Safe and Unsafe Activities and Sports Clay: What are some sports that you would discourage [after hip replacement surgery]? I know there is a huge range of results and people who are dealing with certain physical issues. But are there any sports you’ve seen as a physical therapist that you say “Do not do this after hip replacement surgery?”

Amy: Oh absolutely and just to clarify my youngest total hip replacement patient was eleven. This child had a very aggressive cancerous tumor that invaded her hip, and so she had what is called a Ewing sarcoma. And so, they ended up having to take the hip give her a new hip, and her big goal was she wanted to be able to drive a car. I mean that is really important. So, she was eleven when the process started and she did not drive a car. So, and I have treated, I actually had a ninety five year old who had, so the spectrum of age is even greater than thirty five to eighty two.

Clay: Sure.

Amy: But there are absolutely some things that are just absolute no’s. And most of them are things that make sense, like contact sports. So things like football, rugby, soccer. There was a great little study that came out, I think it was in 2011. Anyway, it basically looked at all of these different sports and it reviewed all of the literature and it was looking at what are the things that we know are absolute no-no’s.

Amy: And we know this because the literature shows us that these people had high rates of failure in their hips. Oh and by the way, this recommendation basically it was a systematic review and when they made these recommendations, they qualify them into three categories. So, the first category was not recommended after a total hip and so the contact sports hockey, football, soccer, rugby, any long distance running. And that just make sense.

Amy: A lot of people take a toll on their hips by doing a lot of running, and that does not mean that running causes hip arthritic changes that create a total hip that necessitated total hip replacements. Do not misunderstand that, but there is a wear and tear process that goes on with people that are running hundreds of miles a month. So, singles tennis, it gets down to just the numbers of steps that go through that new part; racquetball, squash, snowboarding, and that is because of the risk of dislocation for snowboarding.

Amy: High impact aerobics, fast pitch baseball and softball, because of sliding and contact. The kicking that is involved in many of the martial arts is not recommended. Water skiing and handball. So those are the things that under the category of not recommended. And I will tell people flat-out “Listen, you had a bad hip, you have gone through this process to get a good hip. Be nice to it, protect it.” I understand that you are putting yourself at great risk of early failure or other complications, like dislocation and things like that that necessitate revision. So that is in the not recommended category, and then they created this other category that they call “recommended with experience.” And this actually, again, makes sense. Cross-country skiing and downhill skiing, that is not the time to start learning to ski after you have had a new joint. Now, if you have been a lifelong skier and you have the experience, by all means do it. Make a choices. Mogul fields are probably not a great idea.

Clay: Right.

Amy: If you can cross country ski downhill ski safely. Doubles tennis again, not the time to take up tennis if you have never played in your whole life and you finally have a new hip. Now is not the time to take that up. But if you have been an avid tennis player, so I would absolutely and I have a lot of patients that have gone back and my brother included in that category who has gone back onto the tennis court with a joint replacement.

Amy: Ice skating not hockey. But ice skating is okay if you have experience doing that, things like rollerblading same thing kind of inline skating and Pilates. So those are things that we recommend that are qualified as recommended with experience. I will also add now, this study came out, this recommendation, systematic review was published in 2011. Surfing goes into that category. So if you are a surfer, absolutely if you have experience on a board, you are absolutely prepared to get back on that board after a hip replacement. Not the time to start introducing that into your sport life.

Clay: See it makes sense that if you have got experience you can keep yourself from potential injury.

Amy: Precisely, and then the list of things that are highly recommended because again, you know when you are in the rehab world what you realize that people go through the surgeries for they do it purposefully and it is usually to return to some type of function or activity, that they are arthritic or their painful joint would not let them take part in, so golfing, swimming, doubles tennis, stair-climbing, so like the elliptical walking, speed walking hiking, stationary biking, bowling, these are all things that are highly recommended. We want you to go back to these things because they are going to be healthy for you. They are going to sustain the strength in the mobility that you have recovered at that new joint. But they are also going to be safe for it. They are not going to put your new joint at risk.

