Physical Therapy Protocol: Total Hip Arthroplasty - Anterior Approach

Disclaimer: This protocol is a guideline and should be adapted based on individual patient presentation, surgeon preferences, and progress throughout rehabilitation. Always communicate with the referring surgeon regarding specific post-operative instructions and weight-bearing status.

I. Clinical Presentation

Patients undergoing Total Hip Arthroplasty (THA) via the anterior approach typically present with:

• Hip pain, often located in the groin or anterior thigh, potentially radiating to the knee.
• Limited hip range of motion (ROM), particularly internal rotation and extension.
• Pain exacerbated by weight-bearing activities.
• Possible Trendelenburg gait due to weakness of hip abductor muscles.
• Possible leg length discrepancy.
• Post-operative: Minimal soft tissue disruption, potentially faster recovery compared to other approaches, but potential for femoral nerve palsy (less common).

II. Rehabilitation Phases

Phase 1: Acute Phase (0-2 Weeks Post-Op)

Goals: Pain control, edema management, initiate muscle activation, protected weight-bearing (WB), patient education.

• Interventions:
• Patient Education: Hip precautions (typically minimal with anterior approach, but always verify surgeon's preference; may include avoiding excessive hip extension and external rotation initially), WB status education, home exercise program (HEP) instruction.
• Pain and Edema Management: Ice packs, elevation, gentle massage (around the surgical site), pain medication as prescribed.
• Ankle Pumps: To promote circulation and prevent deep vein thrombosis (DVT).
• Quadriceps Sets: Isometric contractions of the quadriceps muscle.
• Gluteal Sets: Isometric contractions of the gluteal muscles.
• Heel Slides: Passive or active-assisted knee flexion and extension within comfortable ROM.
• Assisted Ambulation: With appropriate assistive device (walker or crutches) as per WB status. Focus on proper gait mechanics.

Phase 2: Subacute Phase (2-6 Weeks Post-Op)

Goals: Improve ROM, increase strength, improve gait mechanics, transition to full WB (as tolerated and per physician orders).

• Interventions:
• Continue previous exercises.
• Hip Abduction/Adduction: Sidelying or standing, focusing on controlled movement.
• Bridging: To strengthen gluteal and hamstring muscles.
• Mini-Squats: Focus on proper form and avoiding pain.
• Standing Hip Extension: Controlled movement, avoiding hyperextension.
• Stationary Cycling: Low resistance, focusing on smooth pedaling.
• Gait Training: Emphasis on normal gait pattern, reducing reliance on assistive device.

Phase 3: Strengthening Phase (6-12 Weeks Post-Op)

Goals: Maximize strength and endurance, improve balance and proprioception, prepare for return to functional activities.

• Interventions:
• Continue previous exercises, progressing resistance.
• Single-Leg Stance: Improve balance and proprioception.
• Step-Ups: Forward and lateral.
• Lunges: Forward and lateral, focusing on controlled movement and proper alignment.
• Hip Abduction with Resistance Band: Progression from standing to sidelying.
• Hamstring Curls with Resistance Band: Standing or prone.
• Balance Board/Wobble Board Exercises: To challenge balance and proprioception.
• Pool Therapy (if appropriate): For low-impact strengthening and ROM exercises.

Phase 4: Return to Activity Phase (12+ Weeks Post-Op)

Goals: Return to pre-operative activity level, maintain strength and flexibility, prevent re-injury.

• Interventions:
• Progressive return to recreational activities: Walking, hiking, swimming, golf, etc.
• Sport-specific training: If applicable, with guidance from the physical therapist.
• Home exercise program: Maintain strength and flexibility.
• Education on injury prevention.

III. Exercise Examples

1. Ankle Pumps: Dorsiflexion and plantarflexion of the ankle.
2. Quadriceps Sets: Isometric contraction of the quadriceps muscle.
3. Gluteal Sets: Isometric contraction of the gluteal muscles.
4. Heel Slides: Sliding the heel up the bed or floor to bend the knee.
5. Hip Abduction (Sidelying): Lifting the leg up to the side while lying on the side.
6. Bridging: Lifting the hips off the floor while lying on the back.
7. Mini-Squats: Partial squats, focusing on proper form.
8. Standing Hip Extension: Extending the leg backwards while standing.
9. Step-Ups: Stepping up onto a low platform.
10. Lunges: Forward or lateral lunges, maintaining proper alignment.
11. Single Leg Stance: Standing on one leg, progress difficulty by adding head turns or reaching.

IV. Return to Function Criteria (Evidence-Based)

Return to function should be based on objective measures and patient self-report.

• Pain Level: Minimal pain during functional activities (e.g., pain score < 3/10).
• Range of Motion: Achieved functional ROM for ADLs and desired activities.
• Strength: Adequate strength in hip abductors, extensors, and flexors (assessed using manual muscle testing or dynamometry). Achieving at least 70% strength compared to the non-operative side.
• Balance: Static and dynamic balance within functional limits. Able to maintain single-leg stance for at least 30 seconds.
• Gait: Normal gait pattern without assistive device.
• Functional Testing: Successful completion of functional tasks such as stair climbing, walking for a specific distance, and performing recreational activities without excessive pain or limitations.
• Patient Self-Report: Patient feels confident and capable of performing desired activities.
• Completion of a valid and reliable functional assessment tool (e.g., Harris Hip Score, Lower Extremity Functional Scale). Scoring within acceptable limits.

References: Consult with the referring surgeon and refer to current evidence-based guidelines and research for THA rehabilitation.