce the stress.
Progress to functional exercises as tolerated using
closed-chain and weight-bearing activities. The patient
may require assistive devices while weight bearing. Use
a pool or tank to reduce the effects of gravity to allow
partial weight-bearing exercises without stress.
Develop postural awareness and balance.
Progress the low-impact aerobic exercise program
(swimming, cycling, or walking within tolerance).
Patient Education
Help the patient establish a balance between activity and
rest and learn the importance of minimizing stressful
deforming forces by maintaining muscle strength and
flexibility in the hip region.
Focus on Evidence
Two systematic reviews of studies designed to examine
evidence of the effects of exercise in the management of
hip and knee OA describe support for aerobic exercise and
strengthening exercises to reduce pain and disability.
112,113
The consensus of expert opinion cited by Roddy et al.
112
is
that there are few contraindications and that exercise is rel-
atively safe in patients with OA; however, exercise should
be individualized and patient-centered with consideration
for age, co-morbidity, and general mobility.
An outcome review
36
summarized that moderate- or
high-intensity exercises in patients with rheumatoid arthri-
tis (RA) have minimal effect on the disease activity, but
there is insufficient radiological evidence on the effect in
large joints. Long-term moderate- or high-intensity exercis-
es that are individualized to protect radiologically damaged
joints improve aerobic capacity, muscle strength, functional
ability, and psychological well-being in patients with RA.
JOINT SURGERY AND
POSTOPERATIVE MANAGEMENT
Many joint surgeries are available to treat early- and late-
stage joint disease of the hip and some fractures that com-
promise the vascular supply to the head of the femur. As a
result of advances in arthroscopy of the hip over the past
decade, small to medium-size full-thickness lesions of the
articular cartilage of the acetabulum and head of the femur,
as well as other joint pathologies such as acetabular labral
tears and capsular laxity, now can be managed arthroscopi-
cally.
38
One such procedure, microfracture, involves creat-
ing small fractures of subchondral bone in the area of the
chondral lesion to stimulate growth of fibrocartilage to
replace the damaged hyaline cartilage.
38
Surgical procedures to manage late-stage deteriora-
tion of the hip joint include osteotomy (which is actually
an extra-articular procedure) and arthroplasty, specifically
resurfacing arthroplasty (surface replacement),
47
hemi-
arthroplasty,
79
and total joint replacement arthroplas-
ty.
31,61,75
Arthrodesis and resection arthroplasty of the hip
are considered salvage procedures after failure of arthro-
plasty and when revision arthroplasty is contraindicated
or not feasible.
75
The goals of joint surgery and postoperative manage-
ment are to provide a patient with (1) a pain-free hip, (2) a
stable joint for lower extremity weight bearing and func-
tional ambulation, and (3) adequate ROM and strength of
the lower extremity for functional activities.
It is important for the therapist to have a basic under-
standing of the more common surgical procedures for
management of joint disease and deformity and a thorough
knowledge of appropriate therapeutic exercise interven-
tions and their progression for an effective, safe postopera-
tive rehabilitation program. An overview of two of the
more common procedures, total hip arthroplasty and hemi-
arthroplasty, and guidelines for postoperative management
are described in the following sections.
Total Hip Arthroplasty
One of the most widely performed surgical interventions
for advanced arthritis of the hip joint is total hip arthroplas-
ty (Fig. 20.6). Osteoarthritis is the underlying pathology
that accounts for most primary total hip procedures.
31
Indications for Surgery
The following are common indications for total hip arthro-
plasty (THA), also referred to as total hip replacement
(THR).
26,31,39,44,75,81
652 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
FIGURE 20.6 Total hip arthroplasty. (A) The preoperative film of a severely degenerative hip joint demonstrates the
classic signs of degenerative joint disease. A, N; B arrowed, joint space with superior migration of the femoral head;
B, osteophyte formation at the joint margins of both the acetabulum and femoral head; C, sclerosis of subchondral
bone on both sides of the joint surface; D, acetabular protrusion (a bony outpouching of the acetabular cup in
response to the progressive superior and medial migration of the femoral head). (B) Postoperative film shows a total
hip arthroplasty. Both the acetabular and femoral portions of the joint have been resected and replaced with pros-
thetic components. (From McKinnis,
78
p. 312, with permission.)
years.
8,12
Patient-related instruction in past years took place
the day before surgery when patients were often admitted to
the hospital for preoperative tests. In the current health care
environment, hospital stays have been shortened dramatical-
ly. Preoperative contact with a patient prior to elective sur-
gery now occurs on an outpatient basis individually or in a
group several days before surgery. Preoperative manage-
ment typically includes assessment and documentation of
a patients status as well as patient education about the pro-
cedure and what to expect during the early postoperative
period.
13,55,75,89,114
Patient information sessions are often
coordinated and conducted by a team of professionals from
multiple disciplines who are likely to be involved with a
patients postoperative care. Box 20.4 summarizes possible
components of preoperative management.
13,55,75,89,114
Procedures
Background
Prosthetic designs and materials. Total hip arthro-
plasty has been successfully performed since the early
1960s.
28,31,41,44,86
Sir John Charnley,
28
a surgeon from
England, is credited with the initial research and clinical
application of THA, which subsequently has evolved
into contemporary hip arthroplasty. A variety of implant
designs, materials, and surgical approaches have been
developed and modified over the years since the early
replacements.
31,41,44
Today total hip implant systems typi-
cally are composed of an inert metal (cobalt-chrome and
titanium) modular femoral component and a high-density
polyethylene acetabular component. Other designs in use
are metal-on-metal systems
122
and systems that utilize
ceramic surfaces in the design.
31
Cemented versus cementless fixation. The revolutionary
aspect of the early THA procedures was the use of acrylic
cement, methylmethacrylate, for prosthetic fixation.
Cement fixation allowed very early postoperative weight
bearing and shortened the period of rehabilitation, whereas
Severe hip pain with motion and weight bearing and
marked limitation of motion as the result of joint deterio-
ration and loss of articular cartilage associated with os-
teoarthritis, rheumatoid or traumatic arthritis, ankylosing
spondylitis, or osteonecrosis (avascular necrosis) leading
to impaired function and health-related quality of life
Nonunion fracture, instability or deformity of the hip
Bone tumors
Failure of conservative management or previous joint
reconstruction procedures (osteotomy, resurfacing
arthroplasty, femoral stem hemiarthroplasty, total hip
replacement)
Historically, primary THA was reserved for patients
older than 60 to 65 years of age or the very inactive
younger patient with multiple joint involvement because
the projected life span of primary THA procedures is less
than 20 years.
31,44
For the younger patient with significant
hip joint deterioration, surface replacement (resurfacing)
arthroplasty, a more bone-conserving surgery than THA, is
an alternative that may be considered.
47
However, with
advances in designs, materials, and particularly cementless
fixation and subsequent broadening of patient selection cri-
teria, THA also is considered an option for some younger,
moderately active patients after evaluation on a case-by-
case basis.
5
These individuals are counseled by the surgeon
to anticipate the need for revision arthroplasty later in life.
There are a number of instances in which THA is con-
traindicated. Absolute and relative contraindications are
noted in Box 20.3.
5,14,31
Preoperative Management
Preoperative patient education has been advocated as an
important aspect of the overall rehabilitation plan for many
C H A P T E R 2 0 The Hip 653
BOX 20.3 Contraindications to Total
Hip Arthroplasty
Absolute
Active joint infection
Systemic infection or sepsis
Chronic osteomyelitis
Significant loss of bone after resection of a malignant
tumor or inadequate bone stock that prevents sufficient
implant fixation
Neuropathic hip joint
Severe paralysis of the muscles surrounding the joint
Relative
Localized infection, such as bladder or skin
Insufficient function of the gluteus medius muscle
Progressive neurological disorder
Highly compromised/insufficient femoral or acetabular
bone stock associated with progressive bone disease
Patients requiring extensive dental workdental surgery
should be completed before arthroplasty
Young patients who must or are most likely to participate
in high-demand (high-load, high-impact) activities
BOX 20.4 Components of Therapy-Related
Preoperative Management: Preparation
for Total Hip Arthroplasty
Examination and evaluation of pain, ROM, muscle
strength, balance, ambulatory status, leg lengths, gait
characteristics, use of assistive devices, general level of
function, perceived level of disability
Information for patients and their families about joint
disease and the operative procedure in nonmedical terms
Postoperative precautions and their rationale including
positioning and weight bearing
Functional training for early postoperative days includ-
ing bed mobility, transfers, gait training with assistive
devices
Early postoperative exercises
Criteria for discharge from the hospital
prior to the use of cement fixation patients were subjected
to months of restricted weight bearing and limited mobili-
ty.
31
Cement fixation continues to be used today but has
been noted to have its drawbacks.
15,73,100,109
A significant postoperative complication, identified
a number of years after the first THA procedures were
performed, was aseptic (biomechanical) loosening of the
prosthetic components at the bonecement interface. It
was shown that loosening subsequently led to a gradual
recurrence of hip pain and the need for surgical revi-
sion.
31,44,75,109
Patients who most often developed loosening
were identified as the younger, physically active patients.
In contrast, loosening was not shown to be a particularly
prevalent problem in elderly patients or in young patients
with multiple joint involvement who typically have a limit-
ed degree of physical activity.
44,109
The long-term problem of mechanical loosening of
some cemented implants, most often the acetabular com-
ponent, gave rise to the development and use of cement-
less (biological) fixation.
31,44,75
Cementless fixation is
achieved either by use of porous-coated prostheses that
allow osseous ingrowth into the beaded or mesh-like
surfaces of an implant or by a cementless press-fit tech-
nique.
16,70,106,131
Smooth (nonporous) femoral components
also are being used with cementless arthroplasty. Some
components are manufactured with a coating of a bioactive
compound called hydroxyapatite designed to promote
initial osseous ingrowth.
27
Ingrowth of bony tissue occurs
over a 3- to 6-month period with continued bone remodel-
ing beyond that time period.
Improvements in cemented fixation
15,73,100,109,110
as
well as noncemented fixation
16,70,106,131
have continued, as
has debate over the benefits, indications, and disadvantages
of both forms of fixation. Cement fixation is routinely used
for patients with osteoporosis and poor bone stock and typ-
ically with elderly patients.
15,73,100,109
In contrast, cement-
less fixation is more often the choice for the patient under
60 years of age who is physically active and has good bone
quality.
16,21,70,106,131
In response to a low rate of loosening of cemented
femoral implants but continued problems of loosening of
cemented acetabular components, the use of a hybrid pro-
cedure with a noncemented acetabular component and a
cemented femoral prosthesis is a current alternative.
90
During the first few postoperative weeks, the method
of component fixation may influence a patients weight-
bearing status during ambulation and functional activities.
Overview of Operative Procedures
The operative approaches used to gain access to the
involved joint and to implant the prosthetic components
during THA can be divided into two broad categories:
standard and minimally invasive approaches. For decades
hip arthroplasty procedures have involved the use of
rather long surgical incisions (15 to 25 cm) to expose the
joint. Although long-term outcomes have been successful,
standard surgical approaches impose substantial trauma
to soft tissues and contribute to a lengthy postoperative
recovery period.
A recent advance in primary hip arthroplastythe
use of minimally invasive approaches through mini-
incisions allows adequate exposure of the joint for
insertion of the prosthetic components but reportedly
lessens the trauma of soft tissues. Brief overviews of the
various types of standard and minimally invasive surgical
approaches follow, focusing on which muscles are incised
or left intact during the procedure because the integrity of
these muscles and other soft tissues that surround the pros-
thetic hip influences its postoperative stability and the
extent of restrictions placed on the patient, most notably
during the early phase of postoperative recovery.
2,51,75
Standard surgical approaches. There are several standard
(conventional) approaches that may be used during tradi-
tional THA procedures: posterior (or posterolateral), later-
al, and anterior (or anterolateral). Each has its advantages
and disadvantages.
2,51
Posterolateral approach. This is the most frequently
used approach for primary THA. To access the joint, the
gluteus maximus is split in line with the muscle fibers.
The short external rotator tendons are transected near
their insertion. Consequently, this approach preserves
the integrity of the gluteus medius and vastus lateralis
muscles. Trochanteric osteotomy is not necessary. The
capsule is incised posteriorly in preparation for posterior
dislocation of the hip. The primary disadvantage of this
approach is that it is associated with the highest inci-
dence of postoperative joint instability and resulting sub-
luxation or dislocation of the hip.
66,83,84
To reduce the
risk of postoperative dislocation, repair of the posterior
capsule (posterior capsulorrhaphy) is advocated to pro-
vide maximal soft tissue constraint to the posterior
aspect of the capsule.
29
Direct lateral approach. This approach requires longitu-
dinal division of the tensor fasciae latae, release of up to
one-half of the proximal insertion of the gluteus medius,
and longitudinal splitting of the vastus lateralis.
2,51
The
gluteus minimus also is partially detached from the
trochanter. A lateral approach may, but typically does
not, involve a trochanteric osteotomy. Disruption of
the abductor mechanism is associated with postopera-
tive weakness and gait abnormalities (positive Trende-
lenburg sign).
Anterolateral approach. This approach and an anterior
approach were frequently used for primary THA during
the early years of this procedure.
28,31,51
Today, however,
it is most often reserved for revision arthroplasty or
arthroplasty that involves complex reconstruction. It
is also indicated for patients with muscle imbalances
associated with stroke or cerebral palsy whose standing
posture is characterized by hip flexion and internal rota-
tion.
2,51
Patients exhibiting this posturing are at high risk
of dislocation with a posterolateral approach. The antero-
lateral approach provides excellent stability of the hip
postoperatively but involves detachment and subsequent
repair of the gluteus medius muscle, or it may necessi-
tate an osteotomy of the greater trochanter for adequate
654 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
minimally invasive THA are reduced blood loss, reduced
postoperative pain, shorter length of hospital stay and
lower cost of hospitalization, more rapid recovery of func-
tional mobility, and a better cosmetic appearance of the
surgical scar.
3,6,13,14,115
However, proponents also note that
minimally invasive THA procedures are more technically
challenging, specifically with regard to insertion and align-
ment of the prosthetic components, and that there is likely
to be a higher rate of complications depending on the sur-
geons experience with the new approach and selection
of patients.
3,7
Although most investigators have indicated that mini-
mally invasive THA procedures hold promise and many
reports have provided data about a variety of positive out-
comes associated with minimally invasive approach-
es,
13,14,76
these reports have been limited to descriptions
of practitioner or institutional experiences with selected
patient populations and did not include a comparison
group. Only recently have studies become available that
call into question some of the reported benefits and docu-
ment the rate of surgery-related complications or that
directly compare minimally invasive THA procedures
with traditional THA.
99,137
Focus on Evidence
Woolson et al.
137
conducted a retrospective comparative
study of 135 patients who had undergone primary, uni-
lateral THA with either a standard posterior approach
(85 patients, mean age 63 years) or a minimally invasive
posterior approach (50 patients, mean age 60 years).
Several surgery-related, in-hospital variables and dis-
charge outcomes were evaluated. The participating sur-
geons determined which patients met the criteria for the
minimally invasive procedure with regard to health history
and body mass index. Consequently, the minimally inva-
sive group was thinner and healthier than the conventional
THA group. Despite these demographic differences, there
were no significant differences found between the groups
with respect to the surgery itself (operating time, blood
loss, need for transfusion), nor were there significant dif-
ferences in length of hospital stay or the percentage of
patients discharged diectly home. However, an independent
investigator, who was blind to the type of approach used,
identified a higher rate of complications in the minimally
invasive group, including wound complications, component
malpositioning, and leg-length discrepancy.
Ogonda and colleagues
99
reported the first randomized
controlled trial comparing minimally invasive and tradi-
tional THA in 219 patients who underwent primary, unilat-
eral, hybrid THA performed by the same surgeon. In both
groups a single incision, posterior approach was used, with
the only differences being the length of the skin incision
(the minimally invasive incision 10 cm and the standard
incision 16 cm) and the extent of tensor fasciae latae distur-
bance during the approach (less in the mini-incision group).
All patients and evaluators were blinded to the length of
the incision, and all participated in exercise and functional
training after surgery. No significant differences were found
exposure of the hip joint. In addition to the gluteus
medius, soft tissues disturbed in an anterolateral
approach include the gluteus minimus, tensor fasciae
latae, iliopsoas, rectus femoris, and vastus lateralis
muscles as well as the anterior capsule.
