To date, approximately 2 million hip replacements and 4 million knee replacements have been performed! With reductions in health care reimbursement, physical therapists have found that they are either receiving less reimbursement for the same number of visits or fewer visits allotted per patient. As these patients move along the healthcare ladder, it is a cool opportunity for fitness and golf professionals to get earlier access to this population. If you are not asking clients about their past medical history and know very little about joint replacement, especially when providing golf instruction, it would benefit you tremendously to know more before performing a screen or offering any instruction.
Having a good understanding of the surgical techniques and precautions put in place by surgeons will help you see huge growth in the number of referrals you receive.
The TPI screen can be used in this population to pinpoint golf-related dysfunction and functional challenges a person will face with different activities of daily life, but only when properly considering unique characteristics of joint replacement restrictions. Here are two things to consider when working with patients following a total hip replacement:
Know the specific surgical technique that was performed; anterior vs. posterior are the two most common approaches. Anterior and posterior approaches have slight variances when it comes to precautions. With posterior approaches, the precautions are relatively consistent for approximately the first six weeks:
- No bending beyond 90 degrees at the hip (flexion)
- No crossing the legs (adduction)
- No letting the limb turn inwards (internal rotation)
Always confirm precautions with the patient and surgeon. This is a great opportunity to build a relationship with local surgeons.
More often than not, you will not see precautions with anterior hip replacement approaches. However, this can vary from surgeon to surgeon. In Restrepo, C. et al., “Hip Dislocations: Are hip precautions necessary in anterior approaches,” four hip dislocations occurred at a mean of five days post-op in 2,612 hip replacements. As a general rule, you should avoid movements early on that exacerbate symptoms. As the surrounding tissue heals, I am generally cautious with hip extension beyond 0 degrees and hip flexion beyond 90 degrees that creates pain in the first two to three months.
If you are finding limitations in your screen that are painful, consider referring out if you cannot create change with the tools you have. If motion is limited and not painful, try to improve positions through mobility and strength.
An interesting side note: Regardless of which surgical approach was used, we are commonly seeing retraction and reattachment of at least one out of four of the hip external rotators to allow for placement of the femoral implant. One major difference is that the posterior approach actually allows for reattachment of the musculature, whereas an anterior approach does not. When assessing hip stability and strength during single leg stance, squat and single bridge, trauma to this musculature during surgery may play a role.
If the client’s swing or golf-specific goals require this strength and stability, you need to realistically determine if the trauma sustained during surgery will allow them to achieve these goals. If you are seeing poor quality with the tests mentioned, do a quick exam of the local hip musculature. If you want to dig deeper, feel free to contact the surgeon to get more insight on the surgical approach or the therapist to see how their strength looked at discharge.
Dislocation continues to be a possibility with hip replacements years out from the initial surgery. If a revision surgery was performed, risk goes up even higher. This isn’t meant to instill fear as much as it is meant to bring awareness and respect for the procedure performed. Risk of dislocation following total hip replacement is higher in posterior approaches compared to anterior approaches. The risks are 3.23 % and 2.18%, respectively, after at least 12 months. If the external rotators of the hip were reattached you see the percent of dislocation drop as low as .7% in posterior approaches. The rate of dislocation also increases 1% for every five years. There are many reasons for hip dislocation, with only one being in our control, and that is patient compliance. Signs of anterior and posterior dislocation are:
- Posterior: The hip is flexed, internally rotated, and adducted.
- Anterior: The hip is minimally flexed, externally rotated and markedly abducted
Hip dislocations are not always symptomatic. When they are, common symptoms include:
- Feelings of instability at the hip
- Sudden severe pain and/or inability to weight bear on limb
- Limited ability to move the limb, “feels stuck”
- Sensation that the surgical leg has become shorter
Total hip replacement patients are normally a breeze to work with because of how quickly they recover from surgery. This is GREAT news. Be confident! Total knee replacement is a different story, but we will save this for another post. Just remember the two considerations discussed: (1) the importance of understanding and knowing the surgical approach used and (2) the fact that dislocation continues to be a possibility years out from surgery. Please do not fear total hip replacement patients in your gym. Being able to return to golf without hip pain is more than enough for this group. Getting a skilled TPI coach will just be the cherry on top. This will create an awesome experience for you and your client!
Michael Infantino, DPT, PT
Altman, R. D., MD. (2009). Hip Pain and Mobility Deficits – Hip Osteoarthritis: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther, 39(4), A1-A25. Retrieved May 5, 2016, from http://www.jospt.org/doi/pdf/10.2519/jospt.2009.0301
Goldstein WM, Gleason TF, Kopplin M, Branson JJ. Prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy. J Bone Joint Surg. 2001;83(S2):2–7. [PubMed]
Restrepo, C., Mortazavi, S. M. J., Brothers, J., Parvizi, J., & Rothman, R. H. (2011). Hip Dislocation: Are Hip Precautions Necessary in Anterior Approaches? Clinical Orthopaedics and Related Research, 469(2), 417–422. http://doi.org/10.1007/s11999-010-1668-y
Masonis JL, Bourne RB. Surgical approach, abductor function, and total hip arthroplasty dislocation. Clin Orthop Relat Res. 2002;405:46–53. [PubMed]