Anterior Hip Replacement Rehabilitation Protocol

This protocol outlines a comprehensive physical therapy rehabilitation program following an anterior approach hip replacement. It is a guideline and should be modified based on individual patient progress, surgeon preferences, and any complications. Close communication between the patient, surgeon, and physical therapist is essential.

Pathophysiology

Anterior hip replacement involves surgically replacing the damaged hip joint with prosthetic components through an incision located at the front of the hip. The anterior approach is muscle-sparing, meaning it aims to avoid cutting through major muscles surrounding the hip, potentially leading to faster recovery and reduced post-operative pain. The joint is exposed by releasing some muscles, such as the tensor fasciae latae, or splitting the sartorius and rectus femoris. A new acetabular cup and femoral stem with a ball are implanted, restoring joint articulation. Common indications for hip replacement include osteoarthritis, rheumatoid arthritis, avascular necrosis, and hip fractures.

Phase I: Protection (Weeks 0-3 Post-Op)

Goals: Protect the surgical site, control pain and swelling, initiate early muscle activation, and achieve independent ambulation with an assistive device.

• Precautions: Follow surgeon-specific precautions, which may include weight-bearing limitations (typically weight bearing as tolerated (WBAT) with assistive device), avoiding excessive hip extension, and external rotation (especially with adduction).
• Pain Management: Utilize modalities such as ice, electrical stimulation (TENS), and manual therapy techniques (gentle soft tissue mobilization around the incision) to manage pain and swelling. Educate the patient on proper pain management strategies and medication compliance.
• Edema Control: Implement compression bandages, elevation, and active ankle pumps to minimize edema.
• Therapeutic Exercises:
  • Ankle Pumps: Encourage frequent ankle pumps to promote circulation.
  • Quad Sets: Isometric quadriceps contractions to activate the quadriceps muscle.
  • Gluteal Sets: Isometric gluteal contractions to activate the gluteal muscles.
  • Heel Slides: Assisted or active-assisted hip and knee flexion.
  • Abduction/Adduction: Gentle hip abduction and adduction within a pain-free range, respecting precautions.
  • Short Arc Quads: Using a bolster under the knee, extend the knee against gravity.
  • Standing Weight Shifts: Practice weight shifting in standing, gradually increasing weight bearing as tolerated with assistive device.
• Gait Training: Initiate gait training with an appropriate assistive device (walker, crutches) adhering to weight-bearing restrictions. Focus on proper gait mechanics and balance. Progress to one assistive device as tolerated.
• Transfers: Practice safe transfers in and out of bed, chairs, and toilet using proper techniques and adaptive equipment if needed.
• Patient Education: Thoroughly educate the patient on hip precautions, proper body mechanics, home exercise program, and signs and symptoms of complications (infection, DVT).

Phase II: Loading (Weeks 4-8 Post-Op)

Goals: Improve strength, range of motion, balance, and proprioception. Wean off assistive device (if appropriate).

• Progression Criteria: Reduced pain and swelling, improved range of motion, and ability to ambulate with minimal assistance.
• Therapeutic Exercises:
  • Continue Phase I Exercises: Progress repetitions and resistance as tolerated.
  • Standing Hip Abduction/Adduction: Add resistance with theraband or cuff weights.
  • Standing Hip Extension: With proper form, avoiding excessive lumbar extension.
  • Bridging: Progress to single-leg bridging when appropriate.
  • Mini Squats: Focus on proper form and alignment.
  • Step Ups: Forward and lateral step ups on a low step.
  • Balance Training: Progress from static to dynamic balance exercises, using foam pads or rocker boards.
  • Proprioceptive Exercises: Weight shifting, single leg stance, and reaching tasks.
• Gait Training: Progress gait training, focusing on normalized gait pattern, step length, and cadence. Wean off assistive device as tolerated. Consider using a cane for uneven terrain or longer distances initially.
• Cardiovascular Training: Initiate low-impact cardiovascular activities such as stationary cycling (with appropriate seat height) or walking on a treadmill.
• Manual Therapy: Continue soft tissue mobilization as needed to address muscle tightness or scar tissue restrictions.

Phase III: Return to Function (Weeks 9+ Post-Op)

Goals: Restore full functional capacity, return to pre-operative activity level, and maintain long-term joint health.

• Progression Criteria: Good strength, range of motion, balance, and functional mobility. Independent ambulation without assistive device.
• Therapeutic Exercises:
  • Continue Phase II Exercises: Progress to higher intensity exercises with increased resistance or complexity.
  • Lunges: Forward and lateral lunges with proper form.
  • Single Leg Squats: If appropriate and pain-free.
  • Plyometrics: Gradual introduction of plyometric exercises (e.g., box jumps, hopping) if desired and appropriate for the patient's goals.
  • Sport-Specific Training: Begin sport-specific activities as tolerated, with proper guidance and instruction.
• Functional Training: Focus on activities that mimic the patient's pre-operative activities and hobbies.
• Endurance Training: Progress cardiovascular training to improve endurance and functional capacity.
• Patient Education: Emphasize the importance of maintaining a healthy weight, proper body mechanics, and a consistent exercise program to prevent future joint problems.

Common Special Tests

These tests can be used throughout the rehabilitation process to assess hip pathology and guide treatment. These should be performed cautiously, respecting post-operative healing.

• FABER (Patrick's) Test: Assesses for hip joint pathology (intra-articular or anterior).
• Scour Test: Assesses for hip joint pathology (osteoarthritis, labral tears).
• Trendelenburg Test: Assesses gluteus medius strength and hip stability.
• Thomas Test: Assesses hip flexor tightness.
• Ober's Test: Assesses iliotibial (IT) band tightness.

Disclaimer: This is a general rehabilitation protocol and should be individualized based on patient-specific needs and surgeon's recommendations. Regular assessment and modification of the program are essential to optimize patient outcomes. Always consult with a qualified healthcare professional before starting any new exercise program.