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Hip Arthroplasty

Improving Gait
John OHalloran
PT, DPT, OCS, Cert MDT, LATC, CSCS (Retired)

Not for reproduction or redistribution

Chapter 1
Approaches to Hip Replacement

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Introduction
400,000 procedures a
year
Second most commonly
replaced joint
Leg length discrepancy
Different approaches
Precautions
Rehab

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Leg Length Discrepancy


When should this issue be addressed?
5 - 13% of total hip arthroplasties (THA) have a measureable
leg length discrepancy
Weaker patients are usually given more length
Lifts to correct new leg length (sometimes better avoided and
walking instead)
Corrective stretching/manual therapies
Hiking of hip results from adaptive shortening of other
muscles to compensate
Stretch and strengthen to address this
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

History of Hip Arthroplasty


Originally developed in 1962
Implant survivorship (most successful)
80% will last 20 years
90% will last 10 years

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Lets Discuss
400,000 performed in US annually at a cost of over
three billion dollars (primary only)
Revisions 137% between 2005 - 2030
Research shows that patients get their information from
the therapist on surgery, rehab, and what not to do
Excellent postoperative results reported as high as 98%
Cemented versus non-cemented has changed
Type of approach

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Diseases Requiring THA


Osteoarthritis resulting from age, genetic, and now
than ever, obesity
Most common indication

Inflammatory Arthritis/Rheumatoid Arthritis


Traumatic Arthritis Resulting from fractures and/or
forms of avascular necrosis
Causes femoral head to collapse

Hip dysplasia, shallow cup, etc.

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Posterior Approach
Oldest and most
common approach
Provides greatest view
of surgical field
Restrictions for 6 - 12
weeks postoperatively
Anterior approach is
more common for
younger patients

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Minimally Invasive = Anterior Approach


Typically younger patients
Restriction period is shorter

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Anterior Approach in the Past


Performed by surgeons less experienced with the
technique
Original Goals
Smaller scar
Less pain, bleed, and length of stay (LOS)
Faster rehab

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Anterior Approach in the Past (cont.)


However big learning curve the small scar, the same
pain, and bleed with two to three times more
complications
Femoral neck fractures
Nerve palsies
Dislocation
Difficult to do on obese patients and/or patients with
malalignment, tight/big muscles, previous hardware,
revisions

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Anterior Approach Today


Now surgeons can do these in everyone
Including revisions, hardware removal, complications

Drastically reducing postoperative recovering time


Anterior versus posterior
No difference after 6 weeks according to literature
Anterior approach is still typically better for active people

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

How do Surgeons do an Anterior


Approach?
Go between sartorius
muscle and tensor fascia
No muscle detachment =
no restrictions
X-ray fluoroscopy takes
numerous x-rays to guide
placement of the implant
More likely to get leg
lengths equal and implant
in right position

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Anterior Approach Patient


Holly had an anterior hip
replacement
Yoga teacher and athletic
trainer
Back to all activities and
motions 8 weeks after
surgery
The hip extension move here
would make me nervous the
first 6 8 weeks
Hip capsule fibers need time
to heal and seal up

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hana Table
Surgical table used for anterior approach procedure
Traction causes hip to extend

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Bearing Surfaces
Two main types
1. Metal ball with polyethylene cup (left)

Most traditional approach

2. Metal ball with metal cup (right)

Larger head = greater stability = decreased dislocation

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Ceramic Head with Polyethylene Liner


Popular with young, active groups for durability

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Metal on Metal Debate


In 2010, implants were recalled
due to a 14% revision rate
Normally only 1% revision rate

Abnormal amount of metal


accumulated in body due to
metal shavings from friction of
joint
Chromium and cobalt found in
blood and urine

No longer on the market

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Metal on Metal Debate (cont.)


What were the benefits supposed to be?
Increased longevity potential
Increased stability
Much larger implant resembles the natural femoral head
size

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Metal on Metal Debate (cont.)


