Functional Exercise for the Treatment of a Patient with a History of a Periprosthetic Hip

Fracture

Author: Ryan S. Camp

Research Advisor: Karen E.H. Grossnickle PT, DHSc

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

April 5, 2022

Submitted to the Faculty of the

Graduate Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Karen E. H. Grossnickle, PT, DHSc

Karen E.H. Grossnickle PT, DHSc

Date of Approval: April 5, 2022

 ABSTRACT

Background and Purpose

Hip osteoarthritis (OA) is a degenerative joint disease where articular cartilage and bone is

eroded, subjecting the joint to abnormal forces. If conventional medicine techniques fail to

improve a patient’s symptoms, they ultimately receive a total hip arthroscopy (THA). A major

risk for patients who have had a THA is a periprosthetic fracture. Current evidence suggests that

high intensity resistive strength training, functional weight bearing activities, and balance

training most effectively treat hip fracture. The purpose of this case report was to show if

functional exercise is successful in treating patients with periprosthetic hip fractures.

Case Description

A 54-year-old female presented to outpatient physical therapy approximately 10 months after she

received a right THA and 9 months after a subsequent right periprosthetic hip fracture. The

patient best, worst and current pain ratings were 4, 8 and 6 respectively. She had significantly

impaired passive range of motion (PROM) with right hip flexion 0-100°, extension 0°, and knee

extension 7° away from neutral. Additionally, her active range of motion (AROM)

measurements were significantly less than her PROM measurements, with AROM hip extension

being less than half of her PROM. The patient was only able to resist the examiners pressure for

knee flexion and extension. Both knee movements were measured at a 3+/5. The patient also had

impaired balance as evidenced by her Timed Up and Go (TUG), Berg Balance Scale (BBS), and

Four-Square Step Test (FSST). Her scores for the TUG, BBS, and FSST were 25.72 seconds,

40/56, and 19.84 seconds respectively. The patient had impaired function as evidenced by her

Lower Extremity Functional Scale (LEFS) score of 24/80.

Outcomes

Upon discharge from physical therapy the patient’s pain best, worst, and current pain levels

decreased to 3, 5, and 3 respectively. Additionally, she had significant ROM improvements, most

notably in active hip (0-112°) and extension (0-6°) as well as passive knee extension of 0° and

active knee flexion of 2-134°. The patient’s strength also improved to ≥ 3+/5 for all measured

hip and knee muscle actions. After therapy, she was able to demonstrate improved balance on the

TUG (9.35 seconds), FSST (8.34 seconds), and BBS (47/56) while also completing all

assessments without an assistive device. Lastly, her LEFS score improved to 43/80.

Discussion

Results support the past research on the treatment of older adults with a fracture. Past research

indicated that patients who participate in functional weight bearing activities and balance training

have the best functional improvements. Due to the limited research regarding the treatment of

patients with a periprosthetic hip fracture, this case report sought to test if functional exercise

was also effective in managing patients with periprosthetic hip fracture. The patient attended 18

visits of physical therapy focusing on seated, standing, walking, and stair activities. At the

conclusion of the 18 treatment sessions the patient was had decreased pain, improved hip and

knee ROM, and improved strength. Additionally, the patient was able to meet her goals of

walking without a cane, ambulating a flight of stairs normally, and getting out of the car with

more ease. The results of this case contribute to the limited literature on the treatment of

periprosthetic hip fractures and chronic fracture symptoms. Additionally, this case suggests that

functional exercise may be beneficial for breaking up soft tissue restrictions and restoring normal

tissue integrity in patient who have had a history of multiple surgeries. Future research should

continue to investigate the best treatments for patients with periprosthetic fractures.
Background and Purpose

Osteoarthritis is the most common musculoskeletal disorder affecting major weight

bearing joints including the hips and knees.1 Hip osteoarthritis (OA) is defined as a degenerative

joint disease where articular cartilage, acetabulum, and head of the femur are eroded, and the

joint is subjected to abnormal forces.1 One in four people will likely develop symptomatic hip

OA in their lifetime.2 The abnormal joint forces observed in patients with hip OA often leads to

chronic pain, a loss in hip range of motion (ROM), function, and deformity.1 Due to significant

changes to the articular cartilage, joint capsule, ligaments, and bone, the ultimate result of

untreated hip OA is joint failure.1

Physical therapy is a common conservative option for treating the symptoms of OA

before they become too severe for the patient to perform daily functional tasks. Physical therapy

for hip OA often consists of core and hip strengthening exercises, stretching to increase

flexibility, and gait training to improve function in the community.3,4 Additionally, manual

techniques including hip distraction and joint mobilizations with movement are often used to

help reduce the patient’s symptoms.4 If physical therapy does not help, an orthopedic surgeon

may give the patient a non-steroidal anti-inflammatory drug (NSAID) injection to the hip joint

space to decrease the patient’s symptoms.4 Ultimately; however, if conventional medicine is

unsuccessful an orthopedic surgeon will perform a total hip arthroscopy (THA) to restore

function and improve the patient’s symptoms. Osteoarthritis is the most common indication for

total joint replacement of the hip.5 In 2018, approximately 591,000 hip replacements were

performed in the United States at an estimated total cost of $42 billion.6

There are 3 main surgical approaches that are used in clinical practice with those being

the anterior, lateral, and posterior approaches.7 The lateral and posterior approaches are the most

1
utilized, but approximately 30% of surgeons in North America use the anterior approach.7 With

each surgical approach comes different risks to the patient. Depending on whether the patient has

an anterior, lateral, or posterior approach, the patient may be at increased risk of dislocation,

fractures, or paresthesia (sensory abnormalities).7 Although the posterior approach is one of the

most utilized surgical methods, it has the highest relative dislocation rate at 3.25% of all THAs,

as compared to 2.18% with the anterior approach and 0.55% with the lateral.8

Another major risk to patients who have had a THA is a fracture around the total hip

prothesis, otherwise known as a periprosthetic fracture. Periprosthetic fractures are the third most

common reason for the reoperation of a THA, after infection and dislocation.9 The risk factors

for periprosthetic fracture include the following: old age, female sex, femoral bone

abnormalities, type of implant, surgical revision, implant stability, and whether the patient has

osteoporosis.10 Osteoporosis, which is defined as decreased bone mass density of 2.5 standard

deviations below the average for a young, healthy adult, is the primary determining factor of a

patient’s risk for future fractures.1 Despite this fact, most patients are unaware that they are

osteoporotic until they have lost their balance, fallen, and fractured a bone.11 This is concerning

seeing as how older adult patients who have fractured their hip are at an increased risk of

mortality in the year following their injury.11 This risk of mortality is often due to a deduction in

the patient’s strength, ROM, and overall mobility following a periprosthetic fracture.11 In some

cases, a periprosthetic fracture can also lead to limb loss.12

Due to the increased risk of mortality and other complications, immediate intervention is

needed to address a hip fracture.11 Although many femur fractures can be repaired with closed

reduction and splinting, more serious injuries need to be treated with an open reduction, internal

fixation (ORIF) approach.11 Additionally, after medical intervention, physical therapy is

2
indicated to help improve a patient’s impairments and increase overall function. The primary

goal for physical therapy following a femur fracture is for the patient to be mobilized early.13

Mobilizing a patient refers to the act of getting a patient to move their affected lower extremity

and participate in strength, ROM, and weight bearing activities.13 Clinical practice guidelines

stress the importance of early transfer and ambulation training after a femur fracture with weight

bearing as tolerated to improve bone remodeling and healing.13 During the early stages of

therapy, treatment sessions should be frequent and long in duration depending upon the patient’s

tolerance levels.13 Exercise should additionally focus on improving aerobic endurance levels and

balance to prevent future falls.13

After the acute phase of rehabilitation, it is recommended that the patient take part in high

intensity resistive strength training, functional weight bearing activities, and balance training.13

Specific exercise prescription varies based on the time after the initial injury or surgical repair, a

patient’s impairments, and the patient’s functional limitations. One study by Mangione et al14 had

30 patients 3-5 months post hip fracture participate in 30-40 minutes of resistive exercise 1-2

times a week for 3 months. The participants in the study completed exercises focused on ankle

plantar flexion, hip and knee extension, and hip abduction.14 For the duration of the study, the

patients completed 3 sets of 8 repetitions for the above muscle actions with a weight equal to

their 8 repetition maximum (8-RM).14 The results of the study showed that, compared to the

control group, the exercise group improved in distance walked, gait speed, physical function, and

force production.14

Another study by Sylliaas et al15 took a different approach to resistance training, focusing

on 95 patients who were 24 weeks post hip fracture.15 The participants in this study completed

10-15 minutes of stationary biking or walking on a treadmill before completing 3 sets of 10

3
repetitions for the following exercises: standing knee flexion, sitting knee extension, lunges, and

leg presses.15 Each participant lifted a weight equal to 80% of their 1 rep maximum (1-RM).15

The duration of the study was 12 weeks with exercise training occurring 2 times a week for 45-

60 minutes.15 The results of the study showed similar improvements for the treatment group, who

also improved in gait speed, gait distance, and daily physical function.15

Just as with resistive exercise, functional weight bearing exercise prescription also varies.

