How do you support a client’s hip replacement?
Two years ago, my partner Jeff's active lifestyle came to a halt when he started to notice increasing pain and limited mobility in his right hip, which we found out stemmed from a genetic joint abnormality known as hip dysplasia. Despite efforts in Pilates and yoga, his condition worsened, prompting an x-ray that revealed severe joint damage. His right hip joint was basically bone on bone and the left hip didn’t look much better. Jeff ended up opting for both surgeries to minimise downtime, even though they had to be done a month apart, and then required a journey of comprehensive rehabilitation.
With over 25 years of physiotherapy experience, I understood the importance of discerning the specific type of hip replacement surgery. The three types of hip replacement surgeries are named by the way the surgeon accesses the joint: posterior, lateral, and anterior approach. The anterior approach, a muscle-sparing technique, boasts quicker healing, while the others usually involve cutting through muscles, posing a higher risk of dislocation. Understanding the uniqueness of each patient's case, including the surgeon's techniques, implant materials, and individual health factors, underscores the need for personalized rehabilitation strategies. It’s important to understand because the rehabilitation protocols and time frames can be very different based on the type of surgery performed.
Factors like age, fitness, and overall health also play pivotal roles. This underscores the importance of collaboration between physiotherapists and surgeons to ensure precise guidance through the nuanced landscape of hip replacement rehabilitation.
Jeff ended up having an anterior replacement with a robotic arm assist, which is one of the newest, most technologically advanced and minimally invasive procedures. The robotic arm takes a CT scan of the diseased joint, uploads it into the computer software, and creates a 3D model of the hip. The surgeon guides the robotic-arm within the pre-defined area and the technology helps the surgeon stay within the planned boundaries that were defined when the personalized pre-operative plan was created. This helps to provide more accurate placement and alignment of the implant, and makes the surgery less invasive than other types of joint replacement surgeries. Thus, healing and recovery is faster.
A few years ago, I worked with another young (53 y/o) patient who also had an anterior hip replacement, but without robot assist technology. He is a competitive endurance triathlete and coach, so his goals were to get back to long distance swimming, biking, and running. We also used Pilates for his rehabilitation, and he did great! When I spoke with him last year, he had just finished a 61 hour, 400 mile bike packing race that involved biking, hiking, pushing, and lifting the bike. He said it was the hardest thing he had ever done (and he has done multiple Ironman races), but his hip was perfect!
Most of the other hip replacement patients I have worked with over the years have been older (70s, 80s, and 90s) and were not necessarily athletes. Some of these patients had the anterior approach, for others it was posterior and Pilates for rehabilitation worked well for them all.
Jeff’s treatment post op
To be honest, the first two weeks after each surgery were a bit rough. Jeff had quite a bit of pain and swelling, it was difficult to sleep, and he was weak and nauseous from the anesthesia. All of this is normal after a major surgery. However, the good news is, he was able to walk day one. Weight bearing stimulates in-growth of the bone into the prosthetic cup, so walking is actually encouraged. He had to ice 4-6 times per day to help control the swelling and he started outpatient physio two weeks post-op . He did Pilates on his first day at the clinic.
His goals in studio
In the Pilates studio, the initial goals were restoring his range of motion and gentle strengthening. Due to underuse prior to and after surgery, it is typical for the leg muscles to be very weak. With hip arthritis, the weakest muscles tend to be the hip flexors, hip extensors, external rotators, abductors and adductors, so these are the muscles we focused on. As the weeks progressed, we gradually added in more closed chain (weight-bearing) unilateral exercises to focus on hip stability, balance, and proprioception. And at around week eight, we added in sport-specific type activities and the jump board. Of course, he was doing a lot of core exercises throughout.
With the procedure that Jeff had, patients are able to move the hip in any way that feels comfortable. There are no restrictions on how to move, or hip precautions. However, the first three months post-op, all activity with a potential for a hard impact at high speed, for example- skiing, horseback riding, running, outdoor biking, surfing- must be avoided. At three months post-op the bone is fully bonded and patients are allowed to return to all activities. At three months post-op, Jeff returned to beach volleyball. At four and a half months post-op he returned to surfing.
Suitable exercises for hip rehabilitation
In my opinion, there are many exercises in the Pilates repertoire that are well suited for hip rehabilitation. First, core strength and control is integrated into all Pilates exercises. Second, some Pilates exercises focus on stability (Footwork), others focus on mobility (Hip Work Series- legs in straps) and others provide a perfect combination of both (Scooter). And third, Pilates exercises work the muscles concentrically, eccentrically, and isometrically. This makes them more functional, meaning they more closely simulate everyday activities such as squatting, walking, or stair climbing.
Footwork on the Reformer: great as a warm-up as it uses the larger muscle groups and is attainable for almost everyone. It is a great place to teach clients to focus on both concentric and eccentric contractions as the legs straighten and bend. It reinforces natural upright alignment of the body, but in a zero-gravity position; thus, it strengthens the leg muscles without placing a lot of stress on the joints or putting the client at risk of falling. This makes it an excellent exercise for very early after hip or knee surgery. Some of the objectives that can be achieved in Footwork are: hip extensor strength, knee extensor strength, co-contraction of the core muscles, lumbo-pelvic stability, hip adductor strength and control, and increased range of motion of the hip joints (open V positions).
