Case of the Week 10-25-12: To THA or not THA? - Part 1 | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

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 
Sidegliding:   R significantly limited, L moderately limited

Flexion               Left:  FN                  Right:  DP, sev
Int Rot                Left:  DN, min        Right:  DP, sev
Ext Rot                Left:  DN, min        Right:  DP, mod
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

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