What did the literature say?
Metal ions shown in the blood and urine due to wear
debris
No adverse reactions were documented
No report of cancer or allergic reactions

Journal of Arthroplasty 2005


Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Resurfacing
Now down to 2 - 3% from 6 - 9%
Advantages
Preserves shaft of femur
Head of femur is preserved by
shaving it down and putting a
cap on the femur
Good for athletes

Disadvantages
Not good for people with bone
density issues or avascular
necrosis
Usually not best option for
females
Randelli et al. - Amstutz et al. - De Smet et al. -Australian National Joint Registery 2008
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Resurfacing (cont.)


Need to wait a year for the bone density to build up
again around the peg
Posterior approach

Cook et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Positioning of Joint Head

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Dislocations
2 - 4% of primary TSA, up to 20% of revisions
Causes
Small femoral head
Improper version
Short neck
Infection
Behavior (violated precautions/restrictions)

Restrictions are typically 6 - 12 weeks


Can be up to one year or even for life in some cases
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Dislocations (cont.)
Traditional THA are inherently unstable due to design
Normal hip dislocates from trauma, such as a high
velocity car accident
THA dislocate because the ball is a lot smaller than the
socket
In order to provide a plastic bearing surface and a socket
that is thick enough, the head had to be smaller to have
longevity

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Femoral Head Size Today


Natural hip head is 33% larger than that used in a THA
44 - 56 mm (natural) versus 28 mm (prosthetic)

Femoral heads are getting larger


Resulting in fewer dislocations

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Precautions
Posterior Approach
No hip flexion over 90 degrees
No hip adduction beyond neutral
No hip internal rotation beyond neutral

Anterior Approach
No hip extension beyond neutral
No hip external rotation beyond neutral
No prone lying
No bridging
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Precautions (cont.)
Knee precautions after THA
None
Precautions are based on surgeons preference and the
surgical procedure1

Posterior approach precautions haven't changed much


but anterior approach precautions have
Fewer procedures done in 2005
Surgeons didn't have as much experience and as a
result, there were more precautious
1. Brigham and Womens Hospital
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Chapter 2
Rehabilitation of the Hip

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Rehabilitation
Dimonaco divided hip replacement rehab into Early Stage and
Late Stage
Early Stage
Bed exercises
Precaution and transfer training
Core exercises
Hip stretching

Later
Eccentric contractions for people five years postoperatively
1. Dimonaco M et al. Rehab after THA a systematic review of controlled trials on physical
exercise programs. Eur J. Phys. Med. Rehab . 2009
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Rehabilitation (cont.)


Trendelenburg is caused by a tight psoas 46% of time
and a weak gluteus medius 36%1
Total body movements versus isolation for hip rehab2
Earlier conditioning causes patients to rate satisfaction
higher3
Quadricep function, trunk function, tight psoas, etc.4

1. JBJS 2007
2. Arch Phys Med Rehab 2012

3. Liebs et al 2010
4. Gait and Posture 2012

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Drop
Normal gait versus pathological gait
Normal gait is hip drop of 1 - 2 inches
Pathological gait is hip drop of 2 - 4 inches

To facilitate normal gait, the hip must extend to activate the


gluteus medius
Wall raises with feet even and both arms up
Wall raises with one foot forward, and same arm up
Marching with same arm up
Weight shifting forward and to the side, with opposite arms
Psoas stretching (i.e. door frame stretch)
Trendelenburg exercise side pelvic raises
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Rehab Retro Stepping

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Rehab Upper Extremity Elevation


With Weight Shift

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Chapter 3
Therapeutic Tips

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Therapeutic Tips
Balance is critical to improve gait and stability
Often overlooked

Core Awareness
Eccentric weight shifting for femoral internal rotation
control
Small proximal deficit results in a large distal deficiency

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Rehab Case Study


Tight psoas and quadratus lumborum
Weak gluteus medius
Rehab course of action
Fix cane
Stretch psoas
Release tight muscles
Strengthen weak muscles
Sequencing is the game changer

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Trendelenburg Gait
47% of Trendelenburg
gait caused by tight
psoas
36% caused by weak
gluteus medius

Bhave JBJS 2007


Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Ways to Facilitate Hip Stabilizing


Muscles
Stretch hip flexor
Doorway stretches
Stretch to facilitate inhibited muscle
Upper extremity arm elevation with weight shifting

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Early Hip Flexor Stretching


Slide hand up the wall while squeezing gluteus medius

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Doorway Hip Flexor Stretch


Put patient in runner's stretch position

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Research Gluteus Medius


Journal of Arthroplasty
Compared
Non-Weight Bearing (NWB) exercises for the gluteus
medius
Weight Bearing (WB) gluteus medius exercises in the
early postoperative phase

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Research Gluteus Medius (cont.)