If a trochanteric osteotomy is performed, the trochan-
ter must be reattached and wired in place to stabilize the
osteotomy site until bone healing occurs. The trochanter
is often reattached in a position to improve the mechanical
efficiency of the gluteus medius muscle.
2,51
Complications
associated with trochanteric osteotomy include nonunion,
abductor muscle weakness, and greater than usual soft
tissue irritation and pain from a considerable amount of
internal fixation.
Minimally invasive approaches. As with traditional THA,
minimally invasive THA is an open procedure. However,
with minimally invasive procedures, the joint is approached
through one or two small incisions, usually defined as 10
cm in length.
14
The characteristics of minimally invasive
approaches for THA are summarized in Box 20.5.
The rationale for minimally invasive THA is that,
compared with traditional THA, the use of smaller inci-
sions potentially lessens soft tissue trauma during surgery
and therefore should improve and accelerate a patients
postoperative recovery.
6,14
Benefits cited by advocates of
C H A P T E R 2 0 The Hip 655
BOX 20.5 Features of Minimally Invasive Total
Hip Arthroplasty
Length of incison: 10 cm, depending on the location of
the approach and the size of the patient
14
Most if not all muscles and tendons left intact
Single-incision or two-incision approach
Single incision: usually posterior
45
or anterior,
76
or
occasionally lateral.
7,57
Two-incision: approach: two 4- to 5-cm incisions, one
anterior for insertion of acetabular component and one
posterior for placement of femoral component.
4,13,115,125
Incision location and muscles disturbed
Posterior approach a 7- to 10-cm posterior incision
extending mostly distal to the greater trochanter
between the gluteus medius and piriformis muscles;
short external rotators may or may not be incised (later
repaired), but the abductor mechanism consistently is
left intact.
45,137
Anterior approach: approximately a 10 cm incision
beginning just lateral and distal of the anterior superior
iliac spine extending in a distal and slightly posterior
direction along the belly of the tensor fasciae latae
(TFL); sartorius and rectus femoris retracted medially
and the TFL laterally leaves all muscles intact; no
postopertive precautions.
13,76
Lateral approach: least commonly used; splits the
middle-third of the gluteus medius; anterolateral inci-
sion into the capsule leaves the posterior capsule intact,
eliminating the need to postoperative precautions.
7,57
between groups at the conclusion of the study with respect
to the variables evaluated, including postoperative pain and
use of pain medication, ability to transfer and ambulate
with an assistive device, length of hospital stay, and dis-
charge to home or to a transitional facility. At 6 weeks after
surgery there continued to be no significant differences
between groups related to function or complications.
The investigators in both studies concluded that there
was no objective evidence to support that there are short-
term benefits of minimally invasive THA compared with
traditional THA. Both indicated that long-term, follow-up
studies must be conducted.
Implantation of components and closure. After dislocation
of the joint, an osteotomy is performed at the femoral neck,
and the head is removed. Another option used by some
surgeons for minimally invasive procedures is to cut the
femoral neck in situ without dislocating the hip.
13,76,125
The acetabulum is reamed and remodeled, and a high-
density polyethylene cup is inserted into the prepared
acetabulum.
100,110
A patient with developmental dysplasia
of the hip may require acetabular bone grafting to improve
the stability of the prosthetic joint. The intramedullary
canal of the femur may be broadened, primarily when
cement fixation is to be used; and a stemmed, metal pros-
thesis is inserted into the shaft of the femur.
15,109
It is
important to note that trial components are inserted and
checked radiographically to verify alignment of the compo-
nents, and the hip is moved through a full ROM to assess
its stability before the permanet implants are inserted.
After the prosthetic hip is reduced, the capsule usually
is repaired. The remaining layers of soft tissues that were
incised or detached are securely repaired and appropriately
balanced prior to closure.
Complications
The incidence of intraoperative and postoperative compli-
cations after primary, traditional THA is relatively low.
However, there may be a higher incidence of complications
after minimally invasive procedures due to decreased expo-
sure of the hip joint and the more technically demading
nature of minimally invasive approaches.
3,7
Although only
a small percentage of complications require revision
arthroplasty, any complication can hamper rehabilitation
and restoration of functional mobility.
Intraoperative complications associated with THA
include malpositioning of the prosthetic components,
femoral fracture, and nerve injury. In addition to medical
complications, such as infection, deep vein thrombosis
(DVT), or pneumonia that can occur after any surgery,
postoperative complications that may occur during the
early period of recovery (before 6 weeks or up to 2 to
3 months) include wound healing problems, dislocation
of the prosthetic joint, disruption of a bone graft site
before sufficient bone healing has occurred, and leg-
length discrepancy.
83
Late complications include dis-
location, mechanical loosening of either implant at the
bonecement or boneimplant interface, polyethylene
wear, and in rare instances heterotopic ossification.
Dislocation of the operated hip is a complication that
occurs most frequently during the first 2 to 3 months post-
operatively when soft tissues around the hip joint are heal-
ing. The frequency of early dislocation after current-day
primary THA is reported to be 1% to slightly more than
10%, with a mean of just less than 2%.
80
However, this rate
increases to 5% at 5 years.
80
Most dislocations are nontrau-
matic and occur in a posterior direction.
66,84
Posterior dislo-
cations are often but not always associated with a posterior
surgical approach.
2,51
However, dislocation also occurs after
anterior/anterolateral and direct lateral approaches.
66,75,83,
84,104,139
Patient-related and surgery/prothesis-related risk
factors that may contribute to dislocation are noted in Table
20.2.
80
Precautions to reduce the risk of dislocation after
THA are addressed in the following section on postopera-
tive management (see Box 20.7). Recurrent dislocation
after THA usually must be managed surgically.
Inequality of leg lengths is a complaint of some
patients during the early period of recovery after THA.
103
Although asymmetry of the pelvis and trunk may be evident
656 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
TABLE 20.2 Risk Factors Contributing to Joint Dislocation after Total Hip Arthroplasty
Patient-Related Factors Surgery/Prosthesis-Related Factors
Age 80 to 85 years
80,84
THA for femoral neck fracture
Medical diagnosis: higher risk in patients
with inflammatory arthritis (mostly RA) than
patients with OA
139
Poor qualtiy soft tissue from chronic
inflammatory disease
History of prior hip surgery
Preoperative and postoperative muscle
weakness and contractures
Cognitive dysfunction, dementia
Surgical approach: higher risk with posterior than anterior or
lateral approaches
Malpositioning of the acetabular component
Inadequate soft tissue balancing during surgery or poor quality
soft tissue repair
Experience of the surgeon
Although it is customary to limit weight bearing on
the operated lower extremity after cementless and hybrid
THA,
16,59,131
this practice deserves a closer look. The
rationale for restricting weight bearing is based on the
assumption that early, excesssive loading of the operated
limb could cause micromovement at the boneimplant
interface, thereby jeopardizing the initial stability of the
implant(s), interfering with osseous ingrowth, and con-
tributing to eventual loosening of the prosthetic implants.
Nonetheless, there are also potential benefits of safe
levels of early weight bearing after THA, specifically the
reduction of bone demineralization from decreased weight
bearing and the earlier recovery of functional mobility.
19,21
It has been established that many patients have difficulty
learning and integrating prescribed weight-bearing limita-
tions into daily functional activities and consequently place
greater loads than recommended on the operated extremity,
particularly once postoperative pain has subsided.
133
It is
also known that in the supine position resisted movements
of the lower extremity impose loads on the hip consider-
ably greater than body weight.
97
In light of these considerations, the need for weight-
bearing restrictions after cementles THA currently is
being re-examined.
Focus on Evidence
In two recent randomized, controlled investigations,
19,21
the effects of immediate weight bearing as tolerated dur-
ing ambulation and other functional activities after cement-
less or hybrid arthroplasty were compared with the effects
of restricted weight bearing. No short-term or long-term
adverse effects of immediate weight bearing were identi-
fied in either study. It is important to note that patients
in both studies were relatively young compared with most
patients undergoing hip arthroplasty, and their bone quality
was described as excellent. In addition, all patients in both
studies participated in a comprehensive, supervised postop-
erative rehabilitation program.
In one study,
21
patients assigned to the immediate
weight-bearing group were placed on no weight-bearing
restrictions. These patients were also encouraged to discon-
tinue use of ambulation aids as soon as possible. In con-
trast, those in the restricted weight-bearing group were
required to ambulate with two crutches and were limited
to toe-touch weight bearing for 6 weeks. After 6 weeks
these patients were permitted to bear weight as tolerated.
In the other study,
19
patients in the immediate weight-
bearing group initially used one crutch but were encouraged
to place as much weight as tolerated on the operated lower
extremity. Patients in the delayed weight-bearing group
ambulated with two crutches and were allowed to place
only 10% of body weight on the operated leg for 3 months.
There were no significant differences found between the
two groups in either study on several follow-up evalua-
tions. Authors of both studies suggested that early weight
bearing as tolerated after cementless or hybrid primary
THA can be safe in a young patient population ( 60 to
65 years of age) with excellent bone quality. However, in
during standing and walking, in most instances this is the
result of muscle spasm, muscle weakness (particularly the
gluteus medius), and residual contracture of hip muscles,
which can be managed conservatively. However, a true leg-
length discrepancy, associated with low back and hip pain
or hip dislocation, may be the result of malpositioning of
the prosthetic implants (usually the acetabular component).
If significant, it may necessitate revision arthroplasty.
103
Postoperative Management
Immobilization
After THA there is no need for immobilization of the oper-
ated hip. To the contrary, postoperative rehabilitation
emphasizes early movement. Depending on the type of sur-
gical approach used and the stability of the prosthetic hip,
the operated limb may need to remain in a position of
slight abduction and neutral rotation when the patient is
lying in bed in the supine position. An abduction pillow or
wedge typically is sufficient to maintain the position.
75
Weight-Bearing Considerations
After cemented THA, typically patients are permitted to
bear as much weight as tolerated almost immediately after
surgery.
15,73,100,109
In contrast, with cementless or hybrid
THA, it is often necessary to limit weight bearing on the
operated limb for the first few weeks or up to 3 months. A
number of factors affect the extent and duration of postop-
erative weight-bearing restrictions and the need for an
ambulation aid during transfers, walking, and ascending
and descending stairs. Box 20.6 summarizes these factors.
C H A P T E R 2 0 The Hip 657
BOX 20.6 Early Postoperative Weight-Bearing
Restrictions After Total Hip Arthroplasty
Method of Fixation
Cemented. Immediate postoperative weight bearing as
tolerated.
15,73,75,100
Cementless and hybrid. Recommendations vary from par-
tial weight bearing (toe-touch or touch-down) for at least
6 weeks
16,70,75,90
to weight bearing as tolerated (no restric-
tions) immediately after surgery.
13,19,21
Surgical Approach
Standard versus minimally invasive. Weight-bearing usu-
ally more restricted after standard (traditional) approach
because of more extensive surgical disturbance and
repair than minimally invasive approach.
14
Weight bear-
ing as tolerated may be permissible immediately after
minimally invasive procedure.
13
Trochanteric osteotomy. Although used infrequently,
restricted weight bearing at least 6 to 8 weeks or possibly
12 to 16 weeks for bone healing
Other Factors
Use of bone grafts. Non-weight-bearing or restricted
weight bearing during bone healing.
Poor quality of patients bone. Extended restrictions so as
not to jeopardize the stability of the prosthetic implants.
the clinical setting, the responsibility of determining the
need for protected weight bearing during the early phase
of postoperative rehabilitation after THA remains with
the surgeon.
Exercise and Functional Training
The use of therapeutic exercise interventions for patients
after THA has been reported in the literature for several
decades.
12,24,34,54,111
Although the time frame for and extent
of patient-therapist contact have decreased substantially
since these early descriptive reports were published, the
ultimate goal of rehabilitation remains the same: to opti-
mize a patients postoperative level of function. However,
specific components, frequency, and progression of rehabil-
itation programs have not been consistent or standardized.
37
More often than not rehabilitation programming has cen-
tered on protocols developed by and based on the opinions
or assumptions of individual surgeons or therapy depart-
ments rather than on evidence-based research on the effects
of specific exercises or weight-bearing activities on the hip
joint or on functional outcomes. In addition, exercise proto-
cols often must be adjusted to meet the needs and abilities
of individual patients. Consequently, the effectiveness of
postoperative exercise has not been clearly supported.
A report from the National Institutes of Health (NIH)
has identified the need for consistently applied and eval-
uated long- and short-term intervention strategies for reha-
bilitation after THA.
95
A consensus survey on physical
therapy-related intervention for early inpatient total hip
(and knee) rehabilitation is a step forward in the develop-
ment of consistent guidelines for postoperative manage-
ment.
37
The exercises and functional activities identified
in the consensus document were elements common to most
postoperative programs and only those agreed upon by the
participating physical therapists.
The goals, guidelines, and precautions for exercise and
functional activities after THA discussed in this section
represent not only those interventions identified in the
aforementioned consensus survey but also exercises select-
ed from other resources in the current literature,
22,26,56,75,
89,134
including those for an accelerated rehabilitation pro-
gram after minimally invasive THA.
13
The suggested exer-
cises, functional activities, and precautions are also based
on the results of the available, albeit limited, research on
the impact of specific exercises and functional activities
on the hip joint.
Focus on Evidence
Several related, single-subject studies have measured in
vivo forces acting on the hip and acetabular contact pres-
sures during exercise and gait.
46,64,65,124
Although these
studies involved only two patients after insertion of a
femoral endoprosthesis, not a total joint replacement,
the results raise questions about assumptions made by
clinicians with regard to the selection and progression
of common exercises and functional activities during
rehabilitation after hip arthroplasty. The results of these
studies suggest that active or resistive exercises, per-
formed statically or dynamically, should be initiated and
progressed cautiously. During the acute or postacute phases
of rehabilitation some exercises, such as maximal effort
gluteal setting or unassisted heel slides typically used dur-
ing the acute phase of rehabilitation and manually resisted
isometric abduction during the postacute stage in prepara-
tion for gait and other weight-bearing activities, may actu-
ally generate greater acetabular contact pressures than the
weight-bearing activities themselves.
46,124
Exercise: Maximum Protection
Phase After Traditional THA
Common impairments exhibited by patients during the
acute and subacute stages of soft tissue healing and the
initial phase of postoperative rehabilitation after THA are
pain secondary to the surgical procedure, decreased ROM,
muscle guarding and weakness, impaired postural stability
and balance, and diminished functional mobility (transfers
and ambulation activities). Depending on the type of THA
procedure and the surgeons preference, weight-bearing
restrictions initially may interfere with functional activities.
The emphasis of this phase rehabilitation after a stan-
dard surgical approach is on patient education to reduce
the risk of early postoperative complications, in particular
dislocation of the operated hip. (Risk factors for disloca-
tion after THA are noted in Table 20.2.) Precautions
during functional activities are determined by the surgical
approach used and input from the surgeon about the stabil-
ity of the hip replacement (Box 20.7).
66,75,83,84,104
(Also
refer to Box 20.6 for weight-bearing restrictions.)
Although a posterior surgical approach is associated
with the highest risk of dislocation, all patients routinely
are asked to limit flexion of the hip to 90 and rotation to
45 for about 6 weeks regardless of the approach used.
104
Selected exercises and functional training begin the
day of or after surgery. The frequency of treatment by a
therapist is often twice a day until the patient is discharged
from the hospital,
37
typically by 3 to 4 days postoperative-
ly. Ideally, the prescribed exercises are performed hourly
by the patient.
Goals and interventions. The following goals and inter-
ventions apply to the initial postoperative days while the
patient is hospitalized, continuing through the first few
weeks after surgery when the patient is at home or in
another health care facility.
Prevent vascular and pulmonary complications.
Ankle pumping exercise to prevent venous stasis,
thrombus formation, and the potential for pulmonary
embolism.
Deep breathing exercise and bronchial hygiene to pre-
vent postoperative atelectasis or pneumonia continued
until the patient is up and about on a regular basis.
Prevent postoperative dislocation or subluxation of the
operated hip.