Sherrington and Lord16 recommended that patients who were 7 months post hip fracture

participate in 1 month of daily weight bearing exercise. Additionally, the authors suggested that

when performing weight bearing activities post hip fracture, patients should start with 5 to 50

repetitions depending on patient tolerance and gradually increase as time allows.16 Sherrington et

al,17 in another study, had 120 patients post hip fracture exercise once a day for 4 months. The

patients completed sit-to-stand, forward foot taping, step ups, and step overs to tolerance on their

own via a home exercise program (HEP) proscribed by a physical therapist. The authors found

significant improvements in balance and functional performance for the treatment group.17

Functional balance training is another important intervention for patients following a hip

fracture. Latham et al18 studied the effects of balance training on patients with a prior history of

hip fractures.18 All 232 participants in the study had been previously discharged from physical

therapy. Participants in the intervention group (n=120) completed functional balance tasks

including standing exercises using varying height steps, repeated chair stands, lunges, calf raises,

and other standing balance activities 3 times a week for 6 months.18 Patients in the control group

(n=112) were received cardiovascular nutrition education. After 6 months, the intervention group

was found to have significant improvements in balance as compared to the control group.18

4
 As evidenced by the articles above, functional exercises are an essential component of

improving strength, balance, and function for patients following a hip fracture. Despite this

research, there is a lack of evidence on the best treatment for patients following a periprosthetic

hip fracture. Additionally, there is a lack of evidence regarding physical therapy interventions for

chronic hip fracture symptoms. The purpose of this case report was to examine whether

functional exercise is successful in improving LE strength, ROM, balance, and function in a

patient with a history of a periprosthetic hip fracture and previous failed attempts at physical

therapy.

Prior to preparing this report, consent was obtained from the patient to proceed. All

information contained in this case report meets the Health Insurance Portability Accountability

Act (HIPAA) requirements of the clinical agency for disclosure of protected health information.

This case report was completed under the direction of the Department of Physical Therapy and

with oversight of the College of Graduate Studies at Central Michigan University.

Case Description

Patient History and Systems Review

The patient was a right-side-dominant, 54-year-old female who presented to outpatient

physical therapy approximately 10 months after she received a right THA, and 9 months after a

subsequent right periprosthetic hip fracture. The patient originally received an anterior hip

replacement after years of pain due to OA and failed attempts at conservative treatment. After

she had the right THA surgery, she completed 1 month of physical therapy to improve her hip

and knee strength, range of motion (ROM), and gait. She was successfully discharged from

physical therapy after she improved her impairments and met her functional goals. A week after

discharge from physical therapy, the patient walked down a ramp when she slipped on ice and

5
fell on her right hip. After the fall the patient was unable to weight bear through her right lower

extremity. She was then taken to the nearest emergency department (ED) where the physicians

ordered a radiographic image. The results of the imaging showed a periprosthetic fracture of her

right femur. Her original orthopedic surgeon was not available for the emergency surgery, so the

patient was transported via ambulance to a second orthopedic surgeon 30 minutes away to repair

her fracture that same day.

The surgeon performed an open reduction internal fixation (ORIF) surgery to her right

femur and, 1 month later, the patient was again sent to outpatient physical therapy to improve the

following impairments: severe pain, severely limited hip and knee ROM, decreased hip and knee

strength, decreased balance, and impaired gait. Additionally, the patient was limited to 50%

weight bearing (WB) through her right leg and anterior THA restrictions including the following:

no active hip external rotation, extension, or active hip abduction. After several months of

therapy, the patient began having pain in her right foot and a second radiographic image was

ordered. The imaging showed a fracture of the patient’s third and fourth metatarsal shafts, so she

was given a rigid walking boot and encouraged to continue weight bearing as tolerated (WBAT).

After 2 additional months of physical therapy, consisting of gait training and therapeutic

exercises for ROM, strengthening, and balance, the patient made significant improvements in her

impairments, and was discharged to home. She was given a home exercise program (HEP) to

continue making strength, ROM, and functional improvements at home.

The patient completed her HEP for 3 months before returning to physical therapy due to

increased pain and decreased lower extremity strength and ROM. The fourth round of therapy

focused primarily on stretching and manual techniques to break up newly formed scar tissue and

restore normal ROM. A secondary focus of therapy was to improve core, hip, and knee strength

6
through therapeutic exercise. After approximately 1 month of physical therapy, the patient was

discharged back to her orthopedic surgeon due to an increase in symptoms and minimal increases

in hip and knee strength and ROM. The patient saw her orthopedic surgeon 1 month later and it

was decided that the patient should try one last attempt at physical therapy to aggressively treat

her hip and knee strength and ROM deficits as well as her impaired gait pattern. This was the

start of the plan of care documented in this case report.

The patient had a significant past medical history including the following: avascular

necrosis of her right hip, carpal tunnel syndrome, colon polyps, fatty liver, right femur fracture,

gastroparesis, urinary incontinence, hypercalcemia, and OA of her left knee and right hip.

Additionally, the patient’s surgical history included the following: right THA, right hip ORIF,

left knee arthroscopy, right knee arthroscopy, liver biopsy, appendectomy, cholecystectomy,

hysterectomy, tonsillectomy, and left breast lumpectomy. The patient reported that she smokes

up to 10 cigarettes every day and drinks alcohol on “special occasions only.” Before the initial

examination, the patient received a dual energy x-ray absorptiometry (DXA) scan at her local

physician’s office and was found to have a T-score equal to -3.0, indicating osteoporosis. The

World Health Organization defines osteoporosis as a T-score of -2.5 or lower.19 Refer to Table 1

for the patient’s full medication list.

The patient was seen at an orthopedic outpatient facility where she was alert and oriented

to person, place, time, and situation. At the initial examination the patient reported complaints of

severe anterior-lateral hip pain that extended from her right iliac crest to her right lateral knee

joint line. The pain was described as a tight pulling or stabbing sensation that got worse with

standing, walking, rolling in bed, and general movement of her hip and knee. Pain measures

were used using the Visual Analog Scale (VAS) as described by Downie et al20 where 0 equals

7
no pain and 10 equals extreme pain. The scale is 100 mm long with each number (0-10) being 10

mm apart from each other.20 When asked to rate her pain on the VAS, she reported that her pain

was a 6 out of 10. Additionally, she reported occasional groin pain along her right anterior-

medial thigh, and pain in her bilateral knees with weight bearing and knee bending. She stated

that the only thing that relieved her pain was “not moving” her right hip. She additionally

reported that palpation to her thigh and knee were extremely painful. The patient commented that

her symptoms led to her being more sedentary and afraid of falling again. She noted increased

frustration due to many visits to physical therapy in the past and no significant function

improvements. Throughout the previous 2 months she had noticed decreased strength and ROM

of her right hip and knee. She reported that she had to lift her right leg with the assistance of her

bilateral upper extremities, which made it difficult to transfer off the bed and out of the car. She

had additional inability to ambulate stairs with a reciprocal gait pattern due to her hip flexion and

extension weakness and limited ROM. She reported that she had to use a hand railing when

ascending and descending stairs. She commented that she had to use a standard straight cane at

home and in the community to avoid falling.

The patient lived with her sister in a single-story house that had a fully finished basement.

Her sister was available to help with physical therapy appointments as needed. There were 2

entries to her house, one at the front and another at the back. The entrance at the front of the

patient’s house had a ramp for easy entry. Additionally, the door at the back of the house had 2

steps to enter. The patient predominately used the front door for ease of access. She only

ambulated on stairs when she was doing laundry in the basement. Her house had 10 steps

without a railing to the basement. The patient stated that her goals for therapy were to decrease

her pain levels, improve balance, improve overall strength, and increase her hip and knee ROM.

8
Her functional goals included being able to walk without a cane, ambulate a flight of stairs

normally, and get out of the car with more ease.

Clinical Impressions #1

Based on the patient’s report, she had not made significant gains in previous visits to

physical therapy since she broke her right hip. The lack of progress led the patient to have

increased frustration and decreased confidence in physical therapy. She continued to have large

deficits in hip and knee strength, ROM, and gait. These impairments, her fear of falling, and her

use of a cane for ambulation indicated impaired balance and a high risk of future falls.

Additionally, because of the patient’s osteoporosis, the patient was at a high risk of fractures if

another fall were to occur.

Due to her history of multiple surgeries to the same lower extremity, and her reports of a

sedentary lifestyle, the risk of scar tissue build-up was increased. With an increased risk of

continued soft tissue changes she was susceptible to having further ROM and strength deficits

without immediate physical therapy intervention. Physical therapy was needed to improve the

patient’s impairments and restore function so she could ambulate safely in the community and

participate in ADLs without limitation.

Due to the patient’s symptom presentation, weight bearing, performing sit to stands, and

walking would be very painful for the patient. Performing patient handling techniques would

cause the patient extreme pain. Care and planning were needed going into the examination to

ensure quick measurement and to prevent risk of injury or unnecessary amounts of pain. The

working diagnosis at this time was muscle weakness, decreased ROM, decreased balance, and

impaired gait secondary to the patient’s ORIF and subdermal trauma. It was believed that the

patient had scar tissue buildup and compromised muscular integrity due to multiple surgeries to

9
the patient’s right thigh. Information needed to test this hypothesis and develop an appropriate

plan of care for the patient included the following: a pain score, hip and knee ROM and strength

measurements, gait assessment, balance assessment, agility assessment, and a subjective

functional mobility score.

