Return to Running after hip replacement surgery?
Lately, I got a patient asking me whether he could return to running after he had total hip replacement surgery. As he was significantly younger than most people receiving total hip arthroplasty (THA), this was the first time I personally came across this question. My first thought was, “Yeah sure!”. But then I scratched my head a little bit as I didn’t know the evidence about it.
The growing proportion of younger patients undergoing total hip and total knee arthroplasty places greater expectations on postoperative quality of life. It’s still unclear what the best practices are for sports when it comes to athletic exercise. So let me take you on this run to dive into the research evidence on return to running after hip replacement surgery.
Why am I asking myself this question?
Commonly when treating patients after a hip replacement surgery, you’ll get precautions from their orthopedic surgeon. Often, avoiding hip flexion beyond 90° or avoiding excessive internal and external rotation will be the main focus. Furthermore, we all have heard about the possibility of revision of the prosthesis. In this light, running is increasing the demands around the hip and therefore it is seen as a possible cause for early revision surgery. I wanted to know what the current evidence tells us about running after hip replacement.
But equally important, physical activity guidelines recommend being active several days per week. As we all know, a vast majority of people don’t engage in sufficient amounts of physical activity. Among those who received hip replacement surgery, a large proportion indicates that fear is holding them back from sports participation. Even if running is not the priority for your patient, I think this blog may help you guide patients to re-engage in physical activities and meet the recommendations.
The main reason for not participating in running postoperatively was due to fear (61%), followed by muscle weakness (24%), and pain in the low back or knee (15%). Abe et al., (2014).
What does the evidence say about other hip procedures?
The most evidence concerning return to sport (RTS) after a total hip replacement came from opinions and surveys among surgeons. For example, Klein et al., in 2007, and Swanson et al., in 2009 used questionnaires to gather information from surgeons about their recommendations after THA. The latter study reported that surgeons generally don’t restrict low-impact activities such as level surface walking, stair climbing, level surface bicycling, swimming, and golf. Higher-impact activities were more commonly discouraged, although there was considerable variability in the responses. Swanson indicated that surgeons who performed many hip replacement surgeries generally were more likely to encourage participation in higher-load impact activities.
Kraeutler et al., in 2017 conducted a literature review and proposed a physical therapy protocol for patients who underwent labral repair, acetabular rim resection, or femoral head osteochondroplasty for FAI. So to be clear, not in THA patients. They did so because they experienced many patients failing to return to activity as they were guided by tissue healing guidelines rather than by functional gains in strength, gait, and pain. Although this study discusses another pathology, it is interesting to see the rehab progressions made after a surgery that typically requires limited weight bearing post-operatively.
The program for post osteochondroplasty was accompanied by an ongoing strength program which included exercises such as side plank raises, front planks, band walks, supine bridge, and single leg squat reaches.
Prior to each workout or run, a dynamic warm-up was required with the following exercises. (A) Knee hug to calf raise, (B) in/out heel taps, (C) swing kicks, (D) soldier walks, (E) glute kicks, (F) walking lunges with reach and rotation, (G) lunge twist, (H) quick steps and (I) Single-leg mini-squat to calf raise.
- The first phase of this program was a walking program which was initiated on a treadmill and progressed to outdoor activities. The requirement was being able to walk 30 minutes at a speed of around 3.5 mph which corresponds to 5.6 km/h.
- Phase 2 was a quick response and plyometric activity. They state the following: “Quick muscle response and plyometrics are initiated in this phase, progressing to about 500–600 foot contacts between one and two legs. Thus, if a runner has an average turnover of 170–180 strides/min, then running for 5–7 min would be required to reach the necessary 500–600 single-foot contacts.”
Progression to the walk/run program was allowed when participants had successfully completed phase 1 and the level I plyometric program of phase 2, could walk without limping, and had no pain with daily activities. Here also, the advice was to initiate this program on a treadmill. The following rules had to be followed: (i) No hills or inclines, (ii) no speed work, (iii) work on form and (iv) run every other day. Ideally, they should continue the level II and III plyometric program.
- Phase 3 returned the patient to distance running. During this last phase, patients had to find their baseline. This is the distance the patient can run without pain and again 48h later. Distance, time, and pace had to be carefully noted down to track progress.