Patient and caregiver education about motion restric-
tions, safe bed mobility, transfers, and precautions
during other ADL (see Box 20.7).
658 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
P R E C A U T I O N : If a trochanteric osteotomy was per-
formed, avoid even low-intensity isometric contractions
of the hip abductors during the early postoperative phase
unless initially approved by the surgeon and performed
strictly at a minimum intensity. (See Box 20.7 for additional
precautions after trochanteric osteotomy.)
Regain active mobility and control of the
operated extremity.
While in bed, active-assistive (A-AROM) exercises of
the hip within protected ranges.
Active knee flexion and extension exercises while
seated in a chair, emphasizing terminal extension pro-
gressing to active hip and knee flexion (heel slides),
gravity-eliminated hip abduction (if permissible) by
sliding the leg on a low-friction surface, and active
rotation between external rotation or internal rotation
to neutral depending on the surgical approach. Do
these exercises while lying supine in bed.
Active hip exercises in the standing position with the
knee flexed and extended with hands on a stable sur-
face to maintain balance.
Closed-chain hip flexion and extension, placing only
the allowable amount of weight on the operated
extremity.
Prevent a flexion contracture of the operated hip.
Avoid use of a pillow under the knee of the operated
extremity.
Exercise: Moderate and Minimum Protection Phases
After traditional THA the intermediate and late phases of
rehabilitation begin about 4 to 6 weeks postoperatively.
Monitor the patient for signs and symptoms of disloca-
tion, such as shortening of the operated lower extremity
not previously present.
Achieve independent functional mobility prior
to discharge.
Bed mobility and transfer training, integrating weight-
bearing and motion restrictions.
Ambulation with an assistive device (usually a walker
or two crutches) immediately after surgery, adhering
to weight-bearing restrictions and gait-related ADL
precautions.
N O T E : Arising from a low chair imposes particularly high
loads across the hip joint, producing loads approximately
eight times body weight.
97
If the posterior capsule was
incised during surgery, this places the involved hip at a high
risk of posterior dislocation until soft tissues around the hip
joint have healed sufficiently (at least 6 weeks) or until the
surgeon indicates that unrestricted functional activities are
permissible.
Maintain a functional level of strength and muscular
endurance in the upper extremities and unoperated
lower extremity.
Active-resistive exercises in functional movement pat-
terns, targeting muscle groups used during transfers
and ambulation with assistive devices.
Prevent reflex inhibition and atrophy of musculature in
the operated limb.
Submaximal muscle-setting exercises of the quadriceps,
hip extensor, and hip abductor musclesjust enough to
elicit a muscle contraction.
C H A P T E R 2 0 The Hip 659
BOX 20.7 Early Postoperative Motion Precautions After Total Hip Arthroplasty*
Posterior/Posterolateral Approaches
ROM
Avoid hip flexion 80 to 90 and adduction and internal
rotation beyond neutral.
ADL
Transfer to the sound side from bed to chair or chair
to bed.
Do not cross the legs.
Keep the knees slightly lower than the hips when sitting.
Avoid sitting in low, soft chairs.
If the bed at home is low, raise it on blocks.
Use a raised toilet seat.
Avoid bending the trunk over the legs when rising from
or sitting down in a chair or dressing or undressing.
For bathing, take showers or use a shower chair in the
bathtub.
When ascending stairs, lead with the sound leg. When
descending, lead with the operated leg.
Pivot on the sound lower extremity.
Avoid standing activities that involve rotating the body
toward the operated extremity.
Sleep in supine position with an abduction pillow; avoid
sleeping or resting in a side-lying position.
Anterior/Anterolateral and Direct Lateral Approaches
With or Without Trochanteric Osteotomy
ROM
Avoid flexion 90.
Avoid hip extension, adduction, and external rotation past
neutral.
Avoid the combined motion of flexion, abduction, and
external rotation.
If the gluteus medius was incised and repaired or a
trochanteric osteotomy was done, do not perform active,
antigravity hip abduction for at least 6 to 8 weeks or until
approved by the surgeon.
ADL
Do not cross the legs.
During early ambulation, step to, rather than past, the
operated hip to avoid hyperextension.
Avoid activities that involve standing on the operated
extremity and rotating away from the involved side.
*
Note: These precautions apply to traditional total hip arthroplasty and may or may not be necessary
after minimally invasive procedures, depending on the surgeons guidelines.
The degree of protection of the operated hip required
varies substantially from patient to patient. Some degree
of moderate protection may be necessary for 12 weeks
postoperatively. However, full healing of soft tissue and
bone continues for up to a year after surgery.
The exercises described for these phases usually are
a part of a home program that a patient has learned dur-
ing home-based therapy, on an outpatient basis, or in an
extended care facility. Exercises and functional training
focus on restoration of strength, postural stability and bal-
ance, muscular and cardiopulmonary endurance, and ROM
to functional levels and gradual resumption and necessary
modification of functional activities. Postoperative precau-
tions during ADL are continued for at least 12 weeks and
often considerably longer.
75,89
Patient education continues
throughout these phases of rehabilitation in preparation for
a return to anticipated activities in the home, workplace, or
recreational setting. Return to a full level of functional
activities may take 6 to 8 months.
To prolong the life of the prosthesis, particularly in
patients under 50 to 60 years of age, patients are routinely
advised to refrain from high-impact sports and recreational
activities.
77
If a patients employment involves heavy labor,
vocational retraining or an adjustment in work-related activi-
ties is advised.
Goals and interventions. The following are the goals and
interventions during the intermediate and advanced phases
of rehabilitation.
Regain strength and muscular endurance.
Open-chain exercises within the permissible ranges in
the operated leg against light resistance. Emphasize
increasing the number of repetitions rather than the
resistance to improve muscular endurance.
Bilateral closed-chain exercises such as mini-squats
against light-grade elastic resistance or while holding
light weights in both hands when unsupported standing
is permitted.
Unilateral closed-chain exercises such as forward and
lateral step-ups (to a low step) and partial lunges with
the involved foot forward when full weight bearing is
permitted on the operated lower extremity.
Resistive exercises to other involved areas in order to
improve function.
Improve cardiopulmonary endurance.
Nonimpact aerobic conditioning program, such as
progressive stationary cycling, swimming, or water
aerobics.
Reduce contractures while adhering to motion
precautions.
Gravity-assisted supine stretch to neutral in the Thomas
test position. Pull the uninvolved knee to the chest
while relaxing the operated hip. (At least 10 of hip
extension beyond neutral is needed for a normal gait
pattern.)
Resting in a prone position for a prolonged passive
stretch of the hip flexor muscles when rolling to
prone-lying is permissible and is also tolerable.
Integrate gained ROM into functional activities.
P R E C A U T I O N : Check with the surgeon before initiating
a stretch of the hip flexors to neutral or into hyperextension
if the patient has undergone an anterolateral approach.
Improve postural stability, balance, and gait.
Emphasize use of a cane (in the hand contralateral to
the operated hip) and progressive weight bearing on the
operated limb.
While using a cane, walk over uneven and soft surfaces
to challenge the balance system.
Integrate posture training during ambulation, emphasiz-
ing an erect trunk, vertical alignment, equal step
lengths, and a neutral symmetrical position of the legs.
Continue cane use until weight-bearing restrictions are
discontinued or if the patient exhibits gait deviations,
such as a positive Trendelenburg sign on the operated
lower extremity, indicating gluteus medius weakness.
Cane use is also recommended during extended periods
of ambulation to decrease muscle fatigue.
Focus on Evidence
Use of a cane in the contralateral hand by patients after a
hip replacement has been shown to decrease electromyo-
graphic (EMG) activity in the hip abductor muscles to a
significant degree regardless of whether moderate or near-
maximum force is applied on the cane.
93
In the same study,
ipsilateral cane use produced no significant decrease in
EMG activity in the hip abductor muscles. The degree to
which the decreases in EMG activity reflected a reduction
in forces imposed on the prosthetic hip joint was not deter-
mined in this study. However, in single-subject studies of
two patients with femoral endoprotheses, acetabular con-
tact pressures were reduced by using a cane in the con-
tralateral hand.
46,64,65
Prepare for a full level of functional activities.
Integrate strength, endurance, and balance exercises
into functional activities but continue to avoid applying
high loads during exercise. When weight-bearing
restrictions have been discontinued, strengthen hip and
knee musculature with functional activities such as
ascending and descending stairs step over step.
Progressively increase the length of time and distance
of a low-intensity walking program 2 to 4 days a week.
When walking and carrying a heavy object in one
hand, suggest that the patient hold it on the same side
as the operated hip. Theoretically, this reduces the
amount of stress imposed over time on the prosthetic
hip replacement.
Through patient education reinforce the importance of
selecting activities that reduce or minimize the forces
and demands placed on the prosthetic hip.
Focus on Evidence
The results of research suggest that the forces imposed on
the abductor muscles of the prosthetic hip, as measured by
EMG, are significantly lower when a load is carried in the
arm on the same side as the prosthetic hip compared to
when the load is carried in the contralateral arm. This was
660 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
Have patient maintain an activity log to document func-
tional outcomes.
Some of the short-term outcomes of this accelerated
rehabilitation program reported by Berger et al.
13
were that
patients discontinued use of narcotic pain medication, tran-
sitioned to a cane, and started driving after an average of
6 days. Patients who worked returned to work at an aver-
age of 8 days. Patients walked without an assistive device
at an average of 9 days. At 3 months there were no serious
complications identified.
13
P R E C A U T I O N : These highlights are presented as an
example of a rapid rehabilitation program after minimally
invasive primary THA performed by the same surgeon and
carried out at one institution with a carefully selected group
of patients. Such a program is not appropriate for many
patients undergoing minimally invasive THA and should be
implemented only with necessary planning and ongoing
communication between the surgeon, therapist, and patient.
Outcomes
The assessment of outcomes of THA has focused on
numerous variables, ranging from patient satisfaction and
the impact of THA on function and quality of life to the
assessment of prosthetic designs, materials, methods of
fixation, and rates of complications. The number of fol-
low-up studies on any one of these areas is extensive. A
1990s NIH report pointed out that THA and subsequent
rehabilitation have resulted in a high degree of success
related to pain reduction, improvement in physical func-
tion, and health-related quality of life.
68,95
The report
went on to say that THA results in good to excellent
long-term results for 90% to 95% of patients.
95
However,
the findings of numerous follow-up studies reflect consid-
erable variability of outcomes.
Pain relief, patient satisfaction, and quality of life.
Patient satisfaction after THA as well as the assessment
of pain and perceived level of function and quality of life
as judged by the patient and/or the surgeon generally
reflect a marked decrease in pain and improvement in
function.
107
Historically, patient-related outcomes were
assessed by the surgeon rather than the patient. During
the past decade or two, assessing outcomes from a
patients perspective has become increasingly evident in
the literature. One outcomes study, in particular, pointed
out why there is a need for evaluations by both the patient
and the surgeon to fully assess the long-term outcomes of
THA. During postoperative follow-up when patients
reported little or no pain, patients and physicians assess-
ments of pain and level of satisfaction were similar. How-
ever, as a patients report of continuing pain increased, the
disparity increased between the patients and the physi-
cians assessment of the level of patient satisfaction.
71
Two recent studies have identified several factors
that contribute to unsatisfactory outcomes. Fortin and
colleagues
42
investigated the timing of THA and out-
comes. Although intuitively known by experienced prac-
titioners, this study confimed that patients who had the
worst physical function and pain before surgery had the
found to hold true with and without cane usage.
91,92
As the
patients activity level increases, have the patient avoid
high-impact activities or activities that impose heavy rota-
tional forces on the operated limb. Both factors can con-
tribute to long-term loosening and wear of the prosthetic
implants and eventual failure of the hip replacement.
Accelerated Rehabilitation After
Minimally Invasive THA
For carefully selected patients who have undergone mini-
mally invasive primary THA, an accelerated rehabilitation
program may be feasible to achieve optimal outcomes as
rapidly as possible. However, few guidelines have been
published to date.
Berger and colleagues
13
developed and implemented a
program specifically designed for patients undergoing pri-
mary cementless THA with a two-incision approach.
Patients eligible for the minimally invasive surgery and
accelerated rehabilitation program had to be between the
ages of 40 to 75 years with a body mass index of 35, no
previous hip surgery, and no history of cardiac, vascular, or
pulmonary disorders. The following are key elements of
the accelerated program described by Berger et al.
13
Preoperative activities. Prior to surgery, educate the patient
about the surgical procedure and postoperative rehabilita-
tion program, wound care, and the home exercise program.
Initiate gait training (weight bearing as tolerated) using
crutches and a cane.
Immediate postoperative therapy. Approximately 5 to 6
hours after surgery, if the patient is medically stable, begin
the following activities.
Postoperative bed and chair transfers (weight bearing
as tolerated)
Ambulation with crutches, progressing to a cane as
tolerated
Ascending and descending stairs, one step at a time
Criteria for hospital discharge. The patient is discharged
from the hospital to home when able to perform the fol-
lowing tasks independently while using an ambulation aid.
Transfer in and out of bed
Stand up from and sit down in a standard, firm chair
Walk 100 feet
Ascend and descend a flight of stairs
Berger et al.
13
reported that 97 of the 100 participants
in the study met the crteria for same-day discharge. The
three remaining patients, who delayed therapy because of
nausea or orthostatic hypotension, were discharged the day
after surgery.
Home-based and outpatient therapy. Patients participate
in a home-based therapy program followed by outpatient
therapy once able to drive. There are no specific position-
ing or ROM precautions or weight-bearing restrictions.
Progress to ambulation with a cane as soon as possible.
Continue cane use until able to ambulate with a symmet-
rical gait pattern and no noticable limp.
C H A P T E R 2 0 The Hip 661
poorest outcomes 2 years after surgery. The findings of a
long-term (mean 3.6 years), prospective study by Nils-
dotter et al.
96
of patients who had undergone unilateral
THA for OA also confirmed that a higher preoperative
level of pain predicted poorer outcomes. In addition,
their study revealed that an older age at the time of sur-
gery and postoperative low back pain were predictors of
poor self-assessed outcomes.
Improvements in physical function. Improvements in
ROM, postural stability, strength, and functional mobility
are significant but occur gradually after THA. Patients
typically achieve 90% of their expected level of overall
functional improvement by the end of the first year. Dur-
ing the next 1 to 2 years, patients have self-reported
additional gains in strength, with improvement in func-
tion reaching a plateau at approximately 2 to 3 years.
107
Several studies have documented deficits in physical
function that persist at 1 year and beyond after THA.
Trudelle-Jackson and co-investigators,
132
compared
ROM, static muscle strength, and postural stability (bal-
ance during one-leg stance) in a group of 15 patients
with a mean age 62 years (range 5177 years) 1 year
after unilateral THA. They found no significant differ-
ences in ROM for the operated and uninvolved hips and
small but not statistically significant differences in the
strength of hip and knee musculature. However, they did
find substantial differences between the operated leg and
the uninvolved leg for all parameters of postural stability
measured during one-leg stance. In addition, patients
self-assessed level of physical function was moderately
associated with muscle strength but only weakly with
postural stability.
In another study, Shih and colleagues
120
identified
muscle weakness in the operated lower extremity com-
pared with the uninvolved side in all patients 2 years
after THA, with strength in the hip flexors showing the
slowest rate of recovery. The investigator suggested that
persistent muscle weakness and muscle fatigue during
activities that require endurance may increase the stress-
es placed on the prosthetic implants and contribute to
biomechanical loosening of the implant over time.
120
The
findings of both of these studies suggest that some
patients benefit from a long-term program of strength
and balance training, even after returning to a full level
of functional activity.
Implant design, fixation, and surgical approach. Two to
three decades of studies indicate that both cemented and
cementless THA have yielded equally positive postopera-
tive outcomes in all areas of assessment, with the most
consistent being reduction of pain.
70,109
Despite the suc-
cess of both cemented and uncemented THA, debate
continues as to the benefits and limitations of both types
of fixation. What can be said is that as surgical tech-
nique, prosthetic designs, and materials continue to
improve the rate of failure because of wear and loosen-
ing continues to decrease. A higher rate of loosening
continues to occur in the acetabular component.
109,110
Results of a study of 92 cementless THA procedures
revealed a 100% survival rate of the femoral com-
ponent after 10 years and a 96.4% rate for the acetabular
component.