Examination

Pain. All pain measures were used using the VAS as described by Downie et al20 where 0 equals

no pain and 10 equals extreme pain. The scale is 100 mm long with each number (0-10) being 10

mm apart from each other.20 The VAS for pain has been shown to have excellent test-retest

reliability (ICC=0.94) and construct validity (ICC=0.71-0.91) for patients with rheumatic

diseases.20,21 The patient’s pain was at best a 4 on the 0-10 scale. Additionally, her worst and

current pain levels were 8 and 6 respectively. The scores above indicated that the patient had

moderate to severe pain throughout the last week. Her pain was additionally increased

throughout the course of the examination each time passive range of motion (PROM) was taken

or the patient had to actively move her right hip or knee. Additionally, the patient had severe

pain with palpation to her surgical incision sites (anterior lateral thigh) and her lateral thigh from

her right iliac crest to her knee. Patient pain levels were recorded in Table 2.

Range of Motion. All ROM measurements were calculated using the methods as described by

Reese et al22 using a handheld goniometer and calculated in degrees. Handheld goniometer

measurements have been shown to have good to excellent concurrent validity (ICC=0.88-0.94)

and excellent test-retest reliability (ICC=0.90) with hip range of motion measurements in

patients with hip impingement.23 The tested ROM included: hip flexion, extension, abduction,

and adduction as well as knee flexion and extension. The patient’s right lower extremity was

within normal limits as defined by Reese,22 explained below. The patient’s left PROM; however,

10
was severely limited by pain for all movements. Normal values of the movements above include

the following: hip flexion 0-120°, hip extension 0-30°, hip abduction 0-45°, hip adduction 0-30°,

knee flexion 0-135°, and knee extension of 0°. The patient’s PROM measurements were very

impaired with hip flexion 0-100°, extension 0°, and knee extension 7° away from neutral being

the most functionally restrictive. The patient reported an intense sharp-shooting-stretch feeling

with all PROM exercises. Additionally, the patient had severely limited active range of motion

(AROM) with all hip measurements being significantly less than her PROM measurements, and

hip extension being less than half of her PROM. The patient did, however, have similar AROM

measurements for her knee. The patient’s ROM measurements were recorded in Table 3.

Strength testing. Manual muscle testing (MMT) of the patient’s lower extremities were

performed according to standardized procedures as described by Kendall et al24 to determine the

patient’s strength. All MMT grades were assigned based on the Kendall et al24 defined 5-point

scale with 0 representing the absence of a muscle contraction and 5 representing maximal

strength. Manual strength testing has been shown to have excellent intrarater reliability (ICC =

0.94), interrater reliability (ICC = 0.91), and strong construct validity (ICC = 0.61) for patients

with myositis using the above procedures.25

The tested muscle movements included: hip flexion, extension, abduction, and adduction

as well as knee flexion and extension. The patient demonstrated overall lower extremity (LE)

weakness with the right LE being more impaired than the left. Her left LE was able to resist a

moderate amount of force (4) from the examiner without deviating from the testing position

except for hip extension which could only resist a slight to moderate amount of pressure (4-). For

the patient’s right LE, she was only able to resist the examiners pressure for knee flexion and

extension. Both knee movements were able to resist a slight amount of pressure (3+) from the

11
examiner within her affected range of motion as indicated in Table 3. For the right LE, the

patient was unable to perform the measured hip movements through her full available ROM

against gravity. For hip extension she was able to move her right LE through greater than half of

the ROM with gravity resisted and 100% of the ROM with gravity eliminated (3-). Additionally,

for hip flexion, abduction, and adduction, the patient was only able to move her hip through less

than half of her available ROM against gravity and 100% with gravity eliminated (2-). All

strength grades have been recorded in Table 3.

Ambulation. To access the patient’s gait speed and risk of falling, the Timed Up and Go (TUG) 26

test was used. The TUG has been found to have excellent test-retest reliability (ICC=0.95), and

moderate construct validity (ICC = 0.75) for older, community dwelling adults.27 For the test, the

patient was asked to sit in a chair with her back against the backrest and arms on armrests. She

was then instructed to stand up, walk to a mark 3 meters away, and return to a seated position in

the chair. The normative values for 60 to 69-year-old patients is 7.9 ± 0.9 seconds.26 The patient

completed the task in 25.72 seconds demonstrating a gait significantly slower than people 6

years older than her. The patient’s score indicated that she had decreased function and was at an

increased risk of falling. While performing the TUG, the patient had increased trunk sway and

decreased step length with left being greater than right. Additionally, her right hip extension was

severely limited, causing a decreased stance phase on her right leg. She had increased difficulty

with performing the 180° turn necessary to return to the chair, taking close to 10 steps to do so.

Her TUG test was recorded in Table 4.

Balance. The Berg Balance Scale (BBS) 28 was the first balance specific balance test given to the

patient due to its variety of challenges included standing, sitting, turning, transfers, and stepping.

It has been found that a score of below a 45 indicates a risk of falling in older adults, and a score

12
of below a 40 indicates a near 100% probability of falling.29 The BBS has excellent test re-test

reliability (ICC = 0.77) with older adult populations, and construct validity (ICC = 0.97) with

patients with osteoarthritis.30 The BBS officially tests 14 different areas of balance on a 0 to 4

grading scale with 0 meaning that the patient is unable to complete that task, and 4 essentially

meaning that the patient has no limitations with that activity. The patient had the most difficulty

with tandem standing and standing on one leg, scoring a 1 for those activities. Other difficult

tasks for the patient included reaching outside of her base of support (BOS), stepping onto a

stair, and turning 360°. She scored a 2 in those activities. She was able to complete only 5 of the

14 activities without significant limitations. Those tasks were primarily static standing and sitting

activities. Overall, the patient scored a 40 out of 56 demonstrating an increased risk of falling.

The patient’s BBS scores were recorded in Appendix 1 with definitions of scoring criteria.

The second balance test administered was the Four-Square Step Test (FSST).31 The FSST

was chosen to measure the patient’s balance with an agility task and determine her variable

stepping ability. A score of greater than 15 seconds on the FSST indicates a risk of falling.31 The

test has as specificity of 0.667 and sensitivity of 0.667 for determining the risk of falls for an

older adult patient.32 Additionally, it has excellent test re-test reliability (ICC = 0.98) and strong

concurrent validity with the TUG (ICC = 0.88) in geriatric populations.33 For the test, the patient

starts in the left front square of four squares (one to the right, two behind). The patient is to step

right, then back, then left, then forward and repeat in reverse order until they are back in the

original square. The patient was able to do the FSST in 19.84 seconds, indicating a high risk of

falls and decreased agility. The patient’s FSST score was recorded in Table 4.

Lower Extremity Function. The Lower Extremity Functional Scale (LEFS) 34 was chosen as a

subjective measurement of the patient’s difficulty with everyday activities. The LEFS has

13
excellent test-retest reliability (ICC = 0.85), construct validity (ICC = 0.92), and a minimal

clinically important difference value of 9.9 points in patients with osteoarthritis.35 The test

consists of 20 questions about how the patient’s condition makes it difficult for them to function

throughout the day. Areas questioned include: the ability to complete ADL, walk, run, stand for

prolonged periods of time, and perform bed mobility tasks. The LEFS is on a 0 to 4 scale were 0

= extreme difficulty or unable to perform, and 4 = no difficulty. The patient filled out the form

without physical therapist assistance and score an initial value of 24/80 indicating 30% of normal

function. The patient’s exact question responses are recorded in Appendix 2.

Clinical Impression #2

The patient had impaired ROM in her right LE which was expected based on her history

of physical therapy and her multiple surgical procedures to the same LE. In addition, the patient

had decreased strength in her right hip and knee. The patient had severely limited hip flexion,

extension, abduction, and adduction and was unable to move her LE through her full available

range against gravity. She was, however, able to perform knee flexion and extension through her

full range (which was limited by passive structures) and resist a small amount of pressure given

by the physical therapist. The patient had extremely high pain levels with all movements of her

hip and knee and severe pain with palpation of her thigh. These findings were consistent with the

patient’s reports. In addition to her other impairments, she had decreased balance as evidenced

by her TUG, BBS, and FSST results. The patient had the most difficulty with agility tasks, turns,

single leg stance, tandem stance, and stepping up to a stair during the combined balance tests.

The results of her TUG (25.72 seconds), BBS (40/56), and FSST (19.84 seconds) all indicate that

the patient is at a high risk of falls. She also presented to therapy with a straight cane to improve

14
her balance. After the examination it was determined that the patient had increased scar tissue

buildup and compromised muscular integrity due to multiple surgeries to the patient’s R thigh.

The first goal for therapy was to increase the patient’s hip extension to 10° and knee

extension to 0° to allow for improved walking and standing mechanics. The next goal of therapy

was to improve the patient’s strength to 4- in all measured hip (flexion, extension, abduction,

adduction) and knee (flexion, extension) movements to allow for improved pelvic stability and

mechanics with walking, bending, squatting, and ambulating stairs. Along with strength gains,

the third goal was to improve TUG, BBS, and FSST scores to below 10 seconds, above 45/56,

and below 15 seconds respectively to eliminate the patient’s risk of falling and future injuries.

