Hip Degeneration and Replacements
SET TALK
By Don McCann, MA, LMT, LMHC
MA3267 MH705 MM3717
PREVENTION OF AND WORKING WITH HIP REPLACEMENTS
If you are a massage therapist doing therapeutic work, you are going to run into clients who are in pain from hip problems, hip replacements being the most severe. Unfortunately, after having surgery for hip replacements, many clients, especially the elderly, never fully recover proper alignment, full range of motion, or pain-free function. What is even more unfortunate is that the criteria for hip replacements involves waiting until the client experiences constant severe pain for a period of time before the surgeons will perform the surgery. The tragedy here is that these clients are offered little if any intervention other than drugs for their pain, even after chronic or acute arthritic or degenerative changes are noted in the hip joint. This is very unfortunate especially when deep tissue therapy, properly applied, can relieve and rehabilitate much of the problem. I have had clients who were told they were within a year of a hip replacement due to the pain and degeneration who have become pain-free go for years without having this drastic surgery.
Let’s look at a major cause of pain that is associated with a degenerative hip, and how therapeutic massage can intervene.
A very basic condition that is usually present is a pelvic imbalance, the anterior / posterior rotation of the iliums, that results in the contraction of some of the musculature of the hip, which often involves compression of the nerves. This may occur in the gluteals (maximus, medius, minimus), the piriformis, or rotators. Other muscles that directly affect the rotation of the iliums and cause a tightening of the gluteals in compensation are the quadriceps, adductors, hamstrings, quadratus lumborum, TFL, iliacus, and psoas. These muscles are all involved in a pelvic distortion, either in compensation for or in support of the distortion. I have found that when the pelvic imbalance is released, the tension in these muscles is reduced, and there is a marked improvement in any hip condition a client may present.
To facilitate the release of the pelvic imbalance, the deeper tissues of the pelvis and hip need to be treated. Often these muscles and other soft tissue are inflamed and painful. To effectively treat them, I find it necessary to use a 3-step approach working first to release fluids toxins and surface tensions, second to unwind the myofascial holding patterns, and then to release deep fibers and adhesions last. (see the SET TALK article on Deep Tissue in Massage Message, Nov – Dec 2001, or on the website under Publications). This approach will essentially release many of the causes of hip pain. This sequence not only directly affects the musculature and structure of this area, but reduces the amount of sensation that the client will experience while the contracted tissue is being treated.
It is important to release the tissues responsible for the anteriorly rotated ilium in a hip problem before releasing the compensating spasming muscles that counter that rotation. I find the best results are produced when following this sequence: quadriceps, adductors, hamstrings, gluteals, quadratus lumborum, rotators, TFL, and abdominals. If the pain and problem is in the hip joint of the posteriorly rotated ilium, it is still necessary to release the anteriorly rotated ilium first before the posteriorly rotated ilium. Otherwise, when the client becomes weight bearing, the pelvis will immediately begin slipping into compensation from the anteriorly rotated ilium, and little will be gained for long-term recovery.
Don’t hesitate to work with the hip if it is arthritic or the cartilage is degenerated. I have had many clients come to me with severe pain from arthritis and hip degeneration who are presently walking around pain-free and fully functional. The soft tissue changes from the balanced pelvis took the stress off the hip. So, my important message to you is, by all means do intervention therapy before surgery is ever considered. Unfortunately, many clients will not believe you can make a significant change because a medical doctor has diagnosed a medical problem, and they feel a medical treatment, surgery or cortisone, is the only way to treat the pain. However, people want to feel better. Usually, that is enough of a reason for them to allow you to work with deep tissue therapy on this type of problem.
Treating clients with hip replacements
Many times clients who have had the hip replacement surgery will still be in considerable pain. Once again, proper soft tissue therapy can release that pain and facilitate their rehabilitation. Limiting factors from the surgery are pelvic imbalance, misalignment of leg and hip, leg length difference from an inappropriate length of surgical apparatus, scar tissue and adhesion, and improper gait while walking.
Oftentimes the pelvic imbalance that existed before surgery that was responsible for the degeneration of the hip will not have been addressed, and will now be a stress factor on the surgically repaired hip. It is therefore necessary to bring the hips into structural alignment by balancing the anterior / posterior hip distortion. When this is accomplished, the structure supports the hip and the pressure is equal on the hip joints. Many times this is the key component for the client’s recovery. This process is similar to the pelvic balancing that we would have applied before surgery as previously described in this article. The complications are often increased scar tissue and adhesions from surgery, uneven leg length due to surgical apparatus, and misalignment of the leg/knee/ankle being non-supportive. However, again using the 3-step approach, we will be able to work deeply to soften the scar tissue and adhesions. This will take pressure off compressed nerves, allow more normal circulation, increase the range of motion, and facilitate pelvic balance. When pelvic balance is achieved through these techniques, you will also note an improved alignment of the entire leg and an improved gait. There will also be a relaxing of the compensating muscles that have been working hard to make up for the imbalance – chronically contracting and compressing on nerves.