3
In-depth analyses and current informa-
tion on outcomes of specific prosthetic designs
41
as
well as outcome assessments of cemented,
15,73,100,109
uncemented,
16,70,106,131
and hybrid
90
procedures can be
found in the references noted.
Outcomes of minimally invasive THA compared
with traditional THA are just beginning to be investigat-
ed.
99,137
Significantly more short- and long-term studies
are needed before the value of minimally invasive
approaches can be determined.
Impact of rehabilitation. Despite the number of sources
in the literature that emphasize the importance of rehabil-
itation programs or, more specifically, a postoperative
exercise and ambulation program after THA, the impact
of these postoperative interventions has not been clearly
established. The NIH reported that there is currently
insufficient evidence to determine what constitutes an
appropriate level of physical therapy utilization after
THA. The report went on to say that there does appear to
be a role for these interventions but that the efficacy of
these postoperative programs has not yet been deter-
mined.
95
Studies have demonstrated that access to inpa-
tient physical therapy services does
43,88
and does not
67
decrease a patients length of stay in an acute care facili-
ty after THA. The use of physical therapy services after
THA also has been shown to increase the probability of
discharge to the home setting rather than to another
health-care facility.
43
Studies with control groups that have evaluated the
impact of exercise on functional outcomes in patients
who have undergone THA are few in number. Most of
these studies have looked at the effect of exercise several
months or even a year or two after surgery, not during
the first 6 to 12 weeks. However, Wang and colleagues
134
conducted a randomized, controlled investigation to
determine if a customized exercise program initiated
before scheduled THA had an efffect on the ambulatory
abilities of patients after surgery. Gait velocity was meas-
ured by the 25-meter walk test, and walking endurance
was measured by the 6-minute walk test. Participants in
the exercise group (n 15) took part in two facility-
based and two home-based exercise sessions of station-
ary bicycling and resistance training two times per week
for 8 weeks prior to surgery. At 3 weeks postoperatively,
these patients resumed their individualized exercise regi-
mens, modified to incorporate postoperative precautions,
and continued until 12 weeks. Patients in the control
goup (n 13) underwent no preoperative intervention
and received routine post-THA functional training. At 3
weeks postoperatively the exercise group demonstrated
significantly greater gait velocity and stride length and at
12 weeks significantly greater 6-minute walking distance
than the control group. The investigators concluded that a
customized strength and endurance training program
662 JOINT SURGERY AND POSTOPERATIVE MANAGEMENT
Considerable differences of opinion exist among surgeons
regarding the advantages and disadvantages of one design
versus the other.
58,81,101
Operative procedure. As with THA, a posterolateral
approach is most commonly used. After removing the head
of the femur, the metal-stemmed prosthesis is inserted into
the shaft of the proximal femur. The femoral stem is usually
cemented in place, although bioingrowth fixation has also
been used. Procedures for closure are consistent with THA.
Postoperative Management
There are no studies in the literature that have examined
the effects of comprehensive postoperative exercise
programs exclusively for patients who have undergone
current-day hemiarthroplasty. This is because, for the
most part, considerations and precautions for positioning
and ADL, as well as the components and progression of
the exercise and ambulation program, are similar to those
for postoperative management of THA. These guidelines
are detailed in the previous section of this chapter. As with
postoperative management after THA, selection and pro-
gression of exercises and functional activities after hemi-
arthroplasty also tend to be based on the opinions of
surgeons and therapists as to the potential of specific exer-
cises to remediate impairments and improve functional
performance. Consequently, the effectiveness of exercise
after hemiarthroplasty also remains unclear. Only limited
information on the impact of specific exercises and gait-
related activities on the hip joint per se after hemiarthro-
plasty is available in the literature. Some findings from
several single-subject studies of two patients with femoral
endoprostheses have already been discussed in the previous
section of this chapter on THA.
46,64,65,124
P R E C A U T I O N : Given the significant concerns for long-
term erosion of acetabular cartilage after hemiarthroplasty,
it may be even more critical to avoid exercises that impose
the greatest compressive or shearing forces across the hip
joint and therefore pose the greatest potential for eroding
the cartilaginous surface of the acetabulum. Exercises
should be performed initially at a submaximal level and then
progressed gradually. Unassisted heel slides and maximum
effort gluteal setting exercises may need to be avoided
during the acute phase of postoperative rehabilitation.
124
During the postacute period of rehabilitation exercises,
such as maximum-effort manually resisted hip abduction
may actually generate greater forces across the hip than
protected weight-bearing activities.
46
Outcomes
Present-day modular unipolar and bipolar hemiarthro-
plasty procedures appear to yield similar results in pain
relief, functional outcomes, and type and rate of compli-
cations.
61,81,101
Although acetabular wear was identified
as the primary concern after the unipolar replacement
used during the 1960s and 1970s, the mechanical effec-
tiveness of the bipolar prosthesis in preventing acetabular
erosion has yet to be firmly established.
61
In a study of
community-dwelling patients age 65 years or older
prior to and after THA improved the rate of recovery of
ambulatory function.
In a nonrandomized study of the effectiveness of a
6-week home exercise program with patients who were 6
to 48 months post-THA, the two exercise groups (one
performing ROM and isometric exercises of the hip and
the other performing ROM, isometric, and eccentric
exercises) increased their walking speed, whereas a con-
trol group (no exercise program) did not. Interestingly,
strength improvements were noted in all three groups.
117
The results of these two studies provide useful informa-
tion, but a great deal more research needs to be done on
the effects of exercise on function after THA.
Hemiarthroplasty of the Hip
Indications for Surgery
The following are possible indications for prosthetic
replacement of the proximal femur.
61,63,73
Acute, displaced intracapsular (subcapital, transcervical)
fractures of the proximal femur in an elderly patient with
poor bone stock and an anticipated low-demand level of
activity after surgery
61,81,101,102,127
Failed internal fixation of intracapsular fractures associ-
ated with osteonecrosis of the head of the femur
61,81,101
Severe degeneration of the head of the femur (but an
intact acetabulum) associated with long-standing hip
disease or deformity resulting in disabling pain and loss
of function that cannot be managed with nonoperative
procedures
61,81,102
N O T E : Patients with preexisting degenerative hip disease
who sustain a femoral fracture are candidates for primary
THA rather than hemiarthroplasty.
39,81
Acute, severely com-
minuted intertrochanteric fractures are infrequently man-
aged by primary hemiarthroplasty.
81,128
Procedures
Background. Historically, acute displaced fractures of the
proximal femur in the elderly were treated with unipolar
(fixed head), uncemented metal-stemmed endoprostheses
with marginal results. With the introduction of cement fix-
ation during the 1960s, these results improved.
81
The pri-
mary complication associated with the single-component
unipolar implants, regardless of design or fixation, was
progressive erosion of the acetabular cartilage and subse-
quent pain.
To decrease the problem of acetabular wear, the bipo-
lar hemiarthroplasty was developed. The bipolar design is
composed of multiple components: a metal ball-and-stem
femoral prosthesis (may be modular) that moves within a
free-riding polyethylene shell, which in turn inserts into a
metal cup that moves within the acetabulum. The purpose
of the multiple-surface, load-bearing design is to displace
forces incurred by the acetabulum through the interposed
components rather than directly to the acetabulum to lessen
erosion of the acetabular cartilage.
58,81,101
Both current-day
modular unipolar and bipolar prostheses are in use today.
C H A P T E R 2 0 The Hip 663
(mean age 80 years) who had undergone hemiarthroplas-
ty with either a bipolar implant or a modular unipolar
implant, there were no significant differences between
the two groups at 1 year and 4 to 5 years of follow-up
with regard to functioning in daily activities or rates of
dislocation, infection, or mortality.
135
Another study has
suggested that joint ROM may decrease over time after
bipolar hemiarthroplasty possibly due to the design of
the implants. This decreased range was not associated
with diminished functional abilities.
58
FRACTURES OF THE HIPSURGICAL
AND POSTOPERATIVE MANAGEMENT
Hip FractureIncidence and Risk Factors
One of the more common musculoskeletal problems in the
elderly is fracture of the hip or, more correctly, fracture of
the most proximal portion of the femur in the hip joint area.
The acute signs and symptoms of hip fracture are pain in
the groin or hip region, pain with active or passive motion
of the hip, or pain with lower extremity weight bearing. The
lower extremity appears to be shorter by several centimeters
and assumes a position of external rotation.
61,102
More than 70% of hip fractures occur in individuals
who are more than 70 years of age, and they occur in
women significantly more often than in men.
18,61
In the
United States, for example, women sustain 84.6% of all
hip fractures.
108
Worldwide, the incidence of hip fracture
has stabilized; but the total number of hip fractures per
year is increasing, in part because of the aging of the
population.
18,61,74,102
Fewer than 2% to 3% of fractures
are sustained by persons who are less than 50 years of
age.
61,102
These fractures or fracture-dislocations are
usually associated with high-force, high-impact trauma
but may also be seen with repetitive microtrauma.
61,102
Multiple factors contribute to the increasing incidence
of hip fracture with age. Osteoporosis, a condition associat-
ed with age-related loss of bone density and strength, typi-
cally occurs in the proximal femur and the distal radius and
spine.
61,102
A sudden twisting motion of the lower extremity
or the impact from a fall can cause pathological fracture of
a fragile proximal femur. Although 90% of all hip fractures
in the elderly are associated with a fall,
61
there is always the
question of whether trauma from the fall caused the hip
fracture or a pathological fracture of the hip caused the fall.
Despite the increasing incidence of osteoporosis with age,
the cause of most hip fractures appears to be impaired func-
tional mobility rather than osteoporosis.
10
Balance, protective reactions, and muscle power dete-
riorate with age, thus increasing the likelihood of a fall.
These changes, combined with decreasing ability to absorb
the impact of a fall, contribute to the risk of sustaining a
fracture.
102
Characteristics of falling change with age,
which may also increase the risk of hip fracture in the
elderly. As walking speed decreases with age, particularly
past 70 to 80 years, when a loss of balance and fall occurs
an older person usually drops and falls to the side, rather
than falling forward on outstretched hands as occurs with
faster walking speeds.
61,102
Hip fracture in the elderly is associated with a high
rate of disability because of a loss of independence in
mobility.
32
Many patients require long-term nursing care
and often are permanently institutionalized in extended
care or assisted living facilities. For example, among
women who sustain a hip fracture, approximately 15%
to 25% lose the ability to live independently within the
first year.
18
Although postoperative mortality rates remain
high (approximately 20%),
32
improved surgical techniques
over the past few decades have decreased the need for pro-
longed immobilization or restricted weight bearing, thus
decreasing postoperative complications such as pneumonia
and thromboemboli.
Sites and Types of Hip Fracture
Fractures of the proximal femur are broadly classified as
intracapsular or extracapsular and then further subdivided
by specific location. Sites and specific types of hip fracture
are noted in Box 20.8.
61,78,81,102,127-129
Of these sites, frac-
tures in the intertrochanteric region are most common,
accounting for approximately 50% of all fractures of the
proximal femur.
78
Intracapsular fractures can potentially
compromise the vascular supply to the head of the femur,
which in turn increases the risk of delayed healing, non-
union, or osteonecrosis (avascular necrosis) of the head
of the femur. These complications occur far more frequent-
ly with displaced versus nondisplaced intracapsular frac-
tures.
61,81
Intracapsular fractures are most often sustained
by elderly women.
61,81
In contrast, fracture-dislocation and acetabular trauma
are most common in the young, active individual.
61
Most
fracture-dislocations occur in a posterior direction. This
664 FRACTURES OF THE HIPSURGICAL AND POSTOPERATIVE MANAGEMENT
BOX 20.8 Common Sites and Types
of Hip Fracture
Intracapsular
Fracture site proximal to the attachment of the hip joint
capsule
Further subdivided into femoral head, subcapital and
femoral neck (transcervical or basicervical fractures)
May be displaced, nondisplaced, or impacted
May disturb the blood supply to the head of the femur
resulting in avascular necrosis or nonunion
Extracapsular
Fracture site distal to the capsule to a line 5 cm distal to
the lesser trochanter
Further subdivided into intertrochanteric (between the
greater and lesser trochanters) or subtrochanteric and
stable or unstable (comminuted)
Does not disturb the blood supply to the head of
the femur, but nonunion may occur as the result of
fixation failure
type of fracture often causes traumatic disruption of the
vascular supply to the head of the femur and damage to
joint cartilage, resulting in osteonecrosis and post-traumatic
arthritis, eventually necessitating prosthetic replacement of
the hip joint. However, this need may not arise for many
years.
Open Reduction and Internal
Fixation of Hip Fracture
Indications for Surgery
Surgical intervention by means of open (or possibly
closed) reduction followed by stabilization with internal
fixation (Figs. 20.7 and 20.8) is indicated for the following
types of fractures of the proximal femur.
61,102,127-129
Displaced or nondisplaced intracapsular femoral neck
fractures
Fracture-dislocations of the head of the femur
Stable or unstable intertrochanteric fractures
Subtrochanteric fractures
In the elderly patient, displaced intracapsular fractures
are typically managed with prosthetic replacement of the
femoral head to avoid a relatively high incidence of
nonunion.
101
Some severely comminuted (unstable)
intertrochanteric fractures also may be managed in this
manner.
61,81,128
In a few situations, nonoperative management is the
only option for treatment after hip fracture. Traction is an
appropriate alternative for nonambulatory individuals or
for medically unstable patients who cannot undergo a sur-
C H A P T E R 2 0 The Hip 665
FIGURE 20.7 Reduction and internal fixation of a complete fracture of the
femoral neck. Restoration of alignment and good compression is obtained via
fixation with three compression screws. The black arrows mark the extent of
the fracture line. (From McKinnis,
78
p. 309, with permission.)
FIGURE 20.8 Intertrochanteric fracture of the hip. This postoperative image
shows fracture fixation via a side plate and screw combination device. The
fracture line is evident, extending through the intertrochanteric region to the
proximal femoral shaft. Some comminution is evident, and a large fragment
on the medial shaft is noted. The imposed added densities of swelling of the
soft tissues is seen. (From McKinnis,
78
p. 310, with permission.)
gical procedure.
61,102
The patient remains in bed in traction
just long enough for early healing to occur. Bed to chair
mobilization follows. If weight bearing or ambulation is
feasible, it is delayed until bone healing is sufficient, usual-
ly 10 to 12 weeks or as long as 16 weeks postoperatively.
Procedures
The goal of surgery is to achieve maximum stability and
restore alignment of bony structures of the hip. Surgery is
indicated during the first 24 to 48 hours after injury, partic-
ularly with femoral neck fractures where the risk of disrup-
tion of the vascular supply to the head of the femur is high.
A variety of internal fixation devices are used after open
or closed reduction to stabilize the many types of fracture
of the proximal femur. The type and severity of the frac-
ture and the associated injuries as well as the patients age
and physical and cognitive status all influence the sur-
geons choice of procedure.
61,102
The type of procedure
performed, in turn, affects the progression of postoperative
rehabilitation.
Types of fixation and surgical approach. The most com-
mon current-day internal fixation devices used, based on
the type of fracture, include the following.
61,102,127-129
In situ fixation with multiple parallel cancellous lag
screws or pins for nondisplaced or impacted femoral
neck fractures and possibly for displaced femoral
neck fractures in active patients less than 65 years
of age.
Dynamic extramedullary fixation with a sliding (com-
pression) hip screw and lateral side plate for stable
intertrochanteric fractures; may be combined with an
osteotomy for unstable (comminuted) fractures. The
dynamic hip screw allows sliding between the screw and
plate and creates compression across the fracture site
during early weight bearing.
Static interlocking intramedullary nail fixation or a
sliding hip screw coupled with an intramedullary nail
for subtrochanteric fractures.
An open surgical approach along the lateral aspect of
the hip is used for these procedures. Aspects of some of the
procedures may be performed percutaneously. Soft tissue
disruption differs with each procedure. The tensor fasciae
latae, vastus lateralis, or gluteus medius may be incised
(parallel to the fibers); a capsulotomy is generally per-
formed with femoral neck fractures.
Postoperative Management
The ultimate goal of surgical intervention and postopera-
tive care after hip fracture is to return a patient to his or
her preferred living environment
85
at a preinjury level of
function.