Results showed NWB exercises had no benefit to WB
exercises for gluteus medius activation
So why do NWB exercises (if they are no better) if the
patient can bear weight and perform more functional
gluteus medius exercises?

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Early Phase Outpatient Rehab


Classic case of leg length discrepancy due to adaptive
muscles
First stretch out shortened muscles
Stretch out short and tight muscles
Doorway exercises to release hip flexor and facilitate
the abductors and rotators
Reach to elongate lateral trunk and hip flexor
Reach across

Step up to facilitate gluteus muscles


Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Late Phase Outpatient Rehab


Assess
Balance
Hip flexor mobility
Muscles that control femoral internal rotation eccentrically
Trunk and core control

Incorporate a sequence of therapeutics that will


facilitate objectives
Become impairment-based

JOSPT April 2011


Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Assessments
Assessments give objective information for patient,
payer, and physician
Diagonal exercises, such as chops and lifts
Good for people doing sports
Need proximal stability to get distal mobility

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Dynamic Balance
Need to improve
dynamic balance
Forward arm reach

Trendelenburg and
weakness
Strengthen hip rotators,
gluteus medius, and
hamstrings eccentrically

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Recommendations Following THA, 2011


Survey sent to members of the Hip Society and
American Association of Hip and Knee Surgeons (2007
and 2011)
549 respondents (72%)
30 groups of activities; 37 specific sports
Allowed
Allowed with experience
Not Allowed
Undecided
Klein et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Allowed Activities Following THA


Golf

Stationary bicycling

Swimming

Low-impact aerobics

Doubles tennis

Rowing

Walking
Speed walking

Dancing (ballroom, jazz,


square)

Hiking

Weight machines

Stationary skiing

Stair climber

Bowling

Treadmill

Road Cycling

Elliptical

Klein et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Activities Allowed With Experience


Following THA
Downhill skiing
Cross-country skiing
Weightlifting
Ice skating/rollerblading
Pilates

Klein et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Activities Not Allowed Following THA


Racquetball/squash
Jogging
Contact sports
Football, basketball, soccer

High-impact aerobics
Baseball/softball
Snowboarding

Klein et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Research
Why did snowboarding get a not allowed grade while
other sports like skiing and in-line skating were upgraded
to allowed with experience?
Less familiar activity
Biomechanically surgeons are concerned with the
torque created around the hip when feet are fixed to the
board

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Previously in the
Not Allowed Category
Recently been upgraded to the Activities Allowed with
Experience category per the AAHKS
Downhill skiing
Weightlifting
Ice skating/rollerblading

Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Undecided Activities Following THA