However, after a hip replacement there are some special considerations that you need to be aware of when treating these clients. The first is when the client is on the side, one knee should be on top of the other – the top leg should not cross the sagittal plane of the body. If undue pressure were put on the leg in that position, it is theoretically possible to unseat or detach the apparatus. Another important consideration is that on either side of the head of the trochanter there is usually considerable scar tissue that will need to be addressed. This scar tissue often causes a shortening of the gluteals and IT band and, in essence, the lower leg will no longer be directly beneath the upper leg. If the client spends years walking this way, the next replacement could be a knee replacement. It’s often possible to prevent this by lengthening and softening the scar tissue around the head of the trochanter.
Unfortunately, there will be a limitation as to the length of time any soft tissue treatment can effectively help the client if the apparatus is causing an imbalance due to leg length discrepancy. In my practice I have seen some very substantial differences in leg lengths after the surgical apparatus was inserted. However, what has become evident is that pelvic balancing is still effective for pain relief, but the client cannot remain balanced long term. Consequently, clients with this condition will need the support of continued sessions for years to keep the spasm and scar tissue from causing constant pain and eventual degeneration of the lower leg or back. With this continued support, I have a number of clients living very satisfactory lives relatively pain free.
Another serious complication with hip replacements is increased pressure on the discs of the lumbar spine in the low back, especially when the pelvis hasn’t been balanced or there is a change in leg length. Again, treating to achieve pelvic balance is the number one consideration. When the pelvis is balanced, the sacrum becomes more level, which in turn reduces the curvature of the spine. Consequently, good structural deep tissue therapy is very effective in supporting the lumbar spine and low back for your clients.
Neuralgia is another complication. The incision from the surgery often compromises nerves and sets up a chronic pain syndrome due to the nerve damage. Again, pelvic balancing using the 3-step approach will take the pressure off the replaced hip and help normalize and soften fibrous adhesions and scar tissue that irritate and prevent the nerves from returning to homeostasis. After the scar tissue has softened, a substantial amount of the neuralgia symptoms disappear. The client will feel better and be in less pain.
The goals of rehabilitation include increased strength, range of motion, and functional gait. The better the alignment, the stronger the musculature that was affected by the surgery. In addition, when the fibrous, hardened scar tissue is normalized and softened, it is able to function more like “normal” tissue in its ability to be mobile and support the joint structure. The treatment of the soft tissue of the hip and pelvis will also release splinting, and facilitate increased range of motion quickly, so that physical therapy to strengthen the muscles will be more effective allowing the client to function better while walking, dancing, etc. Also, the muscle tissue will strengthen more easily since the scar tissue and adhesions will have been released allowing greater flexibility of these tissues.
When to start treating after surgery
Common sense goes a long way here. First of all, you need an MD’s release before you work in or near any surgical site. It would not be a practice builder to work over partially healed tissue and irritate or separate the tissues that are trying to heal. Generally speaking, it is better to have the tissues heal with the pelvis in a reasonably good state of balance. Thus, I recommend doing some pelvic balancing with the client before surgery.
After surgery, and the MD’s release of the patient saying the surgery was successful and healed, (usually 3-4 weeks), I will treat the muscles of the hip and pelvis that do not pull on the surgical scar tissue that is forming, but will still provide support to the hip and pelvis by maintaining the structural balance. After the incision is no longer bright red, and appears firmly reknit (usually 5-6 weeks), I find it is okay to start working gently with the developing scar tissue being careful not to pull any tissue away from the knitting incision site. Usually after 8-10 weeks it is okay to work at the incision site to soften and normalize the tissues that are knitting in the scar. Note: don’t do this if the scar does not look healthy, or is bright red. It is also not okay if there is a major indentation along the scar line that could indicate some tissues did not reattach or mend well. In this case, it will take longer for full healing to take place before you are able to work the tissue. It is better to err on the edge of caution than to contribute to a complication. Also, everyone heals at different rates. So, be careful!!
Many of the hip replacements that you will see with the elderly may be years old, and have several almost permanent distortions in the leg, hip and back. You will still have positive results by balancing the pelvis. There may be degeneration in other joints that are now becoming problems and can only be maintained, not improved. Good deep tissue therapy is still better than drugs for the client’s well being. If you feel you aren’t qualified to work deeply in these areas, please take additional training, or refer your client to someone who already has the training and experience.
I hope this has opened your eyes to the very real possibility of successfully treating hip problems using deep tissue massage therapy techniques. Keep up the good massage therapy.