54,61,102
With this goal in mind, a national, interdis-
ciplinary consensus conference of health professionals met
and developed recommendations for optimal care. Among
the recommendations was the need for rehabilitation serv-
ices during recovery, including postoperative exercise and
functional training across the continuum of care.
85
During the initial phase of postoperative rehabilitation,
which begins in the acute care setting, the focus is to get
the patient up and moving as quickly as possible to prevent
or minimize the adverse effects of prolonged bed rest,
including thromboemboli and pulmonary complications,
while protecting the surgically stabilized fracture site. In
addition to helping the patient learn to move safely in bed,
transfer, and ambulate independently with an assistive
device, early postoperative rehabilitation typically includes
patient or caregiver education for wound care, deep breath-
ing and coughing exercises, edema control (use of com-
pressive stockings), proper positioning in bed to avoid
contractures, and an exercise program.
After discharge from the hospital, postoperative func-
tional training and exercise typically continue in a transi-
tional, subacute rehabilitation or skilled nursing facility
or at home. Despite consensus that rehabilitation after
hospital discharge is an essential aspect of postoperative
care,
85
according to the results of a recent systematic review
of the literature
11
there is little evidence derived from ran-
domized controlled investigations of patients functional
outcomes to support that one setting for rehabilitation is
superior to another; nor is there sufficient evidence to
identify the optimal timing for or components of subacute
rehabilitation.
What is known, however, is that most patients are
discharged from rehabilitation services after achieving
independence in ambulation using an assistive device and
necessary daily living activities, parameters typically set
by health care plans. Often services must be discontinued
despite persistent deficits in muscle performance (strength
and endurance impairments) and well before patients have
attained a preinjury level of function, which in turn in-
creases the risk of future injury.
17
Weight-Bearing Considerations
The amount of weight bearing permissible during early
ambulation and transfers is always determined by the sur-
geon for each patient on an individual basis. Factors that
influence the decision are the patients age and bone quali-
ty, the fracture location and pattern, the type of fixation
used to stabilize the fracture site, and the degree of intraop-
erative stability achieved.
54,61,63,102
Recommendations range
from non-weight-bearing, toe-touch, or touch-down weight
bearing (10 lb) to weight bearing as tolerated. Current
methods of internal fixation of the fracture site have
decreased the need for an extended non-weight-bearing
status after surgery.
Many fixation procedures used today make early
weight bearing possible. Some examples of fractures and
fixation procedures in which weight bearing as tolerated is
permissible immediately after surgery are:
Undisplaced, rigidly fixed, or impacted femoral neck
fractures managed with in situ fixation
61,63,102,127
Stable (noncomminuted) intertrochanteric fractures man-
aged with a dynamic (sliding) hip screw and lateral side
plate fixation
61,102,128
Stable subtrochanteric fractures managed with inter-
locking intramedullary nailing and bone-to-bone
fixation
61,102,129
Even when weight bearing is curtailed during ambula-
tion and transfers, the fracture site is still subjected to sig-
nificant forces. For example, moving in bed, getting up to
the side of the bed, and active and resisted ROM exercises
all generate forces across the hip that approach or even
exceed those incurred during unsupported (full weight
bearing) ambulation.
97
Considering this, studies have been
implemented to investigate the risks associated with early
weight bearing after open reduction and internal fixation
of hip fractures.
Focus on Evidence
In one such study, elderly patients with stable as well
as comminuted intertrochanteric fractures treated with
dynamic hip screw and plate fixation were all allowed to
bear weight as tolerated during ambulation with an assis-
tive device immediately after surgery. One year postopera-
tively there was no significant difference between the rate
of implant failure and revision surgery in the patients with
stable fractures and those with comminuted fractures. The
investigators concluded that at least in elderly patients with
comminuted and noncomminuted intertrochanteric frac-
666 FRACTURES OF THE HIPSURGICAL AND POSTOPERATIVE MANAGEMENT
trol of the operated hip during functional activities. All
exercises are performed within a patients level of comfort.
Initially, exercises are directed toward restoring ROM of
the operated hip and developing strength in the upper
extremities and unoperated lower extremity to facilitate
ambulation with an assistive device. It is reasonable to
expect to achieve 80 to 90 of active hip flexion (with
the knee flexed) by 2 to 4 weeks postoperatively.
54,61
There is lack of consensus about the appropriate time
to begin resistance exercises to strengthen the operated
lower extremity. Low-intensity resistance exercises of the
operated hip often are delayed until 4 to 6 weeks postoper-
atively to allow time for the hip muscles incised during
surgery to heal. However, resistance exercises of knee and
ankle musculature may be initiated sooner.
Focus on Evidence
Mitchell and colleagues
82
conducted a randomized con-
trolled trial to determine the effects of 6 weeks of quadri-
ceps resistance exercises during the early phase of
postoperative rehabilitation after hip fracture. All of the 80
patients in the study, described as frail elderly (all 65
years of age, mean 80 years), began a program of ROM
exercises and functional training (described as standard
therapy) after surgery. In addition, at 16 days postopera-
tures that could be stabilized intraoperatively there was
little biomechanical justification for non-weight-bearing
restrictions postoperatively.
63
Excluded from this generalization were patients with
complex fractures in whom satisfactory intraoperative
stabilization could not be achieved, young patients with
displaced femoral neck fractures with in situ fixation, and
patients with severe bone disease (e.g., as the result of
malignancy).
Despite the finding of this study and the recognized
benefits of early ambulation and exercise, there is always
risk, albeit small, of failure of an internal fixation device in
some patients. Therefore, it is important to recognize the
signs of possible displacement or loosening of the fracture
stabilization device as summarized in Box 20.9. The pres-
ence of any of these signs or symptoms should be reported
immediately to the surgeon.
54,61,102
Exercise
Impaired joint mobility, ROM, muscle performance, and
balance are the most common impairments after open
reduction and internal fixation of hip fracture. Exercise
is one of the interventions routinely included in postop-
erative rehabilitation to reduce these impairments.
Hip and even knee motions are quite painful during
the initial postoperative period, affecting ROM and strength
of the operated lower extremity. In addition, some degree
of protection is necessary over the course of soft tissue
healing (approximately 6 weeks) and bone healing (10 to
16 weeks).
127-129
All of these factors affect the progression
of exercise, as do the location and stability of the fracture
site, type of internal fixation used, and which soft tissues
were traumatized at the time of the injury and during sur-
gery. Special considerations for exercise and ambulation
after various types of hip fracture and with specific surger-
ies are noted in Box 20.10.
61,102,127-129
The following sections outline a progression of exercis-
es after open reduction and internal fixation of hip fractures.
Exercise: Maximum Protection Phase
Exercises begin on the first postoperative day to prevent
postoperative complications and to restore a patients con-
C H A P T E R 2 0 The Hip 667
BOX 20.9 Signs and Symptoms of Possible Failure
of the Internal Fixation Mechanism
Severe, persistent groin, thigh, or knee pain that
increases with limb movement or weight bearing
Progressive limb length inequality (shortening of the
involved lower extremity) that was not present immedi-
ately after surgery
Persistent external rotation of the operated limb
A positive Trendelenburg sign during weight bearing on
the involved limb that does not resolve with strengthen-
ing exercises
BOX 20.10 Special Considerations for Exercise
and Gait After Internal Fixation of
Fractures of the Proximal Femur
Multiple hip muscles are traumatized by fracture of the
hip leading to postoperative pain, reflex inhibition, and
weakness. Fractures that involve the following sites cause
damage to the following muscles.
Greater trochanter: gluteus medius
Lesser trochanter: iliopsoas
Subtrochanteric region: gluteus maximus
The tensor fasciae latae (TFL) and vastus lateralis (VL) are
usually incised during surgery, causing postoperative
pain, inhibition, and weakness during hip abduction and
knee flexion.
Adhesion formation may develop between the incised
TFL and VL and restrict motion. Hip adduction and inter-
nal rotation and knee flexion place a stretch on the TFL
and VL, respectively, during ROM exercises and therefore
are often painful.
If there is shortening of the involved limb after fracture
and internal fixation, the distance between the distal
insertion of the gluteus medius on the greater trochanter
and the center of axis of hip motion is often decreased,
thus diminishing the mechanical advantage of the muscle
and causing weakness and a positive Trendelenburg sign
during ambulation.
Intracapsular fractures typically traumatize the capsule,
and internal fixation requires an incision into the capsule
(capsulotomy). Both predispose the capsule to postopera-
tive restriction.
tively half of the patients (intervention group) performed
three sets of 12 repetitions of resisted knee extension of
the operated and unoperated lower extremities initially
at the 50% 1-RM intensity twice a week, progressing to
80% intensity by the fifth week. Of the 80 patients in the
study, 75% completed the 6-week study.
After 6 weeks of resistance training the quadriceps
strength of the intervention group increased bilaterally to a
significantly greater extent than that of the control group.
The intervention group also demonstrated significantly
greater improvement and, as such, a greater reduction
in disability than the control group on a functional mob-
ility test measuring locomotion, balance, and transfers.
However, there were no significant differences in improve-
ment between groups regarding gait velocity or on a test
that measures independence in ADL. There were no train-
ing-related adverse events during the study.
The authors concluded that moderate- to high-intensity
postoperative quadriceps resistance training during early
recovery after hip fracture was functionally beneficial and
well tolerated by the participants despite their age and
fraility.
The following are goals and exercise-related interven-
tions for the initial phase of postoperative rehabilitation.
Prevent vascular and pulmonary complications.
Active ankle exercises (pumping exercises) performed
regularly throughout the day to maintain circulation
and reduce the risk of DVTs and thromboemboli.
Deep breathing exercises and airway clearance to pre-
vent pulmonary complications.
Improve strength in the upper and sound lower
extremities.
Exercises against progressive levels of resistance tar-
geting key muscle groups used to lift body weight dur-
ing bed mobility, standing transfers, and ambulation
with assistive devices.
Emphasis on closed-chain training to simulate the
movement patterns used during these activities.
Prevent postoperative reflex inhibition of hip and
knee musculature.
Low-intensity isometric (setting) exercises of the hip
and knee musculature of the operated extremity.
Depending on the fracture site and its stability, perform
submaximal gluteal, abductor, adductor, and quadriceps
and hamstring setting exercises.
Restore active mobility and dynamic control of the
involved hip and adjacent joints.
Assisted, progressing to active ROM of the involved
hip and knee in progressively more challenging posi-
tions as pain and fracture healing permit. For example,
in the supine position, perform heel slides before
straight leg raises (SLRs) in the supine position. The
shorter moment arm when the knee is flexed places
lower rotational loads on the fracture site than a long
moment arm.
Unassisted SLRs (flexion, abduction, extension) while
standing on the sound leg and holding onto a stable
surface for balance before progressing to SLRs in a
horizontal position.
Pelvic tilts and knee-to-chest movements with the
uninvolved leg to prevent stiffness in the low back
region.
Low-intensity dynamic resistance exercises in weight-
bearing and non-weight-bearing positions as the stabili-
ty of the fracture site allows.
P R E C A U T I O N : When initiating setting and dynamic
exercises of the operated hip after comminuted sub-
trochanteric fractures that required medial cortex recon-
struction, postpone contractions of the abductor and
adductor muscles for 4 to 6 weeks to avoid stresses across
the fracture site.
129
Exercise: Moderate and Minimum Protection Phases
By 6 weeks soft tissues are healed; and by 8 to 12 weeks,
depending on the age and health of the patient, some
degree of bone healing has occurred. By the sixth week of
rehabilitation, except in unususal situations, at least partial
weight bearing or full weight bearing as tolerated, if not
initiated previously, now is permissible. By 8 to 12 weeks,
although a patient gradually can be weaned from use of an
assistive device during ambulation, most continue to use at
least a cane well beyond this time frame.
The emphasis during the intermediate and final phases
of rehabilitation focuses on increasing strength and func-
tional control of the involved lower extremity and gradual-
ly increasing the patients level of functional activities.
Patients typically are discharged from therapy no later than
8 to 12 weeks postoperatively and often earlier.
Extended exercise programs after hip fracture. For
many years there was lack of agreement about the value
of an extended exercise program or if it was appropriate
to include moderate-intensity resistance exercises of the
operated extremity in an elderly patients rehabilitation
program before and even after the fracture site was fully
healed.
54
(Bone healing typically takes 8 to 16 weeks and
up to 6 months in some patients.) However, during the past
few years the findings of several studies have demonstrated
that after a standard course of postoperative rehabilitation
and with clearance from the patients surgeon, an extended
program of properly supervised, carefully progressed
resistance exercises for strength training, begun 6 to 19
weeks postoperatively, is safe and effective.
17,52,74,118,119
The intensity, frequency, and duration of the extended
exercise program varied in these studies, and the equip-
ment used for resistance training ranged from elastic resist-
ance products to weight machines. Features of the exercise
programs implemented in three of the studies are summa-
rized in Table 20.3. Additional details and outcomes of
these studies are addressed at the conclusion of this section
on postoperative management after hip fracture.
The following goals and exercises are appropriate dur-
ing the intermediate and advanced phases of rehabilitation.
668 FRACTURES OF THE HIPSURGICAL AND POSTOPERATIVE MANAGEMENT
Improve strength and muscular endurance in the lower
extremities for functional activities. Refer to the section
on exercise interventions later in the chapter for descrip-
tions of the following exercises.
Bilateral closed-chain active exercises, such as
mini-squats and heel raises using a table or walker
for support and balance and body weight as the
source of resistance as soon as partial-weight
bearing on the operated lower extremity is per-
missible.
Lunges and forward and lateral step-ups when weight
bearing to tolerance is allowable.
Increase flexibility of any chronically shortened
muscles. Muscles typically involved include the ankle
plantarflexors, hip flexors and hamstrings. Suggested
stretching techniques include:
Heel cord stretching with a towel while sitting on a bed
with the knee straight or the assistance of a caregiver
and later while standing.
Hip flexor stretching in the supine/Thomas test position.
Hamstring stretching by sitting on the edge of a table
with one leg supported in hip flexion and knee exten-
sion and the other in extension over the side of the
support surface (see Fig. 20.15).
C H A P T E R 2 0 The Hip 669
TABLE 20.3 Summary of Studies of Extended Exercise Programs Following Surgery for Hip Fracture
First Author and Subjects: (n) and Setting, Format, and Frequency, Duration,
Type of Study Mean Age Timing of Intervention and Types of Exercise Features of PRE Training
Binder
17
RCT with two
groups
Hauer
52
RCT with two
groups
Mangione
74
RCT with three
groups
n 90
Intervention group:
n 46; 80
years
Control group:
n 44;
81 years
n 28; all at least
75 years
Intervention group:
n 15; 81.7
years
Control group:
n 13; 80.8
years
n 33
Resistance group:
n 11; 77.9
years
Aerobic group:
n 12; 79.8
years
Control group:
n 10; 77.8
years
Facility-based; group
format for intervention
group and home-
based program for
control group
Begun no more than 16
weeks postsurgery
Facility-based; group
format; begun 68
weeks postfracture
Home-based; individual
format; begun 19.4,
19.7, and 12.6 weeks
after surgery,
respectively, for
resistance, aerobic,
and control groups
Intervention group: Two
3-month phases,
three weekly
sessions
Phase 1: total of 22
exercises (flexibility,
balance, aerobic
training, low-intensity
resistance exercises)
Phase 2: Moderate- to
high-intensity PRE
added to shortened
phase 1 program
Control group: A
portion of phase 1
exercises, no PRE
Intervention group:
Three weekly
sessions for 3
months; PRE,
balance, and
functional training
Control group:
Stretching, seated
calisthenics,
memory tasks.
Total of 3 months: two
sessions weekly for
2 months, followed
by 1 session weekly
for 1 month
One or two sets, six to
eight reps at 65% of
initial 1-RM
progressing to three
sets, 8 to 12 reps at
85100% initial 1-RM
Weight machines
Exercises: bilateral knee
flexion and extension,
leg press, seated
bench press, biceps
curl, seated rowing
Two sets at 7090% of
1-RM intensity
Weight machines and
body weight resistance
Exercises: leg press,
hip/knee extension,
plantarflexion
Three sets of eight reps
at the 8-RM intensity
Portable resistance unit
or body weight
resistance
Exercises: supine hip
and knee extension,
hip abduction, standing
hip extension; standing
plantarflexion (heel
raises)
PRE, progressive resistance exercise; RCT, randomized controlled trial; RM, repetition maximum.
