Primary THA is the ultimate surgical option to help patients with painful hip osteoarthritis (OA).^1,2,3 Rehabilitation following any major joint replacement surgery is an integral part of the recovery process.^4,5 A variety of hip replacement protocols are used based on surgeon preference and guided by the specific surgical approach. Standard methods (posterior and lateral approaches) to THA have well-recognized postoperative limitations and restrictions that are unique to each type of surgery and are based on known patterns of soft tissue trauma and the attendant risk of hip instability.⁶ The rehabilitation process can vary considerably depending on the surgical technique, and few common standards may exist to guide the physician, patient, or physical therapist as to the optimal course.

Patient rehabilitation after DAA THA involves a carefully designed physical therapy program based on four major criteria. First, tissue healing properties must be taken into consideration when designing a proper time-based implementation of stretching and strengthening exercises. Second, patient-specific tolerance must be considered for the progression and advancement of difficulty of exercises. Third, to prevent postoperative complications, presurgical factors such as previous joint replacements, femoral fracture, neurologic disorders, or ligamentous laxity should be considered. Fourth, weight-bearing status will dictate which postoperative exercises must be avoided or delayed.

In this chapter, we describe a preoperative and a three-phase postoperative rehabilitation protocol that have been optimized for patient recovery after primary DAA THA. We also included a section on the growing telerehabilitation medium as well as physical therapy treatment of greater trochanteric pain syndrome and iliopsoas tendonitis/tendinosis. Our goal is to help standardize the DAA recovery pathway so that these rehabilitation principles can be used by other surgeons and physical therapy professionals, keeping the previous four recovery criteria in mind.

Pain and joint dysfunction lead to the inhibition of periarticular muscles.⁷ For example, severe muscular atrophy can occur in the gluteus medius and external rotators in patients with hip OA.⁷ Therefore, preoperative strengthening of hip muscles, when possible, is desirable to improve postoperative THA recovery. We recommend that patients attend a preoperative joint replacement class in which surgery, expectations, goals, restrictions, and milestones can be discussed. In addition, a preoperative outpatient physical therapy evaluation is advisable to identify patient-specific joint dysfunctions, weaknesses, aberrant movement patterns, flexibility, and strength deficits.

Presurgical patient evaluation will contribute to identifying the optimal rehabilitative program for each patient. Hip range of motion (ROM) is usually limited with OA preoperatively⁸; thus, stretching can be of benefit, particularly because preoperative hip ROM has been shown to be a predictor of postoperative hip ROM.⁹ We recommend isometric quad sets, isometric hamstring sets, isometric hip adduction, isometric gluteal sets, and side-lying hip abduction for preoperative strengthening. Stretching exercises for the quadriceps, hamstring, piriformis, psoas, and iliotibial (IT) band can also increase preoperative hip flexibility. Generalized low-impact aerobic exercises, reconditioning, and weight loss can improve daily function and reduce pain in patients with OA.¹⁰

Telerehabilitation is the delivery of rehabilitation services over telecommunications networks and the internet.¹¹ This digital avenue of treating patients has opened up additional accessibility to care for patients, especially for those who live further away from the clinic. There are a few items to
consider before administering this type of physical therapy care. First, the physical therapy state board in which the physical therapist practices must legally allow telerehabilitation. Second, Medicare and commercial insurers all vary in reimbursement as well as specific allowable Current Procedural Terminology treatment codes. Third, a physical therapist in one state may not be able to treat a patient who resides in another state depending on specific varying regulations. Fourth, the digital audiovisual program used must be Health Insurance Portability and Accountability Act compliant for patient confidentiality.

The telerehabilitation patient examination can be conducted digitally to observe a patient’s gait pattern, check functional strength like squatting, and test balance. After the initial assessment, a patient can possibly have a telerehabilitation appointment once a week in which patients can be shown new therapy exercises according to the outlined three-phase THA DAA physical therapy protocol. Specific pictures of exercises and digital videos can be emailed to the patient for further demonstration and clarification of proper technique. A patient portal is important as well for patients to send specific questions about pain, repetitions, advancement, etc.

During the coronavirus disease 2019 pandemic, telerehabilitation became especially important for the treatment of nonsurgical and postoperative THA patients. Many cities and states were on lockdown with stay-at-home orders or patients in high-risk categories with recommendations to stay quarantined. Some patients had elective THA surgeries canceled and benefited from learning valuable preoperative THA strengthening and flexibility exercises to ultimately assist in postoperative recovery. Postoperative THA patients had the option of virtual appointments once a week for physical therapy. Several program platforms allowed a Health Insurance Portability and Accountability Act-compliant synchronous audiovisual format to digitally treat these patients.

There are many advantages of telerehabilitation, but professional judgment should be used in advising the patient whether to attend an actual in-person physical therapy appointment for very specific testing, examination, and manual therapy interventions or to use telerehabilitation instead. The telerehabilitation space continues to evolve as new software platforms arrive; future review of this mode of physical therapy delivery will be of great clinical interest.

We organize postoperative physical therapy for DAA THA into three distinct phases (Table 40.1). All of the recommended postoperative physical therapy exercises are specially designed to avoid the possibility of anterior hip dislocation in combined limb extension with external rotation. Certain exercises were omitted from the DAA THA protocol based on the relevant anatomy to avoid irritation of the iliopsoas muscle and tendon unit. Specifically, SLR exercises and hip flexion with resistance tubing are avoided because these exercises may aggravate anterior hip pain and dysfunction.