Case Study: Physical Therapy Management of

Hip Osteoarthritis Prior to Total Hip

lorna King, BSc, PT'

0
steoarthritis is a com-
mon problem treated
by physical therapists.
This is a disease char-
acterized by the dete-
rioration of the cartilaginous weight-
bearing surfaces of joints, sclerosis of
subchondral bone, and proliferation
of new bone at the joint margins (2).
Osteoarthritis is the most prevalent
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It is important that we have information on the role of physical therapists in the treatment of
patients with osteoarthritis of the hip prior to total hip arthroplasty. This article describes the
management of a patient with limited range of motion of the right hip due to osteoarthritis. The
patient made a significant improvement with decreased pain, increased range of motion of the right
hip, increased periarticular muscle strength, improved gait, and improved mobility. One year later,
the patient had a right total hip arthroplasty. The rationale of the management of patients with
osteoarthritis of the hip is discussed. In addition, the role of physical therapists in the management
and treatment of patients with osteoarthritis prior to total hip arthroplasty is discussed.
Key Words: osteoarthritis, hip arthroplasty, joint mobilization
'Clinical Supervisor, Out-Patient Physical Therapy Depamnt, Hospital for Special Surgery, 535 E. 70th

rheumatic disease affecting the adult Street, New York, NY 10021

population of the United States, and
estimates are reported at 12.1% of
the population in persons aged
throplasty has a high success rate and osteoarthritis is the initial stage of
25-74 years (8).
results in relief of pain and preserva- cartilage degeneration. The patient
In the involved joints, osteoar- tion of or increase in mobility (5). reported injuring the right leg while
thritis can result in decreased The patient described in this case at an aerobic class 3 months prior to
strength of the periarticular muscles report appeared to have a successful attending physical therapy. She was
(lo), decreased flexibility, and de- outcome following physical therapy. unable to recall any specific mecha-
creased aerobic capacity (2), which A year later, the patient had an unce- nism of injury. The patient attempted
leads to decreased mobility and de-
J Orthop Sports Phys Ther 1997.26:35-38.

mented total hip arthroplasty. This to continue aerobic exercise classes

creased activities of daily living (15).
Goals of physical therapy manage-
ment of patients with osteoarthritis
include control of pain, prevention
of strain or further damage to the
affected joints, improved range of
motion and muscle strength, and
maintenance of or improvement in
functional independence (14). This
is achieved by the use of stretching
and flexibility exercises, strengthen-
ing exercises, aerobic conditioning,
and education on joint protection.
When conservative treatment of
the patient with osteoarthritis is not
successful, then total hip arthroplasty
is the standard surgical intervention
for selected patients with advanced
degenerative arthritis. Total hip ar-
was due to occasional hip pain and
also to the change in the patient's
gait pattern which was unacceptable
to this relatively young patient with
an active lifestyle. This poses two
questions: I) Was the outcome of
physical therapy successful? and
2) What is the role of the physical
therapist in the treatment of patients
with osteoarthritis prior to total hip
arthroplasty?
History
The patient was a 51-year-old
woman employed as an administrator
who presented with a diagnosis of
early osteoarthritis in the right hip.
The operational definition of early
and running during the subsequent 2
months and the pain worsened. The
patient followed up with an orthopae-
dic consultation, X-rays were taken,
and a diagnosis of early osteoarthritis
was made. The patient was immedi-
ately referred to physical therapy.
The patient described the area of
pain as the right groin area, radiating
into the right anterior thigh. She also
complained of right posterior low
back pain. The pain was of a variable,
intermittent-type ache, aggravated by
walking and eased by rest in the su-
pine position. On waking, the patient
felt no pain. The pain was reduced
on rising compared with the pain
following prolonged weight bearing.
During the day, the patient's job in-

.
JOSFT Volume 26. Number 1 * July 1997
 CASE STUDY

volved standing, walking, and sitting.