Open-chain hip and knee exercises initially against
light to moderate resistance (up to 5 lb) with elastic
resistance or cuff weights. Emphasize hip extension
and abduction for a positive impact on ambulation.
Task-specific training, such as stair-climbing or carry-
ing small loads while ambulating.
Improve postural stability and standing balance.
A progression of balance activities appropriate for the
patients age and desired activity level.
Progressive ambulation on various surfaces.
Increase aerobic capacity/cardiopulmonary endurance.
Stationary bicycling, upper body ergometry, or tread-
mill walking.
Aerobic conditioining activities, possibly in an age-
appropriate, community-based exercise class, to
increase walking distance and velocity.
Outcomes
General outcomes. The true measure of success of surgi-
cal intervention and postoperative rehabilitation after hip
fracture is the extent to which a patient can return to his
or her prefracture level of function. The level of prein-
jury functional mobility in patients with femoral neck
fractures has been shown to be a critical factor in postop-
erative survival.
55
In one follow-up study of patients after
hip fracture, only 33% had regained their preinjury level
of function in basic ADL and IADL 1 year postopera-
tively.
59
Given the advanced age and health status of the
average patient who sustains a hip fracture, it is not
surprising that mortality rates 1 year postoperatively are
high, ranging from 12% to 36% depending on the mean
age, general health status, and severity of the fracture.
61
After 1 year mortality rates are equal to age-matched
subjects who have not sustained a hip fracture.
61
Among patients who survive 1 year postoperatively,
the ability to ambulate independently (50 feet on an
uncarpeted surface) was seen in 83% in one study.
9
In a
more recent study 92% of patients returned to independ-
ent ambulation, but only 41% regained their prefracture
level of ambulation.
62
In a follow-up study
121
of 90 com-
munity-dwelling older adults (mean age 83.4 years) 6
months after discharge from the hospital following a fall-
related hip fracture, 53.3% (48/90) had experienced one
or more falls. The need for an assistive device during
ambulation after hip fracture and the patients prefracture
fall history were predictors of a fall after hospital dis-
charge.
Impact of rehabilitation. According to a report of the
National Center for Medical Rehabilitation Research
(NCMRR), the use of therapeutic exercise is one of the
least examined factors affecting outcomes after hip frac-
ture.
136
However, there are at least a few studies, some of
which are randomized controlled trials, available that
have addressed the impact of exercise and functional
training on outcomes. For example, the number of visits
to physical therapy has been positively associated with
the ability to ambulate independently.
9
The results of
another study indicated that the frequency of physical
therapy visits increased the likelihood of regaining func-
tional independence and going directly home from an
acute care setting after hip fracture surgery.
50
As noted previously, the benefits and risks of resist-
ance training have been investigated. In an early random-
ized, controlled study, subjects (most of whom were
living in the community and were an average of 7 months
postfracture surgery) who participated in a 1-month home
exercise program increased the strength of the knee exten-
sors and increased their walking velocity to a greater
extent than the control group.
118
Another study compared
the effects of a 2-week program of weight-bearing versus
non-weight-bearing exercises initiated during inpatient
rehabilitation. It found that both groups demonstrated
substantial improvements in lower extremity muscle
strength, balance, gait, and other functional tasks.
However, there were no significant differences between
groups.
119
This study lends support to the value of both
types of exercise during early rehabilitation.
Recently, studies of the effects of extended, compre-
hensive exercise programs after hip fracture have includ-
ed moderate- to high-intensity resistance training of
multiple muscle groups (see Table 20.2). In the three
studies described in Table 20.2, muscle strength and
performance on a variety of functional mobility and ADL
tests improved to a significantly greater extent in the
groups who participated in resistance training than in the
groups who participated in low-intensity or no resistance
training.
17,52,74
The resistance training group in the study
by Binder and colleagues
17
also reported a significant
decrease in the perceived levels of disability, whereas the
control group, who performed only low-intensity exercis-
es, did not. The resistance training group in the investiga-
tion by Hauer et al.
52
noted improved perception of
walking steadiness but no change in fear of falling.
Moderate- to high-intensity resistance training after
discharge from a standard postoperative program of
exercise and functional training appears to be not only
feasible but safe. Other than reports of mild muscle sore-
ness during the early weeks of resistance exercise pro-
grams, training-related adverse events were reported in
only one study (3 of 46 participants in the resistance
training group).
17
One individual fell during exercise and
sustained a rib fracture; another incurred a metatarsal
fracture that was discovered a few days after an exercise
session; and a third developed ecchymosis at the ankle
after an exercise session. All three participants chose to
complete the program.
Not all types of extended rehabilitation after hip
fracture have been shown to be effective. The results of a
study of individuals in a long-term, home-based, multi-
faceted rehabilitation program (including extensive ADL
and IADL training) for 6 months postoperatively in com-
parison to a traditional postoperative exercise and ambu-
lation program for an equal period of time demonstrated
no significant differences.
130
670 FRACTURES OF THE HIPSURGICAL AND POSTOPERATIVE MANAGEMENT
inance of the tensor fasciae latae and rectus femoris as hip
flexors and abductors, with weak gluteus medius and min-
imus muscles; (2) dominance of the hamstrings over the
gluteus maximus; and (3) shortened lateral rotators.
Because of the relationship of these muscles with the
pelvis and knee, patients may present with low back or
knee symptoms.
Decreased muscular endurance. Muscle fatigue may lead
to faulty postures, stress, and flexibility imbalances as
described above.
Management: Protection Phase
Control Inflammation and Promote Healing
When there is chronic irritation or inflammation from an
acute injury, follow the guidelines as described in Chapter
10, with emphasis on resting the involved tissue by not
stressing or putting pressure on it. Have the patient avoid
the provoking activity; and if necessary, decrease the
amount and time walking or use an assistive device.
Develop Support in Related Areas
Initiate exercises to develop neuromuscular control for
alignment of the pelvis and hip. Avoid stressing the
inflamed tissue. Patient education and cooperation
are necessary to reduce repetitive trauma.
Management: Controlled Motion Phase
N O T E : When the acute symptoms have decreased, initiate
a progressive exercise program within the tolerance of the
involved tissues to improve muscle performance. The pro-
gram should emphasize regaining a balance in length, neu-
romuscular control, strength, and endurance in the muscles
of the hip and the rest of the lower extremity.
Develop a Strong Mobile Scar and Regain Flexibility
Remodel the scar in muscle or tendon by applying
cross-fiber massage to the site of the lesion followed
by multiple-angle submaximal isometrics in pain-
free positions.
Develop a Balance in Length and
Strength of the Hip Muscles
Specific exercises are described in the exercise sections
of this chapter.
Stretch any muscles that are restricting motion with
gentle, progressive neuromuscular inhibition techniques.
Instruct the patient to do self-stretching with proper
stabilization to ensure that the stretches are performed
safely and effectively.
Begin developing neuromuscular control to train the
involved muscles to contract and control alignment of
the femur. Initially, the emphasis is on control, not
strengthening.
Once the patient is aware of proper muscle control and is
able to maintain alignment, progress to strengthening the
weakened muscles through the range.
PAINFUL HIP SYNDROMES/
OVERUSE SYNDROMES:
NONOPERATIVE MANAGEMENT
Related Pathologies and Etiology of Symptoms
Tendinitis or Muscle Pull
Overuse or trauma to any of the muscles in the hip region
can result from excessive strain while the muscle is con-
tracting (often in a stretched position) or from repetitive
use and not allowing the injured tissue to heal between
activities. Common problems include hip flexor, adductor,
and hamstring strains. Poor flexibility and fatigue may pre-
dispose an individual to strain and injury during an activity
or sporting event; and sudden falls, such as slipping on ice,
may cause a strain.
Trochanteric Bursitis
Pain is experienced over the lateral hip and possibly down
the lateral thigh to the knee when the iliotibial band rubs
over the trochanter. Discomfort may be experienced after
standing asymmetrically for long periods with the affect-
ed hip elevated and adducted and the pelvis dropped on
the opposite side. Ambulation and climbing stairs aggra-
vate the condition. Muscle flexibility and strength imbal-
ances and the resulting faulty posture of the pelvis may
be the predisposing factors leading to bursal irritation
(see Box 20.2).
Psoas Bursitis
Pain is experienced in the groin or anterior thigh and
possibly into the patellar area. It is aggravated during
activities requiring excessive hip flexion.
Ischiogluteal Bursitis (Tailors or Weavers Bottom)
Pain is experienced around the ischial tuberosities, espe-
cially when sitting. If the adjacent sciatic nerve is irritated
from the swelling, symptoms of sciatica may occur.
Common Impairments and Functional
Limitations/Disabilities
Pain. Symptoms occur when the involved muscle con-
tracts, when it is stretched, or when the provoking
activity is repeated.
Gait deviations. Slightly shorter stance occurs on the
painful side. There may be a slight lurch when the
involved muscle contracts to protect the muscle
resulting in impaired gait.
Imbalance in muscle flexibility and strength. Muscle flex-
ibility or dominance in use may be the precipitating factor
in many painful hip syndromes. Common imbalances are
described in the introductory section of this chapter; and
imbalances from postural impairments are summarized in
Box 20.2. Overuse syndromes are associated with (1) dom-
C H A P T E R 2 0 The Hip 671
Muscles not directly injured should be stretched and
strengthened if they are contributing to asymmetrical
forces. The patient may not have sufficient trunk coordi-
nation or strength, which may be contributing to the
overuse because of compensations in the hip. See Chap-
ter 16 for suggestions on developing control and stabiliz-
ing function in the trunk muscles.
Develop Stability and Closed-Chain Function
Initiate controlled weight-bearing exercises when tolerat-
ed. Because the individual is probably standing and walk-
ing, he or she may not tolerate much more closed-chain
activities than those previously initiated early during the
healing stage, so proceed with caution. Carefully observe
the exercises so proper movement patterns are used.
Use exercises such as biking or partial weight-bearing
and weight-shifting activities in the parallel bars.
Observe coordination between trunk, hip, knee, and
ankle motions; and exercise only to the point of fatigue,
substitute motions, or pain in the weakest segment in
the chain.
Develop Muscle and Cardiopulmonary Endurance
For muscle endurance, teach the patient how to perform
each exercise safely for 1 to 3 minutes before progress-
ing to the next level of difficulty.
Determine aerobic activities that do not exacerbate the
patients symptoms. It may be that the patient just needs
to modify the intensity or the techniques used in his or
her current program.
Patient Education
Initiate a home exercise program as soon as the patient has
learned neuromuscular control techniques and correct
stretching, strengthening, and aerobic activities. Provide
follow-up instruction for modification and progression of
the program.
Management: Return to Function Phase
Progress Strength and Functional Control
Progress closed-chain and functional training to include
balance and muscular endurance for each activity.
Use specificity principles; increase eccentric resistance
and demand for controlled speed if necessary for return-
to-work activity or sporting events.
Progress to patterns of motion consistent with the
desired outcome. Use acceleration/deceleration drills and
plyometric training; assess the total body functioning
while doing the desired activity. Practice timing and
sequencing of events.
Return to Function
Prior to returning to the desired function have the patient
practice the activity in a controlled environment and for a
limited period. As tolerated, introduce variability in the
environment and increase the intensity of the endurance
activities.
EXERCISE INTERVENTIONS
FOR THE HIP REGION
No matter what the cause, muscle strength or flexibility
imbalance in the hip can lead to abnormal lumbopelvic and
hip mechanics, which predisposes a patient to or perpetu-
ates low back, sacroiliac, or hip pain. (See Chapters 14
through 16 for discussion of impaired posture, common
spinal diagnoses, plans of care, and exercise interventions
for the spinal regions.) Poor hip mechanics from muscle
flexibility and strength imbalances can also affect the knee
and ankle during weight-bearing activities, causing overuse
syndromes or stress to these regions.
EXERCISE TECHNIQUES TO
INCREASE FLEXIBILITY AND
RANGE OF MOTION
The exercise techniques in this section are suggestions for
correcting limited flexibility of the musculature and periar-
ticular tissues crossing the hip. Principles and techniques
of passive stretching and neuromuscular inhibition are pre-
sented in Chapter 4 and those of joint mobilization in
Chapter 5. Specific manual and self-stretching techniques
are described in this section.
Flexibility (self-stretching) exercises, chosen accord-
ing to the degree of limitation and ability of the patient to
participate, can be valuable for reinforcing therapeutic
interventions performed by the therapist. Not all of the fol-
lowing exercises are appropriate for every patient; the ther-
apist should select each exercise and intensity appropriate
for each patients level of function and progress each exer-
cise as indicated. Whenever the patient is able to contract
the muscle opposite the range-limiting muscle, there are
the added benefits of reciprocal inhibition of the shortened
muscles as well as training the agonist (the muscle oppo-
site the tight muscle) to function for effective control in the
gained ROM.
Techniques to Stretch
Range-Limiting Hip Structures
N O T E : Two-joint muscles can restrict full ROM at the
hip. This first section describes stretches to increase just
hip motions, so the two-joint muscles are kept on a slack
across the knee during these stretches. Techniques to stretch
the specific two-joint muscles are described in the second
section.
To Increase Hip Extension
Prone Press-Ups
Patient position and procedure: Prone with hands on a
table at shoulder level. Have the patient press the thorax
upward and allow the pelvis to sag (see Fig. 15.7).
672 EXERCISE TECHNIQUES TO INCREASE FLEXIBILITY AND RANGE OF MOTION
To Increase Hip Flexion
Bilateral Knee to Chest
Patient position and procedure: Supine. Have the patient
bring both knees toward the chest and grasp the thighs
firmly until a stretch sensation is felt in the posterior hip
region. Monitor the position carefully because if the pelvis
lifts up off the mat the lumbar spine flexes and the stretch
force is transmitted there instead of to the hips.
Unilateral Knee to Chest
Patient position and procedure: Supine. Have the patient
bring one knee to the chest and grasp the thigh firmly
against the chest while keeping the other lower extremity
extended on the mat. This position isolates the stretch force
to the hip being flexed and helps stabilize the pelvis. To
emphasize a stretch of the gluteus maximus, have the
patient pull the knee toward the opposite shoulder.
Quadruped (All Fours) Stretch
Patient position and procedure: On hands and knees.
Have the patient rock the pelvis into an anterior tilt, caus-
ing lumbar extension (Fig. 20.11A); then maintain the lum-
bar extension and shift the buttocks back in an attempt to
sit on the heels. The hands remain forward (Fig. 20.11B).
It is important not to let the lumbar spine flex while hold-
ing the stretch position so the stretch affects the hip.
Chair Stretch
Patient position and procedure: Sitting in a chair with the
pelvis rotated anteriorly and the low back extended to sta-
bilize the spine. Have the patient grasp the front of the
chair seat and lean or pull the trunk forward, keeping the
back arched so the motion occurs only at the hips.
To Increase Hip Abduction
Patient position and procedure: Supine with both hips
flexed 90, knees extended, and legs and buttocks against
the wall. Have the patient abduct both hips as far as possi-
ble with gravity causing the stretch force (Fig. 20.12).
P R E C A U T I O N : This exercise also moves the lum-
bar spine into extension; if it causes radiating pain down
the patients leg, rather than just a stretch sensation in
the anterior trunk, hip, and thigh, it must not be per-
formed.
Thomas Test Stretch
Patient position and procedure: Supine with the hips
near the end of the treatment table, both hips and knees
flexed, and the thigh on the side opposite the tight hip held
against the chest. Have the patient slowly lower the thigh
to be stretched toward the table in a controlled manner and
allow the knee to extend so the two-joint rectus femoris
does not limit the range. Do not allow the thigh to exter-
nally rotate or abduct. Direct the patient to let the weight
of the leg cause the stretch force and to relax the tight mus-
cles at the end of the range (Fig. 20.9). A passive stretch
force may be applied manually, or a hold-relax technique
may be used by applying a force to the distal thigh (see
Fig. 4.26).