Additionally, with improved balance, the fourth goal was to eliminate the need for the patient to

use a cane to walk in the community. The last goal for physical therapy was to improve the

patient’s LEFS to 40/80 indicating a significant improvement in lower extremity function and

improved ability to perform ADLs, walk, run, stand for prolonged periods of time, and perform

bed mobility tasks. The patient stated that her goals for therapy were to decrease her pain levels,

improve balance, improve overall strength, and increase her hip and knee ROM. Her functional

goals included being able to walk without a cane, ambulate stairs normally, and get out of the car

with more ease.

Intervention

The patient had a history of many failed attempts at improving lower extremity strength,

ROM, and function with physical therapy. Past treatment sessions worked on therapeutic

resistive exercise, gait training, soft tissue mobilization (STM), and stretching. Due to the

patient’s poor response to these treatments and her functional limitations, it was proposed that

the patient participate in functional exercise to improve her impairments. A secondary area of

15
focus was balance training as the patient progressed with lower extremity strength and ROM.

After the initial examination, the patient had an appointment with her orthopedic surgeon who

told her not to do any resistance exercise. For this reason, resistance exercise, except for body

weight activities, was not utilized. Functional weight bearing exercise and balance training have

both been found to be highly effective in treating patients with hip fractures.13 Additionally,

strength building exercises that take place in seated and standing positions have been shown to

be highly effective in improving gait speed, gait distance, and daily physical function in patients

with a prior hip fracture.15 Lastly, stepping tasks that challenge a patient’s balance have also been

shown to improve balance and functional performance in patients who have had a hip

fracture.17,18 All of the patient’s physical therapy interventions were recorded in Appendix 3.

The patient attended 18 visits of physical therapy over the course of 6 weeks. Each

treatment was 45 minutes in length, and treatment progressions were broken up into three, 2-

week blocks. Each treatment session was started the same way for all 18 visits with a 15-minute

warm up. Additionally, each warm-up had two different exercises. The first exercise consisted of

10 minutes of cycling on a recumbent stationary bicycle. The purpose of this exercise was to

increase hip flexion, knee flexion, and knee extension ROM while also preparing the patient’s

body for more demanding exercise later. Due to patient limitations in ROM, she had a difficult

time completing ADLs and walking in the community. It was proposed that the cyclical motion

of the bike would provide a repetitive stretch to the patient’s joint capsule, scar tissue, and tight

musculature at terminal extension and flexion ROM. By improving the elasticity of the above

structures, it was hypothesized that the patient’s ROM would improve allowing her to function

without limitation in the community. An additional benefit of using the bike was that the patient

could use her unaffected left lower extremity to aide in the bike revolutions.

16
 For the duration of the 18 visits, the patient started at a seat setting of 5 on the recumbent

stationary bicycle. Further progressions were then made according to visit number and patient

tolerance. The resistance level of the bike was set at 3 for all 18 visits. Level 3 allowed the

patient to control her speed throughout the whole ROM while still following the orthopedic

surgeon’s restrictions for no resistive exercise. For the first 2 weeks (6 visits) the patient was

asked to bike in a forward direction at a comfortable pace for all 10 minutes. For visits 7-12 the

patient was also asked to bike in a forward direction, but after 5 minutes, was asked to bike in a

backwards direction (for the remaining 5 minutes). Lastly, during the last 2 weeks of therapy, the

patient was asked to do 5 minutes of forward biking and 5 minutes of backward biking in

addition to gradually lowering the bike seat as tolerated. The seat height was lowered from level

5 to levels 4, 3, and 2 at random time intervals as the patient’s tolerance would allow. The

purpose of lowering the patient’s bike seat was to increase the hip and knee ROM demands for

the patient.

The second warm up activity consisted of 5 minutes of exercise on an elliptical. The

primary focus of this activity was to increase the patient’s hip extension and knee extension

ROM in a standing position to improve the patient’s ability to walk in the community. Elliptical

progressions were made according to visit number and patient tolerance. All elliptical exercises

were completed without resistance in accordance with the orthopedic surgeon’s guidelines for

exercise. For the first 2 weeks of therapy (6 visits) the patient was asked to walk in a forward

direction for all 5 minutes. For visits 7-12 the patient was also asked to bike in a forward

direction, but after 2.5 minutes, was asked to bike in a backwards direction (for the remaining 2.5

minutes). Lastly, during the last 2 weeks of therapy, the patient switched walking direction

(between forward and backward) when the physical therapist randomly called out a direction.

17
The goal of the random switching was to challenge the patient’s balance and her ability to switch

walking direction in terminal hip and knee ranges of motion.

After 15 total minutes of a warmup, the patient then completed 30 minutes of functional

exercise. All treatment sessions had the same three essential components which were 1) seated

exercises, 2) walking and standing exercises, and 3) stair exercises. Seated and stair exercises

were completed in approximately 5 minutes each, while the walking and standing exercises were

completed in approximately 20 minutes total. The patient reported difficulties will all three of

these areas in the initial examination when she commented on her difficulties with getting into

and out of a car, walking, and climbing stairs. For this reason, these three areas of focus were

chosen. Verbal encouragement was utilized throughout the entirety of each treatment to improve

step height, length, and cadence.

Seated Exercises. Seated exercises were used primarily to help the patient improve her ability to

transfer into and out of a car. All seated activities took place with the patient sitting on a hi-lo

treatment table (AM-SX3500; Armedica, Inc.). For this category there were only 2 exercises

prescribed to the patient. Those two exercises were 1) hip flexion marches, 2) repeated sit to

stands. The patient completed 2 sets of 10 repetitions (each side) for all seated exercises.

The first exercise consisted of the patient completing lower extremity alternating hip

flexion marches. For the first 2 weeks, the patient was asked to march in place as fast as she

could. After 2 weeks, the patient progressed to march one leg out to the side, and then back to

midline repeatedly before switching to the opposite side. The patient was encouraged to step as

far to each side as possible. Once the patient improved in this task, she progressed to stepping

onto a short step that was positioned beside the hi-low table. This last progression took place in

the last 2 weeks of therapy.

18
 The second exercise consisted of sit-to-stand progressions. For the first 2 weeks, the

patient was asked to preform repeated sit-to-stands from the elevated hi-lo table. For the first

several visits the patient had to use her arms to assist herself in standing up. After the patient was

able to do that exercise without the use of her arms, the table was lowered for the next 2 weeks.

Additionally, she was asked to sit down from a standing position slowly (slow eccentric

movement). Lastly, for the final 2 weeks of therapy, she was asked to sit at one end of the hi-low

table, perform a sit-to-stand, and sidestep to the other side of the treatment table before sitting

back down. She was asked to repeat this exercise as fast as she could safely in each direction.

Walking and Standing Exercises. The focus of this category was to improve the patient’s ability

to walk in the community without an assistive device. For this category there were several

exercises prescribed and the progressions took place every 2 weeks. All exercises were done in

parallel bars to protect the patient and decrease her fear of falling. For each treatment session the

patient was asked to do a series of variable stepping, walking, and turning tasks. Exercises

focused on improving the patient’s strength, balance, and ROM in multiple planes of movement

including the frontal, sagittal, and transverse plane.

All exercises were completed for 2 sets of 10 repetitions on each side (unless stated

otherwise). Each treatment session attempted to apply multiple side, forward, and backwards

stepping tasks, in addition to pivot turns in both directions. For the first 2 weeks, the patient

completed the following exercises: forward walking with a partial lunge, side stepping,

backwards walking, standing heel raises, and standing toe raises. The goal of the partial lunges

was to improve hip extension ROM of the trail leg, and overall strength of the forward leg. The

patient initially had significant pain, strength, and ROM restrictions with these tasks.

19
 After 2 weeks, progressions were made and exercises were added. The exercises

completed in weeks 3 and 4 consisted of the following: forward walking over with a partial

lunge, backwards walking, side stepping with the trail leg crossing in front and behind the front

leg (commonly known as “karaoke” or “grape-vines”), forward walking over a short (6 inch)

plastic hurdle (Yellow SpeedHurdle; Champion Sports, Inc.), side stepping over a short plastic

hurdle, standing heel raises, standing toe raises, and pivot turning in place (left and right). Hurdle

stepping was added to the patient’s workout program to improve single leg stance stability and

step height. Pivot turns were added to act as a functional stretch to improve the patient’s hip

ROM and stepping capability in the community.

The last 2 weeks of therapy continued to focus on strength, ROM and stepping strategies

while adding more specific balance training. The workout program for the last two weeks

consisted of the following: alternating forward lunges onto a BOSU ball (BOSU Sport 50cm

Balance Trainer; BOSU, Inc.), side lunge onto a BOSU ball, backward step onto a BOSU ball,

forward walking over a tall (12 inch) plastic hurdle (Orange SpeedHurdle; Champion Sports,

Inc.), side stepping over a tall plastic hurdle, pivot turning in place (left and right), narrow base

of support balance on a blue foam square for 2 sets of 30 seconds (Balance Pad Elite; Arex, Inc.),

tandem stance balance on a blue foam square for 2 sets of 30 seconds each foot forward, and hip

hikes. The BOSU ball and blue foam square were added to challenge the patient’s balance and

improve ankle and hip reactions on unstable surfaces. Due to the patient’s improvements in

ROM and strength, the patient was able to proceed much more quickly through the walking and

standing exercises by the end of therapy.