Hip Work Series (legs in straps) on the Reformer or Cadillac: wonderful for increasing mobility of the hips, while demanding stability of the lumbo-pelvic region. Smooth continuous movement of the hip joint is executed while stability of the pelvis is maintained (hip dissociation). The primary muscles worked are the hip extensors, adductors, and abductors. The basic series is a wonderful place to start, and there are lots of progressions and variations. Up and Down Circles in particular are fabulous exercises to not only improve hip joint range of motion, but also to increase adductor strength and control as they are forced to work isometrically, concentrically, and eccentrically.
Scooter: one of my favorite exercises, because it is so functional and so versatile. It is a full body exercise, which develops core and scapular stabilization, hip dissociation, strength of the hip and knee extensors, as well as balance and proprioception. On the standing leg we challenge hip stability, balance, and proprioception; and on the moving leg we get hip mobility and hip extensor strength. When working with hip rehab clients, I like to modify it a bit by moving the foot of the standing leg forward (toward the footbar) so that the focus becomes more on hip extensor strength and mobility, rather than on abdominal strength.
Many of the exercises that we did for Jeff’s rehab were progressions of these three basic exercises.
Is it ever too late to start these exercises?
It’s never too late to use these exercises with patients or clients. Sometimes I’ve used them for the purpose of rehabilitating a hip or knee injury, to help an athlete enhance their performance, or to help prevent injuries from occurring.
Most days, I did the exercises with Jeff, and my hips got so much stronger and more mobile! I also noticed that certain aspects of surfing and yoga were easier for me after 3 months of doing these exercises. It’s important to understand that these exercises can be quite challenging even for people who have not had hip surgery.
The Pilates exercises we did promote hip strength and stability, core strength and stability, hip mobility, and balance. Who doesn’t need these things?
When working with clients who had a posterior or lateral approach, it’s important you are familiar with the specific precautions for this type of surgery and choose or modify exercises accordingly, as there is a risk of dislocation.
Contraindicated positions after a posterior or lateral approach are hip flexion past 90 degrees, adduction past midline, and hip internal rotation. Some examples of contraindicated Pilates exercises for a client who had this type of hip replacement would be Mermaid, Single Leg Hip Circles on the mat, Footwork on the chair, Sidelying Hip Series on CAD: Leg Changes.
It's also important to understand that unexpected issues can arise. A few weeks after Jeff’s first surgery, he developed sciatica type pain in his low back, right buttock and down his right leg. This was relieved with piriformis stretching and correcting his gait pattern so that he was not favouring the right side. Also, it can be difficult to get a good night’s sleep the first few weeks because there is pain when lying on the surgical site.
I think Jeff’s expectation was that once he hit the three month mark and could return to volleyball and surfing, he would bounce right back as if nothing happened. Unfortunately, in my experience, this is not ever the case. Even with a strong, motivated client who diligently does all of their rehab exercises- it takes time for the body to get back to “normal”. This was a bit frustrating for Jeff. He is now six months post-op and getting better every week, but still does not feel 100%. Certain things are still difficult for him, specifically, jumping and quickly changing direction in volleyball, and popping up on a surfboard (due to the hip mobility and hip flexor drive required).
So how do you coach clients through hip rehab?
My advice is to find out what is important to the client, and focus on that goal. Make every session a step toward that goal. For someone who is very active, it is frustrating and depressing to not be able to do what they love.
I think it is important for people to understand why they are doing something, so I always explain what is being achieved by doing each exercise. I also recommend incorporating the client’s hobby or sport into the sessions whenever possible. Once Jeff got comfortable with the Footwork series on the Reformer, I challenged his core strength, focus, and coordination by tossing him a volleyball. We also added the ball toss variation to his Jumping Series. This made the sessions more fun and allowed him to see and feel that his goals were in sight.
As Pilates professionals, I believe the safety and versatility of Pilates allows us to take patients from the early stages of rehabilitation to the long-term goal of a conditioned, efficiently functioning body and that’s pretty incredible.
Learn from Sam in the below videos
You can watch videos of Samantha demonstrating the sorts of exercises she utilises as part of her hip rehab work below…
Footwork - Ball Toss
Jumpboard - Ball Toss
Quadruped Hip Extension
Reformer Kneeling Arms
Reformer Hip work
Standing Hamstring Curl
Reformer Elevator Lunge
Samantha Wood, MPT, MBA, NPCT, RYT, is a licensed physical therapist, a National Pilates Certified Teacher (NPCT), a Yoga Alliance–certified teacher, and an associate faculty member for BASI Pilates. She created and teaches two advanced education courses for BASI Pilates: Pilates for Injuries and Pathologies (for Pilates teachers) and Pilates: Integration Into Therapeutic Practice (for rehabilitation professionals). She is the author of Pilates for Rehabilitation.
Bali Retreat:
You can join Sam in Bali, April 27th-May 4th, for a Pilates & Yoga Retreat at Soulshine- a barefoot luxury resort dedicated to gathering people to share in the joy of wellness, movement, music, incredible food, and good vibes. Sam will be teaching daily mat Pilates classes, and local legend Byron De Marsé will be teaching daily yoga classes. Jungle adventures, swimming or lounging at one of the beautiful pools, amazing healthy food, body treatments at the on-site spa, a fire ceremony, a cultural dinner, sacred temples tour, and a Balinese cooking class are just a few of the highlights of what this retreat has in store for you. Open to all fitness and experience levels. Think of this retreat as a fun way to move your body and supercharge your soul! Find out more here.