- During weeks 1–2, patients should run 2–3 times per week, with two shorter runs between 50% and 60% of their baseline distance and one longer run at the baseline distance.
- During weeks 3–6, patients should run three times per week at their baseline level, with a rest day between each run. Patients should increase their distance by 10% each week.
- Starting in week 5, patients should reassess their baseline and increase running distance accordingly.
The best prognostic indicator for RTS was the previous experience in that sport. The main reason patients did not RTS was the surgeon’s recommendation. Sowers et al., (2023).
What does the evidence say about returning to running after hip replacement surgery (THA)?
Oljaca et al., 2018 consumed the evidence from consensus documents regarding RTS after THA and summarized it in the table below. You can see that in many sports, the evidence regarding RTS has changed over the years.
Boost Your Knowledge about the 23 Most Common Orthopedic Pathologies in Just 40 Hours Without Spending A Fortune on CPD Courses
This research summarized the evidence as follows: “Nevertheless when it comes to clinical outcomes after TKA, there seems to be no difference between the high-activity and low-activity patients. There is almost no difference in the outcome between the groups regarding the incidence of prosthesis-related complications when performing low to moderate-impact sports. Patients who did not participate in sports after THA even reported a 14,3% to 1,6% greater incidence of a replacement due to loosening. When these findings are taken into consideration, it seems reasonable to allow gradual resumption of sports in younger patients.”
There is something to say about this summarizing table. Bender, 2022 measured in vivo joint contact forces and torsion torques and found that bowling which is considered a low-impact activity, for example, produced higher joint contact forces and torsion torques when compared to high-impact soccer. Further, they also found body weight and body mass index influencing these forces during everyday activities.
This was supported by a case-controlled study by Abe et al., in 2014 who found that a minority of the participants ran preoperatively (33 patients (5.4%)), and 23 patients (3.8%) performed jogging postoperatively. These runners reported no hip loosening, abnormal component migration, or excessive wear at a 5-year follow-up. However, in the umbrella review by Sowers et al., 2023, aseptic loosening was the most cited complication after RTS. Patients who intend to resume high-impact activities like tennis should therefore be advised of potential risks and closely monitored during their RTS training.
Ortmaier et al., 2019 evaluated the sport pattern, rate of return to sport, activity level, the extent of sports activity, and subjective rating and sense of well-being in 137 patients (137 hips) after short-stem THA over 18 months. Before surgery, 92% of the patients participated in sports, and 91% of patients resumed their sports activities within the first six months following surgery. Although, the number of sports disciplines that were practiced decreased slightly but significantly from 2.9 to 2.6 (P = 0.025) from preoperative to postoperative periods. This decrease was mostly seen in high-impact activities.
Sowers et al., in 2023 found that the best predictor of RTS was prior participation in that sport. The surgeon’s advice was the primary factor in the patient’s decision not to RTS. Abe et al., 2014 found the main reason for not participating in running postoperatively was due to fear (61%), followed by muscle weakness (24%), and pain in the low back or knee (15%). Ideal targets for physiotherapy rehabilitation if your patient wants to return to running after hip replacement, it seems!
This article discusses the current evidence around the return to running after hip replacement. As there is a clear gap, this article summarizes the best available evidence and my clinical reasoning to inform you. I recommend you to perform a thorough physical examination and a thorough search for evidence corresponding to your individual patient’s presentation. Underlying hip pathology that led to hip replacement (e.g. hip dysplasia, avascular necrosis) may require other precautions.
Hoping to have you informed well, thanks for reading!
Klein GR, Levine BR, Hozack WJ, Strauss EJ, D’Antonio JA, Macaulay W, Di Cesare PE. Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons. J Arthroplasty. 2007 Feb;22(2):171-5. doi: 10.1016/j.arth.2006.09.001. PMID: 17275629.
Swanson EA, Schmalzried TP, Dorey FJ. Activity recommendations after total hip and knee arthroplasty: a survey of the American Association for Hip and Knee Surgeons. J Arthroplasty. 2009 Sep;24(6 Suppl):120-6. doi: 10.1016/j.arth.2009.05.014. PMID: 19698910.
