Introduction
Patients undergoing a total hip replacement will usually be expecting to have a significant reduction in the pain associated with their underlying hip problem as well as an improvement in what they can do with their hip. This is a very reasonable expectation, but in order get the most out of a total hip replacement, it is important to follow an exercise rehabilitation program. This will ensure the the muscles of the hip recover their strength and maintain a stable joint.
Usually you will be seen following the operation by a physiotherapist who will help you with the initial exercises and then guide you through to the time when you are ready to leave the hospital. You will be sent home with an exercise program and will be expected to attend clinics and further physiotherapy appointments in order to continue to progress through your rehabilitation program. The following information should be used as a general guide as to what type of exercises to expect however the individual program prescribed by your physiotherapist should always be adhered to.
Preparation for the operation
You may have your hip assessed before the operation by a doctor or physiotherapist. They will assess strength, flexibility, the nerves in the leg, fitness levels and level of function. At this time you will also be notified of the precautions that need to be taken once the surgery has been performed. These include:
- avoid bending the hip past 90 degrees
- avoid moving the leg inwards past the midline
- avoid turning the leg inwards (internal rotation) past the point at which the foot
- faces upwards
- avoid lying on the side that has been operated on
- avoid pillows under the knee for a prolonged period of time
- a pillow will be placed between the lower legs in order to keep the legs apart. this
- is called an abduction pillow
Phase 1: Days 1-7
The rehabilitation program starts from day one of the operation. It is important that once the operation is performed, you avoid doing any of the things listed above. The goals of phase on of rehabilitation are:
- To safely move from the bed to the toilet or chair
- To walk with the assistance of an aid, such as crutches or a frame
- Adhere to the precautions listed above concerning movements of the hip
- Perform regular exercises to strengthen the hip area and to increase movement of the hip joint
On day one, you will be wearing pressure stockings to prevent clots forming in the legs. The physiotherapist may help you to cough and encourage deep breathing to protect against any chest infections. An exercise program may be started on day one. The exercises that will given within the first few days include:
- Ankle pumps: Slowly moving the foot up and down. This can be performed regularly in the first few days, as often as every 15 minutes. This exercise will help prevent clots forming in the legs.
- Buttock exercises: This exercise involves tightening the buttocks and holding for a count of 5, then repeating this 10 times. No movement will occur at the hip. This is known as an isometric contraction as the muscle length remains constant throughout the contraction. This can be performed 3-4 times per day.
- Quadriceps exercises: The quadriceps are the muscles on the front of the thigh. When you contract these muscles the knee will straighten. Contract the thigh muscles and hold for a count of 5. Repeat 10 times. This can be performed 3-4 times per day.
- Knee bends whilst lying on your back: Slide your heel towards your buttock allowing the knee to bend. Do not bend past 90 degrees. Make sure the knee doesn’t fall inwards or away from the body. Move slowly. Repeat 10 times. This can be performed 3-4 times per day.
Getting moving
Your physiotherapist will help you with getting into and out of bed, sitting in a chair and walking. It is important to try to get moving early as this will improve the speed of recovery. Once you are able to get out of bed and sit in a chair, the physiotherapist will help you to begin walking. Initially you may need the help of a walking frame but within the first week you may be able to walk with the assistance of a walking stick or crutches.
Usually, patients are able to go home within 4-5 days of having had the operation. You will be sent home with an exercise program and receive an appointment for a physiotherapist follow up.
Phase 2: Week 2-8
The second phase of rehabilitation focuses on ensuring the wound is healing and the pain is manageable, improving walking and flexibility, improving strength and functional activities. This phase will include exercises that continue to strengthen the muscles surrounding the hip as well as improve the range of motion of the hip.
Strengthening exercises
These will vary depending on how the hip is recovering. Always follow the advice of your physiotherapist. The following are some examples of hip strengthening exercises appropriate for phase 2:
- Side lying clam shell: Lying on the unaffected side with knees slightly bent and a pillow in between the knees. Keep feet together and lift the top knee as far as is comfortable. Hold for a count of 3 and repeat 10 times.
