THR, Trochanteric bursitis and abduction ex's!

[morwenna]

Hi,

I'm working in a Hip and Knee Replacement clinic in Canada now, and we are`looking at revamping our patient education leaflets.

We do many Birmingham Hip resurfacing surgeries, and the guy who's worked out the post-op exercises for these has dropped resisted abduction as he feels it is accounting for a number of our patients developing trochanteric bursistis.

We've taken out abduction in lying from the early stage THR exercises, and I'm trying to research to see if we need take out side-lying hip abduction, and theraband-resisted abduction in standing which have been introduced at the 6 week mark.

What are people's feelings on this? Has anyone found any research that shows a correlation between hip abd ex's and troch bursitis?

Can we localise Glut med with the hip flexed and thus cause less trauma to the bursa that way? We also have seated hip abd/ext rotation vs theraband, and the clam-shell exercise .... think these are OK?

Better go, patients waiting, but any feedback would be welcome.

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[brizza]

maybe it is the flex/abd exes that are causing the problem,we do a lot of graded abd exes in neutral and none in flexion,and we have been plain sailing for years-no trochanteric bursitis,we also ignore trying to isolate a muscle and just blast the abductors as a group-briz

[sharileedahl]

I agree with Briz from the last post. Haven't seen a lot of issues with trochanteric bursitis after THR (admittedly have seen few Birmingham hips). Have seen more issues with trochanteric bursitis when the abductors are weak rather than the type of exercises that are done to strengthen them. Another note re. strenthening, I usually try to get them doing exercises in weight bearing asap as more functional than sidelying / crook lying. (examples: 1/4 squat with attention to maintaining alignment (i.e. no adduction at knees) and even with theraband around the knees so that they maintain some increased tone in the abductors; once the are able, small step ups and downs (increasing height as able) again ensuring they maintain the alignment from hip to knee to foot)...)

[alophysio]

i agree with sharileedahl above.

I think i read some research somewhere that said that hip ABD is primarily TFL and the glut med is only involved very briefly in initiation etc.

Never seen troc bursitits either in my patients but don't see loads of 'em. Functional exercises and keeping the hip centred in the socket is what i aim for (observed by watching knee control as outlined above).

[morwenna]

Thanks for your input guys.

I'm really not sure there's any problem at all with the exercises we've been doing. Everybody in the world as far as I can see has abd in standing and in lying as routine post-op exercises. It's just that this guy who seems to have the ear of the doctors and authorities in this establishment is insisting that it is his experience!

I do see up to 40-50 patients a day here, and we encounter lateral hip pain fairly regularly ..... I think I'm going to keep my own data on this, and then maybe I can come up with a counter-argument.

[alophysio]

Hi,

Perhaps you can propose a little "study" to see what works for ABD - use the "protocol" exercises and compare to weightbearing functional exercise and see if outcome measures are changed. Shouldn't be hard if you see that many patients a day! Which BTW is a lot of hips and knees!

The other question i had was...What period of time are you seeing the lateral hip pain and how long is it lasting. Perhaps immediately post-op, the swelling causes some muscle dysfunction which results in temporary lateral hip pain?

[morwenna]

Hi,

Perhaps you can propose a little "study" to see what works for ABD - use the "protocol" exercises and compare to weightbearing functional exercise and see if outcome measures are changed. Shouldn't be hard if you see that many patients a day! Which BTW is a lot of hips and knees!

The other question i had was...What period of time are you seeing the lateral hip pain and how long is it lasting. Perhaps immediately post-op, the swelling causes some muscle dysfunction which results in temporary lateral hip pain?

Sorry about the delay in replying ... I did try once, but was having internet problems at the time!

I do indeed "see" vast numbers of arthroplasties on a weekly basis .... but I am growing frustrated with the fact that I am not allowed to "treat" them myself, but can send a referral to a PT clinic for them to have treatment. I am normally allowed to offer advice when I see them, but have to send them to others for ongoing work to be done!

I did decide to document patients with lat hip pain ... as soon as I decided that they seem to have dried up!!
but they did previously seem to be coming in at the 12 wk mark rather than earlier.



It suggests that it starts after the strengthening exercises (that we start them on at 6 wks), but does not yet prove any causality. Normally after 6 weeks we are advising them to start to discard the cane indoors, if they haven't already, and start to make the hip support muscles work when walking. Most will still need a cane outdoors at this time.

To resurrect the argument about FWB after non-cemented hips ...... all our surgeons now allow their patients to routinely WBAT from immediately post-op now, as research has shown there to be no long-term differences in function, but longer rehab in patients kept protected WB for 6 weeks.

This I gather is fairly recent in Canada (/North America?), though I was FWB with uncemented hips before I came here from the UK, so was surprised to find PT's still observing the protected WB thing here when I arrived in 2005!

[alophysio]

HI, why can't you treat yourself?? Surely you can start the treatment and then refer to somewhere closer to their home?

Thanks for the reply though.

Interesting subject. The hips we see are WBAT.

[morwenna]

HI, why can't you treat yourself?? Surely you can start the treatment and then refer to somewhere closer to their home?

Thanks for the reply though.

Interesting subject. The hips we see are WBAT.

I am not permitted to treat because there is a physiotherapy clinic in the same building and it's part of the contract that we have for this premises that we do not offer any physiotherapy as we may be seen to be in competition with them downstairs!

It's complete nonsense of course, and I do give one-off chats to the guys when they attend for their orthopedic follow-ups, but I have to be careful not to be seen as offering a competitive service or they feel threatened!