Kraeutler MJ, Anderson J, Chahla J, Mitchell JJ, Thompson-Etzel R, Mei-Dan O, Pascual-Garrido C. Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol. J Hip Preserv Surg. 2017 Apr 11;4(2):121-130. doi: 10.1093/jhps/hnx012. PMID: 28630733; PMCID: PMC5467407.
Ortmaier R, Pichler H, Hitzl W, Emmanuel K, Mattiassich G, Plachel F, Hochreiter J. Return to Sport After Short-Stem Total Hip Arthroplasty. Clin J Sport Med. 2019 Nov;29(6):451-458. doi: 10.1097/JSM.0000000000000532. PMID: 31688174.
Sowers CB, Carrero AC, Cyrus JW, Ross JA, Golladay GJ, Patel NK. Return to Sports After Total Hip Arthroplasty: An Umbrella Review for Consensus Guidelines. Am J Sports Med. 2023 Jan;51(1):271-278. doi: 10.1177/03635465211045698. Epub 2021 Oct 20. PMID: 34668788.
Oljaca A, Vidakovic I, Leithner A, Bergovec M. Current knowledge in orthopaedic surgery on recommending sport activities after total hip and knee replacement. Acta Orthop Belg. 2018 Dec;84(4):415-422. PMID: 30879445.
Jassim SS, Tahmassebi J, Haddad FS, Robertson A. Return to sport after lower limb arthroplasty – why not for all? World J Orthop. 2019 Feb 18;10(2):90-100. doi: 10.5312/wjo.v10.i2.90. PMID: 30788226; PMCID: PMC6379734.
Latijnhouwers DAJM, Laas N, Verdegaal SHM, Nelissen RGHH, Vliet Vlieland TPM, Kaptijn HH, Gademan MGJ; Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study (LOAS) Group. Activities and participation after primary total hip arthroplasty; posterolateral versus direct anterior approach in 860 patients. Acta Orthop. 2022 Jul 4;93:613-622. doi: 10.2340/17453674.2022.3149. PMID: 35819452; PMCID: PMC9275422.
Innmann MM, Weiss S, Andreas F, Merle C, Streit MR. Sports and physical activity after cementless total hip arthroplasty with a minimum follow-up of 10 years. Scand J Med Sci Sports. 2016 May;26(5):550-6. doi: 10.1111/sms.12482. Epub 2015 Jun 3. PMID: 26041645.
Bender A, Damm P, Hommel H, Duda GN. Overstretching Expectations May Endanger the Success of the “Millennium Surgery”. Front Bioeng Biotechnol. 2022 Feb 14;10:789629. doi: 10.3389/fbioe.2022.789629. PMID: 35237570; PMCID: PMC8882767.
Mooiweer Y, van den Akker-Scheek I, Stevens M; PAIR study group. Amount and type of physical activity and sports from one year forward after hip or knee arthroplasty-A systematic review. PLoS One. 2021 Dec 28;16(12):e0261784. doi: 10.1371/journal.pone.0261784. PMID: 34962967; PMCID: PMC8714096.
Zimmerer A, Navas L, Kinkel S, Weiss S, Hauschild M, Miehlke W, Streit M. Recreational activity after cementless total hip arthroplasty in patients older than 75 years. Arch Orthop Trauma Surg. 2022 Nov;142(11):3059-3065. doi: 10.1007/s00402-021-03896-y. Epub 2021 May 3. PMID: 33938986; PMCID: PMC9522835.
Seyler TM, Mont MA, Ragland PS, Kachwala MM, Delanois RE. Sports activity after total hip and knee arthroplasty : specific recommendations concerning tennis. Sports Med. 2006;36(7):571-83. doi: 10.2165/00007256-200636070-00003. PMID: 16796395.
Meek RMD, Treacy R, Manktelow A, Timperley JA, Haddad FS. Sport after total hip arthroplasty: undoubted progress but still some unknowns. Bone Joint J. 2020 Jun;102-B(6):661-663. doi: 10.1302/0301-620X.102B6.BJJ-2020-0208. PMID: 32475237; PMCID: PMC7241060.