C H A P T E R 2 0 The Hip 673
FIGURE 20.9 Self-stretching to increase hip extension. The pelvis is stabi-
lized by holding the opposite hip in flexion. The weight of the thigh provides
a stretch force as the patient relaxes. Allowing the knee to extend emphasizes
the one-joint hip flexors (iliopsoas), whereas maintaining the knee in flexion
and hip neutral to rotation as the thigh is lowered emphasizes the two joint
rectus femoris and tensor fasciae latae muscles.
Modified Fencer Stretch
Patient position and procedure: Standing in a fencers
lunge-like posture, with the back leg in the same plane
as the front leg and the foot pointing forward. Have the
patient first do a posterior pelvic tilt and then shift the
body weight onto the anterior leg until a stretch sensa-
tion is felt in the anterior hip region of the back leg
(Fig. 20.10). If the heel of the back foot is kept on the
floor, this exercise may also stretch the gastrocnemius
muscle.
FIGURE 20.10 Self-stretching of hip flexor muscles and soft tissue anterior
to the hip using a modified fencers squat posture.
To Increase Hip Abduction and External Rotation
Simultaneously
Patient position and procedure: Sitting or supine with soles
of feet together and hands on the inner surface of the knees.
Have the patient push the knees down toward the floor with
a sustained stretch. The stretch can be increased by pulling
the feet closer to the trunk.
P R E C A U T I O N : When this stretch is performed supine,
teach the patient to stabilize the pelvis and lumbar spine by
actively contracting the abdominal muscles and maintaining
a neutral spinal position.
Patient position and procedure: Standing in a fencers
position but with the hind leg externally rotated. Have the
patient shift the weight onto the front leg until a stretch
sensation is felt along the medial thigh in the hind leg.
Techniques to Stretch
Range-Limiting Two-Joint Muscles
Rectus Femoris Stretches
Thomas Test Stretch
Patient position and procedure: Supine with the hips near
the end of the treatment table, both hips and knees flexed,
and the thigh on the side opposite the tight hip held against
the chest with the arms. While keeping the knee flexed,
have the patient lower the thigh to be stretched toward the
table in a controlled manner. Do not allow the thigh to
externally rotate or abduct. Direct the patient to let the
weight of the leg cause the stretch force and to relax the
tight muscles at the end of the range. The patient can
attempt to further extend the hip by contracting the exten-
sor muscles. (See Figure 20.10 but with the knee flexed.)
N O T E : This is the same stretch used to increase hip
extensionexcept to stretch the rectus femoris the knee
is kept flexed so the range for hip extension is less.
Prone Stretch
Patient position and procedure: Prone with the knee flexed
on the side to be stretched. Have the patient grasp the
ankle on that side (or place a towel or strap around the
ankle to pull on) and flex the knee. As the muscle increases
in flexibility, place a small folded towel under the distal
thigh to further extend the hip.
N O T E : Do not let the hip abduct or laterally rotate or let
the spine hyperextend.
Standing Stretch
Patient position and procedure: Standing with the hip
extended and knee flexed and grasping the ankle. Instruct
the patient to maintain a posterior pelvic tilt and not let the
back arch or the side bend during this stretch (Fig. 20.13).
N O T E : If the rectus femoris is too tight to stretch safely
in this manner, the patient may place his or her foot on a
chair or bench located behind the body rather than grasping
the ankle.
Hamstring Stretches
Straight Leg Raising
N O T E : Straight leg raising (SLR) exercises elongate the
hamstrings by stretching them across the hip using hip
flexion while maintaining the knee in extension.
674 EXERCISE TECHNIQUES TO INCREASE FLEXIBILITY AND RANGE OF MOTION
A
B
FIGURE 20.11 Gluteus maximus self-stretch with lumbar spine stabilization.
(A) The patient on all fours rocks into an anterior pelvic tilt, causing lumbar
extension. (B) While maintaining lumbar extension, the patient shifts the but-
tocks back, attempting to sit on the heels. When lordosis can no longer be
maintained, the end-range of hip flexion is reached; this position is held for
the stretch.
FIGURE 20.12 Self-stretching of the adductor muscles with the hips at 90
of flexion.
is considered a general flexibility exercise and tends to mask
shortening of soft tissues in one region and overstretch
areas already flexible. Whether a person can touch the toes
depends on many factors (e.g., body type; arm, trunk, and
leg length; flexibility in the thoracic and lumbar regions;
hamstring and gastrocnemius length).
60
Patient position and procedure: Supine with a towel under
the thigh. Have the patient perform SLR with one extremi-
ty and apply the stretch force by pulling on the towel to
move the hip into more flexion.
Doorway Stretch
Patient position and procedure: Supine, on the floor, with
one leg through a doorway and the other leg (the one to be
stretched) propped up against the door frame. For an effec-
tive stretch, the pelvis and opposite leg must remain on the
floor with the knee extended.
To increase the stretch when the patient is able, have the
patient move the buttock closer to the doorframe, keep-
ing the knee extended (Fig. 20.14A).
Teach the patient to perform the holdrelax/agonist con-
traction technique by pressing the heel of the leg being
stretched against the doorframe, causing an isometric
contraction, relaxing it, then lifting the leg away from
the frame (Fig. 20.14B).
Chair Stretch
Patient position and procedure: Sitting with the leg to
be stretched extended across to another chair, or sitting at
the edge of a treatment table, with the leg to be stretched
on the table and the opposite foot on the floor. Have the
patient lean the trunk forward toward the thigh, keeping
the back extended so there is motion only at the hip joint
(Fig. 20.15).
Bilateral Toe Touching
N O T E : Bilateral toe touching exercises are often used
to stretch the hamstring muscles in exercise classes. It is
important to recognize that having the patient reach for
the toes does not selectively stretch the hamstrings but
stretches the low back and mid-back as well. Toe touching
C H A P T E R 2 0 The Hip 675
FIGURE 20.13 Self-stretch of the rectus femoris while standing. The femur
is kept in line with the trunk. Care must be taken to maintain a posterior PT
and not arch or twist the back.
FIGURE 20.14 Self-stretching of the hamstring muscles. Additional stretch
can occur if the person either (A) moves the buttock closer to the door frame
or (B) lifts the leg away from the doorframe.
FIGURE 20.15 Self-stretching the hamstring muscles by leaning the trunk
toward the extended knee, flexing at the hips.
Patient position and procedure: Standing. To discourage
the toe touch idea, teach the patient to place the hands on
the hips when bending forward. To specifically stretch the
hamstrings using the standing forward-bend method, teach
the patient to first do an anterior pelvic tilt to extend the
spine; then keep the back stable and bend only at the hips
(hinge at the hips) and go only through the range of for-
ward bending where the spine can be maintained in exten-
sion. The stretch sensation should be felt in the hamstring
region.
P R E C A U T I O N : This stretching technique should not be
used when the patient has low back impairments because
forward bending greatly increases mechanical stress to the
tissues of the low back.
To Stretch the Tensor Fasciae Latae
Standing Stretch
Patient position and procedure: Standing with the side to
be stretched toward a wall and the hand on that side placed
on the wall. Have the patient extend, adduct, and externally
rotate the extremity to be stretched and cross it behind the
other extremity. With both feet on the floor, have the patient
shift his or her pelvis toward the wall and allow the normal
knee to bend slightly (Fig. 20.16). There is a slight side-
bending of the trunk away from the side being stretched.
Side-Lying Stretch
Patient position and procedure: Side-lying, with the leg to
be stretched uppermost. The bottom extremity is flexed for
support and the pelvis tilted laterally so the waist is against
the mat or floor. Abduct the top leg and align it in the
plane of the body (in extension). While maintaining this
position, have the patient externally rotate the hip and then
gradually lower (adduct) the thigh to the point of stretch
(Fig. 20.17). Flex the knee to obtain additional stretch.
N O T E : It is critical to keep the trunk aligned and not
allow it to roll backward because the hip would then flex
and the iliotibial tract would slip in front of the greater
trochanter, and an effective stretch would not take place.
676 EXERCISES TO DEVELOP AND IMPROVE MUSCLE PERFORMANCE AND FUNCTIONAL CONTROL
FIGURE 20.16 Self-stretching the tensor fasciae latae occurs as the trunk
bends away from and the pelvis shifts toward the tight side. Increased stretch
occurs when the extremity is positioned in external rotation prior to the
stretch.
FIGURE 20.17 Tensor fasciae latae self-stretching: side-lying position. The
thigh is abducted in the plane of the body; then it is extended and externally
rotated, then slowly lowered. Additional stretch can occur by flexing the knee.
EXERCISES TO DEVELOP AND
IMPROVE MUSCLE PERFORMANCE
AND FUNCTIONAL CONTROL
During the controlled motion and return to function phases
of intervention when only moderate or minimum protec-
tion of healing tissues is necessary, it is important that the
patient learns to develop control of hip movement while
using good trunk stability. For a muscle that has not been
properly used or that has been dominated by another mus-
cle, exercises begin with developing patient awareness of
muscle contractions and movements through controlled
ROM exercises. If muscle shortening has prevented full
ROM, development of muscle control in any new range
must immediately follow stretching activities. Principles
for improving muscle performance as well as techniques
for manual resistance exercise and methods of mechanical
resistance are described in Chapter 6. Manually applied
resistance should be used when muscles are weak or when
helping the patient focus on specific muscles. Exercises
described in the following sections may be adapted for
home exercise programs. Choose exercises that challenge
the patient to progress toward the functional goals estab-
lished in the plan of care.
Non-Weight-Bearing Exercises
Even though weight-bearing activities dominate lower
extremity function, when a patient is weak or has poor
control of specific muscles or patterns of motion, it is
advantageous to begin exercises in non-weight-bearing
positions so the individual can learn to isolate muscle
activity and control specific motions. In addition, many
functional activities have a non-weight-bearing component,
Standing Abduction
Have the patient, while standing on one leg, bring the
other lower extremity out to the side. Instruct the patient
to maintain the trunk upright, in neutral alignment, and
not let the abducting hip flex or rotate.
Add resistance by applying an ankle weight on the mov-
ing leg or by using pulleys or elastic resistance applied
at right angles to the moving extremity.
The abductors on the stationary lower extremity experi-
ence closed-chain resistance while stabilizing the pelvis,
and the abductors on the moving extremity experience
open-chain resistance.
To Develop Control of and Strengthen
Hip Extension (Gluteus Maximus)
Gluteal Muscle Setting
Use gluteal setting exercises to increase awareness of the
contracting muscle. Position the patient prone or supine
and teach the patient to squeeze (contract) the buttocks.
Forward-Bending Leg Lifts
With the patient standing at the edge of the treatment table
and the trunk flexed and supported on the table, have the
patient alternately extend one hip, then the other. This is
done with the knee flexed to train the gluteus maximus
while relaxing the hamstrings. If the hamstrings cramp
from active insufficiency, the patient is attempting to use
them and should practice relaxing them before progressing
with this exercise. Progress by adding weights or elastic
resistance to the distal thigh.
Quadruped Leg Lifts
Have the patient alternately extend each hip while keeping
the knee flexed (Fig. 20.18). Combine this exercise with
trunk stabilization by first having the patient find the neu-
tral pelvic position, drawing in the abdominal muscles,
then extending the hip (see Chapter 16).
P R E C A U T I O N : Care is taken not to extend the hip
beyond the available range of hip extension; otherwise, the
motion causes stress in the sacroiliac joint or lumbar spine.
such as the swing phase in gait, lifting the leg up to a step
when going upstairs, and lifting the lower extremity into a
car or onto a bed.
To Develop Control of and Strengthen Hip Abduction
(Gluteus Medius and Tensor Fasciae Latae)
N O T E : Muscle imbalances in the hip that contribute to
hip and/or low back pain may be seen if abduction is domi-
nated by the tensor fasciae latae and the stabilizing forces
from the gluteus medius are poorly controlled.
116
This is seen
if the patient flexes and internally rotates the thigh when
abducting the hip. The posterior fibers of the gluteus medius
must be trained to contract while the tensor relaxes. Tech-
niques to do this are described below. If the patient has
good control of rotation, abduction utilizing the synergy
between these muscles is used.
Supine Abduction
Supine abduction is the easiest position in which to initiate
motion because the effects of gravity on the abductors are
eliminated. Have the patient concentrate on isolated hip
abduction while keeping the trunk still. Do not let the
femur roll outward into external rotation.
For very weak patients, provide assistance or place a
skate or towel under the leg to minimize the effects
of friction.
If the patient is not strong enough to progress to the
side-lying position, place a weight, such as a sandbag,
along the outside of the thigh or ankle and have the
patient push the weight outward.
Side-Lying Abduction
Have the patient flex the bottom leg for balance, and
then lift the top leg into abduction, keeping the hip neu-
tral to rotation and in slight extension. Do not allow the
hip to flex or the trunk to roll backward. Add ankle
weights to provide resistance as the patients strength
improves.
If the patient has difficulty controlling hip abduction
in the side lying position, use the following training
sequence.
First have the patient practice externally rotating the
thigh. This may be done with the hip and knee in slight
flexion while the patient lifts the uppermost knee off the
mat or with the hip and knee extended while the patient
rolls the uppermost extremity outward.
Once the patient can control external rotation, have him
or her extend the hip (without arching the spine) and
then abduct the top leg (it should be aligned in the plane
of the body). The patient then slowly adducts and
abducts the thigh against gravity.
N O T E : If the tensor fasciae latae is tight, the range into
extension or adduction may be limited. Stretching of this
muscle should be done prior to this exercise (see Fig. 20.17).
It is important that the patient does not let the hip flex or
internally rotate during this exercise to minimize action of
the tensor fasciae latae.
C H A P T E R 2 0 The Hip 677
FIGURE 20.18 Isolated training and strengthening of the gluteus maximus.
Starting in the quadruped position, extend the hip while keeping the knee
flexed to rule out use of the hamstring muscles. Do not to extend the hip
beyond the available ROM to avoid causing stress to the sacroiliac or lumbar
spinal joints.
To Develop Control of and Strengthen
Hip External Rotation
Prone
The patients knees are flexed and about 10 inches apart.
Have the patient press the heels together, causing an iso-
metric contraction of the external rotators.
Side-Lying
With both lower extremities partially flexed at the hips and
knees and the heel of the top leg resting on the heel of the
bottom leg, have the patient lift the knee of the top leg,
keeping the heels together.
Progression. Have the patient extend the top hip and
knee, aligning the lower extremity with the trunk, then
rolling the leg outward. Progress this to lifting the entire
lower extremity into abduction once the hip is externally
rotated.
N O T E : Do not allow the patient to roll the trunk back-
ward, as this exercise is done to minimize substitution
with the hip flexor muscles.
Standing
With feet parallel and about 4 inches apart, have the
patient flex the knees slightly, then externally rotate
the thighs (so the knees are pointing laterally) while
keeping the feet stationary on the floor. Tell the patient
to maintain external rotation while extending the knees,
then relax the rotation slightly until the patellae point
forward.
Sitting
With knees flexed over the edge of the treatment
table, secure elastic material around the patients
ankle and the table leg on the same side. Have the
patient move the foot toward the opposite side,
pulling against the resistance, causing external
rotation of the hip.
N O T E : Do not allow substitution with knee flexion or
extension or hip abduction.
To Develop Control of and Strengthen Hip Adduction
Side-Lying
With the bottom leg aligned in the plane of the trunk (hip
extension) and the top leg flexed forward with the foot on
the floor or with the thigh resting on a pillow, have the
patient lift the bottom leg upward into adduction. Weights
can be added to the ankle to progress strengthening (Fig.
20.19A). A more difficult position is to have the patient
hold the top leg in abduction and adduct the bottom leg
up to meet it (Fig. 20.19B).
Standing
Have the patient adduct the leg across the front of the
weight-bearing leg. Add ankle weights to provide resist-
ance, or fasten elastic resistance or a pulley at right angles
to the moving leg.
Closed-Chain Weight-Bearing Exercises
Weight-bearing exercises in the lower extremity involve
all of the joints in the closed chain and are therefore not
limited to hip muscles. Most activities bring into play
antagonistic two-joint muscles in which each muscle is
being lengthened across one joint while it is shortening
across another, thus maintaining an optimal lengthtension
relationship. In addition to causing motion, a prime func-
tion of the muscles in weight bearing is to control against
the forces of gravity and momentum for balance and stabil-
ity. Therefore, the exercises described in this section
include balance and stabilization training as well as
strengthening and functional exercises.