Clay: I see. Well that gets to the point that staying active is absolutely essential. That you do not want to pick up downhill skiing necessarily, but you absolutely after hip surgery want to be active in something. And so, it is good to get going.

Amy: I am a physical therapist. I think we all should move. We should move, that is what our bodies are designed to do. They are not designed to sit and be sedentary. They are designed to move us through space.

What It Feels Like When Artificial Hips Fail Clay: Well, that is right. So, I have known you for quite a while and I know you have had patients that have had hip replacement surgeries fail. Can you tell me what symptoms you notice when a patient might come in and say “I had surgery a year and a half ago or two and a half years ago and something feels different. Something sounds different”? Talk about artificial hip failure.

Amy: Sure. Absolutely, well probably, so there are different reasons that hips can fail. But the number one thing that people complain of is pain that is out of context to what they should be experiencing at that point during the rehab process or during the recovery process. So obviously, you have had a joint replacement. We expect it to be swollen. We expect it to hurt. We expect it to be sluggish. It is not going to move well.

Amy: So, there is an expectation of some pain following the surgery but there is a point where that pain should be resolving. And it should be integrating and it usually lives as the tissue is healing. So the bony tissue is healing, where the new hip implant, the new appliance, has been mated with the bony surfaces, so that healing takes place and then the soft tissue around that joint is healing and you are becoming more mobile. So, that pain should frankly just gradually decrease until it is gone.

Amy: When someone’s hip has failed, that does not happen. The other thing that is really interesting, or I think that is telling, is that typically these patients have pain even when they are not moving, and a significant amount of pain. Now again, initially immediately after the surgery, it is normal to have night pain that makes it tough to be comfortable. But after a couple of weeks after a hip replacement, you should be able to sleep for periods of time. Many times people have so much pain that they cannot sleep. Like, it keeps them awake.

Amy: Nocturnal pain is always something that worries me because at the end of the day, we are kind of hardwired to get rest but pain prohibits that. To me, that is, I am always going to look very carefully at this patient because that should be something that initially pain management should be taken care of, so medications, icing, making sure that your activity levels are appropriate for that stage of your recovery.

Amy: If all of those things are in line, and this person is still telling me, “I slept an hour.” I do not like that. Immediately that is a red flag to me that I need to take a really close look at what is going on with this patient. So, pain is out of context to what the pain level should be at that point. Pain that is occurring without moving. So, it is not mechanically driven pain.

Amy: Any type of mechanical clicking, grinding, and these are things that people will sometimes report, you know, it clicks, it grinds, it snaps. Some people have reported they can actually feel it move. So those are things that tell me that something organically is not healthy in that hip, in that newly replaced hip.

Clay: Let me follow up on that. Is it your medical view that a successful hip replacement surgery should end with no pain at all after the rehab is over, and after the recovery is over that there should be little to no pain?

Amy: Absolutely, and when that does not happen, if let us say, and I have seen this before, I have had people show up a year after hip replacement and they say, “You know my hip still bothers me.” And upon assessment, there might be a really good reason. You are profoundly weak, you did not build the strength around this joint to give it stability. So your pain is actually not in the actual hip itself, it is in the pelvis because of the forces that are going through hip joint that and the musculature of the strength is not adequate to control those forces.

Amy: So, sometimes there is a reason that someone has got pain a year later. But in the absence of something like that going on, no, you should not have pain. That is the whole reason that you have this new hip put in. So if you are continuing to have pain, I tell my joint replacement patients that it takes a year to recover from these big surgeries. But that is a pretty reasonable expectation from any orthopedic surgery, be it a rotator cuff repair, an ACL reconstruction, certainly a knee or a hip replacement, or a shoulder replacement. It is not uncommon to have some discomforts and stiffness and irritability up to a year, but after that, no, it should not happen. It should not be painful. So there is a very big difference between, “like I am still aware of it” versus “this thing I can not put weight through it. It hurts so much. I can not walk. I can not sleep. I can not ascend or descend stairs. I can not lift my leg to put it into a car.” These are things that I have seen in failed hips.

Clay: Yes.

Amy: Or even just give way where you weight bear on the leg, on that failed hip, and they will fall. That is a result of a failure.