- Heel raises: Holding onto the back of a chair whilst standing, go up onto your toes and hold for a count of 3. Repeat 10 times
- Standing knee raises: Holding onto the back of a chair, lift your operated leg toward your chest. Do not lift your knee higher than your waist. Hold for a count of 3 and put your leg down. Repeat 10 times.
- Standing hip abductions (lifting leg to side): Hold onto the back of a chair. Be sure your hip, knee and foot are pointing straight forward. With your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on the floor. Don’t try to hold the leg out to the side. Repeat 10 times.
- Standing hip extension (moving hip back): Hold onto a chair. Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts. Return your foot to the floor. Repeat 10 times
All these exercises can be performed twice daily
Exercise bike: The exercise bike is a good way to improve hip strength and flexibility.
Make sure the bike is set up correctly such that when the peddle is at the lowest point, the knee is almost straight. Start with peddling backwards until this is comfortable, then normal peddling can be commenced. 10-15 mins of cycling can be performed daily.
Functional exercises
Walking: A walking stick or a crutch may be used for several more weeks until your full strength and balance skills have returned. Use the walking stick or crutch in the hand opposite the operated hip. Your physiotherapist will help you with the transition from a frame, to walking stick and eventually walking unaided. It may be necessary to perform balance exercises such as standing on one leg or using a wobble board.
Stairs: At first, you will need a handrail for support and you will only be able to go one step at a time. Always lead up the stairs with your good leg and down the stairs with your operated leg. Remember “up with the good” and “down with the bad.” Or “good leg to heaven, bad leg to hell”. You may need to have someone help you until you have regained most of your strength and mobility. Stair climbing is an excellent strengthening and endurance activity. Do not try to climb steps higher than those of the standard height of seven inches and always use the handrail for balance.
Hydrotherapy: The physiotherapist you are seeing may arrange for you to have some hydrotherapy sessions. This involves walking and performing simple hip exercises in the water. Being in the water allows you to move your hip without the full weight of your body and as such it is a good bridging step to performing similar exercises out of the water.
Phase 3: Weeks 8 – 14
At this stage people often feel they have recovered well from the operation. Usually the hip will be moving freely but may not be strong enough. For this reason it is important to continue with exercises that improve strength as well as working on maintaining and improving flexibility. At this stage some of the precautions listed prior to phase 1 are able to be lifted. The following exercises are appropriate for phase 3 of rehabilitation:
Strengthening exercise
Theraband/ elastic band resistance training: The use of a therapeutic elastic band such as therabands is helpful in improving hip strength. The elastic band is looped around the ankle and then attached to a stable object such as a table leg. The hip can be moved forwards, back wards and to the side against the resistance of the theraband. The movement is held for a count of 3 and repeated 10 times
Step ups: Using a stable block of approximately 4 – 8 inches, step ups can be performed. You will need to start with a lower block and build up to a higher block. Step ups can be repeated 20 times.
Cardiovascular exercises
The exercise bike can be continued throughout phase 3 of rehabilitation and treadmill may be added at this time.
Balance exercises
It is important to ensure that your balance returns to normal to avoid the risk of falls. Exercises such as standing on one leg whilst holding the back of a chair are a good first start. This can be progressed to standing freely on one leg and then with eyes closed. The final stage is to use an uneven surface such as a foam roll or rocker board but this should not be attempted unsupervised.
Activity specific training
Once your physiotherapist or surgeon has assessed your hip and found it to be strong and flexible, it may be possible to return to certain low impact sports. It is important to start slow and give your body plenty of time to recover in between attempts. Patients often find they are able to return to golf, doubles tennis or ballroom dancing following a hip replacement but high impact sports such as singles tennis, running, squash and football are not recommended.