Martial arts
Singles tennis

Klein et al.
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS,


Cert MDT, LATC, CSCS (Retired)
Not for reproduction or redistribution

Hip Arthroplasty: Improving Gait

Bibliography
MedBridge Education
Hip Arthroplasty: Improving Gait

John OHalloran PT, DPT, OCS, ATC, CSCS, Cert MDT


1. Baldwin K et al. Whats New in Orthopaedic Rehabilitation? Journal of Bone and Joint
Surgery 2013 Nov; 95-A (22) : 2071-7.
2. Liebs TR et al. Multicenter Randomized Controlled Trial Comparing Early vs. Late
Aquatic therapy after Total Hip or Knee Arthroplasty. Arch Phys Med
Rehab. 2012;93(2):192-199.
3. Bozic KJ et al. The Influence of Procedure Volumes and Standardization of Care on
Quality and Efficiency in Total Joint Replacement Surgery. JBJS. 2010;92-A(11):264352.
4. Suda AJ et al .Are patient expectations of hip and knee arthroplasty fulfilled? A
prospective study of 130 patients. Orthopaedics. 2010; 33:76.
5. Minns Lowe CJ et al. Effectiveness of Physiotherapy Exercises Following Hip
Arthroplasty for Osteoarthritis: A Systematic Review of Clinical Trials. BMC
Musculoskeltet Disord. 2009. 10:98.
6. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of Physiotherapy
after Hip Arthroplasty following Osteoarthritis: A systematic review and meta analysis of
Randomized Controlled Trials. BMJ;2009;10:98.
7. Ewen AM et a. Post-operative Gait Analysis in Total Hip Replacement Patients: A
Review of Current Literature and Meta-Analysis. Gait and Posture. 2012; 36:1-6.
8. Vissers MM, Bussmann JB,Verhaar JA, et al. Recovery of physical functioning after total
hip arthroplasty: systematic review and meta-analysis of the literature. Phys
Ther.2011;91:615-629.
9. Bandholm T, Kehlet H. Physiotherapy exercises after fast track THA and TKA; Time for
a reconsideration? Arch Phys and Rehabil.2012;93:1292-4.
10. Biomet, Inc. www.biomet.com. Retrieved 4/11/07.
11. Depuy Orthopaedics. www.depuyorthopaedics.com. Retrieved 2008-2009.
12. The Burden of Musculoskeletal Diseases in the United States: Prevalence, Societal and
Economic Cost. Chapter 4: Arthritis and Related Conditions. American Academy of
Orthopedic Surgeons. 2008.
13. Millett P, Gobezic R, Baykin R. Shoulder Osteoarthritis: Diagnosis and
Management. American Family Physicians. 2008: 78; 5:605-611.
14. Green A, Norris JR. Imaging Techniques for Glenohumeral Arthritis and Glenohumeral
Arthroplasty. Clinical Orthopedics and Related Research. 1994; 7-17.
15. Sperling JW et al. Shoulder Arthritis in Young Adults: Arthroscopy to
Arthroplasty. Instructional course lectures 2000; 55:67-74.
16. Global Information Inc Report 2007-The Boomer effect on the economy.
17. Leeb, B.et al., A Meta-analysis of Chondroitin Sulfate in the Treatment of OA. Journal of
Rheumatology. 2000; 27:205-211.

Hip Arthroplasty: Improving Gait

18. Divine, Jon G, Zazulak, Bohdanna, Hewett, T. Viscosupplementation for Knee


Osteoarthritis: A Systematic Review. Clinical Orthopaedics &Related Research. 2007;
455:113-122.(2)
19. Kirkley A, Birmingham TB, Litchfield RB et al . A Randomized Trial of Arthroscopic
Surgery for Osteoarthritis of the Knee. New Eng J Med. 2008; 359: 1097-1107.
20. Cochrane Systematic Reviews: Corticosteroid Injection, Viscosupplements, Continuous
Passive Motion for TKA. 2010.
21. Brady. The Patients Role in Rheumatology Care. Current Opinion in Rheumatology.
1998; 10: 146-151.
22. Lorig et al. Health Education for Self-Management in Patients. Arthritis and
Rheumatism vol 36 (4) 1993.
23. Ackerman IN, Bennell KL. Does Pre-operative Physiotherapy Improves Outcomes from
Lower Limb Joint Replacement Surgery? A systematic review. 2004; 50:25-30.
24. McDonald S, Hetrick SE, Green S. Pre-operative Education for Hip or Knee
Replacement. Cochrane Database of Systematic Reviews. 2008; 4.
25. Santavista N et al. Teaching of Patients Undergoing THR. Int J Nurs Stud 31 1994
(2):135.
26. Santaquida P et al. Patient Characteristics Affecting the Prognosis of Total Hip and Knee
Joint Arthroplasty: A Systematic Review. Canadian Journal of Surgery. 2008; 51(6);428436.
27. Herbert R et al. Outcome Measures Outcomes, Not Effects of Intervention. Australian J
of Physio. 2005; 51:3-4.
28. Khan F et al. Multidisciplinary Rehabilitation Programs Following Joint Replacement at
the Hip and Knee in Chronic Arthropathy-Cochrane Systematic Reviews. 2008:Issue 2.
29. Bozic KJ et al. The Influence of Procedure Volumes and Standardization of Care on
Quality and Efficiency in Total Joint Replacement Surgery. JBJS. 2010;92-A(11):264352.
30. Suda AJ et al. Are patient expectations of hip and knee arthroplasty fulfilled? A
prospective study of 130 patients. Orthopaedics. 2010; 33:76.