Closed-Chain Strengthening and Functional Training
Strengthening and balance activities in weight-bearing pos-
tures described in the following section are closely related
and are progressed concurrently as the patient is able.
Hip Hiking/Pelvic Drop
Position the patient with one leg on a 2- to 4-inch block
and alternately lower and elevate the pelvis on the side
of the unsupported leg (Fig. 20.20). This develops control
in the abductors of the stance leg and hip hikers on the
unsupported side.
Focus on Evidence
In an EMG study by Bolglia and Uhl,
20
a series of 16
healthy subjects performing six different abductor exer-
cises using a constant weight. The authors documented
significantly greater maximum voluntary contraction of
the gluteus medius in the stance leg (weight-bearing leg)
during the pelvic drop exercise than during other hip
abduction exercises. In addition, standing hip abduction
showed significantly greater hip abductor activity on the
678 EXERCISES TO DEVELOP AND IMPROVE MUSCLE PERFORMANCE AND FUNCTIONAL CONTROL
A
B
FIGURE 20.19 Training and strengthening the hip adductors. (A) The top
leg is stabilized by flexing the hip and resting the foot on the mat while the
bottom leg is adducted against gravity. (B) The top leg is isometrically held in
abduction while the bottom leg is adducted against gravity.
secure it to a stable upright structure. If the knee
is stable, the resistance can be applied around the
ankle. Fatigue is determined when the patient can no
longer hold the weight-bearing extremity or pelvis
stable.
To resist hip flexion, the patient faces away from where
the resistance is secured.
To resist extension, the patient faces toward where the
resistance is secured (Fig. 20.22A).
To resist abduction and adduction the patient faces so
the band is directed toward one side and then the other
(Fig. 20.22B).
weight-bearing side than on the moving (open-chain)
side; the activity on the weight-bearing side had a compa-
rable maximum voluntary contraction as side-lying hip
abduction.
Bridging
Beginning in the hook-lying position, have the patient
press the upper back and feet into the mat, elevate the
pelvis, and extend the hips (Fig. 20.21).
C H A P T E R 2 0 The Hip 679
FIGURE 20.20 Training the hip abductor and hiker muscles for frontal plane
strenthening and stability.
FIGURE 20.21 Training and strengthening the hip extensor muscles using
bridging exercises. Resistance can be added against the pelvis.
Progressions. Apply resistance against the anterior pelvis
manually or by strapping a weighted belt around the pelvis.
To challenge proprioception and balance, have the patient
perform bridging exercises using a large gym ball posi-
tioned either under the back with feet on the floor or
under the feet while lying on the floor.
Single-Leg Stance Against Resistance
Have the patient stand on the involved leg. Place elastic
resistance around the thigh of the other extremity and
A B
FIGURE 20.22 Closed-chain exercise with elastic resistance around the
opposite leg. (A) Resisting extension on the right requires stabilization
of anterior muscles of the left side. (B) Resisting abduction on the right
requires stabilization of the left frontal plane muscles. To increase dif-
ficulty, the resistance is moved distally onto the leg.
N O T E : This activity is open-chain on the side of the
moving extremity and closed-chain on the weight-
bearing side.
Step-Ups
Begin with a low step, 2 to 3 inches in height; progress the
height as the patient is able. Have the patient step up side-
ways, forward, or backward. Be sure that the entire foot is
planted on the step and that the body is lifted and then low-
ered with smooth motion, with no lurching of the trunk or
pushing off with the trailing extremity.
Progressions: In addition to increasing the step height,
resistance can be added with a weight belt, with weights
in the hands or around the ankle of the non-weight-
bearing leg.
Lunges
Have the patient stride forward and flex the hip and knee
of the forward extremity and then return upright. Repeat,
or alternate legs. Begin with flexing the knee a small range
and progressing to 90 knee flexion.
If the patient has difficulty with balance or control, have
him or her use a cane or rod for balance, or begin the
activity holding on in the parallel bars or beside a treat-
ment table (Fig. 20.23).
It is important to instruct the patient to keep the toes
pointing forward, bend the knee in the same plane as
the feet, and keep the back upright.
Progressions: Progressions include using weights in the
hands for resistance, taking a longer stride, or lunging for-
ward onto a small step. This exercise is progressed to a
functional activity by having the patient lunge and pick
up objects from the floor.
N O T E : A patient with an anterior cruciate ligament (ACL)
deficiency or a surgically repaired ACL should not flex the
knee forward of the toes when performing lunges because
this increases the shear force and stress to the ACL. Individ-
uals with patellofemoral compression syndrome experience
increased pain under these circumstances because the com-
pressive force from the body weight is greater when it is
kept posterior to the knee. Adapt the position of the knee
based on the patients symptoms and presenting pathology.
Wall Slides
Have the patient rest the back against a wall with feet for-
ward and shoulder-width apart. Instruct the patient to slide
the back down the wall by flexing the hips and knees and
dorsiflexing the ankle; then slide up the wall by extending
hips and knees and plantarflexing the ankles (Fig. 20.24A).
If sliding the back directly against the wall causes exces-
sive friction, place a towel behind the patients back.
Progressions: A large exercise ball (Swiss ball) placed
behind the back requires additional control because it is
less stable (Fig. 20.24B). Add arm motions and weights to
develop coordination or add resistance. To develop isomet-
ric strength, have the patient hold the flexed position and
superimpose arm motions with weights.
Partial Squats/Mini-Squats
Have the patient lower the trunk by flexing the hips and
knees as if sitting on a chair. Add resistance by having the
patient hold weights in the hands or use elastic resistance
secured under the feet (see Fig. 21.20). Progress to safe
lifting techniques that involve squatting.
680 EXERCISES TO DEVELOP AND IMPROVE MUSCLE PERFORMANCE AND FUNCTIONAL CONTROL
FIGURE 20.23 Lunge with cane assistance to develop balance and control
for lowering body weight.
A
B
FIGURE 20.24 Wall slides/partial squats to develop eccentric control of body
weight. (A) The back sliding down a wall, superimposing bilateral arm motion
for added resistance. (B) The back rolling a gym ball down the wall, superim-
posing antagonistic arm motion to develop coordination.
N O T E : To protect the ACL, knee flexion range is limited
to 0 to 60, and the patient is instructed to lower the hips
as if preparing to sit on a chair so the knees stay behind
the toes. To protect a patellofemoral compression problem,
instruct the patient to squat only through pain-free ranges
and avoid deep knee bends.
Equipment
Mechanical equipment such as a leg press, Total Gym

treadmill, bicycle, slide board, or Profitter may be used


for strengthening, balance, coordination, and endurance.
Postural Control and Balance Activities
As noted earlier, weight-bearing control and balance
training begin as soon as the patient tolerates partial
weight bearing. For a detailed discussion on balance,
see Chapter 8.
Weight Shifting
If the patient cannot bear full weight, begin in the
parallel bars with part of the weight borne by the
hands. An overhead harnessing system can also be
used to unweight the lower extremities.
Have the patient shift anterior to posterior, side to
side, and obliquely.
Add manual resistance to the motion by applying
pressure against the patients pelvis.
C H A P T E R 2 0 The Hip 681
Balance Activities with Arm Movements
Begin with bilateral weight bearing and progress to uni-
lateral weight bearing. First have the patient move his or
her arms in the sagittal and frontal planes, then progress
to the transverse and diagonal planes.
As the patient demonstrates the ability to balance with
simple arm movements, progress to moving the arms and
following the movement with the eyes and head. Then
progress to moving the entire trunk through planes of
motion following the arm motions.
Marching and Resisted Walking
Once the patient can shift weight and maintain balance
with arm movements, have him or her alternately pick
up each foot and march in place.
Progress to moving each leg forward and backward and
learning to accept weight on the moving leg.
Once the patient can step and walk, progress to resisted
walking by applying resistance at the pelvis or have the
patient walk against an elastic or pulley resistance
secured around the pelvis (Fig. 20.25).
Teach the patient a self-applied stabilization technique
using elastic resistance secured around the thigh or leg
of one extremity and then rapidly move the extremity
forward and backward against the elastic force (see Fig.
20.22 for the setup). The rapid motion requires stabiliza-
tion on the weight-bearing side.
Balance Training on Unstable Surfaces
Have the patient stand with bilateral support on foam,
a rocker board, wobble board, or BAPS board and begin
with single-plane weight shifting forward/backward and
side to side.
Progress by placing the extremities in a diagonal plane
and have the patient shift the weight from one extremity
to the other.
When able, have the patient progress to single-leg activi-
ties on an unstable surface.
Advanced Stability and Balance Activities
Have the patient stand on an unstable surface, such as
a rocker or wobble board, and maintain balance without
the edges of the board touching the ground while a part-
ner tosses a weighted ball to the patient from various
angles.
Have the patient hold onto the two ends of an elastic
resistance band while someone pulls against it in various
directions and with varying speeds.
Functional Training
The level of challenge of the exercise program depends
on the activities the patient is required to perform in his or
her ADL, IADL, work, or sport-related tasks; and the chal-
lenge level therefore affects the desired outcomes. An out-
come may be simply learning how to ambulate forward,
backward, and around obstacles safely, or it may involve
developing a high level of coordination, balance, and skill
to climb, perform complicated dance maneuvers, engage in
gymnastics, or run and jump. Analyze the patients exercise
techniques and adapt them whenever necessary to avoid
unsafe stresses.
Suggestions for progressive functional training
include:
Increase challenges for ambulation, such as having the
patient walk on uneven surfaces, turn, maneuver back-
ward, and walk up and down ramps first under supervi-
sion and then unassisted. As soon as the patient is able,
have him or her practice rising up and sitting down from
chairs of various heights and climbing and descending
flights of stairs.
Incorporate exercises that prepare the musculature for
safe body mechanics such as repetitive squats and lunges.
Progress the exercises by having the patient lift and carry
or push and pull various loads as part of the exercise rou-
tine. Utilize safe patterns of motion that replicate func-
tional requirements.
FIGURE 20.25 Resisted walking using a large elastic resistance band secured
around the pelvis.
Alternating Isometrics and Rhythmic Stabilization
Alternating isometrics and rhythmic stabilization develop
postural adjustments to applied forces.
Apply manual resistance against the pelvis in alternating
directions and ask the patient to hold (with isometric
contractions). There should be little or no movement.
Vary the force and direction of resistance; also vary
where the force is applied by shifting the resistance
from the pelvis to the shoulders and eventually against
outstretched arms (see Fig. 22.15).
At first, use verbal cueing. Then, as the patient learns
control, apply the varying forces without warning.
Progress the patient to unilateral standing.
682 EXERCISES TO DEVELOP AND IMPROVE MUSCLE PERFORMANCE AND FUNCTIONAL CONTROL
Use agility drills such as maneuvering around
and stepping over obstacles. Incorporate running,
jumping, hopping, skipping, and side-shuffle
drills.
If the patient is returning to activities that require
strength and power, incorporate plyometric drills.
For example, have the patient jump from a box or
step; flex the hips, knees, and ankles to absorb the
impact of landing; and immediately jump back up to
the box or step.
Use maximum eccentric loading. Any of the previously
described exercises can be adapted, but it is critical to
assist the patient through the concentric phase of the
exercise and guard him or her through the eccentric
phase as the resistance is great. These are not exercises
the patient can do alone.
I N D E P E N D E N T L E A R N I N G A C T I V I T I E S
Critical Thinking and Discussion
1. Describe the function of the primary muscle groups
of the hip joint in open- and closed-chain situations.
Include their role in stabilizing the pelvis during single
leg stance and the effects on the spine when the pelvis
is moved by the hip musculature.
2. Describe the role of the hip during the gait cycle. Include
muscle activity, motion needed, and pathological gait
patterns when there is muscle weakness or restricted
motion.
3. Analyze the type of gait deviations a patient might
exhibit after internal fixation of a fracture of the pro-
ximal femur, total hip arthroplasty, or hemiarthro-
plasty of the hip.
4. After total hip arthroplasty or internal fixation of a hip
fracture, what are the signs that dislocation of the hip
or loss of fracture stabilization has occurred?
Laboratory Practice
1. Identify and practice the techniques you would use to
treat a mobility impairment if the results of your exami-
nation included decreased joint play versus restricted
flexibility in the hip musculature. Include exercises that
could be used in a home exercise program.
2. Demonstrate a progression of exercises to develop con-
trol and strength in the gluteus medius muscle after total
hip replacement.
3. Develop an exercise routine and progression for an indi-
vidual with hip muscle weakness who wants to return to
work that requires walking, lifting objects that weigh up
to 45 lb, and climbing ladders with 45-lb weights.
Case Studies
1. Mr. C., 57 years of age, is a mail carrier; he has walked
his mail route for 32 years and is proud that he has no
heart problems. Over the past year he has noticed that
his hip hurts after sitting for more than 1 hour and that
there is a marked increase in pain when first getting up
out of a chair and walking. He also has noticed that
there is increased discomfort in his hip and knees near
the end of each workday. The medical diagnosis is
osteoarthritis. Strength testing reveals generally 4/5 on
manual muscle tests except the gluteus medius, which is
3/5. There is mild tightness in the hip flexors, includ-
ing the rectus femoris and tensor fasciae lata. He wants
to avoid being a candidate for total hip replacement
surgery.
Explain why the patients job would perpetuate these
symptoms.
Outline a plan to manage the symptoms; identify meas-
urable goals and interventions you would use to reach
the goals.
What can the patient do to protect his hip joints?
2. Ms. J., a 31-year-old mother, recreational tennis player,
and bowler, is recovering from multiple femoral frac-
tures that she sustained in an automobile accident 3
months ago. There is radiological healing of all the frac-
ture sites, and she is now allowed full weight bearing
and no restrictions in activities. She has significant hip
mobility impairments from joint restrictions and muscle
weakness.
What joint ranges and muscle strength levels are need-
ed for her to return to her functional activities?
Outline a plan to manage the symptoms; identify
measurable goals and interventions you would use to
reach the goals. Using the taxonomy or motor skills
described in Chapter 1, develop a series of progres-
sively more challenging motor tasks under varying
environmental conditions.
3. Mr. C. is a 32-year-old firefighter who strained his ham-
strings at the ischial tuberosity while pulling a 250-lb
individual out of a burning building. It happened 4 days
ago. Currently, he is experiencing considerable pain, is
unable to sit on hard surfaces (because of pressure as
well as flexing the hip), and has pain when arising
from or lowering himself into a chair and climbing
or descending stairs. Hip flexion is limited to 90 and
straight-leg raising to 45. He tolerates minimal resist-
ance to hip extension or knee flexion. This individual
must be able to climb a ladder while wearing his gear
(40 lb) and air pack (40 lb) and carrying a 20-lb hand
tool; in addition, he must be able to carry a 175-lb
individual across his shoulder, drag a heavy body
across the floor, climb five flights of stairs wearing
full gear, and run
1
/
2
mile in 5 minutes to be able to
return to work.
Explain why this patient has impaired function in bio-
mechanical terms.
C H A P T E R 2 0 The Hip 683
Establish goals that reflect treatment of the impair-
ments and desired functional outcomes.
Design a program of intervention at each stage of
tissue healing.
Design a series of exercises that can be used to prepare
Mr. C. for return to function once the muscle has
healed.
4. A 78-year-old woman who lives at home with her hus-
band has been referred to you for home-based physical
therapy. Ten days ago she underwent cemented THA
with a posterolateral approach for late-stage post-
traumatic arthritis associated with injuries sustained
in a horseback riding accident 30 years ago. She has
been home from the hospital for 5 days. She is ambu-
lating with a walker on level surfaces, and weight
bearing is tolerated. The patients long-term goals
are to be able to participate in a community-based
fitness program for older adults and resume travel
vacations with her husband.
Continue progressing her exercise program that was
initiated in the hospital.
Review the precautions she must take for the next 6 to
12 weeks during ADL.
Make suggestions on how she or her husband might
adapt the home environment to help her adhere to the
precautions.
To help her meet her long-term goals, design a
sequence of progressively more demanding func-
tional activities, integrating the taxonomy of
motor tasks (addressed in Chapter 1) and the
principles of aerobic conditioning (discussed in
Chapter 5).
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