As the day progressed, the patient's lliopvw 5 5
symptoms worsened. The patient re- Gluteus maximus 4 5
ported sleeping well. There were no Gluteus rnedius 4 5
complaints of paraesthesias or anaes- Adductors 5 5
thesias. The patient denied any neu- Internal rotators 5 5
External rotators 5 5
rological symptoms related to cauda
equina or spinal cord involvement. TABLE 2. Muscle strength grading.
The patient was in good health, ex- AROM = Active range of molion.
cept for occasional neck and sacro- PROM = Passive range of motion.
iliac problems. She reported occa- TABLE 1. Measured AROM and PROM of hips
hip extension secondary to ilial
sionally seeing a chiropractor for the (in degrees). and/or lumbar compensation.
neck and sacro-iliac problems. Length tests of sartorius or individual
hamstring muscles were not per-
and Stoddard (11). Using this grad- formed but could have provided use-
Evaluation
ing system, the accessory motions of ful information.
On observation, the patient the hip were graded as having consid- On evaluation of the patient's
walked with a pronounced antalgic erable restriction to motion or hypo- gait, she appeared to have a shorter
gait. Structural inspection revealed mobility. The lumbar spine and stride length on the right and de-
decreased weight bearing through knees appeared normal. creased heel strike in an attempt to
the right leg with a slight shift in the On examination of the sacroiliac avoid weight bearing. There was an
lumbar spine toward the left. There joints, there appeared to be less m e increased lumbar lordosis during
appeared to be a flattening of the tion of the right posterior superior midstance and push-off. The patient
right gluteal musculature. On palpa- iliac spine compared with the left. ambulated with a cane.
tion of the pelvic levels in standing, This was significant compared with
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the right posterior inferior iliac spine forward bending and marching tests.
Change in the patient's
gait pattern was
unacceptable.
J Orthop Sports Phys Ther 1997.26:35-38.
Provocation tests of the sacroiliac
joints include iliac compression and
distraction. The importance of these
tests is their usefulness in excluding
joint irritability, hypermobility, and
serious disease (6). There was no re-
production of pain with these tests.
The supine-to-long-sit test was per-
formed for ilial mobility or position.
Treatment
The patient was seen three times
per week over the 7-week course of
treatment. To increase range of mo-
tion, treatment initially consisted of
hip mobilizations, stretches, hold re-
lax, and range of motion exercises.
Hip mobilizations (distraction and
anterior and lateral stretches) were

was lower than the left. The right There appeared to be a 3cm short- performed at grade IV with pro-
anterior superior iliac spine was ening of the right leg length in su- longed hold. The grading scale used
higher than the left and the pelvis pine. When the patient assumed the for treatment movements is that de-
appeared to be in a right posterior long leg sitting position with knees scribed by Maitland (9). Stretches of
ilial rotation. The levels of the extended, the leg length appeared to the iliopsoas, hamstring, quadriceps,
greater trochanters, gluteal folds, and be 1.5 cm long, indicating posterior and piriformis were performed. The
posterior knee creases appeared sym- ilial rotation. range of motion exercises consisted
metrical. Pelvic levels were retested in Manual muscle testing was per- of hip flexion, abduction, and exten-
sitting to remove the possibility of formed on the pelvic, hip, and knee sion. Hold relax for iliopsoas was in-
asymmetry secondary to leg length musculature. The test positions and cluded to increase hip flexibility and
discrepancy, and the asymmetries grading scale for the muscles tested improve hip extension. The patient
persisted. Active and passive ranges are described by Kendall et al (7). started initially using a stationary
of motion are shown in Table 1. On Results are shown in Table 2. shortcrank bike to warm up and,
passive range of motion, there was an On muscle length testing, there over the first 2 weeks of treatment,
abnormal capsular end-feel limiting was tightness in the right iliopsoas, progressed to using a standard sta-
all ranges of motion. Accessory mo- iliotibial band, and hamstring mus- tionary bike. The seat height was low-
tions of the hip were graded accord- cles. Extension of the right hip was ered to accommodate for the de-
ing to the Paris grading system for measured as 5" prior to treatment. creased range of hip extension and
passive motion. This system is based The normal range of hip extension is then raised as the patient progressed.
on the grading systems of Kaltenborn 30" (1). The patient achieved 5" of The patient began pedaling on the

