COTW: To THA or not THA part 2 | Modern Manual Therapy Blog

COTW: To THA or not THA part 2

Part 1 of the case is here. Wondering how this fellow is progressing? Read on to find out!

This was a case done with a fellow. I asked him what the first thing we should look at. The easiest thing to start with is a lumbar screen. If a patient has unilateral lower quarter complaints, what is the first repeated motion you should examine? 

If you said sidegliding in standing (to the painful side), you have been paying attention to this blog - or you are well trained in MDT! Despite the patient having severely limited hip flexion, IR and ER, making him a true slow responder (limited multi-directionally), having crepitus in all motions, I did not assume he was a true THA candidate.

Sidegliding in standing was limited, painful, and very blocked. It took both of us to do at least five or six sets for at least twenty minutes, but slowly, the patient felt relief. After about 30 minutes of shift correction, and eventually progressing to PT overpressure while the patient was actively performing it against the wall (he was a big guy and hard to get to end range using our arms), he eventually had completely nonantalgic gait by the end of the session.

However, his hip was still restricted, indicating true dysfunction (slow responder). We finished with some QL and psoas release, as well as IASTM to the hamstrings, quadriceps, and ITB. This improved his hip flexion, IR, and ER a bit with less resistance throughout the range and at end range. 

The patient's classification would be lumbar posterolateral derangement with accompanying hip dysfunction. In other words, rapid responder, Sx coming from the lumbar spine, slow responding hip. He is cancelling his THA just 3 visits in.

For HEP, he was given SGIS against a wall to be performed hourly and reassess his walking for his own test, retest. He was also instructed on repeated hip IR in hooklying for 3-5 minutes 2-3 times/day to keep the right hip moving.

By the 3rd follow up visit, he was walking without antalgic gait and very pleased with his progress. His complaints in his hip have completely centralized. The hip motion is only slightly better with less resistance throughout the range. He has some lumbar pain, but describes it as aching and states he is at least 75% improved. He went out of town recently and had to cancel, so I will not have another update until later this week.

With the way his hip looked on imaging, the pain, crepitus, and difficulty in all WB positions, it is easy to see why a surgeon would want to perform a THA. His antalgic gait also displayed slight WS to the left, thus further causing a loss of SGIS to the right, perpetuating the far lateral derangement. Assuming his SGIS is equal at next visit, what would be your progression on ther ex?


  1. Great case Dr. E! Sometimes I would like to put on my credentials, 'surgery preventer!' And this case exemplifies what our profession can do. Awesome work...wonder what surgeon thinks?

    I would imagine his glute meds are very weak and possibly causing the compensated trendelenburg/antalgic gait pattern with resultant side shift of the pelvis. Can't go wrong strengthening these. Knee extension lag still bothers me and I would like to focus on that prior to more ROM of hip...considering how limited joint play it seems he has in the hip.

  2. Thanks HV and thanks for the share on your end too! I have only seen him a few times, I forgot to mention, his right knee extension is now 0, with less of a hard end feel.

  3. Great post as usual Dr. E. I have a question related to the initial visit with the shift corrections. What, during that 20-30 minutes of initial treatment when you weren't getting much, if any, relief, made you confident that it was prudent to continue. I often worry about hammering away at something like that for an extended period if I don't see results right away and the pt sometimes wonders why I would continue with something that doesn't seem to be going anywhere. Naivety on my part likely, but just wanted your thoughts.


    Garrett Pfeiffer, DPT

  4. Ok great. Definitely good results. I see cases like this quite often considering high Medicare population in which I work. Did you mention his age? See 40 yr hx of symptoms so must be up there.

  5. Oh anyway there can be an option to get emails from follow up comments? Not that I'm lazy, but easier than coming back to the site to see if you wrote back. :)

  6. Thanks! During the 20-30 minutes, what I didn't mention was that he walked after each set and slowly his walking became less painful, he was more upright, with less shifting to the left. This is why I proceeded. we noted slow but steady improvement. I try not to beat dead horses either!

  7. I get notifications if you write and even every time I write. It must be on disqus when you signed up.

  8. He's in his mid to late 50s I believe. Not as old as you would think.

  9. Man, and I thought I had a great workout during my work day ;).

  10. Well, I'm not randomly in some crazy upside down yoga position on the beach, but I can get a good workout daily as well!