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?

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