Volume 26 Number 1 July 1997 JOSPT


/\R0,%1 = t\c t ~ rmge
w oinwfion n ~ r , w r din dtyrcrs.
TABLE 3. Chronological change in AROM during
phvsical therapy program.
bike for 5 minutes and progressed to
30 minutes on her stationary bike at
home.
To increase strength, the patient
began active exercises of the hip (hip
flexion, abduction, extension) and
progressed to resisted exercises with
a 31b weight. Functional exercises
were added, including sitting-to-
standing, weight-bearing exercises,
for example, contralateral hip exten-
sion and abduction, and gait reedu-
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cation. The patient was instructed in
a home exercise program, which was
the exercises previously described.
The patient was instructed in am-
bulation with a cane at the beginning
of treatment and had progressed to
ambulating without an assistive device
by week 3.
RESULTS
J Orthop Sports Phys Ther 1997.26:35-38.
The patient's chief complaint was
pain. Subjectively, the patient re-
ported a gradual decrease in pain
intensity over the first 5 weeks. By
week 6, the patient reported no groin
or thigh pain, with only minimal pain
in the posterior superior iliac spine
area. In the management of a patient
with a painful arthritic hip, this a p
peared to be an important outcome
measure. Another factor affecting the
patient's function was limited range
of motion. This was measured twice
weekly using a goniometer. The
change in range of motion over the
course of treatment is shown in Table
3. Muscle strength is another factor
which was addressed. This improved
in all of the periarticular hip but did
JOSPT = Volume 26 = Number 1 .Julv 1997
not achieve normal grade muscle joint(s) in functional activities. It has
strength as described by Kendall et al been shown that aerobic weight-bear-
(7). This could be due to not achiev- ing exercises are not detrimental to
ing full hip range of motion com- the patient with osteoarthritis of the
pared with the opposite side. There hip and help to improve the aerobic
was also a change in the accessory capacity (10). Stretching and range
range of motion of the hip (distrac- of motion exercises are frequently
tion and anterior stretch) which im- recommended for patients with o s
proved from considerably restricted teoarthritis, but there are no studies
(Grade 1) to slightly restricted to support this intervention (12).
(Grade 2) as measured by the Paris There are a number of therapeutic
scale as previously mentioned (11). techniques aimed at increasing tissue
The accessory motion of lateral length including joint mobilization,
stretch improved slightly but contin- stretches, and proprioceptive n e u r e
ued to be considerably restricted. muscular facilitation (13). With this
The patient did appear to have a patient, prolonged hip joint stretch-
secondary pelvic dysfunction of poste- es, joint mobilizations, and proprie
riorly rotated innominate. The treat- ceptive neuromuscular facilitation
ment of this pelvic dysfunction was to were all applied with the aim of in-
treat the loss of hip range of motion creasing the range of motion of the
and flexibility. hip. This patient had an abnormal
Overall, the patient's status capsular end-feel of the hip which
changed from ambulating with signif- Cyriax described as suggestive of non-
icant right groin pain with a cane to acute arthritis (4). End-feel is the
being able to ambulate pain free sensation imparted to the examiner's
without an assistive device. On initial hand at the extreme of the possible
evaluation, the patient ambulated by passive range of motion of the joint
increasing the weight through the (4). There did not appear to be any
left lower extremity because it was change in the end-feel of the pa-
too painful to weight bear through tient's hip joint.
the right hip. She had a poor heel By using prolonged stretching,
strike and toe-off and increased lum- joint mobilizations, proprioceptive
bar lordosis from midstance to toe- neuromuscular facilitation, strength-
off. At the end of the physical ther- ening, and aerobic exercises, this pa-
apy program, the patient had no pain tient had a significant decrease in
on walking. However, the gait pattern pain, an increase in range of motion
had not returned to normal. She of the hip, increased strength of the
continued to walk with a decreased periarticular hip musculature, im-
heel strike and increased lumbar lor- proved mobility, and functional abili-
dosis. The speed of walking and agil- ties. The patient was seen three times
ity continued to be less than her pre- per week, which did appear to be the
exacerbation normal. optimum frequency for treatment.
Again, a pain scale was not used
DISCUSSION with this patient but would have p r e
vided documentation of a measurable
The use of strengthening exer- outcome.
cises for patient5 with osteoarthritis is This patient had an uncemented
well documented (2,8,10,12). These total hip arthroplasty 1 year following
patients have Type I1 fiber atrophy in the completion of her physical ther-
muscles supporting the joints ( 12). apy program. During that period, she
Strengthening exercises are used to had continued on a home exercise
gain increased muscle strength in program. The patient reported that
order to provide better shock-absorb the main reason for her choice to
ing capabilities to the joints and have surgery was her inability to walk
maintain and improve the use of the long distances comfortably. The walk-
 CASE STUDY
ing efficiency of patients with osteoar-
thritis of the hip is less than normal
and this improves following total hip
arthroplasty (3). This patient was very
satisfied with the outcome of her sur-
gery and felt she could now walk
much better.
Perhaps the role of the
physical therapist is
to help extend the
t h e before total
hip arthroplasty.
To answer the question posed in
the introduction, this patient did
have a successful outcome following
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physical therapy. The role of physical
therapists in the treatment of patients
with a diagnosis of osteoarthritis of
the hip is to assist in achieving the
highest functional outcome possible,
irrespective of whether they will even-
tually have a total hip arthroplasty.
The outcome of this patient indicates
that physical therapy was successful,
as the patient achieved decreased
pain, increased range of hip motion,
J Orthop Sports Phys Ther 1997.26:35-38.
increased strength, and return-to-
normal activities of daily living.
Particularly with this group of
patients, there are two salient points
to remember: I) the long term re-
sults of uncemented total hip arthro-
plasty in young patients (< 60 years)
remain unknown, and 2) patients in
their 40s and 50s undergoing total
hip arthroplasty present with the
problem of possible mechanical fail-
ure and the need for reoperation in
subsequent years (5). Perhaps the
role of the physical therapist is to
help extend the time before total hip
arthroplasty and assist the patient in
maintaining his/her optimum func-
tional level. In this way, if the patient
does require a total hip arthroplasty,
he/she will be starting the process at
their highest achievable functional
level.
SUMMARY AND CONCLUSIONS
The management of a patient
with limited hip motion due to osteo-
arthritis has been described. Despite
significant functional improvements,
the patient went on to have a right
total hip arthroplasty the following
year. It is concluded that the patient
did have a successful outcome in
physical therapy. Further studies into
the roles of joint mobilization,
stretching, and proprioceptive neuro-
muscular facilitation to increase hip
range of motion are necessary as
these treatment techniques are com-
monly used in the clinic. JOSPT
ACKNOWLEDGMENTS
I would like to express my sin-
cere appreciation to Catherine E.
Patla, MMSc, PT, for her critique and
encouragement.
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Volume 26 Number 1 July 1997 JOSVT