Stair exercises. The rationale of this category was to improve the patient’s lower extremity

strength and ROM while also helping her to ambulate stairs more easily. The patient reported a

20
fear of falling on stairs in the initial examination, so treatment sought to eliminate that fear.

Additionally, the patient’s laundry was in the basement, so it was important to restore this area of

the patient’s function. For this category there were also several exercises prescribed with

progressions every 2 weeks. All exercises were completed for varying repetitions and durations

which are shown below. Additionally, all exercises took place on stairs with 4 steps (6 inch

height), two handrails on each side, and a closed back (Armedica Training Stairs Closed End;

Armedica, Inc.)

For the first 2 weeks, that patient completed the following exercises: standing plantar

flexion stretch at the stairs (2 sets of 30 second holds on each side), standing hamstring stretch on

the stairs (2 sets of 30 second holds on each side), forward lunge on stairs (2 sets of 30 second

holds on each side), and stair climbs with slow eccentric lowering on the way down (4 times up

and down). The forward lunge was focused more on improving the patient’s knee flexion and hip

extension ROM than strengthening. The patient was encouraged to perform a forward lunge on

the highest tolerable stair for a stretch. The patient had extreme pain with this activity, but slowly

started to display ROM improvements by demonstrating a deeper lunge.

The patient had extreme pain with all the above exercises and; therefore, moved very

slowly with compromised balance. She was able to utilize the handrail on the stairs to maintain

her balance throughout all exercises. When performing the stair climbing exercise, the patient

was asked to alternate legs going up. She was unable to perform a reciprocating gait pattern for

the first several weeks. She brought both legs up to the step individually before advancing to the

next step. For the first several weeks, the patient needed to use the assistance of her left upper

extremity to lift her affected lower extremity to the top of each stair using her pant leg.

21
 The only progression for the 3rd and 4th weeks included performing the stair climbs 10

times (up and down) with a reciprocal gait pattern on the way up. The patient was able to display

a reciprocal gait pattern on all repetitions on the ascending phase of the stair climb, but not on

the descending phase. Again, she had to use her left upper extremity to help assist her right leg

on the ascending phase of the stair climb. Around the 5th week of therapy, the patient was

prepared to descend the stairs with a reciprocating gait pattern. She completed 10 ascending and

descending stair climbs with a reciprocating gait pattern for both phases. By the end of therapy,

the patient was able to ascend and descend the stairs without the use of the handrail.

Outcomes

After 18 visits of physical therapy, the patient successfully met all her goals and was

discharged from therapy. Her goals included: decreased pain levels, improved balance, improved

overall strength, and increased hip and knee ROM. Additionally, the patient wanted to walk

without a cane, ambulate on flight of stairs normally, and get out of the car with more ease. All

measurements listed below were taken using the previously established methods for collection.

Pain. Upon discharge from physical therapy the patient’s best, worst, and current pain scores

were 3, 5, and 3 respectively. This was an improvement from the initial examination best, worst,

and current pain scores of 4, 8, and 6 respectively. The minimum clinically important difference

(MCID) for the VAS has been found to be 12 mm.36 Since each number on the VAS is 10 mm

apart, it can be determined that the patient only met the criteria for MCID for her worst and

current pain scores.20,36 Specific values can be seen in Table 2.

Range of Motion. At discharge the patient had improved right PROM and AROM measurements

for all previously measured hip and knee categories. The largest improvements in ROM were in

active hip flexion (0-112°) and extension (0-6°) as well as passive knee extension of 0° and

22
active knee flexion of 2-134°. The patient did not, however, meet the physical therapist’s goals

for active hip extension of 0-10° or active knee extension to 0°. A MDC value for hip

goniometer ROM was not able to be found in the literature. The minimal detectable change

(MDC) for glenohumeral goniometer ROM was; however, obtained and found to be 11-16°.37

Since the glenohumeral and femoral-acetabular joints are both proximal ball-and-socket joints, it

was determined to be a sufficient MDC value for this case report. Applying that research to the

patient’s hip measurements, the patient’s change in passive knee extension from 7° away from

neutral to 0° could be due to error, and, therefore, cannot be considered a significant difference.

Additionally, previous literature states that in order to have a normal gait pattern, a patient must

have the following active ROM measurements: hip flexion 0-30°, hip extension 0-10°, knee

flexion 0-60°, and knee extension 0°.38 The patient was able to obtain adequate hip and knee

flexion ROM for a normalized gait pattern, but she remained limited in active hip and knee

extension.38 Specific measurements were recorded in Table 3.

Strength. Following treatment, the patient had improved hip and knee strength in all categories.

Hip flexion, abduction, and adduction were improved to 3+/5 while hip extension was 4-/5 and

knee flexion/extension was improved to 4/5. Due to the patient’s hip flexion, abduction, and

adduction measurements of 3+/5, the patient did not meet the physical therapist’s goal for all hip

and knee strengths to be equal to or greater than 4-/5. Specific research could not be found

regarding specific MCID or MDC values for MMT. Standard strength testing has been shown to

have excellent intrarater reliability (ICC = 0.94) and interrater reliability (ICC = 0.91), however,

so it can be hypothesized that any change in muscle grade is significant due to high

reproducibility of measurements between one or more data collectors.25 All measurements were

recorded in Table 4.

23
Ambulation. At discharge, the patient was able to ambulate without the use of an assistive device

or help from a physical therapist. Her TUG score was improved from 25.72 seconds to 9.35

seconds. Her score indicated that she was no longer at an increased risk of falling (< 10 seconds),

thereby meeting the physical therapist’s ambulation goal for therapy.26 The minimal detectable

change for the TUG is reported as 0.77 seconds in older adult populations.39 Additionally, the

MCID for post-surgical populations is 3.4 seconds.40 Based on these numbers, the patient’s final

TUG score can be interpreted as a significant improvement as compared to her original score.

Balance. Following treatment, the patient had improvements in balance. The patient had an

improved FSST of 8.34 seconds as compared to her initial examination score of 19.84 seconds.

Additionally, she improved her BBS score from 40/56 to 47/56. Both the FSST (< 15 seconds)

and the BBS (> 45/56) indicated that the patient was no longer at an increased risk for falls,

thereby meeting the therapist’s balance goals for therapy.28,31 The MDC for the FSST is reported

to be 1.8 seconds, while the MDC for the BBS is 3.3 points in older adult populations.41,42

Specific MCID values could not be located in the literature for the FSST or BBS. The patient’s

FSST scores were recorded in Table 6, and BBS scores in Appendix 1.

Lower Extremity Function. The MCID for the LEFS has previously been shown to be 9 points.43

Upon discharge, the patient demonstrated an improvement in LEFS score from 24/80 to 43/80

indicating significant improvements in lower extremity function. Additionally, the patient

indicated that she had no difficulty with 7 of 20 categories including the ability to perform

housework, hobbies, walk between rooms, perform light and heavy house activities, and sit for

prolonged periods of time. Furthermore, the patient responded that she had only a little bit of

difficulty with going up or down 10 stairs, prolonged standing, and rolling over in bed. The

patient’s scores indicate that she had little to no difficulty with half of the functional tasks on the

24
LEFS.34 Her score of 43/80 is greater than 40/80, thereby meeting the therapist’s goal for lower

extremity function. The patient’s LEFS scores were recorded in Appendix 2.

Discussion

The purpose of this case report was to determine if a functional exercise plan would

result in improvements in LE strength, ROM, balance, and function in a patient with a history of

a periprosthetic hip fracture and previous failed attempts at physical therapy. Although there is a

plethora of research regarding the treatment of older adults with a hip fracture, the current

literature fails to examine patient’s with periprosthetic fractures specifically. Additionally, there

is a lack of evidence regarding physical therapy interventions for chronic hip fracture symptoms.

Due to the lack of research regarding periprosthetic fractures, specific interventions chosen for

this case report were based off clinical practice guidelines for older adults and general hip

fractures.

The patient participated in 18 visits of physical therapy over the course of 6 weeks. Each

appointment consisted of the same general layout with 15 minutes allotted for a warm-up, 5

minutes for seated exercises, 20 for walking and standing exercises, and 5 for stair exercises.

Past research indicated that patients who participated in functional weight bearing activities and

balance training have the best functional improvements.13 Additionally, functional activities such

as lunges, sit-to-stands, and gait training were essential for improving a patient’s balance

following a hip fracture.16-18 For this reason, most of the patient’s treatment time consisted of

weight bearing exercises, including those above. The patient’s primary difficulty was with

walking, so as the visits progressed, increased ambulation demands were placed on the patient.

Walking tasks were progressed by having the patient walk over objects and switch directions to

simulate walking in the community. Additionally, due to the patient’s history of falls, specific

25
balance training was added to the patient’s exercise program toward the end of the 6 weeks.

Lastly, since the patient also reported difficulties with transferring from her car, seated exercises

were also in each treatment session.

This workout plan was supported by past research that showed that improvements in

physical function, balance, and gait can be made with an exercise program consisting in

functional seated, standing, and walking activities.14,15 The patient met many of the goals for

therapy including improved balance as evidenced by a TUG score < 10 seconds, a FSST score <

15 seconds, and a BBS score > 45/56. Additionally, the patient improved her LEFS score to ≥

40/80 which met her low extremity functional goal. Furthermore, the patient was able to obtain

adequate hip and knee flexion ROM for a normalized gait pattern, which was indicated by Perry

et al38 to be 0-30° and 0-60° respectively.