Part 3 next week.

My friend Amy Dougherty is a physical therapist in North Carolina and operates Outer Banks Physical Therapy. She is a graduate of the University of North Carolina at Chapel Hill (where I also attended college and law school). She is an outstanding physical therapist and is beloved by her patients on the Outer Banks. Amy answers many of your questions about hip replacement surgery, metal-on-metal artificial hips, and the problems that have arisen from these hip products.

Clay: I want to focus on hip replacement surgery and I know you work with patients who are dealing with that kind of surgery every week. So let me start by asking what are a few reasons a person might need a hip replacement surgery?

Amy: You know, the most common reason is arthritic changes in the hip. So basically arthritis, that is the most common reason. Other reasons can include things like trauma. Some people have congenital mal-alignments where, it is basically called dysplasia where through the process of their development in utero and then following their bony surfaces of the femur, that is the long thigh bone and the acetabulum which is in the pelvis. They do not form correctly, so they might have ill-formed femoral heads. They might have ill-formed or ill-shaped acetabulum. So, the ball and the socket are not really designed well to weight bear. So, a lot of folks that, especially in a young population, that have early onset hip replacements. It is more likely the result of some type of congenital dysplasia. It could be a trauma. So, but arthritic changes is the number one reason and I have total hip replacement patients in my clinic every day. Very popular surgery, yes.

Clay: Very common especially once you get into the middle age and even older.

Amy: Absolutely. It is very common.

Clay: Well, how soon would physical therapy start after a total hip replacement?

Amy: Typically, the PT shows up within 24 hours of your surgery when you are in the hospital. So, what you can expect is basically after you come out of recovery, the physician or the nurse will come and talk with you and tell you when you will start your first PT. Sometimes, it is within 12 hours. It really is all dependent on the amount of time that is projected to be your discharge. Time or day, and that is something that actually frankly is changing dramatically over the course of the last 18 to 24 months. So total hip replacement surgeries are moving from being a two-day event in the hospital, which is what we used to see very commonly, to most likely being a predominantly outpatient surgery within the next five years.

Clay: Outpatient surgery–is that right?

Amy: That is right, and there is some pretty reasonable science to support why transitioning to outpatient is a great idea and is basically because of infection rates and things like that. And so, they are looking, I mean they being the world of orthopedic surgeons and the world of joint replacement specialist. They are looking to transitioning. It is already happening in some places, not on the Outer Banks, but it is happening in some larger cities where they are doing small groups of folks who are good candidates, so they are essentially very healthy people who frankly do not need to be hospitalized. They can go to an Ambulatory Care Center and safely receive a total hip replacement and go home that same day.

Clay: Could it also be maybe that recovering at home is a happier place for people?

Amy: No question. All of us would rather be home than at the hospital, and so the biggest issues that come into play are first and foremost safety, so you have to be safe to go home. Once you are in the recovery room you have to be medically stable. Pain needs to be adequately manage and that is something within the Joint Replacement Community, that is really becoming more and more well-researched and well-managed is how to keep people comfortable while they are recovering from this very big surgery. That is a big event, so managing the pain, making sure that they are safe to ambulate because you can walk on that new hip pretty much as soon as their block wears off as soon as anesthesia allows.

Clay: So whenever you come home, whether it is the same day or a couple days later and the patient is able to get to your office, how soon– so walk us through what PT might look like in the first visit to your office and then in the weeks that follow.

Amy: Typically, I will sometimes see people that are coming straight from the O.R. Basically, they may spend a day and a night in the hospital they come home and they are usually starting with me within a day or two of being home. So sometimes I will see them immediately post-op, some surgeons want those patients to be seen at home anywhere from two to four weeks. Generally based on surgeon preference. Sometimes it has to do with family logistics in that patient might live alone. They can not drive those first couple of weeks. So there are some issues that play into the decision making on whether they start outpatient, which is my clinic, or whether there is seen at home for home-based physical therapy. But if you come to my clinic the first thing that is going to happen is you are going to undergo an assessment, and that is basically where after doing a bunch of intake paperwork, where we make sure that you are actually medically stable, we start talking about your function. We start talking about “Hey, how are you doing?” What is your pain like?” We use pain scales and I expect because it has become such a big movement in orthopedics to better manage people’s pain so that they move.