Total Hip Arthroplasty Phase 1


Supine Short Arc Quad with Towel Roll
Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Daily: 3x
Setup

Step 1

Supine Gluteal Sets


Reps: 10
Sets: 3
Hold (sec): 5

Begin lying on your back with a towel roll


under one knee with your heel resting on
the ground.
Movement
Tighten the muscles in your upper leg to
straighten your knee, hold, then return to
the start and repeat.
Tip
Make sure to keep your back flat against
the floor as you move your leg.

Step 2

Weekly: 5x

Daily: 3x
Setup
Begin lying on your back with your hands resting
comfortably.
Movement
Tighten your buttock muscles, then release and
repeat.
Tip
Make sure not to arch your low back during the
exercise or hold your breath as you tighten your
muscles.

Step 1

Supine Heel Slide with Strap


Reps: 10
Sets: 3
Hold (sec): 5

Weekly: 5x

Daily: 3x
Setup
Begin lying on your back with your legs
straight and a strap around one foot.
Movement
Slowly pull on the strap to bring your foot
toward your buttock.
Tip
Make sure to keep your heel moving
straight toward your buttock in line with
your hip.

Step 1

Supine Ankle Pumps


Reps: 10
Sets: 3
Hold (sec): 5

Step 2

Weekly: 5x

Daily: 3x
Setup
Begin lying on your back with your legs
straight.
Movement
Slowly pump your ankles by bending and
straightening them.
Tip
Try to keep the rest your legs relaxed while
you move your ankles.

Step 1

Step 2

Page 1 of 2

Supine Hip Abduction


Reps: 10
Sets: 3
Hold (sec): 5

Weekly: 5x

Daily: 3x
Setup
Begin lying on your back with your legs
straight.
Movement
Move one leg out to the side as far as you
can without bending at your side.
Tip
Make sure to keep your back on the ground
and do not more your upper body during
the exercise.

Step 1

Bent Knee Fallouts


Reps: 10
Sets: 3
Hold (sec): 5

Step 2

Weekly: 5x

Daily: 3x
Setup
Lie on your back with your knees bent and
feet resting flat on the floor.
Movement
Keeping your trunk stiff, slowly lower one
knee towards the ground, then bring it back
to your starting position. Repeat with the
other leg.
Tip
Do not allow your trunk to rotate during the
exercise.

Step 1

Step 2

Page 2 of 2

Total Hip Arthroplasty Phase 2


Sidelying Hip Abduction
Reps: 10
Sets: 3
Hold (sec): 5

Weekly: 5x

Daily: 3x
Setup

Step 1

Begin by lying on your side.


Movement
Slowly lift your upper leg towards the ceiling
then lower it back to the starting position.
Tip
Make sure to keep your knee straight and
do not let your hips roll backward or
forward during the exercise.

Step 2

Supine Single Bent Knee Fallout


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Daily: 3x
Setup

Step 1

Seated Long Arc Quad


Reps: 10
Sets: 3
Hold (sec): 5

Begin lying on your back with one leg


straight and your other knee bent.
Movement
Movement
Tighten your abdominals and slowly lower
your bent knee toward the ground, then
bring it back to the starting position, and
repeat.
Tip
Make sure to keep your abdominals tight,
low back flat against the ground, and do not
let your trunk rotate.

Step 2

Weekly: 5x

Daily: 3x
Setup
Begin sitting upright in a chair.
Movement
Slowly straighten one knee so that your leg
is straight out in front of you. Hold, and then
return to starting position and repeat.
Tip
Make sure to keep your back straight during
the exercise.

Step 1

Sit to Stand with Hands on Knees


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Step 2

Daily: 3x
Setup
Begin by sitting upright on a chair with your feet
slightly wider than shoulder width apart and your
hands resting on your knees.
Movement
Lean forward at your hips until your bottom starts to
lift off the chair. Move your body into a standing
upright position, then reverse the order of your
movements to return to the starting position.
Tip
Make sure not to let your knees collapse inward
during the exercise.