The patient’s goals were also met after the 18 physical therapy visits. The patient’s goals

for therapy included decreased pain levels, improved balance, improved overall strength, and

increased hip and knee ROM. Additionally, the patient wanted to walk without a cane, ambulate

a flight of stairs normally, and get out of the car with more ease. The patient was not able to meet

the therapist’s goals of active hip extension of 0-10°, active knee extension of 0°, or hip and knee

strength of ≥ 4-/5 for all muscle actions tested.

The patient had been to many previous visits of physical therapy to address her ROM and

strength impairments without any success. Past treatments included predominately therapeutic

resistive exercise, soft tissue mobilization (STM), and stretching. The working diagnosis at the

time of the initial evaluation was that the patient had muscle weakness, decreased ROM,

decreased balance, and impaired gait secondary to the patient’s ORIF and subdermal trauma. It

was believed that the patient had scar tissue buildup and compromised muscular integrity due to

26
multiple surgeries to the patient’s right thigh. Due to the patient’s history of extensive stretching

and soft tissue mobilizations without success, functional exercise was utilized to improve the

patient’s limitations through performing every-day activities.

It was proposed that perhaps muscle co-contraction during weight bearing activities, as

well as challenging the patient regularly at the end of her range during functional activities

would help to break up the patient’s soft tissue adhesions and scar tissue that had built up

secondary to her multiple hip surgeries. The basis behind this argument stemmed from the

principles of dynamic stretching, which often consist of periods of alternating co-contraction and

volitional movement, at the end of the patient’s available range.44-46 Dynamic stretching has been

found to temporarily decrease soft tissue tension, increase maximal contraction force capability,

and decrease passive joint torque. 44-46 Activities such as the recumbent bike warm up, multi-

direction stepping, and stair activities challenged the patient to have a high volume of stretching

in the areas of primary restriction while also allowing the patient to self-select her workout

intensity according to her symptoms. Functional exercise also allowed the patient to utilize her

body weight and gravity in assisting her in moving past the barrier in her soft tissue restrictions.

This was important since the patient was not able to utilize external loads for exercise activities.

The patient’s body weight and gravity alone acted as forces to provide overpressure at the end of

the patient’s available range and allow for improved mobility.

In in traditional stretching, the active component of the muscle is not utilized. Instead, the

patient is asked to relax their muscles to elicit a prolonged stretching, and thereby lengthening of

the structures. 46 By participating in functional exercise, active muscle contraction elicited

dynamic stretching in the exact movements that she needed to improve in her daily life, such as

walking and climbing the stairs. Additionally, the function weight bearing exercises also allowed

27
for muscle strengthening despite the patient’s restrictions for resistance exercise. 14,15 This muscle

strengthening throughout the patient’s everyday functional range is also likely why the patient

had so many improvements towards her functional goals for therapy.

Functional exercise was chosen due to the extensive evidence of its effectiveness in

treating patients with a previous hip fracture.13 Although there is a limited amount of research

suggesting specific treatment strategies for patients with periprosthetic fracture, this case report

sought to test if functional exercise was also effective in managing patients with periprosthetic

hip fracture. The results of this case contribute to the limited literature on the treatment of

periprosthetic hip fractures and chronic fracture symptoms. This contribution is relevant since

periprosthetic fractures are the third most common reason for the reoperation of a THA.9

Additionally, this case supports the use of function exercise weight bearing exercise for

improving ROM and strength in patients with previous failed attempts at physical therapy.

There are several limitations of this study. The first is that both the initial and the final

examinations were completed by a single therapist. It is possible that errors were made within

each examination thereby altering the results of this case report. It is worth noting, however, that

MMT has an excellent intrarater reliability value of ICC= 0.91.25 Additionally, the TUG, BBS,

FSST, and LEFS all have good to excellent test-retest reliability.27-35Another limitation was that

formal gait analysis was never completed. Had a formal gait analysis been completed in the

initial examination, there would be an objective measurement showing improvements in gait

quality over the course of therapy. The patient’s gait pattern and quality significantly improved

over the course of therapy, but due to the lack of a formal assessment at the initial examination,

comparisons are not able to be objectively made. Additionally, the physical therapist performing

the initial examination never formally recorded what they felt when palpating the patient’s leg.

28
Had the physical therapist recorded palpation findings, it would add to a more well-rounded

understanding of the patient’s presentation to therapy before and after treatment.

The physical therapist also failed to describe aspects of the patient’s mobility or ability

to transfer. Descriptions of how the patient performed transfers, such as those out of a vehicle,

would have helped the reader to understand the patient’s condition and gave objective evidence

of the patient’s progress towards her goals. Next, there were different treating therapists over the

course the patient’s time in therapy. It is possible that the interventions administered to the

patient were not the same due to therapist differences. Although the patient was treated primary

by one person, these differences may have resulted in altered outcomes for the patient.

Additionally, as with any case report there was only one participant in this case report so causal

relationships cannot be determined.

Future research needs to be conducted to determine the best treatment methods for

patients with periprosthetic fracture. Although there is a plethora of research on the treatment of

general fractures, there is limited research on the treatment of a periprosthetic fracture. Future

research should also investigate the long-term effects of a periprosthetic fracture on a patient’s

health. While there is much research regarding periprosthetic fractures in the acute phase of

healing, there is little research on patients with chronic symptoms. Research in this area could

help to improve a periprosthetic patient’s function, reduce impairments, and prevent future

injury. Future research may also attempt to find links between periprosthetic repair method and

soft tissue implications for the patient. With research in this area physical therapists and other

health care professionals would be able to create more targeted treatment plans for their patients.

29
References

1 Helgeson K. Chapter 22: Introduction to pathology of the musculoskeletal system. In:

Goodman C, Fuller K, eds. Pathology Implications for the Physical Therapist. 4th ed. St.
Louis, Mo.: Elsevier; 2015, 1216-1316.

2 Murphy LB, Helmick CG, Schwartz TA, et al. One in four people may develop symptomatic
hip osteoarthritis in his or her lifetime. Osteoarthritis Cartilage. 2010;18(11):1372-1379.
doi:10.1016/j.joca.2010.08.005

3 Bieler T, Siersma V, Magnusson SP, Kjaer M, Beyer N. Exercise induced effects on muscle
function and range of motion in patients with hip osteoarthritis. Physiother Res Int.
2018;23(1):10.1002/pri.1697. doi:10.1002/pri.1697

4 Cibulka MT, White DM, Woehrle J, et al. Hip pain and mobility deficits-hip osteoarthritis:
clinical practice guidelines linked to the international classification of functioning, disability,
and health from the Orthopaedic Section of the American Physical Therapy Association. J
Orthop Sports Phys Ther. 2009;39(4):A1-A25. doi:10.2519/jospt.2009.0301

5 Katz JN, Losina E, Barrett J, et al. Association between hospital and surgeon procedure
volume and outcomes of total hip replacement in the United States medicare population. J
Bone Joint Surg Am. 2001;83(11):1622-1629. doi:10.2106/00004623-200111000-00002

6 HCUPnet-Hospital Inpatient National Statistics. HCUPnet. https://hcupnet.ahrq.gov.

Published 2018. Accessed November 23, 2021.

7 Galmiche R, Stephane D, Dobransky J, et al. Does surgical approach influence mid- to long-
term patient reported outcomes after primary total hip replacement? A comparison of the 3
main surgical approaches. Canadian Journal of Surgery. 2020; 63(2):181-189.
Doi:10.1503/cjs.008919.

8 Kwon MS, Kuskowski M, Mulhall KJ, Macaulay W, Brown TE, Saleh KJ. Does surgical
approach affect total hip arthroplasty dislocation rates?. Clin Orthop Relat Res. 2006;447:34-
38. doi:10.1097/01.blo.0000218746.84494.df

9 Lindahl H, Garellick G, Regnér H, Herberts P, Malchau H. Three hundred and twenty-one

periprosthetic femoral fractures. J Bone Joint Surg Am. 2006;88(6):1215-1222.
doi:10.2106/JBJS.E.00457

10 Holder N, Papp S, Gofton W, Beaulé PE. Outcomes following surgical treatment of

periprosthetic femur fractures: a single centre series. Can J Surg. 2014;57(3):209-213.
doi:10.1503/cjs.014813

11 Collins ME, Lieberman G. Traumatic proximal femur frac- tures.

http://eradiology.bidmc.harvard.edu/LearningLab /musculo/Collins.pdf. Accessed July 9,
2012.

