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So, you’re in your 50’s, 60’s, 70’s or older and you’ve had a hip replacement. You have probably opted for this surgery because you were in a lot of pain and your ability to move had been getting worse. Now that you’re on the other side of the surgery you’ve been given a LOT of information about dos and don’ts that may have left you confused, and you probably have questions that have never been answered. This article should help you answer some of those questions, clarify what you’ve been told either by your surgeon, your friends, or “Dr. Google” and help you get the most out of your physiotherapy rehabilitation program.
The Questions
The number one question I’m asked as a physiotherapist is: ‘What activities will I be able to do once I’ve recovered?’ This is a complex question that takes into account your age, your previous activity level, and your general health. If you want the best outcome after your hip replacement, you need to optimize yourself before surgery. This means losing weight if you’re overweight, reducing alcohol intake, quitting smoking and exercising to build strength before surgery. Whether your surgery is next week or 8 months from now, it’s never too late to make the changes necessary for success.
Why should you make these changes?
Losing weight before or even after your surgery reduces the strength necessary to perform activities. This can include simply standing up from a chair, climbing or descending stairs, walking down the block, or shopping at the grocery store. Losing weight decreases the stress placed on your prosthetic hip and improves its longevity. This means you are less likely to wear out the artificial hip and less likely to need a second surgery to replace parts in the future.
Smoking and drinking can delay healing by a magnitude of months and cause healed tissue to become less resistant to stress thus increasing the risk of future injury. Smoking greatly increases the risk of infection post-surgery. Infection can lead to long courses of antibiotics and if antibiotics are unsuccessful at treating the infection, multiple operations to remove the artificial hip, treat with antibiotics and replace the artificial components may be necessary.
Strengthening prior to surgery can help maintain your independence after surgery and means that you are already part way through the rehabilitation process before you have even begun!
Generally, patients who undergo a total hip arthroplasty (hip replacement) are able to resume the activities they did prior to their surgery with considerably less pain and greater ease. Patients are cautioned not to run marathons as this repetitive impact can prematurely wear out an artificial hip and in some cases even fracture bone in your leg or pelvis. Your surgeon is the best resource to determine what activities are safe for you to perform.
Ultimately, it is up to you as the patient to exercise and strengthen in order to achieve your activity goals.
The second most common question is: ‘What are my precautions and why do they exist?’ Precautions following hip replacement vary depending on your surgeon. The most typical precautions include:
No hip flexion greater than 90 degrees – This means not lifting your knee above the level of your hip. Example activities that break this precaution include bending down to pick something up or to put on socks and shoes.
No end range internal and external rotation – This means rotating leg so foot points across body or away from body to side. Example activities that break this precaution include crossing legs in any fashion, and twisting torso or leg all the way to left or right.
No crossing midline. Example activities that break this precaution include crossing legs at ankles, crossing legs at the knee, sitting with knees pointing to the side but torso pointing forward.
These precautions are specific to posterior and lateral approaches and help avoid a hip dislocation. This is a risk because the surgery involved cutting through muscle, tendon, and ligaments that stabilize the hip and these structures have a reduced ability to withstand stress and strain until they are completely healed. A direct anterior approach involves different precautions, namely not turning your leg out (hip external rotation) with hip extension (kicking backward). This position is similar to a plié.
Precautions vary by surgeon and they may ask you to adhere to them for 6 to 12 weeks.
The last question is: ‘Why do I still have pain and how long until I am fully healed?’ Simply put, surgery is planned trauma. Depending on your age, prior experience with pain, and overall health you may have pain for a number of weeks or months. Some patients even have some residual pain for years. The most common cause of continued hip pain is reduced hip muscle strength, specifically gluteal strength. Exercising and maintaining good health go a long way to pain reduction.
The Dos
Ice, Ice, Ice – Jayme Gordon wrote a blog about What to do for a Sprain or Strain which includes instructions on how to I.C.E, which is both the activity as well as an acronym for ‘Ice’ ‘Compress’ and ‘Elevate’. These things are necessary for the first few weeks post-surgery to decrease pain, improve function, and facilitate healing. Check out her blog post for the details!
Hospital Exercises – Most hospitals hand out an exercise sheet and the physiotherapist in the hospital will have taught you exercises to do for your first few days after surgery before you see one of us in the clinic at Royal City Physio. Typically, these exercises include ankle pumps (pointing your toes and pulling your toes to the nose), heel slides (lying on your back, slide your heel on bed towards and away from your butt), quad setting (squeezing the back of your knee down into the bed), quads over roll (placing a towel roll under the knee and straightening your leg over the roll so your heel lifts), and a glute squeeze (squeezing your butt while sitting or lying in bed). You’ll also be given instructions on how to sit and stand from a chair and how to walk with a walker or crutches. These exercises are EXTREMELY important! The leg exercises help prevent blood clots and maintain muscle strength up and down your entire leg. The standing and walking exercises reduce pain, improve your ability to move and prepare you for physiotherapy in the clinic.
Generally, your exercises are your day job while you are recovering from surgery. If you want to return to any kind of activity you should perform these often before seeing your physiotherapist for activity and sport specific exercises.
Lose weight if you are overweight – Losing weight decreases the strength necessary to do your daily activities like stand up from a chair, climb stairs, and walk distances. Losing weight also improves the life of your artificial hip, reducing the need for a revision/replacement of its parts. Finally, losing weight can improve energy. Imagine how much harder it would be to climb stairs and walk long distances with a 20 to 100 lb backpack. Now imagine how much easier it would be to climb stairs and walk long distances without that extra weight.
Go to Physiotherapy – The hospital exercises that you were given are designed to help you manage for your first few days and weeks after your surgery, but are not enough to get you back to activity. Going to regular physiotherapy for hands-on manual techniques and activity specific exercises is necessary to maximize your recovery.
The Don’ts
Don’t break your precautions – Breaking precautions puts you at risk for a hip dislocation and usually results in damaging muscles and tendons around your hip. These precautions are there for safety and to optimize your healing.
Don’t smoke – Smoking reduces healing by an order of magnitude. Studies on bone healing after a fracture show that smokers are 37% less likely to be healed after 2 years as compared to non-smokers (Patel, R., Wilson, Patel, P., & Palmer, 2013). While a hip replacement isn’t a fractured bone, the bone has to grow into the screws and the prosthetic in order to be secure, and this process would be considerably longer in someone who smokes. Smoking also has effects on muscle, tendon, ligament and even skin healing, not to mention the increased risk of infection mentioned earlier!
References:
Patel RA, Wilson RF, Patel PA, Palmer RM. The effect of smoking on bone healing: A systematic review. Bone Joint Res. 2013;2(6):102-11. Published 2013 Jun 1. doi:10.1302/2046-3758.26.2000142
Stephen Baker graduated from Western University with a Masters of Physical Therapy. He has a passion for helping those with neck, hand or knee injuries return to their daily adventures. Book with Stephen today.