Step 1

Step 2

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Hip Abduction with Resistance Loop


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Daily: 3x

Step 1

4-Way Hip:Setup
Begin in a standing upright position with a
resistance band looped around your ankles,
holding a stable object for balance.
Movement
Lift one leg to your side, keeping your knee
straight. Return to the starting position and
repeat.
Tip
Make sure to keep your abdominals tight
and your back straight during the exercise.

Step 2

Standing Quadriceps Stretch with Chair Support


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x Daily: 3x
Setup
Begin in a standing upright position holding onto a
stable surface for support.
Movement
Bend one knee upward and grasp your foot, pulling it
toward your body and pushing your hips forward until
you feel a stretch in the front of your thigh and hold.
Tip
Make sure to keep your back straight and maintain
your balance during the stretch.

Step 1

Step 2

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Total Hip Arthroplasty Phase 3


Seated Hamstring Stretch with Strap
Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Daily: 3x
Setup

Step 1

Begin in an upright seated position in a


chair with a strap around one foot, holding
the ends in your hands.
Movement
Use the strap to slowly straighten your leg
until you feel a stretch in the back of your
thigh.
Tip
Make sure not to arch your back as you
stretch.

Step 2

Half Kneeling Hip Flexor Stretch


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Daily: 3x
Setup

Step 1

Squat with Chair Support


Reps: 10
Sets: 3
Hold (sec): 5

Begin in a half kneeling position with one


knee bent in front of your body.
Movement
Tighten your abdominals, tilt your pelvis
backward, and gently push your hips
forward. You should feel a stretch in the
front of your hip.
Tip
Make sure to keep your hips facing forward
and back straight during the exercise.

Step 2

Weekly: 5x

Daily: 3x
Setup

Step 1

Standing Knee Flexion with Ankle Weight


Reps: 10
Sets: 3
Hold (sec): 5
Weekly: 5x

Begin in a standing upright position with


your hands resting on the back of a chair in
front of you for support.
Movement
Bending at your knees and hips, squat down
as far as is comfortable.
Tip
Make sure to keep your back straight during
the exercise and maintain your balance.
Your knees should not move forward past
your toes during the squat.

Step 2

Daily: 3x
Setup
Begin in a standing upright position with an ankle
weight secured on one leg, with your hands resting on
the back of a chair in front of you for support.
Movement
Slowly bend your knee, lifting the foot with the weight
to a 90 degree angle.
Tip
Make sure to stand up tall and do not bend forward at
the waist during the exercise.

Step 1

Step 2

Page 1 of 2

Lateral Step Down


Reps: 10
Sets: 3
Hold (sec): 5

Weekly: 5x

Daily: 3x
Setup
Begin by standing on a platform or step with one leg
hanging off the edge.
Movement
Maintaining an upright position, bend at your knee and
hip, slowly lowering your foot to the ground, then
return up to the starting position and repeat.
Tip
Make sure not to let your trunk bend forward or your
knee collapse inward as you lower your foot to the
ground.

Step 1

Runner's Step Up/Down


Reps: 10
Sets: 3
Hold (sec): 5

Step 2

Weekly: 5x

Daily: 3x
Setup
Begin in a standing position with one foot resting on a
platform or step in front of your body.
Movement
Slowly step up, raising your knee to a 90 degree angle
and moving your opposite arm at the same time. Then
lower your foot to the ground and repeat.
Tip
Make sure not to let your trunk bend forward or your
knee collapse inward as you lower your foot to the
ground.

Step 1

Hip Hiking on Step


Reps: 10
Sets: 3
Hold (sec): 5

Step 2

Weekly: 5x

Daily: 3x
Setup
Begin standing on a platform, balancing on one leg,
with your other foot hanging off the edge.
Movement
Raise one hip to lift your hanging foot off the ground
as high as you can, then lower it and repeat.
Tip
Make sure to keep your foot relaxed and use your hip
to create the movement. Maintain an upright posture
during the exercise.

Step 1

Step 2

Page 2 of 2