Case of the Week 10-25-12: To THA or not THA? - Part 1 | Modern Manual Therapy Blog

Case of the Week 10-25-12: To THA or not THA? - Part 1


Today's COTW is a self referred patient who found me by a personal trainer at his gym. He was told by several physicians, including his PCP and various specialists that he needed a right THA.


Here is his eval:


Subjective: Pt reports constant right hip pain which started 5 years ago. He also reports a 40 year history of chronic low back pain with laminectomy at L1-2 and L4-5. This was after falling from a tree and landing hyper-extended on a fence for several hours until someone was able to get him down. Other history is significant for a stab wound in the lower left abdomen. Upon repair, he was cut longitudinally along the mid portion of his rectus abdominus. note - he actually joked with the surgeons, why don't you just go in here, it's already open - pointing to his stab scar.


the stab wound - "Can't you just go in through here?"

scar mid abdomen, "Why are you cutting there?" - prior to rectus activation
a diastasis large enough to fit my forearm in - "Gee, thanks Doc - great repair"
Apparently the stab wound missed anything vital.

Pt. states his pain today in the right hip is 10/10.  His hip pain is worse with standing, walking, stairs, and getting up from a chair. Pt. reports difficulty sleeping at night, only 3-4 hours.  He states he is better with sitting but shifting frequently.  Pt. reports he has a total hip arthroplasty scheduled for 12/11/12.

Objective: fair sitting posture
key: F = functional (WNL), D = dysfunctional, N = non-painful, P = painful, PDM = pain during movement, ERP = end range pain, LRF = lat rotation and flexion, MRE = med rotation and extension

Gait:  Pt. ambulates with a severely antalgic gait pattern with decreased stance time on the right 
ROM
Lumbar:
Sidegliding:   R significantly limited, L moderately limited

Hip
Flexion               Left:  FN                  Right:  DP, sev
Int Rot                Left:  DN, min        Right:  DP, sev
Ext Rot                Left:  DN, min        Right:  DP, mod
Knee         
Extension          Left: WNL                Right:  limited end range
The patient's goals in coming for PT was to hopefully avoid his upcoming THA scheduled in early December 2012. His hip on the right had severely limited ROM, with crepitus and pain with most movements. 

The question I posed to my fellow in training is the same I will ask you. What is the first movement you would check on him?

Highlight with a mouse or your finger if you're on a touch screen for a hint -it's a simple WB movement

14 comments:

  1. Hmmm. You mean another mvmt not mentioned above? Lumbar extension?

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  2. I mean of a movement I may have already looked at once above.

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  3. Ben Ness, PT, MS, Cert. MDTOctober 29, 2012 at 2:33 PM

    You didn't mention if (R) Sidegliding increased/decreased his hip pain. I always start proximally when there are Lumbar and LE symptoms. In my reasoning its the Lumbar Spine until proven not then I go distal. You have a huge loss of ROM with (R) Sidegliding and painful weightbearing. I would try repeated (R) sidegliding or extension in lying with hips off center. You know extension is not the pure directional preference due to increases symptoms in standing, walking etc. so I would think this may be a large derangement with a large lateral component. You have hip ROM loss but I would not go there until the Lumbar spine has been cleared. My 2 cents.

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  4. Bingo! Except I always go for SGIS since it can easily be checked for improvement in function and they don't have to get off of a table and potentially lose any reduction you may have provided in the NWB position! I didn't mention it because I would've given it away!

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  5. I was taught that if the answer wasn't obvious by the Hx, then flexion is your friend in teasing the answer out. Since his Hx doesn't reveal a directional preference, I'd start with getting him to slouch in sitting and then do the over-correct and see what that does for him. From there I was taught to exhaust sagital plane movements before exploring lateral components, so I'd check flexion. We could do this in sitting.
    The case reports a limitation in SGR>SGL but doesn't say a visible shift is present. If we were going to go into shift correction or lateral component exploration wouldn't the shift have to be visibly present or sagital plane mechanical testing and treatment options already have to be exhausted before we start doing shift correction/testing?

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  6. Assuming I got a worse or peripheralization from flexion and I treated him into extension and also got a worse or peripheralization that's when I would go into adding a lateral component to the treatment. If he was already in prone I'd shift the hips away from the painful side and have him do EIL - REIL watching to maintain that sidebent position during the exercise. If it then it became no worse/no better w/o peripheralization I would start going up the force progression until I exhausted benefit.

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  7. Cool case. I would like to know too, did you prevent a THA?

    Eric,I'm not MDT but would assume Dr. E would say he had an inclination over yrs of practice to go with side glide moment first and forego flexion. That would be my thought.

    I have a question tho, do you think the knee extension loss would improve wi your back treatment? What do you think would be results if you treated this prior to the lateral extension component?

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  8. Eric, the thing I learned from mentoring several MDT Dips is that they tend to look for missed "shifts" or at least relevant lateral components to derangements. It's not that a shift has to be visible, but that doing shift correction in standing is the first movement I look at in the case of unilateral complaints. I no longer do repeated flexion, unless it's the rare case of an anterior derangement, I only test the movements I think are going to make the Sx better. I never do repeated flexion to see if it's a posterior derangement, most Dips do that, I just think it's unethical do to it for your information while potentially harming a patient.

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  9. You're saying all the great and correct MDT training answers. I'm not sure why the initial MDT training tells you to focus in sagittal first, when the advanced practitioners seem to look at SGIS first. I go to this initially because it's easier to perform, you often make rapid improvements and then it's easier to maintain reduction because they're already WB

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  10. The update on his next 3 visits will be written up next week! It definitely looks like THA was prevented! You're also correct about what experience has taught. Knee extension loss may have improved with lumbar treatment, but it did not in his case, nor did hip motion.

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  11. So you look at the SBR>SBL as being evidence of a lateral component warranting shift correction even without visually being able to see a shift?
    The algorithm does tell you to correct the shift first, but only if you see one.


    Do you think I should modify the algorithm I learned so that unilateral complaints/unilateral SB deficit would warrant a shift correction in standing first before adding the sagital plane movements?


    Looking forward to hearing what his home program was after the eval. EIL with the hips off center?

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  12. Precisely, it's the easiest place to start, it can immediately relieve unilateral complaints (or unilateral more distal on one side than the other) and easier to maintain the reduction since it's already in WB. One DIP explained it to me, as "Most miss a lot of very subtle shifts." I don't look at them as missed shifts, but do as posterolateral or far lateral derangements.

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  13. Did you proceed with Manual Shift Correction right away rather than the "Against a Wall" Self Correction technique? If you skipped the self correction of lateral shift, did you skip it because you find it not effective whereas manual shift correction is effective? What's you're experience in this?

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  14. Yes, I do the manual correction first because I find patients do not get to end range without some overpressure. Getting to end range reduces the derangement faster. I then teach it against a wall or in a doorway for HEP

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