30
12 Müller M, Winkler T, Märdian S, et al. The worst-case scenario: treatment of periprosthetic
femoral fracture with coexistent periprosthetic infection-a prospective and consecutive
clinical study. Archives of Orthopaedic & Trauma Surgery. 2019;139(10):1461-1470.
doi:10.1007/s00402-019-03263-y

13 McDonough CM, Harris-Hayes M, Kristensen MT, et al. Physical Therapy Management of

Older Adults With Hip Fracture. J Orthop Sports Phys Ther. 2021;51(2):CPG1-CPG81.
doi:10.2519/jospt.2021.0301

14 Mangione KK, Craik RL, Tomlinson SS, Palombaro KM. Can elderly patients who have had
a hip fracture perform moderate- to high-intensity exercise at home? Phys Ther.
2005;85:727-739. https://doi.org/10.1093/ptj/85.8.727

15 Sylliaas H, Brovold T, Wyller TB, Bergland A. Prolonged strength training in older patients
after hip fracture: a randomised controlled trial. Age Ageing. 2012;41:206-212.
https://doi.org/10.1093/ageing/afr164

16 Sherrington C, Lord SR. Home exercise to improve strength and walking velocity after hip
fracture: a randomized controlled trial. Arch Phys Med Rehabil. 1997;78:208-212.
https://doi.org/10.1016/s0003-9993(97)90265-3

17 Sherrington C, Lord SR, Herbert RD. A randomized controlled trial of weight-bearing versus
non-weight-bearing exercise for improving physical ability after usual care for hip fracture.
Arch Phys Med Rehabil. 2004;85:710-716. https://doi. org/10.1016/s0003-9993(03)00620-8

18 Latham NK, Harris BA, Bean JF, et al. Effect of a home-based exercise program on
functional recovery following rehabilitation after hip fracture: a randomized clinical trial.
JAMA. 2014;311:700-708. https://doi.org/10.1001/jama.2014.469

19 WHO Scientific Group on The Assessment of Osteoporosis at Primary Health Care Level.
World Health Organization; 2004. 2-3.

20 Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with
pain rating scales. Ann Rheum Dis. 1978; 37:378–81.

21 Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH. Reliability of
pain scales in the assessment of literate and illiterate patients with rheumatoid arthritis. The
Journal of rheumatology. 1990 Aug 1;17(8):1022-4.

22 Reese N, Bandy W. Joint Range of Motion and Muscle Length Testing. 3rd ed. St. Louis,
Mo.: Elsevier; 2017: 331-379

23 Nussbaumer, S., Leunig, M., Glatthorn, J.F. et al. Validity and test-retest reliability of
manual goniometers for measuring passive hip range of motion in femoroacetabular
impingement patients. BMC Musculoskelet Disord. 2010;11(194).
https://doi.org/10.1186/1471-2474-11-194

31
24 Kendall FP. Manual Muscle Testing Procedures. NIH.org Accessed October 20, 2021.
https://www.niehs.nih.gov/research/resources/assets/docs/muscle_grading_and_testing_proce
dures_508.pdf.

25 Pfister BP, de Bruin ED, Sterkele I, Maurer B, de Bie RA, Knols RH. Manual muscle testing
and hand-held dynamometry in people with inflammatory myopathy: An intra- and interrater
reliability and validity study. PLoS One. 2018;13(3):e0194531. Published 2018 Mar 29.
doi:10.1371/journal.pone.0194531

26 Timed Up and Go Test. ThompsonHealth.com. Accessed December 10, 2021.

https://www.thompsonhealth.com/Portals/0/_RehabilitationServices/PT%20Mgmt%20of
%20Knee/Functional_Tests.pdf

27 Steffen TM, Hacker TA, Mollinger L. Age- and gender-related test performance in
community-dwelling elderly people: six-Minute walk test, berg balance scale, timed up & go
test, and gait speeds. Phys Ther. 2002;82(2):128-137. doi:10.1093/ptj/82.2.128

28 Berg Balance Scale. Brandeis.edu. Accessed October 20, 2021.

https://www.brandeis.edu/roybal/docs/Berg-Balance-Scale_Website.pdf

29 Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the probability for falls in
community-dwelling older adults. Phys Ther. 1997;77(8):812-819. doi:10.1093/ptj/77.8.812

30 Jogi P, Spaulding SJ, Zecevic AA, Overend TJ, Kramer JF. Comparison of the original and
reduced versions of the Berg Balance Scale and the Western Ontario and McMaster
Universities Osteoarthritis Index in patients following hip or knee arthroplasty. Physiother
Can. 2011;63(1):107-114. doi:10.3138/ptc.2009-26

31 Langford, Zoe. The four square step test. Journal of Physiotherapy. 2015; 61(3): 162.
https://doi.org/10.1016/j.jphys.2015.03.005.

32 Mathurapongsakul P, Siriphorn A. Four square step test with foam is more accurate than
those without foam for discriminating between older adults with and without fall history. J
Aging Phys Act. 2018;26(4):624-628. doi:10.1123/japa.2017-0363

33 Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple
falling older adults. Arch Phys Med Rehabil. 2002;83(11):1566-1571.
doi:10.1053/apmr.2002.35469

34 Lower Extremity Functional Scale. Emoryhealthcare.org. Accessed October 20, 2021.

https://www.emoryhealthcare.org/ui/pdfs/msk-pt-forms/hip-lefs.pdf

35 Pua YH, Cowan SM, Wrigley TV, Bennell KL. The lower extremity functional scale could
be an alternative to the western Ontario and McMaster universities osteoarthritis index
physical function scale. J Clin Epidemiol. 2009;62(10):1103-1111.
doi:10.1016/j.jclinepi.2008.11.011

32
36 Kelly AM. The minimum clinically significant difference in visual analogue scale pain score
does not differ with severity of pain. Emerg Med J. 2001;18(3):205-207.
doi:10.1136/emj.18.3.205

37 Muir SW, Corea CL, Beaupre L. Evaluating change in clinical status: reliability and
measures of agreement for the assessment of glenohumeral range of motion. JOSPT.
2010;5(3):98-110. Accessed December 12, 2021. https://search-ebscohost-
com.cmich.idm.oclc.org/login.aspx?direct=true&db=rzh&AN=105096216&site=ehost-live

38 Perry J, Burnfield J. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare,
NJ.: SLACK Inc; 2010: 19-149

39 Smith E, Cunningham C, Greene BR, McCarthy Persson U, Blake C. Detecting subtle

mobility changes among older adults: the quantitative timed up and go test. Aging Clinical &
Experimental Research. 2021;33(8):2157-2164. doi:10.1007/s40520-020-01733-7

40 Gautschi OP, Stienen MN, Corniola MV, et al. Assessment of the Minimum Clinically
Important Difference in the Timed Up and Go Test After Surgery for Lumbar Degenerative
Disc Disease. Neurosurgery. 2017;80(3):380-385. doi:10.1227/NEU.0000000000001320

41 Choi YM, Dobson F, Martin J, Bennell KL, Hinman RS. Interrater and intrarater reliability
of common clinical standing balance tests for people with hip osteoarthritis. Phys Ther.
2014;94(5):696-704. doi:10.2522/ptj.20130266

42 Donoghue D; Physiotherapy Research and Older People (PROP) group, Stokes EK. How
much change is true change? The minimum detectable change of the Berg Balance Scale in
elderly people. J Rehabil Med. 2009;41(5):343-346. doi:10.2340/16501977-0337

43 Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale
(LEFS): scale development, measurement properties, and clinical application. Phys Ther.
1999;79(4): 371–383. https://doi.org/10.1093/ptj/79.4.371

44 Opplert J, Babault N. Acute effects of dynamic stretching on mechanical properties result

from both muscle-tendon stretching and muscle warm-up. Journal of Sports Science &
Medicine. 2019;18(2):351-358. https://search-ebscohost-com.cmich.idm.oclc.org/login.aspx?
direct=true&db=rzh&AN=137229735&site=ehost-live

45 Wen-Sheng Z, Jia-Huei L, Shu-Chen C, Kuei-Yu C. Effects of dynamic stretching with

different loads on hip joint range of motion in the elderly. Journal of Sports Science &
Medicine. 2019;18(1):52-57. https://search-ebscohost-com.cmich.idm.oclc.org/login.aspx?
direct=true&db=rzh&AN=134820327&site=ehost-live

46 Vieira DCL, Opplert J, Babault N. Acute effects of dynamic stretching on neuromechanical

properties: an interaction between stretching, contraction, and movement. European Journal
of Applied Physiology. 2021;121(3):957-967. doi:10.1007/s00421-020-04583-3

33
Table 1.
Patient Medicationsa

Medications Reason Dosage Frequency

atorvastatin high cholesterol 20 mg p.o. qpm

cyclobenzaprine muscle spasms 5 mg h.s prn

pramipexole restless legs 0.25 mg p.o qpm

duloxetine depression 20 mg p.o daily

magnesium osteoporosis 200 mg p.o daily

a
mg = miligrams; p.o = by mouth; qpm = once in the evening; h.s = at bedtime; prn = as needed.
Table 2.
Results of Visual Analog Scale20 (VAS)a

Initial Examination Discharge Difference

Best 4 3 1

Worst 8 5 3*

Current 6 3 3*
a
0 = no pain; 10 = most severe pain; VAS standard length = 100 mm; Number (1-10) spacing =
10 mm apart. * = meets MCID criteria; MCID = 12 mm36
Table 3.
Results of Range of Motion22 (ROM)a and Lower Extremity Manual Muscle Testing24 (MMT)b