Because we know that one of the things that is most helpful after joint replacement surgery, be at a hip or knee, is the ability to move. If you have got so much pain, you can not move all of a sudden, your risk factors go up substantially in regards to blood clot or onset of pneumonia. So, we know that moving is important. We will talk about your pain. Make sure that your pain is being adequately managed and then we will start looking at that lower extremity. I will have you walk for me. I will look at edema, will look at bruising, depending on whether your surgical dressings are off or not. I will look at the surgery site. Make sure it all looks good clean and dry, occlusive bandages or it should be in place at that point and then, just basically initiate the onset of PT which is assessing, and then addressing strength loss this most in deficits. We spend a lot of time talking about precautions, because there are some precautions after hip replacements depending on the approach that the surgeon has taken. So, there are some options available in regards to whether you have what is called an anterior approach or posterolateral approach. And so, there are some precautions and we make sure that the patient is well versed in that, and understands why the precautions are important. And then, we start to exercise, we start to move.

Clay: I know it is different for different patients based on how fit they might be, how young they might be. But how long does that therapy last working with you? And then when do you say “Okay, you are free to go but take these exercises home with you and make sure you do them”?

Amy: We start immediately. We start the first day they are there. Nobody leaves my clinic without having things to work on at home.

Clay: And so how long do those exercises last with you versus when you say “Okay you are released from me and you can do these at home without me”?

Amy: Frankly, it depends, and what I have come to realize through a lot of years of clinical practice is the fitness level that someone takes into the operating room. Absolutely dramatically affects how long they are with me. So, if you are pretty active, pretty strong, pretty fit, you just have a bad hip, and you can be all those things by the way, and still have a bad hip. So if you are pretty mobile and you have maintained pretty decent strength pre-op, you are not going to spend much time with me. A couple weeks, maybe. If you are really debilitated and we see this very commonly in people who have really put off having the joint replacement, maybe waited a lot longer than they should have.

Sometimes, there is a concomitant problems going on at the knee, at the foot and ankle, on the contralateral side, will see some problems that affect their ability to ambulate. And at the end of the day, with a hip replacement, our goal is generally normalize gait. I mean, that is what we are looking for and everything that normalized gait entails and so that strength, mobility, balance, neuromuscular control of the extremity. So at the end of the day, that is really what we are looking for is normal gait.

That is what frankly people that are having their hips replaced, they will tell you “I can not walk. I can not ascend or descend the stairs.” I live at the beach, you know people’s inability to get onto the beach is a huge issue. So because you take gait, and now you put it on an unstable surface like sand and the demands are exceptionally greater to be able to walk the beach than are to walk on the sand. So that is something in that first visit that we talk about “What are your goals?” I will specifically ask the patient when I am interviewing them, when I am evaluating them “What are your goals?” [and] “What is it that you have this hip replacement for a reason?” [and] “It is an optional surgery. Your life did not depend on you getting a hip replacement. So, what are your goals?”, “What did you decide, you have decided to make this commitment of time, money, risk, you have done those things to do something. Is it to be able to get through the night without pain?” For some people, that is their ultimate goal. Most people, it is mobility. I want to be able to get onto the beach, you know, some people I work in a beach community. I have patients that their goal is: I need to get back on my surfboard.

Clay: Right.

Amy: If it is somebody who basically just wants to be able to grocery shop and, be able to get their groceries in and out of their car independently and walk with a normal gait, unless they are profoundly weak when we start, it is not going to be too long. So, I know that is a ridiculously vague answer.

Clay: No, everybody’s different.

Amy: But fundamentally, everybody’s different with what they bring into the operating room and everybody’s different with their expectations following. So, the way I rehab a 35 year old, and the expectations and the demands that 35 year old is going to place on that new hip is going to be profoundly different than my 82 year old.

In Part 2, Amy and I discuss recovering from hip replacement surgery, returning to activity and even sports after hip surgery, and the importance of getting active and staying active.