The 30-second article
• You’re increasingly likely to find
yourself training clients with hip or
knee joint replacements, especially if
you train older adults
• There are three main types of
replacement for both the hip and the
knee; total, partial and revision
• Post-surgery, the patient will be
advised of movement restrictions to
adhere to, so ensure you touch base
with their physio before prescribing
exercises for your post-op client
• Be especially vigilant when training
post-op clients to ensure they
practice good technique and avoid
compensating and incorrectly loading
other areas.
get the patient moving. Depending on the type
of surgery, they may be allowed to weightbear immediately, often starting with the use
of a gutter frame and physical assistance by
the physio and nursing staff. The physio will
then guide their range of motion exercises
and educate them in regard to movement
precautions, icing and compression.
Hip precautions are very important
post-op, and it is essential that the patient
is frequently reminded to not bend the hip
further than 90 degrees; not twist the hip
inwards (internal rotation); and not cross the
midline of the body (abduction).
The reason for the precautions is to avoid a
dislocation of the new hip, which unfortunately
is not uncommon. The duration the precautions
need to be adhered to varies, depending on
the surgeon and client (in particular if they have
a history of dislocations), with some lasting
only six weeks and others recommending to
avoid long term. For a fractured femoral neck
managed with a dynamic screw as mentioned
above, there are usually no hip precautions.
Hence why it is important for you to be aware
of the type of surgery and consider potential
precautions when you are designing training
programs for these clients.
As a physio, the main recommendations I
highlight to patients in regard to avoiding the
above movements include:
• sitting in a higher c hair where their hips
are always higher than their knees
• using a cushion to elevate the hips when
sitting, if a low chair is unavoidable
• using a pick up stick to pick things up
from the floor
• alternatively, if a pick up stick will not
suffice, bending down with the nonoperative hip only by extending the
operated leg out behind, keeping it
straight
12 | NETWORK SPRING 2016
• avoiding bending to put shoes on by
wearing supportive shoes that slip on/off
and utilising a shoe horn with a long handle
(or having someone help put them on)
• sleeping with a pillow between their legs
if they are a side-sleeper (to avoid the
leg coming across the midline).
After discharge home (usually with either a
frame or crutches), the physio will work with
the patient through an outpatient role with
the goal of progressing their gait aid (e.g.
frame > crutches > one crutch/stick > no
aid) and commonly recommend activities
including hydrotherapy, stationary bike and
clinical Pilates in the initial stages.
Monitoring for complications is also another
important role, in particular for infection and
deep vein thrombosis (DVT). Personal trainers
should also be on the look out for signs of a
DVT, which include pain, swelling, warm/red
skin and tenderness (usually around the calf).
A DVT can lead to life-threatening conditions
such as a pulmonary embolism, so if you are
suspicious at all, send them straight to the
doctor. Signs of infection (around the scar)
include redness, warmth, tenderness to the
touch, pus or drainage and bad odour, and
potential fever/chills. If you are concerned,
recommend that they cease training and
consult a doctor as soon as possible.
Returning to training post-op
Whether they are a past client returning to
you post-op, or a new client with a history
of a joint replacement, the following points
are important:
• Check with them regarding any remaining
precautions (as mentioned this can vary
person to person). If they have been
advised to avoid flexion past 90 degrees
then adapt either the exercise e.g. avoid
deep squats, or the equipment, e.g. raise
the seat of the exercise bike.
• Despite the surgeon and physio’s best
efforts, they may have residual joint
stiffness that can limit certain
movements, for example lacking full knee
extension can alter hamstring length and
strength and may be associated with
weak quads. Therefore it is important to
monitor their technique on certain
exercises, e.g. a dead lift, to avoid
compensating and incorrectly loading
other regions such as their lower back.
• After knee replacement, many people
find it difficult to kneel (even months or
years later) post-op depending on their
range of motion, pain levels and fear of
damaging the prosthesis. If they are
unable to kneel, adapt your exercises to
seated or standing position if possible.
• Swelling can persist for several months
post-op and can be managed using ice
and compression garments. The
benefits of compression are well
documented, in particular the effect on
blood flow and circulation, therefore
wearing a compression garment during
activity can assist in reducing swelling
during and after activity.
Top tips for clients with joint
replacements
1. Touch base with their physio and don’t
hesitate to ask any questions, no matter
how basic, in particular with regards
their precautions. The client will
appreciate you being careful and it could
also assist in regard to your liability
should something unfortunate happen in
your presence (for example if your client
dislocates their hip).
2. Keep in mind that other joints, including
shoulders, can also undergo joint
replacements. The precautions and
rehab procedures can vary dramatically
depending on the surgery. So again,
don’t be afraid to check in with their
physio or even their surgeon.
3. Focus on functional training that will help
them improve day to day, as having
difficulty with the simple things, such as
stairs or standing from sitting, are often
the reason they had their joint replaced
in the first place.
4. Keep in mind that often those who
underwent elective joint replacements
for osteoarthritis may also be suffering in
other joints of their body. Non-weight
bearing exercises, such as the bike or
cross-trainer will be more favourable for
these clients.
5. Be mindful of your clients’ comorbidities
and incorporate training principles to
address these. For example, balance
exercises for falls prevention in clients with
osteoporosis may assist in preventing a
fracture that leads to a joint replacement.
After all, prehab is the new rehab!
Phebe Corey is a physiotherapist and the founder
of Articfit Joint Supportive Compression Wear.
Phebe was a semi-finalist in The Australian
Women’s Weekly Women of the Future competition
in 2015 for her brand and vision of empowering
women to stay active. articfit.com