Initial Initial
Initial Initial Discharge Discharge
Discharg Discharg Examination Examination
Movemen Examinatio Examinatio : Right : Left
e Passive e Active : Right : Left
t n Passive n Active Strength Strength
Right Right Strength Strength
Right Right Grade Grade
Grade Grade
Hip
0 - 100° lbp 8 – 46° 0-120° 0-112° 2+ 4 3+ 4
Flexion
Hip
0° lbp 8° afn 0-8° 0-6° 3- 4- 4- 4-
Extension
Hip
0 - 34° lbp 0 – 16° 0-36° 0-25° 2+ 4 3+ 4-
Abduction
Hip
0 - 22° lbp 0 – 10° 0-20° 0-10° 2+ 4 3+ 4-
Adduction
Knee
0 - 110° lbp 10 –108° lbp 0-136° 2-134° 3+ war 4 4 4
Flexion
Knee
7° afn, lbp 10° afn, lbp 0° 2° afn 3+ war 4 4 4
Extension
a
° = degrees; lbp = limited by pain; afn = away from neutral; MDC = 11-16°.37
b
2+ = moves through the full range in a gravity eliminated position and less than half the range against gravity; 3- = moves through
the full range in a gravity eliminated position and more than half the range against gravity; 4- = holds test position against slight to
moderate pressure; 4 = holds the test position against moderate pressure24; war = within available range.
Table 4.
Results of Timed Up and Go26 (TUG)a and Four-Square Step Test31 (FSST)b

Initial Examination Difference

Test Discharge Time
Time
TUG 25.72 s 9.35 s 16.37 s *
FSST 19.84 s 8.34 s 11.5 s *
a
s = seconds; distance = 3 meters; normal = below 10 s; risk for falls ≥ 14 s; * = meets MCID
criteria; MCID = 3.4 seconds.40
b
above 15 s = increased risk of falls; * = meets MDC criteria; MDC = 1.8 seconds.41
Appendix 1.
Results of Berg Balance Scale28 (BBS)a
Initial Eval Discharge
4 = able to stand without using hands and stabilize independently
3 = able to stand independently using hands
1. Sitting to Standing 2 = able to stand using hands after several tries 3 4
1 = needs minimal aid to stand or to stabilize
0 = needs moderate or maximal assist to stand
4 = able to stand safely 2 minutes
3 = able to stand 2 minutes with supervision
2. Standing Unsupported 2 = able to stand 30 seconds unsupported 1 = needs several tries to stand 30 seconds 4 4
unsupported
0 = unable to stand 30 seconds unassisted
4 = able to sit safely and securely 2 minutes
3 = able to sit 2 minutes under supervision
3. Sitting Unsupported 2 = able to sit 30 seconds 4 4
1 = able to sit 10 seconds
0 = unable to sit without support 10 seconds
4 = sits safely with minimal use of hands
3 = controls descent by using hands
4. Standing to Sitting 2 =uses back of legs against chair to control descent 3 4
1 = sits independently but has uncontrolled descent
0 = needs assistance to sit
4 = able to transfer safely with minor use of hands
3 = able to transfer safely definite need of hands
5. Transfers 2 = able to transfer with verbal cueing and/or supervision 3 4
1 = needs one person to assist
0 = needs two people to assist or supervise to be safe
4 = able to stand 10 seconds safely
3 = able to stand 10 seconds with supervision
6. Standing Unsupported
2 = able to stand 3 seconds 4 4
Eyes Closed
1 = unable to keep eyes closed 3 seconds but stays steady
0 = needs help to keep from falling
4 = able to place feet together independently and stand 1 minute safely
3 = able to place feet together independently and stand for 1 minute with supervision
7. Standing Unsupported
2 = able to place feet together independently but unable to hold for 30 seconds 4 4
Narrow Stance
1 = needs help to attain position but able to stand 15 seconds with feet together
0 = needs help to attain position and unable to hold for 15 seconds
 4 = can reach forward confidently >25 cm (10 inches)
3 = can reach forward >12 cm safely (5 inches)
8. Reach Forward in
2 = can reach forward >5 cm safely (2 inches) 2 3
Standing
1= reaches forward but needs supervision
0 = loses balance while trying/requires external support
4 = able to pick up slipper safely and easily
3 = able to pick up slipper but needs supervision
9. Pick Up Object From 2 = unable to pick up but reaches 2-5cm (1-2 inches) from slipper and keeps balance
3 4
Floor independently
1 = unable to pick up and needs supervision while trying
0 = unable to try/needs assist to keep from losing balance or falling
4 = looks behind from both sides and weight shifts well
3 = looks behind one side only other side shows less weight shift
10. Head Turns in
2 = turns sideways only but maintains balance 4 4
Standing
1 = needs supervision when turning
0 = needs assist to keep from losing balance or falling
4 = able to turn 360 degrees safely in 4 seconds or less
3 = able to turn 360 degrees safely one side only in 4 seconds or less
11. 360 Degree Turn 2 = able to turn 360 degrees safely but slowly 2 4
1 = needs close supervision or verbal cueing
0 = needs assistance while turning
4 = able to stand independently and safely and complete 8 steps in 20 seconds
3 = able to stand independently and complete 8 steps in >20 seconds
12. Step Up 2 = able to complete 4 steps without aid with supervision 2 2
1 = able to complete >2 steps needs minimal assist
0 = needs assistance to keep from falling/unable to try
4 = able to place foot tandem independently and hold 30 seconds
3 = able to place foot ahead of other independently and hold 30 seconds
13. Tandem Stance 2 = able to take small step independently and hold 30 seconds 1 2
1 = needs help to step but can hold 15 seconds
0 = loses balance while stepping or standing
4 = able to lift leg independently and hold >10 seconds
3 = able to lift leg independently and hold 5-10 seconds
14. One Leg Stance 2 = able to lift leg independently and hold = or >3 seconds 1 2
1 = tries to lift leg unable to hold 3 seconds but remains standing independently
0 = unable to try or needs assist to prevent fall
Total Score: 40/56 47/56*
a
cm = centimeters; 56 = functional balance; below 45 = risk of falling; * = meets MDC; MDC = 3.3 points 42
Appendix 2.
Results of Lower Extremity Functional Scale34 (LEFS)a

Initial
Activities Discharge
Examination
a. Any of your usual work, housework, or school
3 4
activities.
b. Your usual hobbies, re creational or sporting
activities. 4 4

c. Getting into or out of the bath.

0 0
d. Walking between rooms. 3 4
e. Putting on your shoes or socks. 1 2
f. Squatting 0 0
g. Lifting an object, like a bag of groceries from the
3 4
floor
h. Performing light activities around your home. 3 4
i. Performing heavy activities around your home. 2 4
j. Getting into or out of a car. 1 2
k. Walking 2 blocks 0 0
l. Walking a mile 0 0
m. Going up or down 10 stairs (about 1 flight of stairs) 1 3
n. Standing for 1 hour 0 3
o. Sitting for 1 hour 3 4
p. Running on even ground 0 2
q. Running on uneven ground 0 0
r. Making sharp turns while running fast 0 0
s. Hopping 0 0
t. Rolling over in bed 0 3
Column Totals 24/80 43/80 *
a
0 = extremely difficult or unable to perform activity; 1 = quite a bit of difficulty; 2 = moderate
difficulty; 3 = a little bit of difficulty; 4 = no difficulty; * = meets MCID criteria; MCID = 9
points.34,43
Appendix 3.
Treatment Interventions for Weeks 1-6a

Warm-Up Seated Exercises Walking and Standing Exercises Stair Exercises

Week
(15 min total) (5 min total; 2x10 reps each side) (20 min total; 2x10 reps each side) (5 min total)
1) plantar flexion stretch (2x30
sec)
1) recumbent bike (level 5, 1) forward walking with partial lunge
2) hamstring stretch (2x30 sec)
seat 5): 10 min forward 2) backward walking
1) Hip flexion marches in place 3) forward lunge on step (2x30
1-2 2) elliptical (without 3) side stepping
2) Repeated sit to stands from sec)
resistance): 5 min 4) standing heel raises
4) ascending/descending stair
forward 5) standing toe raises
climb with slow eccentric
lowering x4
1) plantar flexion stretch (2x30
1) recumbent bike (level 1) forward walking with partial lunge
sec)
5, seat 5): 5 minutes 2) backward walking
2) hamstring stretch (2x30 sec)
forward, 5 minutes 3) “karaoke” side stepping
3) forward lunge on step (2x30
backwards 1) Hip flexion sidestep marches 4) Short hurdle forward walking
3-4 sec)
2) elliptical (without 2) Sit to stands from low table 5) Short hurdle side stepping
4) ascending/descending stair
resistance): 2.5 min 6) standing heel raises
climb with slow eccentric
forward, 2.5 min 7) standing toe raises
lowering x10 (reciprocal gait
backwards 8) pivot turn in place
up)
1) alternating forward lunges onto a
1) recumbent bike (level BOSU ball 1) plantar flexion stretch (2x30
5, progressive seat 2) side lunge to BOSU ball sec)
lowering 5 to 2): 5 3) backward step to BOSU ball 2) hamstring stretch (2x30 sec)
1) Hip flexion sidestep marches to
minutes forward, 5 4) forward walking over tall hurdle 3) forward lunge on step (2x30
short step
5-6 minutes backwards 5) side stepping over tall hurdle sec)
2) Sit to stands with side stepping to
2) elliptical (without 5) pivot turning 4) ascending/descending stair
each side of the table
resistance): random 6) NBOS on blue foam (2x30 seconds) climb with slow eccentric
forward and 7) tandem stance on blue foam (2x30 lowering x10 (reciprocal gait
backwards sec) up and down)
8) hip hikes
a
min = minutes; sec = seconds; reps.